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OBSERVATIONS 

/ O N T H E 

NATURE and CONSEQUENCES 

OF THOSE 


Injuries to which the H e a d is liable from 
J External Violence. 


To which are added. 


Some few GENERAL REMARKS 


FRACTURES 

‘ I , ; / 

AND 

DISLOCATION Si 
By PERCIVALL POTT, F.R.S. 

AND 

SURGEON to St. Bartholomew’s-Hospital. 





i 









OBSERVATIONS 


ON THE 

NATURE and CONSEQUENCES 

OF THOSE 


Injuries to which the H e a d is liable from 

External Violence. 


By PERCIVALL POTT, F.R.S, 


AND 

SURGEON to St. Bartholomew’s-Hospital, 



Nullum capitis vulnus contemnendum . 


Hippocrates. 



LONDON: 

Printed for L. Hawes, W. Clarke, and R. Collins, 
in Pater-nofter-Row. M.dcc.lxviii. 




























f 





T O 

r ’*• y \ • 

r ' ^ * k . 

JOHN DARKER, Efq; 

TREASURER 


O F 

f- 

St. Bartholomew’s - H o s p i t a l. 


SIR, 

r *• 

T H E polite and friendly treat¬ 
ment which the officers of 

y 

St. Bartholomew’s have always re¬ 
ceived from you, is very gratefully 
acknowledged by them all. 

a 2 Give 





DEDICATION. 

Give me leave, as one of them, 
to return you my particular thanks, 
to beg leave to addrefs the following 
fheets to you, and to fubfcribe my- 

felf, - - 

♦* ' W . < 

SIR, 

Tour obliged , and 

Obedient humble Servant., 


Percivall Pott. 


( * ) 



OBSERVATIONS 


ON THE 

NATURE and CONSEQUENCES 

OF THOSE 

.Injuries to which the H e a o is liable from 

external Violence. 


SECT. I. 

Wounds of the fcalp . 

P REVIOUS to an account of fuch 
wounds and injuries of the head, as 
intereft the fkull, the brain, and its 
membranes* it may not be amifs to take 
fome fmall notice of thofe to which the 
fcalp is liable. For this, though it be called 
the common tegument of the head, yet from 
the variety of parts of which it is compofed, 
from their ftruCture, connections, and ufes,in- 

B juries 













( ? ) 


juries done to it, by external violence, become 
of much more confequence, than the fame 
kind of ills, can prove, when inflicted on 
the common teguments of the red: of the 

The covering, called the fcalp, confifts of 
the cutis; the mem bran a adipofa, or cellu- 
laris; the expanded tendons of the frontal, 
occipital, and temporal mufcles, (forming 
a kind of aponeurofis;) and the membrane 
which immediately covers the bones of the 
fkull, called therefore the pericranium. 

This variety of parts, upon the infliction 
of wounds, blow, &c. frequently occafions 
a variety of fymptoms y which fymptoms 
ought by practitioners to be carefully and 
properly diftinguilhed from each other; not 
only becaufe they often arife from the dif- 
tinCt, and particular nature, of the part 
injured; but becaufe they generally point 
out the mod: effectual means of relief. If 

to thefe confiderations we add another, no 

■- • « 

lefs true, and important, (viz.) that there 
is, and mud: be a condant communication, 
by means of blood-veffels between all the 
parts without, and within the head, it will 
appear that injuries done to this part, tho* 
feemingly, and at flrfl: dght, flight and tri- 
4. > vial* 



( 3 ) 

vial, may fometimes prove of the greateft 
confequence. 

I will not wafte the reader’s time, by en¬ 
tering into a detail of the method of treat¬ 
ing common incifed wounds; but proceed 
immediately to thofe which, (tho’ the mif- 
chief is originally confined to the mere 
fcalp,) yet are frequently very terrible to 
behold; are often attended with alarming 
fymptoms, and fometimes with danger. 
Thefe are what are called lacerated wounds ; 
and, thofe made by pundure. The former 
may be reduced to two kinds* (viz.) thofe 
in which the fcalp, tho’ torn, or unequally 
divided, {till keeps its natural lituation, and 
is not ftript or feparated from the cranium, 
to any confiderable diftance, beyond the 
breadth of the wound : and thofe, in which 
it is confiderably detached, from the parts 
it ought to cover. 

The firft of thefe, if Ample, and not 
combined with the iymptoms, or appear¬ 
ances of any other mifchief, do not require 
any particular, or different treatment, from 
what the fame kind of wounds require in 
all other parts : but the latter, (thofe in 
which the fcalp is feparated, and detached 
from the parts it ought to cover,) are not 

B 2 only. 


* 


( 4 ) 

only, by the different methods in which 
they may be treated, frequently capable of 
being cured, with a confiderable deal, more, 
or lefs, eafe, and expedition; but are alfo 
fometimes a matter of great confequence to 
the health and well-being of the patient. 
Both writers and practitioners differ much, 
in their advice, and conduCt on this fubjeCt. 
With fome it is a pra&ice, immediately to 
remove fuch portion of the fcalp as is fair¬ 
ly and perfedly detached from the parts 
underneath ; with others, to attempt its 
prefervation. 

Each of thefe opinions can be confidered 
in a general fenfe only j not as applicable to 
every individual cafe without diflinCtion : 
and taken in fuch general confideration, 
they cannot be both right. It may there¬ 
fore be worth while to enquire, what rea- 
fons each party has to give for its opinion 
and conduCt. 

They who advife the removal, affirm, 
that when a large portion of the fcalp, has 
been perfectly and totally feparated from 
the parts it ought to cover, and that for 
fon\e confiderable fpace, it will not a - 
gain coalefce or unite with fuch parts ; and 
therefore that an attempt to procure fuch 
i union. 


( 5 ) 

union, by replacing the feparated piece, 
will only protract the time of cure, by fur- 
nifhing a lodgment for matter, and Houghs; 
which matter and Houghs muft prevent the 
thing intended. That in the cafe of large 
wounds, or of thofe produced by great 
force, as we cannot by any means be cer¬ 
tain, that no mifchief is done to the parts 
under the cranium, the replacing the lace¬ 
rated fcalp, may not only prevent our im¬ 
mediate enquiry into the nature of fuch 
mifchief, but may conceal, and hide (at 
leaft for a time) fuch future appearances as 
might furnifh indications for a furgeon’s 
condudh 

They who advife the prefervation of the 
feparated * fcalp, do it upon a fuppofition, 
that it will in general unite again ; that if 
it does, the patient may thereby be fpared 
a great deal of pain ; fave much time, and 
fuftain much lefs deformity : that with 
regard to the immediate enquiry into the 
Hate of thp cranium, it may be made be¬ 
fore’the fcalp is replaced : that if there be 

no 

* I prefume I need not obferve, that when I fay fepa- 
rated , 1 mean only with regard to the inferior fur face of 
fuch piece, and that it is ftill contiguous with fome $art 
of the fkin. 


i 


( 6 > 

no prefent fymptoms which indicate injury 
done to the parts underneath, it would be 
abfurd to aft merely upon the prefumption, 
that there may be fome in future : that it 
will be more proper and vindicable, to do 
what is right at firft; or according to the 
prefent circumftance, and to attend to what 
may happen or occur hereafter, when fuch 
occurrences have happened : and that the 
formation of matter, and floughs, under the 
detached and replaced portion, will not, in 
general, under proper management, prevent 
its reunion. 

It is to be prefumed, that every prafli- 
tioner wifhes to cure his patients as foon as 
he can ; by the leaf! painful means, and in 
fuch manner as fhall be produftive of the 
leaft poffible deformity or defeft ; taking 
care at the fame time, not to be inattentive 
to any evil, which may arife ; nor to omit, 
or negleft doing whatever may be neceffary 
during fuch cure. 

Upon this principle, I make no fcruple of 
declaring it as my opinion, that the prefer- 
vation of the fcalp ought always to be at¬ 
tempted, unlefs it be fo torn as to be abfo- 
lately fpoiled, or there are manifeft prefent 
fymptoms of other mifchief. • This kind of 
, wound 


C 7 ) 

wound is fometimes very terrible to look 
at; and they who have not been accuftomed 
to fee it, may be inclined to think there is 
no remedy but excifion; but I have fo often 
made the experiment of endeavouring to 
preferve the torn piece, and have fo often 
fucceeded, that I would recommend it as a 
thing always to be attempted, even tho’ a 
part of the cranium fhould be perfectly 
bare, unlefs the two circumftances already 
mentioned render it improper or impracti¬ 
cable. The removal of it neceflarily produces 
a larger fore, which mu ft require a good 
deal of time to heal, and muft leave a con- 
fiderable deformity ; the prefervation of it 
prevents both. 

Therefore when fuch cafe occurs, let the 
furgeon be particularly careful to examine, 
whether there are any appearances, orfymp- 
toms, of any other kind of mifchief befide 
what the fcalp has fuftained; and if there 
be neither, let him make the torn piece 
clean from all dirt, or foreign bodies; and 
reftore it as quickly and as perfectly as he 
can to its natural Situation. 

The manner in which it is to be there 
maintained, muft a good deal depend upon 
the particular circumftances of each indivi- 

B 4 dual 


( 8 ) 

dual cafe, and therefore muft be left to the 
furgeon, who will make ufe of plafter, 
bandage, and future, together or feparate-^ 
ly, as he (hall find them mod convenient, 
and beft fitted to the purpofe. 

I am aware that the vefy mention of a 
future in a wound of the fcalp, particularly 
a lacerated one, will ftartle fome of my 
readers, who have been taught that it is 
always wrong in both : I know that this is 
the general dodtrine ; but I know alfo, that 
although it be fometimes true, yet if it be 
implicitly adhered to, it will prevent a prac-^ 
titioner now and then from receiving a very 
ufeful affiftance. A flitch, made with a 
flip-knot, will fometimes, hold the divided 
parts in fuch fituation, as will greatly ex¬ 
pedite a cure : in many cafes a very fhort 
time will anfwer the end, and the thread 
may be removed as foon as ever the purpofe 
is accomplished, or the future becomes ei¬ 
ther improper or ufelefs. 

In fome cafes, this will be all that is re¬ 
quired ; the loofened fcalp will unite with 
the parts from which it was torn and fepa- 
rated, and there will be no other fore, 
than what arifes from the impracticability 
of bringing the lips of the wound into 

fmooth 


/ 


ftnooth and immediate contact ; the fear of 
which fore muft be fmall in proportion. 

On the other hand, it fometimes happens 
that fuch perfe<ft re-union is not to be ob¬ 
tained ; in which cafe matter will be form¬ 
ed and collected in thofe places, where the 
parts do not coalefce j but this does not ne- 
ceflarily make any difference, either in the 
general intention, or in the event j this 
matter may eafily be difeharged, by one or 
two fmall openings made with a lancet; 
the head will ftill preferve its natural cover¬ 
ing ; and the cure will be very little retard¬ 
ed by a few fmall abfeeffes. 

I muft defire not to be mifunderftood: I 
do not mean to fay, that it muft be always, 
and invariably right, to return the loofened 
fcalp, and to endeavour to procure its im¬ 
mediate re-union; or that fuch attempt will 
always fucceed : I only mean to fignify, 
that it is my opinipn, (and that founded on 
experience) that the mere fep^ration or de¬ 
tachment of the fcalp, to however large an 
extent, is not a good, and fufficient reafon, 
for cutting off any part of it in cafes where 
no other mifehief feems to have been done, 
in which the cranium is uninjured, and the 
parts within it unhurt; and, that the at¬ 
tempt 


( IO ) 

tempt to procure a re-union with the parts 
from which it was feparated, tho’ it will 
fometimes fail, yet will mod frequently 
fucceed; and is always worth making ; as 
fuch experiment properly made, can never 
be attended with any real inconveniences. 

In fome cafes, the whole feparated piece, 
will (as I have faid before) unite perfedly, 
and give little or no trouble ; efpecially 
in young, and healthy perfons; in fome, 
the union will take place in fome parts, 
and not in others; and confequently mat¬ 
ter will be formed, and require to be dis¬ 
charged, perhaps at feveral different points; 
and in fome particular cafes, circumflances, 
and habits, there will be no union at all: 
the torn cellular membrane, or the naked 
aponeurofis, will inflame, and become 
lloughy ; a conliderable quantity of matter 
will be collected, and perhaps the cranium 
will be denuded : but even in this ftate of 
things, which does not very often happen, 
where proper care has been taken, and is 
almoft the worft which can happen in the 
cafe of mere, Ample laceration, and de¬ 
tachment, I fay, even in this, if the fur- 
geon will not be too foon, nor too much 
alarmed, nor in a hurry to cut, he will of¬ 
ten 


( “ ) 

ten find the cure much more feafible than 
he may at firft imagine : let him take care 
to keep the inflammation under by proper 
means; let him have patience till the mat¬ 
ter is fairly and fully formed, and the 
Houghs perfectly feparated ; and when this 
is accompliftied, let him make a proper 
number of dependant openings for the difi- 
charge of them ; and let him by bandage, 
and other proper management, keep the parts 
in conflant contact with each other; and he 
will often find, that although he was foiled 
in his firft intention of procuring immedi¬ 
ate union, yet he will frequently fucceed in 
this his fecond; he will ftill fave the fcalp> 
fhorten the cure, and prevent the great de¬ 
formity arifing, (particularly to, women) not 
not only from the fear, but from the total 
lofs of hair. 

I have faid, that this union may often be 
procured, even tho’ the cranium Ihould 
have been perfectly denuded by the acci¬ 
dent ; and it is true; not only tho’ it fhould 
have been ftript of its pericranium at firft; 
but even if that pericranium fhould have 
become floughy and caft off, as I have often 
feen. 


Exfo- 


( 12 ) 

Exfoliation from a cranium laid bare by 
external violence, and to which no other 
injury has been done than merely Gripping 
it of its covering, is a circumftanee which 
would not fo often happen, if it was not 
taken for granted, and the bone treated ac¬ 
cording to fuch expectation; the foft open 
texture of the bones of children and young 
people, will frequently furniffi an incarna¬ 
tion, which will cover their furface, and 
render exfoliation quite unneceffary ; and 
even in thofe of mature age, and in whom 
the bones are ftill harder, exfoliation, is 
full as often the effedt of art, as the inten¬ 
tion of nature, and produced by a method 
of dreffing, calculated to accomplish fuch 
end, under a fuppofition of its being necef- 
fary. Sometimes indeed it happens, that a 
fmall fcale will neceffarily feparate, and the 
fore cannot be perfe&ly healed till fuch re¬ 
paration has been made; but this kind of 
exfoliation will be very fmall, and thin in 
proportion to that produced by art $ that i$y 
that produced by dreffing the furface of the 
bare bone with fpirituous tindures, &c : and 
when a woundon the head, with a found unin¬ 
jured bone, denuded by the accident, fhews 
a difpofition to heal without exfoliation ; it 

never 


( *3 ) 

never can be right to counteract nature, and 
oblige her to do that (he is not inclined to, 
and which (he would accompli(h her pur- 
pofe better without doing. 

If the fcalp be detached by fuch means, 
or with fuch force of inftrument, that the 
fkull, or parts within it have fuffered, then 
the immediate union of the (kin, becomes 
impracticable, and it would be highly in¬ 
judicious to attempt it ; our attention then 
muft be paid to the greater evilj it then be¬ 
comes another kind of cafe, and all that 
need be faid of it in this place, is, that al¬ 
though fuch mifchief does generally require 
the removal of fome part, yet even in this 
lituation, no more of it (hould be cut off 
than what will be neceflary for the detec¬ 
tion and proper treatment of fuch mifchief. 
In (hort, whether confidered as (kin, or as 
the feat of the hair, it ought never to be 
removed wantonly, or without abfolute ne- 
ceffity. 

Small wounds, that is, fuch as are made 
by inftruments, or bodies, which pierce, or 
pundture, rather than cut, are in general 
more apt to become inflamed, and to give 
trouble, than thofe which are larger; and < 
in this part particularly, are fometimes at- 
4 tended 


( 14 ) 

tended with fo high inflammation, and with 
fuch fymptoms, as alarm both patient and 
furgeon. 

The parts capable of being hurt by fuch 
kind of wound, are the fkin, the tela cel- 
lulofa, the expanded tendons of the mufcles 
of the fcalp, and the pericranium. . 

If the wound affeds the cellular mem¬ 
brane only, and has not reached the apo- 
neurofis or pericranium, the inflammation, 
and tumor, affed the whole head, and 
face; the Ikin of which wears a yellowifh 
caft, and is fometimes thick fet with fmall 
bliders, containing the fame coloured fe- 
rum; it receives the impreffion of the ima¬ 
gers, and becomes pale for a moment, but 
returns immediately to its inflamed colour ; 
it is not very painful to the touch ; and the 
eye-lids and ears are always comprehended 
in the tumefadion, the former of which 
are fometimes fo didended* as to be clofed; 
a feverifh heat, and third generally accom¬ 
pany it ; the patient is redlefs, has a quick 
pulfe, and mod commonly a naufea, and 
inclination to vomit. 

This accident generally happens to perfons 
of bilious habit, and is indeed an inflamma¬ 
tion of the eryfipelatous kind; it is fomewhat 

alarming 


( i5 ) 

alarming to look at, but is not often at¬ 
tended with danger. The wound does in¬ 
deed neither look well, nor yield a kindly 
difcharge, while the fever continues, but 
ftill it has nothing threatening in its appear¬ 
ance; none of that look which befpeaks 
internal mifchief; the fcalp continues to ad¬ 
here firmly to the fkull; and the patient 
does not complain of that tenfive pain, nor 
is afflided with that fatiguing reftleffnefs 
which generally attends mifchief under¬ 
neath the cranium. 

Phlebotomy, lenient purges, and the ufe 
of the common febrifuge medicines, parti¬ 
cularly thofe of the neutral kind, generally 
remove it in a fhort time. When the inflam¬ 
mation is gone off, it leaves on the fkin a 
yellowifh tint, and a dry fcurf, which con¬ 
tinue until perfpiration carries them away; 
and upon the difappearance of the difeafe, the 
wound immediately recovers a healthy af- 
ped, and foon heals without any farther 
trouble. t .. 

Wounds and contufionsof the head, which 
affed the brain and its membranes, are alfo 
fubjed to an eryfipelatous kind of fwelling 
and inflammation; but it is very different, both 
in its charader and confequences from the 
preceding. 

In 


( 16 ) 

In tliis (which is one of the effedts of irf* 
fiammation of the meninges) the febrile 
fymptoms are much higher ; the pulfe hard¬ 
er and more frequent; the anxiety and reft- 
leflhefs, extremely fatiguing, the pain in 
the head intenfe ; and as this kind of ap¬ 
pearance is, in thefe circumftances, mod 
frequently the immediate precurfor of mat¬ 
ter forming between the Ikull and dura 
mater, it is generally attended with irregu¬ 
lar fhiverings, which are not followed by a 
critical fweat, nor afford any relief to the 
patient. To which it may be added, that 
in the former cafe the eryfipelas generally 
appears within the firft three or four days; 
whereas in the latter, it feldom comes on 
till feveral days after the accident; when 
the fymptomatic fever is got to fome 
height. In the Ample eryfipelas, al¬ 
though the wound be crude, and undigef- 
ted, yet it has no other mark of mifchief; 
the pericranium adheres firmly to the fkull, 
and upon the ceflation of the fever, all ap¬ 
pearances become immediately favourable. 
In that "which accompanies injury done to 
the parts underneath, the wound not only 
has a fpongy, glafly, unhealthy afpeft, but 
the pericranium in its neighbourhood, fe- 

paratcs 


. ( M ) 

parates fpontaneoufly from the bone, and 
and quits all cohefion with it. In fhort, 
one is an accident, proceeding from a bili¬ 
ous habit* and not indicating any mifchief 
beyond itfelf * the other is a fymptom, or a 
part, of a difeafe, which is occafioned by 
injury done to the membranes of the brain* 
one portends little or no ill to the patient, 
and almoft always ends well * the other 
implies great hazard, and moft commonly 
ends fatally. It is therefore hardly neceffary 
to fay, that it behoves every practitioner 
to be careful* in diftinguifhing them from 
each other* 


If the wotind be a fmall one, and has 
paffed thro’ the tela cellulofa, to the apo- 
rieurofis, and pericranium, it is fbmetimes 
attended with very difagreeable, and even 
Very alarming fymptoms * but which, arife 
from a different caufe, and are very diftin- 
guifhable from what has been yet men¬ 
tioned* 

In this, the inflamed fcalp does not rife 
into that degree of tumefaction, as in the 
eryfipelas ; neither does it pit, or retain the 
impreflion of the fingers of an examiner* 
it is of a deep red colour, unmixt with the 

C v yellow 




( i8 ) 

yellow tint of the eryfipelas •> it appears 
tenfe, and is extremely painful to the touch $ 
as it is not an affection of the tela cellulofa, 
and as the ears and the eye-lids are not 
covered by the parts in which the wound is 
infli&ed, they are feldom, if ever, compre¬ 
hended in the tumor, though they may 
partake of the general inflammation of the 
fkin : it is generally attended with acute 
pain in the head, and fuch a degree of fever 
as prevents fleep, and fometimes brings on 
a delirium* 

A patient in thefe circumftances, will ad¬ 
mit more free evacuations by phlebotomy, 
than one labouring under an eryfipelas : the 
ufe of warm fomentation is required in 
both, in order to keep the flcin clean and 
perfpirable $ but an emollient cataplafm, 
which is generally forbid in the former, 
may in this latter cafe be ufed to great ad¬ 
vantage. 

When the fymptoms are not very pref- 
fing, nor the habit very inflammable, this 
method will prove fufficient ; but it fome¬ 
times happens, that the fcalp is fo tenfe, 
the pain fo great, and the fymptomatic fe¬ 
ver fo high, that by waiting for the flow 
effeft of fuch means, the patient runs a 

rifque 


( i9 ) 

- * i 

Hique from the continuance of the fever ; 
or elfe the injured aponeurofis, and peri¬ 
cranium becoming floughy, produce an 
abfcefs, and render the cafe both tedious 
and troublefome. A divifion of the 
wounded part, by a fimple incifion down 
to the bone, about half an inch or an 
inch in length, will moft commonly re¬ 
move all the bad fymptoms; and, if it be 
done in time, will render every thing elfe 
unnecessary. 

_____V,,- --- ■ 

The injuries to which the fcalp is liable 
from contufion, or the appearances pro¬ 
duced in it by fiich general caufe, may for 
method-fake be divided into two clafles, 
viz. thofe in which the mifchief is confined 
merely to the fcalp ; and thofe in which 
other parts are interefled. 

The former, which only comes under our 
prefent confideration* is not indeed of 
importance, confidered abftradtedly. The 
tumour attending it is either very eafily 
difiipated, or the extravafated blood caufing 
it, is eafily got rid of by a fmall opening. 
I fhould not therefore have thought it of 
fuch confequence, as to be worth mention¬ 
ing in this place, had it not been for an ac- 

C 2 cidenta! 



' ( 20 ) 

cidental circumftance, which fometimes at¬ 
tends it, and renders it liable to be very 
much miftaken. 

When the fcalp receives a very fmart 
blow, it often happens that a quantity of 
extravafated blood immediately forms a 
tumor, eafily diftinguifhable from all others, 
and generally very eafily cured. But it alfo 
fometimes happens, that this kind of tu¬ 
mor produces, to the fingers of an unadvifed 
or inattentive examiner, a fenfation, fo like 
to that of a fradlure, with depreffion of the 
cranium, as may be eafily miftaken. Now, 
if, upon fuch fuppofition, a furgeon imme¬ 
diately removes the tumid fcalp, he may 
give his patient a great deal of unneceflary 
pain, and for that reafon run fome rifque 
of his own character. 

The touch is, in this cafe, fo liable to 
deception, that recourfe fhould always be 
had to other circumftances and fymptoms, 
before an opinion be given. 

* If a perfon, with fuch tumor occafioned 
by a blow, and attended with fuch appear¬ 
ances, and feel, has any complaint, w T hich 
feems to be the effedl of preffure made on 
the brain and nerves; or of any mifchief 
done to the parts within the cranium ; the 

’ + divifion* 


4 


( 21 ) 

V - 

divifion, or removal of the fcalp in order to 
inquire into the date of the fkull, is right 
and neceffary : but if there are no fuch ge¬ 
neral fymptoms, and the patient is in every 
refped perfectly well, the mere feel of 
fomething like a fradure, will not autho¬ 
rize, or vindicate fuch operation, fince it 
will often be found, that fuch fenfation is a 
deception; and that when the extravafated 
fluid is removed, or diffipated, the cranium 
is perfedly found and uninjured. 

The fecond kind of tumor attending the 
contufed fcalp, viz. that which arifes from 
injury done to the cranium, and parts with¬ 
in, does fo abfolutely proceed from, and 
depend upon fuch injury, as not to fall un¬ 
der our confideration in this place at all, 
but will be confidered at large, when we 
come to fpeak of the mifchiefs done to the 
fkull and brain by collifion, or contu- 

fion. - 

From what has been faid it appears, that 
the fcalp, taken in a general fenfe, is, when 
wounded or bruifed, liable to be affeded 
with four kinds of tumor) each of which 
has a diftind caufe, and requires, or permits, 
a different method of treatment. 

c 3 


The 


y 


( 2 2 ) 

The firfl: does not imply any injury done 
to the parts within the fkull ; requires no 
operation; and almofl always is cured by 
general remedies. 

The fecond, or that which is caufed 
by the fpontaneous reparation of the peri¬ 
cranium from the fkull, in confequence of 
internal mifchief, is not at firfl: attended 
with very prefling fymptoms; but whoever 
has obferved their progrefs, and attended 
to their event, mufl: know what fatal, and 
frequently irrefiftible evil, it is the fore¬ 
runner of: nothing lefs than the inflamma¬ 
tion, and putrefadtion of the membranes of 
the brain, and the formation of matter 
between them and the fkull ; and that it is 
a cafe which, of all others, will leafl ad¬ 
mit delay. 

The third, though it fometimes gives 
way to free evacuation, and lenient exter- 
nal applications, yet is fometimes alfo at¬ 
tended with fymptoms, which are too prefi¬ 
xing to wait the effedt of fuch remedies, 
and is capable of being immediately re¬ 
lieved by a divifion of the inflamed and ir¬ 
ritated parts ; whereas the fame incifion, 
made into the firfl kind of tumefadlion, 

woul4 


J 


( 23 ) 

would mod probably exafperate the difeafe, 
and heighten the fymptoms. 

The fourth, confiding of extravafated 
blood, feldom requires any chirurgic ope¬ 
ration f time, and the ufe of the common 
difcutient applications *, almod always dif- 
fipate it ; and it only becomes of confe- 
quence, by the poffibility of its being mif- 
underdood and midreated. 

* Among which I know of none equal to a folution 
Gf crude fal amraon, in vinegar and water, or fpt, 
vin. 


C 4 SECT. 

\ . . 



( 24 ) 


SECT, XL 

Effects of contufion , on the dura mater , and 
farts within theJkulL 


I N order to underhand rightly, and have 
a clear idea of this kind of injury, it is 
neceffary to recolledt, that the veffels of 
the pericranium, thofe of the diploe, or 
medullary fubflance between the two ta¬ 
bles of fome parts of the cranium, and 
thofe of the dura mater within it, do all* 
conftantly, and freely communicate with 
each other ; and that this communica¬ 
tion is carried on, by means of innume¬ 
rable foramina, found, in all parts, of both 
furfaces of the fkull, as well as at the fu¬ 
tures ; that upon the freedom of this com¬ 
munication, depends, the healthy, and found, 
date of all the parts concerned in it ; and, 
that from the interruption, or deftruftion, 
of this, proceed mod of the fymptoms attend¬ 
ing violent contufions of the head, extravafa- 
tions of fluid, between the cranium and 
dura mater, inflammations of the faid mem¬ 
brane. 



( 25 ) 

brane, and Ample undeprefTed fradlures of 
the ikull. 

The pericranium is fo firmly attached to the 
outer furface of the fkull, as not to be fepara- 
ble from it without confiderable violence; and 
when fuch violent feparation is made, in a liv^ 
ing fubjeCt (efpecially if young) the cranium is 
always feen to bleed freely, from an infinite 
number of finall foramina. The dura mater, 
which is a firm ftrong membrane, is almoft 
as intimately attached to the infide of the 
fkull, as the pericranium is to the outfide, 
and by the fame means, viz. by vefiels ; 
and bv thefe means a conftant circulation, 
and communication are preferved, and main-*- 
tained, between the two membranes; and 
the bones dividing them. This, all the 
appearances, which attend the fcalping a 
living perfon, or the feparation of the 
fkull from the dura mater of a dead one, 
(efpecially if fuch perfon died apoplectic, 
or was hanged) prove beyond all doubt: in 
the former, the blood, will, (as I have al-* 
ready obferved) be feen ifluing from every 
point of the furface of the cranium; in 
the latter, not only a confiderable degree of 
force will be found necefiary to detach the 
fawed bone from the fubjacent membrane, 

but. 


( 26 ) 

but, when it is removed, a great number of 
bloody points will be feen all over the fur- 
face of the latter ; which points, if wiped 
clean, do immediately become bloody a- 
gain ; being only the extremities of broken 
veflels. Thefe veffels are largeft at, and 
about the futures; at which places the ad- 
hefion is the ftrongeft, and the haemor¬ 
rhage upon feparation the greateft. 

It has been thought by many, that the 
dura mater was attached to the Ikull, only 
at the futures; that in all other parts it 
was loofe, and unconneded with it;. and, 
that it conftantly enjoyed or performed an 
ofcillatory kind of motion ; or was alter¬ 
nately elevated and deprelfed, This idea, 
and opinion, were borrowed from the ap¬ 
pearance which the dura mater makes in a 
living fubjed, after a portion of the lkull 
has been removed : but although it has 
been inculcated by writers of great emi¬ 
nence, yet it has no foundation in truth or 
nature ; and has milled many praditioners, 
in their opinions, not only of the ftrudure 
and difpolition of this membrane, but in 
their ideas of its difeafes. 

The dura mater does on the internal fur- 
face of the bones of the cranium, the of¬ 
fice 


( 2 7 ) ' 

lice of periofteum, in the fame manner as 
the pericranium does on the external; (at 
lead: they have no other :) to this it is fo 
firmly, and fo generally attached, as to be 
incapable of any, even the fmalleft degree 
of motion. The alternate elevation, and 
fubfidence of it, which are obfervable, when 
any portion of it is laid bare, are owing to 
a very different caufe from any power 
in itfelf; neither is, nor can ever be per¬ 
formed, until a piece of the cranium has 
been forcibly taken away ; and confequent- 
ly cannot poffibly be natural, or neceffary. 

By blows, falls, and other fhocks, fome 
of the larger of thofe veffels which carry 
on this communication between the dura 
mater and the fkull, are broken, and a 
quantity of blood is died upon the furface 
of that membrane. This is one fpecies of 
bloody extravafation ; and indeed the only 
one which can be formed between the fkull 
and dura mater. If the broken veffels be 
few, and the quantity of blood which is 
filed be fmall, the fymptoms are generally 
flight, and by proper treatment difappear 
. — ' ■ \ ' * If 

* This muft be fuppofed to be fpoken in a general 
fenfe 3 becaufe it is well known, that fometimes a very 

fmall 


( 23 ) 

/ " 

If they are large, or numerous, or the 
quantity of extravafated fluid confiderable, 
the fymptoms are generally urgent in pro¬ 
portion : but whether they be flight, or 
conflderable; whether immediately alarm¬ 
ing or not; they are always, and uniformly, 
fuch as indicate preffure made on the brain 
and nerves, viz. ftupidity, drowfinefs, dimi¬ 
nution, or lofs of fenfe, fpeech, and voluntary 
motion. 

This every practitioner knows to be one 
frequent confequence of blows on the head. 
But it alfo often happens, from the fame 
kind of violence, that fome of the fmall 
veflels which carry on the circulation be¬ 
tween the pericranium, fkull, and dura 

i i 

mater, are fo damaged, as not to be able, 
properly to execute that office, although 
there are none fo broken, as to caufe an 
aCtual effuffon of blood. 

Smart, and fevere ftrokes, on the middle 
part of the bones, at a diftance from the 
futures, are moil frequently followed by 
this kind of mifchief: the coats of the 
fmall veflels, which fuftain the injury in¬ 
flame, 

fmall quantity of extravafated fluid, will produce the 
moft alarming and moft preffing fymptoms; and that at 
other times a large quantity will occauon none at all. 


( 29 ) 

flame, and become floughy, and in con- 
fequence of fuch alteration in them, the 
pericranium feparates from the outfide of 
that part of the bone which received the 
blow, and the dura mater from the 
infide ; the latter of which membranes, 
foon after fuch inflammation, becomes 
floughy alfo, and furniflies matter ; which 
matter being colle&ed between the faid 
membrane and the cranium, and having no 
natural outlet, wdiereby to efcape, or be 
difeharged, brings on a train of very terri¬ 
ble fymptoms, and is a very frequent caufe 
of deftrudtion The effedl of this kind 
of violence is frequently confined to the 
veflels conne&ing the dura mater to the 
cranium ; in which cafe the matter is ex¬ 
ternal to the faid membrane ; but it fome- 
times happens, that by the force either of 
the flroke or of the concufiion, the veflels 

which 

* Comment le pericrane a-t-il pu ainfi fe detacher de 
l’os dans le circonference du coup ? ne feroit ce point par 
1’ebranlement ou le tremoufiement de toutes les parties 
integrantes du crane. Si e’eft en confequence d’un tre- 
mouflement pareil que nombre de filets qui attachent le 
pericrane au crane fe font detaches, par la meme raifon, 
plufieurs des filets qui attachent la dure mere au 
crane ont du fe rompre aufli: d’ou s’en eft fuivi un eryfi- 
pele, qu’occafion fuppuration, ou plutot pourriture. Le 
Dra,n. 


J 


( 30 ) 

which pafs between, and conned the two 
meninges, are injured in the fame manner 5 
in which cafe the matter formed in confe- 
quence of fuch violence, is found on the 
furface of the brain, or between the pia 
and dura mater, as well as on the furface of 
the latter ; or perhaps in all thefe three 
fituations at the fame time. 

The difference of this kind of difeafe, 
from either an exiravafation of blood, or a 
commotion of the medullary parts of the 
brain, is great and obvious. All the com¬ 
plaints produced by extravafation, are, (as 
I have already faid) fuch as proceed from 
preffure, made on the brain and nerves, 
and obflrudion to the circulation of the 
blood through the former : flupidity, lois 
of fenfe and voluntary motion, laborious and 
obftruded pulfe, and refpiration, &c. and, 
(which is of importance to remark,) if the 
effufion be at all confiderable, thefe fymp- 
toms appear immediately, or very foon af¬ 
ter the accident. 

The fymptoms attending an inflamed, of 
floughy, ftate of the membranes, in confe- 
quence of external violence * are very diffe¬ 
rent* 

* The difference between thefe two effe&s of external 

1 

violence. 


(• 3i ) 

rent. They are all of the febrile kind ; and 
never, at firft, imply any unnatural pref- 
fure : fuch are, pain in the head, reftlefs- 
nefs, want of fleep, frequent and hard 
pulfe, hot and dry Ikin, flulhed counte¬ 
nance, inflamed eyes, naufea, vomiting, ri¬ 
gor y and toward the end convulfion, and 
delirium. And none of thefe appear at firfl:; 
that is, immediately after the accident; 
feldom until fome days are pad 

' . One 

v 

violence, was very well underftood by Berengarius Car- 
penfis, a moft excellent writer on this fubjeft, who fays, 
44 Interdum etiam acontufione non rumpitur aliqua vena, 
44 fed rumpuntur ligamenta ilia durae matris ; a quibus 
44 refudat aliquid : hifce vero nifi fuccuratur, accidunt 
44 feva accidentia, & mors.’’ 

Paulus iEgineta has alfo very particularly diftinguifhed 
between that degree of contufion, which affedts only the 
outer table of the fkull, and that which injures the dura 
mater. 44 Porro contufionis hujus dure exiftunt differen- 
44 tiae : vel enim calva per totam ipfius craffitiem contun- 
44 ditur ; ut frequenter etiam cerebri membrana abfceffii 
44 occupetur, vel, &c.” 

* tC Nulla autem harum contunonum afpedlu dignofci 
44 poteft j qualis nempe, quantave fit. Non protinus 
44 ab idtu malum fe videndum praebet. 35 Hippocrates. 

46 Sed accidentia quae fequuntur ad praedidtam contufi- 
44 onem, inter commijfuras , non funt per contufionem 
44 tantum; fed funt per putrefattionem panniculi lesji > et cum 
44 venit ad certam quantitatem determinatam incipit fe- 
44 bris, et alia accidentia : & tandem fequitur mors, nifi 
44 cito fuccuratur.” 

Jacobus Berengarius Carpensis. 


I 


( 3 2 3 

One fet or clafs of fymptoms are pro* 
duced by an extravafated fluid, making 
fuch preffure on the brain, and origin of 
the nerves, as to impair or abolifh volun- 
tary motion and the fenfes; the other is 
caufed by the inflamed, or putrid ftate of 
the membranes covering the brain ; and fel- 
dom affedts the organs of fenfe, until the lat¬ 
ter end of the difeafe; that is, until a confi- 
derable quantity Gf matter is formed, which 
matter mu ft prefs like any other fluid. 

I am very fenfible that it is a generally re¬ 
ceived opinion, that blood fhed from its vef- 
fels, and remaining confined in one place, 
will become pus; and that the matter found 
on the furface of the dura mater, toward 
the end of thefe cafes, was originally ex¬ 
travafated blood. But I apprehend both 
thefe pofitions to be falfe. That pure blood, 
fhed from its veflels, by means of external 
violence, and kept from the air; will not 
turn to, or become matter, is (I think) 
proved inconteftibly, by every day's expe¬ 
rience, in many iilftances ; in aneurifms by 
pundture; in retained menfes, by imperfo¬ 
rate vaginae; and in all ecchymofes. True 
pus cannot be made from blood merely; 
as may be known from the manner in 

which 


( $3 ) 

Which all abfcefles are formed* and front 

* 0 

every circumftance attending fuppuration; 
and that the matter, found on the furface 
of the dura mater, after great contufions of 
the head, never was mere blood* I am as 
certain, as obfervation, and experience cart 
make me. 

Some of the French writers have indeed 
divided the fvmptoms of what they call a 
eontufioriof the head, into two kinds \ and 
have named them primitive or original 
fymptoms; and fecondary or confequential 
ones ; arriohg the former, they rank im¬ 
mediate lofs of fenfe, haemorrhage* invo¬ 
luntary difcharge of urine and feces, great 
propenfity to fleep, &C. among the latter 
they reckon fever, delirium* rigor* convul- 
fion* &c. One kind they impute to the 
mere extravafatioii of blood, the other to its 
putrefaction. 

This account, though ingenious and fpe- 
cious* is not founded on fa£t. It is true, 
that the two kinds of fymptoms are very 
diftindt from each other, as well in their 
nature, as in their time and manner of ac- 
Cefs } and fo far the remark is true : but 
from all the obfervation and examination* 
which I have been able to make, both on 

D the 


( 34 ) 

the living and on the dead, they appear t© 
me to proceed from very different caufes. 
That both thefe kinds of fymptoms do now 
and then concur in the fame patient, is be¬ 
yond all doubtand that the cafe is there¬ 
by rendered complex, and more difficult to 
be judged of; but this does not conftantly 
happen; and even when it does, I cannot 
help thinking, that there are generally fuch 
diftinguifhing chara&eriftic marks of each, 

, as may prove the truth of what I have af- 
ferted. 

In order to explain my meaning as clearly 
as I can, I will confder the inflammatory 
effedt of contuflon by itfelf, and indepen¬ 
dent of every other complaint, or injury 
which may accidentally be joined with it. 

If there be neither nffure nor fradture of 
the Ikull,'nor extravafation, nor commo¬ 
tion underneath it, and the fcalp be neither 
conflderably bruifed, nor wounded, the 
mifchief is feldom difcovered, or attended 
to for fome few days. The firfh attack is, 
generally, by pain in the part which re¬ 
ceived the blow. This pain, though be¬ 
ginning in that point, is foon extended all 
over the head, and is attended with a lan¬ 
guor, or dejedtion of ftrength and ipirits, 

which 


( 35 ) 

which are Toon followed by a naufea, and 
inclination to vomit, a vertigo or giddi- 
nefs, a quick and hard pulfe, and an inca¬ 
pacity of fleeping, at leaft quietly. A day 
or two after this attack, if no means pre¬ 
ventative of inflammation are ufed, the part 
ftricken generally fwells, and becomes puf¬ 
fy, and tender, but not painful ; neither 
does the tumor rife to any confiderable 
height, or fpread to any great extent. If 
this tumid part of the fcalp be now di¬ 
vided, the pericranium will be found of a 
darkifh hue, and either quite detachedj or 
very eafily feparable from the fkull ; between 
which and it, will be found a fmall quan¬ 
tity of a dark-coloured ichor. 

If the diforder has made fuch progrefs, 
that the pericranium is quite feparated and 
detached from the Ikull, the latter will even 
now be found to be fomewhat altered in co¬ 
lour from a found, healthy bone. Of this 
alteration it is not very eafy to convey an 
idea by words ; but it is a very viiible one, 
and what fome very able writers have no¬ 
ticed 

From 

* Among thefe Fallopius particularly : <s Infpiciatia 
c< diligenter os dete£tum $ quod os, quando eft in natura 

D 2 “fua. 


i 3 6 ) 

From this time the fymptoms generally 
advance more haftily and more apparently,* 
the fever increafes, the fkin becomes hot¬ 
ter, the pulfe quicker and harder, the 
fleep more difturbed, the anxiety and reft- 
leffnefs more fatiguing, and to thefe are 
generally added irregular rigors, which are 
not followed by any critical fweat, and 
which inftead of relieving the patient, add 
considerably to his fufferings. If the fcalp 
has not been divided or removed* until the 
fymptoms are thus far advanced, the alte¬ 
ration of the colour of the bone will be 
found to be more remarkable 3 it will be 
found to be whiter* and more dry, than a 
healthy one, or, as Fallopius has very juft ly. 
obferved, it will be found to be more like 
a dead bone. The fanies* or fluid* be¬ 
tween it and the pericranium will alfo, in 
this ftate, be found to-be more in quantity, 

and 

fua, eft eoloris fubrubii, non candidr prorfus* nec ru- 
* s bri prorfus, fed eft veluti color miftus ex albo declinans- 
& ad rubicundum, ut ft multo ladle, aut alio colore cas- 
<c dido, poneres parum fanguinis vel alterius rei rubrae, 

Sed ft videritis insequalitatem eoloris in ipfo ofte detedlo, 
<c ita ut adftnt veluti puncla eoloris albi, et aridi offis, 
<c quae aridse particulre aliquando majores funt, aliquanda 
“ minores, &c. feiatis quod os fit contufucn.” 

- Fallopius. 


( 37 ) 

and the faid membrane will have a more 
livid, difeafed afpedt. 

In this flate of matters, if the dura ma* 
ter be denuded, it will be found to be de¬ 
tached from the infide of the cranium ; to 
have loft its bright filver hue, and to be, 
as it were, fmeared over with a kind of 
mucus, or with matter, but not with blood. 
Every hour after this period, all the fymp- 
toms are exafperated, and advance with 
hafty ft rides : the head-ach and thirft be¬ 
come more intenfe, the ftrength decreafes, 
the rigors are more frequent; and at laft 
convullive motions, attended in fome with 
delirium, in others with paralyfis, or coma- 
tofe ftupidity, finifh the tragedy *. 

If 

* The whole pr-ocefs of this very terrible difeafe is very 
accurately related, and very juftly accounted for, by Theo- 
doric. 

44 Si vero ob i&us vehementiam, dura mater a,b ofte 
44 fuerit feparata : vel aliquo modo laefa (fano Sc illaefo ex- 
44 rftente cranio) fie cognofces : cum dolor capitis, 5* 
44 lenta febris, fingulis diebus augmentantur, cculorum an- 
44 guli, ac fi fpafiijari vellcnt, diftorquentur ; genae ru- 
44 bent > (quod fignum pravum eft in qualibet capitis l?e- 
44 fione j) pannus balneatus fuperpofitus, citius deficca- 
<4 tur; cutis etiam arida & ficca ; Sc fi vulnus fuerit, Sz 
64 os difcoopertum, color oftis velocius altcraturj Si prop* 

D 3 * 4 ter 


( 3 § ) 

If the fcalp has not been divided, or re¬ 
moved 'till this point of time, and it be 
done now, a very offenfive difcoloured 
kind of fluid will be found lying on the 
• bare cranium, whofe appearance will be 
fill! more unlike to the healthy natu¬ 
ral one; if the bone be now perforated, 
matter will be found between it and the 
dura mater, generally in confiderable quan¬ 
tity, but different in different cafes and cir- 
cumflances. Sometimes it will be in great 
abundance, and diffufed over a very large 
part of the membrane ; and fometimes the 
quantity will be lefs, and confequently the 

fpace 

44 ter negligentiam curs, sgro fuperveniunt dolores, 5c 
44 febres, fpafmus, fyncope, 5c permiftio rationis.” 

Theodor, de vuln, capit. 
<c Qua vero fuper cerebri membranam fit, utraque ra- 
44 tione difiicilis eft : nam Isefis membranis apparet; ideo 
44 enim febris cum horrore, accedunt faciei rubor, 5c ca^- 
44 lor, longe major quam pro febris modo ; fomnique 
44 tumultuofi ; oculi fubpingues, 5c gramiofi 5c rubentes.” 

Archigenes de fanguine fubtercurrent. 
Petrus e Largelata, having very accurately related the 
fymptoms attending the formation of matter under the 
cranium when fractured, fays : 44 Si autem fradtura fit 
44 parva 5c penetrans, tunc fiunt ilia figna poft aliquod 
44 tempus ; eo quod tunc humidirates quae funt fub cra- 
64 nio putreftunt j 5c tunc fiunt ilia accidentia And 
then very juftly adds, 14 Secundo notes quod omnia ilia acci- 
44 dentia poflunt advenire ex percuftione capitis, cranio 
non fradW’ Pst. e Largesata. 


C 39 ) 

fpace which it occupies fmaller. Sometimes- 
it lies only on the exterior furface of the 
dura mater; and fometimes it is between it 
and the pia mater; or alfo even on the fur- 
face of the brain, or within the fubftance 
of it. 

The primary and original caufe of all 
this, is the ftroke upon the fkull; by this 
the veffels which ihould carry on the circu¬ 
lation between the fcalp, pericranium, fkull, 
and meninges, are injured; and no means 
being ufed to prevent the impending mif- 
chief, or fuch as have been made life' of 
proving ineffectual, the neceffary and mu¬ 
tual communication between ali thefe parts 
ceafes ; the pericranium is detached from 
the fkull, by means of a fanies difcharged 
from the ruptured veffels ; the bone being 
deprived of its due nourifhment and circu¬ 
lation, lofes its healthy appearance; the 
dura mater, (its attaching veffels being de- 
ilroyed, or rendered unfit for their office), 
feparates from the in fide of the cranium, 
inflames and fuppurates. 

Whoever will attend to the appearances 
which the parts concerned make in every 
ffage of the difeafe, to the nature of the 

fymptoms, the time of their accefs, theiT 

D 4 pro- 


\ 




. . C 4 °. ) 

progrefs, and moil frequent event, will find 
them all eafily and fairly deducible from 
the one caufe, which has juft been affigned, 
viz. the contufion, As the inflammation, 
and feparation of the dura mater, is not an 
immediate confequence of the violence, fo 
neither are the fymptoms immediate ; fel- 
dom until feme days have palled : the fever 
at firft is flight, but increafes gradually ; as 
the membrane becomes more and more 
difeafed, all the febrile fymptoms are 
heightened, the formation of matter occa*? 
fions rigors, frequent and irregular, until 
fuch a quantity is collected, as brings on 
delirium, fpafm, and death, . 

Hitherto I have considered this difeafe, 
as unaccompanied by any other, not even 
by any external mark of injury, except per¬ 
haps a trifling bruife of the fcalp ; let us 
now fuppofe the fcalp to be wounded at the 
time of the accident, by whatever gave the 
contufion: or let us fuppofe, that the im¬ 
mediate fymptoms having been alarming, a 
part of the fcalp had been removed, in or^ 
der to examine the fkull ; in Short, let the 
injury be considered as joined v/ith a wound¬ 
ed fcalp. 

In 


( 41 ) 

« . 

In this cafe, the wound will for fame 
little time have the fame appearance as a 
mere fimple wound of this par$, unattended 
with other mifchief, would have; it will, 
like that, at firft difcharge a thin fanies, 
or gleet, and then begin to fuppurate; it 
will digefl, begin to incarn, and look per- 
fe&ly well, But, after a few days, all 
thefe favourable appearances will vanifh ; 
the fore will lofe its florid complexion and 
granulated furface, will become pale, glaf- 
fy, and flabby ; inflead of good matter, it 
will difcharge only a thin difcoloured fa¬ 
nies ; the lint with which it is drefied, in¬ 
flead of coming off* eafily, (as in a kindly 
fuppurating fore) will flick to all parts of it; 
and the pericranium, inflead of adhering 
firmly to the bone, will feparate from it, 
all round, to fome diflance from the edges, * 

This 

* u Ubicunque autem ex vulnere intereundum fit, ne* 
que poffit homo fanitatem recipere, neque fervari, ex 
* 4 his intelligere convenit moriturum j et quod futurum 
“ eft prognofticare. Hyeme plerumque, ante diem quar- 
<c turn, sedate ppft feptimum, accedk febris; quse quum 
<c fupervenit, vulnus reddit non fut colon's Sc faniem mo- 
“ dicam effundit, quodque ex ipfo infiammatum eft emo- 
ritur, glutinofum efticitur & carnem fale conditam reprse- 
61 fentat. Hippocrates de vul. capit. Ulcus neque alitur 
& neque pus maturat, Sc fordid um fit.” Arc hi genes, 

2 


( 42 ) 

This alteration in the face and circum- 
fiances of the fore, is produced merely by 
the difeafed ,ftate of the parts underneath, 
the ikull ; which is a circumftance of 
great importance, in fupport of the dodtrine 
advanced ; and is demonftrably proved, by 
obferving, that this difeafed afpedt of the 
fore, and this ipontaneous feparation of 
the pericranium, are always confined to 
that part which covers the altered, or in¬ 
jured portion of the dura mater, and do 
not at all affedt the reft of the fcalp ; nay, 
if it has by accident been wounded in any. 
other part, or a portion has been removed 
from any part where no injury has been 
done to the dura mater ; no fuch feparation 
will happen, the detachment above will al¬ 
ways correfpond to that below, and be 
found no where elfe. 

The firft appearance of alteration in the 
wound immediately fucceeds the febrile at¬ 
tack; and as the febrile fymptoms increafe, 

the fore becomes worfe and worfe, that is 

. — * 

degenerates more and more from a healthy, 
kindly afpedt. 

Through the whole time, from the firft 

attack of the fever, to the laft and fatal 

* . • 

period, an attentive obferver will remark 

the 


( 43 ) 

the gradual alteration of the colour of the 
bone, if it be bare : at firft it will be found 
to be whiter, and more dry, than the natu¬ 
ral one; and as the fymptoms increafe % 
and either matter is collected, or the du¬ 
ra mater becomes lloughy, the bone in¬ 
clines more and more to a kind of purulent 
hue, or whitifh yellow ; and it may alfo be 
worth while in this place to remark, that 
if the blow was on or very near to a fu¬ 
ture, and the fubjedt young, the faid future 
will often feparate in fuch manner as to let 
through it a loofe, painful, ill-natured fun¬ 
gus ; at which time alfo it is no uncom¬ 
mon 

•t. i* '' ■ ' . , % 4 / i 

» 

* <c Tandem fubpallidum vel album fe oftendit; ubi 
« c autem, jam purulentum eft, aut puftulas in lingua 
nafcuntur, laborans mente non conftante confumitur.” 

Hippocrates de vuln. capitis, 
<c Quando fanies eft infra cranium, ipfo non fraSio era- 
“ nium eft male coloratum : aeger fentit gravedinem in 
ea parte, qua eft fanies.—Eft os fanum, id eft illud cui 

ct adhaeret dura mater, coloris albi, mifti rubedine.-Et 

“ quo feparatio eft major, eo major oftis quantitas eft mu* 
tata in colore.—Ultra vero colorem, cognofcitur etiani 
“ eo quod ficcius fit fano. —-Et ultra colorem, & ficcita- 
“ tern quando incipit ifta feparatio, incipiunt aliqua faeva 
accidentia ; & febris, mentis alienatio, ftupor, vigilae, 
6C &c. ®uia incipit fupra panniculum aggregari materia , 
qua incipit corrumpi 

Jacobus Berengaf.ius Carpensis. 


( 44 ) 

mon thing for the patient’s head and face 
to be attacked with an eryfipelas *. 

I have faid, that in thofe cafes, in 
which the fcalp is very little injured by the 
bruife, and in which there is no wound, 
nor any immediately alarming fymptoms, 
or appearances, that the patient feels little 
or no inconvenience; and feldom makes 
any complaint, until fome few days are part. 
That at the end of this uncertain time, he 
is generally attacked by the fymptoms al¬ 
ready recited. That thefe are not prefling 
at firft, but that they foon increafe to fuch 
a degree, as to baffle all our art ; from 
whence it will appear, that when this is 
the cafe, the patient frequently fuffers from 
what feems at firfl: to indicate his fafety, 
and prevents fuch attempts being made, 
and fuch care from being taken of them, 
as might prove preventative of mifehief. 

But if the integuments are fo injured 
as to excite or claim our early regard, 
very ufeful information may from thence be 
collected ; for whether the fcalp be confi- 
derably bruifed, or whether it be found 
neceflary to divide it, for the difeharge of 

extra- 

* (f Suturas tempore curationis disjungi grave eft.” 

Ax!CHICIN£S I>£ SiGNIS. 


( 45 ) 

extravafated blood; or on account of worfe 
appearances, or more urgent iymptoms, the 
ftate of the pericranium may be thereby 
fooner, and more certainly known : if in the 
place of fuch bruife, the pericranium be 
found fpontaneouily detached from the fkull; 
having a quantity of difcoloured fanies be¬ 
tween them, under the tumid part, in the 
manner I have already mentioned; it may be 
regarded as a pretty certain indication, ei¬ 
ther that the dura mater is beginning to le- 
parate in the fame manner; or that if fome 
preventative means be not immediately ufed* 
it will foon fuflfer > that is, it will inflame* 
feparate from the fkull, and give room for 
a colledion of matter between them. And 
with regard to the wound itfelf, whether if 
was made at the time of the accident, or 
afterward artiflcially, it is the fame thing j 
if the alteration of its appearance be as I 
have related, if the edges of it fpontane- 
oufly quit their, adhefion to the bone, and 
the febrile fymptoms are at the fame time 
making their attack, thefe circumftances 
will ferve to convey the fame information, 
and to prove the fame thing 



* <e Si dans une pi aye. contufe, ou le crane eft decou- 

\ - . , .. “ vert* 


( 46 ) 

This particular effect of contufion is fre* 
quently found to attend on fiffures,. and 
undepreffed fradtures of the crariium; as 
well as on extravafations of fluid, in cafes 
where the bone is intire : and* on the other 
hand, all thefe do often happen without 
the concurrence of this individual mifchief. 
All this is matter of accident but let the 
other circumftances be what they may, the 
Ipontaneous feparation of the altered peri-* 
cranium, in confequence of a fevere blow, 
is almoft always followed by a fuppuration 
between the cranium and dura mater, a 
circumftance extreamly well worth attend¬ 
ing to in fiflures and undepreffed fradtures 
of the fluill; becaufe, it is from this cir¬ 
cumftance principally, that the bad fymp- 
toms, and the hazard, in fuch cafes arife. 

It is no very uncommon thing for a fmart 
blow on the head to produce fome immedi¬ 
ate bad fymptoms ; which after a fhort 
fpace of time difappear, and leave the pa¬ 
tient perfectly well. A flight pain in the 

head, 

<c vert, on trouve a la circonference de la playe, que le pe- 
<c ricrane tienne peu a crane, ou en foit detache, c’eft une 
“ preuve certaine que le crane a fouffert quoiqu’il ne foit 
“ fra&ure ; & s’il a lbufFert, on peut etre afl'ure que la 
** dure mere a fouffert auffi.” Ljs Dran. 


( 47 ) 

head, a little acceleration of pulfe, a ver¬ 
tigo and ficknefs fometimes: immediately 

follow fuch accident, hut do not continue 
many hours ; efpecially, if any evacuation 
has been ufed. Thefe are not improbably 
owing to a flight commotion of the brain ; , 
which having fuffered no material injury 
thereby, foon ceafe. But if after , an interval 
of fome time, the fame lymptoms are re¬ 
newed ; if the patient, having been well, 
becomes again feverilh, and reftlefs, and 
that without any new caufe ; if he com¬ 
plains of being languid and uneafy, fleeps 
difturbedly, lofes his appetite, has a hot 
fkin, a hard quick pulfe, and a flulhed, heated 
countenance, and neither irregularity of 
diet, nor accidental cold, have been produc¬ 
tive of thefe, mifchief is mod certainly im¬ 
pending, and that moft probably under the 
fkull. 

If the lymptoms of preffure ; fuch as 
ftupidity, lofs of fenfe, voluntary motion, 
&c. appear fome few days after the head 
has fuffered injury from external mifchief, 
they do moft probably imply an effufion of 
a fluid fomewhere : this effufion may be in 
the fubftance of the brain, in its ventricles, 
between its membranes, or on the furface 

.... of 


( 48 ) 

of the dura mater t and which of thefe k 
the real filiation of fuch extravafation is a 
matter Of great uncertainty j none of them 
being attended with any peculiar mark, or 
£gn that can be depended upon, as point¬ 
ing it outprecifely : but the inflammation of 
the dura mater, and the formation of matter 
between it and the fkull, in confequence 
of contufion, is generally indicated and pre¬ 
ceded by one which 1 have hardly ever 
known to fail; I mean a puffy, cirCumfcri- 
bed, indolent tumor of the fcalp, and a 
fpontaneous reparation of the pericranium, 
from the fkull under fuch tumor *. 

* r. ■, ■%'. n 

Thefe appearances therefore following a 
fmart blow on the head, and attended with 
languor, pain, reftlefihefs, watching, quick 
pulfe, head-ach, and flight, irregular fhi* 
verings, do almoft infallibly indicate an in-* 

flamed 

* Lorfqu’ on trouve le pericrane detachd, il n’y a point 
a hefiter a faire le trepan. Je fcais que dans urt Cas pa- 
itil on n’auroit rien trouve d’epanche fous le crane, mai$ 
cependant l’operation faite de bonne heure auroit etc I’uni** 
que moyen de fauver le malade s’il etoit pofijble, &c. 

Si done plufieurs experiences nous apprennent que la 
dure mere devient malade en confequence die*la contufion 
de l’os, & que fa maladie degen ere en poumture, ce que' 
a jufqu’ici emporteplufieurs malades malgre de recours ufi* 
tes il faut abfokiment trepanner de bonne heure. 

Le Dr an. 


( 49 ) 

flamed dura mater, and pus, either forming 
or formed between it and the cranium 
By detachment of the pericranum, I do 
not mean every feparation of it from the 
bone which it fhould cover. It may be, 
and often is, cut, torn, or fcraped off, with¬ 
out any fuch cortfequence: but thefe fepa- 
rations are violent ; whereas, that which I 
mean is fpontaneous, and is produced by 
the deftruftion of thofe veifels, by which it 
was connected with the fkull, and by 
which the communication between it, and 
the internal parts was carried on ; and 
therefore it is to be obferved, that it is not 
the mere removal of that membrane which 
caufes the bad fymptoms, but it is the in¬ 
flammation of the dura mater ; of which 
inflammation, this fpontaneous feceffion of 

the 

* Si ftatim ab initio febris prime aut fecundo appareat 
die, ilia proculdubio caufam agnofeat perturbationem 
humorum, ae animi, quum vulnus incuteretur; cefiante 
caufa procatardlica ; ac ubi fe collegerit aeger, definat ilia 
febricula. Si vero primis diebus, nihil febrile, nec ul- 
lum fymptoma fentiat aeger, feque in nullo diferimine ex- 
iftimat, hunc fi fubito, die fcilicet feptimo, vel quarto 
decimo (nihil licet in vi&u, rebufve externis peccaverit 
aeger) ac praeter expe<5fationem febris invadat, fignificat 
latens aliquod, in cranio, cerebro, aut corpore vulnerati. 

Pet. Pa aw. in Hippocrat. 

E 


( 5 ° ) 

the pericranium is an almoft certain indica¬ 
tion. 

A falfe notion prevailed for many years, 
that the dura mater was not in general con¬ 
nected with the internal furface of the 
fkull, except at the futures ; and that in all 
other parts of it, fuch a vacancy was left, 
as gave free room for what they called its 
pulfatory motion This opinion, which 

was 

* If we confider how clearly and plainly many of the 
befl antient writers defcribe the intimate connexion be¬ 
tween the fkull and dura mater ; and how perfectly well 
acquainted many of them were with its morbid feparation; 
we fhall wonder how it came to be again forgot $ but that 
it was is moll certain. In Hippocrates, Paulus iEgineta, 
Rhazes, and others, are many paflages which prove their 
knowledge of the natural ftrudture and adhefion of this 
membrane ; and that fome of the moft eminent writers, 
and pradlitioners, had forgot, or did not attend to it, the 
following quotations, feledfed from many more, may 
evince. 

* c Dura mater calvariae connedlitur futurarum ope ut 
Cl penfile & eredfum teneat cerebrum ; turn etiam ut per 
futuras egrefla pericranium procreat: fpatium vero inter 
sc futuras redfe natura liberum reliquit ut vacuum quod- 
<c dam eflet inter duram matrem & calvariam ; has nimi- 
<c rum ob caufas ; primo ne quicquam cerebri fyftolae Sc 
u diaftolae obftaret; fecundo ne venae, Si arteriae per exter- 
“ nam durae matris partem fparfae levi aliquo idlu in 
c< cranio fadio rumperentur ; poftremo ut ruptis in dura 
** matre venis, fanguis non inter duram Sc piam matrem, 
* 6 fed inter duram & cranium efFunderetur, Sc cranio per- 

4< forato- 


/ 


( 5 * ) 

Was embraced by many, even of the moft 
eminent practitioners, was the principal rea- 
fon, why the bad effeCts of contufions 
of the head were fo little underflood, and 
fo groflly miflreated by them. They fup- 

E 2 * pofed 

* 4 forato facilius extraheretur. Et hie eft ordinarius nature 
44 ordo.” Gul. Fab. Hildanus. 

Felix Wirtz fays, that the elevation of the cranium in 
flight impreftions is needlefs. 64 Id enim motum cerebri, 
“ propter vacuum & diftantiam quae eft inter meningem 
<{ & cranium, minime impedire.” And Hildanus, by way 
of reproof to what Felix Wirtz fays: 44 Aliquando 
44 duram matrem cranio undique adhserere vidimus.” 

Fallopius, fpeaking of the dura mater, fays: 44 Con- 
44 tinuo pulfat, quare non facile fanatur.” 

Petrus e Marchetti fuppofed the dura mater always to 
be at a diftance from the fkull in thofe who were bald. 
Speaking of the treatment of a particular cafe he fays : 
64 Poft feptimam nempe oleum hyperici, quia calvus erat 
44 patiens atque membrana a calvaria diftabat $ quod in 
64 calvis femper obfervavi.” 

Pet. e Marchetti Obf. Chir. 

44 Aliquando contingit ut dura mater cranio fatis firmi* 
44 ter adhsereat, fed haec admodum raro evenire folet aique 
44 pr&ter natures confuetudinem eft.” 

Muys Prax. Rat. Chirurg. 

This was a)fo the opinion of Sylvius, Pacchioni, Am- 
brofe Pare, Serjeant Wifeman, Baglivi, Barbette, and of 
all thofe who maintained the dodtrine of the ofcillation 
of the dura mater; and who believed that that mem¬ 
brane was found fometimes higher, fometimes lower, that 
is^ fometimes nearer to, fometimes farther from the fkull 
at one age, and at one time of the moon, than another. 


C 5 2 ) 

pofcd that the vacuity between the dura 
mater and cranium, was fufficient in gene¬ 
ral, to defend the former from all external 
violence: and the blood and matter, fo 
often found between them, were thought 
to be depofited in a fpace naturally vacant. 
Upon this principle flood both their opinion 
and pra&ice; and therefore it is not to be 
wondered at, that their accounts, in gene¬ 
ral, are fo perplexed, and fo feldom verified 
by the examination of dead fubjedts. 

It fometimes happens, that the fcalp is fo 
wounded at the time of the accident ; or fo 
torn away, as to leave the bone perfectly 
bare, and yet the violence has not been fuch, 
as to produce the evil I am now fpeaking 
of. In this cafe, if the pericranium be 
only turned back, along with the detached 
portion of fcalp, there may be probability 
of its re-union ; and it fhould therefore be 
immediately made clean and replaced, for 
the purpofe of fuch experiment, which, if 
it fucceeds, will fave much time, and pfe > 
vent considerable deformity. If this attempt 
does not fucceed, the detached piece may 
be removed; and the cafe then becomes, as 
if the fcalp, and pericranium had been 
forced away, at the time that the wound 


was 


was firft inflicted; and the worft that can 
happen, is an exfoliation from the bare 
flaill 

It does alfo fometimes happen, that the force 
which detaches or removes the fcalp, does 
alfo occafion the mifchief in queflion ; but 
the integument ?being wounded, or remo¬ 
ved, we cannot have the criterion of the tu¬ 
mor of the fcalp, for the direction of our 
judgment. In thefe circumftances our whole 

attention 

^ Not that exfoliation is the neceffary confequence of 
the fkull being laid bare : this depends on other circum- 
ftances, befides the mere removal of the fcalp, and peri¬ 
cranium. The folidity of the furface of the bones, the 
fize of the, veffels, and the impulfe of the blood through 
them, are what principally determine that. If the cortex 
of the bone be not very hard, and the impulfe of the 
blood be capable of counterbalancing the effe£ts of the 
external air, a granulation of flefh will be generated on 
the furface of the bone, which will cover, and firmly aftv 
here to it, without throwing off the fmalleft exfoliation ; 
efpecially in young fubje<5ts. On the contrary, if the bone 
be much hardened, and the veflels thereby conftringed ; or 
If fuch applications be made ufe of, as will produce an ar¬ 
tificial conftritftion of them, the furface will neceflarily 
become dry, and the juices ceafing to circulate through it, 
it mu ft part with a fcale to a certain depth ; that is, that 
part of the furface through which the circulation ceafes to 
be carried on, will be feparated from, and caft off by, the 
veffels which nourifh the reft of the bone, 

E 3 


( 54 ) 

* \ ' 

attention mu ft, (as I have already faid) be 
directed to the wound and general fymp- 
toms. The edges of the former will, (as 
I have already obferved) digeft as well, and 
look as kindly, for a few days, as if no 
mifchief was done underneath; but after 
fome little fpace of time, when the patient 
begins to be reftlefs, and hot, and to com¬ 
plain of pain in the head, thefe edges 
will lofe their vermillion hue, and become 
pale and flabby ; inftead of matter they 
will difcharge a thin gleet, and the pericra¬ 
nium will loofen from the fkull, to fome 
diftance from the faid edges. Immediately 
after this, all the general fymptoms are in~ 
creafed, and exafperated, and as the inflam¬ 
mation of the membrane is heightened, or 
extended, they become daily worfe and 
worfe, until a quantity of matter is. formed, 
and collected, and brings on that fatal pe¬ 
riod, which, though uncertain as to date, 
very feldom fails to arrive. 

The method of attempting the relief 
of this kind of injury confifts in two 
points, viz. to endeavour to prevent the 
inflammation of the dura mater ; or, that 
being negleCted, or found impracticable, to 
give difcharge to the fluid collected within 

the 


( 55 ) 

the cranium, in confequence of fuch infiam* 
mation. 

Of all the remedies in the power of art, 
for inflammations of membranous parts, 
there is none equal to phlebotomy. To this 
truth many difeafes bear teftimony ; pleu^ 
rifles, opthalmies, ftrangulated hernias, &c. 
and if any thing can particularly contribute 
to the prevention of the ills likely to follow 
fevere contufions of the head, it is this kind 
of evacuation j but then it muft be made ufe 
of in fuch manner as to become truly a 
preventative ; that is, it muft be made ufe 
of immediately, and freely, 

I am very fenfibile, that it will in general 
be found very difficult to perfuade a perfon, 
who has had what may be called only a 
knock on the pate, to fubmit to fuch difci- 
pline, efpecially, if he finds himfelf tole¬ 
rably well. He will be inclined to think, 
that the furgeon is either unneceffarily ap- 
prehenfive, or guilty of a much worfe fault; 
and yet, in many inftances, the timely ufe, 
or the negledt, of this fingle remedy, makes 
all the difference between fafety, and fa¬ 
tality. 

It may be faid, that as the force of the 
blow, the height of the fall, the weight of 

E 4 " the 


( 56 ) 

the inftrument, &c. can never precifely or 
certainly determine the effe<ft, nor inform 
us whether mifchief is done under the bone 
or not, a large quantity of blood may be 
drawn off unneceflarily, in order to prevent 
an imaginary evil. This is in fome degree 
true*; and if the advice which I have iuft 
given was univerfally followed, many peo¬ 
ple would be largely bled without neceffity : 
but then, on the other hand, many a very 
valuable life would be preferved, which for 
want of this kind of afliftance is loft. “ Ni- 
u hil intereft, prasfidium an fatis tutum fit, 
« c quod unicum eft,” is an incontefted maxim 
in medicine and if it be allowed to ufe 

■ v 

fuch means, as may be in themfelves ha^ 
zardous, furely it cannot be wrong to em¬ 
ploy one which is not fo; at leaft, if it be 
confidered in a general fenfe; whatever it 
may accidentally prove to fome few parti¬ 
cular individuals. 

Acceleration, or hardnefs of pulfe, reft- 
leflhefs, anxiety, and any degree of fever, 
after a fmart blow on the head, are always 
to be fufpe&ed and attended to. Imme¬ 
diate, plentiful, and repeated evacuation by 
bleeding, have, in many inftances removed 
th?fe, in perfons to whom, I do verily be¬ 
lieve* 


( 57 ) 

lieve, very terrible mifchief would have 
happened, had not fuch precaution- been 
ufed. In this, as well as fome other parts 
k>f practice, we neither have, nor can have 
any other method of judging, than by com¬ 
paring together cafes apparently fimilar, I 
have more than once or twice feen that 
increafed velocity and hardnefs of pulfe, 
and that oppreffive languor, which moft 
frequently precede mifchief under the bone, 
removed by free and repeated blood-letting; 
and have often, much too often, feen cafes 
end fatally, whofe beginnings were full as 
flight, but in which fuch evacuation had 
been either neglefted or not complied 
with. • ' 

I would by no means be thought to infer 
from hence, that early bleeding will al¬ 
ways prove a certain prefervative ; and that 
they only die to whom it has not been 
applied : this, like all other human means, 
is fallible, and perhaps there are more cafes 

out of its reach, than within it ; but where 

* 

preventative means can take place, this is 
certainly the beft, and the moft frequently 
fuccefsful. 


The 




( 58 ) 

The fecond intention, viz. the difcharge 
of matter collected under the cranium, can 
be anfwered only by the perforation of it. 

When, from the lymptoms and appear* 
ances already defcribed, there is juft reafon 
for fuppofing matter to be formed under the 
lkull, the operation of perforation cannot 
be performed too foon ; it feldom happens 
that it is done foon enough *. 

The propriety or impropriety of applying 
the trephine, in cafes where there is neither 
fiflure, frafture, nor fymptom of extravafa- 
tion, is a point which has been much liti¬ 
gated, and remains ftill unfettled either by 
writers or pra&itioners. 

When there is no reafon for fufpe&ing 
either of thofe injuries, either from the 
lymptoms, or from the appearances ; and 
the pericranium, whether the fcalp be 
wounded or not, remains firmly attached 
in all parts to the lkull, there certainly is 
not, (let the general lymptoms be what 
they may) any indication where to apply 
the inftrument; and confequently no fuffi- 4 
cient authority for ufing it at all. But when¬ 
ever 

* “ His, ubi cito manus admoveatur, falutis aliqua 
6,4 fpes fubeft j ubi ferius, plerique omnes moriuntur,” 

' v Archiginis, 


( 59 ) 

ever that membrane, after the head has re¬ 
ceived an external violence, feparates, or 
is detached fpontaneoufly from the bones 
underneath it; and fuch feparation is at¬ 
tended with the collection of a fmall quan¬ 
tity of thin, brown ichor,. an alteration of 
colour in the feparated pericranium, and an 
unnatural drinefs of the bone, I cannot 
help thinking, that there is as good reafon 
for trepanning, as in the cafe of fradhire ; I 
believe experience would vindicate me, if I 
faid, better reafon ; lince it is by no means 
infrequent, for the former kind of cafe to 
do well without fuch operation ; whereas 
the latter (I mean fuppuration under the 
fkull) never can > 

All the beft practitioners have always agreed 
in acknowledging the neceffity of perforat¬ 
ing the Ikull in the cafe of a fevere ftrokemade 

on 

* “ Les auteurs jufquici, ne nous ont parle du trepan 
• c qu* autant qu’ il pouvoit fervir a relever des pieces du 
w crane enfpncees, par un coup violent, ou a donne 
tc iflue a quelque liqueur, comme feroit du fang, ou du 
<6 pus, epanche, fous le crane. 

“ La contufion de l’os eft un cas, ou le trepan n’eft pas 
cc moins neceflaire ; non a caufe que l’os eft contus, mais 
<c pour prevenir la maladie de la dure mere, & de la pie 
5s mere j qui en eft une fuite prefque indirpenfable.” 

Le Draw, 


( 6o ) 

on it, by gun*{hot, upon the appearance of 
any threatening fymptoms, even though the 
bone fhould not be broken : and very good 
practice it is. A wound by gun-fhct, (as 
far as it relates to the fkull) is to be regarded 
only as one attended with a very high de¬ 
gree of contufion ; and therefore moft likely 
to produce {ymptoms accordingly; among 
which, inflammation of the dura mater 
{lands principal. Experience confirms both; 
moft of the fymptoms, attending wounds 
of the head, made by gun-fhot, are fymp¬ 
toms of contufion ; and the formation of 
matter between the cranium and dura ma¬ 
ter, is a very frequent, and a very fatal 
confequence of fuch contufion. 

In fhort; the fpontaneous feparation of 
the pericranium, if attended with general 
diforder of the patient, with chillinefs, 
horripilatio, languor, and fome degree of 
fever, appears to me, from all the obferva- 
tion I have been capable of making, to be 
fo fure and certain an indication of mif- 
chief underneath, either in prefent, or im^ 
pending, that I {hould never hefitate about 
perforating the bone in fuch circumftan- 
ces. 


When 


( 6i ) 

When the fkull has been once perforated, 
and the dura mater thereby laid bare; the 
flate of the latter, muft principally deter¬ 
mine the furgeon’s future conduct. In fome 
cafes, one opening will prove fufficient for 
all neceflary purpofes, in others feveral may 
be neceflary. This variation will depend 
on the fpace of detached dura mater, and 
the quantity of collected matter. The re¬ 
petition of the operation is warranted, both 
by the nature of the cafe, and by the beft 
authorities, there being no comparifon to 
be made between the poflible inconvenience 
arifing from largely denuding the dura ma¬ 
ter, and the certain, as well as terrible evils, 
which muft follow the formation and con¬ 
finement of matter between it and the fkull. 

It can hardly be neceflary for me to ob- 
ferve, to whoever reflects ever fo little on 
the true nature of thefe cafes, that notwith- 
ftanding the operation of perforation be 
abfolutely and unavoidably neceflary, yet 
the repetition of blood-letting, of cooling 
laxative medicines, the ufe of antiphlogif- 
tic remedies, and a moft ftridt obfervance 
of a low diet and regimen, are as indilpen- 
fably requifite, after fuch operation, as be¬ 
fore : 


( 62 ) 

fore : the perforation fets the membrane 
free from preflure, and gives vent to col¬ 
lected matter, but nothing more : the in¬ 
flamed flate of the parts under the fliull, 
and all the neceflary confequences of fuch 
inflammation, call for all our attention, full 
as much afterwards as before: and altho* 
the patient mud have perifhed without the 
ufe of the trephine, yet the merely having 
ufed it will not preferve him, without every 
other caution and care. 

This being all that our art is capable of 
doing, in thefe melancholy cafes, I wifli I 
could fay, that it was mod frequently fuc- 
cefsful. Sometimes it is: the operation, 
confidered abftraCtedly, is not in itfelf ha¬ 
zardous, and is the unicum remedium, 
for the mod immediately impending, and 
mod threatening mifchief ; fome have been 
faved by it; none can efcape without it ; as 
there are no certain indications, no criteria, 
whereby we are enabled to judge, whether 
it will prove fuccefsful, or not, the event of 
each individual cafe can alone determine. 
When that is happy, the means are very 
juftly commended ; but when it is not fo, 
they ought not therefore to be con- 
4 demned; 


( 63 ) 


demned ; fince they are built on very ra¬ 
tional principles, and are the only means- in 
human power. 

CASE I. 

Poor fellow croffing Tower-hill, got. 



jljl before he was aware of it, into a 
mob, that was endeavouring to refcue a 
failor from a prefs-gang. The man was 
knocked down. When the croud dilperfed, 
he was found fenfelefs, and in that ftate was 
brought to St. Bartholomew’s hofpital; 
where he was immediately let blood, and 
put to bed. In an hour or two, he was fo 
recovered, as to be able to give the pre¬ 
ceding account. 

When Mr. Nourfe (whofe week it was 
for accidents) faw him the next day, the 
man appeared to be perfe&ly well nor did 
any mark of violence appear on his head, 
except one fmall bruife; and that fo flight, 
that it might, with more probability, be 
attributed to the fall, than the blow. How¬ 
ever, as he was pofitive, that he had been 
knocked down, by a very fmart blow, from 
a heavy weapon $ and as he certainly had 


been 


( 64 ) 

been deprived of fenfe a confiderable time 
thereby ; Mr. Nourfe bled him again* and 
ordered him to be kept in bed, and to a 
very low diet. At the end of three days 
the man found himfelf fo well, as to leave 

i 

the hofpital, and go to work. On the 
twelfth day from that of the accident, he 
came to my furgery, and complained of be¬ 
ing much out of order 5 faid, that his head 
was very uneafy; that he was hot* thirfty, 
got little or no lleep, and was, at times, fo 
faint, that he could not purfue his labour. 
He looked ill, affured me he had lived very 
foberly, from the time of his leaving the 
hofpital, and that he had been in hisprefent 
ftate for three days part. I took him into 
the houfe again, bled him, ordered him a 
glyfter immediately, and that he fhould be 
kept in bed. 

Next day, (13th) he was in much the 
fame ftate as the preceding : he had pafled 
a reftlefs night, had dofed now and then, 
but awoke with much difturbance. He 
had a hot fkin, and flufhed countenance, 
mixed with a light yellow tint ; he com¬ 
plained of general pain and tightnefs all 
over his head * but neither to the fight, nor 
to the touch, was there any appearance, or 
4 lenfation, 


( 65 ) 

fenfation, whereon to build a probable flip-* 
pofition, of particular mifchief. He was 
again, by the phyfician’s order, let blood, 
and directed to take the fal abfinthii mix¬ 
ture, with a few grains of rhubarb in it, 
every fix hours. He pafied the enfuing 
night in a difiiurbed manner, and the next 
day, (the 14th) was apparently worfe : his 
fkin was hotter, his pulfe quicker, and his 
pain more acute ; he alfo now thought, that 
one part of his head was tender to the 
touch ; and faid, he was fure, that was the 
part which received the blow. This place 
I examined. The fcalp did feem to be rather 
fuller than natural, but by no means fuffi- 
ciently fo, to enable me to form any judge¬ 
ment by. Toward the clofe of this day he 
had a flight fhivering, was fick, and vo¬ 
mited, and pafied the following night with¬ 
out any fleep at all; talking fomefcitnes in¬ 
coherently, but ftill capable of giving a ra¬ 
tional anfwer to any queftion which en¬ 
gaged his attention. On the 15th day, the 
tumor of the fcalp was more apparent, but 
yet feemed to contain little or no fluid, and 
was about the breadth of a crown piece. I 
would have removed that portion of fcalp ; 
but while I was intending it, the poor man 

F ' had 


( 66 ) 

had a very fevere rigor, which difordered him 
fo much, that he begged to be let alone for 
the prefent. That afternoon he had two 
more fhiverings, pafled very ill the follow¬ 
ing night ; and next morning was delirious. 
The tumor now was more rifen, contained 
palpably a fluid, but was by no means 
tenfe; I took away the whole tumid piece, 
by a circular incifion ; gave difcharge to 
a thin brown fanies, and found the cra¬ 
nium perfectly naked, altered confiderably 
in colour from that of a healthy natural 
one, but without fiflure, fraCture, or other 
evil. That whole night and next day he 
was delirious ; his fkin burning hot ; he had 
frequent fpafms, which fhook his whole 
frame, and that night (the 17th) he died. 

The whole fcalp, except round the edge 
of the incifion, was in a natural ftate; the 
pericranium in every other part, except the 
tumid one, adhered to the bone - y and nei¬ 
ther inflammation, nor tumor of any kind 
all over the reft of the head. Under that 
part of the Ikull from which the pericra¬ 
nium had been detached, and from which 
the fcalp had been removed, a very confi- 
derable collection of matter was found, ly¬ 
ing between the dura mater and cranium, 

but 


( 6 7 ' ) 


but no appearance of difeafe any where 
elfe. 


CASE IL 


Contufion with wound '• 

A Young fellow playing at quoits, was 
flruck down by the perpendicular 
fall of one of them on his head. It made a 
large wound, which bled freely, but did not 
divide the pericranium, and confequently 
did not denude the fkull. The wound was 
brought together by a flitch, made by 
fomebody at hand ; and the man, though 
flunned at HrH by the blow, having vo* 
mited plentifully, was foon well, and the 
next day went to his work, which was that 
of a farrier. The wound was drcflfed daily 
with a fuperficial pledgit, by the perfon who 
iirft faw and Hitched it; and it feemed to 
unite kindly. 

On the fixth day from that of the acci¬ 
dent, he complained of being chilly and 
faint; and when he had done about half a 
day’s work, found himfelf unable to bear 
the heat of the forge, or to Hoop to fhoe an 
horfe, on account of pain in his head : he 
therefore left his fliop, went home, and fent 

F 2 far 


( 68 ) 

for the apothecary who firft had dreffed 
him. The wound not being very carefully 
examined appeared to be healed, and there¬ 
fore was not regarded as any caufe of the 
man’s prefent indifpofition, who was treated 
as having a fever, from cold, and irregula¬ 
rity : he was let blood, and took fome me¬ 
dicines but at the end of three days, (nine 
from the accident) being worfe, and incapa¬ 
ble of hearing the expence of remaining at 
home, he was brought to St. Bartholo¬ 
mew’s hofpital. On the tenth day, from 
that on which he was wounded, I faw him. 
He had a confiderable degree of fevers his 
pulfe was hard and quick, his jflcin hot 
and dry, his face flufihed, his eye languid, 
and he complained of great pain and tight- 
nefs all over his head. The wound was 
apparently, but not really, healed; I could 
pafs a probe underneath, from one end to 
the other of it s and I could feel the cra¬ 
nium bare the whole way. J divided its 
whole length ; found the pericranium 
floughy, and detached to a confiderable dis¬ 
tance, and the bone much altered in colour: 
upon fight whereof, I removed the whole 
feparated part, by a large circular incifion. 

From 


C 69 ) 

From the fymptoms and appearances I 
prognofticated no good. He was again let 
blood, and had a glyfter, and a lenient 
purge, which together produced three ftools. 
That night, (the 10th) he had a rigor, af¬ 
ter which his pain became more intenfe, 
and fever higher. The next morning, (the 
1 ith) he had another fhivering ; and when 
I faw him about noon, he was very incon- 
fiilent. I fet on a trephine clofe to the fa- 
gittal future, on one fide; and gave dis¬ 
charge to a fmall quantity of matter, which 
lay on the furface of the dura mater ; after 
being lightly dreffed, fome more blood was 
draw r n from one of the jugular veins, and 
he w r as ordered to take a draught of the fait 
of wormwood mixture frequently. The 
next day, (12th) he was worfe. I there¬ 
fore fet the trephine on again, but on the 
other fide of the future, and by that means 
let out a confiderable quantity of matter 
from between the fkull and membrane. 
Soon after this, he became more rational, 
and feemed to get a little fleep ; but in the 
evening his pain returned with great vio¬ 
lence, and he had a rigor, which held him 
above an hour. 


When 


( 70 ) 

When I faw him the next day, (13th) 
he was fenfelefs, had a low faltering pulfe, 
and a profufe cold fweat ) foon after which 
he expired. 

Upon removing the upper part of the 
fkull, a large quantity of matter was found* 
under each parietal bone, which had de¬ 
tached the dura mater from its connexion 
with the fkull, for a confiderable fpace, but 
not at the future. On the right fide a por¬ 
tion of the dura mater was become floughy, 
about the breadth of a fhilling $ and under 
this altered part, was matter between the 
two meninges. 

The more firm attachment of the dura ma¬ 
ter at the futures, renders the reparation of 
it at thefe places very difficult: which circum- 
ftance, added to the confideration of the fitu- 
ation of the fagittal future on the very top of 
the head, renders the application of the tre¬ 
phine on each fide of it often abfolutely 
neceffary. For if there be good reafon to 
fufpedt either an extravafation of blood, or 
a collection of matter, in confequence of a 
blow received on this future, and one fide 
only be perforated, the operation may hap¬ 
pen to be performed on that fide where 
the blood or matter does not lie, and will 

5 therefore 


( 7 * ) 

therefore be fuccefslefs; or, on the other 
hand, the extravafation, or fuppuration, may 
be on both fides ; and then the perforation 
of one only cannot anfwer the whole pur- 
pofe, and the patient will as certainly perifli 
as if nothing had been done at all. 

CASE III. 

* 

Contujion without wound. 

A Boy about nine years old, playing 
under an empty cart, whofe fhafts 
were fupported by a flick, was knocked 
down, by the fall of one of them upon 
his head. The child was flunned by the 
blow for a minute or two, but foon be¬ 
came fenfible. When he came home, there 
being a fmall fwelling where the blow had 
been ftricken, his mother applied a bit of 
linen rag, wet with vinegar; and as he ap¬ 
peared to be perfectly well in a day or two, 
he was fent to fchool. 

Five days paffed over before he made any 
complaint; on the fixth, he faid, that his 
head ached; he brought up his breakfaft, 
and could eat no dinner; but in the evening 
feemed to be pretty well again. On the 

F 4 7th, 


1 


( 7 2 ) 

7th, be complained dill more of his head ; 
and faid, that he was very fick, and very cold. 
He was put to bed, but got no reft. As he . 
had not had either fmall-pox, or meafles, he 
was brought home, and treated as if one of 
thefe difeafes was to follow. 

Three days more pafted, and no eruption 
appeared : the fever continued much the 
fame; he was frequently inclined to vomit, 
and what little fleep he got, was extremely 
difturbed. He was, by the order of a phy- 
fician, let blood, had a blifter applied to his 
back, and took fome of the common febri¬ 
fuge medicines. On the 12th day, from 
that of the accident, he was feized with a 
fhivering, which held him more than a 
quarter of an hour 5 after which his pain 
became more acute, and his fever higher. 
Some blood was drawn from his temples by 
leeches, and he was ordered fome other 
medicines. On the 13th, at noon, he had 
another rigor, ftill more fevere than the for¬ 
mer, and of longer duration; and that 
evening he became light headed. By fome 
means or other, the accident of the blow 
was now mentioned to the perfon who at¬ 
tended him; and who defired that a fur- 
geon might look at his head. I found a- 

bout 



( 73 ) 


bout a third part of the left parietal bone 
covered by a flattifh tumor, containing a 
fluid. ' * 

From the appearance of this fwelling, 
from the date of the accident, the attack, 
violence, and duration of the fymptoms, I 
made no fcruple to give my opinion, that 
the blow had been the foie caufe of all the 
child’s illnefs ; that I fufpeCted the fkull 
tinder the tumor to be bare, if not injured; 
that I did alfo believe, that matter was 
forming, or formed, under the fkull ; and, 
that if the laft conjecture was true, the only 
chance the child could have of prefervation, 
mu ft be from the operation of the tre¬ 
phine. 

The fcalp was divided, and the fkull 
found as 1 fufpeCted, that is, perfectly bare, 
and altered from a natural colour; I would 

•% 

therefore have perforated it immediately ; 
but as the bone was not broken, the pa¬ 
rents objected to fuch operation ; and the 
phyfical gentleman, who had the care of 
the boy, not having feen much bufinefs of 
this kind, and not rightly comprehending 
the true nature of the cafe, joined in opi¬ 
nion with the parents, that fuch operation 
was not neceflary. It was therefore not 

performed. 


( 74 ) 

performed, and the whole was committed to 
internal remedies. 

The fever increafed, and the child’s 
ftrength decreafed in proportion : he con¬ 
tinued delirious for three days more, 
then fank into a ft ate of infenfibility, and 
died. 

Having been contradicted* and (as I 
thought) fomewhat improperly overuled, in 
the management of the patient while alive, 
I was the more importunate to get leave to 
examine him when dead. 

All that part of the dura mater which 
had been covered by the left parietal, and 
part of the temporal bone, was detached 
from the faid bones, and covered with a 
confiderable quantity of matter. Under the 
middle part of the former bone, the dura 
mater was difcoloured, and lloughy ; this 
difcoloured part I opened with a lancet, 
and let out near a fpoonful of matter; 
which matter lay between the meninges- 
All the reft of the contents of the head 
were unaffe&ed. 

When firft I faw this child, all chance 
of relief from evacuation was over ; and 
his fymptoms plainly indicated mifchief 
under the fkull. Nothing therefore but 

per- 


( 75 ) ' 

perforation could give him any kind c*f 
chance. 

I do not fay, that this operation would 
have faved him; I am much inclined to 
believe that it would not; but {till it was 
the only thing, that could with propriety 
have been done for him; and therefore it 
ought to have been done, inftead of waft¬ 
ing time with the ufe of internal remedies, 
from which no poffible good could be ex~ 
pedted, or derived. i 

CASE IV. 

Contufion without wound. 


A Labouring man fell from a fcaffold, 
two ftories high, by which he was 
for a few minutes ftunned, and infenfible, 
but foon l'ecovered. He was let blood; 
and having bruifed his right arm, and the 
fame fide of his forehead, he was properly 
drefled, by fomebody in the neighbour¬ 
hood. 

Next day being very well, he returned 
to his labour, and followed it daily for five 
tnore. On the fixth, finding himfelf a 
good deal out of order, he came to the 

hoipital 


A 7 6 ) 

hoipital for advice. He complained, of 
fhooting and frequent pain in his head k , of 
giddinefs, and inclination to vomit ; and 
faid, that he felt, as if a cord was drawn 
tight round his brain. On the right fide 
of his forehead was a fmall tumor, neither 
tenfe, nor painful, but palpably containing 
a fluid# I perfwaded the man to let me 
open it. I found a final! quantity of a 
a brown fluid, covering the bone, perfectly 
denuded of its periofteum; upon which 
difcovery, I removed the whole piece by a 
circular incifion; fourteen ounces of blood 
w T ere drawn from his arm ; a glyfter was 
thrown up, and he w T as confined to his bed, 
and barley water. 

Next morning, (the feventh) his pulfe 
was full, hard, and frequent ; he had flept 
very little, and that in a very difturbed 
manner. He was, by the phyfician’s order, 
let blood again, and directed to take the fal 
abfinthii mixture, with rhubarb fextis ho- 
ris. On the eighth day, he was let blood 
again from one of the jugulars ; and being 
ftill rather coftive, took a gentle purge. On 
the ninth, his pulfe was ftill higher and 
harder, and his Ikin more hot and dry ; 
twelve ounces more of blood were drawn 

S off 


( 77 ) 

off from one of the temporal arteries. That 
evening he had a Chivering ; after which he 
complained that his pains were much in- 
creafed. Next morning, (the tenth) his 
fore looked very ill ; was pale, fpongy, and 
glaffy, and the fcalp feparated from the 
fkull to fome diftance beyond the edges of 
the wound. I fet on a trephine, and re¬ 
moved a piece of the cranium, under which 
the dura mater was fmeared over with mat¬ 
ter, and had loft its bright colour. That 
night he got no deep, and toward morning 
had another rigor. The eleventh, at noon, 
he was manifeftly worfe, in every refpe<ft; 
his pain was intenfe, his fever high, and 
his fore as ill-conditioned as poffible. With 
the largeft trephine I had, I took away 
another piece of the cranium, nearer to the 
temporal bone, and by means of this open¬ 
ing, procured the difcharge of a confidera- 
ble quantity of matter. This done, find¬ 
ing his pulfe ftill high, and full, I drew off 
ten ounces more of blood, and ordered him 
him a glyfter. The lofs of blood produced 
a fwooning, which lafted fome minutes; af¬ 
ter which, he faid, that he thought his head 
was rather ealier. As the evening approach¬ 
ed, his pain returned, wherefore fome leeches 


were 


( 78 ) 

were applied to his temples. That night 
he got a little quiet fleep, and in the morn¬ 
ing of the twelfth day, faid that his head 
was perfectly eafy : a very large difcharge 
of matter had been made through the per¬ 
foration in the cranium, and I thought that 
the wound of the fcalp wore rather a bet¬ 
ter afpedh He was kept ftridtly to a proper 
low regimen; took at firfi: the fal abfinthii 
mixture freely ; when his pain had left him, 
the phylician ordered him the bark ; and in 
a very few days every bad fymptom and ap¬ 
pearance left him. 

Would not this cafe, which ended fo 
happily, have been attended with the moll 
fatal confequences, if the free perforation 
of the fkull had been omitted, or if lefs 
blood had been drawn off? 


CASE 

# 


( 79 ) 


CASE V. 


Contufion with wound. 

Young fellow of about twenty years. 



jCjL was thrown from an unruly horfe, 
againft one of the rails in Smithfield. The 
blow was great ; he lay fenfelefs for above 
an hour, and in that ftate was brought into 
St. Bartholomew’s hofpital. 

He had a large wound on one fide of his 
forehead, the fldn of which was partly torn 
quite off, and partly turned down over his 
eye. The lips of the wound were, by the 
perfon who faw him firfi, brought as near 
together as they would admit; but fuch a 
portion was loft, as neceflarily left the bone 
bare about the breadth of a (hilling. As 
foon as his wound had been examined, he 
was let blood and put to bed. The next 
day, his pulfe being hard and full, he was 
again let blood, and was ordered to have a 
glyfter, a lenient purge, and fome febrifuge 
medicines. On the third, the wounded 
fcalp, and that fide of the face being much 
fwollen, a warm cataplafm was applied over 
the dreflings, and the part was well fo¬ 
mented ; and in about five days more, every 



V 


( 8o ) _ ■ I 

thing wore fo good an afpedt, that the man 
feemed to be getting well apace. On the 
ninth, he complained of being out of or¬ 
der, faid his head ached, and that he had 
not flept the preceding night. He was hot 
and feverilh, and his pulfe hard and full. 
He was therefore let blood again, and or* 
dered to have a glyfter, and to be kept very 
low. On the tenth, in the night, he had 
(as he called it) a chillinefs came all over 
him; after which, his pain was coniidera- 
bly increafed. On the eleventh, his fore 
feemed to fpreaa, difcharged a thin gleet 
inftead of matter; the lint with which it 
was drefled, ftuck fad to all parts of it; * 
and its furface, from having been florid and 
granulated, became tawny and fpongy. 
That day he had another {hivering; and 
on the next, being the twelfth, a conful- 
tation was held on him. He was now 
very hot and feverifh ; his face much flufh- 
ed, an eryfipelas beginning to appear on 
his eye-lids; his fore very ill-conditioned, 
and the bare bone fo much changed from, 
its natural colour, that it looked as if mat¬ 
ter might have been feen through it. Con- 
fideratis confiderandis, it was agreed that 
he had no chance for his life but by perfo¬ 
ration 


ration of the bare cranium. The opera¬ 
tion was immediately performed, and a 
quantity of matter found on the dura ma¬ 
ter. For feveral days the difcharge was 
great, and the man continued very ill; but 
about the eighteenth day the fever left 
him ; he became eafy, the difcharge leffen- 
ed, his fore put on a good face, and he got 
a natural Deep. From this time nothing 
finifter happened, and the man got foon 
well. 


CASE VI. 

Gontujion without wound\ 

A Lad about twelve years old, {landing 
by a man who was playing at cricket, 

t \ 

received a blow from the bat on his fore¬ 
head. The boy became fenfelefs, and as 
he was not known to any body prefent, he 
was brought to the hofpital. He recovered 
his fenfes before he got thither ; but the 
part which received the flroke being much 
fwollen, he was dreffed, let blood, and or¬ 
dered to keep in bed. When I faw him 
next morning he had no complaint, but 
the forenefs of his forehead, under the fkin 
of which there feemed to be a good deal of 

G extrava- 


( 82 ) 

extravafated, coagulated blood. His pulfe 
was full and ftrong; he was therefore again 
let blood : and as he had not had a ftool for 
two days, a glyfler was thrown up, and a 
lenient purge given. A difcutient cerate 
was kept upon his forehead ; and being of 
a coftivp habit, he was purged once in two 
or three days ; and on the ninth, from that 
of the accident, was difcharged from the 
houfe. On the fourteenth, he returned to 
it again, complained of lafiltude, giddinefs 
and head-ach. He was put under the care 
of the phyiician, was let blood, vomited, 
purged^ and took proper medicines ; but 
remained much the fame for three or four 
days : that is, he was feverifh, with a fkin 
too hot, a pulfe too quick, and what little 
fieep he got was unquiet, and ihort. On the 
feventeenth day he had a flight rigor, during 
and after which his pain in the head was 
much more intenfe, and the following day 
all his febrile fymptoms were much exafpe- 
rated; on the nineteenth, he complained 
of tendernefs to the touch on his forehead, 
and great general pain in his head. He 
was again let blood, and was more funk by 
the difcharge than I could have fuppofed ; 
but no rerniiflon of his fymptoms followed. 

His 


( 8 3 ) 

His fleep that night was very little, and 
very unquiet ; toward morning he had two 
diftind fhiverings; and when 1 faw him at 
noon, on the twentieth, his forehead ap¬ 
peared fomewhat tumid and puffy. From 
the continuance and exafperation of his 
fymptoms, and from the new appearance 
on his forehead, I was almofl certain their 
was mifchief on or under the fkull ; I 
therefore divided the fcalp, to examine 
the bone; and found, between it and the 
pericranium, which had quitted its adhe- 
fion for more than the breadth of a crown - 
piece, a fmall quantity of a thin, difcolour- 
ed fluid. 

This (as it appeared to me) put the na¬ 
ture of the cafe out of doubt, and left the 
boy no chance, but from perforation. I 
therefore applied the trephine immediately, 
and gave difcharge to matter formed be¬ 
tween the dura mater and bone : for a 
week after the operation, the difcharge was 
large, and the boy in much hazard; but at 
the end of that time, the fuppuration lef- 

fened; the dura mater incarned kindly; and 

* 

by proper care, and taking freely of the 
decod:, cortic. peruv. he got well. 

G 2 CASE 


/ 


( 84 ) 


CASE VII. 

Cojitufion without wound. 

% 

A Man in the neighbourhood of St. 
Giles's had a quarrel with his wife ; 

in. which he ftruck her over the head with 

* 

a mop-ftick. The blow was a fmart one \ 
but as it neither fetched blood, nor brought 
her to the ground, it only finifhed the dis¬ 
pute, and no farther notice was taken of it. 
The woman followed her bufinefs, which 
was that of crying greens about the ttreets, 
and lived, (to ufe her own words) fometimes 
drunk, fometimes fober, for a week. On 
> the eighth day from that of the blow, /he 
found herfelf fo ill, that {he applied to the 
hofpital for admiffion; and was taken in 
as a phyfician’s patient for a fever. The 
dodor wrote for her and the day after 
this, (the tenth from the accident) the fitter 
of the ward, in cutting off the patient’s 
hair, which was full of vermine, difco- 
vered a fwelling, which fire defired me to 
look at: it was flattifh, about the breadth 
of the palm of a hand ; and lay immedi¬ 
ately a-crofs the fagittal future. The wo¬ 
man 


( 85 ) 

man had now a hard, full pulfe, a hot dry 
fkin, a black tongue, a frequent inclina¬ 
tion to vomit, great third:, intenfe pain in 
her head, and got no ileep. From thefe 
fymptoms and appearances, and from the 
account which the woman now firft gave of 
the blow, I made no hefitation to fay, fuch 
blow was the caufe of all her fymptoms. 
That night die had a fevere rigor; and the 
next day, the eleventh, an eryfipelas had 
taken pofleffion of part of her vifage. I 
opened the tumor, and finding the bone 
bare, cleared away the fcalp largely, and 
circularly. I then applied a trephine on 
one fide of the future and clofe to it; and 
found the dura mater altered in its natural 
colour, and as it were fmeared over with 
matter. She pafied the fucceeding night 
very ill, was in great pain, got no deep, 
and had two fhiverings. When I came to 
her the next day, her whole vifage was co¬ 
vered with an eryfipelas, and fo fwollen, 
that fhe could not open her eyelids. I ap¬ 
plied the trephine on the other fide of the 
future, and found the fame appearance, viz. 
matter on the furface of the membrane. 
She had within the lad two days been let 
blood three times ; and had conflantly taken 

G 3 « ^ fuch 


( ' ( 86 ) - 

fuch medicines as the phyfician had ordered 
for her, and which were calculated to abate 
her fever, and keep her body open. Her 
fymptoms ft ill continued without abate¬ 
ment ; the wound of the fcalp bore as bad 
an afped as poffible, die talked very incon- 
fiftently, got not a wink of deep, and cal¬ 
led perpetually for drink. As the quantity 
of bone made bare by the removal of the 
fcalp gave room for the further application 
of the inftrument, I made a third perfora¬ 
tion near to the firft, and immediately gave 
thereby difcharge to fo large a quantity of 
matter, as to fatisfy me the event muft be 
fatal, v v 7 . r. •' ^ 

The next day the right arm and leg be¬ 
came paralytic, and the day following that, 
from having been raving, fhe funk into a 
date of perfed infenfibility, had a fhort, la¬ 
borious refpiration, a fmall, interrupted, 
faultring pulfe, and cold extremities ; and 
on the fixteenth day from that of the acci¬ 
dent (lie died. 

Upon opening the head, the dura mater 
was found covered with matter, under the 
whole internal furface of both the parietal 
bones ; but the firm adhefion of the longi¬ 
tudinal finus to the fagittal future had pre¬ 
vented 


(■ ■■87 ) 

vented all communication between the two 
collections of matter. 


CASE VIII. 

Gontujion with wound. 


'■«T, 


A Lunatic threw himfelf from a win¬ 
dow, two dories high, and in his 
fall, {truck his head, firft againft a fign-iron, 
and then again ft a flated pent-houfe. 

He was taken up fenfelefs, with three 
wounds on his head; one juft above the 
right temple, and two on the top of his 
head : the wounds were but fmall, nor was 
4 :he pericranium divided in any of them. 
He remained ftupid above twelve hours; 
but being in that fpace of time let blood 
freely twice, he recovered his fenfes, but 
{hewed no figns of a right underftanding. 
He pafled two days and nights in the ut- 
moft diforder and difturbance. He was 
confined in a ftrait waiftcoat, and kept two 
people conftantly employed in holding him ; 
at laft, by repeated phlebotomy, and tak^ 
ing a large quantity of opium, he fell alleep, 
flept near twelve hours, and then awoke 

G 4 „ . . P c » 


♦ 


* * 


( 88 ) 

perfectly tranquil, and perfe&ly rational. 
By the fixth day from that of the fall, his 
wounds were in perfedt good order, and 
feemed to heal without any trouble ; the 
man was in very good health and temper, 
and perfectly rational and intelligent. He 
would have been permitted by his friends 
to have gone out a little way into the coun¬ 
try; but left there fhould be any latent 
mifchief, I advifed him to keep quiet a little 
longer, and to live with great caution; 
which advice was followed. On the tenth 
day from that of the accident, he loft his 
appetite, looked dull and languid, refufed 
food and company; complained that his 
head ached, and faid, that he had not flept. 
So little time had pafled fince he had been 
difordered in his mind, that, from his afpetft 
and manner, I fufpedted a return of his lu¬ 
nacy. I let him blood again, directed that 
he might be kept low, and defired his bro¬ 
ther, who was an apothecary, to give him 
an opiate at going to bed. The next day, 
the eleventh, he laid that his head-ach had 
again prevented him from fleeping all night; 
and that he felt as if a cord was bound tight 
about his brain : his Ikin was too hot, his 


( 8 9 ) 

pulfe was too hard and too frequent ; his 
urine fmall in quantity, and high coloured $ 
and the afpeft of the wounds in the fcalp, by- 
no means fo favourable as they had hitherto 
been : one of them looking more fpongy 
and pale than the others, I examined with 
my probe, and found the Ikull bare for 
fome Ipace, under it. With his own and 
brother's confent, I removed all the fcalp 
covering the bare cranium, and found it to 
be confiderably altered from a natural co¬ 
lour. I bled him again, and defired that 
he might take freely of the fait of worm¬ 
wood and lemon juice until the next day. 
That night he had a fmart rigor *> and the 
next - morning finding him worfe, and more 
difturbed, I made a perforation of the fkull. 
The dura mater under this perforation was 
dull, and had apparently matter on its fur- 
face, though fmall in quantity. He was 
drefied lightly, and, as his pulfe would very 
well bear it, eight ounces more of blood 
were drawn off. The following morning, 
the thirteenth, he had a ftill more fevere 
ihivering: his pain in his head was greater, 
his fever higher, and the whole fore fo 
crude, that the lint was with difficulty re¬ 
moved 


4 


( 9 ° ) 

moved from it. I applied the trephine a- 
gain, and found the fame appearance, viz. 
a dull difcoloured dura mater, and a fmall 
quantity of matter. That evening he had 
another rigor, and was the following day 
manifeftly worfe. Convinced, from the 
fymptoms, of his hazard, and firmly believ¬ 
ing that matter was collected, in fuch man¬ 
ner as not to be difcharged by the two 
openings already made, I ventured to make 
a third, and that a large one ; this produced 
an immediate and large difcharge of pus. In 
feven or eight hours I faw him again, and 
found him eafier and more trafiquil. He 
had flept nearly an hour, and his pulfe did 
not feel fo rapid, nor fo hard. That even¬ 
ing he got more fleep, and the following 
morning anfwered every queftion afked, in 
fuch manner, as to convince every body 
that he was certainly better. To fhorten 
the relation, I (hall only add, that the dif¬ 
charge continued large for feveral days, 
then gradually decreafed : all his lymptoms 
by degrees alfo difappeared, and in no great 
length of time, by proper care, he got very 
well. 


When 


( 9 1 ) 

When this patient was attacked with his 
firft fymptoms, I did not fufpedt the true 
caufe. His want of fleep, his feeming 
anxiety, his taciturnity, and great unwil- 
lingnefs to anfwer any queftions, feemed 
to me, to befpeak a return of his mani¬ 
acal diforder. Upon this fuppofition, I 
gave him the opiate ; hoping, that if i 
could procure fleep, he might be better. 
But when I faw the altered appearance of 
the wound, and found that the pericra¬ 
nium had quitted its adhefion to the ikull, 
I was no longer in doubt, that whatever 
elfe might concur to diforder him, yet all 
his complaints were fairly deducible from 
the effects of his fall. And I apprehend 
he owed the prefervation of his life to the 
treatment he underwent, in confequence of 
fuch fuppofition. 


CASE 


( 9 2 ) 


CASE IX. 


Contnjion with wounds . 
Watchman, whofe ftand was in White- 



chapel, got into a fcuffle with fome 
drunken failors, and received feveral wounds 
and blows on his head ; from fome of which 
he loft fo much blood, that he was the next 
day brought into St. Bartholomew’s hofpi- 
tal in a very weak low ftate. 

Not one of the wounds, which were five 
in number, had pafied the pericranium ; but 
his whole head w r as very much fwollen and 
bruifed. He was in other refpeCts very 
well 3 that is, he did not complain of fick- 
nefs, or any other kind of pain than what 
forenefs the bruifes neceflarily occafioned ; 
and he had the full and perfect ufe of his 
fenfes. As he had already fuftained great 
lofs of blood, and was more than fixty years 
old, I made ufe of no farther evacuation, 
but drefled his head fuperficially, and di¬ 
rected that he fhould be kept in bed. At 
the end of about a week, the general tume¬ 
faction of the head was nearly gone, and 
all the wounds in a healing ftate ; the man 


tranf- 


( 9S -) 

tranfg reded rules of the hofpital by {laying 
out all night, and was difcharged. On the 
fifteenth day from that of the accident, he 
came to me again, complaining of head- 
ach, giddinefs, ficknefs, failure of drength, 
lofs of appetite, and want of deep. 

All the wounds, except one, were per¬ 
fectly healed ; this was on the upper part 
of the right parietal bone; it was crude, 
fpongy, and the exuberant flefli of fuch co¬ 
lour and confidence, as inclined me, (con- 
fidering at the fame time his general iymp- 
toms) to fufpeCt mifchief underneath it. I 
took him into the houfe again, and imme¬ 
diately removed a circular portion of the 
fcalp, including the wound, and found both 
pericranium and fkull in the date I fuf- 
peCted; that is, the former altered, and de¬ 
tached, and confequently the latter bare. 
Neither the age, habit, nor date of the 
man feemed to be capable of bearing free 
evacuation, nor did I in my own opi¬ 
nion believe that there was time for the 
experiment. I therefore perforated the mid¬ 
dle of the bare part of the bone, and found 
a fufficient warrant for having fo done; that 
is, a fmall quantity of matter on the furface 
of the dura mater. His head was drefled 
, lightly. 


( 94 ) 

lightly, a little blood was drawn from 
one of his arms, and a glyfter thrown up to 
procure a ftool. The following night he 
palled ill; had a flight {hivering, got little 
or no fleep, and complained very much, of 
pain in his head ; the bare membrane looked 
very crude, difcharged a thin gleet, and 
preffed hard againft the edges of the bone. 
The next day, his pulfe being confiderably 
rifen, he was let blood again : that after¬ 
noon he had another rigor, and his pain as 
well as fever became more intenfe. 

On the eighteenth day, finding him in^ 
every refpedt worfe, I made another perfo¬ 
ration, juft below the former, and gave 
thereby a difcharge to a larger quantity of 
matter, which the clofe preffure of the dura 
mater againft the edges of the perforation 
had hitherto confined. On the twentieth, 
he was indeed rather eafier, but his fever 
was very high, and both the dura mater 
and fore in the fcalp looked very ill ; where¬ 
fore fufpedting more matter, and being fa- 
tisfied the man had no other chance fcr life, 

I made a third perforation clofe by the fe- 
cond. This procured fo large a difcharge of 
pus, that I w r as very apprehenfive that the 
extent of the mifchief was too great for the 

af- 



( 95 ) 

affiftance of art to prove effectual in ; how¬ 
ever, I was luckily difappointed ; for in a 
very few days more all his bad fymptoms 
gradually left him, and the man got per¬ 
fectly well. 

From confidering all the circumftances of 
this cafe, I am fatisfied, that had not the 
cranium been perforated at all, the man 
muft have died, from the collection and 
confinement of matter : and I am alfo as 
much convinced, that the two former per¬ 
forations would have proved infufficient for 
the purpofe; and that the man owed his 
prelervation to the large removal of bone. 

This is a point of practice, which has by 
no means been fufficiently attended to by 
practitioners, nor fufficiently inculcated by 
the writers of our country at leaf!:. Many, 
who fee and are convinced of the juflnefs and 
propriety of it, want authority to vindicate 
them in propofmg or executing it ; and 
fome part of the difgrace which has been 
call on the operation of the trepan has a- 
rifen from this caufe. Practitioners have in 
general been afraid to make more than one 
opening, and that generally a fmall one. If 
the inflammation be of any extent, or the 
quantity of matter at all coniiderable, this 

one 

5 


' ( 96 ) 

©ne ftnall opening muft prove inefficient, 
either for the relief of the intenfe inflamed 
membrane, or for the evacuation of the 
fluid ; and the only probable chance which 
the patient can have muft be, from the re¬ 
moval of a large portion of bone ; and this 
equally in the cafe of extravafation of blood, 
or ferum, as in that of abfcefs. 


CASE X. 

Contujion joined with extravafation . 

A Fireman, who was at work on the top 
of an houfe, fell in with the roof of 
it; he was taken out fenfelefs, and brought 
in that ftate to the hofpital. 

He had on different parts of his body fe- 
veral wounds and bruifes, but none of 
them feemed to be of any great confe- 
quence. On his head were four, one of fome 
fize, on the upper part of the frontal bone, 
near to the coronal future; two on the left 
parietal ; one on the right fide of his head, 
juft above his ear and a fmall bruife on the 
upper part of the os occipitis. Of all thefe 
wounds, the pericranium was divided in 


one 


( 97 ) 

brie only, viz. that near the coronal fu* 
ture. 

His wounds were dreffed, he was largely 
bled, a glyfter was thrown up, and a pur¬ 
ging mixture was ordered to be given coch- 
leatim> tintil he ffiould have a difcharge per 
anum. The next day he was in the fame 
ftate, perfectly fenfelefs, had the apopledtic 
ftertor, a full labouring interrupted pulfe, 
and fome difficulty of refpiration. He had 
four or five large ftools, wherefore his mix¬ 
ture was difcontinued, but fixteen ounces 
more of blood were drawn from one of the 
jugular veins ; which evacuation was re¬ 
peated again in the evening of the fame 
day, to the quantity of eight more. On 
the third day, being fell perfectly flupid, 
difcharging both urine and feces invo¬ 
luntarily, and having fell a full labouring 
pulfe, both the temporal arteries were open¬ 
ed, and fourteen ounces drawn from thence. 
On the fourth, finding no alteration, and 
being Satisfied that the man’s Hate could 
hardly be made worfe, I determined to per¬ 
forate the cranium, and accordingly fet a 
large trephine on the upper part of the 
frontal bone, where the pericranium had 
been divided. The dura mater was found 

H to 


( 9 3 ) 

to be thinly covered with grumous blood, 
fome of which I removed, and thereby 
made way for the difcharge of more. The 
next day, (the fifth) finding that what dif¬ 
charge had been made, during the night, 
was bloody, and that the man was in no 
refpedt altered for the better, I thought I 
had fufficient authority for repeating the 
operation, which I accordingly did, clofe 
by and below the former; and as the blow, 
by which the wound had been inflidted, 
feemed to have been almoft exactly on the 
top of his head, I made a third opening in 

# ■' i 

the parietal bone, clofe to the future. The 
appearance under all was the fame as under 
the firft, viz. a thin layer of grumous, or 
rather coagulated blood. 

Next day, (the fixth) toward evening, 
the man opened his eyes; and on the fe- 
venth, in the morning, he fpake. The 
difcharge of blood continued for feveral 
days y and at the end of about a week from 
this time, ceafed ; the dura mater and the 
wounded fcalp wearing as good an afpedl as 
could be wifhed, and the patient being eafy, 
and rational. 

On the eighteenth day, he complained of 
pain all over his head, was fick, reached to 

vomit. 


I 


( 99 ) ' 

Vomit, and faid that he was faint and chilly* 
On the nineteenth his face was flufhed, his 
fkin hot, his pulfe quick, and hard. He 
was let blood, and ordered to have a glyfter, 
and to take fome medicines of the febrifuge 
kind. A day or two more palled in this 
manner, his fever not violent, but rather 
increafing than remitting; his pain, tho* 
not acute> yet fuch as to deprive him of his 
lleep ; little rigors occurring irregularly, no 
perfpiration, and an exceffive languor. At 
laft, on the twenty-firft day, on the upper 
part of the os occipitis, on the right fide 
where there had been a fmall bruife, a tu¬ 
mor arofe, fo characterized, as to fatisfy 
me, that the caufe of the late alteration of 
circumftances lay underneath it ; it did not 
rife to any height, and contained a fmall 
quantity of fanies, but covered a portion of 
bone which the pericranium had quitted. I 
removed the fcalp, and would have fet on a 
trephine, but the man obftinately refufed to 
fubmit to it. 

On the twenty-fifth day he loft the ufe of 
his left leg and arm, and was much con-^ 
vulfed, in thofe of his right fide; which 
paralyfis and fpafm continued until the 

H 2 twenty- 


( lOO ) 

twenty-feyenth, and on the twenty-eighth 
he died. 

Upon examining his head, a colleddion 
of matter was found under the bare part of 
the occipital bone ; the dura mater under 
this matter was fioughy and putrid, and a- 
bout a defert fpoonful of matter lay between 
the meninges* juft under the altered part of 
the dura mater. In the part where the 
bloody extravafation had been, every thing 
was perfectly fair and free from difeafe. 

In this cafe there feems to have been as 
clear a diftindion between the bloody ex¬ 
travafation, with its effeds, and the inflam¬ 
matory ftate of the dura mater, with its 
confequences, as can be defired. All the 
firft fymptoms were fuch as were caufed by 
mere, preffure of the extravafated blood 
an obliteration of every fenfible faculty, at¬ 
tended with the principal fymptoms of an 
interrupted circulation. Perforation of the 
fkull, where this extravafation had been 
made, did, by giving difcharge to the 
blood, happily remove thefe, and the man 
was getting well apace, until the ills ari- 
fing from another caufe, viz. the inflam¬ 
matory feceffion of the dura mater, in con- 
3 * fequence 


( 101 ') 

Sequence of contufion, and that in another 
place, began to appear; they indeed made 
their attack rather late, nor did they rife fo 
high as they moil frequently do •, but then it 
muft be considered what difcipline the poor 
man had undergone, and what evacuation 
had been made. Notwithftanding which, 
they bore their true, genuine, febrile, in¬ 
flammatory character, and produced their 
moft frequent event. What perforation of 
the os occipitale might have done, I cannot 
fay ; I fear but little, as the matter was 
not only upon, but underneath the dura 
mater, and that too difeafed. 


CASE 


( *°2 ) 


CASE XI. 

Contufion ninth wound, - 

A Drayman, drunk, and fleeping, fell 
from his dray, and his head was fo 
fqueezed between the wheel and a poft, 
that a coniiderable portion of the fcalp, 
together with the pericranium, was forced 
off from each parietal bone. 

He was brought to the hofpital fenfelefs; 
he was largely let blood, and the feparated 
fcalp being fo bruifed and mangled as to 
afford no probability of re-union, it was 
removed, and the bone dreffed with dry 
lint. The next day the man was fo well, 
and fo perfectly mailer of what fenfe he 
had, that I was inclined to believe, that a 
a great deal of the laft night’s appearance 
was owing principally to liquor. 

In ten days time the edges of the tom 
fcalp were digefled, and bore all the ap¬ 
pearance of fores in a healthy man. One 
of the parietal bones feemed difpofed to 
granulate without any exfoliation, the other 
looked as if it would throw off a feale. 

«>>' v ~' •• * t - v * ' >' + . ■ . 


On 


C 103 ) 

Oil the thirteenth day he was fo well, 
that having a large family to work for, he 
defired to be difcharged from the hofpital, 
and to be made an out-patient; but his 
fores were ftill fo large, and I had fo often 
been deceived by the fallacious appearance 
of fuch cafes, that I perfwaded him to flay 
another week. 

On the fixteenth day he complained much 
of head-ach, and faid, that he was fick and 
chilly; on the feventeenth, the florid, gra¬ 
nulated appearance, and laudable matter of 
the fores, were exchanged for a tawny, 
glafly furface, and a plentiful, thin gleet. 
I bled him freely, and bid him keep in 
bed. On the fame day, toward evening, 
he had a fhivering, and the day following 
two more ; that parietal bone (the left) 
which had hitherto looked as if it would be 
covered by a granulation, without exfolia¬ 
ting, now wore fo difeafed an afpedl:, that I 
fain would have fet a trephine on it imme¬ 
diately, but the man would not permit me. 
Every other means, were ufed, but to no 
purpofe. The fore on the right fide of the 
head continued to look well, but the fcalp 
quitted its adhefion to almofl the whole left 

H 4 parietal 


( 104 ) 

parietal bone, which bone looked very un¬ 
like to an healthy one. 

On the twenty-third day, from that of 
the accident, he died, having been paralytic 
in his right leg and arm from the twenty- 
firft. 

The appearance of the two fores, as well 
as of the two bones, were fo different, that 
I had curiofity to fee the date of the part§ 
underneath each. On the right fide the 
dura mater was in a natural, found, adhe¬ 
rent date. On the left, it was feparated 
from almoft the whole bone, and covered 
plentifully by matter, and was, for about 
the breadth of a half crown, doughy ; un-? 
der the Hough the pia mater was difeafed 
alfo, and matter was alfo formed on the 
furface of the brain. 

The following cafe was brought into St. 
Bartholomew’s hofpital, while I was con¬ 
fined to my houfe by ficknefs. The account 
therefore of the patient, while living, is as 
taken by Mr. Earle, my apprentice ; and 
that of the appearance after death, is in the 
words of the late ingenious Mr. Partridge, 
who affifted Mr. Earle in the examination 

t r * * * .( , t 4 . t .. «, 

sf the body. 


CASE 


( io5 ) 


CASE. XII. 

N the tenth of February, 1765, John 



Vy Biggs, a lad about thirteen years old* 
was driving a horfe round in a grinding 
mill, the horfe not being ufed to the work, 
ran round very faft; the boy fell and re¬ 
ceived fuch a blow from fome part of the 
frame in which the horfe worked, that he 
Jay, depriyed of fenfe, for fome time, that 
is, until fomebody came in to enquire why 
the mill went fo rapid. He had a fmall 
wound on the right fide of his head, and 
no other apparent mark of injury. In a 
few hours, by the affiltance of phlebotomy, 
he feemed to be very well again. His 
wound was dreffed by the family apothe¬ 
cary for a week, during which time, he did 
not feem to have any other complaint, ex¬ 
cept now and then having a flight head-ach. 
The wound, not healing kindly, the boy 
being a country boy, hired only for the 
purpofe of driving the mill-horfe, and the 
people with whom he lived being tired of 
keeping him unemployed, he was brought 
to the hofpital. The wound, was not large, 
apd although he did not feejn to have any 


other 


other complaint 
healing. 


( 106 

# ^ 

, %as nearly three weeks in 


On the eighth of March, he was feifed 
with a fever, beginning with a kind of cold 
fit. On the tenth, he was much diforder- 
ed, complained of acute pain in his head, 
and his wound, which had been healed, 
broke out again ; the pericranium fepara- 
ting from the bone on the twelfth, he be¬ 
came fenfelefs to all outward objedts, was 
convulfed in all his limbs, and jaw-locked. 
On this day Mr. Crane trepanned him, on 
the upper, fore and right fide of the fron¬ 
tal bone. On the furface of the dura ma¬ 
ter was found a confiderable quantity of 
good matter, on the next morning he died. 

The dura mater was detached from the 
cranium, for about an inch all round the 
perforation of the bone; what matter had 
been formed on its furface had been dif- 
charged by the operation, and little or none 
lodged y the pia mater and brain found in 
this part. At about two inches diftance 
from the original wound, higher up, and 
nearer both to the coronal and fagittal fu¬ 
tures, was a fmall tumor about the fize of a 
fplit garden bean; within this was a very 
little difcoloured matter, and under it the 
e bone 


( 1C 7. ) 

bone was bare. The dura mater corre- 
fponding with this tumor was detached, 
black, and floughy, and a confiderable quan¬ 
tity of matter lay under this floughy part, 
Communicating with an abfcefs, formed 
between the two hemifpheres of the brain, 
on the right fide of the falciform procefs. 






SECT, 



\ 


% 


( !°8 ) 


" -A 

SECT. IN. 

Separation, or dejlruffiion, of both tables of 
the Jkullfrom eontufwn. 

T HE reparation of a portion of the 
cranium, confifling of both tables, 
or of the whole thicknefs, happens not un- 
frequently, in old, or neglected venereal dis¬ 
orders. The difeafe, which in thefe cafes 
has its feat in the diploe, often fpoils the 
whole fubflance of the Done, and produces 
a feparation, or exfoliation of its whole 
thicknefs: the dura mater being always 
found, in fuch cafe, to be covered only by 
an incarnation generated from its furface. 

This kind of caries is fometimes of large 
extent, in one piece, but more frequently 
it is of fmaller fize, * and affects different 
parts of the fame fkull. The feparated 
piece is generally quite carious, and appears 
as if it had been worm-eaten, (what the 
French call vermoulue). The furface of 
the bone fo difeafed, is felaom much ele¬ 
vated, though generally fomewhat ; neither 

has 

* I have feen in one cafe, nearly the whole os frontale 
cafi ofr; and in another, the whole left parietal bone. 


( i°9 ) 

has it often the circumfcribed form and 
appearance of a true node, as .it is called; 
though now and then it has. 

The fcalp, which covers a bone in this 
date, is mod frequently difeafed alfo ; fome- 
times with one, large, ill-conditioned fore; 
but more often with a number of crude, 
foul, painful, ferpiginous ulcers; through 
mod of which a probe will difcover a 
rough, bare bone; and from which is con- 
dantly difcharged, a greafy, dinking fanies. 
This complaint is generally accompanied by 
a nodturnal head-ach, pocky fpots, and 
pains about the bread and flhoulders ; and 
is almod always preceded by the former: 
though very frequently that fymptom ceafes, 
either during the mercurial courfes, indi- 
tuted for that purpofe ; or when the peri¬ 
cranium covering the difeafed part, becomes 
foul and doughy. 

The proportion of extent of furface, 
which one table of thefe difeafed parts of 
the cranium bears to the difeafed part of the 
other table, is very uncertain, and often very 
unequal. Sometimes the alteration of the 
outer table is much more extenfive than 
that of the inner; in which cafe, when the 
reparation is made., the detached piece 

comes 


( ilo ) 

conies away very eafily, and the uncovered 
part of the dura mater is fmall, compared 
to the fize of the external fore ; but fome- 
times, on the contrary, the difeafe occupies 
a more ccnliderable extent of the inner 
table than of the outer, and thereby ren¬ 
ders the cafe more difficult and the cure 
more tedious. 

A mercurial courfe, begun, even before 
the fcalp covering the difeafed parts (hall 
have been ulcerated, though it be often 
fufficient, fully and perfectly to eradicate 
the lues from the habit, will neither pre¬ 
vent, nor cure, this local malady; which 
will therefore often remain, after fuch caufe 
of it has been really and totally removed : 
the bone is thoroughly fpoiled, (at leaft in 
the parts affected), and although the difeafe, 
^onfidered abflra£tedly, be cured, yet the 
texture of thefe harder parts neceffarily re¬ 
quires more time to caft off what is un¬ 
found, and to put on a healthy appearance, 
than the fofter do ; the local diilemper will 
remain a long time after. An inattention 
to, or a mifunderftanding of this circum- 
ftance has been the caufe, why many people 
have been haraffed, and even deftroved with 
unneceffary mercurial precedes, when the 


com- 


( III ) 

complaint has been truly local, which it fre¬ 
quently is after proper, previous mercurial 
treatment. Such medicines will be found to 
be fo far from haftening the removal, that 
by fpoiling the conftitution, relaxing the fo- 
lids, impoverifhing and diflolving the flu¬ 
ids, and weakening the vis vitas, they pre¬ 
vent nature from executing her own pur- 
pofe, and really protrafl: and retard that ef¬ 
fect which they are ufed (though injudici- 
oufly) with defign to expedite. Mercury is 
undoubtedly a fpecific for the pox, but it is 
alfo a poifon. It will cure that and fome 
other difeafes ; but its effects on the hu¬ 
man frame are neither light, nor fuperfi- 
cial. It becomes beneficial or prejudicial, 
according to the manner in which it is ap¬ 
plied ; and when it ceafes to do good, it 
will moft certainly do harm. This, though 
a very flagrant inftance of it, is not the 
only one which might be produced : the 
fame obfervation might be made, on the 
maladies proceeding from a difeafed pro- 
ftate, and urethra, producing indurations, 
and fiftulae in perineo ; in which the perfi- 
flance in the ufe of mercurials, after the 
producing lues has been cured, has cofl: 
many a man his life, by aggravating, and 

con* 


( m ) 

continuing that fymptomatic heftic fevef* 
(the neceflary confequence of pain and ir¬ 
ritation) which it ftiould be the whole bu~ 
finefs of art to calm and attemperate. In 
all thefe cafes a ftrong decodtion of farfapa-* 
rilla, with milk, for the common drink * 
a foft, nutritive diet, a clear air, and the 
free ufe of the Peruvian bark, will be 
found to be more conducive to the patient’s 
recovery, than any continued ufe of mer¬ 
cury, By the former he will be reftored 
and ftrengthened, by the latter he will be 
irritated, wafted and deftroyed* 

The fame kind of exfoliation or fepara** 
tion of both tables of the cranium, is fome- 
times the confequence of mere external vio* 
lence 

The 

* Morgagni deduces this from mifchief done to the vef- 
fels of the diploe. <c Antequam de Calvarise i&ibus ver~ 
« ba facere definamus, Iliad non eft praetereundum, utra- 
« que ejus tabuia prorfus illsefa, illaefifque fubje&arum 
meningum vafts, accidere aliquando ab i&u valido ob- 
€t tuft corporis, ut vafcula, quae inter tabulas medullae 
<c fubferviunt, rumpantur, Sc fanguinem fundant; qui 
procedente tempore eorruptus, eoque acrior fadlus, 
quod iuccus medullofus admifceatur, qui turn mora et 

** calore, in peflimam degeneret rancedinem, interiorem 
u tabulam carie afficiat; hominique, jam i&u oblito, Sc 
nihil ejufmodi timenti, intro defluens, meninges vitiet* 
neeemque afferat,” 

De Sedibus Sc Caufis, Sec . 


( ) 

The four following examples, which have 
fallen within my own knowledge, I fhall re¬ 
late without any comment* 

CASE XIIL 

A Gentleman's coachman was thrown 
from his box, on the road between 
London and Richmond, and received a 
Wound in his forehead, which divided the 
pericranium* and denuded the bone about 
an inch above the finus. The man received 
no other harm in the fall $ the lips of the 
wound were brought together by future* 
and he drove home. 

The next day his majfler, who was a go¬ 
vernor of St* Bartholomew's* and a timo¬ 
rous man, fent the patient into that houfe. 
As he feemed perfectly well, and the wound 
looked as if it would unite without any 
trouble, I dreffed him only with a fuperfi- 
cial pledgit. This did not fucceed, and the 
edges, inftead of uniting* became fpongy. I 
therefore ordered him to be dreffed with a 
little dry lint, thinking that the bare bone 
would foon throw off a final! fcale, and 
finifh the matter. At the end of three 
Weeks every thing was exadtly in the fame 

I ftate; 


( ”4 5 t 

ftate ; the bone bare, and not likely to ex¬ 
foliate, and the edges fpongy. Being in 
perfect health, the man was tired of the 
confinement of the hofpital, and was per¬ 
mitted to go home, taking drefiings with 
him. 

At the end of two months from the 
date of the fall, he returned to the hofpital 
again, and defired me to look at his fore ; 
which was not only not healed, but dis¬ 
charged much too large a quantity of mat¬ 
ter. The opening was about the fize of a 
filver three-pence, round, foft, and fpongy; 
upon feeling with a probe, I thought that 
the bone receded too much for a mere loofe 
exfoliation, and as the bone receded, the 
difcharge of matter increafed. Upon re¬ 
peated trials, I was thoroughly fatisfied, 
that both thefe circumftances were true, 
and alfo that the loofe piece was much too 
large to be extracted from the prefent open- 
ifig. 

I confidered, that the removal of a cir¬ 
cular piece of {kin would leave a fear, 
which would not only be a great defor¬ 
mity, but a deformity which would be liable 
to mifeonftrudions; and as there were 
no bad fymptoms to be obviated, nor any 
i , thing 



brought it away. It was the whole thick- 
nefs of the cranium, in every part firm, 
hard, and perfectly white 5 and it left the 
dura mater covered by a florid healthy in¬ 
carnation. I laid the divided fcalp down 
upon the membrane, without any interven¬ 
ing dreffing, and the fore healed in a few 



CASE XIV. 



elderly Woman riding in an hack- 


jLjl ney landau, by a fudden jolt ftruck 
her head with great violence againft an iron 
hook, at the top of it, put there to hold 
the two parts of the roof together. The 
blow gave her exquifite pain for the inftant, 
but that foon ceafed; and as it caufed nei-^ 
ther wound nor tumefaction, the took no 
farther notice of it. At the end of near two 
months, {he was feized with a violent pain 
in her head ; fo violent, that for feveral 
nights {lie was obliged to have recourfe to 


I 2 


laudanum. 


( u 6 ) 

* 

laudanum, in order to obtain a little broken 
reft. 

In about a week her pain went off, and 
a tumor arofe, juft where ftie had been 
ftricken ; that is, juft in the middle of the 
fagittal future. 

Mr. Brown, of Little Britain, had the 
care of her; with him I faw her; we open- 
ed the tumor; and difcharged a confiderable 
quantity of difcoloured and very ofifenfive 
matter. I paffed my finger into the open¬ 
ing, and to my great aftonifhment found 
it touched the dura mater. We removed a 
circular piece of the fcalp, and found the 
two ofla parietalia bare, and carious for a 
confiderable extent, on each fide of the fu¬ 
ture; and in the middle of this carious 
piece, juft in the trail of the future, a 
hole large enough to admit eafily any man's 
finger, without touching the edges of the 
bone. 

No exfoliation was found in the matter, 
or on the membrane; the dura mater lay 
at a confiderable diftance from the fkull, in 
that part ; the difcharge from within was 
large and very offenfive; and about three 
weeks, from the time of opening, {he died 
fuddenly in a kind of fit. 


CASE 


K 

( tij ) 


CASE XV. 

✓ 

I N the middle of September 1763, a 
woman about fixty years old fell down 
flairs backwards ; fhe was ftunned by the 
blow, which her head received from one of - 
the fteps, and lay fenfelefs fome time. 

There w T as neither wound nor confider- 
able bruife; fhe was let blood, and kept 
quiet for fome few days; at the end of 
which, finding no inconvenience either ge¬ 
neral or particular, fhe ceafed to regard it. 

On the eighteenth of December, fhe was 
taken into the hofpital, for a fwelling on 
the right fide of her head, nearly of the 
fize of a fplit Sevile orange. This tumor 
fhe faid, had been preceded by a fevere 
head-ach without fever; but as fhe did not 
then believe that her fall had any fhare in 
the produ&ion of her prefent complaint, 
file faid nothing about it. 

Her head being fhaved, the tumor ap¬ 
peared full of a fluid. I divided the 
icalp, and let out a quantity of greafy 
offenfive matter. Upon further examina¬ 
tion, the bone was found to be bare, and 
carious. I removed fuch a portion of fcalp, 

13 - as 


( US ) 

as brought the whole into view. The na¬ 
tural texture of the bone was deftroyed, 
and in it were feveral holes, through which 
a probe might eafily be paffed, and from 
which matter was difcharged in fuch mam 
ner, and with fuch motion, as plainly 
proved, that it came from within the ca¬ 
vity of the fkull. 

She remained in the hofpital until the 

JL 

middle of March ; during which time no 
alteration appeared in any part of the bare 
bone. 

The affairs of her family now required 
her to be at home. She was in perfect 
good health ; was difcharged from the hof¬ 
pital ; and as fhe lived very near to me, one 
of my young gentlemen undertook to take 
care of her. On the twenty-eighth of 
March 1764, a fmall part of the bare bone 
came away, and left the dura mater co¬ 
vered by an healthy incarnation ; and on 
the twelfth of April following, the whole 
remainder, being about a third part of the 
parietal bone, did the fame. From firft to 
lad {he had no kind of uneafinefs, and thu 
fpre healed without any trouble. 

/ * t JmtErn m 




CASE 


( 11 9 ) 


CASE XVI. 

I N that ever memorable defence, made • 
by Capt. Gilchrift, on board (as I think) 
the Southampton man of war, againft a 
moft fhameful fuperiority of French force; 
a failor received a fevere blow on his head 
by a large fplinter; a fmall wound and a 
confiderable bruife were the immediate con- 
fequence; but they were fo foon well, that 
the man did duty in a few days. At about 
feven weeks diftance from the time of the 
accident, he began to complain of great 
pain in his head ; which pain in a few days 
rendered him fo incapable, that he was put 
into the hofpital at Gofport. He remained 
there about three weeks, frequently but 
not conftantly in pain; and during that 
time had three or four fits, like epileptic 
ones. 

He was now fent to St. Bartholomew’s 
hofpital, and put under the care of Dr. Pit¬ 
cairn, by whofe order he was bled, purged, 
and took feveral medicines. The man hav¬ 
ing one day mentioned the circumftance of 
the blow, the doftor defired that I might 
examine him, 

I 4 There 




( * 20 ) 

There was not the lead degree of fwel- 
ling or inflammation, no mark or veftige 
of a fear, nor any elevation of the fcalp, 
or fluctuation of fluid under it. While I 
was examining his head, he had a flight 
attack of fpafm ; but on my defifting, he 
became eafy and tranquil. 

The circumftance of this attack, while 

/ 

% \ . ; 

I w T as prefling upon the part did not at 
that inftant ftrike me, as worthy notice, 
but upon reflexion it appeared much fo. 
The next day I made the fame experiment, 
with the fame effect ; that is, upon hard 
preffure he became convulfed, which con- 
yulfion ceafed upon removing the fingers, 
but was followed by a rigor. On the fol¬ 
lowing day I ventured to repeat the experi¬ 
ment i but the man was fo immediately 
and io terribly convulfed, that I determined 
never to try it again. 

1 informed his phyfician of all that had 
paffed, and we agreed, that confidering the 
inefficacy of all that had hitherto been 
done, and what had lately happened, the 
pioft probable method of attempting his 
Relief would be, by denuding and perhaps 
perforating the cranium, in the place where 
the preffure produced fo ftrange an effeCL 


t 


( 121 ) 

The next day I removed a circular piece 
of the fcalp, and found the pericranium 
not of a healthy or found colour, nor ad¬ 
herent to the bone \ which bone was ca¬ 
rious, and had feveral fmall holes in it* 
through which a fanies rofe and fell, ac¬ 
cording to the motion of the blood in the 
brain. I applied a large trephine, without 
any regard to the future, and removed a 
piece of fkull, During the time of the 
operation, the poor man fuffered greatly 
from fpafm; but that over, he became eafy 
and quiet. 

i N 

The dura mater was detached from the 
flcull, and had matter on its furface ; which 
matter was extremely offenfive. The enfu- 
ing night he paffed ill; and the next day 
had fuch a rigor, that I verily thought it 
was the laft trouble the man could have. 
The day after this I found him vaftly bet¬ 
ter ; the difcharge from his head had been 
large, but he had not fuffered any return 
either of fpafm or rigor, and his principal 
complaint was extreme lownefs. 

The phyfician prefcribed for him; his 
medicines agreed well with him, and every 
thing for feveral days wore a favourable 
afpedt* On a fuddeji, he was fei^ed with all 

the 


I 


( 122 ) 

the lymptoms of a peripneumony, and, on 
the third day from that feizure, died. 
No apparent canfe of mifchief was found 

either within or on the outlide of the 

**• 

head, the dura mater was well incarned. 

p 9 

and no lodgment of matter. 


* * 

•'V 


\ 

- ' V t -f ’ . i : l \ 

/ 

J ; . - . * ... ^ 


SECT. 





A 



( 123 ) 


SECT. IV. 

Fi/fures, andfraBures of the cranium , with¬ 
out deprefjion . 

F Radures of the cranium were, by the 
ancient writers, divided into many 
different forts, each of which was diftin- 
guiflied by an appellation of Greek ety¬ 
mology, borrowed either from the figure of 
fradure, or the difpofition of the broken 
pieces. Thefe are to be found in moft of 
the old books : but as they merely load the 
memory, without. informing the under- 
{landing, or afiifting the praditioner, mo¬ 
dern authors have generally laid them 
afide. 

This kind of injury is divifible into two 
general heads, viz. thofe in which the 
broken parts keep their proper level, or 
equality of furface, with the reft of the 
fjcull ; and thofe in which they do not: or, 
in other words, fradures without depref- 
fion, and fradures with. 

Thefe two diftindions are all which are 
really neceffary to be made, and will be 
found to comprehend every violent divifion 

of 


( 124 ) 

of the parts of the fkull, (not made by a 
cutting-inftrument) from the fineft capillary 
fiflure, up to the moft complicated fradure : 
for Mures and fradures, differing from each 
other only in the width of the breach, or 
in the diftance of the feparated parts; and 
the difpofition of broken pieces, in large 
fradures, being fubjed to an almoft infinite 
variety ; diftindions and appellations drawn 
and made from thefe circumfiances, might 
be multiplied to even three times the old 
number, without imparting the fmalleft de¬ 
gree of ufeful knowledge to the man, who 
fhould be at the pains to get them by 
heart. 

What are the fymptoms of a fradured 
cranium ? is often afked; and there is hard¬ 
ly any one who does not, from the autho¬ 
rity of writers, both antient, and modern, 
anfwer, vomiting, giddinefs, lofs of fenfe, 
fpeech, and voluntary motion; bleeding at 
the ears, nofe, and mouth, &c. This is 
the dodrine of Celfus, which has been moft 
invariably copied by almoft all fucceeding 
authors, and implicitly believed by almoft 
all readers 

The 

V , »,ii . > , *,VJ 

* c< Igkur ubi percufla eft calvaria, protinus requires 
dum eft, num bilem is homo vomuerit, num oculi 

** eju$ 


( 125 ) 

The fymptoms juft mentioned do indeed 
very frequently accompany a broken fkull? 
but they are not produced by the breach 
made in the bone ; nor do they indicate 
fueh breach to have been made. They 
proceed from an affedtion of the brain, or 
from injury done to fome of the parts 
within the cranium, independant of any 
ill which the bones compofing it may have 
fuftained. They are occaftoned by violence 
offered to the contents of the head in ge¬ 
neral; are quite independant on the mere 
breach made in the bone; and, either do, 
or do not accompany fracture, as fuch frac¬ 
ture may happen to be or not to be com¬ 
plicated with fuch other ills. 

They are frequently produced by extra- 
vafations of blood, or ferum, upon, or be¬ 
tween the membranes of the brain ; or by 
fhocks, or concuffions of its fubftance, in 
cafes where the fkull is perfe&ly in tire and 
unhurt. On the other hand, the bones of 
the fkull are fometimes cracked, broken, 
nay even depreffed ; and the patient fufFers 

none 

<e ejus obcsecati fint; num per nares, aurefve fanguis ei 
effluxerit; num conciderit; num fine feniu quafi dor- 
<c miens jacuerit ? &c. haec enim non nifi ojfe fratio eve* 
niuntt l- 


( 126 ) 

fione of thefe fymptoms In fhort, "at 
the breach made in the bone is not, nor 
can be, the caufe of fuch complaints, they 
ought not to he attributed to it ; and that 
for reafons, which are by no means merely 
fpeculative. For the practitioner, who fup- 
pofes that fuch fymptoms do neceflarily, 
and certainly imply, that the cranium is 
fradtured, mull regulate his condudt by 
fuch fuppofition ; and remove the fcalp, very 
often without either neceffity, or benefit; 
that is, without difcovering what he looks 
for: and, on the other hand, if he does 
find the fkull to be broken; believing all 
thefe complaints to be caufed by, and de- 
ducible from, the fradture, he will moft 
probably pay his whole attention to that 

fuppofed 

* <c Si Isefus inftar dormientis fenfus expers deprehenda- 
“tur; fi oculi ejus obcsecati fuerint; fi obmutuerit; fi 
<c bilem vomuerit; fi animalis inftar malleo idti conciderit. 
€C hsec omnia maximam & fubitaneam fignificant cerebri 
commotionem, perturbationem, ac concuflionem, qua 
non rara integro manente, nec ulla ex parte rupto cranio , 
“ mortem percufTo adferunt. ,, ' Pet. Pa aw. 

ci Dans les playes de tete, les accidens que les auteurs 
<c anciens ont appelles primitifs parcequ’ils arrivent dans 
l’inftant meme de la bleflure, ne font nullement des ac- 
<c cidens, ni des fignes, de la fradlure fubfiftant, mais des 
“ accidens, & des fignes, de la commotion de cerveau.” 

3 Le Dran. 


( 127 ) 

fuppofed caufe, and may think, that when 
he has done what the rules of his art pre- 
fcribe for fuch cafe, he has done all that is 
in his power. An opinion not infrequent¬ 
ly embraced $ and which has been the de- 
ftrudion of many a patient : for, as on the 
one hand, the lofs of fenfe, fpeech, and 
voluntary motion, as well as the haemor¬ 
rhage from the nofe, ears, &c* are fome- 
times totally removed by, or at leaft difap- 
pear during the ufe of free and frequent 
evacuation, without any operation on the 
fcalp or Ikullj fo on the other, as thefe 
fymptoms and appearances are not pro¬ 
duced by the folution of continuity of the 
bone, they cannot be remedied by fuch 
chirurgic treatment, as the mere fradure 
may require. 

If any one doubts the truth of this doc¬ 
trine, I would delire him to confider the 
nature, as well as moll generally fuccefsful 
method, of treating thefe lymptoms ; and 
at the fame time, to refled ferioully, on 
the operation of the trepan, as pradifed in 
limple, undeprelfed fradures of the fkull. 

The ficknefs, giddinefs, vomiting, and 
lofs of fenfe and motion, can only be the 

confe- 


( i« ) 

confequence of an affedion of the brain , 
as the common fenforium* They may 
be produced by its having been violent¬ 
ly Ihaken ; by a derangement of its me¬ 
dullary ftrudure, or by unnatural prefliire 
made by a fluid extravafated on its fur-* 
face, or within its ventricles ; but never 
can be caufed by the mere divifion of the 
bone, (confidered abftradedly) which divi-» 
fion, in a Ample fradure, can neither prefe 
on nor derange the ftrudure of the parts 
within the cranium. 

If the folution of continuity in the bone 
be either produced by fuch a degree of vio* 
lence, as hath caufed a confiderable diftur- 8 
bance in the medullary parts of the brain, 
or has difturbed any of the fundions of the 
nerves going off from it; or has occafioned 
a breach of any veflel, or veflels, whether 
fanguine or lymphatic; and that hath been 
followed by, an extravafation, or lodgement 
of fluid, the fymptoms neceftarily confer 
quent, upon fuch derangment, or fuch pref- 
fure, will follow $ but they do not follow, 
becaufe the bone is broken ; their caufeS 
are fuperadded to the fradure ; and altho’ 
produced by the fame external violence, are 

* yet 


3 


( 129 ) 

yet perfectly and abfolutely independant of 
it; fo much fo, that, as I have already ob- 
ferved, they are frequently found where no 
fradture is. 

The operation of the trepan is frequent¬ 
ly performed in the cafe of fimple fradtures, 
and that very judicioufly and properly; but 
it is not performed, becaufe the bone is 
broken, or cracked : a mere fradture, or 
fiffure of the fkull, can never require perfo¬ 
ration, or that the dura mater under it be 
laid bare ; the reafon for doing this fprings 
from other caufes than the fradture, and 
thofe really independant on it. They fpring 
from the nature of the mifchief which the 
parts within the cranium has fuftained, and 
not from the accidental diviAon of the 
bone. From thefe arife the threatening 
iymptoms $ from thefe all the hazard; and 
from thefe, the neceffity, and vindication, 
of performing the operation of the trepan. 

If a Ample fradture of the cranium was 
unattended in prefent with any of the be¬ 
fore-mentioned fymptoms, and there was 
no reafon for apprehending any other evil 
in future; that is, if the folution of con¬ 
tinuity in the bone was the whole difeafe, 
it could not poffibly indicate any 'other cu- 

K Native 


( i3° ) 

rative intention, but the general one, in all 
fractures, viz. union of the divided parts. 
But • how can fuch union be promoted or 
afiifted by perforation ? it moft certainly 
cannot ; and yet perforation is abfolutely 
neceffary in feven cafes out of ten, of Am¬ 
ple undeprefled fradtures of the fkirll. Let 
us for a moment enquire why it is fo. The 
'reafons for trepaning in thefe cafes are, 
firft, the immediate relief of prefent fymp- 
toms arifing from preffure of extravafated 
fluid; or fecond, the difcharge of matter 
formed between the fkull and dura mater, 
in confequehce of inflammation •> or third, 
the prevention of fuch mifchief as experi- 

V 

ence has fhewn may, moft probably, be 
expe&ed from fuch kind of violence offered 
to the laft-mentioned membrane. , Thele 
are the only reafons that can be given for 
perforating the fkull, in the cafe of an un- 
depreffed fracture ; and very good, and 
very juftifiable reafons they are; but not 
drawn from the fra&ure. 

In the firft cafe, (that of an extravafated 
fluid within the cranium), the relief from 
perforation is not only fometimes imme¬ 
diate, but frequently is not attainable by 
any other means. This is a fufficient proof 
; not 


( * 3 * ) 

hot only of its utility* but of its- necef* 
fity. ; 

In the fecdnd, (of formation of matter 
between the fkull and dura mater)* it is the 
unicum remedium : there is no natural out¬ 
let, by which fuch matter can efcape * and 
the only chance of life is,, from the opera¬ 
tion. 

In the third, that of mere frafture c With- 
Out depreffion of bone, or the appearance 
of fuch fymptoms as indicate commotion, 
extravafation, or inflammation, it is ufed 
as a preventative, and therefore is a matter 
of choice, more than immediate necefiity. 

Many practitioners, both antient and mo¬ 
dern, have therefore difufed and condemned 
it; and have, in cafes where there have 
been no immediate bad fymptoms, advifed 

us to leave the frafture* to nature, and not 

^ * > 

to perform the operation as a preventative, 
but to wait until its necefiity may be indi¬ 
cated by fuch fymptoms, as may both re¬ 
quire and vindicate it. This is a point of 
the utmofl: confequence in practice; and 
ought to be very maturely confidered. 

They who objedt to the early ufe of the 
trephine fpeak of it as being frequently 
unneceflary, and as rendering the patient 

K z liable 


( * 3 2 ) 

liable to feveral inconveniencies, Which may 
arife from uncovering the dura mater, be¬ 
fore there is any good, or at leaft any appa¬ 
rent reafon for fo doing. And in fupport of 
this their opinion* they alledge many in- 
flances of fiimple fradure, which have been 
long undifeovered, without being attended 
with any bad fymptoms ; and of others, 
which though known and attended to from 
the firft, have done very well, without fuch 
operation. 

, They who advife the immediate ufe of 
the inftrument, do it upon a preemption, 
that, in confiderable violence received by 
the head, fuch mifehief is done to the dura 
mater, and the veflels by which it is con¬ 
ceded to the cranium, that inflammation 
of the faid membrane muft follow 5 which 
inflammation generally produces a colledion 
of matter, and a fymptomatic fever, which 
moft frequently baffles all our art, and ends 
ill the deftrudion of the patient. 

What the former afiert is undoubtedly 
fometimes true. There have been feveral 
inftances of undeprefled fradures of the 
fkull, which either from having been un¬ 
difeovered at firft,. or negleded, or having 
been under the care of a praditioner who 

has 


( »33 ) 

has difliked the operation, have done very 
well without it. This is certainly true, but 
is not fufficient to found a general rule of 
practice upon : in matters of this fort, a 
few inftances are by no means fufficient to 
eftabliffi a precedent: what has been, or 
may accidentally prove beneficial to a few, 
may be pernicious to the multitude : that 
which is found to be mod frequently ufeful, 
is what we ought to abide by ; referving to 
ourfelves a liberty of deviating from fiach 
general rule in particular cafes. 

This is one of thofe perplexing circutn- 
ftances, which all writers lament, and all 
practitioners feel; but which, inftead of 
merely complaining of, we fliould endea-, 
vour, as much as in us lies, to correct. 

In order to obtain what information we 
can on this fubjeCt, we ffiould confider, 
firft, what the mifchiefs are, which may, 
mod probably be expeCted to follow, or 
which mod frequently do follow, when 
perforation has been too long deferred, or 
totally negleCted; fecondly, what prejudice or 
inconvenience does really arife from, or is 
thought to be caufed by the operation itfelf, 
confidered abftraCtedly ; and thirdly, what 
proportion the number of thofe who have 

K 3 done 


( 134 ) / 

done well without it, bears to that of thofe, 
who may truly be laid to have been loft for 
want of it ; or of thofe, to whom it rnight 
have afforded fome chance of relief. 

With regard to the firft, J have already 
obferved in the cafe of fimple undepreffed 
fradtures, whenever the trephine is applied* 
jt mull be with defign either to relieve, or 
to prevent ills arifing from other mifchief 
than the mere breach in the bone; which 
breach, confidered (imply, and abdradedly, 
can neither caufe fuch ills, nor be relieved 
by fuch operation. One, and that the moft 
frequent of thefe mifchiefs is, the inflam¬ 
mation, detachment, and fuppuration of 
the dura mater, and confequently the col¬ 
lection of matter between it and the flcull $ 
a cafe of all others, attending wounds of 
the head, the mod prefling, the moft ha¬ 
zardous, and the lead within our power to 
relieve. On this fubjecl, I have exprefled 
my fentiments fo much at large, under the 
preceding article contiifion , that it is need-* 
lefs to repeat them here. I (hall therefore 
take the liberty of referring the reader back 
to that, and only remind of a circumdance 
well worth his attending to, viz. that there 
are no immediate, or early marks or lymp- 

tom$. 

* * ** " ▼ 


( _ *35 ) 

toms, whereby he can certainly know, whe¬ 
ther fuch kind of mifchief is done or not; 
and that when fuch complaints come on, 
as indicate that fuch mifchief has been re¬ 
ceived, although the operation is all that is 
in our power to do, yet it is very frequentr 
ly unfuccefsful Indeed the only proba¬ 
ble 

V * 

* The {late of the dura mater, under fimple fradlures 
and fiflures of the cranium, has been very nicely obferv- 
ed, and very juftly defcribed, by fome of the beft writers 
of antiquity. 

Si ad cerebri membranam ufque pervenerit fradtura, 
non rademus, fed agnofcere conabimur utrum mem- 
brana ab ofle recefterit, an afftxa permaneat. Si enim 
ipfa manet, inflammatio nulla infeftat vulnus, & pus 
lc codtum apparet. Si ceflerit membrana, augentur dolo- 
<c res, et febris fimiliter ; os alium fumit colorem ; pus 
c< tenue, & crudum effertur; & ft medicus negligenter 
<c rem tradfat, nec perforatiene utitur, hoc graviora fymp- 
ct tomata aboriuntur ; nempe bilis vomitus, convulfto, 
mentis delirium, & febris acuta.” 

Paulus /Egineta. 

<c Dico debet dari ftgnum fradturae, a qua removeatur 
<c panniculus groflus. In primo debes fcire difpofitionem 
“ fyphac ; utrum eft adherens, an non j videlicet, ft ad- 
cc hasferit offi non fiet in vulnus apoftema calidum ; 

& licet accidit, modicum erit j aerugo manebit de eo 
w modica; & putredo erit digefta. Sed ft fuerit remctus, 
tc vehementiores erunt dolores, & febres, mutabitur color 
€i oflis, & corrumpetur, & manebit de co putredo tenuis.” 

Rhazes. 

K 4 


Si 


( * 3 6 ) 

ble method of preventing this evil feems 
to be, the removal of fuch a part of the 
fkull, as by being broken appears plainly to 
have been the part where the violence was 
inflifted ; and which, if the dura mater be¬ 
comes inflamed, and quitting its connexion 
fuppurates, will, in all probability, co-* 
ver and confine a colle&ion of matter, for 
which nature has provided no outlet. This 
I take to be, nojt only the beft, but the 
only good reafon, for the early ufe of the 
trephine in fimple undeprefled fractures of 
the fkull : and I muft add, that it appears 
to me to be fully fufficient to vindicate 
and'authorife it. That it frequently fails 
of fuccefs, is beyond all doubt; the extent 
and degree of the mifchief being too great 
for it to relieve ; but that it has preferved 
many a life, which muft have been loft* 
without it, I am as well fatisfied of, as I 
am of any truth, which repeated experi¬ 
ence-may have taught me. 

* In 

Si rima fit in fuperfkie, cerebri membrana non abfce^ 
dente, eadem adhibeatur, quae ad os nudatum demonftra- 
ta eft : cerebri vero membrana abfcedente & humore ibi 
colle&o, poft primos curationis dies ad terebram properari- 
dum eft, &c. 

Oribasius, 


( 137 ) 

In matters of this fort, pofitive proof 
and convi&ion are not in our power; all 
that we can do is, by making a compari- 
fon of the condudt and event of a number 
of fimilar cafes, to come as near to truth as 
we can, and to get probability on our fide. 

The fecond confideration which I pro- 
pofed to be made was, what mifchief, or 
inconvenience may moft reafonably be fup- 
pofed to follow, or to proceed from the mere 
operation confidered abfiradtedly. They who 
are averfe to the ufe of it, as a preventative, 
alledge, that it occafions a great lofs of time ; 
that it is frequently quite unneceflary; and 
that the admifiion of air to the dura mater, 
as well as the laying of it bare, is neceflarily 
prejudicial. 

The former of thefe is undoubtedly true; 
a perfon whofe fkull has been perforated, 
cannot pofiibly be well (that is cured) in fo 
fliort a fpace of time, as one who has not 
undergone fuch operation; fuppofing fuch 
perfon to have fuftained no other injury 
than the mere fradture : and if the majo¬ 
rity of the people, whofe fkulls are broken, 
were fo lucky as to fuftain no other 
injury, that is, if no other mifchief was in 
thefe cafes in general done to the parts con¬ 
tained 


( i3 8 ) 

tained within the fkull, the objection to 
perforation, would be real, and great, and 
the operation a matter of more ferious 
confideration. But this is feldom, too 
feldom the cafe ; by much the larger 
number of thofe, who fuffer a fradture of 
the fkull, are injured with regard to other 
parts, and labour under mifchief of ano¬ 
ther kind, additional to the fradture ; that 
is, the parts within the cranium are injured 
as well as the cranium itfelf. This being 
the cafe, the lofs or wafte of a little time 
•ceafes to be an objedt of fo great impor¬ 
tance. The hazard, which it is fuppofed 
may be incurred from laying bare the dura 
mater, is indeed a matter of fome weight, 
fo much fo, that it certainly ought not to 
be done, but for very good reafons and 
yet, although I am clearly of this opinion, 
I think that I may venture to fay, that let 
the fuppofed hazard be what it may, it can¬ 
not in the nature of things, be, by any 
means equal, to that which muji be incur¬ 
red by not doing it, when fuch operation 
becomes neceffary. In fhort, if we would 
form a right judgment of this point, the 
queftion concerning it ought to ftand thus ; 
is the chance of ill which ?nay proceed 

- from 


( *39 ) 

from merely denuding the dura mater, 
equal to that, of its- not being fo hurt by 
the blow, as to inflame, and fuppurate ? 
Or is the mifehief which may be incurred 
by mere perforation of the Ikull, equal to 
the good which it may produce ? Thefe 
queftions, let thole who have feen mo ft bu- 
finefs of this kind, and who are therefore 
the beft jridges, confider and determine. 
For my own part, I have no doubt, that 
although by eftabliftdng it as a general rule 
to perforate in all cafes, fome few would 
now and then be fubjedted to the operation, 
who might have done-very well without it; 
yet, by the fame pradtice, many a valuable 
life would be preferved, which muft inevi¬ 
tably be loft without it, there being no de¬ 
gree of comparifon between the good to be 
derived from it, when ufed early, as a pre¬ 
ventative, and what may be expedted, if it 
be deferred till an inflammation of the dura 
mater and a fymptomatic fever make it ne- 
ceflary. 

The third confideration, viz. what pro¬ 
portion the number of thofe w 7 ho have ef- 
caped without the operation, bears to that 
of thofe who have periflied for want of it, 
is in great meafure included in the two pre- 


i 


C *40 ) 

ceding j at leaft the determination of them, 
muft alfo determine this. 

My own opinion muft, till I find reafon 
to alter it, be the rule of my own conduct; 
and tho* I would not by any means pretend 
to obtrude the former on any one, yet I 
think it in fome meafure incumbent upon 
me in this place to give it. 

The number of cafes of this kind, which 
are necefiarily brought into a large hofpital, 
fo fituated as Bartholomew’s is, in the mid¬ 
dle of a populous city, where all kinds of 
hazardous labour are carried on, has en¬ 
abled me to make many obfervations on 
them; and although I have now and then 
feen fome few of them do well without 
the ufe of the trephine, yet, the much 
greater number, whom I have feen perifti 
with collections of matter within the cra¬ 
nium, who have not been perforated, and 
for whom there is no other relief in art or 
nature, has, I muft acknowledge, rendered 
me fo very cautious and diffident, that al¬ 
though I will not fay, that I would always 
and invariably perform the operation, in 
every cafe of Ample fraCture; yet the cafe 
muft be particularly circumftanced, the 

profpeCt 


i 


( * 4 » ) 

profpedt much fairer than it moft frequently, 

is, and my prognoftic delivered in the moft 
guarded apprehenfive manner when I omit 

it. I ihould be forry to be fo mhunderftood, 
as to have it fuppofed that I mean to fay, 
that I think the denudation of the, dura 
mater a matter of abfolute indifference, or 
that no ill can proceed from it : this, I 
know is a point concerning which the beft 
practitioners have differed, and concern¬ 
ing which, we ftill ftand in need of infor¬ 
mation $ but I think I may venture to fay, 
what is fully to my prefent purpofe, viz. 
that inlarging the opening of a fraCture, by 
means of a trephine, will not produce or. 
occafion much rifque or hazard, additional 
to what mult be occafioned by the frafture 
itfelf: that has already let in the air upon 
the membrane, and therefore that confide- 
ratiqn is, at lead: in fome degree, at an 
end, and the principal point to be deter¬ 
mined ftill remains the fame, viz. whether 
upon a fuppofition, that the dura mater 
may poflibly not have been fo injured as to 
inflame and fuppurate in future, the ope¬ 
ration ought not to be praCtifed, as a pre¬ 
ventative, but, on the contrary, ought ra¬ 
ther to be deferred until worfe lymptoms 

Z indicate 


/ 


( 14 * ) 

indicate the neceffity of it ? or whether it 
ought in general to be performed early, in 
order, if poffible, to prevent and guard a- 
gainft very probable, as well as very terri¬ 
ble mifchief ? 

I know that it may be faid, that a frac- 

; 

ture, if of any confiderable fize, or whofe 
edges are fairly diftant and unconnected, 
will of itfelf make fome way for difcharge 
from within; and fo it certainly may, and 
does, in the cafe of an effufion of fluid 
blood; but even in this it very feldom 
proves fufficient for the purpofe. But does 
not the diftant feparation of the edges im¬ 
ply greater feparation of the attaching vef- 
fels of the dura mater ? and does not expe¬ 
rience too often prove this to be the cafe ? 
In truth, the great advantage which is 
fometimes derived from confiderable frac¬ 
tures, is moft frequent in thofe cafes where 
portions of bone are fo loofe as to be re¬ 
movable, which removal of bone ftands 
in place of perforation, and makes much 
more for the neceffity of the operation in 
other cafes than againft it, if properly con- 
fidered. 

I may poffibly be told that Hildanus, 
Wifeman, and others of great and defer- 
r ved 


( r 43 ) ' 

ved reputation, have been of the former 
opinion. I know they have; and when I 
differ from thefe, or any other good autho¬ 
rity, I hope that I (hall always do it with 
caution- and diffidence ; but I hope alfo, 
that I ffiall never hefitate to differ from 
any, and every authority, when I think 
that I have truth on my fide, and the good 
of mankind in my view. The above-men¬ 
tioned writers, together with almofl: all 
their contemporaries, had, in ffrnple frac¬ 
tures of the fkull, but one objeCt in con¬ 
templation, the extravafation of blood ; this 
they regarded as the caufe, both of the 
early {ymptoms, and of the late ones ; con¬ 
sidering it, as a&ing either by preffure or 
putrefaction; and therefore, when there was 
no immediate fign of fuch extravafation, 
from the effedts of preiTure, they faw no 
neceffity for early, or immediate perfora¬ 
tion. But had they not forgotten the uni- 
verfal adhefion of the dura mater to the cra¬ 
nium ? had they not, without any, or in>- 
deed contrary to all authority from anato¬ 
my, formed to themfelves an erroneous idea 
of the difpofition of thofe parts, with re¬ 
gard to each other * ? Had they conceived 
* rightly 

* Some of the writers of this time, fpeak of the fup- 

pofed 


C 144 ) 

rightly of the confequences of an inflam-* 
mation and detachment of that membrane, 
I am much inclined to believe, that they 
would have altered their opinion, and not 
in general have left penetrating fractures of 
the fkull to nature; although they had, in 
fome meafure the authority of Celfus for 

,fo doing % a 

I n a • Before 

V • ' >y • / w- «**• . 0 '*>'**,•'*■ ■ • > ‘t- 1 • 1 * ^x ?:• C 

pofed vacuity between the dura mater and fkull, as being 
calculated for the reception of extravafated fluid, in cafe 
of accident: which opinion reminds me of that of a 
much later writer, who fays, “ that the os unguis was 
«* made fo thin, for its more eafy perforation in the ope- 
“ ration of the fiftula lacrymalis. 

* 66 In omni vero fiflo fra£tove ofle, protinus antiqui- 
ores medici, ad ferramenta veniebant quibus id qxciae- 
« rent. Sed multo melius eft ante emplaftra experiri, 
« quae calvariae caufa componuntur,” &c. 

Celsus. 

Whoever has an inclination to amufe himfelf with the 
different opinions of different writers on the fubje<5t of- 
perforating, or not perforating, will find them in Palfyn, 
Rohalt, and many others. 

But that the frequent ill effects of negle&ing this ope¬ 
ration were not unattended to by many, the following 
quotation, taken from a number of fimilar ones, may 
evince. 

“ Et fcias, ficut volunt veteres, quod non eft excufatio 
ab incifione, & remotione cranii, cum in eo penetrans 
« frafturafit; & haec propter duo; primo quod os capitis, 
ficut di&um eft, debilem facit porum. Secundo, quia fi, 
offe jam reftaurato, accident interius (quantocunque mo« 

u dice, 




( 45 ) 

Before I enter upon the* account of the 
prefent and moft proper method of treat¬ 
ing Ample undepreffed fradures of the fkull, 
it may, perhaps, be not amifs to make a 
fhort inquiry into the opinions which our 
remote anceflors have delivered down to us 
on this fubjed* to take a curfory view of 
their intention and condud* and to exa¬ 
mine, whether the difference between their 
pradice, and ours be well grounded or not^i 
it being neither antiquity nor novelty, but 
utility only, which can demand our re-* 
gard. 

That extravafation of blood, and forma¬ 
tion of matter, between the fkull, and 
membranes of the brain, were the two 

* 

principal caufes, of bad fymptoms, and of 
death, in fradures of the cranium, and 


that 


i( dice) generatio faniei, vel alicujus humoris iuperflui ex- 
pellendi, quomodo, jam reftaurato ofle, poftet expel- 
li,” &c. 

* c Primum notabile eft iftud, quod in fra£tura cranii 
M debes prohibere apoftema, ne aecidat in cerebro aut in 
panniculis, &c. Tertium, notabile fit iftud ; quod ft 
“ intentio medici folurn eflet, in occupatione folutionis 
<c continuitatis, vel fra&urse, ftante apoftemate, mufta 
<c mala accidentia poffent confequi, ut corruptio panni- 
f c culi, febris, apoplexia, rigor, j&c.” 

Bertapai*. 

^ - L 


* 


/ 


(HO ) 

that the only rational method of obtaining 
relief in either cafe was, by making fuch 
an opening in the bone as would give dis¬ 
charge to the faid fluids, was full as well 
known to our anceftors as to us. Their 
intention and ours therefore were effentially 
alike, and the material difference between 
our conduct and theirs confifts in the man¬ 
ner in, and the inftruments by, which w r e 
endeavour to execute fuch intention. If 
the breach in the bone was fmall, and no 
iymptoms of immediate extravafation at¬ 
tended, their principal apprehenfion was 
that the fanies, or matter, which they fup- 
pofed muff neceflarily be excreted from the 
edges of the fracture, would drop down, 
lodge, and be colle&ed on the furface of the 
dura mater. 

To prevent this evil, they endeavoured 
to enlarge the fradture by abrafion of its 
edges, by means of fcalpra, or rugines. 
Thefe fcalpra were many in number, and 
various in their fize and figure, accord¬ 
ing to the opinion or whim of the prac¬ 
titioner. Figures of thefe are to be feen 
in many writers ; in Andreas a Cruce, in 
Scultetus, in Fabritius ab Aquapendente, in 

Beren- 


5 


( *47 > 

Berengarius, &c. &c. &c. * But whoever 
examines them, and attends to their pro- 
pofed ufe, will find them liable to great ob¬ 
jection; he will find that the ufe of them 
muft be irkfome to the patient, tedious to the 
operator, and unequal to the end propofed. 
That by fuch kind of inftrument the open¬ 
ing of a fmall fracture may be enlarged, is 
beyond all doubt ; but if the breach be at all 
large, or of any length, fuch method of 
enlarging it muft at beft be a very opcrofe 
one ; it muft jarr, and fhake the patient's 
head immoderately ; if executed unfkil- 
fully, or inattentively, it muft be attended 
with hazard of wounding the dura mater , 
.and, when finifhed, could not properly an- 
fwer the purpofe for which it was de- 
figned. 

Of thefe defe&s, fome of the practitio¬ 
ners were in fome meafure fenfible ; and 
therefore, if the fracture was of fuch fize, 
or fo circumftanced, that thefe fcalpra abra- 

foria 

* cc Ex fra&uris vero quae ad cerebri membranas per- 
“ venerunt, fi (implex fradura fit, anguftis fcalpris uten- 
“ dum; fin cum contufione aliqua, quod contufum eft 
ic excidi debebit ; idque vel terebellis prius in circuitum 
* £ foratum, ac mox fcalpris admotis, vel protinus ab initio 
u cyclifcis,” Galen* 

hz 


( H 8 ) 


foria would mofi: probably prove infufficleftt, 

, ' O $ 'S 4fS 1 

that is, if the accident watf produced by 
fuch force, or attended with fuch degree of 
contufion, as to render it probable that the 
parts within were injured, they did not then 
depend upon this method by abrafion, but 
had recourfe to others, by which they re¬ 
moved a portion of the cranium In the 
execution of this purpofe alfo, they found 
themfelves fubjedt to many inconveniencies, 
arifing partly from the awkward and un** 
manageable form and make of their in- 
ftruments, and r partly from the inartificial 
manner in which they applied them. . 


Terebrae, and terebellae, of various forts* 
figures and fizes, the cyclifcos, or fcalpef 
exciforius, and a variety of modioli were 


invented, and ufed for this purpofe, figures 
of which may be feen in Vidus Vidius's 
comment on Hippocrates de vuln. capit. in 
Peter Paaw on the famfe; in Andreas a 
Cruce’s ofiicina; in Albucafis and others. 

If the piece of bone intended to be re^ 
moved was larger than could be compre-* 

> hended 


*«In 

iis quae ufque ad cerebri membranam divi fafunt, 
** fi tola rima fit, iifdem radulis utendum ; ficollifio aliqua 
<c una iit, terebris exfcindere collifum oportet, fcalpr» 
“ adhibitis.” Oribasius. 


( 149 ) 

hended within the modiolus then in ufe, 
aijd which was a very defe&ive inftrument in 
many refpe&s, the operation was performed 
by means of terebrse; which operation was 
ftill more coarle, more fatiguing, and more 
hazardous than that by the mere fcalpra. 

The piece intended to be taken away 
was furrounded with perforations, made at 
itnall diftances * from each other, and then 

either 


* 44 Miniftri juxta aflideant, quorum unus caput Isefi 
44 contineat, alter, opportuna minifteria faciat. Aurium 
44 foramina lana coa&a obturanda funt, ne fonitu in ex- 
44 cifione terreatur. His fa£tis, infigendus calvarise eft 
44 mucro acutus terebrae; qua laefum os colorem mutavit, 
44 juxta integrum ; deinde lente habena terebram convex 
44 tere debemus, donee incifo ofli mucro infiftat; ac 
44 turn citatius, circumagere oportet habena terebram 
44 convertente, donee mucro in fpacium inter duplex 
44 os defeendat; ubi autem foramen altius ada<ftum fit 
44 ultra craflitudinem fpacii inter duplicem teftam oilis 
44 quod perforatur, turn terebra multo circumfpe&ius 
4 f cqnvertenda eft, ne repente defeendens cerebri mem- 
44 branam violet. Cum jam terebra ada<fta fuerit, ut 
44 vel conje£tura deprehendatur totam oflis craflitudinem 
44 efle perforatam, vel perparum folidae fedis infra relic- 
44 turn, tunc is qui operatur, altitudinem deguftet de- 
44 mifla tenuis acus obtufa parte ; ac fi quid continuse fe- 
44 dis etiam reliquum fit, deprimendus altius terebrae mucro 
44 eft, eaque lente circuma&a, folidum os perforandum. 

44 Eadem quoque facienda funt in aliis foraminibus, do¬ 
nee rima in ambitu perforata fit. Septa vero media inter 

44 foramina 

' L 3 • ' 

"' ' ‘ J > • '• fifur 

•aUlrEAa* 4 J ".'iWi-.j,- - 


«K 

-•rt 


i, J 


( I 5° ) 


either the fcalper exciforius or the fcal- 
prum lenticulatum was introduced, and, 
by means of repeated flrokes with a heavy 
mallet, was driven thro 5 all the interfpaces 
between each perforation. By thefe means 
the portion of bone fo furrounded was re¬ 
moved, and the dura mater was laid bare. 
The tedioufnefs which mull attend the 
making fo many perforations, the diftur- 
bance given to the patient’s head, as well 
by the terebra, as by the mallet and" chizrf, 

the 


foramjna fatjs habent fpatii, fere quantum fpecilli an-' 
gufti averfa pars eft. Fadtis foraminibus, turn ad exci- 
* c fionem, quae dicitur, veniendum eft, ut excifis turn fo- 
raminibus turn mediis, l^fa ofla removeantur.” 

Oribasjus. 

* c Modus autem perforations eft, ut figas unum trypa- 
norum (terebrarum) fuper os in circuitu, & revolvas ip-. 
£4 fum intra manus tuas, donee feias quod os terebratum 
54 eft; deinde fiat perrnutatio ad alium locum: 5c fic 
perrnutatio fiat ufque ad ultimum neceffitatis. Deinde 
cum alio inftrumento, quod qicitur fpatumen, ab uno fo» 
* e ramine ufque ad aliud os incidatur, &c.” 

Brunus Chir. Mag. 

* 4 Pone trvpanum fupra os circa feifiuram, ubi vis fom- 
f* men facere, 5c revolve ipfum ini^a manus tuas donee 
penetret ; deinde muta ipfum ad alium locum, 5c fic 
fac tot foramina, quot fufticiant; deinde pone fpatu- 
* 4 men in uno foraminum, 5c levando manum, fuperius 
54 incidatur terminus, qui eft inter foramen 5c foramen^ 
? 4 Jc fac fic donee feparatur os totum.” 

Brun. Chir. Pary, 


ToJrarUp^fe i$c. 



1 . 

QM/cZ/mw. 3J^?inao/i/i/if iaa>. ^ 

4 . Sca//iefy/i/anus. oJaz//ie/i caw***. ^ 
















































* 






( H 1 ) 


the hazards of wounding the membranes 
of the brain, and the coarfenefs and un- 
handinefs of the whole procefs, are too ob¬ 
vious to need a comment Of 


* <e Quod vero per cyclifcos opus adminiftratur, ne id 
<c quidem omnino vitio caret, quum quatiat immodice 
44 caput, quod potius quietem poftulat.” Galen. 

<c At quae per terebellam ratio quidem fungitur, parum 
44 tuta eft, propterea quod dum audacius earn tradlant, 
u duram meningem non raro violant.” Galen. 

** Saepe fcalpros pulfantes adeo ut totum cerebrum per- 
eC moveatur.” Galen. 

<c Acuta terebra quamplurimas anguftas perforationes, 
<c cranii fraduras ambientes, radioli craftitudine equidif- 
** tanfces forma re folent ; quod vero inter foramina refidet, 
4C aut re&is, aut curvis fcalpris malleolo plumbeo adadfis 
44 refcindere expedit. Lenticulato fcalpro, adadio malle- 
44 olo, id fieri poteft ; horridus tamen quidem modus eft, 
44 ac in opere tardus.” 

44 Scalpra hsec omnia citra malleoli operam nullius mo- 
44 menti funt ; moventur neceffario malleolo adadto, prae- 
44 fertim in rimis, quae ad diploidem ufque pertingunt; ex- 
* c cavant totum o $ y forti adhibita percujjione^ non into fed in- 
44 commode” Andreas a Cruce. 

44 Malleus ad percutiendum lenticulatum debet efte de 
44 pi umbo, ut in parva quantitate magis ponderet. 

Guido. 

<e Cavere oportet, ut in terebellae admotione, ne aliens, 
44 verum qua parte craftiftimum os effe vifum fuerit, in 
44 earn Temper terebellam admotam adigito.” 

Hippocrat. 

44 Saepe accidit, ut terebrse repente adadfoe, ob natura- 
44 lem perforatorum oftium debilitatem, vel tenuitatem, 
u membranam fauciarint.” Oribasius, 

L 4 


( J S 2 ) ) 

Of this mod of them were fenfible; they 
felt the inconveniencies, and dreaded the dan¬ 
ger fo much, as to run into great abfurdities, 
merely to avoid them. They found that 
they not only wounded the dura mater, but 
fometimes the brain itfelf ; and therefore 
had recourfe to fuch precautions, as they 
thought mod likely to prevent thefe evils. 
By forxie we are advifed, not to make the 
perforation quite through the bone, but to 

endeavour to leave a thin lamina of it in¬ 
tire, By others, to leave the piece, which 
the modiolus or terebra had furrounded, 
adhering to the dura mater, to be caft off 
by its fuppuration, left the hafty detach-* 
ment of it fhould be mifchievous 

The 

* (( Quod ft ftatim initio vulneris infii&i, curationi ad- 
hibearis, os ad membranam ufque iimul Sc femel ex- 
fcindere non pportet, Sec . Praeterquam quod aliud fu- 
it beft periculum, ft ftatim ad membranam ufque auferas, 
ne inter operandum membranam laedas. Sed inter fe- 
<c candum id obfervato, ut poftquam eo res perdu&a, ut 
* c parum abfit cjuin univerfum os pertufum fit, jamque 05 
* c vacillare incipit, ab ulteriore fe&ione abftineas, oflique, 
* c ut fponte porro fecedat, permittas. Namque ofli, quod 
fe&um eft, Sc fine exfeftione reliftum nihil detriment) 
accjdere poteft. 

* c Cum itaque terebrse occurrit ufus, ft ftatim curationi 
? e adhibearis, cayefis ne ad membranam ufque penetrat, ve* 
** rum portio pflis tenuis relinquenda.’’ Bippocrat» 


( *5r) > 

The cautions laid down by Hippocrates 
and others, concerning the part of the bone 
whereon to fix the inftrument, and the 
great attention which they admonifh the 
operator to pay to its execution, all proceed 
from the fame fear. For the fame reafon,’ 
or from the fame well-grounded apprehen- 
fion, it will be found that many of the belt 
pradtitioners endeavoured to furnifh their per¬ 
forating infiruments with fuch guards or 
defences as fhould prevent them from going 
too deep %-yjpiq 3flJ 

tbsbauo ull In 

* <c Terebellis autem ipfis, ut mergi non poflunt fupra 
** cufpidem, nonnulli fupercilium extans efficiunt.’* 

Galen. 

At quia dum terebrum hoc circumagitur, periculum 
<c imminet ne membranae laedantur, ideo nonnulli quo mi- 

-v 

“ nus abberrarent, Sc hoc periculi genus evitarent, terebras 
<c excogitarunt quae mergi non poflunt, & ob id a Grx- 
cis abaptifta dicuntur.” 

Andreas a Cruce. 

<c Si autem os forte durum eft, tund oportet ut perfores 
in circuitu ejus, antequam adminiftres inciforia cum tere- 
u bris, quae nominantur terebrae non profundantes $ Sc 
u non nominantur ita, nifi quoniam ipfae non pertrarifeant 
terminum oflis,, ad illud quod eft poft ipfum, propterea 
quod terebro eft extremitas rotunda fuper illud, quod eft 
fub capite ejus acuto, fimilis margini, Sc circulus par- 
vulus prohrbet fubmergi Sc pertranfire fpiflitudinem oflis. 
Et qonvenit tibi, ut accipias ex iftis terebris numerum 
1 > ■ -v •' *11 multum* 


( J S4 ) 

In Albucafis, in Andreas a Cruce, and 
many others, are figures and defcriptions of 
modioli, duabus, tribus, vel quatuor alis 
muniti, of thofe as well as of terebellae, 
called abaptiftse, mefpilatas, torculatas, &c. 
the number and variety of thefe is ve¬ 
ry large, although they are all formed 
upon the fame principle, and all calculated 
for the fame purpofe, viz. to perforate the 
ficull without w r ounding the membrane un¬ 
derneath, 

—* % 

multum, quorum unum quodque convfniat quantitati 
ic fpiffitudinis oflis, donee prsefens fit tibi omni cranio te- 
rebrum,” &c. Albucasis. 

“ Modiolus fuit veteribus duplex, eflque etiamnum ho«* 
die vulgaris, turn & qui duplicem habet orbem, al- 
terum fupra alterum extantem. Hie abaptiftos Grae- 
“ cis ; facit namque orbis five limbus extans ne profundius 
li mergi queato Hunc itaque rteferibit Galenus 6. meth. 
<c cap. 6. Quidem autem quo minus aberrarent, tales 
<c terebellas excogitarunt quae mergi nequeant, quas inde 
<s abaptifta vocant. Circumcurrit enim parum, fupra te- 
c< rebellae fupercilium circulus alius parvus. Sane expedit 
complures id genus ad manum habere, ob quameun- 
“ que cranii craffitudinem ; nam craffiori longior convenit 
“ terebra, tenuiori brevior,” &c. 

Pet. Paaw in Hippocrat. 

“ Si autem validum fuerit os, prius illud terebellis abap- 
“ tlflis vocatis perforatur. Ejufmodi vero funt quae paulo 
“ fupra acumen cufpidis eminentias habent, impedientes 
u ne ad cerebri ufque membranam demergi poffint.” 

‘ Paul. ^Eginet. 



1 AJj.Guaftfee/. 7o?rfsvr.i~, 

6.7. 8. (h/an/rof Jfrtf/p/i.* —> 


To frontpage 154 • 


































































t 













> 



/ 













( i5S ) 

derneath. But whoever will confider the 
very different thicknefs of different Ikulls, 
and of different parts of the fame fkull, 
and at the fame time refled: on the extreme 
awkwardnefs of all thefe inftruments, will 
immediately fee, how very little depen- 
dance is to be laid on fuch defences, and 
how mifchievous the ufe of them muff very 
frequently have proved. In fhcrt, an at¬ 
tentive confideration of what our remote 
anceftors have delivered down to us on this 
fubjed, may fatisfy us that their obferva- 
tions on the appearances and fymptoms of 
the ills attending this kind of mifchief, that 
is, fradures of the cranium, were in general 
extremely j ufi: and true, (perhaps, more fo than 
thofe of many moderns) that their curative 
intention, or methed of aiming at the relief 
or cure of fuch ills, was rational and juft; 
but, that the inftrumental part of their art 
was fo deficient, fo awkward, and fo un¬ 
handy, that they were thereby, not only in 
general prevented from accomplifhing the 
good they intended, but were not infrequent¬ 
ly driven into almoft unavoidable mifchief. 

Redudion of the number of inftruments 
tP be ufed in an operation, and an extreme 

fimplicity 



( *5$ ) 

fimplrcity and plainnefs in thofe which may 
be required, are a part of the merit of mo^ 
dern furgery. 

The majority of the inftruments, with 
which our anceftors perforated the cranium, 
were contrived to make way for the admif- 
fion of other inftruments ; fuch as the fcal- 
per exciforius, the cyclifcos, the fcalprum 
lenticulatum, &c. with which they remo¬ 
ved a portion of bone. Even the modioli, 
which were ufed by them, were fo fmall in 
the diameter of the faw, as to take away a 
very fmall piece at each application ; which 
circumftance neceflarily leflened the benefit 
which might be expeded from the ufe of 
it, and rendered its repetition more fre¬ 
quently neceflary than it needed to have 
been, if it had been made larger. 

Inftead therefore of that ftrange variety, 
and multiplicity of inftruments, which I 
have already mentioned to have been ufed 
by them, we now require only a trephine 
of fuch a fize as to remove a fufficient 
quantity of bone at once, and an elevator ; 
or perhaps, now and then, a pair of for¬ 
ceps. Thefe are all we ever can want; and 
thefe may be fo made, as to be manageable 
by the hand of any man of common judg¬ 
ment. 


( 157 ) 

ment, with great eafe to himfelf, with very 
little fatigue and no hazard to the patient. 
With thefe we can make as large or as fmall 
an opening in the fkull as we pleafe ; either 
for the relief of the dura mater, for the dis¬ 
charge of blood or matter, or for the ele¬ 
vation of depreffed or extra&ion of loofe 
pieces of bone, and that without difturb- 
ing the patient greatly, or incurring any 
rifque of wounding the brain or its mem¬ 
branes *. 

I have already faid, that what are called 
the principal and diagnoftic figns of a frac¬ 
tured 

* It has been cuftomary to ; make the handle of the 
trephine of iron, and to form the extremity of fuch handle 
in fuch manner, as to make it ferve the purpofe of an 
elevator ; thus combining, as it were, two inftruments in 
one. This, I think, is a great fault; fuch iron handle 
adds confiderably to the weight of the inftrument, and. 
that in a wrong part of it; and thereby renders it lefs 
manageable. The handle of this inftrument fliould be 
made of light wood, not too long, and of an o£langular 
figure. Whoever will try the fame inftruments, thus 
differently made, will, 1 think, be immediately fenfible of 
the preference due to the lighter handle. It is almoft im- 
poffible for the handle of an inftrument, whofe point or 
extremity is to be worked with, to be too light. It is no 
uncommon thing to fee couching needles, and inftru¬ 
ments of like kind, laden with heavy bone handles, the 
inconvenience of which is too obvious to mention. 

5 


( -58 ) 

tured flcull are by no means to be depend¬ 
ed on, as indicating fuch mifchief to exift j 
it can therefore be hardly neceffary to ob- 
ferve, that what are called the uncertain 
figns require our regard ftill lefs. Thefe 
have been mentioned by many writers, who 
have copied each other ; fuch are, the hold¬ 
ing a filk or horfe-hair tight between the 
grinding teeth and the hand, and the mak¬ 
ing it vibrate by ftriking on it $ the biting 
an hard body, and attending to the pain 
produced by fuch aCtion, with feveral other 
of like fort; which, not to mention that 
they imply the patient to be fenfible and in¬ 
telligent, are fo truly equivocal as to deferve 
no notice 

All confiderations alfo, which are drawn 
from the manner in which the violence was 
given or received, from the weight or kind 
of weapon or body inflicting it, from the 
force of the blow, the heighth of the fall, 
&c. are all equally fallacious for every 
body knows that very terrible lymptoms 

and 

* <c Item percutiatur caput cum levi bacculo ficco, de 
falice aut de pino, &c pone aurem tuam apud caput > & 
is fi lanum eft, tunc audies fonum fanum \ fi fraftum aut 
4t fciflum, audies fonum mutum.” 


Lanfranc, 


( *59 ) 

and confequences are fometimes produced 
by accidents feemingly flight; and, on the 
contrary, that people often efcape unhurt, 
from what might reafonably have been expec¬ 
ted to have proved prejudicial to them. In 
fhort, nothing but the fight and touch are 
to be at all depended upon. 

If the integuments are not wounded, or 
if the wound made in them be fo fmall as 
not to admit a proper examination of the 
bone, and the circumftances of the cafe 
are fuch aa render fuch inquiry neceffary, a 
portion of the fcalp fliould be removed. 
The manner of doing this has formerly 
been the occaflon of much difference of 
opinion ; but there can be no doubt about 
the greater propriety of removing a piece of 
the fcalp for this purpofe, by an incifion, 
in a circular form, it being that form which 
mud afford the cleared: view. If there be 
no wound, the point ftricken fhould be 
made the center of the incifion ; if there 
be a wound, fuch wound fliould be made 
the center of the piece to be removed; and 
fuch piece, fhould always be of fize fuffi- 
cient to render the application of the tre¬ 
phine eafy If 

* It may perhaps be remarked, that through the whole 
< . of 


I 


( 160 ) 

If the fcalp be wounded, and the wouncT 
be large enough to render the fracture vili- 
ble, the courfe of that muft be the opera¬ 
tor's direction in making his incifion ; and, 
if the Ikin be much torn and bruifed* or 
Ipoiled, it will generally be found advife- 
able to take away all that is fpoiled at once; 
as the removal of it will add very little to 
the patient's pain, or the length of the 
cure, and the leaving it on, in this ftate, 
may be attended with great future incon¬ 
venience. 

Scalping (as it is called) Ihould always be 
executed with a knife, and that knife fliould 
be fo held as to cut through the fkin and 
pericranium, in a perpendicular manner, 
down to the bone at once, that the fize of 
the bare bone may be fully equal to that of 
the-wound in the fcalp. 

It is hardly neceffary to infert a caution 
againft preffing hard with the fcalping knife, 
in the cafe of large fractures, attended ei¬ 
ther 

of this treatife, whenever I have occafion to fpeak of the 
operation of perforating the fkull, I mention the trephine 
only, and take no notice of the trepan, the inftrumeflt 
ufed by moft of our immediate fathers, and ftill in ufe 
through almoft all France $ my reafon is, that the latter 
is an unmanageable one, and liable to moft of the hazard 
and inconvenience attending the terebrse and terebellae. 


( . J61 ) 


, ther with great reparation of the broken 
edges, or with loofe pieces, the danger is 
fo obvious. And it is alfo as obvious, that 

"* • ' . sj V ; V - • 4 - • ■ .!- I 

there can be but one method of avoiding 
fuch- hazard, viz. by removing the fcalp 
from, or rather making the incifion in a part 
beyond, the fradlure, and where the bone is 
firm and ftable. By thefe means, not only 
the rifque of hurting the membranes and 
. brain will be avoided, but the whole mif- 
chief will be more fairly and clearly brought 
into view ; a thing, which fooner or later 
mufi be done, and is always heft done at 
firft. No part of the fcalp fhould be wan¬ 
tonly or unneceffarily cut away: but it 
fhould always be remembered, that this 
operation is, and fhould be performed, with 
intention to bring, if poffible, the whole 
fradture into fight * and that whatever falls 
fhort of fulfilling fuch intention (if prac¬ 
ticable) is wrong, not only, as it does not 
immediately anfwer the purpofe for which 
it is intended, but it generally puts the pa¬ 
tient under a neceflity of undergoing the 
fame pain and trouble a fecond time. 

When the cranium is laid bare, it may 
not be improper to remark, that writers in 
general have cautioned us to beware of 

M mif- 



( *62 ) 

miflaking either a future, or the impreffion 
of a veflei on the furface of the bone, for 
a fradlure : I fay, that they have in ge¬ 
neral cautioned us not to miftake one of 
thefe for the other, but have not informed 
us of the mark by which we may be ena¬ 
bled to make the necefiary diftindlion, al¬ 
though fuch mark is almoffc conftant and 
invariable. From the track of a fradlure, 
or fiffure, the pericranium is always found 
loofe and detached ; whereas to the arterial 
fulcus, and to the uninjured future, it is 
always adherent; befides which, the edges 
of a fradlure will always be found rough to 
the probe or finger, and the fulcus always 
fmooth ; not to add, that the difpofition of 
the future is pretty certain, and their ap¬ 
pearance in general not extremely like to 
that of a fradlure. 

When the fcalp is much bruifed, or 
wounded, fuch wound or bruife points out 
' the place from whence the piece fhould 
be removed, in order to examine the bone; 
and, even although no fradlure fhould be 
found, is an authority and vindication of 
fuch operation, efpecially if the general 
fymptoms were at all urgent; fuch fymp- 
toms implying mifchief fomewhere, and 
5 ' fuch 


( ) 

/ 

fuch external mark rendering it clear* where 
the external violence caufing fuch mifchief 
was inflidted. But all the ancient, and 
many of the modern writers fpeak of a 
particular kind of fradture, in which the 
fcalp covering it is perfedlly fair and unin¬ 
jured ; and this they call a contra-fiffure. 
By the general account, it is pretty clear, 
that the majority of thofe who have fpoken 
of this kind of fracture have fuppofed 
that the breach made in the bone was moft 
frequently in the part of the cranium dia¬ 
metrically oppofite to that which received 
the blow ; this the term contra-fiffure im¬ 
plies, and this they moft certainly do in gene¬ 
ral mean ihould be underftood by it, as ap¬ 
pears by their directing us to examine and to 
remove the oppofite part of the fcalp, if no 
mifchief be found under the part ftricken, 
and the patient labours under what are 
called the fymptoms of a fradtured Ikull. 

If the fymptoms of a fradtured cranium 
were certain, and to be depended upon, 
this accidental circumftance, of a breach in 
the bone, having been now and then found 
in a diflant, or even in the oppofite part, 
might be an inducement to look for fuch 
mifchief there, when it is not found under 

M 2 the 


( i6 4 ?)- 

f- * *, % 

the part ftrickbn. "A fradlure, we might 
then fay, there is fomewhere; and it hav¬ 
ing, in fome iriftances, been found in the 
oppofite part of the head, it might be right 
to look for it there. But, as what generally^ 
pafs for, and are called the fymptoms of a 
fractured fkull, are by no means to be de¬ 
pended upon, as indicating fuch complaint 
to exift any where, as they are producible 
by concuffion, by extravafation, by contu- 
fion, &c. and are frequently found where 
the fkull is intire and unhurt, they cannot 
be deemed a fufficient authority for remo¬ 
ving the fcalp where no apparent mark of 
violence is left. The fmalleft degree of 
wound or bruife will, in cafes where the 

( ; ■ \ - ‘j ^. - . . ' . . i y s t '.. v* '% 

fymptoms are urgent, vindicate the removal 
of fcalp from fuch part but where there is 
no local indication where to operate, I cannot 
fee any vindicable reafon for operating at all 

Hie 

* Morgagni, in his book de Caufis & SedrbuS, has 
very juftly obferved, M that if by contrafifiure was meant 
<s a breach in that part of the cranium which is diame- 
trically oppofite to the part wounded or bruifed, (as 
<c fome have affirmed) there could be none of that diffi- 
tc culty which they all allow of finding, or that frequent 
4< difappointment in not finding it at all, fince an inqui- 
i ry into fuch oppofite part, muft always have led to the 

<c difeovery. 


( i 65 ) ; 

The chirurgical intention in perforating 
the fkull, in the cafe of fimple. undepreffed ; 
fradhires, is, as I have already obferved, ei¬ 
ther to give immediate difcharge to fluid, 
fuppofed to be extravafated between the 
cranium and membranes of the brain; or 
to obviate, and prevent fuch ills, as may 
moft probably be expedled to arife from the 
contufion caufing the fradture ; or to let out 
matter already formed in confequence of 
the inflammation following fuch contu¬ 
fion. 

In each of thefe it is mod probable, that. 

v $' >■* 

the mifchief, be it which it may, either is 
or will be feated principally under the track 
of the fradture ; and therefore, whenever 
the trephine is applied for either or any of 
thefe purpofes, it ought always to be fet on 
in fuch manner as that the fradture fliould, 

if 

u difcovery. So that inftead of the term oppofite , that of 
another, part of the cranium ought to have beenufed.” 
And then the whole of this, which has puzzled fo 
many, will amount to no more than what every prac¬ 
titioner muff know, which is, that we frequently find, 
in. cafes of great violence, that the fkull has been 
broken, in a place very diftant from that which received 
the blow, and which we are not led to the knowledge 
of by any apparent external mark. 

M 3 


• \ 


1 


( 166 ) 

if poiiible, traverfe the circle defcribed by 
the faw, or at leaf!* fo that the inflrument 
might always comprehend the fradture 
within it. 

I am aware that the direction given by 
moil of the old writers on this fubjedt is 
very different from what 1 have mention¬ 
ed ; but the inffruments with which they 
operated, were fo different from ours, and 
the advantage arifing from the comprehen- 
fion of the fradlure within the trephine are 
fo great, and fo manifeft, that I muff take 
the liberty of inculcating a conflant atten¬ 
tion to it, as to a circumflance from which 
great advantages are derivable. 

The faw or crown of the trephine fhould 
never be too fmall, efpecially if the patient 
be full grown ; a circumflance which I 
thought it right to mention, becaufe the in-? 
ftrument-makers are very apt to make them 
fo* 

' ■ The 

P The beft practitioners have, at times, found them- 
felves neceftitated to apply the inftrument repeatedly in 
the fame cafe, in order to remove a ccnfiderable quantity 
pf hone J and among the writers on this fubjeft, are fre¬ 
quent relations of fuch fa<fts. The practice is un¬ 
doubtedly juft and right ; but I cannot help thinking, 
from what I have feen of the perforating inftruments of 

many 


I 


( i 6 7 ) 

The. number of perforations which it 
may be neceffary to make, can only be de¬ 
termined by the nature of each individual 
cafe. 

If the operation be performed on ac¬ 
count of fuch fymptoms as feem to indi¬ 
cate a bloody extravafation, and fo free a 
difcharge is produced by one opening, as 
alleviates or removes the fymptoms, that one 
may be all that may be neceffary ; but if 
the firft perforation only difcovers the di- 
feafe, and is not followed by fuch difcharge 
as relieves, or removes the fymptoms, the 
operation ought to be repeated again and 
again. 

If there be no fymptoms of extravafation, 
and the inftrument has been applied in a 
preventative fenfe merely, the length of the 
fradure muft determine the number; one 

1|L , *1 if j ! f • ' » £ ' • . ' . „ ‘ , ,1 l > ■: *■ 

or two only may be made at fir/t, and it 
may be right to wait for farther diredion 
from future circumstances. The circum- 

ftances 

many of our predecefiors, that a part of their trouble, 
and of the fatigue of their patients in fuch cafes, might 
have been much lefiened, had the circle of their faw been 
larger. The advantage of a large circle is great; the in¬ 
convenience imaginary. 

M 4 


( 168 ) 

ftances which may render a repetition of 
the operation neceftary are, acceffion, or 
increafe of fever; large difcharge of mat¬ 
ter, or lodgment of the fame fluid; inflam¬ 
matory tenfion of that part of the dura 
mater, which has already been denuded, 
&c* Directions to be given by a writer 
can, on this fubject, be only and truly ge¬ 
neral , all the reft muft be left to the judg¬ 
ment of the furgeon, which judgment muft 
be formed from the peculiar nature of 
each individul cafe. 

When the operation has not been per¬ 
formed as a preventative, but to give dif¬ 
charge to that matter which a fymptoma- 
tic fever indicates to have been formed,^ 
the quantity of fuch fluid, the extent of 
the feceffion of the dura mater, and the 
ftate of that membrane, muft determine 
the conduct of the operator. The only 
chance of relief is, from laying bare a 
large portion of it, that the difcharge may 
be as free, and the confinement as lit¬ 
tle as poflible; nothing but this can do 
good, the fpace of time in which it may 
prove beneficial is very fhort, that once 
elapfed is abfolutely irrecoverable, and 
the necefiary operation for obtaining fuch 
. 4 , end 


«. ’• ... . 4 , ^ 

end may fall as well be totally neglected, 
as done by halves, or too late. 

The extent of the injured and feparated 
dura mater, and confequently of the va-~ 
cuity for the formation and lodgment of 
.matter, is a thing of fo much confequence, 
that it is to be wiftied we were able 
to difcover it with more precifion and 
clearnefs than we feem to be able to do. 
It is the greate'ft circumftance of hazard to' 
the patient, and of direction to the fur-/ 
geon. It is that which, if undifcovered or 
negledted, rauft deftroy the former, and 
that, which when difcoverable, and at¬ 
tended to by the latter, is not only his in¬ 
formation, but his vindication. 

The concealment of the dura mater with- 
in the cranium is one great caufe of this 
great obfcurity. This neceffarily prevents" 
us from knowing the true date of the faid 
membrane, as much and as certainly as it 
is to be wifhed we could ; but dill I can-' 
not help thinking, that there are fome cir- 
cumftances and appearances, as well be¬ 
fore perforation as after, which, if care¬ 
fully and duly attended to, may throw fome 
light on this obfcure part of furgery. For 
example, if, upon dividing the fcalp, the 

peri- 


( i7° ) 

pericranium is found to be altered, and per- 
fe&ly feparated from the ikull to which it 
ought naturally to adhere; or if, fome few 
days after fcalping, (as it is called) the 
edges of fuch wound fpontaneoufly quit 
their adhefion to the bone all round, to 
fome distance, and inftead of being firm, 
florid, and healthy, become loofe, tawney, 
and flabby; or if the Audi, upon being denu¬ 
ded, is plainly of a colour different from that 
of a healthy found bone, with a healthy found 
membrane under it; or if fuch bone, after 
having been either accidentally or defignedly 
laid bare, undergoes fuch morbid change of 
afpedt, and the patient is at the fame time 
reftlefs and feverifh, with ten five pain in the 
head, and irregularly returning fits of heat 
and chillinefs; I think, that we may mod 
reafonably prefume, that the dura mater in 
fuch patient is inflamed ; and that the feat 
of fuch inflammation is under fuch bare 
and altered part of the Ikull. 

This prefumption, as I have juft obferved, 
may take place before perforation; but, if 
added to thefe circumftances, which appear 
before the operation, we find upon perfo¬ 
rating that the membrane is inflamed, de¬ 
tached, altered from its natural texture and 

bright- 


( J 7i ) 

brightnefs, or fmeared over with matter, 
the cafe is then clear, as to its nature; and 
it is as clear, that nothing but the removal 
of a confiderable portion of the Ikull can 
either give room for the inflammatory ten- 
fion of the membrane, or make way for 
the difcharge of matter generated on its 
furface, the two circumftances on which 
the well-being of the patient depends, the 
two intentions which muft be fulfilled, and 
which nothing but free perforation can 
enable us to fulfil. Whatever degree of 
hazard may be fuppofed to be incurred, by 
having expofed the dura mater to the air, 
cannot be increafed by the mere compara¬ 
tive fize of the opening ; and if we may 
be allowed to expofe our patients to any 
rifque at all, it can only be upon a fuppo- 
fition, that a greater degree of good may 
be deducible from it. 

It fometimes happens, that one of the 
bones of the ikull is cracked, and the dura 
mater underneath fuch crack is fo injured 
as to become inflamed, and in procefs of 
time to fuppurate j but there being no early 
or immediate fymptom of fuch mifchief, 
and the fcalp being neither wounded nor 
bruifed in fuch manner or degree as to 

authorifc 


( * 7 2 ) 

authorife the removal of the fcalp, the true 
nature of the cafe is not known, nor the 
impending mifchief attended to, until the 
fymptoms of inflammation begin to appear. 
Ifi this Situation, after an uncertain number 
of days, (fometimes more, fometimes lefs) 
the patient finds himfelf out of order, is 
reftlefs, does not get natural or quiet fleep, 
is flufhed and chilly by turns, feels pains of 
the dull tenfive kind all over his head, but 
particularly in the part where the blow was 
inflicted. Soon after he has got into this 
flate, the part fo pained becomes in fome 
degree tumid, the febrile fymptoms ad¬ 
vancing notwithftanding every internal af- 
liftance. If in thefe circumftances the tu¬ 
mid part of the fcalp be divided, and the 
cranium be found bare, (the pericranium 
having fpontaneoufly quitted its adhefion) 
whether it be broken or not, mifchief is cer- 
tainly forming * underneath it> and the one 
remedy is perforation. 

It 

* <e Offium rima occulta interdum non ante fepti- 
ct mum diem, interdum non ante decimurn quartum, in- : 

terdum ferius fe oflendit, turn caro ab ofle recedit; 
< 4 tumque os lividum apparet; dolores item ichorum dif- 
64 fiuentium excitantur j atque base diflRculter rernediis 
cedunt.” ’ . Hippocrates. 


( *73 ) 

It alfo fometimes happens, that a fine 
capillary fiffure runs, or is continued, un¬ 
der an undivided part of the fcalp, from 
the extremity of a fradture to a diftance 
greater or lefs or, in other words, the 
fradture in its track, from being open and 
apparent, becomes capillary, and is either 
not feen or not attended to. If the dura 
mater, under fuch fiffure, does not become 
inflamed, it ‘ may pofiibly never give any 
trouble ; but if it does become inflamed 
and fuppurate, the fcalp covering fuch fif¬ 
fure will, at the end of fome days, fwell, 
and become tender to the touch j the peri¬ 
cranium will, by feparating from the bone, 
form a finu-s along the track of the fiffure, 
a difcharge of gleet will be made from it 
upon preffure, and the divifion of it will 
difplay the breach in the bone. 

Notwithstanding the fradture from which 
this fiffure is continued be large and open, 
and the trephine may alfo have been-more 
than once ufed to fuch fradture, yet, when 
the appearances are fuch as I have related, if 
the patient be not intirely free from all gene¬ 
ral fymptoms of inflammatory mifchief, it 
may be depended upon, that the membrane 
under the fiffure is difeafed, and if a conve¬ 
nient 


( *74 ) 

nient opening be not made upon the part 
aggrieved, bad confequences will follow, 
notwithftanding all that may have been 
done to the more vifible and open part of 
the fradture. A very ftrong and convin¬ 
cing proof of the nature of a local inflam¬ 
mation of the dura mater, as well as of the 
moft proper method of treating fuch dif- 
order. 

In cafes of great violence offered to the 
head, whether the fkull be broken or not, 
it fometimes happens, more particularly in 
young fubjedts, that we find a future confi- 
derably disjoined; in which circumftance I 
do not remember ever to have feen one 
fingle inftance of a recovery *. 

I cannot take leave of this fubjedt with¬ 
out reminding the young pradtitioner, that 
although it be impoflible for any one, in 
the cafe of highly inflamed or fuppurating 
dura mater, to get well without perforation 
of the fkull, yet that operation muft be 

confidered 

* u Repentina futurarum disjundio, ft caufam atten- 
das, fine aliqua cerebri concufiione efle non potefl: ft 
<c effedum, non fine violenta craflae meningis, illuc ma- 
<c gis adhaerentis diftradione, ac annedentium fibrillarum 
‘ ac vafculorum laceratione,” &c. 

Morgagni de Caufts 5c Sed. 


( l 7S ) 

confidered only as one abfolutely necefiary 
part of the procefs toward obtaining a 
cure $ and that phlebotomy, gentle evacua¬ 
tions per anum, proper febrifuge remedies, 
and a ftri<5t low diet and regimen, will 
be full as necefiary after fuch operation as 
before it. The removal of a piece of bone 
takes off fome preflure from the tenfe and 
inflamed membrane, frees it in fome de¬ 
gree from its confinement, and gives dis¬ 
charge to matter and gleet; but it does no 
more; and every means which can ferve 
to appeafe the febrile heat, to leffen the 
velocity of the circulating fluids, to render 
the ikin perfpirable, and the patient cool 
and eafy, are full as necefiary after as be¬ 
fore fuch operation. 


CASE 


/ 


( 176 ) 



CASE XVII. 

* 

Simple fraBure .' 

Principal overfeer of one, of the great 
roads near to this town was thrown 
down with great violence, while he was 
giving directions to the labourers. He fell 
with his forehead againft a fharp ftone, and 
lay fenfelefs for a few minutes, but foon 
recovered himfelf and walked hqme. The 
, ftone had made a confiderable wound, the 
lips of which were fo torn and bruifed, 
that the furgeon »who firft faw him cut 
' them away, and by that means detected a 
fraCture, or rather a fifiure, of about .an 
inch and half or two inches in length, on 
the upper or middle part of the os frontale. 
The man had neither ftcknefs, giddinefs, 
vomiting, fever, nor any other bad fymp- 
tom for feveral days; on which account 
nothing was done to the fraCture, which 
a was drefled with dry lint only. He was 
twice let blood, and kept to a low cool regi¬ 
men. At the end of feven days, he /ound 
himfelf fo well, that he was defirous of 
going out ; but that not being permitted, 

he 


( 1 77 ) 

he flayed at home, and took great care of 
himfelf. On the eleventh day he found 
himfelf out of order, faid that his head 
ached, that his flomach was not right, 
and eat no dinner. The following night 
he got but little reft. On the thirteenth day, 
having pafled very unquietly the preceding 
night, he did not rife ; and when his fur- 
geon came to drefs him, finding him fe- 
verifh, he let him blood, and gave him a 
lenient cathartic. In the fpace of two days 
more, all his fymptoms were exafperated; 
his head-ach was great and conftant, his 
fever high, he got no fleep at all, the 
edges of the wounded fcalp became foul, 
loofe, and fpongy, and his forehead and 
vifage were attacked with an inflammatory 
fwelling of the eryfipelatous kind. On the 
fixteenth day he had a fevere rigor, and 
was fomewhat delirious, and his eyes be¬ 
came fo tumefied that he could not open 
them. In this ftate I found him. Being in¬ 
formed of what I have here related, and 
having examined the bare cranium, I could 
not hefitate to fay, that I apprehended his 
complaint prpceeded from the formation 
and confinement of matter within the fkull; 
and that the little chance the man had 

N muft 


( r 7 8 ) 

muft be from immediate perforation in the 
track of the fiffure. 

The operation was performed, and the 
dura mater found covered with matter. He 
was dreffed lightly, and loft twelve ounces 
of blood. 

The next day I was informed that he 
was very rational but his fever unremit¬ 
ting, and that he got no fleep. On the 
nineteenth day I faw him again, along with 
the late Mr. Bethune ; the difcharge from 
within the Ikull was large, and the bare 
bone and wounded fcalp looked very ill; all 
his other fymptoms much the fame. 

On the twenty-firft I was fent for again. 
He was now delirious in a high degree, 
paralytic in one arm and leg, and frequent¬ 
ly convulfed in the other, the difcharge was 
large and remarkably oftenfive, his tongue 
black, the fkin of his body burning hot 
and dry, that of his extremities cold and 
moiftj and 1 fuppofe I need not tell the 
reader what happened that night. 


CASE 


r • 


( 179 ) 


CASE XVIII. 


Young man playing at cudgels in. 



Moorfields received a ftroke on his 


forehead ; it did not feem either to himfelf 
or the fpe&ators to have been a fevere one, 
but as it produced blood it was deemed by 
the laws of the game a broken head, and 
he was obliged to yield to his antagonift. 

As it gave him no trouble, he took no 
notice of it ; was for feveral nights after¬ 
wards engaged in the fame diverfion, and 
followed his daily labour. On the ninth 


day from that on which he received the 
blow, he thought that his forehead was 
fomewhat fwollen, and felt tender to the 
touch, on the eleventh it was more tume¬ 
fied and more painful, and on the twelfth 
found himfelf fo much put of order, that 
he applied to be received into St. Bartholo¬ 
mew’s hofpital. 

An incifion was made into the tumor; a 
thin brown ichor was difcharged, and a 
bare bone being difcovered, a circular piece 
of the fcalp was removed, which difcover¬ 
ed a fra&ure. The trephine was applied 
twice along the track of the fracture, by 


N 2 


which 


l 


( i8 0 ) 

which means it was almoft totally removed. 
The dura mater was found difcoloured, and 
beginning to have matter on its furface. 
The patient was let blood, and ordered to 
take the fal abfinth. mixture with a few 
grains of rhubarb in it every fix hours. 
The iucceeding night was pafled ill ^ the 
patient complained much of pain, and got 
little or no fleep. On the fourteenth his 
fever was high, his fldn hot, and his pulfe 
full and hard; fourteen ounces more of 
blood were taken from one of the jugulars ; 
and as he ftill continued coftive, a lenitive 
purge was given a few hours afterwards. 
On the feventeenth every thing bore a bad 
afpect, both as to his wound and his gene¬ 
ral ftate : he got no reft, his fever was 
high, and the wound very ill-conditioned. 
His head was again carefully examined, in 
order if pofiible to difcover fome other 
injured part. No fuch injury was found; 
and it being impoflible that he fhould re¬ 
main in his prefent ftate, evacuation feem- 
ed to be his only chance, and therefore 
fourteen ounces more of blood were drawn 
from one of the temporal arteries, by which 
he fainted, and after which he feemed to 
be fomewhat eafier. 


For 


( i8i ) 

For three days from this time he feem~ 
to be confiderably better ; but on the twen¬ 
ty-fir ft he was again in as much pain as 
ever, and the fore again began to put on a 
bad afpedh 

The benefit which he had once already 
received from phlebotomy had been mani- 
feft •, and as his pulfe was well able to bear 
it again, the temporal arteries were again 
opened, and he was bled till his pulfe failed 
fo much and fo fuddenly that I was not 
a little alarmed. By proper care he was 
brought to himfelf, and I had no other 
trouble during his cure than what pro¬ 
ceeded from his extreme weaknefs, which 
the bark foon removed. 

Although this man may very juftly be 
faid to have been faved by the frequent 
repetition of phlebotomy, yet as matter 
was beginning to be formed on the furface 
of the dura mater, and as fuch matter 
could have no outlet whereby to efcape, it 
is very clear, that unlefs the cranium had 
been perforated he muft have perifhed. 



CASK 


( I** ) 

CASE XIX. 

T H E driver of a poft-chaife was 
thrown from his horfe near to Ware 
in Hertfordfhire, and ftruck his head a- 
gainft what they call a fiepping-ftone in a 
wafh-way. He was ftunned by the blow, 
and carried into a public houfe ; but in half 
an hour’s time found himfelf fo well as 
to be able to carry the chaife to the place 
he was going to, which was juft by. The 
next day, finding himfelf perfectly well, he 
went to work again, and continued to do 
fo for fix days. On the feventh, he found 
himfelf fick, vomited twice, and had a kind 
of fainting fit followed by a great pain in 
his head, and fome degree of fever. From 
the hardfhip and the irregular manner of 
thefe peoples living, his complaints were 
fuppofed to be owing to cold, and to in¬ 
temperance, and he was treated accord¬ 
ingly: but on the ninth day, a tumor ap¬ 
pearing on that part of his head which 
had received the blow, a furgeon examined 
it, and upon opening the tumefied part 
found a fiffure running diagonally acrofs the 
whole parietal bone. The next day he was 

brought 

K* 


( • i 8 3. ) 

brought to St. Bartholomew’s hofpital. His 
ikin was hot, his pulfe hard and quick, and 
he complained that his head felt as if 
it was fqueezed between two trenchers. 
The whole fifiure being brought into view, 
the trephine was applied three times along 
the track of it ; from each perforation, a 
quantity of matter was difcharged, and un¬ 
der each the dura mater was much altered. 
All poffible care was taken of him, but to 
no purpofe : every day produced an exafpe- 
ration of his lymptoms. On the fourteenth 
he became paralytic on one fide, and on 
the fixteenth funk into a ftate of perfedt 
infenfibility, and toward evening died. The 
whole internal furface of the left parietal 
and temporal bones was detached from the 
dura mater, and covered a large quantity of 
matter. 



CASE 


( i8 4 ) 


;/ 



CASE XX. 


Bricklayer’s labourer was knocked 



jfjL down by the fall of a large heavy 
pan-tile, which made a large wound in the; 
fcalp, and broke the fkull. The fradture 
began in the left parietal bone, and traver- 
ling the coronal future ran about an inch 
in the os frontale. 

He was fopn brought to the hofpital, 
where the fcalp was immediately removed, 
fo as to make way for the trephine ; which 
inftrument was applied on each fide of the 
future, in fuch manner as to comprehend 
the fradfure in each application of it. 

The dura mater was found to be unin¬ 
jured 5 there was neither extravafation, nor 
any other mark of mifchief* The patient 
was freely and repeatedly let blood, kept 
to a proper regimen, and prefcribed for by 
the phyfician. In two months he was dis¬ 
charged perfe&ly well, and had not dur¬ 
ing his cure one fingle bad fymptom. 

It may very reafonably be remarked, that 
this was one of thofe cafes which would 
have done well without the operation, 
which I am much inclined to believe : but 


does 



( '8; ) 

x f * ^ • . 1 * f * 

does not this cafe, as well as many others of 
like fort, prove alfo, that the laying bare 
the uninjured dura mater is not a matter 
of fuch hazard, as fome have fuppofed it 
to be ? 

k K ‘ - * 

CASE XXL 

A Girl about nine years old fell from 
the top of a pretty high hay-rick at 
Iflington, and pitched with her head on the 
ground, which was hard and dry. She 
was carried home bleeding freely from a 
wound on one fide of the upper part of the 
head, and a furgeon in the neighbourhood 
examining her found that her flcull was 
broken ; upon which the was brought to 
the hofpital. The fracture was deteded % 
it began in one parietal bone, and pafling 
the future ended in the other, making a 
courfe of about three inches in all. It was 
open, and blood difcharged through it. 

The trephine was applied to it on each 
bone, the dura mater was not hurt. She 
had neither ficknefs, ftupor, pain, nor fe¬ 
ver, and got well without any trouble ; not 
even having an exfoliation from the bare 
cranium, 

4 . . ~ 4 . *4 


The 


( 186 ) 


The fame remarks as were applicable to 
the foregoing cafe are, perhaps, equally fo to 
this. 

CASE XXII. 


A Farrier’s fervant received a blow from 
the foot of a horfe which he was 
fhoeing. The blow knocked him down, 
and bereaved him of fenfe. He lived near 
Smithfield, and was brought to the hofpi- 
tal fenfelefs. 

I faw him in lefs than half an hour, and 
found him to all appearance well, his 
fenfes perfectly recovered, and no remains 
of the injury vifible fave a fmall bruife on 
his forehead. A difcutient cerate was ap¬ 
plied to the bruife, he was let blood, a 
purge was ordered for the next day, and 
he was advifed to keep very quiet. 

On the third day he was perfe&ly well, 
had no general complaint, and the bruife 
on his forehead was what is commonly 
called black and blue. 

He continued well until the evening of 
the feventh day, in which he complained 
of being faint, chilly, and uneafy in his 
head, particularly his forehead. The fol¬ 
lowing 


-( i8 7 * ) 

lowing night he was reftlefs, and in -the 
morning was lick and giddy, and had no 
appetite. His pulfe was very little rifen; 
however twelve ounces of blood were taken 
from his arm, and he was ordered to take 
the fal ablinth. mixture fextis horis, and 
keep in bed. The ninth and tenth days 
were palTed in much the fame manner, 
but on the eleventh his fever rofe high, 
and the part of his forehead which had 
received the blow became fwollen and 
tender. On the thirteenth the tumefied 
part palpably contained a fluid, and was 
therefore opened. A fradture of about two 
inches in length was difcovered, running 
from juft above the frontal finus upward. 
The trephine was applied in the moft de¬ 
pending part, and matter found between the 
membrane and bone. The day after this 
operation, finding his pulfe to be full and 
hard, I bled him lo freely that he fwooned, 
and was fome minutes before he recovered. 
That night he palled much ealier ; and al¬ 
though the difcharge of matter was confi- 
derable for fome time, yet by proper care 
and due management, both phyfical and 
chirurgical, he got well* 

I will 


( i88 ) 


I will not aflert it to be a general 
but as far as my own experience and obfer- 
vation go, I think that I have feen more 
patients get well, whofe injuries have 
been in or under the frontal bone, than 
any other bones of the cranium. If this 
fhould be found to be generally true, may 
not the reafon be worth inquiring into ? 


CASE XXIII 


Lad about feventeen, the fon of 3. 



JTjL plafterer, was at work with his fa¬ 
ther at the manfion-houfe, and fell front 
a fcaffold a confiderable height. He lay fenfe- 
lefs for fome minutes, but in a little time 
was fo much recovered as to walk. On the 
left lide of his head was a fmall bruife. 

' ' 4 * • V . * 

which gave him little or no pain. He had 
no fymptoms which indicated that he had 
fuftained any mifchief; and after having 
ftaid at home a day or two at the perfwa- 

lion of his mother, he returned to his bufi- 
nefs. On the ninth day, from that of his 
fall he was feized with a violent {hooting 
pain in his head, was fick, and had a kind 
of convulfive fit. 


A$ 


2 


( 189 1 

As it was not fuppofcd that his fall had 
any fhare in that attack, no notice was taken 
of it ; a few ounces of blood were drawn 
from his arm, and the apothecary who had 
the care of him gave him fome of thofe 
medicines that are called nervous. 

His head-ach, fever, arid watching, con¬ 
tinued without remiffion for feveral days, 
and at the end of three weeks he died, pa¬ 
ralytic on one fide, and convulfed on the 
other. 

A fmall fwelling having appeared on his 
head three or four days before his death, 
his father defired me to come and look at it, 
after that event had happened. 

The pericranium was feparated from the 

left parietal bone quite acrofs, by means of 
a fradture which traverfed the length of 
the whole bone. A quantity of matter was 
lodged between the inner furface of the faid 
bone and the outer one of the dura mater, 
and a fmaller collection of matter was alfo 
found between that membrane and the pia 
mater. 


CASE 


( 19 ° ) 


CASE XXIV. 


Young man about twenty-two was 



jljL brought into St. Bartholomew’s ho- 
fpital, confiderably hurt by a fall from a 
high fcaffold. 

The radius of his right arm was broken 
about its middle; the tibia and fibula of 
his left leg were both broken, and one or 
two of his ribs. 

By proper care, in about five weeks, he 
was fo well as to be permitted to get out of 
bed. The firft day of his rifing he com¬ 
plained of being fick and giddy, which 
was imputed to weaknefs and confinement, 
and therefore difregarded. For three or 
four days after this period he complained 
of conftant pain in his head, got no fleep, 
and was conftantly feverifh. As he had 
never made any complaint of his head, nor 
had apparently fuftained any injury on that 
part, Mr. Nourfe (whofe patient he was) 
could not fufpeft: any, and therefore con¬ 
tented himfelf with the common antiphlo- 
giftic regimen. At the end of the fixth 
week, he complained that his head was 
painful to the touch j and the day after he 


had 


( I 9 x ) 

had made this complaint, he had a fevere 
rigor, which lafted half an hour. On the 
twenty-ninth day a fwelling, palpably con¬ 
taining a fluid, appeared on the fide of his 
head. Mr. Nourfe opened it, and found a 
fradture of the parietal bone three inches 
long at leaft, through which matter ifliied 
freely. The trephine was applied, a large 
quantity of matter was difcharged, and the 
dura mater was found floughy; under 
which floughy part was another collection 
of matter between the membranes, and un¬ 
der this latter abfcefs the brain was con- 
fiderably difcoloured. He died on the fif¬ 
tieth day from that of his fall. > 

CASE XXV. 

A B O y, belonging to a horfe-dealer 
in Smithfield, was thrown from a 
horfe, with great violence, againfl one of 
the fheep-pens. He had a large wound 
and a fradture, which began about the mid¬ 
dle of the frontal bone; and pafling the co¬ 
ronal future, ended in the right parietal. 

A trephine was fet on the fradture in the 
frontal bone, and a fmall quantity of gru- 
mous blood difcharged from between the 

cranium 


4 


( * 9 * ) 

\ t 

cranium and dura mater. All that day and 
night he continued fenfelefs; but the next 
day, by means of a fecond plentiful bleed¬ 
ing, he recovered his fenfes. To render 
every thing (as I hoped) fecure, a fmall tre- 
phine was applied on the other fide of the 
future, which feemed to comprehend all 
the breach made in the parietal bone. 

For nine days from this time every 
thing looked well, and the boy was free 
from complaint ; but on the twelfth from 
the accident, he complained of being much 
out of order ; and the next day the fore 
looked ill, and a thin gleet was difchar- 
ged from the dura mater through the lint, 
which now ftuck fall, to it inflead of com¬ 
ing off eafily as ufual, and covered with 
good matter. 

For three days from this time, both the 

t 

boy and fore remained in much the fame 
ftate. On the feventeenth, in drefiing him, 
I obferved a fpongy kind of papilla on one 
part of the fore, which was very tender to 
the touch, and from which was difcharged 

upon prefiure, a thin fanies kind of fluid; 

> 

by means of a probe pafled through this 
papilla, I difcoverea a finus with bare bone 
its whole length ; the divifion of this de¬ 
tected 


, ( 193 ) 

% 

felted a capillary fiflure, - of at lead two 
inches in length. A trephine was fet oil it, 
and the dura mater was found difcoloured, 
and with matter on its furface. By means 
of free evacuation at firft, and as free 
life of the bark afterwards, this patient got 
well* 


CASE XXVI. 

T WO female inhabitants of St. Giles's 
got drunk together, and quarrelled ; 
one of them threw a ftool at the other, 
and knocked her down* The edge of the 
ftool cut through the fcalp, and broke the 
left parietal bone* The fracture ran front 
the middle of the bone as far as the fagittal 
future. The girl was drdfed that night by 
fomebody in her neighbourhood, and was 
brought the next morning to the hofpital. 
As /he had no bad fymptom of any kind, 
the operation was deferred, and fhe went 
on very well for a week, at the end of 
which time fhe began to complain in fuch 
manner, and her fore bore fuch an alpedl, 
that I thought there mufl be mifchief un¬ 
der the cranium. A trephine was fet on 
the fra&ure , the dura mater was found 
: • O floughy 


f 194 ) 

llbughy and purulent. She was Med again' 
freely, and took proper medicines. On 
the fifteenth day fhe had a fhivering, and 
after it a very brifk fever. On the feven- 
teenth fhe was worfe in every refpeft. 
On the eighteenth a tumor appeared, on 
the other fide of the head. This was open¬ 
ed, and a fiffure difcovered in the right os 
parietale. A trephine was fet on this fif- 
fure, and a difcharge given to a large quan¬ 
tity of matter. Every thing that could be 
done for her was done ? but on the twenty- 
third day file died. 

The dura mater was feparated from both 
the parietal bones,, and matter found in 
large quantity under each*. 

it was for many years a generally received 
opinion, that one ufe of the futures of the 
cranium was, to prevent the pafTage of a 
fradture from one of the bones to another. 

This purpofe they may undoubtedly have 
often accidentally ferved ; but that they 
are generally incapable of fo doing, ma¬ 
nifold experience evinces. Fradlures are* 
often feen to pafs regularly through a future,, 
from one bone to the adjoining, without any 
difcontinnation or impediment. This is a 

fa£i 


( *95 ) 

i> , i , / 

fact which ought, by writers and lefttifers* to 
be conftantly inculcated, as an inattention to 
it may be of very bad confequence to indi¬ 
viduals : for the,practitioner who fuppofes 
that a future will certainly, or not unfre- 
quently, x fet bounds to a fraCture, will, 
when he has traced fuch kind of breach in 
one bone as far as the future into which it 
may happen to run, not think it at all necef* 
fary to go farther and examine the adjoining 
bone* ' { 

A fgfpicion of ' tjie pricier adhefion of 
the dura mater to the fkull at the places of 
thefe futures than every where elfe, the fi-* 
tuation of what are called finufes immedi¬ 
ately under the futures, and a fear that ei* 
ther high and dangerous inflammation mud 
follow the violent detachment of a part of 
them, or that an unreftrainable and fatal 
haemorrhage mull enlue from a breach of 
thofe veifels which pafs from the finuifes 
through the futures, have $eterred moft of 
our anceftors from* meddling with them, 

• -««r ^ 

and induced them to deliver down to us 
frequent prohibitions againfl the applica¬ 
tion of perforating inilrumcnts upon therm 
Neither of thefe apprehenfions are founded 
in fa£t, or in ftriCt truth* The feparation 

O a o£ 


V l 9 6 ) 

. ’ rs ' f . * 4 .* ' /• v ,. 

of the fkull from the longitudinal finus is 
not attended neceflfarily with any kind or 
degree of inflammation peculiar to itfelf, or 
more than any other part of the dura ma¬ 
ter ; nor is the laceration, or breach of the 
communicating veflels between this finus 
and the future which covers it, necefTarily 
followed by any fuch degree of haemorrhage 
as to prove hazardous or alarming; as I 
have more than, once experienced. 

A perforating inftrument moft Certainly 
ought not wantonly or unneceflarily to be 
fet on this part; and this for a reafon not 
drawn from any peculiar hazard attending 
fuch operation. The larger fize, and greater 
number of veflels here than in other parts 
of the bone, will certainly caufe fuch a 
degree of bleeding or haemorrhage, as tho’ 
eafily reftrainable when the piece of bone is 
removed, may yet, in the a<5t of perfora¬ 
tion, confiderably embarrafs and perplex a 
young operator : it will therefore behove 
him, in general, to avoid comprehending 
the future within his faw ; but ftill it is 
right that he fhould know, that when par¬ 
ticular circumftances render it abfolutely 
neceflary, fuch thing may be done very 
confiftently with his patient’s fafety. Not 


( i97 •) 

only a part of the fagittal future, covering 
the longitudinal finus, may be removed with 

Ml, 

a trephine, if neceflary, and no hazard be 
incurred from the breach of the attaching 
veffels; but a wound of the finus itfelf is 
by no means necejjarily attended with an 
nnreftrainable or fatal haemorrhage. 

The very writers themfelves, who are fo 
apprehenfive of a wound of this part, for¬ 
get the relations they every now and then 
give us of fragments of broken bone fafely 
extracted from it. 

A miftake concerning the nature of the 
dinufes w’as (I fuppofe) the foundation of 
thefe apprehenfions. The idea which mod 
of our anceftors had of the motion of the 
dura mater induced them to believe that, 
as the finufes were compofed of this mem¬ 
brane, a wound made in them, like a wound 
in an arterial tube, could hardly reunite. 
It is now univerfally known, that they are 
merely venal, and that there is no fuch im¬ 
pediment to the immediate coalefcence of a 
wound in them, when it may happen to be 
accidentally inflidted. 


O 3 CASE 


( 198 ) 


CASE XXVII.. 


BOY about eight years old, ths 



JTjL Ion of a Jew merchant in the 
city, received a blow on his head with a 

flick from his tutor. The flroke made him 

■ : • - 

giddy for a few minutes; but as no blood 
was fhed, and the pain foon ceafed, he 
concealed it till it was difcovered by his 
barber that his head was fwollen in that 
part. In the middle of the top of his 
head was a tumor, about the fize of a 
common wall-nut; it was indolent, had a 
dull kind of pulfation, and palpably con¬ 
tained a fluid. 

Mr. Serjant Amyand and Mr. Shipton 
were joined with me. In their prefence I 
divided the tumor with a knife, and let out 
a quantity of fluid venal blood. When as 
much had been difcharged as the tumor 
might b e fuppofed to have contained, we 
were furprized to find the blood ftill con¬ 
tinue to flow, plainly not from the wounded 
fcalp but from the bottom of the cavity. 

Upon examination, it was found that 
jhc fagittal future was broken, that a por¬ 


tion 


i 199 ) 

tion of the fradure was forced into the 
finus, and that the blood iffued by the fides 
of this fragment. 

Extradion of this fragment was attemp¬ 
ted, but to no purpofe. By the diredion of 
the confultants, I made a fmall perforation 
on one fide of the future; but when that 
was done, the point of the elevator could 
not be fo introduced as to get the broken 
piece out. The trephine was then applied 
on the other fide of the future, and to the 
fame effed, or rather no effed. The frag¬ 
ment was only capable of being extraded 
as it had gone in. At laft, after much de¬ 
liberation and converfation about the hazard 
of wounding a finus, (which was indeed al¬ 
ready wounded by the broken bone) it was 
agreed to fet a trephine on the future, in 
fuch manner that the whole furface £hou!d 
be comprehended within its circle. This 
w r as done; but when the elevator was ap¬ 
plied, the piece fa wed came out in frag¬ 
ments, and left the one portion which had 
pierced the finus ftill flicking in it. We were 
then neceflitated to lay hold of it and ex- 
trad it with a pair of forceps. A flux 
of blood followed, but by the application 
of a fmall doffil of dry lint, held on for a 

O 4 few 


\ 


( 2CO ) 

few minutes, it ceafed, and never recurred. 
The patient is alive at the time of my wri¬ 
ting this. 

CASE XXVIII. 

A Girl about fixteen was knocked down 
by her mother with an iron poker of 
confiderable weight $ the latter immediately 
ran away, and the former was brought 
fenfelefs to the hofpitak She had a large 
wound on the top of her head, with con¬ 
fiderable fracture of the fagittal future. The 
broken pieces were fo large, and fo loofe, 
as to be eafily removeable without any per-t 
foration. When they were taken away, 
the longitudinal finus was left bare, at leaft 
two inches in length ; but no haemorrhage 
followed the removal of the fragments. 

For three days fhe was bled twice a day, 
from one part or other of her, and ftools 
were procured in fuch manner as was pof- 
fible, but to no purpofe ; fhe {till remained 
perfe&ly and abfolutely fenfelefs. On the 
fifth day, finding her ftill in the fame ftate, 
and verily believing that nothing in art 
could at all ferve her, I made an opening 
>yith a lancet into the longitudinal finu^ 

V ' y , t . * 

and 


? '201 ^ •- " 

and fuffered the blood to run off, until hef 
countenance, which was much flushed, be¬ 
came pale, and her pulfe, which till now 
had been full and ftrong though labouring,* 
faultered confiderably; in (hort, till (he 
(hewed as much as a fenfelefs perfcn could 
the marks of a deliquium from inanition. I 
then put a bit of lint on*the orifice, and or¬ 
dered the nurfe to keep her finger lightly 
on it until I had vifited the reft of the houfe. 
When I returned, the part (hewed no dif- 
pofition to bleed again, nor did it ever af¬ 
ter. That afternoon (he opened her eyes 
and moved her arms, and the next morn¬ 
ing was fenfible enough to afk for drink. 
She retained her fenfes for feveral days, but 
a fever coming on (he became delirious and 
convulfed, and died fo on the feventeenth 
day from that of her admiffion into the 
hofpital. 

Upon examination, after death, a confi- 
derable abfcefs was found on the furface of 
the brain, on one fide of the falciform pro- 
cefs of the dura mater. 

!** I (hould be very forry to be lo mifunder- 
ftood, as to. have it conceived that I have 
related thefe cafes with a view to encou¬ 
rage the opening the longitudinal finus; 

that 



( not f 

that is far from my intention; I only mean, 
by adducing thefe inftances, to prove that 
our fears of irremediable mifchief from fuch 
wounds, whether accidentally or artifici¬ 
ally inflidted, are not well grounded ; and 
that we may, in fome defperate cafes, have 
recourfe to fuch means as have been fup- 
pofed to be either impracticable or unwar¬ 
rantable. A furgeon fhould ever be cautious, 
but ill-grounded apprehenfions will necefia- 
rily prevent improvements, and hinder us 
In fome cafes from attempting what may 
prove beneficial to mankind. Had every 
fucceffor to Hippocrates been of his opi¬ 
nion, the operation of lithotomy had ne¬ 
ver arrived at its prefent ftate of perfection, 
and mankind had been fuffered to languish 
under, and be deftroyed by, a moil tedious 
as well as excruciating malady. 


{ 203 ) 


SECT. V. 

Fraptures of the cranium with deprejjion. 

» 

S IMPLE fraftures of the fkull, or thofe 
in which the parts of the broken boi>e 
are not deprefled from their fituatior>> dif¬ 
fer from what are called fiflures only in 
the diftance of the edges of the breach from 
each other. When the feparation is confi- 
derable it is called a fra&ure, when it is 
very fine and fmall it is called a fifliire. 
The chirurgical intention and re(juifite 
treatment is the fame in each, viz. to pro¬ 
cure a difcharge for any fluid which may 
be extravafated in prefent, and to guard 
againft the formation or confinement of 
matter in future. But in fra&ures attended 
with deprefiion the intentions are more. 
In thefe the deprefled parts are to be ele¬ 
vated, and fuch as are fo feparated as to be 
incapable of re-union, or of being brought 
to lie properly and without preffing on the 

brain, are to be totally removed. 

% 

Thefe circumftances are peculiar to a de¬ 
prefled fra&ure ; but although they are pe¬ 
culiar, they muft not be confidered as foie,' 

but 


( 204 f 

but as additional to all thofe which have 
been mentioned at large under the head of 
Ample fracture : commotion, extravafation, 
inflammation, fuppuration, and every, ill 
which can attend on or be found in the 
latter, are to be met with in the former, 
and will require the fame method of treat¬ 
ment. 

To free the brain from preflure, and to 
provide a free difeharge for blood or lymph 
at prefent, or for matter in future, by ele¬ 
vating the depreflfed pieces, and by remo¬ 
ving fuch as were loofe, was as well known 
to the antients to be the proper curative 
intentions, as they can be to us ; but the 
means which they made ufe of in order to 
accomplifh thefe ends were fomewhat dif¬ 
ferent to what are now ufed, and laboured 
under fome inconveniences which later 
practitioners have corrected. This difference 
it may be worth w’hile to inquire into. 

Moft of the attempts made by our ancef- 
tors, for the elevation of depreffed parts of the 
cranium, were made by the application of 
inflruments to the parts fo depreffed. This 
was a palpable imperfection, to fay no more 
of it ; but this was not all ; for the inflrur 
ments which they made ufe of on thefe 

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Tojivntpa^e <205. 


































( 205 ) 

occafions were not only to be fattened td 
the deprefled part of the bone, but required 
alfo fome degree of force to be ufed in 
fattening them to fuch part. The troclea 
tripes, the troclea bipes, and all the pieces 
of machinery defigned by Albucafis, Guido, 
Andreas a Cruce, Fabritius ab Aquapenden- 
te. Pare, and Scultetus, as well as thofe 
delineated by Hildanus, and Peter Paaw, 
are proofs of this: they all require a per¬ 
foration to be made in the deprefled piece, 
either by or for the fcrew with which it is 
to be elevated. Now, not to mention that 
moft of thefe inttruments were fo complex 
as to render them extremely awkward and 
unmanageable, it is obvious, that by the 
application of any of them to the deprefled 
pieces, (efpecially if they were loofe) all the 
ills arifing from preflure made on the parts 
underneath mutt be increafed; and that 
in many cafes they could not be ufed at all. 
Celfus has indeed directed the meningo- 
phylax to be ufed as an elevator; which 
inftrument differs but little from the ele¬ 
vator ufed at prefent, either in form or 
manner of application ; but then the open¬ 
ing, through which it is to be introduced, 
is to be made either with the terebra or 

the 


( 2o6 ) 

the cyclifcos, the inconveniences of which 
have already been remarked. In fhort, all 
the objedions which the old perforating 
inftruments were liable to in Ample unde-* 
preffed fradures being of ftill greater force 
in fradures with depreffion, and the appli¬ 
cation of any kind of inftrument whatever 
to the outer furface of a deprefied or loofe 
piece of fkull being palpably wrong, and 
liable to hazard, the prefent praditioners 
are certainly vindicable in having laid them 
all afide, and in having endeavoured to ac- 
complifh the fame end by means which 
are lefs hazardous and kfs operofe. The 
trephine is (as I have before obferved) the 
only perforating inftrument ufed by the belt 
of the prefent praditioners in England * 
with this, an opening is made in the found 
undepreffed part of the cranium, and thro' 
fuch opening an inftrument called from 
its ufe an elevator is introduced. This 
perforation fhould either comprehend the 
border of the fradure, where that is pofil- 
ble, or if that cannot conveniently be done' 
ftiould be made as near to it as poffible, for 
reafons too obvious to need recital. What 
number of perforations may be neceflary 
can only be determined by the particular 

cir- 


( 207 ) 

circumflances of each individual cafe; all 
the intentions which may arife from extra* 
vafation of fluid, or probability of fuppu- 
ration, as well as thofe from the depreffion 
of bone, muft be fulfilled, or the work 
will be left imperfedt, and little chance of 
good will attend it. 

When the whole difeafe feems to confift 
in the mere depreffion of the bone, and 
what fymptoms attend feem to proceed 
from that alone > the elevation of fuch por¬ 
tion may procure immediate remiffion of 
fuch fymptoms, and afford a reafonable 
profpedt of fuccefs. But as the injury is 
not always of fo Ample a nature, as other 
parts are fo frequently hurt and other mif- 
• chief done by fuch great violence, the re¬ 
miffion, or difappearance of fuch fymptoms 
as arife merely from fuch preffure, cannot 
be a fufficient warrant, either fo if promifing 
or for expecting fuccefs.. The dura mater 
und.er the depreffed piece, or even in ano¬ 
ther part of the head, may have been fo 
hurt as to become inflamed, and to fup- 
purate, the fymptoms of which will not 
appear immediately, nor in general until 
fome time is paft; but however late they 
may come on, they will not therefore be 

the 


s f 208 f 

the lefs certain or the lefs hazardous. Thd 
early attack of thofe which are caufed by 
extravafated fluid, or depreffed bone,’ do by 
no means preclude the later acceflion of 
fuch as arife from inflammation and pu¬ 
trefaction. The deprefled piece of bone 
does mod certainly require our immediate 
help, but the afliftance lent to that, how¬ 
ever proper and effectual, does not render 
it at all lefs neceflary to guard againfl: fuch 
ill as may mofl reafonably be expeCted to 
proceed from violence fuftained by the parts 
underneath. A blow, which has been fuf- 
ficient to break and deprefs a portion of the 
fkull, very frequently does fuch damage to 
the tender veflels which communicate be¬ 
tween that bone and the meninges, as to 
be the caufe of much more, as well as 
greater ill, than what is deducible from the 
mere fraCture ; and, confequently, altho’ 
the elevation of the bone is one very necef- 
fary part of the furgeon's bufinefs in thefq 
cafes, yet it is very far from being all that 
he has to do. All the ills which may be 
apprehended, from every other pofiible effeCt 
of fuch violences, are to be feared and 
guarded againfl:, and that full as much in 

/ 1 — * 

the'fraCture with deprefli'on, as in that 
without. 

• . 1 


This 


( 209 ) ' 

This is a part of practice which ought 
to be very carefully attended to. The ge¬ 
nerality of writers have contented them- 
felves with directing us to raife up the de- 
preffed parts, and thereby to endeavour to 
remove fuch fymptoms as are caufed by 
the mere prefTure which the bone makes on 
the brain ; but have either totally negledted, 

. or very {lightly palled over, what is of full as 
much confequence to the patient ; I mean, 
the injury which is mod frequently done to 
the membranes of the brain, and which* 
if negledted, will certainly produce, that fe¬ 
ver* and thole fymptoms, which fo often 
baffle the whole power of medicine. 

The combination of different ill effedts, 
proceeding from the fame primary violence, 
and concurring in the fame fuhjedt, toge¬ 
ther with the great difficulty of diftiriguifli- 
ing them from each other, is one of the 
principal caufes of that perplexing uncer¬ 
tainty attending wounds of the head. When 
one caufe of bad fymptoms has been re¬ 
moved, another, or even feveral others, 
may ftill remain, each of which firigly may 
be fufficient to deftroy the patient s and 
therefore, although the means firft made 
ufe of may have been fuch as have been 

P pointed 


( 2*0 ) 

pointed out by the earlieft and moft alarm-* 
ing fymptoms, and extremely proper for the 
relief of fuch complaint, had it been the 
only one the patient laboured under* yet 
in the cafe of a complication, by not be¬ 
ing fufficient to anfwer every requifite in¬ 
tention, they very often anfwer none; at 
lead: ftot effectually ; and producing only a 
temporary and partial relief, prove a greater 
aggravation of our difappointment. 

This every practitioner fhould know, and 
th is the friend of every patient fhould be 
made acquainted with, left the former, be¬ 
ing deceived by an appearance of amend¬ 
ment, be induced to promife what it will 
not be in his power to perform ; and the 
latter, having had their hopes exalted, fhould 
be the more feverely hurt by their difap¬ 
pointment. 

If the fradture be but fmall, the depref- 
fion little, and the force with which it was 
produced not great, the elevator introduced 
through the perforation may be fufficient 
to fet it to rights, and, if there be no ur¬ 
gent fymptoms nor any mifchief done to 
the internal parts, may be fufficient for all 
purpofes. But if the force was great* if 
the fymptoms are immediate and preffing, 
i if 


: . ( 211 ) 

if the fradture runs in a form inclined to a 
circular one, or if the deprtffcd piece be 
cracked all round, the bed and fafeft way 
is to remove the whole or greater part of 
the portion fo deprefled and circumfcribed. 

To thofe who are unufed to things of 
this fort, fo large an opening as fuch me¬ 
thod of adting muft make will have a very 
tremendous appearance ; and they may be 
inclined to fufpedt much hazard and incon¬ 
venience from laying bare fo large a portion, 
of the dura mater ; but let all fuch remem¬ 
ber, that however large the quantity of 
membrane may be which fhall be thus de¬ 
nuded by the operation, yet the fame quan¬ 
tity at lead, mod probably a much larger, 
would, in all likelihood, become inflamed, 
and generate matter on its furface ; which 
matter, for want of a timely, ready, and 
fufficient outlet, would do confiderably more 
mifchief, than the mere detection of the faid 
membrane can do. 

In cafes where the broken pieces of a de- 
prefled fradture are widely feparated from 
each other, and fome of them a good deal 
loofened, the expediency and the pro¬ 
priety of removing fuch pieces is acknow¬ 
ledged by every body; but few people at- 

P 2 . ‘ tend 


{ 2IZ ) 

tend to the reafon, or inquire why Inch 
practice is juft and proper ; if they did, they 
would alfo fee that the free removal of bone 
was equally proper in the cafe of great vio¬ 
lence, as in that cf loofened or widely fe- 
parated pieces. In the latter,, the broken 
parts are removed, becaufe their re-union 
with the reft of the cranium, and the 
preservation of the attachment of the du¬ 
ra mater to the inner furface of them* 
is thought impoffible, or at lead: highly 
improbable; and that therefore they muft 
be in the way, and hinder the free dif- 
charge of matter from the fuppurating 
membrane r. and is not the fame inconveni¬ 
ence full as likely to attend the former ? Is 
it the violence done to the bone, and thro ? 
it to the membrane, which caufes the in¬ 
flammation and fuppuration ? or is it the 
loofened or feparated ftate of the broken 
part ? If it be the former* (as it moft un¬ 
doubtedly mu ft be) the fame precautions, 
the fame method of treatmen t mu ft be 
equally neceftary in the one as in the other; 
the reafons, the intentions are the fame in 
each, and if the conduct be not the fame 
the patient will fuffer*. 

The 


( 213 ) 

'The peculiar circumftances of each indi¬ 
vidual cafe muft furnifh direction to the 
practitioner for his particular conduCL Rules 
to be laid down by a writer on fuch fub- 
jedt can be only general. The parts which 
are deprelTed muft be elevated, fuch as are 
•loofe and cannot be brought to lie even, 
fuch as cannot be prevented from preffing 
on the membrane, or fuch as wound or ir¬ 
ritate it, muft at all events be taken away > 
the free difcharge of blood or lymph, in 
.prefent, and of matter in future, muft be 
provided for, and therefore every fymptom 
and appearance muft carefully and early be 
attended to, left the moft proper opportu¬ 
nity of giving afliftance be not embraced. 

The circumftances juft mentioned are 
fuch as cannot be negleCled but at the rifque 
of the patient, and therefore the prohibi¬ 
tions which our forefathers have delivered 
down to us, with regard to the parts of the 
fkull, on which they fay we ought not at 
any rate to apply our perforating inftru- 
ments, muft be received with feme limi¬ 
tation. 

The places forbidden as improper are, 
the .futures, the lower part of the os occi- 
pitale, the oila temporum, and that part of 

P 3 the 


( 214 ) 

the os frontale where the finufes are fitu- 
a ted. 

That a trephine may without hazard be 
applied on‘ a future, I have already faid. 
When it may with equal utility be fet on 
any other part the futures fhould undoubt¬ 
ed!}/ be avoided, and that for a good rea- 
fon, exclusive of any peculiar hazard : but 
that part of a future may (the cafe requir¬ 
ing it) be fafely removed, is true beyond all 
doubt. That many of the old practitioners 
were very apprehenfive of mifchief from 
hence, is not to be wondered at by any body 
who cooiiders their idea of the nature of the 

• , 1 Y T i 

fubjacent finufes, and the ftrange unma¬ 
nageable inftruments with which they ope¬ 
rated. Not that there are wanting old wri¬ 
ters who have held the doCtrine of operat¬ 
ing on a future, when neceffary, very de- 
fenfible, among whom is J. Baptift. Cor*« 
tefius. 

Perforation of the temporal bones has been 
forbid, both on account of the artery and 
the mufcle which are on its furface, uhre- 
ftrainable haemorrhage having been dreaded 
from the one, and fatal convulfion from the 
other ; but experience may convince us, 
that neither of thefe apprehenfions are 


( 2I 5 ) 

ftriftly juft. The temporal artery, when 
divided, is often capable of being reftrained 
bv compreftion, and always by ligature ; 
and that fatal convulfion, which is vulgarly 
called the locked jaw, though it produces 
one of its mofc ftriking and mod vifible ef¬ 
fects on thefe mufcles, is not neceflarily 
produced by a wound of either of them, 
more than by a wound of any other. In 
fhort, the upper part of the temporal bones 
may be laid bare, if neceffary, by an inci- 
iion made through the mufcles covering 
them * and may alfo be perforated. Such 
operation does not indeed often prove 
fuccefsful; but the failure of fuccefs does 
not proceed from the nature of the parts 
operated upon., but from a circumftance of 
much more confequence, and generally 
without remedy ; which is, that in thefe 
fractures the breach is moft commonly con¬ 
tinued on to the bails of the fkull, and is 
alfo moft frequently attended by a large ex- 
travafation within or under the brain and 
cerebellum 

When 

* Whoever will examine the difpofition of the tempo¬ 
ral mufcle will fee, that its aponeurofis covers a very 
£pnfiderable part of the inferior border of the os parietale \ 

P 4 an4 


o 


( 216 ) 

When the depreffed parts have been 
raifed up 5 the loofe ones removed, extra- 
vafated fluid difcharged, the brain freed 
from preflure, and way made for the free 
exit of whatever may be formed or colleo 

V 

ted, the bare dura mater fhould be dreffed 
as eafily and lightly as pofiible. Our ance- 
flors had a multiplicity of medicaments, • 
which they ufed upon thefe occafions, and 
were very precife in fuiting them to the 
different dates (as they called them) of the 
fore and membrane, They were alfo very 
exadt in making and applying thofe pieces 

of linen or of filk, called findons, which 

■ 

they ufed to imbue with the faid remedies, 
and drefs the bare dura mater with. I have 
taken no notice of either, becaufe I verily 
believe that the majority of the former 
were abfolutely ufelefs, and that the very 
exact application of the latter was prejudi¬ 
cial, by confining, in fome degree, what 
ought to be difcharged with the utmoft 
freedom. 

Wounds of the brain, among writers on 
this fubjeci, have alfo generally made a dif- 

' " . * tindt 

arc! confequently, that fuch part of that bone can never 
be laid bare without a divifion or removal of a part of the 
faid aponeurotic expanfion. 


( 21 ? ) 

tindl chapter; but the treatment of them is 
fo very little different from thofe which 
have been already related, that they may 
fairly be comprehended under the Tame 
article. 

The brain is wounded either by the in- 
ftrument or body whereby the fkull is bro¬ 
ken, or by broken parts of the cranium j 
foreign bodies alfo, fach as bullets, fpiin- 
ters, parts of weapons, wadding of fire¬ 
arms, &c. are fometimes lodged in it; but 
let the wound or fra&ure be what it may; 
or whatever other circumftances may hap¬ 
pen to attend, the chirurgic treatment 
is fhort and plain, viz. to remove all 
Inch parts of the broken fkull, as may 
prefs, wound, or irritate the brain, or its 
membranes y to take away all fuch extra¬ 
neous bodies, as can eafily, and without vi¬ 
olence be got at and extracted ; and to 
make fuch an opening, as may mod: conve¬ 
niently ferve the purpofe of difcharging 
blood, ferum or matter, either in prefent 
or in future. When all thefe things have 
been done, and the patient has been put 
under a proper regimen, both of diet and 
medicine, the furgeon has done his duty, 
and may fay with Mr. Pope, 

“Thus 


i 


( *iS ) 


l c Thus far was right; the reft we leave 
“ to heaven.” 

For with regard to the dreflings proper in 
thefe cafes, they are not at all different from 
thofe which ought to be ufed, where nei¬ 
ther the brain nor its meninges are hurt. 
They fhould be foft, light, and not confift 
of any thing greafy, or which can poffiblv 
irritate or inflame ; nor fhould they be ap¬ 
plied in fuch manner or quantity as to prefs 
or obftrudt the free difcharge of fluids of 
any kind. Soft dry lint is perhaps equal 
to any or all others. In the chirurgicai 
writers are to be found a great many for¬ 
mulas, but whoever places confidence in 
them, for any fuppofed merit of their own! 
will find himfelf much difappointed, 

I cannot quit this fubjedt, without mak¬ 
ing a fhort remark on the bandages moft 
frequently advifed, and ufed in wounds of 
the head. 

In all the writers on the fubjedt of faf- 
cix, are to be found defcription and deli¬ 
neations of thofe which are faid to be moft 
proper for the head. On paper they are 
^ i '" Y neat; 


( 219 ) 

neat and elegant, in the application they 
require a final! degree of pra&ice and dex¬ 
terity/ and when applied nicely may im- 
pofe on the ignorant, and on thofe who 
have not feen much of or reflected much 
on their inconvenience. They prefs, heat, 
and painfully confine the head, even when 
applied in the beft and moft ingenious 
manner ; and when put on aukwardly or 
negligently are ftill more troublefome, and 
lefs ferviceable. All that can ever pofiibly 
be wanted in thefe cafes from bandage 
piufi: be, merely to keep the drefiings in 
their place without any degree of confine¬ 
ment or prefiure ; and this purpofe will al¬ 
ways be better accomplifhed by a loofe cot¬ 
ton or yarn night-cap, than by the nicefl: 
and mofi: elaborate bandage that ever was 
Invented 

CASE 

* On this fubjeft I was very glad to find To very good a 
judge as Oribafius, of the fame opinion. 

cC Haec autem omnia non fafciis continentur, propter 
44 pondus, fed velamento, ut cohibeantur, neque cerebri 
44 membrana gravatur ; ac velamenti media pars, quaete- 
44 rebrato refpondet, forfice exciditur, ut apertum fiat, at- 
44 que in illud fpatium lana mollis, in extremis conftridl^, 
duplex inditur, &c. 

u Pleriquc 


{ 220 ) 


CASE XXIX. 


Girl about fifteen years old, eroding 



jT1L Smithfield on a market-day, was tof- 
fed by an ox, and fell with her head on the 
- flat {tones within the polls. As her drefs 
was mean, and nobody knew any thing of 
her, (he was brought fenfelefs into the ho- 
fpital. She had a large bruife on the right 
fide of her head, through which I plainly 
felt a fracture with depreflion. The fcalp 
being removed from that part, the fradure 
was found to be large, and the depreflion 
considerable; it traverfed the os parietale 
from before backward, in its middle part 
between the Sagittal and temporal futures, 
and the depreflion was of the upper part of 
the bone. I applied a trephine on the in¬ 
ferior and undeprefled part, and by means 


of 


Flerique omnes non alia vlncbara terebratos deligant; 
fed fola redimiculi circumdudione contenti Tint. Quin- 
€5 etiam ipfa quoque ulcera extra terebrationem, quoad 
* c fieri poteft, conari debemus fine fafciis curare ; non 
ct modo quia gravantur compreifis iis quae fub vinculis 
ec impofita ipfis fuerant, verum etiam quia plus quam par 
<c eftcalefaciunt. Etenim quod in aliis partibus vindura, 
44 id ( in capite pofitio praeftabit, ideo deligare fupervaca- 
64 neum erit. ,> 


Oribasius de frad. ex Heliodoro. 


of an elevator raifed the whole to a per- 
fed: equality. Her head was drefled light¬ 
ly, and fixteen ounces of blood were taken 
from her. She pafled the following night 
very unquietly, and the next morning was 
ftill fenfelefs. She was again freely bled, and 
a purge was given, which foon operated. On 
the third day her pulfe admitting, and her 
eircumftances requiring it, fhe was bled a- 
gain. On the fourth day fhe became fenfi- 
hle, and on the fifth was furprifingly well. 
She remained fo until the ninth, on the 
evening of which fhe complained of head- 
ach, ficknefs and giddinefs. She was again 
let blood, and put under the diredion of 
the phyfician, who ordered forne medi¬ 
cines for her* From the ninth to the thir¬ 
teenth day fhe remained much the fame,, 
that is to fay feverifh, and complaining of 
heat, third, head-ach, and watching. On 
the fourteenth fhe had a fevere rigor, and 
the fore on the fcalp as well as the denuded 
dura mater wore a very bad afped. From 
this time fhe became daily worfe and worfe, 
in every refped ; and on the twentieth day 
from that of the accident fhe died, hav- 

K. * 

ing been terribly fliaken by fpafms for fe¬ 
deral hours. 


( 222 ) 

All the internal furface of the os panel ale 
above the fradture was detached from the 
dura mater, and covered with matter, 
which could not obtain free difcharge at 
the perforation, the membrane being in¬ 
flamed and thruft up tight againft it. 

I will not pretend to aflert, that repeated 
perforation of the upper part of the bone 
would have preferved her ; but I mu ft fay, as 
the cafe turned out, it would have been her 
beft, if not her only chance ; and that, if 
I had known at that time as much of thefe 
cafes as I think I have fince learned, I 
fhould certainly have taken away the grea- 
teft part if not the whole of what had been 
deprefled. 


CASE 

/ i JH • if fV/ ■ ■ 




( 223 ) 


CASE XXX, 

A Gentleman’s fervant riding carelefly 
and haftily thro’ London, was thrown 
from his horfe, and ft ruck his forehead a- 

i 

gainft a iharp ftone. There was a confider- 
able wound on the fcalp, and a fradlure, 
with depreffion of the os frontale. The 
man was perfectly deprived of fenfe, the 
bone was confiderably deprefied, and a 
large quantity of blood iffued from un¬ 
derneath the deprefied part. A trephine 
was applied on the undeprefled part, and 
the - elevation accomplifhed; he was let 
blood freely, and drefled lightly. On the 
fecond and third days he was let blood a- 
gain. On the fourth he recovered his fen- 
fes, and from that day to the ninth feem- 
ed to go on well. On the ninth in the eve¬ 
ning he complained of pain and lafiitude, 
and was ill that night and all the next day. 
On the eleventh he was worfe, and (to ufe 
his own words) faid, his brains were bound 
round with a fillet like a collar of brawn. 
His pulfe was hard, frequent, and jarring, 
his ikin hot, and he got no fleep at alb As 

the 


.( 224 ) 

the man was evidently and haftily getting 
into a hazardous ftate, I was determined to 
try what a free removal of bone would do; 
and with a large trephine took away al- 
moft the whole of w r hat had been depreffed. 
The dura mater was not purulent, but dull 
in colour, and fmeared over with What 
Morgagni juftly fays, is gelatinis inftar. 

He was again and again let blood, as his 
pulfe would bear, and the phyfieian ordered 
proper medicines for him. For four days 
from this time he continued much the 
fame, but after that every thing changed 
for the better; he took the cortex freely, 
and in about three months was difeharged 
well. 

As I would not pretend to affert, that 
removal of more bone would have proved 

fuccefsful in the preceding cafe, fo neither 
will I fay that the recovery of this man 
was owing to it. I can only fay, I verily 
believe both, and that I am forry I did not 
make the fame experiment in both. The cafes' 
were materially fitnilar ; and the analogical 
is the only method we have of reafoning on 
fubje&s like this, wherein we* cannot have 
demonflration, 

: .V " > \ ' CASE 


/ 


( 22 5 ) 


CASE XXXI, 

A BOY about fourteen years old, fol- 
** * lowing a led horfe, was defired by 
the fervant, in whofe hand the horfe was, 
to ftrike him $ the boy did fo, and received 
a blow from one of the horfe’s heels, which 
brought him to the ground fenfelefs. He 
had on the upper and middle part of his 
forehead a large wound, which difclofed a 
confiderable fradure, with depreifion. 

The fradure ran nearly in a tranfverfe 
diredion acrofs the bone, and the depref- 
lion was of the upper part. A trephine 
was applied, an elevator introduced, and 
the depreffed part of the bone with fome 
difficulty made to lie even. The head was 
dreffed lightly, and the boy was let blood 
largely. He continued fenfelefs all that 

night, was let blood twice the next day, 
and had a purge, and a glyfter. On 
the fourth day he {hewed fome figns of 
feqfe, and in two more, being again let 
blood and kept very low, was quite fenfi- 
ble. From this day until the fourteenth, 
every circumftance was promifing, but on 

that 

* 4 ' I 


I 


( 226 ) 

that day he again became ill his pulfe 
from this time was hard and quick, and, in 
(hort, he had for three or four days ail the 
fymptoms of mifchicf under the cranium. 
On the nineteenth I made a large perfora¬ 
tion in that part of the bone which had 
been depreffed and elevated, and gave dif- 
charge to a very large quantity of ofFenlive 
matter. On the twenty-fecond he became 
delirious and convulfed, and on the twenty- 
third died. 

I removed all the upper part of the cra¬ 
nium, and found the dura mater altered in 
colour, and feparated from the whole fron¬ 
tal bone, from the fra&ure quite up to the 
fagittal future; and under the faid mem¬ 
brane, matter to the quantity pf about half 
an ounce. 


EASE 




{ 227 } 


/ 


<• 

CASE XXXII. , 


T H E following cafe was fent to me 
by a very ingenious practitioner at 
fome diftance from London, and may, a- 
mong others of like fort, ferve to prove, 
that it is not the formation of matter be¬ 
tween the fkull and dura mater, but the 
confinement of it there, which is the caufe 
of the bad fymptoms, and of the hazard. 

A boy fell from a cart loaded high with 
hay, and pitched perpendicularly on his 
head. The blow ftunned him for a few 
minutes, but he foon got up again, faid 
he was not hurt, and walked home with 
the cart. 

As he made no complaint at home, his 
mafter took no farther notice of his fall, 
and the boy followed his daily labour in the 
farm-yard. 

At the end of a fortnight he came to 
my friend, and defired him to look at a 
fwelling on the upper part of the right fide 
of his head. The tumor appeared to be 
full of matter, and the furgeon divided the 
£talp, and let out a confiderable quantity. He 

palled 


( 228 ) 

paffed his finger in, in order to examine 
whether the cranium was bare or not, and 
was not a little aftonifhed to find it not 
only bare but confiderably broken. He 
removed the tumid portion of the fcalp; 
ar*d having fo done, found the diftindt pie¬ 
ces of bone fo loofe as to be taken away 
without any refifiance, and fo large as to¬ 
gether to make nearly a third part of the 
parietal bone. The dura mater under them 
was clean, and well incarned. 

The boy had no one bad fymptom from 
firft to laft, came to the furgeon’s houfe 
every day to be drefied, and was alfo in 
the farm-yard daily. 


( 229 ) 

\ • ' • * V K i ,» % i **” 

, 1 > \ I .1 > * y* ■ * A * v 

SECT. VI. 

, v ", /C : / i '■ v v ’ '• .* L ' 

jE xtravafation and commotion . • 

, v . ». > , _ % 

G REAT and hazardous as the eviU 
are which proceed from fra&ures of 
the fkull, they do not exceed thofe which 
are caufed either by the extravafation of 
fluids within its cavity, or by the concuf- 
fion or derangement of the fubflance of 
the brain ; whether we regard the diffi¬ 
culty under which a practitioner labours in 
forming a judgment of the true nature of 
the cafe, or the uncertainty, or the fre^ 
quent fatality of the event. 

The fhock which the head fometimes re*- 
ceives by falls from on high, or by ftrokes 
from ponderous bodies, does not infrequent-* 
ly caufe a breach in feme of the veffels, 
either of the brain or its meninges y and 
thereby occafions extravafation of the fluid, 
which fhould circulate through them. This 
extravafation may be the only complaint 
produced by the accident; or it may be 

t 

joined with, or added to, a fradture of the 
fkull. Rut this is not all, for it may be 
produced not only when the cranium is 

un- 



.( 2 3 ° ) 

unhurt by the blow, but even when no vio¬ 
lence of any kind has been offered to or 
received by the head. 

Vertigo, vomitings ftupidity, haemor¬ 
rhage, iofs of fenfe and motion, either par¬ 
tial or total, are the fyrnptoms of this kind 
of mifehief; fometimes one* or more, fome- 
times all, in the fame fubjedt. Thefe 
fyrnptoms, which are ail eafily accountable 
for from extravafation of fluid and unna¬ 
tural preffure made on the brain and nerves* 
are, as I have already at large remarked*, 
frequently miflaken as indications of a di- 
feafe which, confidered kbftradtedly, can 
never caufe them ; I mean a fimple unde- 
prefled fradture of the cranium ; it may be 
accompanied by them, but cannot caufe 
them. 

When a fluid is extravafated in. any con— 
fiderable quantity within the cavity of the 
cranium, if any bad fyrnptoms are produ¬ 
ced by it at all, they are, and mull: be* 
fuch as indicate prefiure made on the hrain r 
and origin of the nerves; occafioning there¬ 
by either difturbance or abolition of the 
offices of fenfe and motion; and this in dif¬ 
ferent degree, according to the quantity* 
kind, and fltuation of the prefling fluid ; 

2 and. 


( 23 1 ) 

and to thefe are. fometimes added hs?mof* 
rhage from the nofe or ears. Thus far, I 
think, we may pronounce pofitively but 
to our very frequent mortification we find, 

thefe are the only circumftances which in 
fuch cafes we can depend upon, every thing 

elfe which relates or belongs to them, be* 

ing involved in a mofl: perplexing obfcurity* 

We not only have no certain infallible rule 

whereby to diftinguifh what the prefling 

fluid is or where it is fituated, but we are 

in many inflances abfolutely incapable of 

* 

knowing whether the fymptoms be occa- 
fioned by any fluid at all; for a fragment of 
bone, broken off from the internal table of 
the cranium, and. making an equal degree 
of preffure, will produce exactly the lame 
complaints. 

Sometimes indeed the cafe is otherwife ; 
and, from concomitant appearances, the true 
nature of the difeafe may with fome de¬ 
gree of certainty be known ; but this does 
not happen very often. 

Many of our anceftors, when no fradture 
was difcove-rable in the cranium of a per* 
fon labouring under fuch fymptoms as 

have been mentioned, in confequence of 

Q a violence 


( 23 2 ) . 

violence offered to the head, contented 

# * " 'tOw 

themfelves with calling the cafe a concuf- 
fion ; and although they had no very precife 
idea annexed to the term, yet they feldom 
went farther for a folution : like teeth and 
worms in infants, or like nerves in women, 
it Satisfied ignorant inquirers. The crani¬ 
um was not broken, the mifchief was out 
of fight, moft probably out of reach, and 
they had not often the curiofity or the 
anatomical judgment to examine after death 
into the real ftate of the cafe. 

That a concufiion or commotion of the 
fubflance of the brain is a circumftance 
which frequently happens, is a truth be¬ 
yond all doubt; and that it is often the 
caufe of death, is as true ; but that many 
of the cafes which, the fkull being found 
not broken, have pafled for concufiions, 
have been really produced by very dif¬ 
ferent caufes, has often been incontefta- 
bly proved by the examination of fuch per- 
fons heads after death; where fuch extra- 
vafations of blood or lymph or both have 
been found, as would fairly and rationally 
account, both for the fymptoms, and for 
the event. 

A. 


6 


( 233 ) - s .,. 

A concuffion and an extravafation arc 
very diftind caufes of mifchief, though not 
always very diftinguifhable. 

M. Le Dran, and others of the modem 
French writers, have made a very fenfible 
and juft diftindion between that kind and 
degree of lofs of fenfe which arifes from 
a mere commotion of the brain, and that 
which is caufed by a mere extravafation, in 
thofe inftances in which the time of the 
attack or appearance of fuch fymptoms 
are different or diftind. The lofs of fenfe, 
w T hich immediately follows the violence, 
fay they, is raoft probably owing to a com¬ 
motion ; but that which comes on after an 
interval of time has paft, is moft probably 
caufed by extravafation. 

This diftindion is certainly juft and good, 
as far as it will go. That degree of aboli¬ 
tion or diminution of fenfe, which imme¬ 
diately attends or follows the blow or fall, 
^nd goes off again without the affiftance of 
art, is in all probability occafioned by the 
fudden fhake or temporary derangement 
of the contents of the head; and the feme 
kind of fymptoms recurring again fome 
time after they had ceafed, or not coming 
on until fome time has paired from the re- 


( 234 ) 

ceipt of the violence, do mod probably pro-* 
ceed from the breach of a veffel within of 
upon the brain. But unluckily we have it 
not very often in our power to make this 
exadt diftindtion. An extravafation is often 
made fo immediately, and fo largely, at 
the inftant of the accident, that all fenfe 
and motion are inftantaneoufly loft, and 
never again return. And it alfo fometimes 
happens, that although an extravafation may 
poffibly not have been made at the mo¬ 
ment of the accident, and the firft com¬ 
plaints may have been owing to commotion 
merely, yet a quantity of fluid having been 
fhed from its proper velTels very foon after 
the accident, and producing its proper 
lymptoms, before thofe caufed by the com¬ 
motion have had time to go off, the fimila- 
rity of the effedts of each of thefe different 
caufes is fuch, as to deprive us of all power 
of diftinguifhing between the one and^ the 
other, or of determining with any tole¬ 
rable precifion to which of them fuch 
fymptoms as remain are really owing. 

When an extravafation of any kind is 
made, either upon or within the brain, if 
it be in fuch quantity, or fo fituated as tb 
diforder the oeconomy of the animal, it al¬ 
ways 


( 235 V 

t I » 

ways produces fuch diforder, by making an 
unnatural preffure on the parts where it lies. 
The nature and degree of the fymptoms 
hereby produced are various and different in 
different perfons, and under different cir- 
cumftances, according to the kind, quan? 
tity, and fituation of the preffing fluid. 
Sometimes it is mere fluid blood, fometimes 
blood in a ftate of coagulation, fometimes 
it is a clear lymph, and at others blood 
and water are found mixed together ; each 
of thefe is found either Ample or mixed in 
different fltuations, that is, between the 
Ikull and dura mater, between the dura and 
pia mater, or in the natural cavities of the 
brain called its ventricles, and fometimes, 
in cafes of great violence, they are found 
at the fame time in all thefe different parts. 
Sometimes a conflderable quantity is fhed 
inflantly, at the time of the accident; and 
fometimes the breach by which the effufloii 
is made is fo circumftanced, both as to na¬ 
ture and fituation, that it is at firfl very 
fmall, and increafes by fafter or flower de¬ 
grees. In the former, the fymptoms are 
generally immediate and urgent, and the 
extravafation is of the bloody kind ,* in the 
latter, they are frequently flight at firft, 
appear after fome little interval of time, 

increafe 


( 236 ) 

increase gradually till they become urgent 
or fatal, and are in fuch cafe generally oc- 
cafioned by ext'ravafated lymph. So that 
although the immediate appearance of bad 
fymptoms does moft certainly imply mif- 
chief of fome kind or other, yet, on the 
other hand, no man ought to fuppofe his pa¬ 
tient free from hazard, either becaufe fuch 
fymptoms do not (hew themfelves at firfl, or 
becaufe they appear to be but flight : they 
which come on late, or appearing flight at 
firfl: incteafe gradually, being full as much to 
be dreaded as to confequence as the more 
immediately alarming ones; with this mate¬ 
rial difference between them, that the one 
may be the confequence of a mere concuf- 
fion of the brain, and may by means of 
quietude and evacuation go quite off; 
whereas, the other being moft frequently 
owing to an extravafation of lymph, (tho 7 
fometimes of blood alfo} within the fub- 
fiance of the brain, are very feldom remo¬ 
ved by art. 

Extravafations of any kind, and wherever 
fituated within the cranium, are very ha¬ 
zardous, and much more frequently end 
fatally than happily; but confidered as rela¬ 
tive to the art of furgery, that which con- 
fifts of merely fluid blood fituated between 

the 


( 2 37 ) 

the cranium and dura mater is certainly the 
bed, as it is the neared to the furface, and 
admits the greateft probability of being re¬ 
lieved by perforation of the fkull ; grumou§ 
or coagulated blood, although in the fame 
Situation, by being mod frequently adhering 
to the membrane, is not fo readily dis¬ 
charged as the preceding, and therefore 
more likely to prove dedrudtive: and .all 
thofe which are either under the meninges, 
or within the cavities or fubdance of the 
brain, as they are very feldom within our 
exadt knowledge, fo they are alfo generally 
beyond the reach of our art. 

The method of treating people under 
thefe unhappy circumdances is fomewhat 
different, according to the fuppofed or mod 
probable nature of the complaint, and ac¬ 
cording to the fymptoms and appearances 
which it produces or which accompany it. 
When the fymptoms which imply a preffure 
made on the brain or nerves have been oc¬ 
casioned merely by a Shake or concuflion, 
and neither blow nor other external vio¬ 
lence has been offered to or received by the 
head, we have no rule whereby to form ~ 
any other than a general opinion ; no mark; 
which can point out to us, either the pre- 

• S ✓ •» . . 


( * 3 S ) 

eife nature of the difeafe, or its particular 
fituation; confequently we have no direc¬ 
tion from what part of the head to remove 
the fcalp, or where to apply a perforating 
inftrument, and therefore no authority for 
perforating at all. In this cafe, the only 
chance of relief is from phlebotomy and an 
open belly , by which we may hope fo to 
leffen the quantity of the circulating fluids as 
to affift nature m the diffipation or abforp- 
tion of what has been extravafated. This 
is an effeCt which, although not highly 
improbable in itfelf, yet is not to be ex¬ 
pected from a flight or trifling application 
of the means propofed. The ufe of them 
mud be proportioned to the hazard of the 
cafe. Blood muft be drawn off freely and 
repeatedly, and from different veins, the 
belly muft be kept conftantly open, the 
body quiet, and the ftriCteft regularity, of 
general regimen muft be rigidly obferved. 
By thefe means, very alarming fymptoms 
have now and then been removed, and 
people in feemingly very hazardous cir- 
cumftances have been recovered. Inftances 
of thefe fucceffes are not indeed fo fre¬ 
quent as we could wifh, but they have been 
'fufliciently fo ta ^arrant the attempt, efpe- 

dally 


( 2 39 ) 

daily in cafes where there are no indica-* 
tions to authorize the ufe of any other. But 
when the fymptoms of extravafation are the 
confequenee of fuch external violence as 
leaves a mark where it was inflidted, and 
when the fcalp is fo bruifed or wounded as 
to (hew the place where, we then have fome 
degree of affiftance, both in forming a judg¬ 
ment of the mod probable nature of the 
complaint, and in ufing the means mofl 
likely to prove fuccefsful in its relief. For 
if the effufion has been the confequenee of 
the fftroke which the head has received, 
and fuch effufion is made immediately un¬ 
der the part fo ftricken, the perforation of 
the cranium in this place may give difeharge 
to the extravafated fluid ; and the wound 
or bruife in the fcalp fhews us the point 
from whence we ought to remove a portion 
of it, in order to perforate the cranium. 
This I fay is fometimes the cafe, and the 
confequenee is fometimes fo fortunate that 
we fave a perifhing patient. But, although 
it does now and then happen that we are 
fo lucky, yet fuch fuccefs is by no means 
certain or to be depended upon. Every 
thing relative to this kind of diforder is fal¬ 
lible and uncertain j anc^though the extra¬ 
vafation 


( 240 ) 

vaiation is fometimes found immediately un¬ 
der the external mark, yet it often happens 
that it is not, and that the effufion is made 
in a part diftant from that mark, and to 
which we have nothing to lead us. Upon 
the whole, although a bruife or wound of 
the fcalp does not in thefe cafes neceffarily 
or certainly point out the feat of an extra- 
vafation, yet when bad fymptoms urge 
and evacuation has been fully and unfuc- 
cefsfully tried, fuch mark may be deemed 
a lufficient though not an unerring autho¬ 
rity for making farther inquiry, by remo¬ 
ving the fcalp and perforating the cranium: 
for this is a kind of cafe in which we are 
not to expert certainty, and in which we 
muft be content with fuch information as 
we can obtain. The opportunities which 
we have of being ferviceable are but few; 
we fhould therefore fuffer none to efcape, 
but embrace even poflibility. The ge¬ 
neral advice given by Fabritius ab Aqua- 
pendente * is applicable to no part cf fur- 

gery 

* “ In vulneribus quae natura fua admodum periculp- 
fa funt, peflimum eft expediare prava fymptomata ; & 
“ tunc demum providere, cum foifitan occafio praeterjit, 
nec amplius providere licfet.” 

Fab, ab A^uapendente, 


( 241 ) 

gery more than to this; in which the loft 
t>f a very fhort fpace of time is abfolutely 
irretrievable. 

If the extravafation be of blood, and that 
blood be in a fluid date, fmall in quantity, 
and lying between the fkull and dura ma¬ 
ter, immediately under or near to the place 
perforated, it may happily be all difcharged 
by fuch perforation* and the patient’s life 
may thereby be faved; of which many in- 
ftances are producible. But if the event 
does not prove fo fortunate, if the extra- 
Vafation be fo large or fo fituated that the 
operation proves infufficient, yet the fymp- 
toms having been urgent, general evacua¬ 
tion having been ufed ineffectually, and a 
wound or bruife of the fcalp having pointed 
out the part which moft probably received 
the blow ; although the removal of that 
part of the fcalp fliould not deteCl any in- 
jury done to the bone, yet the fymptoms 
hill fubfiffing, I cannot help thinking, that 
perforation of the cranium is in thefe cir- 
cumftances fo fully warranted, that the 
omiffion of it may truly be called a negledt 
of having done that which might have pro¬ 
ved ferviceable, and, rebus fic ft antibus , can 
do no harm. It is very true, that no man can 

R before- 




( 242 ) 

beforehand tell whether fucji operation, wilt 
prove beneficial or not, becaufe he cannot 
know the precife nature, degree, or fitua.- 
tion of the mifehief ; hut this uncertainty, 
properly confidered, is fo far from being a 
diffiiafive from the attempt, that it is really 
a ftrong incitement to make it r it being 
full as impoffible to know that the extrava- 
fated fluid does :tiot lie between the fkulL 
and dura mater, and that under the part 
ftricken, as that it does y and if the latter 
fhould be the cafe, and the operation be 
riot performed, one, and moft probably the 
only means of relief, will have been omitted- 
Morgagni, in his book de Caufis et Sq- 
dibus, &c. has treated this fubjedt exprefly,, 
and has enumerated all the objections which, 
may be made to the perforation of the era- 
.nium, in the cafe of efifufion of fluid within 
.f it, but among others he has mentioned a 

popu- 

* * 4 Namutfigna fint, ex quibus liceat fufpicari fangui- 
14 nem intra calv^riam efie efFufum, quis fare pro certo- 
44 pollit, an revera; et fi hoc etiam feiret, in quam par- 
64 tem efFufus Fit, & quod confequitur, ubi os fit pertere- 
\ <4 brandum, &c. 

44 Nam pra?ter unum, qui majorem fortafie exterius do- 
<c lorem moveat, alia effe pofliint loca, Tub quibus ma* 
<c jus rev'era Jateat internum vitiura. 


« In 


( 2 43 ) 

popular one, which prevails much among 
his countrymen, viz. the fear of having 
been thought to have deftroyed thofe, whom 

in the nature of things they could not 

’ - * 

fave, “ ne fic occifi, qui fervari non potu- 
9C erant, viderentur.” With all poffible de¬ 
ference to fo able a man, I mull; fay, that 
this does not feem to me to be by any 
means a good reafon, or one which ought 
to be formed into a maxim for practitioners: 
it is founded on the weaknefs and incapa¬ 
city of thofe who pretend to judge of what 
they do not underftand, and therefore fhould 
never be embraced through a felf-interefted 
principle by thofe who know better. If 

fuch 

<c In ccgnofcendo quam fallaces fepe Tint conje&urae, 
*« vel hinc apparet, quod 5c fi pars ipfa i£ta, ab zegro in- 
dicatur, imo ecchymofi 5c tumore fe ipfam praeclare 
indicet, non raro tamen cafus incidunt,- in quibus alia 
“ pars fit contufa, alia in quam effufio fada fit. 

«« Satis jam fuperque intelligis cafus incidere, in qui- 
c< bus aut nulla, aut tarn levia, inter initia fe ofFerunt, 
« effufi intra cranium fanguinis figna, tot autem, 5c tarn 
gravia, poftlongum intervallum confeflim fe ingerunt,ut 
neque primo ilio opportuno tempore aeger ex timore pe- 
16 riculi, ufterebram admittat, neque extremo fperare 
« polfent medici, opem fe per earn allatur'os, tam longo 
“ fpatio 5c tam perniciolis indiciis extantibus.” 

Morgagni de Caufis 5c Sed, Mprbor. 

R 2 ■ 


* 


i 


( 244 ) 

fuch rule was univerfally admitted, ws 
fliould often be prevented from employing 
a critical opportunity, or ufing what in 
many cafes is the unicum remedium, not 
only in this difeafe but in many others* 
The cafe of Ptolomey, cited by him from 
Livy, although brought as a firong corro¬ 
boration of his own opinion, really can 
prove nothing, unlefs it could be made to 
prove that terebration was the caule of r or 
at lead accelerated, the patient’s death ; 
which it can by no means be made to do. 
No man, who is at all acquainted, with this 
fubjedt, will ever venture to pronounce or 
promife fuccefs from the ufe of the tre¬ 
phine, even in the mo ft apparently flight 
cafes; he knows that honeftly he cannot; 
it is enough that it has often been fuccefs- 
ful where and when every other means 
have failed. The true and juft confidera- 
tion is this ; does the operation of perfora¬ 
ting the cranium in fuch cafe add at all to 
that degree of hazard which the patient is 
in before it is performed ? or can he in 
many inftances do well without it ? If it 
does add to the patient’s hazard, that is 
certainly a very good reafon for laying it 
afide, or for ufing it very cautioufiy > but if 

it 


( 2 45 ) / 

lit does not (which I verily believe,) and the 
only objection made to it is, that it fre¬ 
quently fails of being fuccefsful, furely it 
cannot be right to difufe that which has 
often been not only falutary but the caufa 
fine qua non of p.refervaiioa, merely be- 
caufe it is alfo often unfuccefsful, that is, 
becaufe it is not infallible. 

I fliouId be extremely forry to fay any 
.thing which might miflead my reader, but 
I cannot help thinking, that dark and ob~ 
fcure as this part of furgery is, yet there 
; are fornetimes appearances and circu.mflan- 
: ces, which may be faid pofitively to in¬ 
dicate the operation ; among which I rec¬ 
kon the fpontanepus detachment of the 
pericranium from the ikull, in confequence 
of a heavy blow, attended with iymptoms 
of flupefacSdon or lofs of fenfe. 

Whenever the dura mater is feparated 
from its attachment to the inner furface of 
the cranium, the pericranium covering the 
outer part of the fame bone is generally 
detached alfo. When this feparation is 
produced by the formation of matter, in 
ponfequence of inflammation, the tume¬ 
faction of _ the fcalp, which denotes this ef- 
; R 3 fed. 


( 246 ) 

fed:, appears fome days after the violence 
has been received, and is always accompa¬ 
nied with a fymptomatic fever. The effiw 
fion of a coniiderable quantity of extrava^ 
fated blood on the furface of the dura mas¬ 
ter, as it abfolutely feparates that membrane 
from the bone and cuts off all communis 
cation between that part and the fcalp, fo it 
does in the fame manner oblige the peri-* 
cranium to quit its attachment to the fkull, 
of which I have remarked frequent inftan^ 
ces; and I have alfo moil: frequently ob- 
ferved, that the blood in fuch cafes has 
*■ been coagulated, and very adherent to the 
membrane. Now if this obfervation fhould 
be found to be moft frequently true, that 
: is, ff a detachment of the dura mater from 
within the ikull, by means of an extravafa- 

v 

' tion, be found to be moft frequently ac¬ 
companied by a ■'’detachment of the pericra¬ 
nium on the outfide, have we not thereby 
an indication both why and where we 
' ought to perforate ? The operation may not 
be fuccefsful, but defperation cannot be fub- 
mitted to while there is the moft extreme 
degree of probability of being ferviceable. 

A free difeharge by means of it may 
produce a cure, or it may prove only a 

tempo- 


( 247 ) 

temporary relief, according to the diffe¬ 
rent circumftances of different cafes : the 
idifappearan.ee or even the alleviation of 
the mo ft; p re fling fyrnptoms is undoubtedly 
a favourable circurnftance, but is not to be 
.depended upon as abfolutely portending a 
good events either a bloody dr limpid ex¬ 
tra vafatiun may be formed or forming be¬ 
tween the meninges, or upon or within 
the brain, and may prove as certainly per¬ 
il: nous in feture as the more external ef- 
fuiion would have done had it not been dif- 
-charged ; or the dura mater may have been 
fo damaged by the violence of the blow as 
to-indame and fupp urate, and thereby de¬ 
stroy the patient. The complaints arifing 
from extravafition, and from fuppuration, are 
(as I have already at large obferved) very diffe¬ 
rent and 4iftin<5t from each other; the for¬ 
mer may be relieved, or even totally remo¬ 
ved, and the latter not prevented, nor in¬ 
deed be capable of prevention ; of this every 
practitioner (hould be aware, left he expeCt 
and promife too much. 

The nearer the extravafated fluid lies to 
the cranium the better; therefore that 
which is iituated between the flcull and dura 
mater is, caeteris paribus, the moft favour- 

R 4 able 


- ( -243 ) 

able of any. If the difeafe lies between the 
dura and pia mater, mere perforation of the 
flcull can do nothing; and therefore if the 
fymptoms are prefling, there is no remedy 
but divifion of the outer of thefe mem¬ 
branes. The divifion of the dura mater is 
an operation which I have feveral times feen 
done by others, and have often done myr 
felf ; I have feen it, and have found it now 
and then fuccefsful ; and from thofe in (lan¬ 
ces of fuccefs, am fatisfied of the propriety 
and necefiity of its being fometimes done; 
but let not the pra&itioner, who has not 
had frequent opportunity of feeing thefe 
kinds of things, prefume, from the light 
manner in which this neceffary operation 
has been fpoken of by a few modern wri¬ 
ters, that it is a thing of little confequence ; 
for it mod certainly is not. Wounds of the 
membranes of the brain, by whatever body 
inflicted, or in whatever manner made, 
have always been deemed, and (which is 
more to the purpofe) have always been 
found, to have been hazardous. There is 
indeed feme difference between a wound 
made by a clean lancet or knife, and one 
made by bone, bullet, or any thing which 
bruiles or tears ; but this relates only to the 

manner. 


( 249 ) 

• • > r * 

manner, the part wounded is the fame in 
all; and whether the dura mater be divided 
by' a lancet, or by a fragment of bone, or 
any other body, it is equally divided, and 
the air is let in in the fame manner on the 
pia mater, or brain, which become thereby 
fubjeCt to all the ills which fuch wound or 
fuch expofition are capable of caufing. 

Authors indeed do every now and then 
tell us ftrange ftories, and give us ftrange 
accounts of incifions made into the menin¬ 
ges and brain in* fearch of foreign bodies, 
of extravafated fluids, &c. but let the young 
practitioner read thefe relations with fome 
referve pf faith, and recolledt that the ex¬ 
cellent advice given by a very able man, 
homines non admiratione afficere, fed eis 
utiliora docere,” is not always attended 
to. Cautjon and fear are different things ; 
where any good can be done, it ought to 
be attempted by every practicable and jufti- 

fiable means; but where no good is reafon-^ 
ably to be expected, there is no authority 
for doing any thing. The divifion of the 
dura mater I have feen to be neceffary, and 
I have feen it to be fuccefsful but all 
wounds of it are far from being matters of 
indifference. Every chance of life is to be 

embraced. 


C 2 5 0- ) 

embraced, and a good furgeon will never 
hefitate to execute whatever appears feafi- 
ble, or even poffibly beneficial ; but at the 
fame time he will not ad without fome 
fuch kind of warranty as {hall prove th.at 
his patient’s benefit was his one objed, and 
will take care his prognoftic lhall not expofe 
him juftly to the cenfure of being either 
ignorant, unfeeling, or fool-hardy. 

Upon the removal of a piece of bone by 
means of the trephine, if the operation has 
been performed over the part where the 
difeafe is fituated, and the extravafation be 
of the fluid kind and between the cranium 
and dura mater, fuch fluid, whether it be 
blood, water, or both, is immediately feen, 
and is partly difeharged by fuch opening; 
if, on the other hand, the extravafation be 
of blood in a coagulated or grumons ftate, 
it is either loofe, or in Jbme degree adher- 
rent to the dura mater; if the former of 
thefe be the cafe, it is either totally or par¬ 
tially difeharged at the time of or foon after 
ihe operation, according to the quantity or 
extent of the mifehief; if the latter, the 
perforation difeovers, but does not immedi¬ 
ately difeharge it. In both inftances, the con- 
dud of the furgeon, with regard to repeti- 

P - i • tier* 


{ 251 ) 

tion of the operation, mitft be determined 
by the particular circumftances of each in¬ 
dividual cafe; a large extravafation muft 
neceffarfly require a more free removal of 
bone than a fmall one ; not only on account 
of freedom of difcharge, but on account of 
larger detachment of dura mater ; and a 
grumous or coagulated extravafation re¬ 
quires a ftill more free ufe of the inftru- 
ment, not only becaufe the blood in fuch 
ftate is difcharged with difficulty, but be¬ 
caufe the whole furface of the dura mater 
fo covered is always put under the necef- 
lity of fuppurating, which fuppuration has 
but one chance of a happy event, and that 
derivable from the free ufe of the perfo* 
rator. 

When the extravafation is not between 
the cranium and dura mater, but either be* 
tween the meninges, or in the ventricles of 
the brain, the appearances are not only dif¬ 
ferent from the preceding ftate of the cafe, 
but from each other. 

When the extravafated fluid lies between 
the Ikull and dura mater, as foon as that 
extravafation is difcharged, or the grumous 
blood has been wiped off, the dura mater 
appears flaccid, eafily yields to or does -not 

refill 


( 2 5 2 ) 

N 

refill the impreflion of a finger, and (the 
difeharge being made) enjoys that kind of 
motion, that elevation and deprefllon, which 
our fathers fuppofed it to have naturally and 
always, but which is only the confequence 
of the circulation through the brain, and 
the artificial removal of the piece of bone. 
But when the extravafation is fituated be¬ 
tween the meninges, or on the furface of the 
brain, the appearance is not the fame. In 
this cafe there is no difeharge upon remo¬ 
ving the bone, and the dura mater, inftead 
of being flaccid and readily obeying the 
motion of the blood, appears full and tur¬ 
gid, has little or no motion, and prefiing 
hard againfl the edges of the perforation, 
rifes into a kind of fpheroidal form in the 
hole of the perforated bone. If the extrava¬ 
fation be of the limpid kind, the membrane 
retains its natural colour; but if it be either 
purely fluid blood, or blood coagulated, and 
the fubjeft young, the colour of the mem¬ 
brane is fo altered by what lies under it, that 
the nature of the cafe is always determinable 
from this circumftance. 

Be the extravafated fluid what it may, it 
has no natural outlet ; abforption was the 
only chance the patient had whereby to get 

rid 


( 2 S 3 ) 

fid of it without an operation, and that wc 
mull now fuppofe to have failed; an artifi¬ 
cial opening therefore mult be made, by the 
divifion of the dura mater, and perhaps of 
the pia alfo. This operation, under the cir- 
cumfiances and appearances already men¬ 
tioned, is abfolutely necefiary, and has been 
fuccefsful ^ it is performed to give difcharge 
to what cannot be got rid of by any other 
means, . and confills in a divifion of the 
membrane or membranes, made in a crucial 
form with the point of a lancet. The ope¬ 
ration in itfelf is extremely Ample and eafy, 
but the patient is thereby put into the ftate 
of one whofe meninges have been wounded, 
with only this difference, that the wound 
made for this purpofe is fmooth and fimple, 
and inflidted with the leal! poffible violence ; 
whereas an accidental wound of the fame 
parts may be lacerated, contufed, and at¬ 
tended with circumftances which mull ag¬ 
gravate the evil, and may induce worfe con¬ 
ferences. 


Of commotion or concuffion of the folid 
parts of the brain, we have only a negative 
kind of proof, and therefore are ftill more 
° in 





( 254 ) 

in the dark* than we are with regard to ex¬ 
tra vafation. 

Very alarming fymptoms, followed fonie- 
times by the moil fatal confequences, are 
found to attend great violences offered to 
the head; and upon the ftrideft examina¬ 
tion both of the living and the dead* nei¬ 
ther fiflfure, fradure, nor extravafation of 
any kind can be difeovered. The fame 
fymptoms, and the fame event, are met 
with when the head has received no in¬ 
jury at all ab externo, but has only been 
violently fhaken; nay, when only the body 
or general frame has feemed to have fuf- 
tained the whole violence. It is a com¬ 
monly received opinion, that a concuflion 
of the brain is always in proportion to the 
refiftance which the cranium makes ; that 

if the latter fuftains a confiderable degree of 

^ *■ * 

fradure, the former is but flightly injured, 
and that the concuflion of its contents is 
great in proportion. This may fometimes be 
the cafe ; violent and even fatal commotions 
of the brain happen when no injury has 
been done to the fkull, and very large and 
terrible fradures are fometimes unattended 
with any fymptoms of concuflion; all this 
is fometimes true, but the pofition can by 

. , 1 no 


(' m ) 

no-means be admitted as a general principle* 
whereon to form our judgment, or whereby 
to regulate our eonduft, experience fre¬ 
quently contradicting it. 

The fymptoms attending a concuffion are 
generally in proportion to the degree of 
violence which the brain itfelf has fudained* 
and which indeed is cognizable only by the 
fymptoms. If the concuffion be very great* 
all fenfe and power of motion are immedi¬ 
ately abolifhed, and death follows foon t 
but between this degree and that flight 
condition (or dunning, as it is called) which 
attends mod violences done to the head* 
there are many dages. Sometimes a con¬ 
cuffion produces the fame kind of oppref- 
iive fymptoms as an extravafation, and the 
patient is either aimed or totally bereft of 
fenfe : at other times no fuch fymptoms 
attend, but the patient gets no deep at all* 
has a wild look, an eye much like to that 
of a perfon who has long watched through 
apprehenfion and anxiety* talks much and 
very inconfidently, has a hard labouring 
pulfe, feme fmall degree of fever, and fome- 
times an inclination to vomit; if not re¬ 
tained, the patient will get out of bed, and 
a£t with a kind of frantic abfurdity, and 

appears 


( 2 5 6 ) 

Appears in general much hurt by a ftrong 
light. A debility of underftanding, an idiot 
look, a failure of memory, a paralytic af¬ 
fection of fome one part or limb,, the lots 
of fenfe, fpafm, refolutioii or rigidity of 
fome one part or miifcle, are often the con- 
fequence of it. Thefe complaints are fome- 
times cured, but fome of them do fome- 
times remain through the reft of life. 

To diftinguilh between an extravafation 
and a commotion by the fymptoms only is 
frequently a very difficult matter, fometimes 
an impoffible one. The fi.mil arity of the 
effects in fome cafes, and the very fmall 
ipace of time which may intervene between 
the going off of the one and acceffion of 
the other, render this a very nice exercife 
of the judgment. The firft Running or 
deprivation of fenfe, whether total or par¬ 
tial, may be from either, and no man can 
tell from which j but when thefe firft fymp- 
toms have been removed, or have fponta- 
neoufly difappeared, if fuch patient is again 
oppreffed with drowfinefs, or ftupidity, or 
total or partial lofs of fenfe, it then becomes 
moft probable that the firft complaints 
were from commotion, and that the lat¬ 
ter are from extravafation; and the greater 
l the 


( 2 57 ) 

the. (fiftance of time between the two, the 
greater is the probability not only that an 
extravafation is the caufe, but that the ex- 
travafation is of the limpid kind, made 
gradatim, and within the brain. 

Whoever ferioufly refleds on the nature 
of thefe two caufes of evil within the cra¬ 
nium, and confiders them as liable to fre¬ 
quent combination in the fame fubjed, and 
at the fame time confiders, that in many 
inftances no degree of information can be 
obtained from the only perfon capable of giv¬ 
ing it (the patient), will immediately be fen- 
fible, how very difficult a part a praditioner 
has to ad in many of thefe cafes, and how 
very unjuft it muft be to call that ignorance, 
which is only a juft diffidence arifing from 
the obfcurity of the fubjed, and the impof- 
fibility of attaining materials to form a clear 
judgment. 

When there is no reafon to apprehend 
any other injury, and commotion feems to 
be the foie difeafe, plentiful evacuation by 
phlebotomy and lenient cathartics, a dark 
room, the moft perfed quietude, and a 
very low regimen, are the only means in 
our power; and are fometimes fuccefsful. 


S 


( M ) 

Having in the preceding fheets frequently 
fpoken of the trephine, I have only to add, 

*■ *. - 4 . 

that if fuch operation be attended with fuc- 
qefs, that is, if an extravafated fluid be 
thereby difcharged, a deprefled bone eleva- 

4 ' 1 ^ ‘ , 

ted, matter which had been formed be¬ 
tween the fkull and dura mater let out, or 
the inflammatory tenfion of the membrane 
prevented in fuch manner as to refcue the 
patient from the danger he was in from 
fuch accident; in fuch cafes, I fay, that the 
bare dura mater readily obeys the motion of 
the blood through the brain, and is freely 
elevated and deprefled; by degrees it lofes 
its bright filver hue and becomes purulent 
and floughy, and then carting off this flough 
is covered by a granulation of new fleflh, of 
firm confidence and florid red colour; a 
moderate quantity of good matter is dif¬ 
charged daily, and the new incarnation rifes 
gradually through the perforation, until it 
gets above the edges of it, when joining 
with that which either has fprung from the 
furface of the bare cranium, or which has 
thrown off from thence a final! exfoliation, 
they together make a firm cicatrix. Du¬ 
ring all this time the patient is generally 
free from fever or pain, gets good fleep, 

has 


( *59 ) 

has a natural appetite, and feems as near to 
being in health as his circumftances can 
permit. 

On the other hand, if the mifchief be 
fuch that all means prove ineffectual, the 
appearances are very different. The dura 
mater, inftead of cafting off a thin flough 
and incarning kindly, becomes hard, tenfe, 
and foul ; in a few days it generally thrufts 
up an ill-natured fungus, which preffing 
hard againft the edges of the perforation, 
prevents the difcharge from within ; the 
bare bone becomes blackilh or deeply yel¬ 
low, and the edges of the fore in the fcalp 
are painful, loofe, flabby, and have no con¬ 
nection with the bone on which they lie ; 
the difcharge is a thin flunking gleet, and 
large in quantity 3 the patient is hot, thirily 
and iieeplefs 3 the tongue is black, the pulfe 
hard and quick ; fometimes a delirium, and 
fometirnes frequent fpafins diforder and 
ffake his whole frame 3 his countenance is 
fluffed and has a yellow tint, his eyes, 
lofe all their natural brightnefs and feern 
funk in their orbits, and his rigors, which 
were at fir ft flight and few, become more 
frequent and more fevere as his difiblution 
approaches. A flight degree of thefe fymp- 

S 2 toms 


( 260 } 

toms is fometimes got the better of by 
proper care and treatment; but if they are 
far advanced, or run very high, we may ufe 
the words of a very excellent writer on this 
fubjedt, I mean Berengarius Carpenfis : Hie 
cajus ejl de bis, e quibus non evadunt aliqui, 
niji mihi dei. 

CASE 

The fentiments of a very ancient writer on this matter 
are fo very juft and appofite, that I hope the reader will 
excufe the length of the quotation. 

“ Qui fanefeere polTunt, vel perituri funt, ex his con- 
c< jicere eft; plurimum quidem ex ipfo vulnere, deinde & 
ex reliquo corpore. 

Salubriter fe habentium r.otae funt, ulcus non dolens, 
cerebrique membrana naturalem colorem, ac motum 
66 fervans, & ulcus poft fuppurationem imminuh Pus al- 
6< bum, aequale, modice craftum, non maleolens. Ulcus 
quod initio album apparuit, poft aliquod tempus rube- 
feere, carnem milto fimilem producere, fquamulafque 
<c fuis temporibus emittere ; fine perturbatione fomnum 
i( capere ; fine febre efts, cibum appetere ; alfumpta dU 
6i gerere j aequas excretioncs fieri ; glandulas, quae primis 
44 diebus apparuerant, aut eryfipelas cito diffolvi. 

44 Eos, qui periclitantur, cognofcere licet turn afpedlu, 
46 turn ex iis quae vulneri caeteroque corpori accidunt, & 
44 iis quae excernuntur. Color igitur plerumque langui- 
4C dus & permanens, pcriculofus, oculique concavi & ex- 
4 ‘ tantes, &c. Ulcus dolere, magis interdiu, retorridum- 
fieri, atque omni plerumque tumore carere, vel faniem 
sc manare tenuem, ac male olentem ; orafque fedtae carnis 
u admodum rubras h flaccidas efle, atque ubi magis re- 
flexae fint, tunc abfcedere cutem ab offe moleftum eft* 
e< membranamque vulneratam imrnobilem efte, exalbidam 

46 vei 


4 


( 261 ) 


CASE XXXIII. 


Young fellow about twenty-four years 



JljL old was thrown by the fwing of a 
crane at the water-fide from a window two 
ftories high, and pitched his head on a fu- 
gar hogfliead. He was taken up fenfelefe, 
and brought in that hate to St. Bartholo¬ 
mew’s hofpital. 

He was immediately let blood freely, and 
his head being firft clean ihaved was very 
carefully examined, but no external mark of 
violence was found. Next morning he was 
bled again, and the fame operation was 
repeated in the evening of that day, and 
twice in the courfe of the third. On the 
fourth day both the temporal arteries were 


opened. 


cc vel lividam apparere, vel nigram, vel plurimum inflam- 
matam aut procidentem, purgatamque, iterum fponte 
** non ob aliqua re externa fordefcere. Orieasius 
de Signis. 

cs Spem vero certam faciunt, membrana mobilis ac fui 
fcc coloris, caro increfcens rubicunda, facilis motus max- 
“ illae, atque cervicis. 

“ Mala figna funt membrana immobilis, nigra vel livida, 
ec vel aliter coloris corrupt!, dementia, acris vomitus, 
lc nervorum diftenfio vel refolutio.—Caro livida, maxil- 
** larum atque cervicis rigor.” Celsus, 



( 262 ) 

opened, and bled freely. On the fifth day 
he died, his fymptoms not having remitted 
in the fmalleit degree. The cranium was 
perfectly uninjured. The dura mater every 
where adherent, and no fluid of any kind 
between it and the fkuli. Between the 
dura and pia mater was a confiderable quan¬ 
tity of fluid blood, and principally toward 
the lower part of the brain, 

CASE XXXI 7 . 

A Hackney coachman was thrown from 
his box in Holborn, and fell on his 
head, as it was thought. He became im¬ 
mediately infenfible, and was brought fc to 
the hofpital. No mark of violence was to 
be found on any part of his head, and there¬ 
fore, although his fymptoms were fuch as 
rendered an extravafatign mofl: probable, yet 
there was no authority for fetting on the in- 
ftrument on any particular part. Every 
thing was done for him both by the phyfi- 
cian and myfelf, from which any advantage 
might reafonably be expected ; but on the 
third day he expired, having never fhewed 
any figns of fcnfe. 


AH 


( 263 ) 

. All the fpace between the frontal bone 
and the dura mater was covered with gru- 
mous blood, firmly adherent to the latter. 

CASE XXXV. 

A Bricklayer’s labourer fell from a high 
fcafifold, broke one arm and one 
thigh, and was brought to the hofpital a- 
bout two hours afterward in a Rate of Ra¬ 
pidity. When his arm and thigh were put 
to rights his head was examined, but no 
niark of mifchief difcovered. He was bled 
freely, and (tools procured on each day for 
four, but he continued in the fame Rate ; 
on the fifth a fmall tumor arofe on the right 
fide of his head. The fcalp was removed, 
and the bone being found bare, it was im¬ 
mediately perforated. The perforation made 
way for a large difcharge of blood, which 
had been contained between the dura mater 
and (kulh On the firR and fecond day from 
this operation he remained the fame ; blood 
was drawn from fome part of him on each, 
and the difcharge continued large and free 
through the opening made in the bone. On 
the third day from the application of the 
trephine, he became toward evening fome*- 

S 4 what 


( 264 ) 

what fenfible. On the fourth, having ta¬ 
ken a laxative medicine, he had a fmart 
purging which laded fome hours. On the 
fixth he was quite calm and fenfible, but 
being reduced to a very low date by his free 
and frequent evacuations, it was thought 
right to give him the cortex. This agreed 
well with him, and from this time he had 
no other difficulty or trouble. 


CASE XXXVI. 

A Boy about ten years old, climbing up 
a ladder which was fet too perpendi¬ 
cularly, fell from an height of more than 
twenty feet ; he lay fome time before he 
was found, and then was carried home per¬ 
fectly void of fenfe. In about three hours 
after the accident I faw him. He lay quite 
ftupid and fenfelefs, now and then vomited, 
had a hard, full, labouring pulfe, and ait 
obdruCted refpiration. No mark of violence 
appeared on his head. He was bled freely, 
and had a dimulating glyder, which pro¬ 
cured a free difcharge. During three days 
he was let blood twice a day ; on the fourth, 
a fmall degree of tumefaction appeared on 
the right fide of his head near to the digit- 

I taj 


{ ) 

tal future 5 it was not very manifeft, nei¬ 
ther did it appear to contain any confidera- 
able quantity of fluid ; but the very defpe- 
rate circumftances the child was in induced 
me to open it, and, finding the Ikull bare, 
to perforate. The dura mater was covered 
with blood, which difcharged freely, both 
at the time of the operation, and during all 
the next day. On the third day from the 
operation he was ft ill infenfible. A fecond 
perforation was made juft below the flrft, 
and a third on the other ftde of the future* 
Blood was difcharged freely from all three. 
He was drefled lightly, and his pulfe being 
ft ill ftrong, more blood was drawn from one 
of the jugulars* The next day he was ra¬ 
ther better, but far from fenfible. The 
day following that, he recovered his under- 
ftanding, and could make figns for what he 
wanted. It was near a week more before 
he got his fpeech, but in the end he got 
perfectly well. 


C A S R 



( 266 ) 

# 

CASE XXXVII. 

A Boy between three and four years old, 
the fon of a merchant in my neigh¬ 
bourhood, was at play with his brother on 
a bed, and fell from thence on a foft bed- 
fide carpet. He pitched on his head, 
and complained immediately of being lick 
and giddy, but having vomited, was foon 
after fo well that no farther notice was 
taken of his fall. On the fourth day from 
this, his ficknefs and giddinefs returned. Dr. 
Lee was fent for, who not regarding the fall 
as having any ihare in his complaint, gave 
him an emetic, and ordered him fome of 
thofe medicines which are called nervous. 
For the fpace of five days from this time, 
he continued to be now and then fick and 
giddy, and was very unwilling to ftir or be 
ftirred. On the eleventh he complained 
that he could not fee, and that evening had a 
fort of fit. On the thirteenth his right arm 
became ufelefs. On the fifteenth he could 
not ftand. From this evening he became 
ftupid; on the eighteenth expired. 

Between the dura and pia mater was a 
confiderable quantity of bloody ferum about 
the bafis of the brain. 


5 


CASE 


( 267 ) 


CASE XXXVIII. 

Woman came to my houfe, complain- 



A ing that her hufband had kicked her 
down flairs, and had broke her fkull. On 
the back part of her head was a fmall 
wound, but the pericranium was not di¬ 
vided, nor was there any reafon to fuppofe 
the bone to be hurt. For twelve days the 
remained without any general complaint; 
but on the thirteenth the began to be giddy 
and dim-fighted. 

I took her into the hofpital, where the 
was taken all poffible care of ; but the be¬ 
came firft paralytic, and then comatofe, and 
fo died. The ventricles of the brain were 
full of extravafated ferum, and near the 
origin of the medulla oblongata was a 
large lump of firmly coagulated blood. 


CASE 


( 268 ) 


CASE XXXIX. 


Carpenter’s labourer in Blackfryers 



fell from a fcaffold of a confiderable 


beighth, and in his way down, ftruck a 
piece of timber, which following him hit 
him on the head. The man fell on his 
breech. He was brought to the hofpital 
fenfelefs. The mark on his head made by 
the timber was fcarcely vifible, and did not 
imply any mifchief underneath. He was 
freely let blood, and his body emptied by a 
glyfter adminiftered that day. The next 
day more blood was drawn from one jugu¬ 
lar, and the third the fame operation re¬ 
peated. On the fourth he fpake, and on 
the fifth was fo fenfible as to give an ac¬ 
count of the place from whence he fell. On 
the fixth, feventh, eighth, ninth, tenth, and 
eleventh, he was free from complaint, except 
on the two laft he was too much inclined to 
dofe. On the twelfth he found fome difficulty 
in pronunciation, and faid, that it was with 
great difficulty that he could keep himfelf 
awake. As his pulfe would very well bear 
it, more blood was drawn away by open- 


( 2f5 9 ) 

Ing the temporal artery, and a blifter was 
applied to his neck. On the fifteenth he 
could hardly Ipeak at all, and was never 

awake unlefs difturbed for that purpofe. 
On the eighteenth he loft the ufe of his 
left fide, and on the twentieth died. 

About the lower part of the brain was 
found a fmall quantity of bloody ferum, and 
all the ventricles were filled with a clear 
lymph. 

CASE XL. 

A Boy about fifteen was thrown over 
the head of a horfe, who fell down 
with him in Smithfield. There was on 
the fide of his head a large wound with a 
bare parietal bone ; and although there was 
no appearance of fraCture, yet the violence 
having been great, and the boy being per¬ 
fectly ftupid, I immediately perforated the 
bare bone, fufpeCting an extravafation on 
the dura mater. That membrane was per¬ 
fectly fair and adherent, nor was there any 
appearance of extravafation either upon or 
under it. The next day he was ftill infen- 
fible. I examined the membrane again very 

carefully., 


C 2 7 ° ) 

carefully, in order to fee whether there was 
any authority for dividing it, but could find 
none. Blood was drawn from different 
parts in large quantity, but to no purpofe; 
he lived three days as it were in a deep fleep, 
and then died. There was no injury done 
to the fkull; no extravafation of either 
blood or ferum, either upon or between the 
membranes, nor any unnatural appearances 
in the cavities of the brain. But upon the 
plexus choroides was a lump of coagulated 
blood, near as big as half a fmall chefnut. 

In the courfe of thefe papers, I have 
more than once faid, that although' the 
fymptoms arifing from preffure made on the 
brain and nerves, or on the meninges, were 
uniform and clear and perfectly difiindt 
from thofe caufed by inflammation, yet that 
they very feldom indicate what kind of 
body fuch preffure was made by ; whether 
blood, water, or bone ; and confequently, 
that although the diforders proceeding from 
preffure were perfectly diftinguifhable from 
thofe caufed by inflammation, yet they 
were not at all or very feldom fo with re¬ 
gard to each other. Some of the immedi- 



( 2 7 I ) 

ately preceding cafes are proofs, with re¬ 
gard to blood and lymph, and what follow 
will I think in fome degree prove that the 
fymptoms are the fame, when they are 
caufed by bone, or by blood and bone to¬ 
gether. 


CASE XLI. 


A Child about nine years old received a 
blow from a cricket-bat on the upper 
part of his forehead, which brought him 
to the ground, and deprived him of fenfe. 

I found him with a confiderable tumor on 
his.forehead, and coniidering the ftate he 
was in, would have removed immediately 
a part of the fcalp ; but a dabbler in fur- 
gery, who was a relation, undertook to 
cure him by an application. On the third 
day I was fent for again, and found him 
nearly in the fame ftate as I left him. I 
divided the fcalp, and found a fradlure with 
depreffion. By means of the trephine and 
elevator the deprefled part was raifed, and 1 
the dura mater being found in a very good 
ftate, and no apparent extravafation in the 
cafe, nothing more was done at that time. 

Proper 


( * 7 * ) - 

Proper medicines were ordered to procure 
ftools. The next day his fymptonts were 
the fame, except that his pulfe was lefs la^ 
bearing, and he had not the apoplectic 
ftertor, which he had till then. I exami¬ 
ned the bone, which lay perfectly fmoQth, 
nor was the dura mater at all elevated into 
the perforation. Blood was freely drawn 
from the temporal arteries, and a ftimula- 
ting glyfter adminiftered. On the fifth day 
no alteration. I applied a trephine in the 
middle of that part of the bone which had 
been depreffed and elevated. The dura ma¬ 
ter was thinly covered with grumous blood, 
which being gently wiped away more of 
the fame appeared for two or three days 
this difcharge continued in fmall quantity ; 
the boy gradually recovered his fenfes, and 
and in due time got well. 



CASE 


( 2 7 3 ) 

J ' * ' 

CASE XLIL 

A Young woman was thrown out from 
a country waggon, upon a bt v oad flat 
pavement, and faid to have pitched upon 
her head. She was inftantly deprived of 
fenfe, and brought to the hofpital in that 
ftate. Her head was immediately fhaved, 
and examined, but found to be fo abfolutely 
free from all mark of violence, that I was 
in doubt of the truth of the account given 
of her. She was freely let blood, and fome 
medicines directed to be got down, in or¬ 
der to empty her. The next day (he was 
in the fame ftate. More blood was drawn 
off, and her cathartic repeated. The third 
day fhe being exadtly the fame, both the tem¬ 
poral arteries were opened. On the fourth, 
there being no alteration, I determined to 
apply a trephine on that part of her head, 
on which (he was faid to have fallen, and 
which when prefled hard, feemed to produce 
fuch motion in her as if it gave lome pain. 

In a cafe of lefs neceflity this would 
hardly have been an authority, but here 
fomething was to be attempted. I remo¬ 
ved a large piece of fcalp, and found the 
pericranium, though not detached abfolute¬ 
ly, yet not naturally or firmly adherent. I 

T an- 

x 


( 2 74 ) 

applied the trephine, and when I had 
worked a few feconds, I took out the in- 
ftrument to clean it, but was much furpri- 
zed to find in it a piece of the upper table 
of the fkull. I put in my finger to feel 
what was underneath, and found that it 
touched the remaining table, which rece¬ 
ded from the finger, and returned again 
upon removing it; and when I prefied the 
faid loofe piece hard, the girl’s whole frame 
was fpafmodically agitated. What was to 
be done ? it appeared to me, that if all her 
fymptoms were not caufed by the preflure 
of the loofe piece, yet they were certainly 
aggravated by it, that it mud therefore be 
taken away at ail events,, and that it was 
much too large to be extracted at the pre- 
fent opening; befide which, as it ran upward 

toward the finus, I fhould not have chofera 

\ 

to have run the rifque of an haemorrhage 
from thence while the finus was covered 
with bone. I perforated all round the pre- 
fent opening with a fmall trephine, in fuch 
manner, that each perforation fo bordered 
on the other as that the whole fhould make 
one opening. 

For near one half of the circle the outer 
table only came away in the infirument, 
leaving the inner loofe and covered with 

blood. 


( 275 ) 


blood, but in all the lower part, the tre^ 
phine went through both tables, and left 
the dura mater covered with grumous blood 
alfo. When the circle was finifhed, the 
loofe portion was eafily taken away ; its 
upper part made a part of the fagittal fu¬ 
ture, but no blood followed its reparation. 
The dura mater under the whole was thinly 
covered with grumous blood. Next day 
fhe retained her urine, and opened her 
eyes. In two, more (he recovered her fpeech, 
and became as rational, as I fuppofe (he 
ever had been ; and would in all probability 
have done well, as far as regarded the evils 
produced by mere preffure; but after fome 
days matter formed between the detached 
dura mater and the fkull, and the fympto- 
matic fever ufually accompanying fuch mif- 
chief, came on with fuch rapidity, that all 
the efforts of art were vain. 


CASE XLIII. 


Porter at work at the water-fide, was 



X jk knocked down by a blow from an iron 
hook, at the end of the tackle belonging 
to a crane. He was fenfelefs for near half 
an hour, but after that was fo well as to 
walk home. The next morning he loft his 
2 ’* fight, 


( 27 6 ) 

light, and by the evening his fpeech, and 
faculty of walking. In this date he was 
brought to the hofpital. He was largely 
let blood, and thoroughly emptied, and I 
intended, if thefe evacuations did not mate¬ 
rially ferve him, to have examined the date 
of that part of the bone whereon the blow 
was received - y but that night he died. 

Upon examining his head, a piece of the 
inner table of the right os parietale, of a- 
bout an inch and half in length, and not 
quite fo broad, was found detached frQm the 
outer table, having a quantity of blood 
both between them and on the furface of the 
dura mater. 

Thefe are the only indances which I have 
met with of fradure of the internal table 
alone; though I make no doubt, that fomc 
of thofe who have been faid and thought to 
have been dedroyed by concuflion, have 
funk under this kind of mifchief. 


FINIS . 


SOME FEW 


GENERAL REMARKS 

O N 

FRA CTU R E S 

AND 

DISLOCATIONS. 



By PERCIVALL POTT, F.R.S. 


AND 


SURGEON to St. Bartholomew’s-Hgspital.- 



Navetn agere ignarus navis timet ; abrotanum <egro 
Non audety ni/t qui didicit dare. Quod medicorwn eft 
Promittunt medici : tradiant fabriiia fabri. 


Horat, 



LONDON: 

Printed for L. Hawes, W. Clarke, and R. Collins, 
in Pater-nofter Row. M.dcc.lxviii. 














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i * ' * ' •» 

Dodor ANTHONY ASKEW, 

• . . ■ v ' . * • ; • ' v 

AND 

Dodor RICHARD TYSON, 

. - 

physicians 

T O 

St. Bartholomew's- Hospital, 

$' ’■ - k ••«*»; ; • * - 

The following flieets are addrefled as a fmall 

j 1 * • 

teftimony of the regard and efteem of 
their 

{ i ' | * 

Sincere Friend, and 

Very Humble Servant, 


Percivall Pott. 





f 







( I ) 



O N 

«r 

Fractures and Dislocations. 

y O part of furgery is thought to be 
1 fo eafy to underdand, as that which 

-A- ^ relates to fraCtures and diflocations. 
Every, the mod inexpert, and lead; indruc- 
ted practitioner, deems himfelf perfectly 
qualified to fulfil this part of the chirurgic 
art; and the majority, even of thefe, are 
affronted by an offer of inftruCtion, on a 
fubjeCt with which they think themfelves 
already fo well acquainted. 

This is alfo the opinion of a confiderable 
part of the people. They regard bone-fet- 
ting (as it is called) as no matter of fcience; 
as a thing which the mod ignorant farrier 
may with the utmod eafe become foon and 
perfectly mader of ; nay, that he may re¬ 
ceive it from his father and family, as a 
kind of heritage. We all remember the 
great, though fhort-lived reputation, of the 

B late 











' ( 2 ) 

late Mrs. Mapp. We all remember, that 
even the abfurdity and impracticability of 
her own promifes and engagements were 
by no means equal to the expectations and 
credulity of thofe who ran after her, that 
is, of all ranks and degrees of people, from 
the loweft labourer or mechanic, up to 
thofe of the moft exalted rank and ftation ; 
feveral of whom not only did not hefitate 
to believe implicitly the moft extravagant 
afifertions of an ignorant, illiberal, drunken 
female favage, but even follicited her com¬ 
pany, and at leaft feemed to enjoy her con- 
verfation. 

The defire of health and eafe, like that 
of money, feems to put all underftandings 
and all men upon a level ; the avariticus are 
duped by every bubble, the lame and the 
unhealthy by every quack. Each party re- 
figns his underftanding, fwallows greedily, 
and for a time believes implicitly the moft 
groundlefs, ill-founded and delufory promi¬ 
fes, and nothing but lofs and difappoint- 
ment ever produces convi&ion. Arts, trades, 
and manufactures are allowed to be learned 
in general, by thofe who have employed a 
proper quantity of time and attention in 
fuch purfuits; and it feems moft Angularly 

unjuft. 


' ( 3 ) 

Unjuft, as well as untrue, to fuppofe that 
phyfical people are the only part of man-* 
kind who are all either fo dull as not to 
be able to learn, or fo profligately wicked 
as not to praCtife their art to the beft of 
their judgment, and to the greateft poflible 
advantage of mankind. — Surely there are, 
and always have been among us, as well as 
in all other claifes, men truly able and per¬ 
fectly honeft ; men, who well underftand 
the fcience which they profefs, and who 
praCtife it, not only with great ability, but 
with ftriCt integrity. I cannot be fuppofed 
to fay or to mean this as a vindication of 
every individual. Different men have dif¬ 
ferent powers and capacities. The multi¬ 
tude with us, as with all ranks and degrees 
(not excepting any) will always be deficient. 
Advancements in knowledge will always be 
owing to the ingenuity and induftry of a 
few particular people ; but fuch advance¬ 
ments will always, in due time, more or lets 
influence the reft. They have fo done; 
and notwithftanding that there remains a 
great deal yet to be done, to bring furgery 
to that degree of perfection of which it is 
capable, yet, whoever will compare the 

B 2 prefect 


( 4 ) 

prefent pra&ice of it with that of a very 
few years ago, cannot juftly or with any 
degree of candor, with-hold his commenda¬ 
tion from his contemporaries. 

I remember fome years ago to have 
heard a judge from the bench tell a jury* 
that he believed a country bone-fetter knew 
full as much, if not more of the matter of 
his own bufmefs, than any, the moft emi¬ 
nent furgeon in the kingdom. I will not 
enter into a difquifition concerning the 
rightnefs of the judge’s opinion. Perhaps 
his lordfhip might very little underftand the 
thing concerning which he decided fo pe¬ 
remptorily * without either injuftice or par¬ 
tiality, I may certainly fuppofe him to have 
been a much more able lawyer than fur¬ 
geon : and I believe it will alfo be allowed, 
that general reflections of this kind are, and 
muft be, the confequences of a petulant at¬ 
tempt to be witty, rather than of convic¬ 
tion y and therefore, at beft, are frivolous 
and idle. But, on the other hand, I am 
very willing to allow (what indeed I have 
already allowed) that many parts of furgery 
are ftill capable of confiderable improve¬ 
ment ; and this part perhaps, as much as, 
if not more than any, it being one of thofe 


is) , ' 

in which a general obfervance of and rigid 
adherence to old prefcribed rules, have 
prevented the majority of practitioners from 
venturing to think for themfelves, and have 
induced them to go on in a beaten track, 
from which they might not only fafely, but 
advantageoufly deviate. 

The general doCtrine relative to fraCtures 
is contained under the following heads, as 
parts of the treatment of them. 

Extenfion. 

Counter-extenfion. 

Coaptation or fetting. 

Application of medicaments. 

Deligation or bandage. 

Pofition. 

Prevention or relief of accidents. 

This is the general arrangement of the 
fubjeCt by moft of the writers on it, and a 
very juft and proper one it is; but notwith-* 
Handing the parade of books under thefe 
various heads, much lefs alteration will be 
met with, fince the times of Hippocrates, 
Galen and Celfus, than an inquirer might 
expedt, or than the fubjedt is capable of, 

I muft defire that what I have faid may 
not be mifconftrued. I do not mean that 
there are not, and have not at all times 

B 3 been 


( 6 ) 

been, men of particular ingenuity, who 
have deviated from the common methods, 
and have greatly improved the art ; but ftill 
the common methods are the fame, and the 
multitude of practitioners religioufly follow 
them. Let me not therefore be charged 
with prefumption or arrogance, if I fay, 
that under aimed: every of the foregoing 
heads the pradice is capable of confiderable 
improvements ; improvements which would 
(how rationality and fenfe in the furgeon, 
and produce eafe and convenience to the 
patient, 

I am aware that fome of my readers may 
be inclined to charge me with affeCting to 
deviate from the commonly preferibed rules, 
and to contradict opinions, which a great 
length of time, and a Jong fucceffion qf 
writers have given fan & ion to. 

---- —-- “ q U2 e 

iC Imberbes didicere, fenesperdendafated,’" 

is a hard leifon fometimes to human vanity, 
and what requires fome degree of candor 
to learn. But, on the other hand, if it was 
not now and then praCtifed, I know not 
how fuch an art as furgery (whofe bails is 
experience) could ever be improved. Our 

anceitors 





( 7 ) 

anceftors deferve our bed; thanks for the af- 
fiftance which they have given us; where 
we find them to be right, we are obliged to 
embrace their opinions as truths j but im¬ 
plicit faith is not required from man to 
man, and our reverence for our predecefiors 
muft not prevent us from ufing our own 
judgments. Antient and modern are mere 
founds, and can fignify nothing in this cafe, 
unlefs with the former we can conned: an 

idea of truth eftabliftied and confirmed by 

* 

time and experience, and with the latter 
that of demonftrable improvement upon 
what has gone before. 

If what I have to urge is not capable of 
being verified, and confirmed by experience, 
it muft fink into nothing ; but if upon trial 
it fhall be found by the majority, (as it has 
been by me and fome others) to be not only 
true and practicable, but highly conducive 
to the eafe and benefit of the aftlided, it 
ought to have as much weight, though de¬ 
livered by a living writer, as if it had pro¬ 
ceeded from the remoteft antiquity : its ufe, 
not its date, ihould give it value. If prac¬ 
titioners fince the time of Albucafis had 
been contented with his dodrine, and never 
had ventured to think for themfelves, fur- 

.bayo'iqmi ad B 4 t S cr Y 


(-8 ) ' 

gery had not been what it now is, and its 
great merit would ftill have confifted in 
the multiplicity of its hot irons. In fhort, 
to fuch as think that we are feldom or never 
to deviate from the opinions and practice 
of thofe who have gone before us, I (hall 
take the liberty of anfwering in the words 
of the great Mr. Locke, who fays, “ the 
“ floating of other mens opinions in our 
<c brains makes us not one jot the more 
<e knowing, though they happen to be true. 
<e And beaten trails lead thofe whofe 
“ thoughts reach only to imitation, “ non 
“ quo eundem eft, fed quo itur.” 

Before I enter on the fubjeil, the reader 
will give me leave to acquaint him, that it 
is by no means my intention to write a re¬ 
gular treatife on frailures, although I think 
the fubjeit well deferving of, and even re¬ 
quiring one. I only mean to throw out a 
few hints, which I hope may prove intelli¬ 
gible and ufeful. 

The firft article in the general arrange¬ 
ment is extenfion; under which may alfo 
be comprehended the fecond or counter^- 
extenfion. 


In 


( 9 ) 

In order to accomplifh this, we are di¬ 
rected, if the fracture be of the thigh or 
leg, to place the patient in a fupine pofiure, 
and the broken limb in a flraigbt one $ then 
having the upper part of it held firm and 
fteady, by proper affiflants, we are ordered 
by means of hands, ligatures, lacs, or even 
in fome cafes by pieces of machinery, to 
make fuch an extenfion or ftretching of the 
limb lengthways, as fhall enable the fur- 
geon to place the ends of the broken bone 
in as apt, that is, in as even a pofition, with 
regard to each other, as the nature of the 
fradhire will admit.*——'This is a fhort de¬ 
scription of what, in the vulgar phrafe, is 
called fetting a broken bone, and is mod 
commonly a painful operation to the pa¬ 
tient, a fatiguing one to the operator and 
his affiflants, and what is worfe, is in 
many inftances found to be inefficacious ; 
at lead, not fully to anfwer the inten¬ 
tion of the one, or the expectation of the 
other 

Writers 

* (( Inftruments for extenfion are threefold; firft, the 
< c furgeons hands, &c. fecondly, funes & habense, a fort 
“ of bandage fit to pluck at, in order for extenfion ; 

** thirdly. 



( IO ) 

Writers in general are very precife and 
formal in the dire&ions which they have 
given, for the due and proper accomplish¬ 
ment of this purpofe. They have told us, 
that the extenfion Should be made flowly 
and gradually ; and fhould be continued till 
the ends of the bone are Separated from 
each other Sufficiently, to admit of the 
fradure being Set without rifque of breaking 
off any points or inequalities, and to enable 
us to place them perfedly Smooth and even. 

<c thirdly, there are organa & machinemata, engines 
* c ufed by us and invented by the ancients.” 

Wiseman. 

The very mention of funes, habenae, organa and ma¬ 
chinemata, implies a force exceeding that of mere hands. 
A degree of force, which in a fradure never can be 
wanted, if the limb be rightly placed ; a degree of force, 
which muft in the nature of things do mifchief; and a 
degree of force, whofe whole effed, however great, muft 
ceafe immediately upon its being removed ; unlefs the 
fradure be particularly and luckily circumftanced. 

There are not wanting inftances of the mufcles fur¬ 
rounding a bad though fimple fradure having been torn 
by extenfion, and fpafm and other mifchief thereby pro¬ 
duced. See cautions on this fubjed, laid down by many 
old writers, particularly by Galen and Albucafis, 


All 


I 


( 11 ) 

All this, like many other of the preceptive 
parts of phyfic and furgery, is very pretty 
on paper, but not often found to be practi¬ 
cable in the chamber. The direction to 

• i • • ■ 

continue the extenfion until the ends of the 
bones are at a certain difiance, lengthways 
from each other, plainly implies a confide- 
rable degree of violence ; the limb mutt by 
fach force be not only made longer than 
its fellow, or than nature ever intended it 
fhould be, but this procruftian method of 
lengthening it is ordered to be executed 
while the limb is in fuch pofition as tp put 
all the mufcles moil on the firetch, and 
render them lead likely to yield to it. 
Now, not to fay a word of the great pro¬ 
bability of the points and edges of the 
fraCture wounding the furrounding mufcles, 
or of fuch wounds being more painful or 
worfe in their confequences when inflicted 
on parts thus ftretched, or of the addition 
that tuch force muft make to the laceration 
already neceffarily made by the fraCture j I 
fay, not to mention a word of all this, can 
the method itfelf (without confidering any 
accidental adjunCtcircumflances) bepraCtifed 
in every fraCture, or even in the majority of 
fraCtures ? Will it be done properly by the 

rude, 


V 


( 12 ) 

rude, the inattentive, and the ignorant ? if at¬ 
tempted by fuch, will it not be, is it not 
frequently productive of pain, tumefaction, 
inflammation, and extravafation ; which are 
fet to the account of the nature of the frac¬ 
ture and to inevitable neceflity ? and when 
done ever fo properly, will it, can it, in an 
oblique or fplintered fraCture, anfwer the 
purpofe it is intended for, or produce a 
more happy coaptation ? 

Whence arife thefe evils ? from whence 
proceed the difflculty and the fo frequent 
difappointment ? 

In order to underftand this rightly, let us 
for a moment confider, what is or ought to 
be meant by the terms extenfion and coun- 
ter-extenfion, and why they become necef- 
fary: for if the greater part of the pain at¬ 
tending fnch method, and the frequency of 
difappointment, both to patient and fur- 
geon, fhould be found to arife from this 
part of the procefs, and that fuch part can 
be either difufed without prejudice, or al¬ 
tered with advantage, we ought to think 
ourfelves happy in having it in our power to 
correCl our error. 

Neither extenfion nor counter-extenfion 
can ever be neceflary, on account of the 
5 mere 


( r 3 ) 

mere fradure, confidered abftradedly. The 
broken ends of the bone or bones are of 
themfelves inadive, and if not aded upon 
by other parts they would always remain 
motionlefs. When any attempt is made to 
put them into motion, they of themfelves 
can make no poflible refinance, nor can 
any be made on their part, fave an acciden¬ 
tal one arifing from the points of the frac¬ 
ture being entangled with each other ; and 
when they have been once, by the hand of 
the furgeon, placed properly and evenly 
with regard to each other, they would of 
themfelves for ever remain fo. What then 
is the reafon why fradured bones always 
fuffer a greater or a lefs degree of difplace- 
ment ? why is a broken limb almofl always, 
(hotter than its fellow ? what creates the 
refiftance, which we always find in attemp¬ 
ting to bring the fradured parts aptly toge¬ 
ther ? whence does it proceed, that when 
we have done all that is in our power (ac¬ 
cording to this mode of ading) the ends of 
the fradure will in many cafes become again 
difplaced, and lamenefs and deformity fre¬ 
quently enfue ? In fliort, what are the parts 
or powers which ad on the bones, and 

which 


C H ) 

! 

which by Co adting on them produce all 
thefe confequences ? 

Thefe parts are the mufcles, the only 
moving powers in an animal body. By the 
adtion of thefe on the bones all locomotion 
is performed,- and cannot be performed with¬ 
out them: and although all bones, when 
broken, are in fome degree difplaced and 
fhortened, yet it will always be found, that 
in proportion as the mufcles furrounding 
or in connexion with a bone, are ftrong or 
numerous, or put into adtion by inadver¬ 
tence or fpafm, fo will the difplacement of 
the ends of fuch bone, when fradtured be. 
The even and fmooth pofition of the fractu¬ 
red ends of a tibia, when the fibula ,of the 
fame leg is intire and unhurt, that is, when 
the mufcles therefore cannot adt upon the 
former ; the vifible and immediate defor- 

* » » f 

mity, when both the before-mentioned bones 
are broken nearly in the fame place ; that 
is, when the mufcles can adt upon and dis¬ 
place fuch fradture ; the great difficulty fre¬ 
quently met with, in endeavouring to get a 
broken os femoris, to lie even, tolerably 
fmooth, and to prevent fuch broken limb 
from being' much fhorter than the other, 

are. 


( i5 ) 

are, among others which might be produced, 
fuch ftrong and irrefragable proofs as need 
no comment. 

From the mufcles then, and from them 
only, proceeds all the difficulty which we 
meet with in making our extenfion, and by 
the refiftance of thefe, and of thefe only, 
are we prevented from being always able to 
put the ends of a fractured bone immedi¬ 
ately into the moft apt contact. 

Let us in the next place confider, what 
it is which gives to a mufcle, or to the prin¬ 
cipal mufcles of a limb, the greateft power 
of refilling any force applied to them ab ex- 
terno, in order to draw them out into grea¬ 
ter length; for whatever that is, the fame 
thing will be found to be the caufe of the 
different degrees of refiftance in fetting a 
fracture. 

Does not the putting the mufcles in a 
ftate of tenfion> or into a date approaching 
nearly to that of tenfion, almoft neceffarily 
produce this effedt ? or, in other words, does 
not that pofition of a limb, which puts its 
mufcles into or nearly into fuch a date, give 
fuch mufcles an opportunity of exerting 
theii greateft power either of adtion or of 
refiftance ? This I believe cannot be de- 

j ■ . 

rued, 


> 


4 


< *6 ) ' _ 

nled. On the other hand, what is the ftatc 
or pofition of a mufcle which is moft likely 
to prevent it from acting, and to deprive it 
moft of its power of refiftance ? or what is 
that pofition of a limb, which in the cafe 
of a broken bone will moft incapacitate the 
mufcles from acting on and difplacing it, 
and in the greateft degree remove that re¬ 
fiftance which they have it in their power 
to make to the attempts for the redudion 
of fuch fradure ? Is it not obvious, that 
putting a limb into fuch pofition as {hall re¬ 
lax the whole fet of mufcles belonging to 
or in connexion with the broken bone,'muft 
beft anfwer fuch purpofe ? Nothing furely 
can be more evident : if this be granted, 
will it not, muft it not follow, that fuch 
pofture of a broken limb muft be the beft 
for making the redudion ; that is, it muft 
be that in which the mufcles will refift the 
leaft and be leaft likely to be injured, that 
in which the broken bone will be moft ea- 
fily fet, the patient fuffer leaft pain in pre- 
fent, and that from which future lamenefs 
and deformity will be leaft likely to happen. 
A little attention to what frequently occurs, 
may perhaps ferve to illuftrate and confirm 
this dodrine better than mere afiertion. 

What 


( J 7 ) 

What is the reafon why no man, how¬ 
ever fuperficially acquainted with his art, 
ever finds much trouble in fetting a fradured 
os humeri, and that with very little pain, 
and a very fmall degree of extenfion ? Is 
it not becaufe both patient and furgeon 
concur in putting the arm into a date 
of flexion ; that is, into fuch a ftate as re¬ 
laxes all the mufcles furrounding the broken 
bone? and is it not for the fame reafon that 
we fo very feldom fee (comparatively fpeak- 
ing of this bone with others) a deformity in 
confequence of a fradure of it ? Let the re- 
dudion be attempted with the arm extended 
from the body, and the difficulty of fetting 
will be much increafed : let the arm be de- 
pofited in an extended ftraight pofition, and 
the fradure will be difplaced and lie uneven. 

Apply the fame kind of reafoning to the 
os femoris ; that bone whofe fradure fo 
often lames the patient, and difgraces the 
furgeon. 

Will it not be more cogent, and more 
conclufive, in proportion as the mufcles in 
connexion with this bone are more nume¬ 
rous and ftronger ? I would afk any man 
who has been much converfant with acci¬ 
dents of this kind, what is the pofture 

C which 


( IS ) 

which almoft every perfon whofe os femoris 
has been newly broken puts himfelf into* 
in order to obtain eafe, until he gets proper 
affiftance ? Do fuch people flretch out their 
limb, and place their leg and thigh flraight* 
and refling on the calf and heel ? I believe fel- 
dom or never. On the contrary, do not fucb 
people almoft always bend their knee, and 
lay the broken thigh on its outfide ? and is> 
not the realon why this muft be the mofl 
eafy poflure, obvious ? 

From want of attention to, or from not 
underflanding thefe few felf-evident princi¬ 
ples, many people permit their patients to 
fuffer confiderable inconvenience, both pre- 
fent and future. 

It is a maxim univerfally taught and re¬ 
ceived, that a fractured limb may be in fuch 
flate, as not to admit of the extenfion ne- 
cefiary for its being fet ; that is, if afli- 
flance be not at hand, when the accident 
happens, if they who bring the patient 
home do it io aukwardlv or rudely as to- 
bruife and hurt the part, if from drunken- 
nefs, folly or obftinacy in the patient, it 
happens that the limb is fo difordered that 
it is found to be much fwollen,. inflamed 

and 


t 19 ) 

ahd painful, it is allowed not to be In a 
ft ate to admit extenfion. 

This, I fay, is a general maxim, and 
founded upon very juft principles ; but what 
is the general practice in confequence of it? 
It is, to place the limb in an extended, 
ftraight pofition; to fecure it in that, and then 
by proper means, fuch as fomentation, poul¬ 
tice, &c, to endeavour to remove the ten- 
fion and tumor. Now if it be confidered 
that the fwollen, indurated, and inflamed 
ftate of the mufcles is the circumftance 

y ♦ 

which renders extenfion improper, furely it 
muft be obvious that fuch pofition of the 
limb, as neceffarily puts thefe very mufcles 
in fome degree on the ftretch, muft be a 
very improper one for the accomplishment 
of what ought to be aimed at. Under this 
method of treatment, the fpace of time 
which paffes in the removal of the tenfion 
x is fometimes conftderable, fo confiderable 
that a happy and even coaptation becomes 
afterward impracticable $ and then this ac¬ 
cident, which nine times in ten is capable 
of immediate relief, is urged as an excufe 
for unneceffary lamenefs and deformity. 

How then are we to conduct ourfelves in 
fuch circumftances ? The nature of the com* 

‘ G a plaint 


( 2 0 ) 

plaint points out the relief. Extenfion is 
wrong; a ftraight pofition of the thigh or 
leg is a degree of extenfion, and a ftill 
greater degree of it in proportion as the 
mufcles are in fuch circumfiances as to 
be lefs capable of bearing it. Change of 
pofture then muft be the remedy, or ra¬ 
ther the placing the limb in fuch manner as 
to relax all its mufcles, muft be the moft 
obvious and certain method of relieving all 
the ills arifing from a tenfe ftate of them : 
which change of pofture will be attended 
with another circumftance of very great 
confequencej which is, that the bones may 
in fuch pofture be immediately fet, and not 
one moment’s time be thereby loft; a cir¬ 
cumftance of great advantage indeed ; for, 
whatever may be the popular or prevailing 
opinion, it is demonftrably true, that a 
broken bone cannot be too foon put to 
rights ; as muft appear to every one who 
will for a moment confider the necefiary 
ftate of the mufcles, tendons and membranes 
furrounding, and the medullary organs con¬ 
tained within a large bone broken and un- 
fet ; that is, lying in an uneven irregular 
manner. Can any truth be more clear, 
than that if the fra&ure, tenfion and tu- 
i mefadtion 


{ 2i ): 

mefa&ion be fuch that the mufcles can-- 
not bear to be ttretched out in the manner 
neceffary for letting the broken bone, with¬ 
out cauling great pain, and perhaps bring- 
on ftill worfe fymptoms, the more the po¬ 
rtion of that limb makes its mufcles ap¬ 
proach toward a ft ate of tenfioir, the lefs 
likely it mult be that fuch fymptoms fhould 
remit, and the longer it mutt be before the 
wilhed-for alteration can happen ; and con- 
fequently, that while the accomplilhment of 
fuch purpofe is by every other means 
aimed at, the poiition of the limb ought 
moil certainly to contribute to, and not to 
counteract it ? In fhort, if the experiment 
of change of pofture be fairly and properly 
made, the objections to immediate reduc¬ 
tion, from tenlion, tumor, &c. will moft 
frequently be found to be groundlefs, and 
the fraCture will be capable of being put to 
rights, as well at firtt as at any diftance of 
time afterward. 

Ex tenlion having been made, and the 
broken ends of the bone having been placed 
as fmooth and as even as the nature of the 
cafe will admit, the next circumftance to 
be attended to is the application of feme 
medicament to the limb ; particularly to the 

C 3 fraCtured 


( 212 ) 

fyadtured part of it. In this different peo¬ 
ple aft differently. Some make ufe of an 
ad he five, or what they chufe to call a ro- 
borant plafter ; fome, of what is commonly 
called a cere-cloth ; others apply fpirit. viru 
with oil, vinegar and white of egg ; and 
others the fpirit. mindereri, the folution of 
crude fal ammoniac in vinegar and water, 
or fome fuch kind of medicine. 

To the cere-cloth, provided it neither 
flicks to the fkin, nor is capable of irrita¬ 
ting it, there can be no objection ; neither 
can there be any to all the others, except 
the adhefive plafter ; that muft for ever be 
wrong upon every rational principle. The 
intention in applying any kind of external 

medicine to a broken limb is, or ought to 

* * 

be, to reprefs inflammation, to dilperfe ex- 
travafated blood, to keep the fkin lax, moift 
and perfpirable, and at the fame time to af¬ 
ford fome though very fmall degree of re- 
ftraint or confinement to the fradture, but 
not to bind or prefs ; and it fhould alfo be 
calculated as much as poflible to prevent 
itching, an herpetic eruption, or an eryfipe- 
latous efflorefcence. Adhefive plafters of 
$11 kinds, let the competition of them be 
what it mav, are from this one quality the 


( 23 ) 

leaft likely to contribute to any of the good 
ends propofed, and the moft likely to be 
the caufe of the contrary inconveniences, 
which ought moft carefully to‘be avoided. 
They cbftrudtperfpiration, they heat thefkin, 
•they produce itching, eruption and inflam¬ 
mation; and if the fradture be quite fur- 
rounded by them, and the limb be from 
any caufe ever fo little inclined to fwell, 
they make a tight, painful and pernicious 
ftridture; much greater even than a roller, 
and lefs likely to relax. At St. Bartholo¬ 
mew’s hofpital we ufe a cerate made by a 
folution of lytharge in vinegar, which with 
foap, oil, and wax, is afterward formed 
into luch confidence as juft to admit being 
fpread without warming. 

This lies very eafy, repels inflammation, 
is not adherent, comes off clean, and very 
feldom if ever irritates or caufes either 
herpes or eryfipelas. But let the form and 
compofition of the application made to the 
limb be what it may, one thing is clear, 
viz. that it fhould be put on in fuch man¬ 
ner as that it may be renewed and fhifted 
as often as may be neceflary, without mo¬ 
ving the limb in any manner; it being cer¬ 
tain, that when once a broken thigh or leg 

C 4 has 


( 24 ) 

has been properly put to rights, and has 
been deported properly on the pillow, it 
ought not ever to be lifted up or moved from 
it again without neceffity, until the fradure 
is perfedly united ; and it is as true that 
fuch neceffity will not very often occur. 
This may perhaps feem flrange to thofe who 
are accuftomed to roll iimple fradures, and 
confequently to lift them up every three or 
four days, in order to renew fuch kind of 
bandage : but the neceffity of this motion 

* s 

arifes merely from the kind of bandage 
made ufe of, and not from any circumftance 
of the fradure itfelf. That the frequent 
motion of a fradured limb cannot poffibly 
contribute to the eafe of the patient, will, 
I fuppofe, be readily admitted ; as I fup- 
pofe alfo it will, that when a broken limb 
has been pnce depofited in the bed pofi-r 
tion poffible, it is impoffible to mend that 
pofitiop, 2nerely by taking fuch liqib up 
and laying it down again ; from whence it 
jnuft follow^, that fuch kind of apparatus 
as neceffitates the furgeon frequently to dir 
fturb the limb, cannot be fo good as one that 
doe£ not ; provided the latter will accom- 
pliflrthe fame kind of cure as the former ; 
the truth of which pofition will appear in 

' the 


( 25 ) 

the moft fatisfadory manner to any who 
will take a view , of the method in which 
limple fradures are treated at the before- 
mentioned hofpital. Such application having 
been made as the furgeon thinks right, the 
next thing to be done is to put on a proper 
bandage.—— That ufed by the ancients and 
by the majority of the prefent praditioners, 
is what is commonly called a roller. This 
is of different length, according to the fur- 
geon’s choice, or as it may be ufed in the 
form of ope, two or more pieces, Hip¬ 
pocrates ufed three Celfus fix ; but the 
prefent people feldom ufe more than one. 
By fuch kind of bandage three intentions 
are aimed at, and faid to be accomplifhed, 
viz. to confine the fradure, to reprefs or 
prevent a flux of humors, and to regulate 
the callus -f* : but whoever will refled feri- 

oufly 

* See on this fubjed Fab. ab Aquapendente, Wifeman, 
Scultetus, Hildanus, Petit, Du Verney. 

f “ On applique la premiere fur l’endroit meme de la 
^ fradure. Son milieu doit repondre au centre. On fait 
<c trois 1 tours circulaires : ce qui fert a affermir cet endroit, 
qui eft le feul, qui ait befoin d’etre aflujetti, comme 
<{ etant le feul qui peut. fe deranger, ts* a contenir le fuc 
* c nouricitr O' empecher , quil ne s’echappe trap abondamment 
f* & trap irregxdiere'mcnt a l y eniour de la frafiure ; ce qui 
f* feroitrjw cal ires difforme” 

Du Verney, 




( 26 ) 

eufly on this matter will foon be convinced, 
that although fome fort of bandage is ne- 
celfary in every Ample fradure, as well for 
preferving fome degree of fteadinefs to the 
limb, as for the retention of the applica¬ 
tions, yet none, nor neither of thefe three 
ends can be anfwered merely, or even prin^- 
cipally, by bandage of any kind whatever : 
and therefore if this fhould be found to be 
true, that is, if it fhould appear that what- 
ever kind of deligation be made ufe of, it 
cannot be a principal, but only an acceffo- 

p 

rial kind of affiftance, and that in a fmall 
degree and very little to be depended upon, 
it will follow, that fuch kind of bandage as 
is moft difficult to be applied with juflnefs 
and exaditude, fuch as is fooneft relaxed 
and out of order, fuch as ftands moft fre¬ 
quently in need of renewal, and in fuch re¬ 
newal is moft likely to give pain and trou¬ 
ble, muft be more improper and lefs eligi¬ 
ble than one which is more eafily applied, 
lefs liable to be out of order, and which can 
be adjufted without moving the limb. 

The ancient method of applying the rol¬ 
ler in cafe of Ample fradure of the leg or 
thiph, was to make * four or five turns 

round 

See.'a.particular account of this in Fab. ab Aquapen- 
dente, and in Serjeant Wifeman. 


( 2 7 ) 

round the fradure firft, and then to con¬ 
tinue the bandage upward and downward, 
until the whole limb was enveloped pro¬ 
perly. This was done in this manner with 
a double view ; to keep the broken ends of 
the bone in their place, and to prevent the 
influx of humor. Modern practitioners* 
although they have the fame ends in view, 
generally begin their bandage from the in¬ 
ferior extremity of the limb, and continue 
it up to the top. Whether the old or the 
later method be followed, whether one or 
more rollers be made ufe of, the whole is 
executed while the limb is kept by means 
of the afliftants in the fame extended pof- 
ture in which the coaptation was made, fo 
that the whole bandage is finifhed before 
the leg is depoflted on the pillow ; in the 
doing all which, if from the tired ftate of 
the furgeon or either of his afiiftants, or 

if from the awkwardnefs or unhandinefs of 

any 

* The extraordinary length of time ufed by fome in 
putting a fradure to rights, renders what I have called the 
tired Jlate of the affiants an object of importance. The 
good politico of the fracture depends as much or more on 
them than on the furgeon. If the affiftant who holds the foot 
varies from the proper manner, I defy the furgeon to re- 
drefs the fradure without the concurrence of fuch af- 
fttoit. 


( 28 ) 

any of the parties concerned, the true and 
exadt pofition of the limb be at all deviated 
from, the ends of the bone will again be in 
fome degree difplaced, and the bandage in^ 
ftead of being of ufe will become prejudi¬ 
cial, by preffing hard on the inequalities of 
the fradture : to which let me add, that the 
roller, efpecially when applied to a leg, if 
it be not put on with due dexterity, that is, 
if it does not fet perfedtly fmooth and even, 
is the moft unequal and worft kind of ban¬ 
dage in ufe. 

Thefe objections, however juft, are not 
the leaft to which the roller in the cafe of 
Ample fradlure of the leg or thigh are lia¬ 
ble ; for, as I have already hinted, it muft 
in a very {hort fpace of time, even while 
the parts furrounding the fradture are in the 
moft tender and moft painful ftate, be re¬ 
newed, and that more than once ; which 
renewal cannot be executed without again 
taking the limb off from the pillow, again 
committing it to the hands of affiftants, and 
again running a rifque of difplacing the 
fradture: all which, not to mention the 
repetition of pain to the patient every time 
fuch operation is performed, and which 
muft be at leaft every four or five days, are 


( 29 ) 

(as I have already faid) very material objec¬ 
tions to the roller, even in the moft judi¬ 
cious and dexterous hands, and ftill more fo 
in thofe of the rude and ignorant. 

The prevention of a flux of humors to 
a broken limb, by bandage, is a common 
phrafe ; but they who ufe it have either no 
idea at all annexed to it, ora very erroneous 
one. 

If by the points and edges of the broken 
bone the mufcles and membranes be una¬ 
voidably wounded and torn, or if the fame 
kind of mifchief be incurred by the inad¬ 
vertence or indifcretion of the patient, or 
of thofe who aflifted in getting him home, 
or from the violence ufed in extending the 
limb and fetting the fradture, inflammation 
mu(l be excited, and pain and tumefaction 
will be the confequence; and thefe will con¬ 
tinue for fome time in every fradture ; but 
that fpace will be longer or jfhorter in dif¬ 
ferent cafes and under different circumftan- 
ces: evacuation, reft, and a favourable po¬ 
rtion of the limb will, and do in general, 
remove all thefe complaints; but bandage 
can contribute nothing more than by keep¬ 
ing the applications in their proper place * fo 
far from it, that if the bandage be a roller it 

muft, 


( 3$ ) 

muft, by the frequent neceffity of its being 
adjufted, and the frequent motion of the 
limb, in fome degree counteract the proper 
intention of cure. 

The old writers are in general very pre- 
cife as to the number of days during which 
the roller Should be fuffered to remain with- 
out being fhifted, and the number of times 
which fuch fhifting fhould be repeated 
within the firft fortnight This exaditude 
is by no means neceffary ; but if the ban¬ 
dage be fuppofed t6 be of any ufe at all, it 
is obvious, that it ought to be renewed or 
adjufted as often as it may ceafe to perform 
the office for which it is deligned, or when¬ 
ever it fhall be found to counteract fuch of¬ 
fice, that is, as often as it fhall become fo 
flack as not to contain the fradure at all, or 
whenever the limb fhall be fo fwollen, that 
the roller makes an improper degree of 
ftridure 5 the former generally occurs every 

four 

* ct Tertio die a deligatione fadta, Hippocrates fafcias 
<e refolvit, &c. Fadta bona deligatura & pruritu non in- 
<c fedante, a tertio ufque ad feptimum oportet aegrum 
u deligatum detinere. 

u Septimo membrum rurfus lblvendum peifundendum 
w aqua tepid a & l!ganduQi,’ > 


Fab, ab Aquapmdente. 


( 3 1 ) 

four or five, days, the latter is moi! frequent 
within the firft week* 

In moft of the writers on the fubjedt of 
fractures, we alfo find marks or figns laid 
down for our information concerning the 
due or undue effedt of the bandage on the 
limb. They tell us, that when that part 
of it which is below the termination of the 
roller does not fwell at all, that the ban¬ 
dage is not fufficiently ftridt, and will not' 
retain the fradture ; that when the fame 
part is confiderably fwollen, or tenfe, or in¬ 
flamed, it implies, that the binding is too 
ftrait, and that a moderate degree of tume- 
fadtion is a fign that the deligation is pro¬ 
perly executed ** 

■ ' In 

i > * * - 

* See on this Fab. ab Aquapendente, who fpeaks of 
rather copies the ientiments of Hippocrates and Celfus. 

Terminus in ftringendo debet efte bona laborantis tole- 
tc rantia : ut deligatum leviter premat. Sc fie turn conti- 
Ci neat Sc ftabiliat fra&uram, turn humores exprimat. 
cc Sunt etiam alia hujus ftgna, quae altero die apparent ^ 
cc fi enim aeger eo die quo deligatus fentiat fe valentius 
66 ftringi,. poftero vero die tumor laxus, mollis Sc parvus 
cc appareat, bona eft deligatio, quia jam humores a parte 
u fradfa funt exprefti. Si vero aut nullus tumor aut mag- 
<4 nus Sc durus poftridie in manu vel pede appareat, prava 
tc eft deligatura ; quia ilia non continet haec vero nimis 
ic ardta eft Sc inflammationem mpvet. Id notandum fa- 

fcias- 

2 


/ 


( 3 2 ) 

In confequence of thefe precepts, many 
pratflitioners look more anxioufly after this 
degree of tumefadion, than after the true 
and exad pofition of the limb, and cannot 
be induced to believe, that any thing can 
be wrong under this appearance ; although 
if they would for once aflume the liberty 
of thinking for themfelves, they might be 
convinced, that even this degree of level¬ 
ling is wrong, that it implies fome kind of 
obftrudion to the circulation, and cannot 
ferve any good purpofe ; and confequently 
that as far as it may be fuppofed to be the 
effed of bandage, fo far that bandage muft 
be faulty. 

The third purpofe for which the roller is 
faid to be ufed, is the regulation and re- 
ftraint of the callus. 

If we were to form pur notion of callus 
by what the generality of writers have faid 
on this fubjed, we fliould fuppofe, that it 
was not only a particular juice always ready 
for the purpofe, but that, if not reftrained 
and regulated by art, it would always flow 
in fuch quantity, as to create trouble and 

deformity ; 

<c fcias magis ftringi debere in parte fra&a, quam alibi, 
<c ut pars fradta magis illsefa fervetur, ab humorum de- 
“ fluxu.” 


( 33 ) 

deformity; that there were fpecific reme¬ 
dies for increasing or decreasing it, and that 
it always required the hand and ad of fur- 
gery to manage it. That the callus is fo 
far a particular juice, as that it confifts of 
whatever is deStined to circulate through 
the bones for their particular nourishment, 
is beyond all doubt; and that this gelatinous 
kind of fluid is the medium by which frac¬ 
tures are united is as true; but that it re¬ 
quires art to manage it, or that art is in 
general capable of managing and directing 
it, is by no means true. That this callus 
or uniting medium does oftentimes create 
tumefadion and deformity, or even lame- 
nefs, is true alfo; but the fault in thefe cafes 
does not lie in the mere redundance of fuch 
juice ; it is derived from the nature of the 
fradure, from the inequality of it when fet, 
and from the unapt poiition of the broken 
ends with regard to each other ; nor is Sur¬ 
gery or the furgeon any otherwife blame- 
able in this cafe, than as it was, or was not 
originally in their power to have placed 
them better. It is the inequality of the 
fradure which makes both the real and ap¬ 
parent redundance of callus, and the tu¬ 
rn c fad ion in the place of union. When a 

D bone 


'S y 

bone has,bcerv broken tJfely., ^0r jpearl^ 
-fq,, and its neither 

|nanjE : nor-great, ;> when-:fu,eh broken parts 
have been happily and proj^er-ly coaptated, 
and. proper methods have been, ufed to keep 
them condantly and deadily inJuch- date-of 
coaptation, the divided parts unite by th® 
intervention of the circulating/juice,- juft 
as the fofter parts do, allowing a different 
fpace of time for different texture and con¬ 
fidence. When the union of a broken bone 
under fuch circumdances has been procured, 
the place where fuch union has been made 
will be very little perceptible, it will be no 
deformity, nor will it occafion any inconve¬ 
nience It will indeed be difcoverable, like 
a cicatrix of a wound in a fofter part, but there 
will be no redundance of callus, becaufe none 
will be wantedjf neither will there be any 
rieceffity for any particular management on 
the part of thfc furgeon, to reprefs or keep 
it . in order : when a bone has.been 

r» — - • y’ •! A J' • fe . J J IJ | » .J. ;S „ VJ _ 

broken very obliquely or very unequally, 
when the parts pf .a fradture are,fo circumr* 
danced as not to adpit of exadk coaptation, 
\yhen fuch ex ad: coaptation as the fradure 
perhaps would have admitted has not been 
judicioudyinade, -when from unmanageable- 
M ; J * '■ m i '“ a ! nels. 




( 35 ) 

tiefs, inadvertence or (pafiti, the proper poll- 
lion o£the limb has not been attended to ot 
prelerved, in all filch cafes there mu-ft be 
confiderable inequality of fufface j there tnuft 
be rifings on one fide and depreflions 06 ano¬ 
ther ; and in filch cafeS the juices circula¬ 
ting through the bone, ednnot accomplifh 
the union in the fame quantity, the fame 
time, or in the fame manner* The broken 
parts not being applied exaCily tb each 
other, there cannot be the fame aptitude to 
Unitdj and according to the greater or leffer 
degree of exactitude in the coaptation, that 
is, according as the ends of the bones are 

~ ~ • 7 • 'k. ' ’’ i ■ ’ " "* ! ii ;; 1 

or have been placed more or lefs even with 

‘ f. -rvy i-. ? tjp r-% •* * , •**.;'* • 

regard tO each other, will the inconvenience 
and the deformity be $ and ftill molt Where 
the fraCture is riot fet at all, but the broken 
ends of the rone unite laterally, or by 
touching each others tides. The reafon of 
all this is fo obvious, without having re- 
courfe to a particular Ipecific juic§ under the 
name of callus, that it would be Ufi infult 
mpon the readers underftanding to explain 
it farther The periofteum covering 


* On the fubjeCt of callus, the edited <>f E)ti V<?*ftey 
tells a ftory from Galen, and which himfelf feems not to 

D 3 disbelieved 



( 36 ) 

every fracture, will remain thickened for 
feme time, and a degree of fulnefs or ri- 
fmg will be thereby caufed about the place 
where fuch fradure has been united, but 
time, and the ufe of the mufcles, foon in 
general remove this. 

In fhort this dodrine of callus, confidered 

* 

as a particular kind of juice, and as being 
liable to great redundance if not prevented by 
art, has not only milled many people, but has 
often been made ufe of as a cover to igno¬ 
rance and negled. When lamenefs and defor- 

* 

mity have been the confequences of one or 
both thefe caufes, more than of the nature 
and circumllances of a fradure, the callus 
has been found ready at hand to take the 
blame, and the ideal exuberance of this 
cement has often been urged, as an excufe 
for real want of knowledge, or for grofs 
negled. 

The bed and mod ufeful bandage for a 
Ample fradure of the leg or thigh, is what 
is commonly known by the name of the 
eighteen-tailed bandage, or rather one made 
on the fame principle, but with a little dif- 

, ference 

dlibelieve, viz. that a callus'in a particular cafe, was fo 
redundant as to tranfude through the fkin, and to keep the 
©emprdfes conftantly wet. 


, 








: i v 




r 


















•• - id;,: , 

■ ■' .V-'' 

■ ", 


















' 


1 < 


> f° 




: 

- * 






















r , f 




' t 4 

«■ 4 * . 






> 




■ - 


■ ■ ■ ■< .. ■ 


# 
















ftJilCC psujf 37. 


























( 37 ) 

ference in the difpofition of the pieces. 
The common method is to make it fo 5 that 
the parts which are to furround the limb, 
make a right angle with that which runs 
lengthways under it ; inflead of which, if 
they are tacked on fo as to make an acute 
angle, they will fold over each other in an 
oblique direction, and thereby fit more 
neatly and more fecurely, as the parts will 
thereby have more connexion with and 
more dependance on each other. In com¬ 
pound fradures, as they are called, every 
body fees and acknowledges the utility of 

6 <7 

this kind of bandage preferable to the rol¬ 
ler, and for very obvious and convincing 
reafons, but particularly becaufe it does not 
become neceffary to lift up and difturb the 

« 

limb every time it is dreffed, or every time 
the bandage loofens. 

The pain attending motion in a com- 
pound fradure, the circumfiance ,of the 
wound, and the greater degree of in (lability 
of parts thereby produced; are certainly 
very good reafons for drefiing fuch wound 
with a bandage, which does not render 
motion neceffary; but I fhould be glad to 
know what can make it neceffary, or right, 
or eligible; to move a limb in the cafe of 

f) 3 fimplc 


( 38 * 

fimple fracture ? what benefit c^n be pro^ 


/'■<• V o»Oi° 

' can 


if well fet. 


pofed by it ? wnat u 
it ? When a broken'bone h 
and the limb well placed* wh^t poffible ad¬ 
vantage can arife from moving it ? furely 
none ; but on the contrary, pain and prof 
bable mifchief. Is it not the one 'great 
intention* to procure unition ? Can moving 
the limb every two or three days contribute 
to fnch intention ? muft it nbt on the con«* 


trary pbftuuS and retard iti Is npt perfedl 
quietude as necelfary toward the union of 
the bone, in a fimple as in a compound frac¬ 
ture f It is true, that in the one therfc is a 

* S' 

wound whjch requires to be drefled, and 

• * Z'' ‘“S ' v ' » » 

the motion of the limb may in general be 
attended with rather more pain than in the 
Other * but does motion ip the fimple frac¬ 
ture give cafe, or procure more expeditious 
union ? — 


Every benefit then which can be fuppofed 
to be obtained from the ufe of the common 


bandage qr roller, is equally attainable from 
the ufe of that which I have juft mentioned, 
with one additional, and to the patient molt 
invaluable advantage, viz. that of never finding 
it neceflary to have his leg or thigh once du¬ 
ring the cure removed from the pillow on 
* which 



( 39 ) 

which it has been properly depofited. In 
fliort, to quit rea&ning and fpeak to fad, 
it is the conftant practice at St. Bartholo¬ 
mew's, and attended with all pofiible fuc- 
cefs. We always ufe the eighteen-tailed 
bandage, and never move the limb to re¬ 
new or adjuft it jjL 

The parts of the general apparatus for a 
ijtjjple Jradure* which come next in order, 

ate,tke fpUntfe u }lBm * aauV .r.: ,* ; " :> 

f5$f33|e& vsu*e generally made of pafterboard, 
twood, or fome refilling kind of fluff,; and 
are ordered to be applied lengthways onjhe 
broken limb > in fome cafes three, in/others 
four; for the p\qre fteady and quiet,dptep- 
0 @on of the fradure. ‘ rfl y, ' ad y Cia 
odi That Iplints properly made and judiciopQy 
applied are .very ferviceable, is beyond ^ll 
doubt, but’their^utility depends much.qn 
their fize and the manner in which they are 

,;applied.^d , 1 ^ ! 

In general pradice, they are made of fuch 
-length, as not to reach either upward or 
” downward. 


* See the different opinions of different French practi¬ 
tioners, with their reafons on this fubjedl, in Du Verney, 
Traite des Maladies des Os. 

-D 4 



'£ 4 ° ) 

downward, fo far as the roller extends ; not 
to comprehend either the upper or the 
lower joint of the broken bone, and to ex¬ 
ceed the fra&ure either way not many irn 
dies : they do not, for example, in the 
broken leg, comprehend either the joint of 
the knee, or the joint of the ancle, and adfe 
only on the fradture % • 

In 

if ... ' *« 

* This is the old dodlrine, and has been alrnofl uni- 
verfally and conftaritly adhered to and followed. Our 
forefathersj finding that fuch fplints as they ufed and ap-: 
plied in tfieir manner excited pain and inflammation, did 
not ufe, but forbad them until after feven days were paft, 
and the firfl: inflammation, as thev thought, was over. 

After this, they put them on to flrengthen the fradure* 
as they faid, and therefore made them fhort for that pur<? 
pofe only, exprefsly cautioning us againft the only method 
of applying them (in the cafe of broken leg) in which they 
can be really useful, viz. that in which they comprehend 
fiofh the knee and ancle. 

44 Ferularum ufus idem eft ac pannorum ad fraclum o$ 
4e continendum, ut maneat immotum, etiamfi membrum 
44 univerfum moveatur. 

44 Jubet Hippocrates Icves efle ferulas-& aequalcs & ad 
* 4 extrema refimas, &c. « 

44 Sid & hreviores ferulas efle pracipit ipfa vin&ura, ne 
4: quanda cutem proximam tentare valeant eminentem 

plerumque oh humores receptos, quos fafeiae extur- 
4 ‘ bant. Id quoque cavere oportet, ne ad oftium emi- 
44 nentias, quales in ima tibia & fura funt, ferulae per^- 
f { ringant, <kc. Sic. &c.*’ 

Oribafius de Fradfuris. 

: ** ^ Secj 


( 4i ) 

In 1 ' thiY-fcalfher df application and of thU 

fize, they are in fa 61 neither more nor lefs 

^ * * ■ * • ► 

than compreffes, and compreffes made of 
very bad materials. All the good that ever 
is, or that can be done by them, when of 
fuch length and fo applied, might certainly 
be done in a better manner by a more pro-* 
per kind of comprefs, and every difadvan-? 
tage, which a hard refilling comprefs, inju-* 
dicioufly applied is capable of producing, i$ 
probable to refult from them thus ufed. 

The true and proper ufe of fplints is to 
preferve fteadinefs in the whole limb, with^ 
out comprefling the fra6lure at all. By the 
former they become very afliftant to the cu¬ 
rative intention, by the latter they are very 
capable of caufing pain and other inconve-* 
pienoes ; at the fame time that they cannot 
in the nature of things, contribute to tht 
fteadinefs of the limb. 

T 1 f - f 

In order to be of any real ufe at all, 
fplints fhould, in the cafe of a broken leg, 

reach 


<c Sed hop tempore (poll feptimum diem) vipe plagufy- 
f c rum oportet ferulas apponere. 

“ His utebatur Hippocrates demum poll: feptimum 
* c diem ; quia ante feptimum magis urgebat intentio ar« 
pends infiammationis, quam intentio flabiliendi frac ? 
ff turam j poll feptimum autem contra accidie” 

f^b. ab Aquapend^ntpi 


( 4 * ) 

f^ach above knee and below the ancle * 
(bould be ernty two in number, and Ihould 
be fa guarded with tow, rag or cotton, that 
they fliould prefs only on the joints, and 
not at all on the fradture. 

By this they become really ferviceable; 
but a fhort fplint, which extends only a lit¬ 
tle above and a little below the fradture, and 
does not take in the two joints is an ahfur- 
dity; and what is worfe, it is a mifchievous 

abfurdity. .^hns 

By preffing on both joints, they keep not • 
only them, but the foot fteady, by pref¬ 
fing on the fradture only, they cannot re¬ 
tain it in its place, if the foot be in the 

V •.**’ ' .. i t i.i'j) ,, ... / t -! w . 

fmalleft degree difplaced, but they may, 
and frequently do occafipn mifchief, by 
rudely preffing the parts covering the frac¬ 
ture againft the edges and inequalities of it. 

I fuppofe it will be faid, that although 
fhort fplints do not of themfelves/uftam-and 
keep fteady the twq joints, aridt cpnfequeqt- 
Jy the limb, yet that purpofe ip. the broken 
leg may be and is fulfilled by junks, fa,- 
nons and other contrivances; to which ,1 
anfwer, that then the fhort fplints are :jn 
that cafe of no ufe at all,, and had better, tye 
laid afide ; they fhould be ufed fpr np ptfagr 
il pur- 


( 43 ) 

p ufpofe> -but ' that of keepings the limb 
fteaSy-j-arid if they do not anfwer that end, 
they are ah incumbrance, and multiply the 
Articles in the apparatus for a fractured leg, 
very unneceflarily. 

In the cafe of a fractured os femoris, if 
the limb be laid in an extended pofture, one 

fplint fhould certainly reach from the hip to 
the outer ancle, and another (fomewhat fhor- 
ter) fhould extend from the groin to the inner 
ancle. In the cafe of a broken tibia and 
fibula, there never can be occalion for more 
than two fplints, one of which fhould ex¬ 
tend fronv above the knee to below the ancle 

f ’ * $ ■ ' :■ . •< 

bn one fide, and the other fplint fhould do 
the fame on the other fide. The manner 
of applying them, if the limb be depofited 



u '-y- 

1 



next Eftici 

trauofibltf 1 

[c # t 

-1 > . ‘it 

if • 

,r\ ** ' 

^ Lib 


<> - 


^‘This, and indeed the moft effential 
article in the treatment of a frafture is, 
the pofition of the limb. Upon the judi¬ 
cious or injudicious, the proper or impro¬ 
per execution of this, depends the eafe of 
the patient during his confinement, and the 
free ufe and natural appearance of his limb 
afterward. 

- ^ If 


( 44 ) 

If* 1 meant to defcribe, or if I approved 
(pardon the phrafe) the common method of 
placing the broken leg and thigh in a 
Straight manner* this would be the place to 
mention the many very ingenious contri* 
Vances and pieces of machinery, which 
practitioners r both ancient and modern, 
have invented for the purpofe of keeping 
the whole limb ftraight and Steady, that is, 
of keeping all the mufcles furrounding the 
fradtured bone constantly upon the ftretch, 
and at the fame time of preventing any in¬ 
equality in the union of it, and any Shor¬ 
tening of the limb, in confequence of fuch 
inequality. 

But as it is my intention by thefe Sheets, 
to inculcate another, and as it appears to me 
a. better difpoiition of the Jiipb, in which 
fuch boxes, cradles, and pieces of machi¬ 
nery are not wanted, nor can be ufed, it is 
needlefs for me to fay any thing about 
them. 

According to this plan, the fradtured. leg 
and thigh Should be depofited on the pil¬ 
low, in the very pofture in which the ex- 
tenfion was made, and the fradiure fet, 
that is with the knee bent, 

* I have 


5 


( 45 ) 

1 have already been fo explicit, or per¬ 
haps prolix, on the tenfe and lax ftate of the 
mufcles, as depending on pofture, under the 
head of extenfion, that I fliall fpare the 
reader, as well as myfelf a^ good deal of 
trouble by referring back to that article.. 
All that is there urged, or that can be urged 
for making the extenfion, that is, for fetting 
a fradure in fuch difpofition of a limb or 
its mufcles, is equally powerful and con- 
clufive with regard to the manner of de¬ 
porting and leaving it after it has been fet. 
Whatever render reduction and coaptation 
eafy, muft as neceftarily maintain e.afe du¬ 
ring the confinement, preferve re&itude of 
figure, and prevent difplacement. The 
fame principle muft acft on both occa.fions, 
and whether the dpdlrine be right or wrong, 
confidered by itfelf, it muft be equally fo in 
both circumftances, that is, in the manner 
of fetting a fradure, and in the manner of 
depofiting the limb afterward In the 

cafe 

* It has been faid, that the ftraight pofition of a limb, 
by putting the mufcles on the ftretch, induces them td 
contribute to the fecurity of the fracture again# difplace^ 
ment. If this be the cafe in general, how happens ft 
that thofe bones are always found moft liable to be dis¬ 
placed when broke#, ^nd to be mo# difficult tpiceep i# 
their proper place, which are furrounded by the mofl an$J 
by the ftrongeft mufcles f [ 


( 4 * ) 

c^fc of the fradtured os humeri, the only 
pofition in which it can with any tolerable 
convenience to the patient be placed, is 
with the elbow bent, that very pofition 
Which neceffarily relaxes and removes all 
the refiftance of the furrounding mufcles* 
Daily experience evinces the utility of this, 
by our very feldom meeting with lamenefs Of 
deformity after it, notwithstanding the pre- 
vdling apprehenfion of exuberant callus. 

The deformity frequently confequent to 
the frafture of the bones of the cubit, par** 
ticularly that of the radius only, will gene¬ 
rally, if not always, be found to be in pro¬ 
portion as the mufcles concerned in the 
pronation and fupination of the hand hap¬ 
pen to be put more or lefs into a ftate of 
adtion, or tenfion by the pofition of the 



In the thigh the cafe is ftill more obvi¬ 
ous, as the mufcles are more numerous and 
ftronger. 1 3 

The ftraight pofiure puts the majority 
of them into adtion, by which • adtion 
that part of the broken bone, which is 
next to the knee, is pulled upward, and by 
palling more or lefs underneath that part 
1 ' which 



• ( 47 ) 

which is next to the hip, makes :an inequality 
or rifing in the broken part, and produces a 
fhortnefs of .the limb. K 

In the fracture of both bones of the leg 
the cafe is ftill ^he fame ; a ftraight pofition 
putg the mufcles upon endeavouring to aft;. 
a. moderate flexion of the knee relaxes them, 
and takes off fuqh propenfity *• 

The difpofition therefore of the broken 
cubit ought to be that which, by putting the 
hand into a middle ftate between pronation 
and fupination, and by bending the fingers 
moderately, keeps the radius fuperior l to 
the ulna; or:in other words,; the palm of 
the hand fhould be applied to the bread, 
the thumb fhould be fuperior, the little fin¬ 
ger inferior; and the hand fhould he kept in 
this poftureconftantly by mean? pf twofplints, 

which fhould reach from the joint of, the. 

• » 

elbow on each fide, and fhould be extended 
below the fingers ; or the fame purpofe 
may be ftill better anfwered by a firnple 
neat contrivance of the very ingenious Mr* 

Gooch 


~L / 

* In proportion as the frafture fhall happen to be more 
or lefs oblique, the truth of this doctrine will upon expe- 


. riment be found to be more or lefs apparent, as well as 
ufeful. 


I 



( 4 * ) 

Croocli of Norfolk ; of which he has given 
a draught, and which is preferable to a 
common fplint, by its admitting the lingers 
to be more eafily bent. 

The pofition of the fra&ured os femoris 
fhould be on its outfide, refting on the great 
trochanter ; the patient’s whole body fhould 
be inclined to the fame fide ; the knee 
fhould be In a middle Hate, between perfedl 
flexion and extenfion, or half bent; the 
leg and foot lying on their outfide alfo, 
fhould be well fupported by fmooth pil¬ 
lows, and fhould be rather higher in their 
level than the thigh; one very broad fplint 
of deal, hollowed out and well covered 
with wool, * rag, or tow, fhould be placed 
under the thigh, from above the trochanter 
quite below the knee, and another fome- 
what fhortef fhould extend from the groin 
below the knee on the infide, or rather in 
this polture on the upper fide ; the bandage 
fhould be of the eighteen-tail kind, and 
when the bone has been fet, and the thigh 
well placed on the pillow, it fhould not, 

without 

* If the pillow on which the broken thigh i$ placed be 
jiof too thick, the fplint may with equal advantage be 
placed underneath fuch pillow, and in many cafes this will 
be found to be the belt manner of ufing it. 


\ 


( 49 ) 

Without rieceffity, (which neceffity in this 
method will feldom occur) be ever moved 
from it again until the fra&ure is united 5 
and this union will always be accomplifhed 
in more or lefs time in proportion as the 
limb fhall have been more or lefs di- 
fturbed. 

In the fra&ure of the fibula only, the 
pofition is not of much confequence, be-* 
caufe by the tibia remaining intire, the 
figure of the leg is preferved and extenfion 
quite unneceflary; but ftill even here the 
laying the leg on its fide, inftead of the 
calf, is attended with one very good confe- 
quence, viz. that the confinement of the 
knee in a moderately bent pofition, does 
not render it fo incapable of flexion and ufe 
afterward, as the ftraight or extended po¬ 
fition of it does, and confequently that the 

* 

patient will be much fooner able to walk, 
whole leg has been kept in the former po- 
fture, than he whofe leg has been confined 
in the latter. % 

In the fradture of both tibia and fibula, 
the knee flhould be moderately bent, the 
thigh, body and leg in the fame pofition as 
in the broken thigh. If common fplints be 
ufed, one fhould be placed underneath the 

E . leg,,: 


( 5 ° )' 

leg, extending from above the knee to below 
the ancle, the foot being properly fupported 
by pillows, holders, &c. and another fplint 
of the fame length iliould be placed on the 
upper fide, comprehending both joints in the 
fame manner; which difpolition of fplints 
ought always to be obferved, as to their 
length, if the leg be laid extended in the 
common way, only changing the nominal 
pofition of them, as the pofture of the leg 
is changed, and calling what is inferior in 
one cafe, exterior in the other, and what is 
fuperior in one, in the other interior 

If Mr. Sharpe’s fplints be made ufe of, 
there is in one of them a provifion for the 
more eafy fupport of the foot and ancle, by 
an excavation in, and a prolongation of the 

lower 

■*. - • -I ^ J X ' ' 

All writers on this fubjedl agree in giving us cautions 
about defending the heel and filling up the hollow from it 
to the calf of the leg, and this they do on account of the 
pain, excoriation, and even ulceration, which fometimes 
attends the ftraight pofition, with the limb refling on the 
heel. 

Many of them have alfo taken notice of an accident 
fometimes attendant on a broken leg, but which really 
ought to be fet to the account of the pofture in which fuch 
leg is placed, more than to that of the fra&ure; 1 mean 
the /bunking or wafting of the calf. 


( ) 


lower or fibular fplint, for the pufpofe of 
keeping the foot fteady. > 


I hope that I have exprefled my meaning 
clearly; I fhould be very forry to be mif- 
taken, becaufe it appears to me to be a 
matter of fome confequence; and if what 

I • have faid be intelligible, the reader will 
underftand from thence, that I mean to 
fignify that, (in my opinion,) extenfion will 
in general be made with more facility, and 
coaptation more happily executed, that a 
patient will fuffer a great deal lefs pain, 
during thefe operations, as well as during 
the neceflary confinement for a broken leg 
or thigh, and that both patient and furgeon 
will be lefs likely to be difappointed in 
their intention and wi£h, that is, that the 
former will be lefs liable to lamenefs or de¬ 
formity, when a fradtured thigh or leg has 
been treated in the way I have defcribed 
than in the common one. 

The refiftance neceffarily made by the 
mufcles, joined to the great inftability of 
parts in every fpecies of fradtured leg or 
thigh, except in the few where the bones 

E 2 are 


• ( 52 ) 

are broken tranfverfely, has conftantly ex- 
ercifed the invention and ingenuity of prac¬ 
titioners, in devifing means to prevent ine¬ 
quality in the callus as it is called, and fliort- 
nefs and deformity in the limb. Our books 
abound with draughts and defcriptions of 
machines for this purpofe; ligatures, pul- 
lies, leaden weights and fradture-boxes, fo 
conftrudted, as to overcome and conftantly 
to refill that adlion of the mufcles furroun¬ 
ding the broken bone, that natural ten¬ 
dency in them to contract, which the ex¬ 
tended pofition of the limb necefiarily in¬ 
duces. Every body w r ho has been conver- 
fant with matters of this fort, knows that 
even the bell of thele various contrivances, 
often prove fuccefslefs, and every one who 
will refiedt ever fo little may fee why they 
mull be fo. That they do prove inef¬ 
fectual, the number of deformed legs and 
fhortened thighs, which are daily met with, 
evinces and that they mull frequently 
prove fo will be obvious to every one, who 
will confider that the eftedt can laid no lon¬ 
ger than the caufe is continued, unlefs 

\ 

there happens to be fome very favourable 

circumflance 


- ( S3 ) 

eircumfiance In the fradiure itfelf. What 

5 * 

I mean is this, when the redudlion of the 
fradiure is fet about, the limb is put into 
fuch pofition, that the furrounding mufcles 
refill the extending force very confiderably, 
and this in proportion to their flrength and 
number : that force is continued and in- 
creafed till the mufcles give way, and the 
refiftance being overcome, an opportunity is 
thereby obtained of placing the ends of the 
fradiure in as apt pofition with regard to 
each other, as the nature of it will admit. 
If the fradiure be of the tranfverfe kind, that 
is, if the ends of the broken bone be large 
and afford a good deal of fpace for contadl 
with each other, fuch appofition will con¬ 
tribute a good deal to the keeping the limb 
fleady and the fradiure even; but if the 
fradiure be of the oblique kind, if there 
be feveral loofe pieces, and confequently 
neither large contadl nor (lability from the 
apportion, or if due extenfion has not been, 
made or could not, or if the ends of. the 
bones have not been judicioufly and proper¬ 
ly fet, the mufcles will adl as foon as the 
extenfion is relaxed, the fradiure will be 
more or lefs difplaced, according to the na¬ 
ture of it, the limb will be fliortened, the 

E 3 time 


( 54 ) 

time of union will be prolonged, and the 
place of it (the callus, as it is called) will 
be in proportion more or lefs unequal. 

I take it for granted that it will be allied, 
Have not our anceftors in all times happily 
redreffed fradtured legs and thighs, by the 
method which they have delivered down to 
us, and which in the preceding pages I 
have taken the liberty to object to ? have 
not fuch limbs frequently been rendered as 
ftraight, as ufeful, and as little deformed as 
poffible ? I anfwer, moh certainly, yes ; it 
is an undoubted truth and cannot be denied. 
But in my turn, let me be permitted to afk. 
Whether in the fame method great and even 
unfurmountable difficulty is not frequently 
met with ? whether in many cafes the act of 
fetting, as it is called, is not excefiively 
painful at the time, and productive of in¬ 
flammation and other difagreeable fymp- 
tqms afterward ? and whether in fpite of all 
care, of every contrivance, of every fpecies 
of machinery which has yet been ufed, 
broken thighs and legs are not often, very 
often left deformed, crooked and Shortened, 
and that merely from the aCtion of the mufcles 
and the obliquity or {battered ftate of the 
fraCture ? The fadt is notorious, and the 

foie 


* . 


( 55 ) 

foie queftion is, Whether or no a different 
difpofition of the parts, preventing fuch ac¬ 
tion and fuch refinance, will in many in- 
ftances prevent thefe evils ? to which, from 
repeated experience, I anfwer yes. If this 
fhould be found to be the cafe in general, 
of which I make no doubt ; that is, if by 
this method, many of fuch unfortunate 
cafes, as in the common method of treat¬ 
ment difappoint both patient and furgeon, 
fhould be found in general to fucceed fo well 
as to fatisfy both, it will prove all I wifh it 
fhould prove. Superior utility and more 

frequent fuccefs are all I contend for. 

Many people did very well under amputa¬ 
tion before the double incifion was pradti- 
fed ; but is the double incifion therefore no 
improvement ? The operation for the bu¬ 
bonocele may be performed with that cl uni¬ 
fy inflrument the probe fcifiars, but is the 
bifioury therefore not preferable ? A fur- 
geon may cut off fome ounces, or even 
pounds of flefh from a patient’s backfide, 
in order to cure a finus, but is the cure by 
the fimple divifion of that finus therefore 
not eafier or more expeditious ? Neither of 
thefe can (I think) be proved, unlefs it can 
at the fame time be proved, that pain is no 

E 4 .evil. 


( 56 ) 

£vil, confinement not at all -irkfcme, and 
that deformity and elegance of figure are 
fynonimous terms. 

Let not the reader fancy that* I would 
dare to amufe him with fpeculation, or 
merely fpecious reafoning on a fubjed like 
this. What I have fa id is from experience, 
repeated experience both of myfelf and of 
others, for a confiderable length of time 
paft, and on a great variety of fubjeds ; 
from an experience which has perfectly fa- 
tisfied me, and I think will every man who 
will make the trial fairly and candidly. *— I 
do not pretend to fay, that by thefe means 
every kind of broken bone will infallibly 
and certainly be brought to lie finooth, 
even, and of proper length $ if I did, they 
who are verfed in thefe things, would know 
that I laid too much ; but I will fay, (what 
i$ fbfiieient for my purpofe) that it will not 
only fucceed in all thole, in which the old 
method can ever be fuccefsful, but alfo in 
the majority of thofe in which it is not nor 
in the nature of things can. In thofe for¬ 
tunate cafes, in which either method will do, 
the old one is fatiguing, inconvenient, and 
even fometimes offenfive, from the fupine 

an4 


( 57 ) 

and confined podure of the patient; where¬ 
as that which is here propofed, gives the 
patient much greater liberty of motion for 
every purpofe either of choice or neceffity, 
and in many of thofe cafes, wherein the old 
method proves mod frequently fo far fuc- 
cefslefs, as to leave the limb fhort, lame, 
or deformed ; I fay, in mod of thefe the 
propofed method will not be attended with 
thefe inconveniences. 

I have already faid, that in mod cafes of 
broken thigh or leg, the method jud de- 
fcribed will be attended with great fuccefs : 
but there is one particular cafe in which 
its utility is dill more confpicuous ; a cafe, 
which according to the general manner of 
treating it, gives infinite pain and trouble 
both to the patient and furgeon, and very fre¬ 
quently ends in the lamenefs and difappoint- 
ment of the former, and the difgrace and 
concern of the latter: I mean the frafture 
of the fibula attended with a diflocation of 
the tibia. 

Whoever will take a view of the leg of 
a Ikeleton, will fee that although the fibula 
be a very fmall and flender bone, and very 
inconfiderable in drength, when compared 
with the tibia, yet the fupport of the lower 
4 joint 


( 53 ) 

joint of that limb, (the ancle) depends fo 
much on this flender bone, that without it 
the body would not be upheld, nor loco¬ 
motion performed, without hazard of dido- 
cation every moment. The lower extre¬ 
mity of this bone, which defcends confide- 
rably below that end of the tibia, is by 
ftrongand inelaftic ligaments firmly connect¬ 
ed with the laft-named bone, and with the 
aftragalus, or that bone of the tarfus which 
is principally concerned in forming the joint 
of the ancle. This lower extremity of the 
fibpla has, in its pofterior part, a fuperficial 
fulcus for .the lodgment and paffage of the 
tendons of the peronei mufcles, which are 
here tied down by ftrong ligamentous cap¬ 
fuls, and have their aCtion fo determined 
from this point or angle, that the fmalleft 
degree of variation from it, in confequenee 
of external force, muft neceflarily have con- 
fiderable effedt on the motions they are de- 
figned to execute, and confequently diftort the 
foot. Let it alfo be confidered, that upon the 
due and natural (late of the joint of the ancle, 
that is, upon the exadfc and proper difpofi- 
tion of the tibia and fibula, both with re¬ 
gard to each other and to the aftragalus, de¬ 
pend the juft difpofition and proper adion 
" • • of 

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I 


I 


( 59 ) 

of feveral other mufcles of the foot and 
toes ; fueh as the gaftrocnemii, the tibialis 
anticus, and pofticus, the flexor pollicis 
longus, and the flexor digitorum pedis lon¬ 
gus, as muft appear demonftrably to any 
man who will firft diflfeCt and then atten¬ 
tively confider thefe parts. 

IF the tibia and fibula be both broken, 
they are both generally difplaced in fuch 
manner, that the inferior extremity* or that 
connected with the foot is drawn under 

that part of the fractured bone, which is 
connected with the knee ; making by this 
means a deformed, unequal tumefaction in 
the fraCtured part, and rendering the broken 
limb fhorter than it ought to be, or than 
its fellow. And this is generally the cafe, 
let the fraCture be in what part of the leg 
it may. 

If the tibia only be broken, and no aCt 
of violence, indifcretion, or inadvertence be 
committed, either on the part of the pa¬ 
tient or of thofe who conduCt him, the 
limb moft commonly preferves its figure and 
length ; the fame thing generally happens 
if the fibula only be broken, in all that 
part of it, which is fuperior to letter A in 
the annexed figure, or in any part of it be¬ 
tween 


( 6o ) 

tween its upper extremity, and within two 
or three inches of its lower one. 

I have already faid, and it will obvioufly 
appear to every one, who examines it, that 
the fupport of the body and the due and 
proper ufe and execution of the office of 
the joint of the ancle depend almoft en¬ 
tirely on the perpendicular bearing of the 
tibia upon the aftragalus, and on its firm 
connection with the fibula. If either of 
thefe be perverted or prevented, fo that the 
former bone is forced from its juft and per¬ 
pendicular pofition on the aftragalus, or if 
it be feparated by violence from its con¬ 
nexion with the latter, the joint of the 
ancle will fuffer a partial diflocation inter¬ 
nally * ; which partial diflocation cannot 
happen without not only a confiderable ex- 
tenfion, or perhaps laceration of the burfal 
ligament of the joint, which is lax and 
weak, but a laceration of thofe ftrong ten¬ 
dinous ligaments, which connect the lower 
end of the tibia with the aftragalus and os 
calcis, and which conftitute in great meafure 
the ligamentous ftrength of the joint of 
the ancle. 

This 

* See the figure at the preceding page. 


( 61 ) 

This is the cafe, when by leaping or 
jumping the fibula breaks in the weak part 
already mentioned, that is within two or 
three inches of its lower extremity. When 
this happens, the inferior fradured end of 
the fibula falls inward toward the tibia, that 
extremity of the bone which forms the 
quter ancle, is turned fomewhat outward 
and upward, and the tibia having loft its 
proper fupport, and not being of itfelf ca¬ 
pable of fteadily preferving its true perpen¬ 
dicular bearing, is forced off from the aftra- 
gulus inwards, by which means the weak 
burfal, or common ligament of the joint is 

violently ftretched, if not torn, and the 
* 

ftrong ones, which faften the tibia to the 
aftragalus and os calcis, are always lace¬ 
rated, thus producing at the fame time a 
perfed fradure and a partial diflocation, to 
which is fometimes added a wound in the 
integuments, made by the bone at the in¬ 
ner ancle. By this means, and indeed as a 
neceffary confequence, all the tendons which 
pafs behind or under, or are attached to the 
extremities of the tibia and fibula, or os 
calcis, have their natural diredion and difi- 
pofition fo altered, that inftead of perform-: 
ing their appointed adions, they all contri- 

, bute 


i 


( ) 

bute to the diftortion of the foot, arid that 
by turning it outward and upward. 

When this accident is accompanied, as it 
fometimes is, with a wound of the integu¬ 
ments of the inner ancle, and that made by 
the protrufion of the bone, it not infre¬ 
quently ends in a fatal gangrene, unlefs 
prevented by timely amputation, though I 
have feveral times feen it do very well with¬ 
out. But in its mod: Ample ftate, unaccompa¬ 
nied with any wound, it is extremely trotf- 
blefome to put to rights, ftill more fo to keep 
it in order, and unlefs managed with addrefs 
and fldll, is very frequently productive both 
of lamenefs and deformity ever after. 

After what has been faid, a farther expla¬ 
nation why this is fo is unneceflary. Who- 
ever will take even a curfory view of the 
difpofition of the parts, will fee that it muft 
be fo. By the fra&ure of the fibula, the 
dilatation of the burial ligament of the 
joint, and the rupture of thofe which 
fhould tie the end of the tibia firmly to the 
aftragalus and os calcis, the perpendicular 
bearing of the tibia on the aftragalus is loft, 
and the foot becomes diftorted ; bv this di- 
ftortion the direction and acftion of all the 
mufcles already recited are fo altered, that it 

becomes 


( 63 ) 

becomes (in the ufual way of treating this 
cafe) a difficult matter to reduce the joint, 
and, the fupport of the fibula being gone, a 
more difficult one to keep it in its place after 
redu&ion. If it be attempted with com- 
prefs and ftridt bandage, the confequence 
often is a very troublefome as well as pain¬ 
ful ulceration of the inner ancle, wh ( ich 
very ulceration becomes itfelf a reafon why 
fuch kind of preffure and bandage can be 
no longer continued ; and if the bone be 
not kept in its place, the lamenefs and de¬ 
formity are fuch, as to be very fatiguing to 
the patient, and to oblige him to wear a 
fhoe with an iron, or a laced bufkin, or 
fomething of that fort for a great while, or 
perhaps for life. 

All this trouble, pain, difficulty, and in¬ 
convenience, are occafioned by putting and 
keeping the limb in fuch pofition, as necef- 
farily puts the mufcles into aCtion, or into a 
fate of refinance, which in this cafe is the 
fame. This occafions the difficulty in re¬ 
duction, and the difficulty in keeping it re¬ 
duced ; this diftorts the foot, and by pul¬ 
ling it outward and upward makes that 
deformity, which always accompanies fuch 
accident $ but if the pofition of the limb 

be 


C 64 ) 

be changed, if by laying it on its outfide 
with the knee moderately bent, the mufcles 
forming the calf of the leg, and thofe 
which pafs behind the fibula and under the 
os calcis, are all put into a ftate of relaxa¬ 
tion and non-refiftance, all this difficulty and 
trouble do in general vanifh immediately; 
the foot may eafily be placed right, the 
joint reduced, and by maintaining the fame 
difpofition of the limb, every thing will in 
general fucceed very happily, as I have 
many times experienced. 

Two kinds of fradure there are, and 
only two that I can recoiled: (relative to the 
limbs) which do not admit of the bent po- 
fition of the joints, I mean that of the pro- 
cefius olecranon at the elbow, and that of 
the patella 5 in thefe a ftraight pofition of 
the arm and leg is necefiary, in the former 
to keep the fradured parts in coritad till 
they are united, in the latter, to bring 
them as near to each other as may beft ferve 
the purpofe of walking afterward 

With 

* Although a ftraight pofition of the limb is necefiary 
for the broken patella, yet this very pofition becomes fo 
upon the fame principle, as renders the bent pofture moft 
advantageous in the broken tibia and* femur, viz. the re¬ 
laxation 


) 


( 65 ) 

' I 

With regard to the fradture of the pa¬ 
tella, an opinion has long and generally pre¬ 
vailed, which feems to me to have no foun¬ 
dation in truth, or (when duly confidered) 
even in probability ; it is, that the great de¬ 
gree of ftiffnefs in the joint of the knee, 
which is fometimes found to be the confe- 
quence of this kind of fradture, is owing 

t0 > 

taxation of the mufcles and tendons attached to the frac- 
tured bone. 

Whoever will for a moment attend to the difpofition of 
the pieces in a patella, which has been broken tranfverfely, 
will fee how little neceflary or ufeful the many contri¬ 
vances of bandages, ftraps, compreffes, buckles, buttons, 
&c. to be found in writers are, efpecially all that part of 
them which are applied to the inferior fragment. 

By the a&ion of the united tendons of the extehfores 
mufcles of the leg, the fuperior fragment is pulled up¬ 
ward and feparated from the inferior, but the latter re¬ 
mains nearly if not abfolutely where it was before the 
accident; there is nothing to a£t upon it, and therefore it 
cannot, nor does it move. 

The extenhon of the leg puts the mufcles attached to 
the upper part of the broken bone into a ftate of relaxa¬ 
tion, and prevents their acting ; and though a fmall com- 
prefs juft above this piece, with a moderate bandage, may 
be ufeful toward retaining it, yet it is the pofition of the 
leg which muft keep the broken piece down, and effect 
the cure. 


F 


( 66 ) 

to, or produced by, a quantity of callus fal¬ 
ling into It from the edges of the broken 
bone, and that the nearer the broken pieces* 
are brought to each other, the more likely 
fuch confequence is. 

Every part of this dodtrine feems equally 
abfurd. In the firft place, the fractured 
bone is by no means capable of fupplying 
fuch a quantity of callus, as to produce this 
end, unlefs it may be fuppofed to run from 
it as folder from a plumber's ladle ; in the 
fecond place, if this was the cafe, the moft 
likely, and indeed the only probable way of 
preventing the depofition of fuch juice, muft 
be by bringing the broken pieces into clofe 
eontadt ; and in the third place, there is no 
authority from the appearance of fuch joints 
after death, (at leaft as far as my experience 
goes) to fuppofe this to be the cafe, or to 
countenance fuch opinion. The caufe there¬ 
fore of this rigidity, which is now and 
then found to attend the broken patella,, 
muft be fought for elfewhere, viz. in the 
long reft and confinement of the joint, as a. 
means ufed by many to procure exadt union j 
in mifchief done to the ligament, which is 
formed by the united tendons of the four ex- 

tenfor 


( 67 ) 

tenfor mufcles of the leg, at the time of 
and by the fradlure; and in the nature of 
the fradlure itfelf, that is, the manner in 
which the bone fhall happen to be broken. 

But, be all this as it may, the fadt un¬ 
doubtedly is, that they walk bed after luch 
accident, whofe patella has been broken 
tranfverfely, and that into two nearly equal 
fragments ; whofe confinement to the bed 
has been fhort, that is, no longer than while 
the inflammation laded ; whofe knee, after 
fuch period, has been daily and moderately 
moved ; and in whom the broken pieces are 
not brought into sxadt contadl, but lie at 
fome fmall didance from each other. 

I cannot take leave of this fubjedl of Am¬ 
ple fradtures, without mentioning a circum- 
dance relative to them, which although, 

when rightly underdood, is of little or no 

' • ' - ♦ 

^importance, yet by being mifunderflood, 
becomes frequently of considerable confe- 
quence. 

I mean, the ufe of the term, rijing end 
of a broken bone . 

By the expreffion, any one unacquainted 
with thefe things would be inclined to 

F a think. 


( 68 ) 

think, that the prominent part of a broken 
bone rofe, or was elevated from its natural 
place, and became by fuch riling fuperior to 
the other part or extremity of the fradure. 
This would certainly be the idea of an ig¬ 
norant perfon, and as fuch would be of lit¬ 
tle confequence; but by the practice of 
many, who call themfelves furgeons, it is 
as certainly their idea alfo, and this renders 
it a matter of great confequence. Many 
inftances are producible, in which our con- 
dud: is in great meafure regulated by the 
language which we ufe. Having no ideas 
annexed to our words, leads us into abfur- 
dity, and unrntelligibility, but falfe ones in¬ 
fluence us (till more, and frequently produce 
very material errors. 

The fiftula lachrymalis, the fiftula in pe¬ 
ri naeo> and that in ano, are glaring proofs 
of this* and my prefent fubjed is full as 
much fo : for upon the erroneous idea an¬ 
nexed to the term rifing end , ftands all the 
abfurd pradice of comprefs, bolder, and 
Arid bandage in the cafes of Ample frac¬ 
ture 

The 

% I was fome few years age> carried by a furgeon, fince 

dead* 


no n- 


( 69 ) 

The truth is, that there is really 
Jing end to a broken bone ; I mean, when 
applied, as the term ufually is, to the leg, 
thigh and clavicle. There is indeed a fu- 
perior or prominent end or part, and an 
inferior or depreffed one, but the former of 
thefe is in its proper place, from which it 
cannot by art be moved, and the latter, 
which is not in its proper place, is very 
capable by art of being put into it. 

Perhaps this may to fome appear a mere 
play of words, a nominal diftindion with¬ 
out a real difference ; but when the influence, 
which a right or wrong idea of this pro¬ 
duces on practice, is attended to, the con- 
fequence will be obvious and ferious. 

When a collar bone, os femoris, or tibia 
and fibula are broken, by the aclion of the 
mufcles, by the motions of the patient, and 
by the mere weight of the inferior part of the 
arm, thigh or leg, the fra&ured ends of fuch 

bones 

dead, to fee a contrivance of his own to keep down the 
rifing end of a broken tibia. It was fomewhat upon the 
principle of Petit’s tourniquet, and calculated to a£t by 
compreflion. I told him my opinion freely, but the in¬ 
ventor was wedded to his invention, and the firft fimple 
fra£ture he applied it to, he thereby converted into a 
compound one, by preiiing the bone through the fkin, 

Z ' F 3 • 


( 7° ) 

bones are difplaced, and always difplaced 
in fuch manner, that the inequality oc- 
caliened neceffarily by fuch difplacement, 
proceeds from the inferior end of the frac¬ 
tured bone being retracted or drawn under 
the fuperior : this produces a tumefaction 
or unequal riling, and the upper extremi¬ 
ty of the fracture is therefore called the 
riling end of it. Now the man who re¬ 
gards this riling end, as that part of the 
fraCture which has by fuch riling got out 
of its place, and not as having acciden¬ 
tally become the prominent part merely by 
the inlinuation or retradion of the other 

''*L > ' . /> , v v 't 4- . I ^ ^ 

part underneath it, will go to work w 7 ith 
bolder, comprefs and bandage, in order to 

bring and keep fuch end down ; by which 
means he will give his patient confiderable 
pain, and while he depends on fuch means 
alone, will mod certainly be frudrated in 
his intention and expectation, the means not 
being adequate to the propofed end. But 
the man who looks on this in the true 
light, that is, who looks on the fuperior 
part, as being in its proper place, and the 
inferior, as being difplaced by the weight 
of the limb, and the aCtion of the muf- 
cles, will know, that by the mere pofition 

.. ... . ■ , - ■ < . qf 


{ 7 1 ) 

of fuch limb, he lhall be able to remedy all 
the inconvenience and deformity, as far as 
they are by art capable of remedy, without 
the parade, or the fatigue of ufelefs appa¬ 
ratus. 

He will, for example, know that the 
prominent part of a broken clavicle, that 
part of it which is next to the fternum, is 
juft where it fhould be, and that the infe¬ 
rior part, that which is connected with the 
fcapula, is out of its place, by being drawn 
down by the weight of the arm ; and there¬ 
fore inftead of loading, as is ufual, the pro¬ 
minent part with quantities of comprefs, 
which never can do any fervice, he, by a 
proper elevation of the arm, will bring the 
lower end upward into contad: with the 
other, and thereby with very little trouble 
eafily accomplilh what he never can do in 
any other manner, however operofe. 

The fame thing will happen from the 
fame principles in the leg and thigh; a pro¬ 
minence, or a riling end there always will 
be, but that riling end is never to be 
brought down by any preffure from com¬ 
prefs or bandage ; the fallen or inferior one, 
muft always be brought up to it by the 
proper polition of the reft of the limb : 

F 4 this 

V • '3 


( 72 ) 

this will always remove the inequality as 
far as it is removeable, and nothing elfe 
can 

* In a profeft regular treatife on this fubje&, it would 
bq right to take notice of what may be called the infortu- 
nia or accidental evils, which fometimes accompany even 
fimple fra&ures ; fuch are, difeafe arifing from injury done 
to the medullary membrane, within the bones, in bad 
habits ; haemorrhage, or a fpecies of fpurious aneurifm, 
from a wound of the interofleal artery, between the tibia 
and fibula, or of either of the carpal arteries: mifchief 
from the fra&ure becoming accidentally the feat of the 
crifis of a fever, deficiency of callus, or the accident of 
the broken bone not uniting : the fraftured limb becom¬ 
ing the feat of an eryfipelas, terminating in a dough of the 
common membrane and periofteum : the gelatinous juice 
or callus, which fhould unite the fra&ure, being in fo mor¬ 
bid a ftate, a$ to produce a kind of caries with exoftofis, 
inftead of its doing its proper duty, &c. Of all thefe 
there are examples, but they do not come within the plan 
which I prefcribed to myfelf when I began thefe papers. 


* . -V, i 


COM. 


( 73 ) 


COMPOUND FRACTURES. 

I Ufe the term compound fradture in the 
fenfe in which the Englifh have always 
ufed it, that is, to imply a broken bone 
complicated with a wound. 

In this kind of cafe the firft objedt of 
confideration is, whether the prefervation of 
the fradtured limb can, with fafety to the 
patient’s life, be attempted ; or in other 
words, whether the probable chance of 
deftrudtion from the nature and circumftan- 
ces of the accident, is not greater than it 
would be from the operation of amputation. 
Many things may concur to make this the 
cafe. The bone or bones being broken in¬ 
to many different pieces, and that for a 
confiderable. extent, as happens from broad 
wheels, or other heavy bodies of large fur- 
face, pafling over, or falling on fuch limbs; 
the fkin, mufcles, tendons, &c. being fo 
torn, lacerated and deftroyed, as to render 

gangrene 






( 74 ) 

gangrene and mortification the moft proba¬ 
ble and moft immediate confequence; the 
extremities of the bones forming a joint, 
being crufhed; or as it were comminuted, 
and the ligaments connecting fuch bones 
being torn and fpoiled are, among others, 
fufficient reafons for propofing and for per¬ 
forming immediate amputation. Reafons, 
which (notwith(landing any thing that may 
have been faid to the contrary) long and re¬ 
iterated experience has approved, and which 
are vindicable upon 'every principle of hu¬ 
manity, or chirurgic knowledge. 

When a furgeon fays, that a limb which 
has juft fuffered a particular kind of com¬ 
pound fraCture, ought rather to be imme¬ 
diately cut off, than that any attempt fhould 
be made fpr its prefervation, he does not 
mean by fo faying, that it is absolutely im- 
poflible for fuch limb to be preferved at all 
events $ he is not to be fuppofed to mean 
fo much in general ; though fometimes even 
that will be obvious ; all that he can truly 
and juftly mean is, that from the experience 
of all time, it has been found that the atr 
•tempts to preferve limbs fo circumftanced, 
have moft frequently been fruftrated by the 
death of the patients, in confequence of 

fuch 


( 75 > 

fuch injury; and that from the fame experi¬ 
ence, it has been found, that the chance of 
death from amputation is by no means equal 
to that arifing from fuch kind of fradure. 

Every man knows that apparently defpe- 
rate cafes are fometimes cured ; and that 
limbs fo (hattered and wounded, as to ren¬ 
der amputation the only probable means for 
the prefervation of life, are now and then 
faved. This is an uncontroverted fad}, but 
a fad: which proves very little againft the 
common opinion; becaufe every man of 
experience alfo knows, that fuch efcapes are 
very rare, much too rare to admit of being 
made precedents, and that the majority of 
fuch attempts fail 

This 

* The baron Van Swieten, writing as many others 
have done, that is, theoretically on furgery, advifes us, 
in the cafe of very bad compound fra&ure, which may 
moft probably require amputation, to defer the operation, 
until we have tried the force of antifeptic fomentations 
and applications of like kind for two or three days ; and 
this opinion and advice he builds, in fome meafure, on 
a remarkable fuccefs of La Motte, in a feemingly defpe- 
rate cafe, of a man’s leg mafhed by the wheel of a heavy 
carriage. 

That De La Motte’s patient efcaped, I make no doubt, 
becaufe he has faid fo ; but the furgeon fhewed much 
more rafhnefs in attempting to fave fuch a limb, than he 
would hare done in the amputation of it, the operation 

would 


X 76 ) 

This confideration relative to amputation 
is of the more importance, becaufe it mod 
frequently requires immediate determina¬ 
tion $ every minute of delay is in many in- 
ftances to the patient’s difadvantage, and a 
very fhort fpace of time indeed, frequently 
makes all the difference between probable 
fafety and fatality. If thefe cafes in gene¬ 
ral would admit of deliberation for two or 
three days, and during that time fuch cir- 
cumftances might be expedted to arife, as 
ought neceffarily to determine the furgeon 
in his condudt, without adding to the pa¬ 
tient’s hazard, the difference would be con- 
fiderable ; the former would not feem to be 
fo precipitate in his determination, as he is 
frequently thought to be, and the latter 
being more convinced of the neceflity, 

would 

would have been the more juftifiable pra&ice.—With re¬ 
gard to the baron’s advice, to ftay two or three days, I 
take the liberty to add, that if you do that, ftay feveral 
more; for at the end of that time (I mean two or three 
days) the patient will have very little chance indeed from 
the operation, much left than he would have had at the 
time of the accident. 

I fhould be very forry to be thought a patron or an ad- 
vifer of rafhnefs or cruelty ; but in what I have here faid, 
I believe I fhall have every man in the profellion, who has 
either true humanity or found judgment founded on expe¬ 
rience, on my fide* 


( 77 

would fubmit to it with lefs reluCtancc. 
But unhappily for both parties, this is fel- 
dom the cafe ; and the firft opportunity 
having been negleCted or not embraced, we 
are very frequently denied another. Here 
therefore the whole exertion of a man's 
judgment is required, that he may neither 
raffily and unneceflarily deprive his patient 
of a limb, nor through a falfe tendernefs or 
timidity, fuffer him to perifh, by endea¬ 
vouring to preferve fuch limb. Some de¬ 
gree of addrefs is alfo neceflary upon fuch 
occaiion, in order to convince the patient, 
that what feems to be determined upon ha- 
ftily and with precipitation, will not fafely 
admit of longer deliberation. 

The limb being thought capable of pre- 
fervation, the next confideration is the re¬ 
duction of the fraCture. The eafe or diffi¬ 
culty attending this, depends not only on 
the general nature of the cafe, but on the 
particular diipofition of the bone with re¬ 
gard to the wound. 

If the bone be not protruded forth, the 
trouble of reducing and of placing the 
fraCture in a good pofition, will be much 
lefs, than if the cafe be otherwife; and in 
the cafe of protrufion or thrufting forth of 

the 


( 7 8 ) 

the bone or bones, the difficulty is always 
in proportion to the comparative fize of the 
wound, through which fuch bone has 
paffied. In a compound fraCture of the leg or 
thigh, it is always the upper part of the 
broken bone which is thruft forth. If the 
fra&ure be of the tranfverfe kind, and the 
wound large, a moderate degree of extent 
lion will in general eafily reduce it ; but if 
the fraCture be oblique* and terminates, as 
it often does, in a long ffiarp point, this 
point very often makes its way through a 
wound no larger than juft to permit fuch 
extenfion. In this cafe the very placing 
the leg in a ftraight pofition in order to 
make extenfion, obliges the wound or ori¬ 
fice to gird the bone tight, and makes all 
that part of it, which is out of fuch wound, 
prefs hard on the fkin of the leg under¬ 
neath it. In thefe eircumftances, ajl at¬ 
tempts for reduction in this manner will 
be found to be impracticable ; the more 
the leg is ftretched out, the tighter the 
bone will be begirt by the wound, and 
the more it will prefs on the fkin under¬ 
neath. 

Upon this occafion, it is not very unu- 
fual to have recourfe to the fa\v> and by 
l: z that 


( 79 ) 

that means to remove a portion of the pro¬ 
truded bone. 

I will not fay that this is always or abfo- 
lutely unneceffary or wrong, but it moft 
certainly is frequently fo. In fome few in- 
ftances, and in the cafe of extreme fharp- 
pointednefs of the extremity of the bone, 
it may be, and undoubtedly is right: but 
in many inftances it is totally unneceffary. 

The two moft proper means of overcom¬ 
ing this difficulty, are change of pofture of 
the limb, and enlargement of the wound. 
In many cafes the former of thefe under 
proper conduct will be found fully fufficient, 
and where it fails, the latter fhould always 
be made ufe of. Whoever will attend to 
the effedt, which putting the leg or thigh 
(having a compound fracture and protru¬ 
ded bone) into a ftraight pofition always 
produces ; that is, to the manner in which 
the wound in fuch pofition girds the bone, 
and to the increafed difficulty of reduction 
thereby induced, and will then, by chan¬ 
ging the pofture of fuch limb from an ex¬ 
tended one, to one moderately bent, ob- 
ferve the alteration thereby made, in both 
the juft-mentioned circumftances, will be 
fatisfied of the truth of what I have fiid, 

and 


C 8o ) 

and of the much greater degree of eafe and 
practicability of reduction in the bent, than 
in the extended pofition, that is, in the 
relaxed, than in the ilretched flate of 

the mufcles. Reduction being found im¬ 
practicable, either by extenfion or change 
of pofture, the obvious and neceflary re¬ 
medy for this difficulty is enlargement of 
the wound. This to fome practitioners, 

who have not feen much of this bufinefs, 
appears a difagreeable circumftance, and 

therefore they endeavour to avoid it ; but 
their apprehenfions are in general ground- 
Iefs and -ill-founded, in enlarging the wound 
there is neither difficulty nor danger, it is 
the fkin only which can require divifion, 
and in making fuch wound there can be no 
poffible hazard. It is needlefs to fay that 
the divifion ffiould be fuch as to render re¬ 
duction eafy y or to remind the practitio¬ 
ner, that fuch enlarged opening may ferve 
very good future purpofes, by making way 
for the extraction of fragments, and the 
difcharge of matter, floughs, &c. 

If the bone be broken into feveral pieces, 
and any of them be either totally fepa- 
rated, fo as to lie loofe in the wound, or if 
they be fo loofened and detached as to ren- 
i der 


( 81 ) 

Aer their union highly improbable* all fuch 
pieces ought to be taken away but they 
lliould be removed with all poflible gentle- 
nefs, without pain, violence or laceration, 
without the rifque of haemorrhage, and 
with as little poking into the wound as pof- 
iible. If the extremities of the bone be 
broken into fharp points, which points 
wound and irritate the furrounding parts, 
they mulf be removed alfo. But the whole 
of this part of the treatment of a com¬ 
pound fradture fhould be executed with 
great caution ; and the pradiitioner fhould 
remember, that if the parts furrounding 
the fracture be violated, that is, be torn, 
irritated, and fo difturbed as to excite great 
pain, high inflammation, &c. it is exadtly 
the fame thing to the patient and to the 
event of the cafe, whether fuch violence be 
the neceflary confequence of the fradture, or 
of his unneceflary, and awkward manner of 
poking into and difturbing the wound. The 
great objedts of fear and apprehenfion in a 
compound fradture (that is, in the fir ft or 
early ftate of it) are, pain, irritation and 
inflammation j thefe are to be avoided, pre¬ 
vented, and appeafed by all poflible means, 
let every thing elfe be as it may ; and al- 

G though 


( 82 ) 

though certain things are always recited, 
as neceffary to be done, fuch as removal of 
fragments of bone, of foreign bodies, &c. 
&c. &c. yet it is always to be underftood, 
that fuch afts may be performed without 
prejudicial or great violence, and without 
adding at all to the rifaue or hazard neceffa- 
lily incurred by the difeafe. 

Reduction of or fetting a compound frac¬ 
ture is the fame as in the Ample, that is, 
the intention in both is the fame, viz. by 
means of a proper degree of extenfion to 
obtain as apt a pofition of the ends of the 
fradture with regard to each other, as the 
nature of the cafe will admit, and thereby 
to produce as perfect and as fpeedy union as 

To repeat in this place what has already 
been faid under the head of extenfion would 
be tedious and unneceffary. If the argu¬ 
ments there ufed for making extenfion, with 
the limb fo moderately bent as to relax the 
mufcles, and take off their power of refi- 
ftance, have any force at all, they muff 
have much more, when applied to the pre¬ 
fen t cafe: if it be allowed to be found very 
painful to extend, or to put or keep on the 
Itretch, mufcles which are not at all or but 
*' . flightly 



/ 

( 8 3 ) 

flightly wounded, and only liable in fuch 
extenfion to be pricked and irritated, it is 
felf-evident that it mud: be much more lo 
when the dime parts are torn and wounded 
confiderably; when the ends of thefradlured 
bone have made their way quite through 
them, divided the {kin, and laid all open to 
the accefs of the air. 

Every confluence which does or may be 
fuppofed to flow from wound, pain or irri¬ 
tation, in confequence of violence, muft ne- 
ceflarily be much greater, when a lacerated 
wound, and that made by the bone, is 
added to the fradture ; not to mention the 
ills arifing from extending or firetching out 
mufcles already torn or half divided. 

One moment’s reflection muft be fuffi- 
cient to convince any reafonable man : but 
experience is the only proper teft of all 
thefe kinds of things. Let this method of 
treatment then, be fairly and properly fub- 
jedted to it; and if the great advantage of 
the one over the other does not appear, that 
is, if the lefs fenfation of pain by the pa¬ 
tient, and the more happy, more perfect, 
and more expeditious accomplifhment of 
his purpofe by the furgeon, do not deter¬ 
mine greatly in favour of relaxed pofition, 

G z I am. 


( H ) • 

I am, and have for a confiderable length of 
time been, greatly miftakeh. 

The wound dilated, (if neceffary) loofe 
pieces removed, (if there were any) and the 
frafture reduced, and placed in the beft 
poflible pofition, the next thing to be done 
is to apply a drefling. 

On this fubjedl a great deal has been faid 
by writers, particularly by fuch of them as 
have implicit faith in external applications ; 
but, in order to be able to execute this part 
of the procefs properly, a man has only to afk 
himfelf. What are the intentions which, by 
any kind of drefling to a compound fradture, 
he means to aim at the accomplifhment of ? 
And a rational anfwer to this will give him 
all that he can want to know. 

The dreffing neceflary in a compound 
frafture, is of two kinds, viz. that for the 
wound, and that for the limb. By the for¬ 
mer, we mean to maintain a proper opening 
for the eafy and free difcharge of gleet, 
floughs, matter, extraneous bodies, or frag¬ 
ments of bone, and this in fuch manner, 
and by fuch means, as fhall give the lead 
poflible pain or fatigue, fhall neither irritate 
by its qualities, nor opprefs by its quantity, 
nor by any means contribute to the deten- 
4 tion 


C 85 ) 

tion or lodgment of what ought to be dif- 
charged. By the latter, our aim flhould be 
the prevention or removal of inflammation, 
in order, if the habit be good, and all other 
circumftances fortunate, that the wound 
may be healed, by what the furgeons call 
the firfl: intention, that is, without fuppu- 
ration or ahfcefs; or that not being pradlica- 
ble, that gangrene and mortification, or 
even very large fuppuration may be pre¬ 
vented, and fuch a moderate and kindly de¬ 
gree of it eftablifhed, as may beft ferve the 
purpofe of a cure. The firfl: therefore, or 
the drefiing for the wound, can confift of 
nothing better or indeed fo good, as foft 
dry lint, laid on fo lightly as juft to abforb 
the fanies, but neither to diftend the wound, 
or be the fmalleft impediment or obftrudtion 
to the difcharge of matter. This lint 
fliould be kept clear of the edges, and the 
whole of it fhould be covered with a pied- 
git fpread with a foft eafy digeftive. The 
times of drefling muft be determined by the 
nature of the cafe $ if the difcharge be 
fmall or moderate, once in twenty-four 
hours will be fufficient; but if it be large, 
more frequent drefling will be neceflary, as 
well to prevent offence, as to remedy the 

Q 7 incon- 


( 86 ) 

inconveniences arifing from a great difcharge 
of an irritating (harp fanies. 

The method of treating the limb) witn a 
view to the prevention of fuch accidents 
and fymptoms, as pain, inflammation, and 
laceration of parts are likely to produce, is 
different with different practitioners j (ome 
ufing from the very fi ft, relaxing, greafy 
applications, others applying medicines of 
very different nature. Both thefe may be 
right conditionally, that is, according to 
different circumftances in the cafe, but they 
cannot be equally fo in the fame circum¬ 
ftances. 

l Many pradlitioners are accuftomed to en¬ 
velope compound fradures in a loft, warm 
relaxing cataplafm tom the very firft ; whe¬ 
ther the limb be in a tenfe fwollen ftate or 
not. This, if I may take the liberty of 
faying lb, appears to me to be injudicious. 
When from negled, from length of time 
paffed without affidance, from mifcondud 
or drunkennefs in the patient, from auk- 
wardnefs aud unhandinefs in the affiftants, 
or from any other caufe a tenfion has taken 
pofiefdon of the limb, and it is become tumid, 
fwollen and painful, a warm cataplafm is 
certainly the heft and moft proper applica- 


2 


( 8 7 ) 

tion that can be made, and that for very 
obvious reafons; the ftate of the parts under 
thefe circumftances is fuch, that immediate 
union is impoffible, and nothing but a 
free and plentiful fuppuration can difti- 
pate or remove impending mifchief; every 
thing therefore which can tend toward 
relaxing the tenfe, fwollen, and irritable 
ftate of the parts concerned, mull neceffa- 
rily be right; the one thing aimed at, 
{plentiful fuppuration) cannot be accom- 
plifhed without it. But when the parts 
are not in this ftate, the intention feems to 
be very different. To relax fwollen parts, 
and to appeafe pain and irritation by fuch 
relaxation, is one thing ; to prevent inflam¬ 
matory defluxion and tumefaction is certainly 
another ; and they ought to be aimed at by 
very different means. In the former, a 
large luppuration is a neceffary circumftance 
of relief, and the great means of cure; in 
the latter it is not, and a very moderate de¬ 
gree of it is all that is required. The warm 
cataplafm therefore, although it be the heft 
application that can be made ufe of in the 
one cafe, is certainly not fo proper in the 
other, as applications of a more difcutient 
kind, fuch as mixtures of fpirit. vini, vine- 

G 4 gar 


( 88 ) 

gar and water, with crude fal ammoniac* 
fpirit. Mindereri, acet. litharg. and medi¬ 
cines of this clafs, in whatever form *the 
furgeon may chufe. By thefe, in good ha¬ 
bits, in fortunately circumftanced cafes, and 
with the affiftance of what flhould never be 
negleded, I mean phlebotomy, and the 
general antiphlogifiic regimen, inflamma¬ 
tion may fometimes be kept off, and a cure 
accomplifhed, wdthout large colledions or 
difcharges of matter, or that confiderable 
degree of fuppuration, w 7 hich though- ne- 
ceffary in fome cafes, and almoft unavoi¬ 
dable in others, are and muft be rather pro¬ 
moted and encouraged than retarded or pre¬ 
vented, by warm relaxing applications of 

i L • s 

the pultice kind. 

Compound fradures in general require to 
be dreffed every day, and the wounded 
parts not admitting the fmalleft degree of 
motion wdthout great pain, perfed quietude 
becomes as neceffary as frequent dreffing. 

The commpn bandage therefore (the rol¬ 
ler) has always in this cafe been laid alide, 
and what is called the eighteen-tailed ban¬ 
dage fubftituted, very judicioufly, in its 
place. Of this I have already Ipoken fa 
largely, as to make repetition unneceflary. 

i 4 * 

Splints* 


( 8 9 ) 

Splints, that is, fuch fliort ones as arc 
moft commonly made ufe of in fimple frac¬ 
tures, are by all forbid in the compound, 
and that for the fame reafon which ought 
to have prevented them from having ever 
been ufed in the former, viz. becaufe the 
probable good to be derived from them can 
be but little, and the probable mifchief is 
obvious and confiderable. 

But although fhort fplints are for many 
reafons palpably improper in both cafes, yet 
thofe of proper length, thofe which reach 
from joint to joint, comprehend them both, 
and, applied on each fide of the leg only, 
are very ufeful both in the Ample and 
in the compound fra&ure, as they may, 
thus applied, be made to keep the limb 
more conftantly fteady and quiet, than it 
can be kept without them. 

With regard to pofition of the limb, I 
have already been fo explicit, when fpeak- 
ing of the fimple fra&ure, that to fay any 
thing more about it here would be an abufe 
of the reader’s time and patience. The 
only, or the material difference between a 
fimple and a compound fradture, as far as 
relates to this part of the treatment, is, 
that as the parts furrounding the broken 

bone 


( 9° ) 

bone in the latter are more injured, and 
confequently more liable to irritation, pain, 
inflammation, and all their confequences, 
therefore every method and means, by 
which the alleviation of fuch fymptoms, 
and the prevention of fuch confequences 
can be obtained, is ftill more neceflary and 
requifite. Among thefe the pofture of the 
limb is fo principal a circumftance, that 
without its concurrence every other will be 
fruitlefs. The points to be aimed at are, 
the even pofition of the broken parts of the 
bone, and fuch difpofition of the mufcles 
funounding them, as is mod fuitable to 
their wounded, lacerated ftate, as (hall be 
leaft likely to irritate them, by keeping 
them on the ftretch, or to produce high in¬ 
flammation, and at bell large fuppuration. 
Thele, I fay, are the ends to be purfued ; 
and how much the pofition of the limb 
does, and muft necefiarily contribute to the 
advantage or difadvantage juft recited, muft 
be fo obvious to any body capable of re¬ 
flexion, that nothing more need be faid 
about it. 

At the beginning of thefe fheets, I have 
faid, that it was not my intention to write a 
regular treatife, but only to throw out a few 

hints. 


( 9 * ) 

hints, which I hoped might prove ufeful to 
fuch as have not yet received better infor¬ 
mation. The part of my fubjeCt at which 
I am now arrived, does not indeed admit of 
much more: a few general precepts are all 
which a writer can give ; the particular 
method of conducting each particular cafe, 
muft be determined by the nature of that 
cafe, and by the judgment of the furgeon. 

Every body knows, or ought to know, 
that thefe cafes, of all others, require at 
firft the mod rigid obfervance of the anti¬ 
phlogistic regimen; that pain is to be ap- 
peafed and reft obtained, by anodynes ; that 
inflammation is to be prevented or removed, 
by free and frequent bleeding, by keeping 
the body open, and by the adminiftration 
of fuch medicines as are beft known to 

ferve fuch purpofes.-And that during this 

firft ftate or ftage, the treatment of the 
limb muft be calculated, either for the pre¬ 
vention of inflammatory tumefaction, by 
fuch applications as are in general known 
by the title of difcutients; or, fuch tumor 
and tenfion having already taken poflfefiion 
of the limb, that warm fomentation, and 
relaxing and emollient medicines are re¬ 
quired. 


If 



( 9 2 ) 

If thefe, according to the particular exi¬ 
gence of the cafe, prove fuccefsful, the con- 
fequence is, either a quiet eafy wound, 
which fuppurates very moderately, and 
gives little or no trouble j or a wound, at¬ 
tended at firft with confiderable inflamma¬ 
tion, and that producing large fuppuration 
with great difcharge and troublefome for¬ 
mation and lodgment of matter. If on the 
other hand our attempts do not fucceed, 
the conlequence is gangrene and mortifica¬ 
tion. 

Thefe are the three general events or ter¬ 
minations of a compound fracfture j and 
according to thefe mull the fugeon’s con¬ 
duct be regulated. 

In the firft inftance, he has indeed nothing 
to do but to avoid doing mifchief, either by 
his manner of drefilng, or by difturbing the 
limb. Nature let alone will accomplifh her 
own purpofe ; and art has little more to do 
than to preferve the due pofition of the 
limb, and to take care that the drefiing ap* 
plied to the wound proves no impediment. 

In the fecond ftage, that of formation 
and lodgment of matter, in confequence of 
large fuppuration, all a furgeon’s judgment 
will fometimes be required in the treatment 

both 


( 93 ) 

both of the patient and his injured limb. 
Inlargement of the prefent wound, for the 
more convenient difcharge of matter * % 
new or counter-openings for the fame pur- 
pofe, or for the extra&ion of fragments of 
broken or exfoliated bone, will very fre¬ 
quently be found neceflary, and muft be 
executed. In the doing this, care mull be 
taken that what is requifite be done and no 
more, and that fuch requifite operations be 
performed with as little difturbance and 
pain as pofiible ; the manner of doing bufi- 
nefs of this kind, will make a very material 
difference in the fufferings of the patient. 

Very contrary, or at leaft very different 
intentions, feenl to me to require the fur- 
geon’s very particular attention in the two 
parts of this ftage of the difeafe. 

Previous 

* It is a practice with fome, from a timidity in ufing a 
knife, to make ufe of bolfters and pi after- comprefles for 
the difcharge of lodging matter. Where another, or a 
counter opening can conveniently and fafely be made, it 
is always preferable; the comprefs fometimes acting dia¬ 
metrically oppofite to the intention with which it is ap¬ 
plied, and contributing to the lodgment by confining the 
matter; befide which, it requires a greater degree of pref- 
fure to make it efficacious, than a limb in fuch circum- 
fiances generally can bear. 


( 94 ) 

Previous to large fuppuration, or conflde- 
rable collections and lodgments of matter, tu¬ 
mefaction, induration, and high inflamma¬ 
tion, attended with pain, irritation, and fever, 
require evacuation by phlebotomy, an open 
belly, and antiphlogiftic remedies, as well 
as the free ufe of anodynes, and fuch appli¬ 
cations to the limb as may molt ferve the 
purpofe of relaxation. But the matter ha¬ 
ving been formed and let out, and the pain, 
fever. See. which were fymptomatic there¬ 
of, having difappeared or ceafed, the ufe 
and purpofe of fuch medicines and fuch 
applications ceafes alfo, and they ought 
therefore to be difeontinued. By evacuation, 
&c. the patient’s Arength has neceflarily 
(and indeed properly) been reduced; by ca^ 
taplafm, &c. the parts have been fo relaxed 
as to procure an abatement or ceflation of 
inflammation, a fubfidence of tumefaction, 
and the eAablijhment of a free fuppura- 
tion; but thefe ends once fairly and fully 
anfwered, another intention arifes, which 
regards the fafety and well doing of the pa¬ 
tient, nearly, if not full as much as the 
former, which intention will be neceflarily 
fruArated by purfuing the method hitherto 
followed. The patient now will require 

refeCtion 


( 95 . ) 

rcfe&ian and fupport, as much as he before 
flood in need of reduction ; and the limb, 
whofe indurated and inflamed (late hitherto 
required the emollient and relaxing pul- 
tice, will now be hurt by fuch kind of ap¬ 
plication, and ftand in need of fuch as are 
endued with contrary qualities, or at leafl: 
fuch as fhall not continue to relax. Good 
light eafiiy digefted nutriment, and the Pe- 
* ruvian bark, will befl: anfwer the purpofe of 
internals; the difcontinuation of the cata- 
plafms, and the application of medicines of 
the corroborating kind, are as neceflary with 
regard to externals 

In fhort, if there be any rationale in the 
ufe of the cataplafm in the firfl: ftage, its 
impropriety in the fecond niuft be evident 
from the fame principles. So alfo with re-^ 
gard to evacuation, and the antiphlogiflic 

regimen, 

» 

* It is furprifing how large and how difagreeable a dis¬ 
charge will be made for a confiderable length of time, in 
fome inftances, from the detention and irritation of a 
Splinter of bone If therefore fuch difcharge be made, 
and there be neither fin us nor lodgment to account for it, 
and all other circumftances are favourable, examination 
fhould always be made, in order to know whether fuch 
caufe does not exift, and if it does, it mull be gently and 
carefully removed. 


( 9 6 ) 


regimen, when all the good propofed to be 
obtained by them has been received, a pur* 
fuit of the fame method mull become in* 
jurious, and that for the fame reafon why 
it was before neceflary and beneficial. 

A non-attention to this, has, I believe, 
been not infrequently the caufe of the lofs 
both of limbs and lives. 

Every body who is acquainted with fur- 
gery knows, that in the cafe of bad com¬ 
pound fra&ure, attended with large fuppu- 
ration, it fometimes happens, even under 
the beft and moft judicious treatment, that 
the difcharge becomes too great for the pa¬ 
tient to fuftain, and that after all the fa¬ 
tigue, pain and difcipline, which he has 
undergone, it becomes neceifary to com¬ 
pound for life by the lofs of the limb 
This, I fay, does fometimes happen under 
the beft and moft rational treatment; but I 

am 

* There is one circumftance relative to compound frac¬ 
tures, which perhaps may be deemed worth noting j 
which is, that 1 do not remember ever to have feen it 
neceflary to amputate a limb for a compound fra&ure, on 
account of the too great difcharge, in which the fra&ure 
had been united. In all thofe cafes, where the operation 
has been found neceflary on account of the drain, the 
fracture has always been perfetfly loofe and difunited. 


( 97 ) 

am convinced that it alfo is now and then 
the confequence of purfuing the reducing, 
the antiphlogiflic, and the relaxing plan too 
far. I would therefore take the liberty fe- 
rioufly to advife the young pra&itioner, to 
attend diligently to his patient’s pulfe and 
general ftate, as well as to that of his frac¬ 
tured limb and wound ; and when he finds 
all febrile complaint at an end, and all in¬ 
flammatory tumor and hardnefs gone, that 
his patient is rather languid than feverifb* 
that his pulfe is rather weak and low than 
hard and full, that his appetite begins to 
fail, and that he is inclined to fweat or 
purge without aflignable caufe, and this in 
confequence of a large difeharge of matter 
from a limb which has fuffered great in- 

i 

flammation, but which is now become ra¬ 
ther foft and flabby than hard and tumid, 
that he will in fuch circumftances fet about 

the fupport of his patient, and the flreng- 

> 

thening of the difeafed limb tot is mribus % 
in which I am from experience fatisfied, he 
may often be fuccefsful, where it may not 
be generally expected that he would. At 
leaft he will have the fatisfadion of having 
made a rational attempt ; and if he is 

H obliged 


( 98 ) 

obliged at laft to have recourfe to amputa¬ 
tion, he will perform it, and his patient 
will fubmit to it with 1&| reluctance, than 
if no fuch trial had been^iade. 

I have faid, that a compound fraCture 
either unites and heals as it were by the nrft 
intention, which is the cafe of fome of the 
lucky few, (and was my own ;) or it is at¬ 
tended with, high inflammation, multiplied 
abfcefies and large fuppuration, demanding 
all a furgeon’s attention and {kill ; and even 
then fometimes ending in the lofs of limb 
or life, or both ; or, that all our attempts 
prove fruitlefs from the firft, and gangrene 
and mortification are the inevitable confe- 
quence of the accident. 

The two firft I have already fpoken to, 
the laft onlv remains. 

Gangrene and mortification are fometimes 
the inevitable confequences of the mifchief 
done to the limb at the time that the bone 
is broken ; or they are the confequences of 
the laceration of parts made by the mere 
protrufion of the faid bone. 

They are alfo fo£ietirnes the efifeCt of im¬ 
proper or negligent treatment; of great vio¬ 
lence ufed in making extenfion j of irrita¬ 
tion 


( 99 ) , • 

lion of the wounded parts, by poking after 
or in removing fragments or fplinters of 
bone ; of painful "dreffings ; of improper 
difpofition of the limb* and of the negledt 
of phlebotomy, anodynes* evacuation, &c. 
Any, or all thefe are capable either of in¬ 
ducing fuch a ftate of inflammation as 
fhall end in a gangrene, or of permitting 
the inflammation neceflarily attendant upon 
fuch accident, to terminate in the fame 
event. 

When fuch accident or fuch difeafe is 
the mere confequence of the injury done to 
the limb, either at the time of or by the 
frafture, it generally makes its appearance 
very early; in which cafe alfo* its progrefs 
is generally too rapid for art to check. For 
thefe reafons, when the mifchief feems to 
be of fuch nature as that gangrene and 
mortification are moft likely to enfue, no 
time can be fpared, and the impending mif¬ 
chief muft either be fubmitted to or pre¬ 
vented by early amputation. I have already 
faid, that a very few hours make all the 
difference between probable fafety and de- 
ftrudtion. If we wait till the difeafe has 
jtaken poffeffion of the limb, even in the 

H z fmalleft 


( 100 ) 

fm all eft degree, the operation will ferve no 
p-urpofe, but that of accelerating the pa¬ 
tient’s death. If we wait for an apparent 
alteration in the part, we fhall have waited 
until all opportunity of being really fer- 
viceable is paft. The difeafe takes poffeffion 
of the cellular membrane furrounding the 
large blood vefiels and nerves fome time be¬ 
fore it makes any appearance in the integu¬ 
ments, and will always be found to extend 
much higher in the former part, than its 
appearance in the latter feems to indicate. • 
I have more than once feen the experiment 
made of amputating, after a gangrene has 
been begun, but I never faw it fucceed, it 
has always haftened the patient’s deftruc- 
tion. 

As far therefore as my experience will 
enable me to - judge, or as I may from 
thence be permitted to dictate, I would 
advife that fuch attempt fhould never be 
made ^ but the firft opportunity having been 
negledied or not embraced, all the power 
of the chirurgic art is to be employed in 
affifting nature to feparate the difeafed part 
from the found; an attempt which now 
and then, under particular circumftances, 

- i , has 


/ 


( 101 ) 

fias proved fuccefsful, but which is fo rarely 
£o, as not to be much depended upon. 

If the parts are fo bruifed and torn, that 
the circulation through them is rendered 
impra&icable, or if the gangrene is the im¬ 
mediate efred of fuch mifchief, the confe- 
quence of omitting amputation, and of at¬ 
tempting to fave the limb is, as I have al¬ 
ready obferved, mod; frequently very early 
deftrudion ; but if the gangrenous mif¬ 
chief be not merely and immediately the 
effed of the wounded date of the parts, 
but of high inflammation, badnefs of ge¬ 
neral habit, improper difpofition of the 
limb, &c. it is fometimes in our power fo 
to alleviate, corred, and alter thefe caufes, 
as to obtain a truce with the difeafe, and a 
feparation of the unfound parts from the 
found. The means whereby to accomplifli 
this end mud, in the nature of things, be 
varied according to the producing caufes or 
circumftances : the fanguine and bilious 
muft be lowered and emptied ; the weak 
and debilitated mufi; be aflifted by fuch me¬ 
dicines as will add force to the vis vitas; 
and errors in the treatment of the wound 
or fradure mud; be corrected j but it is evi- 

II 3 dent 


( 102 ) 

dent to common fenfe, that for thefe there 
is no poffibility of prefcribing any other 
than very generalrules indeed. The na¬ 
ture and circumdances of each individual 
cafe mud determine the practitioner s con- 
duCt, 

In general, inflammation will require 
phlebotomy and an open belly, together 
with the neutral antiphlogistic medicines, 
pain and irritation will dand in need of 
anodynes, and the Peruvian bark, joined in 
fome cafes and at fome times with thofe of 
the cooling kind, at others with the cor¬ 
dial, will be found neceffary and ufeful. So 
alfo tenfion and induration will point out 
the ufe of fomentation and warm relaxing 
cataplafms, and the mod foft and lenient 
treatment and dreffing. But there are two 
parts of the treatment of this kind of cafe 
mentioned by the generality of writers, 
which I cannot think of as they feem to 
have done. One is the ufe of dimulating 
antifeptic applications to the wound ; the 
other is, what is commonly called fcarifica- 
tion of the limb. (Let it be remarked, 
that I fpeak of both thefe, as prefcribed 
^nd pradtifed while the gangrene is forming, 

as 


( i°3 ;.) 

as it were, and the parts are by no means 
mortified.) While the inflammatory ten- 
fion fubfifls, alleviation of pain, and relaxa¬ 
tion of the wounded and fwollen parts, in 
order to obtain a fuppuration, and confe- 
quently a feparation, feem to conftitute the 
intention, which ought to be purfued upon 
the moft rational principles : warm irrita¬ 
ting tinctures of myrrh, aloes and euphor- 
bium ; mixtures of tin<£t. myrrh, with mel 
iEgyptiac. and fuch kind of medicines, 
which are found to be frequently ordered, 
and indeed are frequently ufed, particularly 
in compound fradtures produced by gun- 
fhot, feem to me to be very oppofite to 
fuch intention, and very little likely to pro¬ 
duce or to contribute to the one thing 
which ought to be aimed at, I mean the 
eftablifliment of a kindly fuppuration. I 
know what is iaid, in anfwer to this, viz. 
that fuch kind of ffimulus affifits nature in 
throwing off* the difeafed parts : but this is 
a kind of language, which I believe will be 
found upon examination to have been firfl 
ufed without any lufficient or good ground, 
and to have been echoed ever fince upon 
truft. It had its foundation in the opinion 

H 4 . ‘ ; that 


, ( I0 4 ) 

that gunlhot wounds were poifonous, and 
that the mortification in them was the ef¬ 
fect of fire* and it has been continued ever 
fince, to the great detriment of many a 
fufferer, A gunfhot wound, whether with 
or without fradture, is a wound accompa¬ 
nied with the higheft degree of contufion, 
and with feme degree of laceration, and 
every greatly contufed and lacerated wound 
requires the fame kind of treatment, which 
a gunfhot wound does, as far as regards-the 
foft parts. The intention in both ought to 
be to appeafe pain, irritation, and inflam¬ 
mation, to relax the indurated, and to un¬ 
load the fwollen parts, and by fuch means 
to procure a kindly fuppuration, the confe- 
quence of which mufl be, a feparation of 
the difeafed parts from the found. Now 
whether this is likely to be befl: and fooneft 
accomplifhed by fuch dreflings and fuch 
applications as heat and Simulate, and 
render the parts to which they are applied 
crifp and rigid, may fairly be left to com¬ 
mon fenfe to determine. 

Scarification, in the manner, and at the 
time in which it is generally ordered and 
performed, has never appeared to me to 

have 


i 


( 10 5 ) 

have ferved any one good purpofe. When 
the parts are really mortified, incifions made 
of fufficient depth will give difcharge to a 
quantity of acrid and offenfive ichor ; will 
let out the confined air, which is the effect 
of putrefaction, and thereby will contribute 
to unloading the whole limb; and they 
will alfo make way for the application of 
proper dreffings.——But while a gangrene 
is impending, that is, while the parts are 
in the highefl fiate of inflammation, what 
the benefit can be which is fuppofed or ex¬ 
pected to proceed from fcratching the fur- 
face of the fkin with a lancet, I never could 
imagine; nor though I have often feen 

it praCtifed, do I remember ever to have 
feen any real benefit from it. If the fkin 
be ftill found and of quick fenfation, the 
fcratching it in this fuperficial manner is 
painful, and adds to the inflamed ftate of 
it; if it be not found, but quite altered, 
fuch fuperficial incifion can do no pofiible 
fervice; both the fanies and the imprifoned 
air are beneath the membrana adipofa, and 
merely fcratching the fkin in the fuperficial 
manner in which it is generally done, will 
not reach to, or difcharge either. 

From 


i 



( io6 ) 

From what has been faid, it will appear, 
that there are three points of time, or three 
ftages of a bad compound fra&ure, in which 
amputation of the limb may be neceftary 
&iright, and thefe three points of time 
are fo limited, that a good deal of the ha T 
zard or fafety of the operation depends on 
the obfervance or non-obfervance of them. 

The firft is immediately after the acci¬ 
dent, before inflammation has taken pof- 
feflion of the parts. If this opportunity be 
neglected or not embraced, the confequence 
is either a gangrene or a large fuppuration 
with formation and lodgment of matter. If 
the former of thefe be the cafe, the opera¬ 
tion ought never to be thought of, till there 
is a perfect and abfolute feparation of the 
mortified parts. If the latter, no man can 
poffibly propofe the removal of a limb, un¬ 
til it be found by fufficient trial, that there 
is no profpecft of obtaining a cure without, 
and that by not performing the operation, 
the patient's ftrength and life will be ex- 
haufted by the difcharge. When this be¬ 
comes the hazard, the fooner amputation is 
performed the better. In the firft inftance, 
the operation ought to take place before 

inflam- 


( ) 

inflammatory mifchief is incurred; in the 
fecond we are to wait for a kind of crifis of 
fuch inflammation ; in the third, the pro¬ 
portional ftrength and ftate of the patient, 
compared with the difeharge and the ftate of 
the fra&ure, mull form our determination. 


( io8 ) 



Of Dislocations in general. 

r | ^HE principle inculcated fo frequently 
1 . in fome of the foregoing pages, con¬ 
cerning the extended or relaxed, that is, 
the refiftent or non-rehftent ftate of the 
mufcles, as depending on the pofition of 
the limb, may be applied with equal truth 
and equal advantage to diflocations, as to 
fraftures. Neither of them can indeed be 
rightly underftood or judicioufly treated 
without fuch confideration. In both a per¬ 
fect knowledge of the difpofition, force, 
attachments and ufes of the mufcles, at 
leafl: thofe of the limbs, are abfolutely and 
indifpenfably necelfary ; and if the young 
ftudents would be careful in attending to 
the plain and obvious parts of anatomy; if 
they would with their own hands diffedl the 
mufcles, tendons, blood-veffels and nerves; 
if they would examine minutely the ftruc- 
ture, difpofitions and connexions of all the 

parts 






( 109 ) 

parts which form the various joints, with 
their ligaments, and attend to the effedts 
which the adtions of the mufcles and ten¬ 
dons connected therewith muft neceffarily 
have on them, they would have much more 
precife and adequate ideas of luxations* 
than many of them have ; they would have 
ideas of their own, not taken upon truft 
from writers, who have for ages done little 
more than copy each other, and they would 
adt with much more fatisfaclion to them- 
felves. 

By what our forefathers have faid on the 
fubjedt of luxations, and by the defcriptions 
and figures which they have left us of the 
means they ufed, of what they call their 
organa and machinemata, it is plain that 
force was their objedt, and that whatever 
purpofes were aimed at or executed by thefe 
inftruments or machines, were aimed at and 
executed principally by violence. 

Many, or moft of them indeed, are much 
more calculated to pull a man’s joints afun- 
der, than to fet them to rights. I will not 
go fo far as to fay, that they are all equally 
bad or improper; but I will venture to af¬ 
firm, that hardly any of them are fo con¬ 
trived as to execute the purpofe for which 

they 


( 116 ) 

they fhould be ufed, in the manner moft 
agreeable, or moft adapted to the nature or 
mechanifm of the parts on which they are 
to operate, or to accomplilh fuch purpofe in 
the moft eafy and moft practicable manner, 
and confequently, as I have already faid, they 
adt by force principally. 

Nor is that all forne of them labour un¬ 
der another defeCt, and that capable of pro¬ 
ducing great mifchief; which is, that the 
force or power of the inftrument is not 
always determinable, as to degree, by the 
operator, and confequently may do too little 
or too much, according to different cir- 
cumftances in the cafe, or more or lefs cau¬ 
tion or ralhnefs in the furgeon. 

I know very well that many of thefe are 
now laid afide, and that fome few have 
been fo altered, as to become ufeful ; but 
ftill the fame kind of principle, on which 
thefe inftruments were originally founded 
and conftru&ed, very generally prevails, and 
violence is ufed, to the great fatigue, pain, 
and inconvenience of the patient, in many 
cafes, in which dexterity, joined to a 
knowledge of the parts, would execute the 
fame purpofe with facility and eafe, 

.. In 


( III ) 

In diflocations, as in fradtures, our great 

attention ought to be paid to the mufcles 

belonging to the part affedted. Thefe are 

the moving powers, and by thefe the joints 

as well as other moveable parts are put into 
* 

adtion : while the parts to be moved are in 
right order and difpofition, their adtions 
will be regular and jull, and generally de¬ 
terminable by the will of the agent, (at 
leaft in what are called voluntary motions ); 
but when the faid parts are difturbed from 
that order and difpofition, the adtion or 
power of the mufcles does not therefore 
ceafe, far from it, they ftill continue to ex¬ 
ert themfelves occafionally, but inftead of 
producing regular motions, at the will of 
the agent, they - pull and diftort the parts 
they are attached to, and which by being 
difplaced cannot perforin the fundtions for 
which they were defigned. 

From hence, and from hence principally, 
arife the trouble and difficulty which attend 
the redudtion of luxated joints. The mere 
bones compofing the articulations, or the 
mere connedting ligaments, would in general 
afford very little opposition, and the repla¬ 
cing the diflocation would require very lit¬ 
tle trouble or force, was it not for the re¬ 
finance 


i 


( 112 ) 

finance of the mufcles and tendons attached 
to and connected with them: for by exa¬ 
mining the frefh joints of the human body* 
we (hall find that they not only are all mo¬ 
ved by mufcles and tendons* but alfo, that 
although what are called the ligaments of 
the joints do really conned: and hold them 
together, in fuch manner as could not well 
be executed without them, yet, in many 
inftances they are, when ftript of all con¬ 
nexion, fo very weak and lax, and fo dila¬ 
table and diftradile, that they do little 
more than conned the bones and retain the 
fynovia; and that the ftrength as well as 
the motion of the joints, depends in great 
meafure on the mufcles and tendons con¬ 
nected with and pafiing over them; and 

/ ■ ' V 

this in thofe articulations which are de- 
figned for the greateft quantity, as well as 
the celerity of motion. Hence it mu ft fol¬ 
low 7 , that as the figure, mobility, adion, 
and ftrength of the principal joints de¬ 
pend fo much more on the mufcles and 
tendons in connexion with them, than on 
their mere ligaments; that the former are 
the parts which require our firft and grea- 
teft regard, thefe being the parts which 
will neceflarily oppofe us in our attempts 

for 


( n 3 ) 

for reduction, and whofe refinance muft be 
either eluded or overcome : terms of very 
different import, and which every pra&f- 
tioner ought to be well apprifed of. 

From the fame examination is to be 
obtained a kind and degree of very ufe- 
ful information, which the fkeleton can¬ 
not afford. I mean an acquaintance with 

i 

the ligaments themfelves both external and 
internal, the cartilages both fixed and move- 
able, and the parts furnifhing what is called 
the fynovia. 

This to thofe who are perfectly acquain¬ 
ted with the fubjedt, may feem too obvious 
to have needed mention ; but no one who 
has not examined the joints can poffibly 
have this kind of neceffary knowledge, and 
I am convinced that there are many practi¬ 
tioners who have no idea of articulations, 
but what the affemblage of dry bones has 
furnifhed them, and which muft be very 
inadequate. 

I have neither leifure nor inclination at 
prefent to enter into this matter minutely, 
or indeed as it deferves ; befide which, I 
have, I fear, fufficiently exercifed my rea¬ 
ders patience already in the foregoing (beets. 

I 1 I will 


> ( i14 ) 

I will therefore detain him no longer than 
while I mention a few leading principles 
relative to luxations in general, drawn from 
the ftrudture of the parts concerned, and 
which appear to me to be applicable with 
very little, if any variation, to every particu¬ 
lar fpecies. 

1. Although a joint may have been luxated 
by means of considerable violence, it does 
by no means follow, that the fame degree 
of violence is neceffary for its reduction. 

2. When a joint has been luxated, at 
lead: one of the bones of which it is cotn- 
pofed, is detained in that its unnatural fitu- 
ation, by the adtion of fome of the mufeu- 
lar parts in connexion with it; which ac¬ 
tion by the immobility of the joint, be¬ 
comes, as it were, tonic, and is not under 
the direction of the will of the patient. 

3. That the mere burfal ligaments of 
fome of the joints endued with great mo¬ 
bility are weak, diftradlile, and condant- 
ly moiflened; that for thefe reafons they 
are capable of differing condderable vio¬ 
lence without being lacerated ; but that 
they are alfo fometimes mod: certainly 
torn. 


4.’ That 


( H5 ) 

4. That did the laceration of the faid li¬ 
gaments happen much more frequently 
than I believe it does, yet it cannot be a 
matter of very great confequence, as it nei¬ 
ther totally prevents reduction, when time- 
ly and properly attempted, nor a confequent 
cure ** 

That 

'* In the accident of a diflocated tibia, from a broken 
fibula, the ftrong, inelaftic, tendinous ligaments, which 
fatten the end of the former bone to the aftragalus and os 
calcis, are frequently torn ; and as thefe by proper care 
aimofl always do well and recover all their ftrength, there 
is the greateft reafon to expert, that the more weak, di- 
ftraCtile ones do the fame. The only mifchief which 
feems moft likely to follow from a laceration of the latter, 
is from an effufion of the fynovia ; of which, I think I 
have (in a bad habit) feen an inftance in the joint of the 
ancle. That the laceration of the burfal ligament of the 
(houlder cannot be a frequent or general impediment to re¬ 
duction appears to me, from my never having in more 
than twenty years care of an hofpital, met with a fingle 
inftance of its impracticability, when attempted in 
time. 

S\ 

For it can hardly be fuppofed, that fuch kind of acci¬ 
dent fhould never have fallen to my lot, or to the people 
who have aCted under me. 

But even if this could be fuppofed, I can alfo fay, that 
I do not remember impoflibility of reduction to have 

2 2 , happened 


( 1 ‘ 6 ) 

5. That fuppofing fach accident ta be 
frequent, yet as it is impoflible to know, 
with any kind of certainty, whether it has 
happened or not, or in what part of the liga¬ 
ment, it cannqt be admitted as a rule for 
our condudf, nor ought fuch mere conjec¬ 
ture to produce any deviation from what we 
ought to do, were there no fuch fuppoli- 
tion. Could we know with certainty when 
and where this had happened, very ufeful 
information might indeed be drawn from 
it. 

6. That all the force ufed in reducing a 
luxated bone, be it more or lefs, be it by. 
hands, towels, ligatures or machines, ought 
always to be applied to the other extremity 
of the faid bone, and as much as poffible 
to that only. 

In every joint capable of diflocation, the 
fame circumftance which renders it liable to 
be difplaeed, is alfo a very coniiderable affi- 
ftance in its reduction. I mean the dilata- 
bility or diftra&ile power of the ligaments, 
their capacity of giving way when ftretched 
or pulled at. 

This- 

happened to any of the other gentlemen of the houfe, 
tinder the fame circumftances. 


( ri 7 ) 

This is perhaps the ftrongeft argument 
which can be produced, why all the force 
made ufe of in reducing a diflocated joint 
fhould be applied to that bone only, and 
not to the next. By the yielding nature of 
the ligaments of the luxated joint, reduction 
is to be accomplifhed. The ligaments of 
the other articulation, which is not luxated 
are yielding alfo ; and all the force which 
is applied to the bone below or adjoining, 
tnuft necefiarily be loft in the articulation 
which is not luxated, and can be of little 
or no fervice in that which is. 

Let this principle be applied to the diflo- 
cation of the joint Gf the fhoulder, and it 
will fhew us why the ambi, in which the 
whole arm is tied down, and fubje£ted to 
the extending power of the faid inftrument, 
is defective, and may be pernicious. Why 
inftruments built on the fame general prin¬ 
ciple, but in which the fore-arm is not 
faftened down, but left at liberty and not 
lubjecfted to the ligature, execute their pur¬ 
pose with a great deal lefs torce. Why the 
vulgar but frequently very fuccefsful me¬ 
thod of reducing this joint, by placing the 
operator’s heel in the axilla of the fupine 
patient, fometimes fails, the furgeon not 

/ 3 having 


( ”8 ) 

having proper afMance, and contenting 
himfelf with pulling at the patient’s wrift 
only. It will alfo fhew us, why in the cafe 
of a luxated os femoris at the joint of the 
hip, the flrength of five or fix people di^ 
vided between the joint of the knee arid 
that of the ancle, fliall be infufficient, and 
that of four, nay three of the fame affi- 
Hants Shall in the fame cafe prove fufficient, 
by being all, and properly applied to the 
knee and femur only, as I have more than 
once feen. 

Many other applications of this principle 
might be made, but thefe are fufficient to 
thofe who understand the principle itfelf 
and fee its force. 

7. That in the reduction of fuch joints, 
as are compofed of a round head, received 
into a focket, fuch as thofe of the fhoulder 
and hip, the whole body Should be kept ~as 
Heady as pofiible, for the fame reafon as in 
the foregoing. 

8. That in order to make ufe of an ex^ 
tending force with all poffible advantage, 
and to excite thereby the lead: pain and in¬ 
convenience, it is necefiary that all parts 
Serving to the motion of the diflocated joint, 
Or in any degree eonne&ed with it, be put 

' into 



( 1 r 9 ) 

into fuch a ftate as to give the fmallefl poffi- 
ble degree of refinance. 

This I take to be the firjft and great prin¬ 
ciple by which a furgeon ought to regulate 
his conduct in reducing luxations. This 
will £hew us why a knowledge of all the 
mufcular and tendinous parts, acting upon, 
or in connexion with the articulations, is 
abfolutely neceffary for him who would do 
his bufinefs fcientifically, with fatisfadtioa 
to himfelf or with eafe to his patient. It 
will fhew us, that the mere pofition of 
the limb below the luxated joint, is what 
muft either relax or make tenfe the parts in 
connexion w ? ith that joint, and confequent- 
ly that pofture is more than half of the bu¬ 
finefs. It will fhew us, why fome times 
the luxated os humeri flips in, as it were, 
of its own accord, by merely changing the 
pofition of the arm, when very violent at¬ 
tempts, previous to this, have proved fuc- 
cefslefs. It will fhew us why extending the 
arm in a ftraight line horizontally, or fo as 
to make a right angle with the body, mufl 
in fome inftances, render all moderate at¬ 
tempts fruitlefs. Why the method of at¬ 
tempting reduction by the heel in the axilla 
is fo often fuccefsful, notwithflanding two 

/ 4 very 


( 120 )) 

very confiderable di fad vantages under which 
it labours, viz. part of the force being loft 
in the elbow, and the tenfe ftate of one 
head of the biceps cubiti. Why the tying 
down the fore-arm in the common ambi is 
wrong, for the fame reafons. Why the 
fore-arm fhould at all times (let the method 
of reduction be what it may) be bent, viz. 
becaufe of the refiftance of the long head 
of the biceps in an extended pofture. Why 
when the os humeri is luxated forward, or 
fo that its head lies under the great pectoral 
mufcle, the carrying the extended arm 
backward, fo as to put that mufcle on the 
ftretch, renders the reduction very difficult, 
and why, on the contrary, the bringing the 
arm forward, fo as to relax the faid muf¬ 
cle, removes that difficulty, and renders re¬ 
duction eafy. Why the reduction of a luxa¬ 
ted elbow, fhould always be attempted by 
bending the faid joint. Why, when the 
inner ancle is diflocated in confequence of 
a fracture of the fibula, it is extremely dif¬ 
ficult at all times, and fometimes impracti¬ 
cable, either to reduce or to keep reduced* 
the faid joint, while the leg is in an exten-. 
ded pofture ; and why a bent pofture of the 
leg enables us with cafe to accompliih both 

thofe 


( 121 ) 

thofe ends. Why in the cafe of difloeation 
of the head of the os femoris, (be it in 
what manner it may) a ftraight pofition of 
the leg and thigh, will always increafe’the 
difficulty of reduction ; and why that very 
diftorted and bent difpofition, in which the 
patient will always place it for his own eafe, 
is, and muft be the pofture moft favourable 
for redudion; becaufe it is and muft be 
that pofture in which the mufcles, moft like¬ 
ly to make oppofition, are moft relaxed and 
rendered leaft capable of refiftance 

9. That in the redudion of fuch joints 
as confift of a round head, moving in an 
acetabulum or focket, no attempt ought to 
be made for replacing the faid head, until 

it 

* In the attempts for reduction of a luxated hip, there 
is one circumflance, which by being overlooked or not 
attended to, has more than once rendered every effort 
vain. 

It is ufual and indeed neeefiary to tie down and confine 
the patient on a bed or table, in order to keep his body 
firm and fteady; one part of the bandage or trapping by 
which he is confined is fixed in the groin, and paffing over 
his belly and under his buttock, is faftened above or ra¬ 
ther beyond his head to fomething immoveable. If this 
bandage be placed (as I have feen it) in the groin on the 
fide of the luxated bone, it will prove fo far from being 
afiiflant, that it will neceffarily fruftrate every attempt. 


( 122 ) 

it has by extenfion been brought forth from 
the place where it is, and nearly to a level 
with the faid focket. 

This will (hew us another fault in the 
common ambi, and why that kind of ambi, 
which Mr. Freke. called his commander, is 
a much better inftrument than any of them, 
or indeed than all ; becaufe it is a lever 
joined to an extenfor > and that capable of 
being ufed with the arm, in fuch pofition 
as to require the leaft extenfion, and to ad¬ 
mit the mod: ; befide which it is graduated, 
and therefore perfectly under the dominion 
of the operator. 

It will fhew us, why the old method by 
the door or ladder, fometimes produced a 
fradure of the neck of the fcapula 5 as I 
have feen it do in our own time. 

Why if a fufficient degree of extenfion 
be not made, the towel over the furgeon’s 
Ihoulder, and under the patient’s axilla, 
muft prove an impediment rather than an 
affiftance, by thrufling the head of the hu¬ 
merus under the neck of the lcapula, in- 
ftead of direding it into its focket. 

Why the bar or rolling-pin under the 
axilla produce the fame effed* 

3 Why 


( 123 ) 

Why the common method of bending 
the arm (that is, the os humeri) downward, 
before fufficient extenfion has been made, 
prevents the very thing aimed at •, by pufh- 
ing the head of the bone under the fcapula, 
which the continuation of the extenfion for 
a few feconds only would have carried into 
its proper place. 

I know it is faid, that mere extenfion 
only draws the head of the bone out from 
the axilla, in which it was lodged, but does 
not replace it in the acetabulum fcapulae. 
To which I will venture to anfwer, that 
when the head of the os humeri is drawn 
forth from the axilla, and brought to a le¬ 
vel with the cup of the fcapula, it muft be 
a very great and very unneceflary addition 
of extending force, that will or can keep it 
from going into it. All that the furgeon 
has to do, is to bring it to fuch level ; the 
mufcles attached to the bone will do the 
reft for him, and that whether he will or 
not. 

Indeed if all the rational means and me¬ 
thods for reducing a luxated fhoulder be 
examined, they will be found to adt upon 
this principle, however differently this mat¬ 
ter may appear to thofe who have not attend¬ 
ed 


( m ) 

cd to i U Even the common ambi fucceeds 
by means of the extenfion, which the car¬ 
rying the arm down with it produces, and 
not by its lever. That part of the inftru- 
ment fb far from helping, is often a confi- 
derable hindrance, and even fometimes 
fruftrates the operator's intention, by pufh- 
ing the head of the bone againft the fcapu- 
la, before it is fufficiently drawn out from 
the axilla. 

If it was neceffary to add any thing in 
fupport of this aodtrine, I fhould fay, that 
the fuppofition of laceration of the burfal 
ligament, being a circumftance frequently 
attending this luxation, and proving an inir- 
ped-iment to reduction, is a flxong induce¬ 
ment to us to be always attentive to the 
making fuch extenfion, it being much more 
likely that the head of the bone fhould re¬ 
turn back by the fame rent in the ligament, 
when fueh ligament is moderately ftretched 
out, than when it may be fuppofed to lie 
wrinkled or in folds. 

10. The lafi: principle which I fhall take 
the liberty to mention, and which I would 
inculcate very ferioufiy is, that whatever 
kind or degree of force may be found necef¬ 
fary for the reduction of a luxated joint, 


( 125 D 

that fuch force be employed gradually$ that 
the leifer degree be always firffctfied, and 
that it be increafed gradatirH*. • ' 1 * 

Whoever reflects on what is intended by 
extenfion, what the parts are whieli refill 
and how that refiftance may be 'beft -over-¬ 
come, will want little argument to induce 
him to accede to this principle; the advan¬ 
tages deducible from attending to it, and the 
difadvantages which may and do follow the 
negleCt of it, are fo obvious. 

They who have not made the experiment 
will not believe to how great a degree a 
gradually increafed extenfion may be carried 
without any injury to the parts extended ; 
whereas great force, exerted hafiily, is pro¬ 
ductive of viry Terrible \and* very lading 
mifchief. 

I know that the vis percuffionis, as it is 
called, has been recommended, as having 
been fuccefsful in fome difficult luxations ; 
but I have feen fuch bad confequences from 
it, that I cannot help bearing my teftimony 
againft it. The extenfile and diftraCtile 
quality of the membranes, mufcles and li¬ 
gaments, enables them to bear the applica¬ 
tion of very great force to them, without 
hurt if fuch force be applied gradually, 

and 


2 


I T2d ) 

and proper time be allowed for the parts to 
give way in j but great force, fuddenly ap¬ 
plied, is capable of producing the moll mif- 
chievous confequences $ and that in many 
other parts of furgery, befide what relates 
to luxations*