SURGERY

S U R G E R Y.

SURGERY, a branch of medicine, including the knowledge of all those diseases wherein the application of the hand is necessary, whether such diseases are occasioned by external injuries, or take their rise

from internal causes, with the method of performing all manual operations which may be necessary in such cases.

PART I. HISTORY OF SURGERY.

THAT surgery was coeval with the other branches of medicine, or perhaps antecedent to any of them, will not admit of doubt. The wars and contentions which have taken place among mankind almost ever since their creation, necessarily imply that there would be occasion for surgeons at a very early period; and probably these external injuries would for some time be the only diseases for which a cure would be attempted, or perhaps thought practicable.—In the sacred writings we find much mention of balsams, particularly the balm of Gilead, as excellent in the cure of wounds: though at the same time we are informed that there were some wounds which this balsam could not heal; as indeed we know, at this day, there are many wounds which, though curable by internal medicines, will resist the most powerful external applications.

Concerning the surgery practised among the Egyptians, Jews, and Asiatic nations, we know little or nothing. The Greeks were those from whom the art descended to us, though they confessedly received it from the eastern nations. The first Greek surgeons on record are Æsculapius, and his sons Podalirius and Machaon. Æsculapius flourished about 50 years before the Trojan war; and his two sons distinguished themselves in that war both by their valour and skill in curing wounds. This indeed is the whole of the medical skill attributed to them by Homer; for in the plague which broke out in the Grecian camp, he does not mention their being at all consulted. Nay, what is still more strange, though he sometimes mentions his heroes having their bones broke, he never takes

notice of their being reduced or cured by any other than supernatural means; as in the case of Æneas, whose thigh-bone was broken by a stone cast at him by Diomed. The methods which these two famous surgeons used in curing the wounds of their fellow-soldiers seems to have been the extracting or cutting out the dart which inflicted it, and applying emollient fomentations or styptics, when necessary, to the wound: and to these they undoubtedly attributed much more virtue than they could possibly possess; as appears from the following lines, where Homer describes Eurypylus as wounded and under the hands of Patroclus, who would certainly practise according to the directions of the surgeons.

Patroclus cut the forky steel away;
Then in his hands a bitter root he bruised,
The wound he wash'd, the styptic juice infus'd.
The closing flesh that instant cess'd to glow;
The wound to torture, and the blood to flow.

Till the days of Hippocrates we know very little of what was the practice of the Greek surgeons. From him, however, we learn, that the practice of blood-letting, cupping, and scarification, was known to them; also the use of warm and emollient fomentations, issues made with hot irons, pessaries, injections, fumigations, &c. Hippocrates also gives directions with regard to fractures, luxations, ulcers, fistulas. He directs the extension, reduction, bandages, and splints, proper to be used in fractures and luxations of different bones, with several machines to increase the extension when necessary. He directs the laxity and

History. and tightness of the bandages; the intervals for unloosing and binding them on again; the position and repose of the fractured member, the regimen and diet; and he mentions the time when a callus is usually formed. He treats also of fractures of the skull, and the method of applying the trepan. In his treatment of ulcers, he speaks of reducing fungous flesh by means of escharotics, some of which are alum, nitre, verdigrease, quicklime, &c.

4
Surgery becomes a distinct branch.
In the time of Ptolemy Philopater of Egypt, medicine, all the branches of which had hitherto been practised by the same person, was now divided into three, viz. the dietetic, pharmaceutical, and surgical; from which time to the present, surgery has continued to be reckoned a distinct profession from medicine, though very improperly, in the opinion of the best authors.

5
Archagathus the first Roman surgeon expelled the city.
Surgery appears not to have existed in Rome, notwithstanding the warlike genius of the people, for more than 500 years. Archagathus, a Greek, was the first professor of that art in the city; and so frequently employed the knife, hot irons, and other cruel methods of cure, that he was branded with the opprobrious title of hangman, and expelled the city, where no physician or surgeon of eminence again made his appearance for 180 years. At this time Asclepiades undertook the profession of medicine; but seems to have dealt little in surgery. Neither have we any thing of importance on that subject till the time of Celsus, who flourished during the reigns of Augustus and Tiberius.—In his surgery, all the improvements from Hippocrates to his own days are collected; the most minute and trifling diseases are not omitted. An eminent surgeon, of the moderns, emphatically exhorts every person in that profession "to keep Celsus in his hands by day and by night." He describes the signs of a fractured skull, the method of examining for the fracture, of laying the skull bare by an incision in the form of the latter X, and afterwards of cutting away the angles, and of applying the trepan, with the signs of danger and of recovery. He observed, that sometimes, though very rarely, a fatal concussion of the brain might happen, the blood-vessels within the skull being burst, yet the bone remaining entire. After the operation of the trepan, sponges and cloths wet in vinegar, and several other applications, were made to the head; and, throughout, severe abstinence was enjoined. In violent fractures of the ribs, he ordered venesection; low diet; to avoid passions of mind, loud speaking, motion, and every thing that might excite coughing or sneezing; cloths wet in wine, roses and oil, and other applications, were laid over the fracture. The cure of fractures, in the upper and lower extremities, he said were nearly alike; that fractures differ in degree of violence and danger, in being simple or compound, that is, with or without a wound of the flesh, and in being near to the joint. He directs the extension of the member by assistants; the reduction, by the surgeon's hands, of the fractured bones into their natural situation; and to bind the fractured part with bandages of different lengths, previously dipped in wine and oil: on the third day fresh bandages are to be applied, and the fractured member fomented with warm vapour, especially during the inflammation. Splints,

if necessary, are to be applied, to retain the bones in a fixed position. The fractured arm is to be suspended in a broad sling hung round the neck: the fractured leg is to be inclosed in a kind of case, reaching above the ham, and accommodated likewise with a support to the foot, and with straps at the side, to keep the leg steady: in the fractured thigh-bone, the case is to extend from the top of the hip to the foot. He describes the method of treating compound fractures, and of removing small fragments of splinters of bones; and the manner of extracting darts. In luxations of the shoulder, he mentions several methods of giving force to the extension, and of replacing the dislocated bone. One method similar to Hippocrates was, to suspend the patient by the arm; the fore-part of the shoulder, at the same time, resting upon the top of a door, or any other such firm fulcrum. Another method was to lay the patient supine, some assistants retaining the body in a fixed position, and others extending the arm in the contrary direction; the surgeon, in the mean time, attempting, by his hands, forcibly to reduce the bone into its former place.

If a large inflammation was expected to ensue after a wound, it was suffered to bleed for some time, and blood was drawn from the arm. To wounds accompanied with considerable hæmorrhage, he applied a sponge wet in vinegar, and constant pressure: if necessary, for the violence of the hæmorrhage, ligatures were made round the vessels, and sometimes the bleeding orifice was seared up with the point of a hot iron. On the third day fresh dressings were applied. In considerable contusions, with a small wound of the flesh, if neither nerves nor blood-vessel prevented, the wound was to be enlarged. Abstinence and low diet, in all such accidents, was prescribed; cloths wet with vinegar, and several other applications, were directed to the inflamed part. He observes, that fresh wounds may be healed without compound applications: Hippocrates used a piece of dry sponge, and condemned greasy ingredients. In external gangrene, Celsus cut into the sound flesh; and when the disease, in spite of every effort, spread, he advised extirpation of the member. After cutting to the bone, the flesh was then separated from it, and drawn back, in order to save as much flesh as possible to cover the extremity of the bone. Celsus, though extremely diffuse in the description of surgical diseases, and of various remedies and external applications, yet is nearly silent on the method and process of extirpating members; from which, comparing his treatise with the modern systems, we might infer, that the operation was then seldom practiced than at present. He describes the symptoms of that dangerous inflammation the carbuncle, and directed immediately to burn or to corrode the gangrened part. To promote the suppuration of abscesses, he ordered poultices of barley-meal, or of marsh-mallows, or the seeds of linseed and fenugreek. He also mentions the compositions of several repellent cataplasms. In that superficial inflammation called the erysipelas, he applied cerus, mixed with the juice of solanum or nightshade. Sal ammoniac was sometimes mixed with his plasters.

He is very minute in describing diseases of the eyes, ears, and teeth, and in prescribing a multitude of remedies and applications. In inflammation of the eyes, he.

the enjoined abstinence and low diet, rest, and a dark room: if the inflammation was violent, with great pain, he ordered venesection and a purgative; a small poultice of fine flower, saffron, and the white of an egg, to be laid to the forehead to suppress the flow of pituita; the soft inside of warm white bread dipped in wine, to be laid to the eye; poppy and roses were also added to his collyriums, and various ingredients too tedious to enumerate. In chronic watery defluxions of the eyes, he applied astringents, cupped the temples, and burnt the veins over the temple and forehead. He couded cataracts by depressing the crystalline lens to the bottom of the orbit. Teeth, loosened by any accident, he directed, after the example of Hippocrates, to be fastened with a gold thread to those adjoining on each side. Previous to drawing a tooth, he ordered the gum to be cut round its neck; and if the tooth was hollow, it was to be filled with lead before extraction, to prevent its breaking by the forceps. He describes not only the inflammation, but likewise the elongation, of the uvula: he also describes the polypus, and some other diseases affecting the nose.

He describes several species of hernia or ruptures, and also the hydrocele or dropsy of the scrotum, and the manual assistance required in those complaints. After the return of the intestines into the abdomen, a firm compress was applied to that part of the groin through which they protruded, and was secured by a bandage round the loins. In some cases, after the return of intestinal ruptures, he diminished the quantity of loose skin, and formed a cicatrix, so as to contract over the part, to render it more rigid and capable of resisting. He describes various diseases of the genital parts, a difficulty of urine, and the manner of drawing off the water by a catheter; the signs of stone in the bladder, and the method of sounding or feeling for that stone. Lithotomy was at that time performed by introducing two fingers into the anus; the stone was then pressed forward to the perineum, and a cut made into the bladder; and by a crooked instrument, made in a particular form, the stone was extracted. He describes the manner of performing this operation on both the sexes, of treating the patient, and the signs of recovery and of danger. Hippocrates had even ventured to cut into the kidney, either to give a discharge to abscesses or to extract stones.

Celsus directed various corrosive applications and injections to fistulas; and, in the last extremity, opened them to the bottom with a knife, cutting upon a grooved instrument or conductor. In old callous ulcers, he made a new wound, by either cutting away the hard edges, or corroding them with verdigrease, quick-lime, alum, nitre, and with some vegetable escharotics. He mentions the symptoms of caries in the bone; directed the bone to be laid bare, and to be pierced with several holes, or with the trepan, or to be burnt or rasped, in order to promote an exfoliation of the corrupted part; afterwards to apply nitre and several other ingredients. One of his applications to a cancer was auripigmentum or arsenic. He directed the manner of tapping the abdomen in the ascites, and of drawing blood by the lancet and cupping-glasses. His cupping-glasses seem not to have been so convenient as the modern: they were made either of brass or horn, and were unprovided with a pump. He cured vari-

ose veins by ligation or by incision. He gives directions for extracting the dead foetus from the womb, in whatever position it should present; and, after delivery, applied to the private parts soft cloths wet in an infusion of vinegar and roses. In Celsus's works there is a great redundancy and superfluity of plasters, ointments, escharotics, collyriums, of suppurating and discentient cataplasms, and external applications of every kind, both simple and compound: perhaps, amongst the multitude, there are a few useful remedies now laid aside and neglected.

The last writer of consequence who flourished at Rome was Galen, physician to the emperor Marcus Aurelius. His works are for the most part purely medicinal; however, he wrote also on surgery, and made Commentaries on the Surgery of Hippocrates. He opened the jugular veins, and performed arteriotomy at the temples; directed leeches, scarification, and cupping-glasses, to draw blood. He also described with accuracy the different species of hernia or ruptures.

In the year 500 flourished Aëtius, in whose works we meet with many observations omitted by Celsus and Galen, particularly on the surgical operations, the diseases of women, the causes of difficult labours, and modes of delivery. He also takes notice of the dracunculus, or worm under the skin, a disease at present common in Africa. Aëtius, however, is greatly excelled by Paulus Egineta, who flourished in 640; and whose treatise on surgery is superior to that of Celsus or all the other ancients. He directs how to extract darts; to perform the operation sometimes required in dangerous ruptures or hernia, where the intestines cannot by any other means be returned back; he directs also to tie up punctured arteries in the operation for the aneurysm. Galen, Paulus, and all the ancients, speak only of one species of aneurysm, and define it to be "a tumour arising from arterial blood, extravasated from a ruptured artery." The aneurysm from a dilatation of the artery is a discovery of the moderns. In violent inflammations of the throat, where immediate danger of suffocation was threatened, Paulus performed the operation of bronchotomy. In obstinate defluxions upon the eyes, he opened the jugular veins. He describes the manner of opening the arteries behind the ears in chronic pains of the head. He wrote also upon obstetrics, on difficult labours, and other female diseases. Fabricius ab Aquapendente, a celebrated surgeon of the 16th century, has followed Celsus and Paulus as text-books.

From the time of Paulus Egineta to the year 900, no writer of any consequence, either on medicine or surgery, appeared. At this time the Arabian physicians Rhazes and Avicenna revived in the East the medical art, which as well as others was almost all entirely extinguished in the West. Avicenna's Canon Medicinus, or General System of Medicine and Surgery, was for many ages celebrated through all the schools of physics. It was principally compiled from the writings of Galen and Rhazes. The latter had correctly described the spina ventosa, accompanied with an enlargement of the bone, caries, and acute pain. In difficult labours he recommends the fillet to assist in the extraction of the foetus; and for the same purpose Avicenna recommends the forceps. He describes the composition

History. tion of several cosmetics to polish the skin and make the hair grow or fall off.

9 Albucasis brings surgery in repute among the Arabians. Notwithstanding this, however, it was not till the time of Albucasis, who flourished in the year 1000, that surgery came into repute among the Arabians. Rhazes complains of their gross ignorance, and that the manual operations were performed by the physicians servants. Albucasis enumerates a tremendous list of operations, sufficient to fill us with horror. The hot iron and cauteries were favourite remedies of the Arabians; and, in inveterate pains, they resorted, like the Egyptians and eastern Asiatics, great confidence in burning the part. He describes accurately the manner of tapping in the ascites; mentions several kinds of instruments for drawing blood; and has left a more ample and correct delineation of surgical instruments than any of the ancients. He gives various obstetrical directions for extracting the foetus in cases of difficult labours. He mentions the bronchocele, or prominent tumour on the neck, which, he tells us, was most frequent among the female sex. We are also informed by this writer, that the delicacy of the Arabian women did not permit male surgeons to perform lithotomy on females; but, when necessary, it was executed by one of their own sex.

10 Leprosy introduced into Europe. From the 11th century to the middle of the 14th, the history of surgery affords nothing remarkable except the importation of that nauseous disease the leprosy into Europe. St. Lewis king of France had caught the leprosy in the Crusades; and in order to a cure, was prescribed the blood of young children, as a potion, by the Jewish physicians. It does not appear that either external or internal remedies were of any avail in curing it, or indeed thought to be so; but, by taking proper precautions to separate the infected from the sound, it gradually disappeared. The discovery of America introduced a new and more terrible disease than the leprosy, namely, the venereal; which at its origin appeared in loathsome ulcers affecting the genitals, and by degrees the palate and uvula. Swellings and buboes arose in the groin: in its more advanced stages, excruciating pains were felt in the bones, especially at night; scabs and small running sores covered the skin; nodes or protuberances appeared in the forehead; the bones became at length carious, enlarged, and rotten: many, after lingering for months under such wretched calamities, others, for a year or more, lost their palate, nose, eyes, lips, teeth, genitals; and, before death, presented a cadaverous spectacle of deformity and corruption. Even at this day, when the disease has become much milder, venereal ulcers will sometimes appear with such inveteracy as to give no small trouble to the surgeon who attempts to remove them.

11 Introduction of the venereal disease. Soon after this the scurvy, with all its train of direful, and for a long time incurable, ulcers, rigid muscles, and rotten gums, made its appearance. The state of medical knowledge did not, in those ages, admit of a certain and easy cure either for the venereal disease or scurvy, nor was the true cure of the latter known till within these few years.

12 Of the scurvy. At the beginning of the 16th century surgery was held in contempt in this island, and was practised indiscriminately by barbers, farriers, and low-gelders: the barbers and surgeons company continued for 200 years after to be incorporated, both in London and

13 State of surgery in Britain in the 16th century. Vol. X.

Paris. In Holland and some parts of Germany, even at this day, barbers exercise the razor and lancet alternately. The surgeons company in London, however, have now disengaged themselves from that dishonourable connection: they are now likewise authorized to examine and to grant certificates to young surgeons, which qualify them to purchase or to be appointed to a medical commission in the army or navy. Even yet, too great distinction between physicians and surgeons is by far too great, and their reciprocal ignorance of these different branches of the same science frequently embarrasses both physician and surgeon, often to the great danger of the patient, as will appear in the sequel of this article.

14 Surgery, in the strict limitation of the word, is principally confined to wounds, fractures, luxations, tumours, ulcers, and to the different manual operations, instruments, and bandages. These are the themes of general systems of surgery. On this science and art, amongst the ancient surviving writers, Hippocrates, Celsus, Galen, P. Ægineta, and Albucasis, alone possess any intrinsic excellence.

It is within the last three centuries that we have any original improvement in surgery, from the æra of the Arabians; nor do we know of any eminent British surgical writers until within the last 130 years. "In Germany," says Heister, "all the different surgical operations, at the beginning even of the 18th century, were left to empirics; the rest were contented to cure a wound, open a vein or an abscess, return a fractured or luxated bone; but they seldom or never ventured to perform any of the difficult operations: he also speaks of their gross ignorance of the Latin language."

15 The first surgical work of the 16th century, entitled to any pre-eminence or criticism, is that of J. Carpus; but in the effulgence of later writers his light is scarce perceptible. F. ab Aquapendente, an Italian, published a system of Surgery, containing a description of the various diseases, accidents, and operations. Boerhaave pays this author the following compliment: Ille superavit omnes, et nemo illi hanc disputat gloriam; omnibus potius quam hocce carere possumus. About the same period, A. Parey, a Frenchman, made several important additions to surgery, particularly in his collection of cases of wounds, fractures, and other accidents which occur during war. The ancients, who were ignorant of powder and fire-arms, are defective in this part of military surgery. Parey pretends to have first invented the method of tying, with a needle and strong silk-thread waxed, the extremities of large arteries, after the amputation of a member. The ligature of the blood-vessels is, however, merely a revival of the ancient practice, which had fallen into disuse: throughout the dark ages, the hot iron, cauteries, and strong astringents, were substituted in its place. B. Maggins and L. Botallus wrote on the cure of gunshot wounds. J. A. Cruce wrote a system of surgery.

16 In the 17th century, surgery was enriched with several systems, and with detached or miscellaneous observations. The principal authors are, M. A. Severinus, V. Vidius, R. Wiseman, Le Clerc, J. Scultetus, J. Mangetus, C. Magatus, Spigellius, F. Hildanus, T. Bartholin, P. de Marchett.

The 18th century opens with several eminent surgical

cal writers and improvements. In the operation of lithotomy, as described by Celsus, the rectum or lower gut, and often the femoral ducts, were wounded, fistulas ensued, or the power of generation was annihilated. The moderns therefore invented three methods different from that of Celsus. One method, and the earliest, was to introduce a catheter into the urethra and bladder, and upon that to make a direct incision through the urethra into the bladder. J. de Romanis, an Italian, in the 16th century, was the original inventor of this operation, a description of which was published by his pupil Marianus. Another method, much later invented, was to distend the bladder as large as possible with urine, and when thus enlarged and elevated, to open into it through the abdominal muscles, immediately above the os pubis. These were called the high and low operations; Celsus's, the apparatus minor. A French priest called Frere Jacques introduced another improvement, somewhat different from the modern low operation, or apparatus major. Jacques's incision was directed obliquely and to one side of the urethra, avoiding as much as possible to open any considerable extent of the urinary canal. Inconveniences still attended these various experiments in lithotomy. Jacques was a bold rash man, and ignorant of anatomy; of 60, cut by him for the stone, 25 died soon after; others survived, but under an incontinence of urine and fistulas, and only 13 were perfectly cured. The priest's operation and success is described by J. Merrey. A grooved catheter was afterwards invented to conduct the incision-knife; other surgeon added the cutting-gorget; and, with these improvements, Jacques's lateral operation is now considered as one of the most safe and successful. Douglas, Chefelden, and afterwards Le Dran, took uncommon pains to explain and to improve this operation. J. Denys also wrote well on the stone and lithotomy.

J. Petit of Paris wrote on diseases of the bones, of M. Petit, fractures, dislocations, and caries. Boerhaave says, Transtus hic nunquam sibi parem habuit. Petit invented the screwed tourniquet, which can be braced or relaxed at pleasure, and, in the hurry of battles, is extremely useful to compress the large arteries, and to stop the hemorrhage. Tourniquets were not used until towards the end of the 17th century. The ancients, previous to amputation, only made a tight ligature round the member, or attempted to grasp and compress the arteries with the hand and fingers: from these defects, amongst them, the amputation of any large member was thought tremendous, and was too frequently fatal. Of late years, the agaric, growing upon old oak-trees, has been extolled as a powerful styptic in hemorrhages from large vessels.

A complete description of the different surgical accidents and diseases, and of the principal surgical operations, as executed from the beginning of the 18th century to the present time, with descriptions and plates of the instruments and bandages, will be seen in those celebrated writers, French, German, and English, P. Dionis and De la Faye, J. Garengeot, H. F. le Dran, L. Heister, and S. Sharp. Heister's System consists of two quarto volumes, and is prefaced with a large catalogue of writers. To Sharp's Compendium of the surgical operations is added a volume called A

Critical Inquiry into the Modern Practice of Surgery. History. To these may be added, Saviard's Surgical Observations, J. Z. Platner's Surgical Institutions. On gunshot wounds, and on fractures, Ranby and Bromfield merit perusal. Splints of a new construction, to retain fractured bones in a steady position until a callus is formed, were invented by Sharp, and improved by Pott. Gouch, with meritorious ingenuity, has invented and published a description of several machines, to secure fractured bones in a fixed station. As such accidents occur so frequently in life, and above all during war, every invention of this sort, and the author, is entitled to public thanks. There is infinitely more skill and address required to save a fractured member, than to cut it off. Knives and saws are dreadful alternatives; and we have already an exuberant stock of treatises on extirpation.

Numbers had dragged through a great part of life, Of 20 diseases of the urethra and fistulas. and many had died in excruciating agony, from obstructions of the urethra and fistulas, the consequence of venereal gleets, and other causes. To remedy such complaints, we find bougies of different constructions and materials recommended by the moderns, and described with more or less accuracy in most of the surgical systems. In the present century, Daran and Goulard have written dissertations expressly upon this subject. Goulard's Treatise on the Preparations of Lead, and its utility in external inflammations, sprains, contusions, and a variety of complaints, is also well entitled to perusal.

In preventing the protrusion of inguinal ruptures, Of 21 ruptures. the modern steel-bandages called trusses are more effectual than the ancient. The nature of the hernia congenita, or inguinal rupture of infants, was obscure before the publications of Haller, Hunter, and Pott. The last author has written excellent treatises on ruptures, and on the hydrocele.

On diseases of the eyes, and surgical operations on 22 Diseases of those organs, the most celebrated treatises are written the eye. by Maitre Jean, C. St Yves, D. Mauchard, and Taylor. Daviel, a modern French surgeon, rejected the operation of depressing the crystalline lens with a needle to the bottom of the orbit, in couching of cataracts; he made an incision through the external coat of the eye, and extracted this humour entire. In the former mode, the lens frequently ascended, and again interrupted the rays of light.

On the teeth, their diseases, the dentist operations, Of 23 the dentition of infants, we have two excellent treatises, one in French, the other in English, written by P. Fauchard and by J. Hunter. We do not meet amongst the ancients with any mention of artificial teeth. Hippocrates and Celsus only direct the immediate re-inflating into their sockets found teeth suddenly loosened from the jaw. With us, artificial teeth are commonly made from the hard tusk of a sea-horse. Another modern invention, in which, unfortunately, the advantages and disadvantages are balanced, is that of transplanting found teeth of similar shape and size from one head, and fixing them instantaneously into the fresh sockets of another person's jaws; there they are tied to the neighbouring teeth by a waxed silk thread, and in a few weeks are firmly grasped and secured by the gums.

Through the writings of almost all the eminent anatomists,

History. tomists, there are a variety of miscellaneous surgical observations. To recapitulate their names in detail would be superfluous.

The great superiority of the moderns above the an-

cients in the knowledge of anatomy, and the superiority likewise in the construction and workmanship of their instruments, necessarily render all their operations much more safe and prosperous.

PART II. THEORY OF SURGERY.

²⁴
Theories of surgery and medicine connected. IN the extensive signification in which we have taken the word surgery, it is plain that the theory must include the greatest part, if not the whole, of the theory of medicine. Fevers, for instance, may terminate by a critical swelling; and the surgeon who should ignorantly attempt to discuss a tumor of this kind, might do much mischief. Ulcers may arise from various internal causes; and the person who should attempt to cure them by external applications alone would certainly fail. In like manner, the treatment of a simple wound becomes exceedingly different, according to the constitution and habit of body in the person who is wounded: from all which it is plain, that there is no theory which will in all cases answer; but that the surgeon must be well acquainted with the other branches of medicine, or he cannot practise with any kind of certainty or success.—We shall begin, however, with those cases where the cure is most easy.

SECT. I. Of Simple Wounds.

²⁵
Of mortal wounds. The first thing to be considered in the inspection of a wound is, whether it is likely to prove mortal or not. This knowledge can only be had from anatomy, by which the surgeon will be able to determine what parts are injured; and, from the offices which these parts are calculated to perform, whether the human frame can subsist under such injuries. It is not, however, easy for the most expert anatomist always to prognosticate the event with certainty; only this rule he ought always to lay down to himself, to draw the most favourable prognosis the case will bear, or even more than the rules of his art will allow. This is particularly incumbent on him in sea-engagements, where the sentence of death is executed as soon as pronounced, and the miserable patient is thrown alive into the sea upon the surgeon's declaring his wound to be mortal. There are, besides, instances on record where wounds have healed which the most skilful surgeons have deemed mortal. In the war before last, an officer was shot quite through the body by a musket-ball, which penetrated the substance of the lungs; yet he recovered, though not without great difficulty. Mr Forster informs us that Tupia, a native of the island of O-Tahitee, had been run through the body by one of the spears headed with the bone of the sting-ray; and yet this wound was healed. He informs us also, that in others of that country he had observed the marks of such desperate wounds, that he could not imagine how life could have subsisted under them. In general, however, those wounds are justly deemed mortal.

²⁶
The most favourable prognosis ought always to be drawn. ²⁷
Instances of desperate wounds being healed. ²⁸
Different kinds of wounds which are necessarily mortal. 1. That penetrate the cavities of the heart, and all those wounds of the viscera where the large blood-vessels are opened; such are large wounds of the lungs, liver, spleen, kidneys, stomach, intestines, mesentery, pancreas, uterus, aorta; of the iliac, celiac, renal, mesenteric, and carotid arteries, (especially if they are wounded near their origin), of the subclavian

also or vertebral, of the vena cava, the iliac vein, internal jugular, vertebral, renal, or mesenteric veins; of the vena porta, and of other large veins that lie deep in the body; because their situation will not admit of proper applications to restrain the flux of blood.

2. Those wounds are no less mortal than the former which obstruct or entirely cut off the passage of the animal-spirits through the body. Such are wounds of the cerebellum, medulla oblongata, and some violent strokes of the brain itself; though the cortical substance of the brain may be much injured, and yet the patient recover. There is reason to apprehend very great danger when the small veins or arteries which are contained in the cranium are injured: for the blood flowing from them into the internal sinuses of the brain, either produces too great a pressure upon those very tender parts of the brain, and so obstructs the course of the blood and spirits; or, being corrupted, putrifies the brain itself, if it cannot be evacuated by the assistance of the trepan; which is the case when this accident happens at the lower part of the cranium, or in the sinuses of the brain. Nor is there less danger where the nerves which tend to the heart are wounded, or entirely divided; for, after this, it is impossible for the heart to continue its motion.

3. To this class also are to be referred all wounds that entirely deprive the animal of the faculty of breathing. Therefore there is great danger where the aspera arteria is completely divided; for, where it is only divided in part, it may be healed again by the assistance of an expert surgeon. To this place also belong violent shocks of the bronchia, mediastinum, and diaphragm, especially the tendinous parts of it.

4. Those wounds also which interrupt the course of the chyle to the heart are no less incurable than the former; such are wounds of the stomach, intestines, receptacle of the chyle, thoracic duct, and larger lacteals: to which we may add wounds of the oesophagus, if they are large; though death is not so sudden an attendant upon these wounds, but for want of nourishment they are greatly weakened by degrees, and die consumptive.

5. Wounds which are inflicted upon membranous parts that are situated in the abdomen, and contain some secreted fluid on the bladders, either for the bile or urine, the stomach, intestines, receptacle of the chyle, and lacteal vessels. The fluids contained in these parts, when once they are let loose into the cavity of the abdomen, cannot be properly discharged, and therefore easily corrode the internal parts of the body; and the membranes that contained them are generally so fine, that they will not admit of agglutination, especially since no medicine from without can be applied; though some few, indeed, have recovered after slight wounds in these parts.

6. We shall next proceed to describe those wounds which prove fatal if neglected and left to nature. By these are meant those wounds that produce instant death.

death unless relieved by present assistance, but are curable by a good surgeon called in time; such are wounds of the larger external blood-vessels, which might be remedied by ligature. Of this kind are wounds of the brachial or crural artery, unless they are too near the trunk of the body. Wounds in the large arteries of the cubit or tibia, of the branches of the external carotid and temporal artery, are of this kind; to these may be added wounds of the jugular and other veins situated upon the external parts of the body.

7. Wounds are properly said to become mortal by accident, where the patient's death is occasioned either by the ill conduct of the patient himself, or by the ignorance or neglect of his surgeon, the wound itself being deemed curable. Under this head are to be reckoned, 1. Those wounds which the surgeon has neglected to cleanse sufficiently, though he had it in his power to do it; as when some foreign body, which might easily have been extracted, is left in the wound by the carelessness of the surgeon, and produces inflammations, hæmorrhagies, convulsions, and at last death itself. So in wounds of the thorax and abdomen, if the surgeon does not use his utmost diligence to evacuate the grumous blood, it will corrupt there, and, by drawing the neighbouring parts into consent, will expose the patient to instant death. Therefore great care must be taken that the lips of the wound do not close till the blood which is collected in the cavity of the body be all evacuated, if possible; which may be easily perceived by the difficulty of breathing, and other bad symptoms, being removed: but if any of the larger internal vessels are wounded, then all attempts to discharge the blood are vain; for the violence of the hæmorrhagy takes off the patient. 2. Wounds also are reckoned mortal by accident which are treated or searched in too rough a manner by the surgeon; for if wounds be handled roughly that are full of nervous parts or large blood-vessels, there is great danger of bringing on hæmorrhagies, convulsion, inflammation, gangrene, and death itself. The case also is the same. 3. In external wounds which are flight of themselves, but the patient is lost by the violence of the inflammation which is brought on and increased by the surgeon's injudicious treatment. Or, 4. When any one is taken off by the violence of the hæmorrhagy from a wound of the hand or foot; for in this case a surgeon might easily have stopped the blood by the application of proper remedies, or by ligature. Or, 5. Where the patient is guilty of any intemperance in eating or drinking, of excess of any passion, of exposing himself to the cold air, or of using any violent exercise; for by this means wounds, more especially those of the head, by being liable to fresh hæmorrhagies and other dangerous accidents, frequently become mortal, notwithstanding the surgeon uses his utmost care and skill. Under this head also are to be reckoned, 6. Those wounds of the head where the patient is lost by the vast quantity of blood which is extravasated in the cavity of the cranium, and confined there; but where he might have been relieved, if the trepan had been used in time; for though wounds of this kind generally prove incurable, yet, as there is a possibility of saving a person in these circumstances by the use of the trepan, this

may properly be reckoned amongst the doubtful cases, and not deemed absolutely mortal.

In examining wounds, the next consideration is, whether the parts injured are such as may be supposed to induce dangerous symptoms, either immediately or in some time during the course of the cure. In order to proceed here with any degree of certainty, it is necessary to be well acquainted with those symptoms which attend injuries of the different parts of the body. If the skin only and part of the cellular substance is divided, the first consequence is an effusion of blood; the lips of the wound retract, become tumefied, and red and inflamed; leaving a gap of considerable wideness, according to the length and deepness of the wound. Along with this inflammation, if a very considerable portion of skin and cellular substance is divided, a slight fever seizes the patient; the effusion of blood in the mean time stops, and the wound is partly filled up with a cake of coagulated blood. Underneath this cake, the small vessels pour forth a clear liquor, which in a short time becomes converted into pus. Below this pus granulations of new flesh arise, the cake of coagulated blood loosens, a new skin covers the place where the wound was, and the whole is healed up; only there remains a mark, called a cicatrix or scar, showing where the injury had been received.

All wounds are accompanied with a considerable degree of pain, especially when the inflammation comes on; and this though the division reaches no farther than the skin and cellular substance. But if the muscular fibres are also divided, the pain is much greater, because the sound part of the muscle is stretched by the contraction of the divided part and the action of the antagonist muscle, which it is now less fitted to bear. The wound now also gaps much more than where the cellular substance only is divided, inasmuch that if left to itself the skin will cover the muscular fibres without any intervention of cellular substance, and not only a very unsightly cicatrix remains, but the use of the muscle is in some measure lost.—If the muscle happens to be totally divided, its parts retract to a very considerable distance; and unless proper methods be taken, the use of it is certainly lost ever afterwards.

If by a wound any considerable artery happens to be divided, the blood flows out with great velocity, and by starts distinguishing the pulse of the artery; the patient soon becomes faint with loss of blood; nor does the hæmorrhagy stop until he faints away altogether, when the ends of the divided vessel close by their natural contractility; and if as much vis viva still remains as is sufficient to renew the operations of life, he recovers after some time, and the wound heals up as usual. The part of the artery which is below the wound in the mean time becomes useless, and its sides collapse, so that all the inferior part of the limb would be deprived of the vital fluid, were it not that the small branches sent off from the artery above the wounded place become enlarged and capable of carrying on the circulation. Nature also, after a wonderful manner, often produces new vessels from the superior extremity of the divided artery, by which the circulation is carried on as formerly. How-
ever, the consequences of such a profuse hæmorrhagy may be very dangerous to the patient, by inducing

Theory. extreme debility, polypous concretions in the heart and large vessels, or an universal dropy in case the patient recovers. This happens especially where the artery is partially divided; because then the vessel cannot contract in such a manner as to close the orifice: however, if the wound is but small, the blood gets into the cellular substance and intestines of the muscles, swelling up the member to an extreme degree, forming what is called a spurious aneurysm. Thus the hæmorrhagy soon stops externally; but great mischiefs are apt to flow from the confinement of the extravasated blood. This is now found to have the power of dissolving not only the fleshy parts, but also the bones themselves; and thus not only the use of the limb is entirely lost, but the patient is brought into great danger of his life, if proper assistance be not obtained in a short time.—It not unfrequently happens, that when a large artery has been wounded or totally divided, so that the parts which were wont to be supplied with blood by that vessel become totally or in great measure deprived of it, a mortification then ensues which cannot be prevented or cured: in some cases the limb remains paralytic or insensible through life.

Theory. Wounds of the membranes, nerves, or tendons, are attended with the most direful symptoms. The peculiar symptom indeed which attends a wounded membrane is an erysipelas. This is to a membrane what a simple inflammation is to a fleshy part: and hence the danger of an erysipelas of the face more than of any other part of the body; for there is such a connection between the external and internal membranes all over the body, that an affection of the one seldom fails to bring on an affection of the other. When a nerve or tendon is entirely divided, the pain is but trifling, though the consequences are often dangerous. If the nerve is large, all the parts to which it is distributed below the wound immediately lose the power of motion and sensation; nor is it uncommon, in such cases, for them to be seized with a gangrene. This, however, does not hold universally. According to Dr Kirkland's opinion, it takes place only when all or the greatest part of the nerves belonging to a particular part are divided or tied. "If the spinal marrow" says he, "is divided near to the head, we know the parts below soon lose their action irrecoverably; or if the bundle of nerves passing out of the axilla were divided or tied, sensation in the greatest part of the arm below would probably be lost. But we all know, that in performing the operation for an aneurysm in the arm, if the nerves which accompany the brachial artery are tied, a temporary numbness is only felt, and sensation in any degree below the ligature is not lost.—I have seen the superior cubital nerve torn asunder above the elbow, in a gun-shot wound, with considerable loss of substance; and a temporary palsy only was the consequence."

Theory. When the tendon belonging to any muscle is totally divided, that muscle immediately exerts its contractile power; the divided ends of the tendon are removed to a considerable distance; and, unless proper assistance is obtained, the action of the muscle is forever lost. But when either nerve or tendon happens to be partially divided, the case is much worse. The distraction of the parts which remain whole, occasion-

ed by the divided parts contracting themselves, occasions the most excruciating pain, which frequently terminates in convulsions of the worst kind, particularly those most fatal spasms termed tetanus and episthotanus, which often attend wounds in nervous or tendinous parts.

Wounds which penetrate the cavities of the thorax or abdomen are always exceedingly dangerous, because there is scarce a possibility of all the viscera escaping unhurt. A wound is known to have penetrated the cavity of the thorax principally by the discharge of air from it at each inspiration of the patient, by an extreme difficulty of breathing, coughing up blood, &c. Such wounds, however, are not always mortal, though very frequently so. The lungs, nay even the heart itself, may be wounded, and yet the patient recover. Van Swieten relates, that a flag was found to have a cicatrix of a wound formerly inflicted on the cone of its heart. The same author also is of opinion, that wounds even of the right ventricle are not absolutely mortal, as the force of contraction in this ventricle is not very great: however, it is otherwise when the left ventricle is wounded, the great force with which it contracts, continually dilating the wound, and extravasating the blood in such quantities, that life cannot possibly subsist.—Wounds of the diaphragm are almost always mortal, either by inducing fatal convulsions immediately, or by the ascent of the stomach, which the pressure of the abdominal muscles forces up through the wound into the cavity of the thorax; and of this Van Swieten gives several instances.—Even though the wound does not penetrate into the cavity of the thorax, the very worst symptoms may follow. For if the wound descends deeply among the muscles, and its orifice lies higher, the extravasated humours will be therein collected, stagnate, and corrupt in such a manner as to form various sinuses; and after having eroded the pleura, it may at length pass into the cavity of the thorax. The matter having once found a vent into this cavity, will be continually augmenting from the discharge of the sinuous ulcers, and the lungs at last consumed by soaking in corrupted matter. This is most to be dreaded from those sinuous ulcers which run behind the ribs; for there is then no opportunity either of compressing the parts, or dilating the wound in order to procure a discharge of the matter. If, in cases of wounds in the thorax, the ribs or sternum happen to become carious, the cure will be extremely tedious and difficult. Galen relates the case of a lad who received a blow upon his sternum in the field of exercise: it was first neglected, and afterwards badly healed; but, four months afterwards, and matter appeared in the part which had received the blow. A physician made an incision into the part, and it was soon after cicatrized: but in a short time a new collection of matter made its appearance, and upon a second incision the wound refused to heal. Galen found the sternum carious; and having cut off the diseased part, the pericardium itself was observed to be corroded, so that the heart could be seen quite naked; notwithstanding which, the wound was cured in no very long time.

Great caution is necessary in determining whether the wound has really penetrated into the thorax or the abdomen: for the former descends much farther in the

the back than in the fore part; and there are instances of surgeons penetrating the abdomen instead of the thorax, when attempting to perform the operation for an empyema. However, as the lungs are almost always wounded when the cavity of the thorax is penetrated, the symptoms arising from thence can scarcely be mistaken.—Another symptom which frequently, though not always, attends wounds of the thorax, is an emphysema. This is occasioned by the air escaping from the wounded lungs, and infiltrating itself into the cellular membrane; which being pervious to it over the whole body, the tumour passes from one part to another, till at last every part is inflated to a surprising degree. An instance is given, in the Memoirs of the Royal Academy, of a tumour of this kind, which on the thorax was eleven inches thick, on the abdomen nine, on the neck six, and on the rest of the body four; the eyes were in a great measure thrust out of their orbits by the inflation of the cellular membrane; and the patient died the fifth day. This was occasioned by a stab with a sword.

Wounds of the abdomen are not much less dangerous than those of the thorax, by reason of the importance of the viscera which are lodged there. When the wound does not penetrate the cavity, there is some danger of an hernia being formed by the dilatation of the peritoneum through the weakened integuments, and the danger is greater the larger the wound is. Those wounds which run obliquely betwixt the interstices of the muscles often produce sinuous ulcers of a bad kind. For as there is always a large quantity of fat interposed every where betwixt the muscles of the abdomen, if a wound happens to run between them, the extravasated humours, or matter there collected, not meeting with free egress through the mouth of the wound, often makes its way in a surprising manner through the panniculus adiposus, and forms deep sinuities between the muscles; in which case the cure is always difficult, and sometimes impossible.

If a large wound penetrates the cavity of the abdomen, some of the viscera will certainly be protruded through it; or if the wound is but small, and closed up with fat so that none of the intestines can protrude themselves, we may yet know that the cavity of the abdomen is pierced, and probably some of the viscera wounded, by the acute pain and fever, paleness, anxiety, faintings, hickup, cold sweats, and weakened pulse, all of which accompany injuries of the internal parts. The mischiefs which attend wounds of this kind proceed not only from the injury done to the viscera themselves, but from the extravasation of blood and the discharge of the contents of the intestines into the cavity of the abdomen; which, being of a very putrescent nature, soon bring on the most violent disorders.

Hence wounds of the abdominal viscera are very often mortal, though not always so. It appears, that the small intestines have been totally divided, and yet the patient has recovered. Wounds both of the small and large intestines have healed spontaneously, even when they were of considerable magnitude; so that both the contents of the intestine have been freely discharged thro' the wound in it, and part of the intestine itself has been protruded through the wound of the integuments. When this last is the case, however, there is great danger from the mere contact of the external air; and

indeed the wound most commonly proves generally mortal where any considerable portion of the intestine has been protruded, even though itself should not be wounded.

When the mesentery is injured, the danger is extreme, both on account of the blood-vessels which are every where dispersed through it, and the membranous liver very nature of the mesentery itself, which is as subject to dangerous, the erysipelatus inflammation as the other membranes of the body. Wounds of the liver are also exceedingly dangerous, on account of the nature of that viscus; for as the circulation of the blood is there very slow, and the substance of the liver itself is exceedingly soft and tender, the smallest acrimony in the matter is sufficient to destroy the whole, by producing incurable abscesses. Wounds of the spleen and pancreas are said not to be dangerous; and there are even some instances of these parts being cut out of living animals without any considerable injury; but those of the kidneys, urinary bladder, and gall-bladder, are almost always mortal.

Wounds of the head, even though they penetrate only through the external integuments, are not without danger, chiefly on account of the danger arising from the membranes of the brain, the pericranium, and the concussion of the brain by the stroke of the wounding instrument. Even contusions on the head, without any external wound, have sometimes brought on the most violent symptoms, and this when every thing seemed for a while to be in a fair way. Mr Pott, in his excellent Treatise upon Injuries of the Head from external Violence, divides wounds of the head into two kinds, viz. lacerated wounds, and those made by puncture. The former he subdivides into other two kinds, viz. those in which the scalp, though torn or unequally divided, still keeps its natural situation, and is not separated from the cranium to any considerable distance beyond the breadth of the wound; and those in which it is considerably detached from the parts it ought to cover. The latter are the most dangerous; Of those in as in such cases the pericranium is most commonly inflamed, and communicates the injury to the membranes of the brain, whence follow the most fatal symptoms. Small wounds, or such as are made by instruments that pierce rather than cut, are in general more apt to be troublesome than those which are larger, and, in the head particularly, are sometimes attended with very alarming symptoms. The parts capable of being hurt by such wounds are the skin, tela cellulosa, the expanded tendons of the muscles of the scalp, and the pericranium. If the wound affects the cellular membrane only, and has not reached the aponeurosis or pericranium, the inflammation and tumour affect the whole head and face, the skin of which wears a yellowish cast, and is sometimes thick set with small blisters containing a serum of the same colour. It receives the impression of the fingers, and becomes pale for a moment, but returns immediately to its inflamed colour: it is not very painful to the touch, and the eyelids and ears are always comprehended in the tumefaction: the former are sometimes distended in such a manner as to be closed; a feverish heat and thirst generally accompany it; the patient is restless, has a quick pulse, and most commonly a nausea and inclination to vomit. This generally happens to persons of a

51
Wounds of the mesentery and liver very dangerous.

52
But not those of the spleen and pancreas.

53
Of wounds of the head.

54
Mr Pott's division of them into two classes.

55
Of those in which the scalp is separated from the cranium.

2

bilious

Theory. bilious habit, and is indeed an inflammation of the erysipelatus kind; but though its appearance is alarming, it is not often attended with danger. The wound does indeed neither look well, nor yield a kindly discharge while the fever continues; but still the scalp continues to adhere firmly to the skull, and the patient does not complain of that tenfive pain, nor is afflicted with that fatiguing restlessness, which generally attends mischief underneath the cranium.

Of such as affect the brain and its membranes. Wounds and contusions of the head which affect the brain and its membranes are also subject to an erysipelatus kind of swelling and inflammation, but very different both in its character and consequences from the preceding. In this the febrile symptoms are much higher; the pulse harder and more frequent; the anxiety and restlessness extremely fatiguing; the pain in the head intense, and generally attended with irregular shiverings, which are not followed by a critical sweat, nor afford any relief to the patient. These shiverings are most frequently a sign of matter forming between the dura mater and the skull; and indeed shivering generally accompanies the formation of matter in any part of the body, as shall be explained when we come to treat of abscesses. In the former case, the erysipelas generally appears within the first three or four days; whereas in the latter it seldom comes on till several days after the accident, when the symptomatic fever is got to some height. In the simple erysipelas, although the wound be undigested, yet it has no other mark of mischief; the pericranium adheres firmly to the skull, and upon the cessation of the fever all appearances become immediately favourable. In that which accompanies injury done to the parts underneath, the wound not only has a spongy, glassy, unhealthy aspect; but the pericranium in its neighbourhood separates of its own accord from the bone, and quits all cohesion with it. These appearances indicate great danger, and commonly end in death.

Of wounds which pass through all the integuments to the pericranium. If the wound be a small one, and has passed thro' the tela cellulosa to the aponeurosis and pericranium, it is sometimes attended with very alarming symptoms. The inflamed scalp does not arise to such a degree of tumefaction as in the erysipelas, neither does it pit or retain the impression of the fingers. It is of a deep red colour, unmixed with the yellow tint of the erysipelas: it appears tense, and is extremely painful to the touch. As it is not an affection of the tela cellulosa, and as the ears and the eye-lids are not covered by the parts in which the wound is inflicted, they are seldom, if ever, included in the tumour, though they may partake of the general inflammation of the skin: it is generally attended with acute pain in the head, and such a degree of fever as prevents sleep, and sometimes brings on a delirium.

Of those where the skull is cleft, or even a part of it entirely taken off, sometimes with and sometimes without injuring the brain. These wounds, though very dangerous, are not always mortal, unless the medullary substance of the brain be injured; for this never fails to bring on death in a short time. There have been instances of people who by wounds of this kind had a considerable portion of the dura mater exposed for the remainder of their life, and yet felt no remarkable inconvenience, farther than that the brain was exceedingly tender; and they felt great pain, giddiness, dimness of sight, &c. even on a slight pressure of that part.

ingly tender; and they felt great pain, giddiness, dimness of sight, &c. even on a slight pressure of that part.

In wounds of the joints there is always a considerable difficulty of cure, by reason of the efflux of the synovia, which serves for lubricating the parts; and there is also great danger on account of the number of tendons, ligaments, and synovial glands, which are situated about the articulations. In this case, small wounds are more dangerous than large ones, especially when the former cannot be enlarged. The danger is least when the wound is situated in the upper part of the joint, and has not penetrated through the capsular ligament. The symptoms attending a wounded joint are, violent pain, inflammation, &c. with an efflux of thick whitish matter almost of the consistence of honey, called melicera, and is indeed no other than the synovia which lubricates the joint. This flux it is very difficult to restrain, and by it the wound is prevented from healing: at last the wound degenerates into an ulcer with callous lips, which ends in an incurable fistula; and even if the wound should at last be healed up, the joint for the most part remains stiff and contracted, so that the limb cannot be stretched out.

From the preceding account of the symptoms attending wounds in the different parts of the body, the surgeon may be enabled to judge in some measure of the event; though it must always be remembered, that wounds, even those which seemed to be of the slightest nature, have, contrary to all expectation, proved mortal, chiefly by inducing convulsions or a locked jaw; so that no certain prognostic can be drawn on sight of recent wounds. We shall now, however, proceed to consider their treatment.

For the cure of wounds, it has been already observed, that the ancients imagined balsams, the juice of herbs, &c. to be a kind of specifics. In after-ages, and in countries where balsams are not easily to be procured, salves have been substituted in their place; and even at this day there are many who reckon a salve or ointment essentially necessary for healing the slightest cut. It is certain, however, that the cure of wounds cannot be effected, nay, not even forwarded in the least, by ointments, unless in particular cases or by accident.

That power which the human frame has of repairing the injuries done to itself, which by physicians is called vis medicatrix naturae, is the sole agent in curing external injuries, and without this the most celebrated balsams would prove ineffectual. There are three stages to be observed in the cure of a wound: the first, called digestion, takes place when the ends of the wounded vessels contract themselves, and pour out the liquor which is converted into pus. As soon as this appears, the second stage, in which the flesh begins to grow up, takes place; and as this proceeds, the edges of the wound acquire a fine bluish or pearl colour, which is that of the new skin beginning to cover the wound as far as the flesh has filled it up. This process continues, and the skin advances from all sides towards the centre, which is called the cicatrizing of the wound. For the promoting of each of these processes, there were ointments formerly much in vogue. A composition of turpentine and the yolk of an egg was named digestive ointment, from the power it was supposed to have of promoting the formation of pus; basilicon and other ointments were supposed to promote

mote the growth of flesh, and there were ointments also for cicatrizing. But it is now found, that no ointment whatever is capable of promoting these operations; and it is only necessary to keep the wound clean, and to prevent the air from having access to it. This, indeed, nature takes care to do by covering the wounded part with a cake of coagulated blood; but if a wound of any considerable magnitude should be left entirely to nature, the pus would form below the crust of coagulated blood in such quantity, that it would most probably corrupt, and the wound degenerate into a corroding ulcer. It is necessary, therefore, to cleanse the wound once a-day; and for this purpose it will be proper to apply a little ointment spread on soft scraped lint. For the first dressing, dry lint is usually applied, and ought to be allowed to remain for two or three days, till the pus is perfectly formed; after which the ointment may be applied as just now directed; and, in a healthy body, the wound will heal without further trouble. As to the ointment employed, it is almost indifferent what it be, provided it has no acrid or stimulating ingredients in its composition; and hence the digestive ointment above-mentioned is rather hurtful than otherwise, on account of the stimulating nature of the turpentine which makes part of its composition.

But though, in general, wounds thus easily admit of a cure, there are several circumstances which require a different treatment, even in simple divisions of the fleshy parts, when neither the membranous nor tendinous parts are injured. These are, 1. Where the wound is large, and gapes very much, so that, if allowed to heal in the natural way, the patient might be greatly disfigured by the scar. In this case, it is proper to bring the lips of the wound near to each other, and to join them by future, either of the dry or bloody kind, as the wound is more superficial or lies deeper.

2. When foreign bodies are lodged in the wound, as when a cut is given by glass, &c. it is necessary by all means to extract them before the wound is dressed; for it will never heal until they are discharged. Sometimes it happens that these bodies are situated in such a manner as not to be capable of being extracted without lacerating the adjacent parts, which would occasion violent pain and other bad symptoms. In this case it is necessary to enlarge the wound so that these offending bodies may be easily removed. This treatment, however, is chiefly necessary in gunshot wounds, of which we shall treat in the next section.

3. When the wound is made in such a manner that it runs for some length below the skin, and the bottom is much lower than the orifice. In this case, the matter collected from all parts of the wound will be lodged in the bottom of it, where, corrupting by the heat, it will degenerate into a fistulous ulcer. To prevent this, we must use compresses, applied so that the bottom of the wound may suffer a more considerable pressure than the upper part of it. Thus the matter formed at the bottom will be gradually forced upwards, and that formed at the upper part will be incapable of descending by its weight; the divided parts in the mean time easily uniting when brought close together. Indeed, the power which nature has of uniting divided parts of the human body is very surprising; for, according to authors of credit, even if a piece of flesh

is totally cut out, and applied in a short time afterwards to the place from whence it was cut, the two will unite. On this principle Taliacotius, professor at Bologna, pretended to restore lost parts, as noses, ears, lips, &c. by cutting out a piece of the arm and adapting it to the part. But though these are justly looked upon to be ridiculous pretensions, we are certain that a part cut out of a living body does not entirely lose its vital power for some time, as is evident from the modern practice of transplanting teeth; and from an experiment of Dr Hunter's at London, where he put the testicle of a cock into the belly of a living hen, which adhered to the liver, and became connected to it by means of blood-vessels*. We have therefore the greatest reason to hope, that the divided parts of the human body, when closely applied to each other, will cohere without leaving any sinus or cavity between them. However, if this method should fail, and matter still be collected in the depending part of the wound, it will be necessary to make an opening in that part in order to let it out; after which, the wound may be cured in the common way.

4. During the course of the cure it sometimes happens, that the wound, instead of filling up with fleshy granulations of a florid colour, shoots up into a glassy-like substance which rises above the level of the surrounding skin, at the same time that, instead of laudable pus, a thin ill-coloured and fetid ichor is discharged. In this case the lips of the wound lose their beautiful pearl colour, and become callous and white, nor does the cicatrizing of the wound at all advance. When this happens in a healthy patient, it generally proceeds from some improper management, especially the making use of too many emollient and relaxing medicines, an immoderate use of balsams and ointments. Frequently nothing more is requisite for taking down this fungus than dressing with dry lint; at other times defecative powders, such as calamine, tutty, calcined alum, &c. will be necessary; and sometimes red precipitate mercury must be used. This last, however, is apt to give great pain, if sprinkled in its dry state upon the wound; it is therefore most proper to grind it with some yellow basilicon ointment, which makes a much more gentle, though at the same time efficacious, escharotic. Touching the overgrown parts with blue vitriol is also found very effectual.

Hitherto we have considered the wounded patient as otherwise in a state of perfect health; but it must be observed, that a large wound is capable of disordering the system to a great degree, and inducing dangerous diseases which did not before exist.—If the patient is strong and vigorous, the pain and inflammation of the wound great, a considerable degree of fever may arise, which it will be necessary to check by bleeding, low diet, and other antiphlogistic regimen, at the same time that the inflamed lips of the wound and parts adjacent are to be treated with emollient fomentations or cataplasms till the pain and swelling abate. On the other hand, it may happen, when the patient is of a weak and lax habit, that the vis viva may not be sufficient to excite such an inflammation in the wound as is absolutely necessary for its cure. In this case, the edges of the wound look pale and soft; the wound itself ichorous and bloody, without any signs of fleshy granulations; or if any new flesh shoots

Theory. up, it is of the fungous glassy kind above-mentioned. To such wounds all external applications are vain; it is necessary to strengthen the patient by proper internal remedies, among which the bark has a principal place, until the wound begins to alter its appearance. In such persons, too, there is some danger of a hectic fever by the absorption of matter into the body when the wound is large; and this will even take place during the course of the cure, even when the appearances have been at first as favourable as could be wished. This happens generally when the wound is large, and a great quantity of matter formed: for by this discharge the patient is weakened, so that the pus is no sooner formed, than it is by the absorbent vessels re-conveyed into the body, and feverish heats immediately affect the patient. For this the best remedy is to exhibit the bark copiously, at the same time supporting the patient by proper cordials and nourishing diet. Indeed, in general, it will be found, that, in the case of wounds of any considerable magnitude, a more full and nourishing regimen is required than the patient, even in health, has been accustomed to; for the discharge of pus alone, where the quantity is considerable, proves very debilitating, if the patient is not strengthened by proper diet. And it is constantly found, that the cure of such sores goes on much more easily when the patient is kept in his usual habit of body, than when his system is much emaciated by a very low allowance; and, for the same reason, purgatives, and whatever else tends to weaken the constitution, are improper in the cure of wounds.

70
Of hæmorrhagies. Hæmorrhagies very frequently happen in wounds, either from a division of one large artery, or of a number of small ones. In this case, the first step to be taken by the surgeon is to effect a temporary stoppage of the blood by means of strong compression. In the head, as well as in the trunk of the body, the easiest method of applying pressure of this kind is by means of dossils of linen or charpie, held firmly upon the mouths of the bleeding vessels, either by the hands of an assistant or the use of a proper bandage: but it is better when pressure can be applied to the superior part of the artery, as it not only secures the vessel equally well, but admits of the necessary ligature being applied with greater freedom. Where accidents of this kind, therefore, happen to any of the limbs, and pressure can be made on the superior part of the artery, the tourniquet is immediately to be applied.

71
Ancient surgeons defective in the knowledge of stopping hæmorrhagy. The patient being in this manner secured from immediate danger, the surgeon must take the proper means for preventing any return. In this the ancients were extremely defective. Being ignorant of the use of the tourniquet, and equally so of the method of tying up blood-vessels, they could only apply dossils of linen covered with astringent powders for the small arteries, and for the larger ones they had no other resource but fearing with red-hot irons. This cruel remedy they applied even in cases of amputation; and we find that some ancient chiro-surgical writers ordered the flesh to be divided down to the bone by a red-hot knife: but the effects even of this are by no means to be depended upon farther than as a temporary relief; for, in general, the pulsation of the larger arteries soon overcomes all resistance from the eschar occasioned by

the cautery. Styptic powders are still less efficacious; and though sponge, agaric, and fungous substances of various kinds, have been recommended even by the more skilful modern surgeons, yet the application of the ligature, and that alone, can be depended upon where the larger arteries are divided. In performing this operation there are two different methods; one in which the nerve which runs along with the artery, and part of the circumjacent muscles, are taken in with the artery in the ligature; the other, in which the divided artery is taken hold of by a pair of forceps, or by an hooked instrument called the tenaculum, and tied up by itself. The former method is liable to great objection, on account of the violent symptoms it occasions; particularly extreme pain, spasms, and convulsions, not only of the part affected, but even of the whole system.

Spasmodic twitches are frequently found † to occur after the amputation of limbs, and are often the source of much distress. In some instances they are no doubt to be considered as the effect of other causes; but in various cases it has happened, that demonstrative proof has been obtained of their arising from the ligatures of arteries having been applied in an improper manner. When such convulsive affections occur after amputations, and the usual means of preventing them have failed, effectual relief may be frequently obtained by destroying the ligatures altogether, so as to remove the compression upon the nerves; care being taken at the same time to renew the ligatures upon the arteries immediately, without comprehending any of the contiguous parts.

72
Ligature of the vessels. Practitioners have commonly been afraid of tying up blood-vessels by themselves without the intervention of some of the surrounding parts, on the supposition of the coats of arteries not being of a sufficient firmness for bearing that degree of compression necessary for the prevention of hæmorrhagy.—This, however, originates from an idea of the coats of arteries not being so strong as they really are, and of a great degree of force being necessary for compressing the sides of arteries into close contact with one another. But it is now well known, that even very small arteries are possessed of much firmness: and it is also certain, that, even in the largest arteries of the arm or thigh, a very slight degree of compression is fully sufficient, not only for restraining hæmorrhagy, but for securing the ligature on the very spot to which it is first applied; and in small vessels the force necessary for this purpose is trifling indeed, being far less than is commonly practised. It has also been objected to this mode of securing blood-vessels by themselves, that the ligatures, although they should not cut the arteries through, yet are more apt to slip than when some of the surrounding parts are comprehended along with them; and, in some instances, it is said that arteries retract so far, that they cannot in any other way be laid hold of than by means of the crooked needle in the ordinary method. Long and repeated experience, however, of a few individuals, of this mode of taking up arteries by themselves, has put the fact beyond a doubt, that it is equally secure as any other yet invented (A).—Fatal hæmorrhagies after capital operations, either from inattention or some

other cause, do now and then indeed happen in the hands of the most able practitioners; but occurrences of this nature have as frequently happened when the curved needle was employed, as when the blood-vessels were secured by themselves without any of the contiguous parts being included.

In a few instances it may happen, that a bleeding vessel, from lying at the bottom of a deep wound, cannot be laid hold of in any other manner than by the curved needle being made to pass round it. Such occurrences, however, are exceedingly rare. Among other advantages which the tying of arteries by means of the tenaculum has over the old mode of operating, there is still one we have not yet taken notice of. It often happens, after amputations and other operations where the larger arteries have been tied, that the ligatures do not come easily away, from being made to run so deep as with the curved needle is commonly necessary. In some instances much pain and trouble has occurred from this circumstance, the ligature remaining quite immovable for a great many weeks: and after all, we have seen it necessary for the surgeon to put the patient to a great deal of pain, by being obliged to cut out the threads with a scalpel. But when the tenaculum is used, every risk of this kind is effectually avoided, from the ligatures generally falling off of their own accord, in the course of the third or fourth dressing of the sore.

From what has been said, therefore, we shall consider it as a practice that ought to be established, that, in forming the ligature of arteries, the nerves and other contiguous parts should be carefully avoided.

The principal artery being in this manner secured, all the vessels or the part must one after another be taken up in the same manner, by first loosening the tourniquet in order to discover them, and afterwards applying the ligature to each in the manner directed. It often happens, however, that the loss of blood the patient has sustained, a tendency to deliquium which may take place for the time, the fear he labours under, and the degree of cold to which the sore is exposed, have all together such an effect upon the smaller arteries, as to prevent them for the time from discharging their contents; and as arteries left in such a state without being secured, generally burst out on the removal of these causes, a circumstance which always occasions much trouble to the practitioner, as well as a great deal of pain to the patient, every surgeon therefore ought to pay the nicest attention to this point. The tourniquet should be made perfectly loose; any coagulated blood on the surface of the sore ought to be carefully washed off with a sponge and warm water; and the patient, if faintish, ought to get a glass of wine or some other cordial; and after all, the surgeon ought to examine, with the most minute attention, the usual course which the vessels of the part are known to take. This being done, every artery of the part, even the smallest that can be distinguished, ought to be secured with a ligature: for such vessels as appear exceedingly trifling while the part is yet exposed to the air, after the patient becomes warm in bed, when of course the solids become relaxed and the fluids expand, even the smallest branches of arteries that happen to be neglected, will now be capable of producing much mischief, by discharging very considerable quantities of blood; and, as little or no injury can ever occur by the proper application of ligatures to all the arteries that present themselves, the greatest attention ought at all times to be paid to this circumstance.

When the principal arteries of a stump or other large wound have been taken up, and a little blood continues to be discharged, but appears to come from sundry small vessels only, the surgeon, unless he is much accustomed to this kind of business, is induced to think, that as they are very trifling to appearance, so he need not be at the trouble of tying them, as the necessary compression of the bandages proper for the wound will in all probability effect a total stoppage of the hemorrhage. In a general oozing of a small quantity of blood from the whole surface of a sore, and when no particular vessel can be distinguished, there is a necessity for trusting to this remedy; but whenever an artery can be discovered, of whatever size it may be, it ought unquestionably to be secured by a ligature. It very rarely happens that any inconvenience occurs from ligatures when properly applied; but many lives have been lost from a remissness in this article. But when, from the deepness of a wound, or from any other cause, some particular artery cannot be properly secured by the tenaculum, in this case we are under the necessity of employing the crooked needle. But it frequently happens, that considerable quantities of blood are discharged, not from any particular vessel, but from all the small arteries over the surface of the sore. In wounds of great extent, particularly after the extirpation of cancerous breasts, and in other operations where extensive sores are left, this species of hemorrhage often proves very troublesome by being exceedingly difficult to suppress.

Bleedings of this kind seem evidently to proceed from two very different and opposite causes. First, Either from too great a quantity of blood contained in the vessels, or from an over-degree of tone in the vessels themselves; or, perhaps, from a combination of both these causes. But, secondly, Such evacuations undoubtedly happen most frequently in such constitutions as are very relaxed and debilitated; either from a putrid dissolved state of the blood, or from a want of tone in the containing vessels, or, in some instances, from a concurrence of both.

In constitutions perfectly healthy, when the fluids are not tainted with any degree of putrefaction, and the solids are possessed of their natural tonic powers, on the occurrence of wounds even of the most extensive nature, as soon as the larger arteries are secured, all the small vessels that have been divided, in consequence of that contractile power with which in a state of health they are endowed, and from the stimulus of the external air to which they are now exposed, are diminished not only in their diameters, but also in their length; in consequence of which, they recede considerably within the surface of the surrounding parts. This cause of itself would probably in the greatest number of instances prove sufficient for restraining all loss of blood from the smaller arteries; but, in the sound state of constitution of which we have now been speaking, another very powerful agent is provided by nature for producing the same effect. From the extremities of the divided vessels which at first discharged red blood only, there now, in their contracted state, oozes out a

Theory. more thin, though viscoid fluid, containing a great proportion of the coagulable parts of the blood; and this being equally distributed over the surface of the wound, by its balsamic agglutinating powers has undoubtedly a very considerable influence in restraining all such haemorrhagies.

that in all such circumstances, much larger doses of the remedy are necessary than in ordinary cases requiring the use of opiates. Small doses, instead of answering any good purpose, seem frequently rather to aggravate the various symptoms; so that whenever they are here had recourse to, they ought always to be given in quantities sufficient for the intended effect.

Although haemorrhagies of this nature do now and then occur in firm vigorous constitutions, yet they undoubtedly happen much more frequently in relaxed enfeebled habits, where the solids have lost part of their natural firmness, and the fluids have acquired some degree of putrefaction. As the vessels in this situation of matters are supposed to have been deprived of that degree of tone of which we wish them to be possessed, instead of restraining the patient from the use of cordials, as is done usually in every case of haemorrhagy, a moderate use of generous wine ought to be immediately prescribed; for nothing, it may be observed, tends so much, in such circumstances, to restrain haemorrhagies, as a well-directed use of proper cordials. By tending to invigorate and brace the solids, they thereby enable the arterial system to give a due resistance to the contained fluids; and the same cause, it may be observed, has a considerable influence in restoring to the fluids that viscosity of texture, of which in all such instances we suppose them to be deprived.

Whenever, therefore, such tedious haemorrhagies occur in relaxed debilitated habits, a free use of Port, Madeira, or any other wine whose strength and goodness can be depended on, ought to be immediately allowed; a nourishing diet also becomes proper; the patient ought to be kept cool; and the mineral acids, from their known utility in every species of haemorrhagy, ought also to be prescribed. Rest of body is here proper too; and opiates, when indicated either by pain or spasmodic affections of the muscles, ought never to be omitted.

Together with these remedies adapted to the general system, particular dressings, appropriated to the state of the parts to which they are to be applied, have been found very beneficial. We have already remarked, that in firm healthy constitutions, as soon as the discharge of blood which naturally occurs in every large wound is over, the parts come soon to be covered with a viscoid coagulable effusion from the mouths of the now retracted arteries; but in constitutions of an opposite nature, where the solids are much relaxed, the blood in general is found in such a dissolved state as to afford no secretion of this nature.

In order therefore to supply as much as possible the deficiency of this natural balsam, different artificial applications have been invented. Dusting the part with starch or wheat-flour, has sometimes been found of use; and gum arabic in fine powder has been known to answer when these failed.

Applications of this kind, indeed, have been used with success in all such haemorrhagies, with whatever habit of body they happen to be connected; but they have always proved more particularly serviceable in relaxed constitutions, attended with a dissolved state of the blood and an enfeebled muscular system. We may here use with freedom, too, a remedy which in such circumstances generally proves serviceable, but which, in constitutions of an opposite nature, ought never to be

be employed. The remedy alluded to is alcohol, or any other ardent spirits, impregnated with as great a quantity as they can dissolve of myrrh or any other of the heating viscoid gums. The balsamum traumaticum of the shops, a remedy of this nature, has long been famous for its influence in such cases: but that indiscriminate use of this and similar applications which has long prevailed with some practitioners, has undoubtedly done much harm; for as they are all possessed of very stimulating powers, they of course tend to aggravate every symptom in wounds connected with a tense state of fibres, when much pain, and especially when spasmodic muscular affections prevail. But in constitutions where the blood appears to be in a dissolved state, and where the arterial system seems evidently to require a stimulus, remedies of this class come to be very useful; inasmuch that, in every constitution of this kind where hemorrhagies prove troublesome, no application whatever is found to answer better than charpie immersed in an agglutinating spirituous balsam of this nature.

By a due perseverance in one or other of the plans here pointed out, it will seldom happen that hemorrhagies of this nature are not at last put a stop to: but when the contrary does occur, when, notwithstanding the use of the remedies recommended, a discharge of blood still continues, together with the means already advised, an equal moderate pressure ought to be applied over the whole surface of the sore, to be continued so long as the necessity of the case seems to indicate.

In finishing the dressings of such wounds, after the charpie and compresses have been applied, a bandage properly adapted to the part ought to conclude the whole, and in such a manner as to produce as equal a degree of pressure over the surface of the sore as possible. But it now and then happens that no bandage whatever can be so applied as to produce the desired effect; and in such cases the hand of an assistant is the only resource. In these instances, a person's hand being firmly applied over the dressings so as to produce a very equal degree of pressure, will commonly succeed when no other remedy is found to have much influence.

Wounds of the nerves, tendons, and membranes, as they are attended with much more violent symptoms than those where even considerable arteries are divided, so they frequently resist every method of cure proposed by the most skilful practitioners. In the simple process of blood-letting, it frequently happens that the tendinous expansion called the aponeurosis of the biceps muscle is wounded, or even the tendon of that muscle itself is punctured, by the point of the lancet; or sometimes a nerve which happens to lie in the neighbourhood is partially divided. Any one of these wounds, though they are the smallest we can well suppose to be given, are frequently very dangerous and difficult of cure. It sometimes immediately happens on the introduction of the lancet, that the patient complains of a most exquisite degree of pain; and when this occurs, we may rest assured that either a nerve or tendon has been wounded. On some occasions, by proper management, such as evacuating a considerable quantity of blood at the orifice newly made, by keeping the part at perfect rest, and preserving the patient in as cool a state as possible, the pain at first complain-

ed of will gradually abate, and at last go off entirely, without any bad consequence whatever. At other times, however, this pain which occurs instantaneously on the introduction of the lancet, instead of abating, begins soon to increase; a fullness, or small degree of swelling, takes place in the parts contiguous to the wound; the lips of the sore become somewhat hard and inflamed; and, in the course of 24 hours or so from the operation, a thin watery serum begins to be discharged at the orifice.

If by the means employed relief is not soon obtained, these symptoms generally continue in nearly the same state for two or perhaps three days longer. At this time the violent pain which at first took place becomes still more distressing; but instead of being sharp and acute as before, it is now attended with the sensation of a burning heat, which still goes on to increase, and proves, during the whole course of the ailment, a source of constant distress to the patient. The fullness and hardness in the lips of the wound begin to increase, and the swelling in the neighbouring parts gradually extends over the whole member; from the foot upwards over the thigh, when the operation has been done in the lower extremity; and from the elbow down the fore-arm, and along the humerus over to the pectoral muscle and other contiguous parts, when the accident has occurred at the usual place of blood-letting in the arm. The parts at last become exceedingly tense and hard; an erysipelatus inflammatory colour frequently appears over the whole member; the pulse by this time has generally become very hard and quick; the pain is now intense, the patient exceedingly restless; twitchings of the tendons occur to a greater or lesser degree; on some occasions, a locked jaw and other convulsive affections supervene; and all these symptoms continuing to increase, it most frequently happens, that the torture under which the patient has been groaning is at last terminated by death.

Different opinions have prevailed respecting the cause of these symptoms. By some they have been imputed to wounds of the tendons. By others the tendons are supposed to be so entirely destitute of sensibility, as to be quite incapable of producing so much distress; so that wounds of the nerves they consider on all such occasions as the true cause of the various symptoms we have mentioned.

One or other of these ideas continued to be the only source for explaining the various phenomena found to occur in this malady, till a different opinion was at last suggested by the ingenious Mr John Hunter of London. Mr Hunter supposes, that all the dreadful symptoms found now and then to be induced by the operation of blood-letting, may be more readily accounted for from an inflamed state of the internal surface of the vein, than from any other cause. Such a state of the vein he has often traced in horses that have died of such symptoms from venesection, where the internal coat of the vein was always found much inflamed, not only in the neighbourhood of the part where the orifice was made, but on some occasions the inflammation extended along the whole course of the vein, and seemed at last to reach the heart itself. Some instances, too, have occurred, of the same appearances in the human body, where the veins after death were found in a state of high inflammation. And on other occasions,

Theory. inflammation having in this manner been once excited, has been known to terminate in suppuration; and the matter thus produced being in the course of circulation carried to the heart, Mr Hunter supposes that in such cases death may have been induced by that cause alone.

Bell's Surgery, p. 113. There can be no reason to doubt the fact held forth by Mr Hunter, that in such instances the vein in which the orifice has been made has frequently after death been found greatly inflamed: but however ingenious his arguments may be for concluding that this state of the vein is the original cause of all the bad symptoms enumerated, and although we must allow that such an inflammatory affection of a vein must have a considerable influence in aggravating the various symptoms previously induced by other causes; yet we may very fairly conclude, that it could not probably in any one instance be able to account with satisfaction for their first production.

Objections to his hypothesis. In many instances the patient, at the very instant of the operation, feels a very unusual degree of pain. In some cases, the violence of the pain is almost unsupportable: now this we can never suppose to have been produced by the mere puncture of a vein; for although the coats of veins are not perhaps entirely destitute of feeling, yet we know well that they are not endowed with such a degree of sensibility as to render it probable such intense pain could ever be induced by their being punctured in any way whatever. This inflamed state of the veins therefore, as detected by Mr Hunter after death, must be considered rather as being produced by, than as being productive of, such affections; and that such ailments should frequently produce an inflammation of the contiguous veins, is a very probable conjecture. In the course of 48 hours or so from the operation, when the febrile symptoms are just commencing, such a degree of hardness and evident inflammation is induced over all the parts contiguous to the orifice, that it would be surprising indeed if the vein, which is thus perhaps entirely surrounded with parts highly inflamed, should escape altogether. We shall therefore proceed upon the supposition of this inflamed state of the veins being a consequence rather than the cause of such ailments; and of course we now revert to one or other of the opinions long ago adopted on this subject, that all the train of bad symptoms found on some occasions to succeed to venesection, proceeds either from the wound of a nerve or of a tendon.

92 Tendon when punctured produce as bad symptoms as wounded nerves. That a partial wound of a nerve will now and then produce very distressing symptoms, no practitioner will deny: but it has been attempted to be shown, that tendons are almost totally destitute of sensibility; and it has therefore been supposed, that their being wounded can never account for the various symptoms known to occur in such cases. There is great reason however to think, that in different instances the same train of symptoms have been induced by different causes; that in one instance a wounded nerve, and in others pricks of the tendons, have given rise to them, as we have already supposed.

93 Method of cure. However, in order to prevent as much as possible the consequent inflammation and other symptoms which usually ensue, a considerable quantity of blood should be immediately discharged at the orifice just made: the limb, for several days at least, ought to

be kept in a state of perfect rest, care being at the same time taken that the muscles of the part be all preserved in as relaxed a state as possible: the patient should be kept cool; on a low diet; and, if necessary, gentle laxatives ought to be administered.

By such management alone, the fatal symptoms we have enumerated may frequently be prevented; and when they do occur in cases where the above precautions have not been taken, they may be considered to be as much the consequence of negligence in the after-treatment, as of any thing peculiarly bad in the nature of the original accident.

When, however, notwithstanding the means recommended, the symptoms, instead of diminishing, rather become more violent; if the lips of the orifice turn hard and more inflamed, if the pain becomes more considerable, and especially if the swelling begins to spread, other remedies come then to be indicated. In this state of the complaint, topical blood-letting, by means of leeches applied as near as possible to the lips of the wound, frequently affords much relief; and when the pulse is full and quick, it even becomes necessary to evacuate large quantities of blood by opening a vein in some other part.

94 External applications. The external applications usually employed in this state of the complaint, are, warm emollient fomentations and poultices. In similar affections of other parts no remedies with which we are acquainted would probably be found more successful; for as warm fomentations and cataplasms prove in general very powerful agents in the formation of pus, and as nothing would so certainly relieve the symptoms which usually occur here as a free suppuration, applications of this nature were made therefore with some apparent propriety: but it is now almost certain, that little or no advantage is ever to be expected from remedies of this class. And in fact we find, in the complaint now under consideration, that all such applications, instead of being productive of any advantage, rather do harm. The heat of the part is here one of the most distressing symptoms; so that, instead of affording relief, warm emollient applications rather tend to augment this source of uneasiness. The lips of the wound, from not being capable of producing a good suppuration, are by the additional heat applied to them through the medium of such applications, rendered still more hard, swelled, and of course more painful; and the swelling of the contiguous parts also becomes more diffuse over the rest of the member.

By Ambrose Parre, Dionis, Heister, and others, instead of emollient remedies, oil of turpentine, tincture of myrrh, and other heating applications, are recommended. "That these would not prove effectual," says Mr Bell, I cannot from experience pretend to say; for suspecting their powerful stimulating effects might in cases of this nature prove too irritating for parts already by disease rendered exquisitely sensible, I have never, I must own, ventured to use them: but I can from repeated experience assert, that cooling astringent applications afford much more ease, and, upon the whole, in all such ailments, prove more effectual, than of great use. warm emollients; and of this class the most effectual I have ever used, are the saturnine applications. The parts chiefly affected being alternately covered with cloths wet with a solution of saccharum saturni, and

95 Cooling astringents.

pledgets spread with Goulard's cerate, are kept more cool and easy than by any other remedy I have ever happened to use."

In all such cases therefore, so soon as the number of leeches proportioned to the violence of the symptoms have been applied to the parts chiefly affected, and have discharged a sufficient quantity of blood, the swelling ought to be covered with pieces of soft linen wet in the saturnine solution; and these being kept constantly moist for the space of a few hours, should be succeeded by Goulard's cerate; and thus every part, in any degree affected, ought to be alternately covered with one or other of these applications so long as any degree of swelling remains.

The febrile symptoms which occur must at the same time be attended to, by keeping the patient cool, on a low diet, preserving a lax state of the bowels; and, if necessary, farther quantities of blood ought to be evacuated.

For the violence of the pain, which is sometimes so excessive as to destroy entirely the patient's rest, opiates ought to be freely exhibited; and when twitchings of the tendons and other convulsive symptoms supervene, medicines of this kind become still more particularly necessary. In order, however, to have a proper influence in this state of the complaint, opiates ought to be given in very full doses; otherwise, instead of answering any good purpose, they constantly tend to aggravate the different symptoms, not only by increasing the heat and restlessness, but by having an evident influence in rendering the system more susceptible than it was before of the pain and other distressing effects produced upon it by the wound: whenever opiates, therefore, are in such circumstances employed, the doses ought always to be considerable.

It often happens, however, in this very alarming disorder, either from neglecting the matter altogether on the accident first happening, as is too frequently the case, or from an improper subsequent treatment by warm emollient applications, that opiates and all the other remedies enumerated are afterwards had recourse to without any advantage whatever: the fever, pain, and swelling of the parts continuing, convulsive affections of the muscles at last occur, all tending to indicate the most imminent danger. In this situation of matters, if we have not immediate recourse to some effectual means, the patient will soon fall a victim to the disorder; and the only remedy from which in these circumstances much real advantage is to be expected, is a free and extensive division of the parts in which the orifice producing all the mischief was at first made. We know well, from the repeated experience of ages, that much more pain and distress of every kind is commonly produced by the partial division either of a nerve or of a tendon, than from any of these parts being at once cut entirely across. Now the intention of the operation here recommended, is to produce a complete division of the nerve or tendon we suppose to have been wounded by the point of the lancet, and which we consider as the sole cause of all the subsequent distress.

The operation now recommended being attended with a good deal of pain, and being put in practice for the removal of symptoms from which it is perhaps difficult to persuade the patient that much danger can

occur, all the remedies we have mentioned should be first made trial of before it is proposed: but at the same time, care ought to be taken that the disorder is not allowed to proceed too far before we have recourse to it; for if the patient should be previously much weakened by the feverish symptoms having continued violent for any length of time, neither the remedy now proposed, nor any other with which we are acquainted, would probably have much influence. So soon therefore as the course already prescribed has been fairly tried, and is found to be inadequate to the effects expected from it, we ought immediately to have recourse to a free division of the parts chiefly affected; the manner of doing which will be described in its proper place.

These are the general methods of treating simple wounds of the nerves, tendons, or membranes; but where the wounds are very large, and attended with great distraction, laceration, and loss of substance, some farther directions will be necessary; but of these we shall treat in the next section. The total division of a tendon is not attended with much danger where division of tendons. 99

Wounds of the thorax, even tho' none of the viscera should be wounded, we may yet reasonably expect that a considerable quantity of blood will be extravasated; and this, if very large, must be evacuated if possible. However, it ought to be particularly observed, that this extravasated blood should not be discharged before we are assured that the wounded vessels have done bleeding. When the pulse appears sufficiently strong and equal, the extremities are warm, no hiccup or convulsion appears, and the patient's strength continues, we may then know that the internal hæmorrhagy has ceased, and that the means for discharging the blood may now be safely used. It may, however, be doubted whether the extravasated blood ought always to be discharged by art; since it is apparent from the most faithful observations, that matter, water, blood, &c. have vanished from the cavities of the thorax, and been afterwards discharged by sweat, urine, &c. Yet this but seldom happens; and if we were to trust to nature only in these cases, it is certain that many would perish from a destruction of the vital viscera by the extravasated and putrid blood, who by an artificial extraction of the same blood might have been saved. The extraction therefore is to be attempted, by putting the body in such a posture that the blood may flow out through the orifice of the wound; by sucking through a flexible tube, obtuse at the end, and having holes in its sides; by injections of diluent, attenuating, and deterring liquors; by dilating the wound, or perforating the thorax a little above the diaphragm, as in the operation for an empyema. By one or other of these methods, wounds of the thorax may generally be cured, provided the viscera are not injured in such a manner as to render them incapable of performing the offices of life.

In wounds of the abdomen, where the intestines are injured, they must, if possible, be joined by what is called the Glover's suture; though, when the wound

Throy. is small, they may be left to themselves. In all wounds of the abdomen, however, there is great danger from the entrance of the air between the integuments and the viscera. This, if confined, will be rarefied to an extreme degree, and occasion the most violent pains, with incredible distension of the abdomen. It is necessary therefore, that the air which has entered should be expelled, by sucking and the effort of respiration; after which the integuments are to be sewed together, and the wound is to be cured in the same manner as directed for simple wounds: only it will require to be dressed as seldom as possible; and a spare diet, with other antiphlogistic regimen, is here absolutely necessary.

102
Of the intestines prolapsed through a wound without being injured.

It sometimes happens, that, through a large wound of the abdominal integuments, the intestine comes out without being injured; yet, if it remains for any time exposed to the air, the case is commonly very dangerous. If assistance can be had at the moment the wound is given, the intestines are immediately to be replaced, and the patient laid in such a posture that they cannot by their own gravity fall out again. However, if assistance is not procured in time, and thus the intestine is become dry and cold, it ought to be well fomented before it is replaced. Celsus advises also, that those parts of the intestine which prolapsed last should be first replaced, after which the patient should be gently shaken, that each of the intestines may reduce itself to its proper place, and there remain.—This advice is very necessary to be observed; otherwise violent gripes and other bad consequences may follow. Garengeot also gives us another advice of no small consequence, namely, that if the wound is in the middle of the abdomen under the navel, penetrating through the rectus muscle on either side, then the prolapsed part of the intestine or omentum is frequently liable to be returned under that muscle, between its body and the tendinous capsule, which very loosely encompasses this muscle below the navel; since it might thus be falsely imagined that the intestine was returned into the abdomen, whence the most violent disorders might ensue. If the intestines are already cold and dry, before any attempts are made to replace them, we ought first to be certain that life remains in these parts: otherwise we might expect an absolute mortification; and though the mortified parts should cast off, the contents of the intestines would escape into the cavity of the abdomen; whence the death of the patient would follow, after the most miserable disorders.

When the wound of the abdomen is large, the intestines easily prolapse, but are as easily returned. But when part of an intestine has been forced through a narrow wound, the disorder is much more dangerous. For the prolapsed intestine being distended by flatus, or the ingested aliments driven thither by the peristaltic motion, it will be inflamed, tumefied, and incapable of being returned through the stricture of the wound; whence a stoppage of the circulation and gangrene will soon follow. In this case the utmost care is to be taken to reduce the intestine to its natural size; and warm fomentations are among the principal means for this purpose. If these should fail, some practitioners of great eminence have advised the puncturing of the intestine in different places in order to discharge the flatus. This practice has also

been recommended in an incarcerated hernia: but is exceedingly disapproved of by Mr Pott; and even in the present case it seems to be very dubious whether any good can possibly arise from it. To puncture any part that is already inflamed, must undoubtedly add to the inflammation; and it is very improbable that the discharge of flatus procured by the punctures would at all be a recompence for the bad consequences produced by the increased inflammation. The method recommended by Celsus seems in this case to be much more eligible; namely, to dilate the wound in such a manner as to reduce the intestine with ease. Sometimes these methods may succeed, and the intestine be preserved whole; though at other times it unavoidably happens that part of it is lost either by suppuration or gangrene. In these cases we must use our utmost endeavours to make the two ends of the intestine unite; and if they do so, the loss of the gangrened or suppurated part will not be much felt: but if this should be found impracticable, the upper part of the intestine should be joined to the edge of the wound; where it will ever afterwards perform the office of an anus, and the faeces will continue to be discharged that way through life. It is to be remarked, however, that even in the most favourable case, viz. where the divided ends of the intestine unite, there will always remain a stricture on the part; for which reason it is requisite that the patient should be very temperate in his diet, eat soft food, and by small quantities at a time; otherwise there will be danger of an obstruction in the place of union, and a rupture may ensue.

103
Treatment necessary when part of the intestine is gangrened.

104
Remarkable case of wounds in the abdomen.

When the omentum appears prolapsed, the same general treatment is to be observed; only that, when it is dry and mortified, the dead part may safely be extirpated.—We shall conclude the article of abdominal wounds with a case from the memoirs of the academy of sciences for the year 1705, which shows that we ought not to despair, even though the most desperate symptoms should take place, as long as any vis vitæ remains. A madman wounded himself in 18 different places of the abdomen. Eight of these penetrated the cavity, and injured the contained viscera; he had a diarrhoea, nausea, and vomiting, tension of the abdomen, with difficult respiration and violent fever, so that his life was despaired of. During the first four days, he was blooded seven times; and during the greatest part of the cure his diet consisted almost entirely of flesh-broths, with the addition of some mild vegetables. By these means he was not only cured of his wounds, but restored to his right senses. Seventeen months after, he went mad again, and threw himself over a precipice, by which he was instantly killed: on opening the body, the wounds were found to have penetrated the middle lobe of the liver, the intestinum jejunum, and the colon.

105
Wounds of the head. In wounds of the head, where the cellular membrane only is affected, and the aponeurosis and peri-cranium untouched, phlebotomy, lenient purges, and the use of the common febrifuge medicines, particularly those of the neutral kind, generally remove all the threatening symptoms mentioned, n^o 105. When the inflammation is gone off, it leaves on the skin a yellowish tint and a dry scurf, which continue until perspiration takes them away; and upon the removal of

Theory. of the disease, the wound immediately recovers an healthy aspect, and soon heals without further trouble. But in the worst kind of these wounds, that is, where a small wound passes through the tela cellulosa and aponeurosis to the pericranium, the patient will admit of more free evacuations by phlebotomy than in the former. In both, the use of warm fomentations is required; but an emollient cataplasm, which is generally forbid in the erysipelatus swellings, may in this latter case be used to great advantage. Where the symptoms are not very pressing, nor the habit very inflammable, this method will prove sufficient; but it sometimes happens that the scalp is so tense, the pain so great, and the symptomatic fever so high, that by waiting for the slow effect of such means, the patient runs a risk from the continuance of the fever; or else the injured aponeurosis and pericranium, becoming sloughy, produce an abscess, and render the case both tedious and troublesome. A division of the wounded part, by a simple incision down to the bone, about half an inch or an inch in length, will most commonly remove all the bad symptoms; and if it be done in time, will render every thing else unnecessary.

In wounds of the joints, if any thing can be done to save the limb, it must be by dilating the wound in order to discharge the humour, which collects in great quantity. At the same time the most cooling and disicuent remedies are to be applied to the neighbouring parts, while the wound itself is to be treated with drying gums and balsams. Relaxing and emollient applications are bad, as causing a great efflux of humour, which at any rate is too copious. The air and cold are likewise to be avoided, and all applications to the wound ought to be of the warm and stimulating kind.

SECT. II. Of contused and lacerated Wounds, without or with Fractures of the Bones.

WHEN the small vessels are broken by a blow with any hard instrument without penetrating the skin, at the same time that the solid fibres of the part are crushed, the injury is termed a contusion; and when at the same time the skin is broken, it is termed a contused and lacerated wound; because in this case the parts are not fairly divided as with a knife, but torn asunder or violently stretched.

Every contusion therefore, whether the skin is broken or not, may properly be reckoned a wound; for where the injury is so slight that none of the contents of the small vessels are extravasated, it scarce deserves to be mentioned. The immediate consequence of a contusion, therefore, is a swelling, by reason of the extravasation just mentioned; and the skin becomes discoloured by the blood stagnating under it: but as this fluid, even though covered by the skin, cannot long remain in its natural state, it thence happens, that the contused part soon loses its florid red colour, and becomes blue or black; the thinner parts being in the mean time gradually taken up by the absorbent vessels, which at last happens to the blood itself; the blue disappears, and is succeeded by a yellowish colour, showing that the blood is now dissolved; after which the part recovers its former appearance, and the ruptured vessels appear to have united as though nothing had happened.

These are the symptoms which attend the slightest kind of contusions; but it is evident, that where the blow is so violent as to rupture or crush some of the large nerves, blood-vessels, tendons, or membranes, all the bad consequences already mentioned which attend simple wounds of those parts will ensue, and they will not at all be alleviated by the circumstance of the skin being whole. Hence it is easy to see how a contusion may produce ulcers of the worst kind, gangrene, sphaecelus, carious bones, &c.; and if it happens to be on a glandular part, a scirrhus or cancer is very frequently found to ensue. Even the viscera themselves, especially of the abdomen, may be injured by contusions to such a degree as to produce an inflammation, gangrene, or scirrhus, nay instant death, without rupturing the skin; and such a blow as a man may strike with his fist will often be sufficient for this purpose, as has been observed in the case of some celebrated boxers.

That the bones may be fractured along with a contusion, is known by every day's experience; however, without being broken, it is certain that they may be so crushed and injured, that the medullary substance contained in them may be vitiated, and thus the most grievous disorders may ensue. But in no part whatever are contusions more dangerous than in the head, as has been confirmed by the most fatal experience. Mr Pott divides into two classes those injuries to which the head is liable from contusion, viz. those in which the mischief is confined to the scalp, and those where the other parts are concerned. The former is of little consequence; the tumour attending it being easily removed, or the extravasated blood with which it is filled may be discharged by a small opening. One circumstance, however, he says, attending this tumour, requires considerable attention; for the tumour here sometimes produces to the fingers a sensation as if the cranium was broken and depressed; whence an inexperienced surgeon might be apt to remove the scalp as in the real fracture, and thus give his patient a great deal of unnecessary pain. The touch therefore being in this case fallacious, it is necessary to wait for the appearance of other symptoms before we proceed to a division of the integuments.

The most dangerous contusions of the head are those where the dura mater and parts within the skull are extremely affected; and in order to have a clear idea of this kind of injury, it is necessary to recollect, that the vessels of the pericranium, those of the diploe, or medullary substance between the two tables of some parts of the cranium, and those of the dura mater within it, do all constantly and freely communicate with each other; and that this communication is carried on by means of innumerable foramina, found in all parts of both surfaces of the skull, as well as at the sutures; that upon the freedom of this communication depends the healthy and sound state of all the parts concerned in it; and that from the interruption or destruction of this proceed most of the symptoms attending violent contusions of the head, extravasations of fluid between the cranium and dura mater, inflammations of the said membrane, and simple undepressed fracture of the skull.

The pericranium is so firmly attached to the outer surface of the skull, as not to be separable from it with-

Theory. without considerable violence; and when such violent separation is made in a living subject (especially if young), the cranium is always seen to bleed freely from an infinite number of small foramina. The dura mater, which is a firm strong membrane, is almost as intimately attached to the inside of the skull, as the pericranium is to the outside, and by the same means, viz. by vessels; and by these means a constant circulation and communication are preserved and maintained between the two membranes, and the bones dividing them. This all the appearances which attend the scalping a living person, or the separation of the skull from the dura mater of a dead one, (especially if such person died apoplectic or was hanged), prove beyond all doubt. In the former, the blood will (as we have already observed) be seen issuing from every point of the surface of the cranium: in the latter, not only a considerable degree of force will be found necessary to detach the sawed bone from the subjacent membrane, but, when it is removed, a great number of bloody points will be seen all over the surface of the latter; which points, if wiped clean, do immediately become bloody again, being only the extremities of broken vessels. These vessels are largest at and about the sutures; at which places the adhesion is the strongest, and the hæmorrhage upon separation the greatest.

112
Communication between the outside and inside of the cranium.

113
Mistakes concerning the attachment of the dura mater.

It has been thought by many, that the dura mater was attached to the skull only at the sutures; that in all other parts it was loose and unconnected with it; and that it constantly enjoyed or performed an oscillatory kind of motion, or was alternately elevated and depressed. This idea and opinion were borrowed from the appearance which the dura mater makes in a living subject, after a portion of the skull has been removed: but although it has been inculcated by writers of great eminence, yet it has no foundation in truth or nature; and has misled many practitioners in their opinions, not only of the structure and disposition of this membrane, but in their ideas of its diseases.

114
Extravasations of blood within the cavity of the skull.

The dura mater does, on the internal surface of the bones of the cranium, the office of periosteum, in the same manner as the pericranium does on the external, (at least they have no other): to this it is so firmly and so generally attached, as to be incapable of any even the smallest degree of motion. The alternate elevation and subsidence of it, which are observable when any portion of it is laid bare, are owing to a very different cause from any power in itself; neither are nor can they ever be performed, until a piece of the cranium has been forcibly taken away, and consequently are not natural or necessary.

By blows, falls, and other shocks, some of the larger of those vessels which carry on this communication between the dura mater and the skull are broken, and a quantity of blood is shed upon the surface of that membrane. This is one species of bloody extravasation, and indeed the only one which can be formed between the skull and dura mater. If the broken vessels be few, and the quantity of blood which is shed be small, the symptoms are generally slight, and by

Theory. proper treatment disappear (s). If they are large or numerous, or the quantity of extravasated fluid considerable, the symptoms are generally urgent in proportion: but whether they be slight or considerable, whether immediately alarming or not, they are always and uniformly such as indicate pressure made on the brain and nerves, viz. stupidity, drowsiness, diminution or loss of sense, speech, and voluntary motion.

But it also often happens, from the same kind of violence, that some of the small vessels which carry on the circulation between the pericranium, skull, and dura mater, are so damaged as not to be able properly to execute that office, although there are none so broken as to cause an actual effusion of blood.

115
What injuries are most likely to produce an inflammation of the dura mater.

Smart and severe strokes on the middle part of the bones, at a distance from the sutures, are most frequently followed by this kind of mischief; the coats of the small vessels which sustain the injury inflame, and become sloughy; and in consequence of such alteration in them, the pericranium separates from the outside of that part of the bone which received the blow, and the dura mater from the inside: the latter of which membranes, soon after such inflammation, becomes sloughy also, and furnishes matter; which matter being collected between the said membrane and the cranium, and having no natural outlet whereby to escape or be discharged, brings on a train of very terrible symptoms, and is a very frequent cause of destruction. The effect of this kind of violence is frequently confined to the vessels connecting the dura mater to the cranium; in which case the matter is external to the said membrane: but it sometimes happens, that by the force either of the stroke or of the concussion, the vessels which pass between and connect the two meninges, are injured in the same manner; in which case, the matter formed in consequence of such violence is found on the surface of the brain, or between the pia and dura mater, as well as on the surface of the latter, or perhaps in all these three situations at the same time.

116
The difference of this kind of disease from either an extravasation of blood or a commotion of the medullary parts of the brain, is great and obvious. All the complaints produced by extravasation are (as we have already said) such as proceed from pressure concussions, made on the brain and nerves, and obstruction to the circulation of the blood through the former; stupidity, loss of sense and voluntary motion, laborious and obstructed pulse and respiration, &c. and (which is of importance to remark) if the effusion be all considerable, these symptoms appear immediately or very soon after the accident.

The symptoms attending an inflamed or sloughy state of the membranes, in consequence of external violence, are very different; they are all of the febrile kind, and never, at first, imply any unnatural pressure: such are, Pain in the head, restlessness, want of sleep, frequent and hard pulse, hot and dry skin, flushed countenance, inflamed eyes, nausea, vomiting, rigor; and toward the end, convulsion, and delirium. And

(s) This must be supposed to be spoken in a general sense; because it is well known, that sometimes a very small quantity of extravasated fluid will produce the most alarming and most pressing symptoms; and that at other times a large quantity will occasion none at all.

none of these appear at first, that is, immediately after the accident; seldom until some days are past.

One set or class of symptoms are produced by an extravasated fluid making such pressure on the brain and origin of the nerves as to impair or abolish voluntary motion and the senses: the other is caused by the inflamed or putrid state of the membranes covering the brain, and seldom affects the organs of sense until the latter end of the disease; that is, until a considerable quantity of matter is formed, which matter must press like any other fluid.

It is a generally received opinion, that blood shed from its vessels, and remaining confined in one place, will become pus; and that the matter found on the surface of the dura mater toward the end of these cases was originally extravasated blood. But that pure blood shed from its vessels by means of external violence, and kept from the air, will not turn to or become matter, is proved incontestably by every day's experience in many instances; in aneurysms by puncture, in retained menses by imperforate vaginae, and in all ecchymoses. True pus cannot be made from blood merely; as may be known from the manner in which all abscesses are formed, and from every circumstance attending suppuration: and that the matter found on the surface of the dura mater, after great contusions of the head, never was mere blood, we are as certain as observation and experience can make us.

Some of the French writers have indeed divided the symptoms of what they call a contusion of the head, into two kinds; and have named them primitive or original symptoms, and secondary or consequential ones: among the former, they rank immediate loss of sense, hæmorrhagy, involuntary discharge of urine and faeces, great propensity to sleep, &c.; among the latter they reckon fever, delirium, rigor, convulsion, &c. One kind they impute to the mere extravasation of blood, the other to its putrefaction.

This account, though ingenious and specious, is not founded on fact. It is true, that the two kinds of symptoms are very distinct from each other, as well in their nature as in their time and manner of access; and so far the remark is true: but from the best observation and examination, both on the living and on the dead, they appear to proceed from very different causes. That both these kind of symptoms do now and then concur in the same patient, is beyond all doubt; and that the case is thereby rendered complex, and more difficult to be judged of: but this does not constantly happen; and even when it does, there are generally such distinguishing characteristic marks of each, as may prove the truth of what is here asserted.

If there be neither fissure nor fracture of the skull, nor extravasation, nor commotion underneath it, and the scalp be neither considerably bruised nor wounded, the mischief is seldom discovered or attended to for some few days. The first attack is generally by pain in the part which received the blow. This pain, tho' beginning in that point, is soon extended all over the head, and is attended with a languor or dejection of strength and spirits, which are soon followed by a nausea and inclination to vomit, a vertigo or giddiness, a quick and hard pulse, and an incapacity of sleeping, at least quietly. A day or two after this attack, if no means to prevent inflammation are used, the part ge-

nerally swells, and becomes puffy and tender, but not painful; neither does the tumour rise to any considerable height, or spread to any great extent. If this tumid part of the scalp be now divided, the pericranium will be found of a darkish hue, and either quite detached or very easily separable from the skull; between which and it will be found a small quantity of a dark-coloured ichor.

If the disorder has made such progress that the pericranium is quite separated and detached from the skull, the latter will even now be found to be somewhat altered in colour from a sound healthy bone. Of this alteration it is not very easy to convey an idea by words; but it is a very visible one, and what some very able writers have noticed. Among these Fallopius particularly: Inspectis diligentius et detestum: quod or, quando est in natura sua, est coloris subrubri, non candidi prorsus, nec rubri prorsus, sed est veluti color mixtus ex albo declinans ad rubicandum, ut si multo lacte, aut alio colore candido, poneres parum sanguinis vel alterius rei rubre. Sed si videritis inaequalitatem coloris in ipso esse detestum, ita ut ad sint veluti puncta coloris albi, et aridi ossis, que arida aliquando maiores sunt, aliquando minores, &c. sciatis quod or sit contusum.

From this time the symptoms generally advance more hastily and more apparently; the fever increases, the skin becomes hotter, the pulse quicker and harder, the sleep more disturbed, the anxiety and restlessness more fatiguing; and to these are generally added irregular rigors, which are not followed by any critical sweat, and which, instead of relieving the patient, add considerably to his sufferings. If the scalp has not been divided or removed until the symptoms are thus far advanced, the alteration of the colour of the bone will be found to be more remarkable: it will be found to be whiter and more dry than a healthy one; or, as Fallopius has very justly observed, it will be found to be more like a dead bone: the fancies or fluid between it and the pericranium will also, in this state, be found to be more in quantity, and the said membrane will have a more livid diseased aspect.

In this state of matters, if the dura mater be denuded, it will be found to be detached from the inside of the cranium, to have lost its bright silver hue, and to be as it were smeared over with a kind of mucus, or with matter, but not with blood. Every hour after this period, all the symptoms are exasperated, and advance with hasty strides: the headache and thirst become more intense, the strength decreases, the rigors are more frequent, and at last convulsive motions, attended in some with delirium, in others with paralysis or comatose stupidity, finish the tragedy.

If the scalp has not been divided or removed till this point of time, and it be done now, a very offensive discoloured kind of fluid will be found lying on the bare cranium, whose appearance will be still more unlike to the healthy natural one; if the bone be now perforated, matter will be found between it and the dura mater, generally in considerable quantity, but different in different cases and circumstances. Sometimes it will be in great abundance, and diffused over a very large part of the membrane; and sometimes the quantity will be less, and consequently the space which it occupies smaller. Sometimes it lies only on the exterior surface of the dura mater; and sometimes it is between

Theory. it and the pia mater, or also even on the surface of the brain, or within the substance of it.

¹²⁴
Cause of these symptoms. The primary and original cause of all this is the stroke upon the skull: by this the vessels which should carry on the circulation between the scalp, pericranium, skull, and meninges, are injured; and no means being used to prevent the impending mischief, or such as have been made use of proving ineffectual, the necessary and mutual communication between all these parts ceases; the pericranium is detached from the skull, by means of a sanies discharged from the ruptured vessels; the bone, being deprived of its due nourishment and circulation, loses its healthy appearance; and the dura mater (its attaching vessels being destroyed, or rendered unfit for their office) separates from the inside of the cranium, inflames, and suppurates.

Whoever will attend to the appearances which the parts concerned make in every stage of the disease, to the nature of the symptoms, the time of their access, their progress, and most frequent event, will find them all easily and fairly deducible from the one cause which has just been assigned, viz. the contusion. As the inflammation and separation of the dura mater is not an immediate consequence of the violence, so neither are the symptoms immediate, seldom until some days have passed: the fever at first is slight, but increases gradually; as the membrane becomes more and more diseased, all the febrile symptoms are heightened; the formation of matter occasions rigors, frequent and irregular, until such a quantity is collected as brings on delirium, spasm, and death.

¹²⁵
Appearances when the scalp is wounded. Hitherto we have considered this disease as unaccompanied by any other, not even by an external mark of injury, except perhaps a trifling bruise of the scalp: let us now suppose the scalp to be wounded at the time of the accident, by whatever gave the contusion; or let us suppose, that, the immediate symptoms having been alarming, a part of the scalp had been removed in order to examine skull.

In this case the wound will for some little time have the same appearance as a mere simple wound of this part, unattended with other mischief, would have; it will, like that, at first discharge a thin sanies or gleet, and then begin to suppurate; it will digest, begin to incarn, and look perfectly well. But after a few days all these favourable appearances will vanish; the sore will lose its florid complexion and granulated surface, will become pale, glassy, and flabby; instead of good matter, it will discharge only a thin discoloured sanies; the lint with which it is dressed, instead of coming off easily (as in a kindly suppurating sore), will stick to all parts of it; and the pericranium, instead of adhering firmly to the bone, will separate from it all round, to some distance from the edges.

This alteration in the face and circumstances of the sore, is produced merely by the diseased state of the parts underneath the skull; which is a circumstance of great importance in support of the doctrine advanced; and is demonstrably proved, by observing that this diseased aspect of the sore, and this spontaneous separation of the pericranium, are always confined to that part which covers the altered or injured portion of the dura mater, and do not at all affect the rest of the scalp; 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 such separation will happen; the detachment above will always correspond to that below, and be found nowhere else.

The first appearance of alteration in the wound immediately succeeds the febrile attack; and as the febrile symptoms increase, the sore becomes worse and worse, that is, degenerates more and more from a healthy, kindly aspect.

Through the whole time, from the first attack of the fever to the last and fatal period, an attentive observer will remark the gradual alteration of the colour of the bone if it be bare: at first it will be found to be whiter and more dry than the natural one; and as the symptoms increase, and either matter is collected or the dura mater becomes sloughy, the bone inclines more and more to a kind of purulent hue or whitish yellow: and it may also be worth while in this place to remark, that if the blow was on or very near to a future, and the subject young, the said future will often separate in such a manner as to let through it a loose, painful, ill-conditioned fungus; at which time also it is no uncommon thing for the patient's head and face to be attacked with an erysipelas.

We have said, that in those cases in which the scalp is very little injured by the bruise, and in which there is no wound, nor any immediately alarming symptoms or appearances, that the patient feels little or no inconvenience, and seldom makes any complaint until some few days are past. That at the end of this uncertain time, he is generally attacked by the symptoms already recited. That these are not pressing at first, but that they soon increase to such a degree as to baffle all our art; from whence it will appear, that when this is the case, the patient frequently suffers from what seems at first to indicate his safety, and prevents such attempts being made, and such care from being taken of them, as might prove preventative of mischief.

¹²⁶
Useful information. But if the integuments are so injured as to excite or claim our early regard, very useful information may from thence be collected. For whether the scalp be considerably bruised or not, if in the place of such bruise the pericranium be found spontaneously detached from the skull, having a quantity of discoloured sanies between them, under the tumid part, in the manner already mentioned, it may be regarded as a pretty certain indication, either that the dura mater is beginning to separate in the same manner, or that, if some preventative means be not immediately used, it will soon suffer; that is, it will inflame, separate from the skull, and give room for a collection of matter between them. And with regard to the wound itself, whether it was made at the time of the accident, or afterward artificially, it is the same thing; if the alteration of its appearance be as above related, if the edges of it spontaneously quit their adhesion to the bone, and the febrile symptoms are at the same time making their attack, these circumstances will serve to convey the same information, and to prove the same thing.

This particular effect of contusion is frequently found to attend on fissures and undepressed fractures of the cranium, as well as on extravasation of fluids in cases where the bone is entire; and on the other hand,

Theory. all these do often happen without the concurrence of this individual mischief. All this is matter of accident: but let the other circumstances be what they may, the spontaneous separation of the altered pericranium in consequence of a severe blow, is almost always followed by a suppuration between the cranium and dura mater; a circumstance extremely well worth attending to in fissures and undepressed fractures of the skull, because it is from this circumstance principally that the bad symptoms and the hazard in such cases arise.

127 Separation of the pericranium followed by a suppuration of the dura mater. It is no very uncommon thing for a smart blow on the head to produce some immediate bad symptoms; which after a short space of time disappear, and leave the patient perfectly well. A slight pain in the head, a little acceleration of pulse, a vertigo, and sickness, sometimes immediately follow such accident, but do not continue many hours, especially if any evacuation has been used. These are not improbably owing to a slight commotion of the brain; which having suffered no material injury thereby, they soon cease. But if after an interval of some time the same symptoms are renewed; if the patient, having been well, becomes again feverish and restless; and that without any new cause; if he complains of being languid and uneasy, sleeps disturbedly, loses his appetite, has a hot skin, a hard quick pulse, and a flushed heated countenance, and neither irregularity of diet nor accidental cold have been productive of these, mischief is most certainly impending, and that most probably under the skull.

128 Signs of an effusion of fluid under the cranium. If the symptoms of pressure, such as stupidity, loss of sense, voluntary motion, &c. appear some few days after the head has suffered injury from external mischief, they do most probably imply an effusion of a fluid somewhere. This effusion may be in the substance of the brain; in its ventricles, between its membranes, or on the surface of the dura mater: and which of these is the real situation of such extravasation, is a matter of great uncertainty; none of them being attended with any peculiar mark or sign that can be depended upon, as pointing it out precisely: but the inflammation of the dura mater, and the formation of matter between it and the skull, in consequence of contusion, is generally indicated and preceded by a puffy, circumscribed, indolent tumour of the scalp, and a spontaneous separation of the pericranium from the skull under such tumour.

These appearances therefore following a smart blow on the head, and attended with languor, pain, restlessness, watching, quick pulse, headache, and slight irregular shiverings, do almost infallibly indicate an inflamed dura mater, and pus either forming or formed between it and the cranium.

By detachment of the pericranium is not meant every separation of it from the bone which it should cover. It may be and often is cut, torn, or scraped off, without any such consequence: but these separations are violent; whereas this is spontaneous, and is produced by the destruction of those vessels by which it was connected with the skull, and by which the communication between it and the internal parts was carried on: and therefore it is to be observed, that it is not the mere removal of that membrane which causes the bad symptoms, but it is the inflammation of the dura mater; of which inflammation this spontaneous

secession of the pericranium is an almost certain indication. Theory.

Besides the mischiefs already mentioned, Mr Pott observes, that sometimes an exfoliation or separation of both tables of the cranium takes place from external violence, such as happen spontaneously in old or neglected venereal disorders. This disease, which has its seat in the diploe, often spoils the whole substance of the bone, and produces a separation of a part of it. This kind of venereal caries is most frequently of a small extent, and affects different parts of the skull; though sometimes it may be of large extent in one piece. The separated part is generally quite carious, and appears as if it had been worm-eaten. The surface of the bone so diseased is seldom much elevated, though generally somewhat: neither has it often the circumscribed form and appearance of a true node, as it is called; though now and then it has.

The scalp which covers a bone in this state is most frequently diseased also; sometimes with one large ill-conditioned sore; but more often with a number of crude, foul, painful, serpiginous ulcers; through most of which a probe will discover a rough bare bone, and from which is constantly discharged a greasy flaking sanies. This complaint is generally accompanied by a nocturnal headache, pocky spots, and pains about the breast and shoulders; and is almost always preceded by the former, though very frequently that symptom ceases, either during the mercurial courses instituted for that purpose, or when the pericranium covering the diseased part becomes foul and sloughy.

The proportion of extent of surface which one table of these diseased parts of the cranium bears to the diseased part of the other table, is very uncertain, and often very unequal. Sometimes the alteration of the outer table is much more extensive than that of the inner; in which case, when the separation is made, the detached piece comes away very easily, and the uncovered part of the dura mater is small compared to the size of the external sore: but sometimes, on the contrary, the disease occupies a more considerable extent of the inner table than of the outer, and thereby renders the case more difficult and the cure more tedious.

129 Separation of both tables of the cranium sometimes takes place. Where the skull is broken, the most violent symptoms frequently, though not always, take place at the very beginning. Mr Pott divides this kind of injury into two general classes, viz. those in which the broken parts keep their proper level, and those in which they do not; or, in other words, fractures without and fractures with depression. The symptoms of a fractured cranium have been universally reckoned, Loss of sense, giddiness, vomiting, bleeding at the ears, nose, mouth, &c. But though these do frequently accompany a broken skull, they are by no means produced by the breach made in the bone, nor do they indicate any such breach to have been made. They proceed entirely from some violence offered to the contents of the cranium, and either do or do not accompany fractures as they happen to be joined with such injuries or not. These symptoms are frequently produced by extravasations of blood or serum upon the membranes of the brain, or between them. They may also be the consequence of shocks or concussions of the brain itself, where the skull is perfectly entire. On the other

¹³¹ Theory. other hand, the bones of the cranium are sometimes cracked, broken, nay, even depressed, and the patient suffers none of these symptoms. Hence it is difficult to know when the skull is fractured and when it is not: and hence arises one source of danger in contusions and wounds of the head; for as it is impossible to know whether the cranium is fractured or not, the surgeon is often not warranted to divide the scalp until some urgent symptoms appear, after which it too frequently happens that all assistance comes too late. But if by any means the surgeon is assured that the skull is broken, it will then be incumbent on him at all events to proceed in the manner to be afterwards directed for curing these kinds of injuries.

¹³² Difficulty of knowing whether the skull is fractured or not. Sometimes, though rarely, it happens that one of tables of the skull only is injured; but in this the symptoms are so much alike with the foregoing, that it is needless to take further notice of them: we shall therefore only consider one symptom more, and which attends injuries done to the substance of the brain itself. This is a fungous excrescence of the brain, somewhat resembling the fungous or proud flesh already mentioned, which grows up in ill-conditioned wounds in any part of the body. These fungi of the brain arise very suddenly and unexpectedly, and expand to a considerable bulk; and grow the largest when the patient is seized with a violent fever. However, they are seldom formed when the dura mater continues entire; for this membrane, being very strong, sufficiently confines the brain: but when it is divided, together with the pia mater, the fungi increase most of all. These substances seem entirely to be produced from the cortical substance of the brain, and never have any portion of the medulla; whence they are sometimes extirpated with safety, though their appearance is at any rate to be accounted a very bad symptom.

¹³³ Fungi of the brain. In violent contusions and lacerations of the membranes and tendons, all the symptoms which we have before mentioned will arise with aggravation; and death very frequently ensues, after the most terrible convulsions. These are very frequent in gunshot wounds; but the different ways in which people may be affected in consequence of these wounds, it is impossible to recount. One thing to be observed in gunshot wounds is, that the entrance of them is always narrower than the place where the ball comes out, provided it goes quite through the limb; because the violent impetus of the ball drives in and contuses the flesh before it as it goes in, while it lacerates and tears it out in going through the other side. By reason of this extreme contusion and laceration, there is frequently very little hemorrhage from gunshot wounds, even when considerable vessels are injured; and hence probably proceeds the notion of an eschar in gunshot

wounds, as if they were burnt by the heat of the bullet. But it is impossible that a true eschar can in this case be formed; because it is demonstrated that bullets acquire no heat while flying in the air, nor unless they strike upon an hard obstacle. That a violent distension of the vessels will prevent hemorrhage, is plain from the case of those who have unhappily got their arms torn off by entangling about mills or other machinery; for in none of these do the axillary artery bleed, notwithstanding its magnitude. The reason of this seems to be, that the vessels entirely lose their elasticity, and collapse by the pressure of the surrounding parts in such a manner that the blood cannot pass through them.

¹³⁶ Theory. With regard to the cure of simple contusions of the fleshy parts, they are in general easily removed by the common discutient applications, of which none is better than vinegar and crude sal ammoniac. If the blow has been very violent, the part will perhaps suppurate; in which case it is to be treated as afterwards directed when we come to speak of tumours. The danger of contused wounds in the head, however, is greater than in any other part of the body. Here it sometimes happens, that the scalp is so wounded at the time of the accident, or so torn away, as to leave the bone perfectly bare, and yet the violence has not been such as to produce the evil abovementioned. In this case, if the pericranium be only turned back along with the detached portion of scalp, there may be probability of its reunion; and it should therefore be immediately made clean and replaced, for the purpose of such experiment, which, if it succeeds, will save much time, and prevent considerable deformity. If this attempt does not succeed, the detached piece may be removed, and the case then becomes as if the scalp and the pericranium had been forced away at the time that the wound was first inflicted; and the worst that can happen, is an exfoliation from the bare skull (c).

¹³⁷ Cure of simple contusions. It does also sometimes happen, that the force which detaches or removes the scalp does also occasion the mischief in question; but the integument being wounded or removed, we cannot have the criterion of the tumour of the scalp for the direction of our judgment. In these circumstances our whole attention must be directed to the wound and general symptoms. The edges of the former will digest as well, and look as kindly for a few days, as if no mischief was done underneath: but after some little space of time, when the patient begins to be restless and hot, and to complain of pain in the head, these edges will lose their vermilion hue, and become pale and flabby; instead of matter, they will discharge a thin gleet; and the pericranium will loosen from the skull, to some distance from the said edges. Immediately after this, all the general symptoms

(c) Not that exfoliation is the necessary consequence of the skull being laid bare; this depends upon other circumstances besides the mere removal of the scalp and pericranium. The solidity of the surface of the bones, the size of the vessels, and the impulse of the blood through them, are what principally determine that. If the cortex of the bone be not very hard, and the impulse of the blood be capable of counterbalancing the effects of the external air, a granulation of flesh will be generated on the surface of the bone, which will cover and firmly adhere to it, without throwing off the smallest exfoliation, especially in young subjects. On the contrary, if the bone be much hardened, and the vessels thereby constricted; or if such applications be made use of as will produce an artificial constriction of them; the surface will necessarily become dry, and, the juices ceasing to circulate through it, it must part with a scale to a certain depth; that is, that part through which the circulation ceases to be carried on will be separated from and cast off by the vessels which nourish the rest of the bone.

symptoms are increased and exasperated, and as the inflammation of the membrane is heightened or extended, they become daily worse and worse, until a quantity of matter is formed, and collected, and brings on that fatal period which, though uncertain as to date, very seldom fails to arrive.

The method of attempting the relief of this kind of injury consists in two points; viz. to endeavour to prevent the inflammation of the dura mater; or, that being neglected, or found impracticable, to give discharge to the fluid collected within the cranium in consequence of such inflammation.

Of all the remedies in the power of art for inflammations of membranous parts, there is none equal to phlebotomy. To this truth many diseases bear testimony; pleurisy, ophthalmies, strangulated hernias, &c. and if any thing can particularly contribute to the prevention of the ills likely to follow severe contusions of the head, it is this kind of evacuation: but then it must be made use of in such a manner as to become truly a preventative; that is, it must be made use of immediately, and freely.

It will in general indeed be found very difficult to persuade a person, who has had what may be called only a knock on the pate, to submit to such discipline, especially if he finds himself tolerably well. He will be inclined to think, that the surgeon is either unnecessarily apprehensive, or guilty of a much worse fault; and yet, in many instances, the timely use or the neglect of this single remedy makes all the difference between safety and fatality.

It may be said, that as the force of the blow, the height of the fall, the weight of the instrument, &c. can never precisely or certainly determine the effect, nor inform us whether mischief is done under the bone or not, a large quantity of blood may be drawn off unnecessarily in order to prevent an imaginary evil. This is in some degree true; and if the advice just given were universally followed, many people would be largely bled without necessity: but then, on the other hand, many a very valuable life would be preserved, which for want of this kind of assistance is lost. And if it be allowed to use such means as may be in themselves hazardous, surely it cannot be wrong to employ one which is not so; at least if it be considered in a general sense, whatever it may accidentally prove to some few particular individuals.

Acceleration or hardness of pulse, restlessness, anxiety, and any other degree of fever, after a smart blow on the head, are always to be suspected and attended to. Immediate, plentiful, and repeated evacuation by bleeding, have in many instances removed these, in persons to whom, in all probability, very terrible mischief would have happened had not such precaution been used. In this, as well as some other parts of practice, we neither have nor can have any other method of judging, than by comparing together cases apparently similar. It is by no means, however, to be inferred from hence, that early bleeding will always prove a certain preservative; 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 cases out of its reach than within it: but where preventative means can take place, this is certainly the best, and the most frequently successful.

The second intention, viz. the discharge of matter

collected under the cranium, can be answered only by the perforation of it.

When, from the symptoms and appearances already described, there is just reason for supposing matter to be formed under the skull, the operation of perforation cannot be performed too soon; it seldom happens that it is done soon enough.

The propriety or impropriety of applying the trephine in cases where there is neither fissure, fracture, nor symptom of extravasation, is a point which has been much litigated, and remains still unsettled either by writers or practitioners.

When there is no reason for suspecting either of those injuries, either from the symptoms or from the appearances, and the pericranium, whether the scalp be wounded or not, remains firmly attached in all parts to the skull, there certainly is not (let the general symptoms be what they may) any indication where to apply the instrument; and consequently no sufficient authority for using it at all. But whenever that membrane, after the head has received an external violence, separates, or is detached spontaneously from the bones underneath it, and such separation is attended with the collection of a small quantity of thin brown ichor, an alteration of colour in the separated pericranium, and an unnatural driness of the bone, we cannot help thinking that there is as good reason for trepanning as in the case of fracture: we believe experience would vindicate us, if we said better reason; since it is by no means unfrequent for the former kind of case to do well without such operation, whereas the latter (we mean suppuration under the skull) never can.

All the best practitioners have always agreed in acknowledging the necessity of perforating the skull in the case of a severe stroke made on it by gunshot, upon the appearance of any threatening symptoms, even though the bone should not be broken: and very good practice it is. A wound by gunshot (as far as it relates to the skull) is to be regarded only as one attended with a very high degree of contusion, and therefore most likely to produce symptoms accordingly; among which, inflammation of the dura mater stands principal. Experience confirms both: most of the symptoms attending wounds of the head made by gunshot, are symptoms of contusion; and the formation of matter between the cranium and dura mater is a very frequent and very fatal consequence of such contusion.

In short, the spontaneous separation of the pericranium, if attended with general disorder of the patient, with a chilliness, horripilatio, languor, and some degree of fever, appears to us, from all the observation we have been capable of making, to be so sure and certain an indication of mischief underneath, either present or impending, that we should never hesitate about perforating the bone in such circumstances.

When the skull has been once perforated, and the dura mater thereby laid bare, the state of the latter must principally determine the surgeon's future conduct. In some cases one opening will prove sufficient for all necessary purposes, in others several may be necessary. This variation will depend on the space of detached dura mater and the quantity of collected matter. The repetition of the operation is warranted both by the nature of the case, and by the best authorities, there being no comparison to be made between the

the possible inconvenience arising from largely denuding the dura mater, and the certain as well as terrible evils which must follow the formation and confinement of matter between it and the skull.

It can hardly be necessary to observe, that notwithstanding the operation of perforation be absolutely and unavoidably necessary, yet the repetition of blood-letting, of cooling laxative medicines, the use of antiphlogistic remedies, and a most strict observance of a low diet and regimen, are as indispensably requisite after such operation as before: the perforation sets the membrane free from pressure, and gives vent to collected matter, but nothing more: the inflamed state of the parts under the skull, and all the necessary consequences of such inflammation, call for all our attention full as much afterwards as before; and although the patient must have perished without the use of the trephine, yet the merely having used it will not preserve him without every other caution and care.

In those cases where the bone is evidently fractured, if the solution of continuity be either produced by such a degree of violence as hath caused a considerable disturbance in the medullary parts of the brain, or has disturbed any of the functions of the nerves going off from it, or has occasioned a breach of any vessel or vessels, whether sanguine or lymphatic, and that hath been followed by an extravasation or lodgement of fluid, the symptoms necessarily consequent upon such derangement, or such pressure, will follow; but they do not follow because the bone is broken: their causes are superadded to the fracture; and although produced by the same external violence, are yet perfectly and absolutely independent of it; so much so, that, as we have already observed, they are frequently found where no fracture is.

The operation of the trepan is frequently performed in the case of simple fractures, and that very judiciously and properly. But it is not performed because the bone is broken or cracked: a mere fracture or fissure of the skull can never require perforation, or that the dura mater under it be laid bare. The reason for doing this springs from other causes than the fracture, and those really independent on it. They spring from the nature of the mischief which the parts within the cranium have sustained, and not from the accidental division of the bone. From these arise the threatening symptoms, from these all the hazard, and from these the necessity and vindication of performing the operation of the trepan.

If a simple fracture of the cranium was unattended in present with any of the before-mentioned symptoms, and there was no reason for apprehending any other evil in future, that is, if the solution of continuity in the bone was the whole disease, it could not possibly indicate any other curative intention but the general one in all fractures, viz. union of the divided parts. But how can such union be promoted or assisted by perforation? It most certainly cannot; and yet perforation is absolutely necessary in seven cases out of ten of simple undepressed fractures of the skull. The reasons for trepanning in these cases are, first, the immediate relief of present symptoms arising from pressure of extravasated fluid; or, second, the discharge of matter formed between the skull and dura mater in consequence of inflammation; or, third, the

prevention of such mischief as experience has shown may most probably be expected from such kind of violence offered to the last-mentioned membrane.

In the first case (that of an extravasated fluid within the cranium), the relief from perforation is not only sometimes immediate, but frequently is not attainable by any other means. This is a sufficient proof, not only of its utility, but of its necessity.

In the second (of formation of matter between the skull and dura mater), there is no natural outlet by which such matter can escape; and the only chance of life is from the operation.

In the third, that of mere fracture, without depression of bone, or the appearance of such symptoms as indicate commotion, extravasation, or inflammation, it is used as a preventative; and therefore is a matter of choice more than immediate necessity.

Many practitioners, both ancient and modern, have therefore disused and condemned it; and have, in cases where there have been no immediate bad symptoms, advised to leave the fracture to nature, and not to perform the operation as a preventative, but to wait until its necessity may be indicated by such symptoms as may both require and vindicate it. This is a point of the utmost consequence in practice, and ought to be very maturely considered.

They who object to the early use of the trephine, speak of it as being frequently unnecessary, and as rendering the patient liable to several inconveniences which may arise from uncovering the dura mater before there is any good or at least any apparent reason for so doing. And in support of this their opinion, they allege many instances of simple fracture, which have been long undiscovered, without being attended with any bad symptoms; and of others which, though known and attended to from the first, have done very well without such operation.

They who advise the immediate use of the instrument, do it upon a presumption that, in considerable violence received by the head, such mischief is done to the dura mater, and the vessels by which it is connected to the cranium, that inflammation of the said membrane must follow; which inflammation generally produces a collection of matter and a symptomatic fever, which most frequently baffles all our art, and ends in the destruction of the patient.

What the former assert is undoubtedly sometimes true. There have been several instances of undepressed fractures of the skull, which either from having been undiscovered at first, or neglected, or having been under the care of a practitioner who has disliked the operation, have done very well without it. This is certainly true, but is not sufficient to found a general rule of practice upon: in matters of this sort, a few instances are by no means sufficient to establish a precedent: that which is found to be most frequently useful, is what we ought to abide by; reserving to ourselves a liberty of deviating from such general rule in particular cases.

This is one of those perplexing circumstances which all writers lament, and all practitioners feel; but which, instead of merely complaining of, we should endeavour, as much as in us lies, to correct.

In order to obtain what information we can on this subject, we should consider, first, what the mischiefs are.

are, which may most probably be expected to follow, or which most frequently do follow, when perforation has been too long deferred or totally neglected; secondly, what prejudice or inconvenience does really arise from, or is thought to be caused by, the operation itself, considered abstractedly; and, thirdly, what proportion the number of those who have done well without it bears to that of those who may truly be said to have been lost for want of it, or of those to whom it might have afforded some chance of relief.

With regard to the first, we have already observed in the case of simple undepressed fractures, whenever the trephine is applied, it must be with design either to relieve or to prevent ills arising from other mischief than the mere breach in the bone; which breach, considered simply and abstractedly, can neither cause such ills, nor be relieved by such operation. One, and that the most frequent, of these mischiefs, is the inflammation, detachment, and suppuration of the dura mater, and consequently the collection of matter between it and the skull; a case of all others attending wounds of the head, the most pressing, the most hazardous, and the least within our power to relieve. Indeed, the only probable method of preventing this evil seems to be the removal of such a part of the skull as, by being broken, appears plainly to have been the part where the violence was inflicted; and which, if the dura mater becomes inflamed, and quitting its connexion suppurates, will, in all probability, cover and confine a collection of matter for which nature has provided no outlet.

The second consideration proposed was, What mischief or inconvenience may most reasonably be supposed to follow or to proceed from the mere operation considered abstractedly. They who are averse to the use of it as a preventative, allege that it occasions a great loss of time; that it is frequently quite unnecessary; and that the admission of air to the dura mater, as well as the laying of it bare, is necessarily prejudicial.

The former of these is undoubtedly true: a person whose skull has been perforated cannot possibly be well (that is, cured) in so short a space of time as one who has not undergone such operation, supposing such person to have sustained no other injury than the mere fracture; and if the majority of the people whose skulls are broken, were so lucky as to sustain no other injury, that is, if no other mischief was in these cases in general done to the parts contained within the skull, the objection to perforation would be real and great, and the operation a matter of more serious consideration. But this is seldom the case; by much the larger number of those who suffer a fracture of the skull, are injured with regard to other parts, and labour under mischief of another kind additional to the fracture; that is, the parts within the cranium are injured as well as the cranium itself. This being the case, the loss or waste of a little time ceases to be an object of so great importance. The hazard which it is supposed may be incurred from laying bare the dura mater is indeed a matter of some weight: so that it certainly ought not to be done but for very good reasons: and yet, let the supposed hazard be what it may, it cannot, in the nature of things, be by any means equal to that which must be incurred by not doing it

when such operation becomes necessary. In short, if we would form a right judgment of this point, the question concerning it ought to stand thus: Is the chance of ill which may proceed from merely denuding the dura mater, equal to that of its not being so hurt by the blow as to inflame and suppurate? Or is the mischief which may be incurred by mere perforation of the skull, equal to the good which it may produce? These questions, let those who have seen most business of this kind, and who are therefore the best judges, consider and determine.

The third consideration, viz. What proportion the number of those who have escaped without the operation bears to that of those who have perished for want of it, is in great measure included in the two preceding; at least the determination of them must also determine this.

"The number of cases of this kind (says Mr Pott) which are necessarily brought into a large hospital situated as Bartholomew's is, in the middle of a populous city, where all kinds of hazardous labour are carried on, has enabled me to make many observations on them; and although I have now and then seen some few of them do well without the use of the trephine, yet the much greater number whom I have seen perish with collections of matter within the cranium, who have not been perforated, and for whom there is no other relief in art or nature, has, I must acknowledge, rendered me so very cautious and diffident, that although I will not say that I would always and invariably perform the operation in every case of simple fracture, yet the case must be particularly circumstanced, the prospect much fairer than it most frequently is, and my prognostic delivered in the most guarded apprehensive manner, when I omit it. I should be sorry to be so misunderstood as to have it supposed that I mean to say, that I think the denudation of the dura mater a matter of absolute indifference, or that no ill can proceed from it. This I know is a point concerning which the best practitioners have differed, and concerning which we will stand in need of information; but I think I may venture to say, what is fully to my present purpose, viz. that enlarging the opening of a fracture by means of a trephine will not produce or occasion much risk or hazard additional to what must be occasioned by the fracture itself: that has already let in the air upon the membrane; and therefore that consideration is, at least in some degree, at an end, and the principal point to be determined still remains the same, viz. Whether, upon a supposition that the dura mater may possibly not have been so injured as to inflame and suppurate in future, the operation ought not to be practised as a preventative, but, on the contrary, ought rather to be deferred until worse symptoms indicate the necessity of it? or, Whether it ought in general to be performed early, in order, if possible, to prevent and guard against a very probable as well as very terrible mischief?

"I know that it may be said, that a fracture, if of any considerable size, or whose edges are fairly distant and unconnected, will of itself make some way for discharge from within: and so it certainly may and does, in the case of an effusion of fluid blood; but even in this it very seldom proves sufficient for the purpose. But

does

Theory. does not the distant separation of the edges imply greater separation of the attaching vessels of the dura mater? and does not experience too often prove this to be the case? In truth, the great advantage which is sometimes derived from considerable fractures, is most frequent in those cases where portions of bone are so loose as to be removable; which removal of bone stands in place of perforation, and makes much more for the necessity of the operation in other cases than against it, if properly considered.

¹⁵⁵
Cases of
contusions
of the head
without any
wound,
mentioned
by Mr Pott. In confirmation of the above doctrine Mr Pott adduces a great many cases. Of contusions of the head without any wound he mentions five. The first, a man that was knocked down in a mob; he soon recovered his senses, and, after being plentifully bled, was to appearance well in three days. Six days after, he was taken ill with the symptoms of a beginning inflammation of the dura mater; which having continued three days, he was again taken under Mr Pott's care.—It was now twelve days from the accident; and after this the symptoms continually increased until the seventeenth day, when he died. Two days before his death, a tumour, which had arisen on the spot where the injury had been received, was laid open, and a thin brown sanies discharged. The cranium was altered from its healthy appearance, but without fracture or fissure. On opening the head, a considerable quantity of matter was found betwixt the dura mater and the skull under the diseased part, but nowhere else.

The second case was a boy of nine years of age, who had been stunned for a minute or two by a fall from a cart. In two days he seemed to be quite well; but in five days after, that is, in seven from the accident, he complained of the symptoms already mentioned; which having continued for six days longer, Mr Pott was called, and found about a third part of the parietal bone covered with a flatish tumour, containing a fluid. The scalp was now divided, and the cranium found in a diseased state; but a physician who also attended him over-ruled Mr Pott when he intended to perforate it. The child grew worse, and died in three days. On opening the body, a collection of matter was found below the diseased part of the bone; and about the middle of it the dura mater was discoloured and sloughy, containing about a spoonful of matter betwixt it and the pia mater.

In the third case, a labourer fell from a scaffold two stories high, by which he was stunned, but seemed well next day. Five days after, he began to complain of the usual symptoms of an oppressed brain, to which was added a sensation as if a cord was drawn tight round the encephalon; and on the right side of his forehead was a small tumour, which being opened, was found to contain a brown fluid. The bone was diseased, and a circular piece of the scalp cut out. However, as only internal remedies, such as bleeding, neutral salts, &c. were made use of, all the symptoms were aggravated. On the tenth day, the sore was pale, spongy, and glassy, and the scalp separated from the skull to some distance. This day a piece of the bone was removed, and the dura mater under it found smeared with matter. Next day he was worse in every respect; upon which a larger piece of the bone was removed, and a considerable quantity of matter

discharged. This done, finding his pulse still high and full, ten ounces of blood were drawn off, and a glyster injected. The loss of blood produced a swooning, which lasted some minutes, after which he said he thought his head was easier. As the evening approached, the symptoms returned, and therefore some leeches were applied to his temples. That night, for the first time, he got a little quiet sleep, and in the morning of the 12th day he said that his head was perfectly easy: a very large discharge had been made through the perforation in the cranium, and the wound in the scalp had rather a better aspect. He was kept strictly to a low regimen; took at first the sal absinthii mixture freely: when his pain had left him, his physician ordered him the bark; and in a very few days every bad symptom left him.

The fourth case was a lad of about twelve years of age, who was struck senseless by the blow of a bat on his forehead, as he stood beside a man playing at cricket. A considerable swelling arose on the part: he was treated with bleeding, purging, and the antiphlogistic regimen; and at the end of nine days was discharged as well. In five days after, 14 from the accident, he returned with complaints of an oppressed brain. The symptoms continued to increase, notwithstanding all that could be done, till the 20th, when the forehead which had formerly been swelled and subsided, beginning again to look tumid and puffy, the integuments were divided; the pericranium was found to have quitted its adhesion for more than the breadth of a crown piece, and between it and the bone was a small quantity of thin discoloured fluid. The trephine being applied, a large discharge of matter continued for a week; and the boy again got well.

The sixth case terminated fatally, though the trephine was applied on the tenth day. The patient was a woman, a seller of greens; who, in a quarrel with her husband, had been struck over the head with a mopstick. The blow neither fetched blood nor brought her to the ground; and she continued, notwithstanding an irregular life, for a week, without any complaint: she was then taken with the usual symptoms; and, two days after, the operation was performed on one side of the sagittal suture, and close to it. The dura mater was altered from its natural colour, and smeared over with matter. All the symptoms were now aggravated, and a violent erysipelas came on; upon which the trephine was applied on the other side the suture, and the same kind of appearance found as before. The symptoms continued without any abatement; and a third opening being made near to the first, vent was thereby given to so large a quantity of matter, that Mr Pott was convinced the event must be fatal. Accordingly the patient died on the 16th day; and upon opening the head, the dura mater was found covered with matter, under the whole internal surface of both parietal bones; but the firm adhesion of the longitudinal sinus to the sagittal suture had prevented all communication between the two collections of matter.

Of seven cases of contusion with one or more wounds, mentioned by the same author, four died, notwithstanding the operation being performed; the collections of matter being so large, or so situated, that it was impossible to give vent to it by art. One of these

Theory. cases was remarkable, as it shows the difference between symptoms arising from an injury done to the brain at the time the contusion is received, and that which spontaneously follows the inflammation of the dura mater: we shall therefore give it in Mr Pott's own words.

"A fireman who was at work on the top of an house, fell in with the roof of it; he was taken out senseless, and brought in that state to the hospital.

"He had on different parts of his body several wounds and bruises, but none of them seemed to be of any great consequence. On his head were four, one of some size, on the upper part of the frontal bone, near to the coronal suture; two on the left parietal; one on the right side of his head, just above his ear; and a small bruise on the upper part of the os occipitis. Of all these wounds, the pericranium was divided in one only, viz. that near the coronal suture.

"His wounds were dressed, he was largely bled, a glyster was thrown up, and a purging mixture was ordered to be given cochleatim, until he should have a discharge per anum. The next day he was in the same state, perfectly senseless, had the apoplectic stertor, a full labouring interrupted pulse, and some difficulty of respiration. He had four or five large stools; wherefore his mixture was discontinued, but sixteen ounces more of blood were drawn from one of the jugular veins; which evacuation was repeated again in the evening of the same day, to the quantity of eight more. On the third day, being still perfectly stupid, discharging both urine and faeces involuntarily, and having still a full labouring pulse, both the temporal arteries were opened, and fourteen ounces drawn from thence. On the fourth, finding no alteration, and being satisfied that the man's state could hardly be made worse, I determined to perforate the cranium; and accordingly set a large trephine on the upper part of the frontal bone, where the pericranium had been divided. The dura mater was found to be thinly covered with grumous blood, some of which I removed, and thereby made way for the discharge of more. The next day (the fifth), finding that what discharge had been made during the night was bloody, and that the man was in no respect altered for the better, I thought I had sufficient authority for repeating the operation; which I accordingly did, close by and below the former; and as the blow by which the wound had been inflicted seemed to have been almost exactly on the top of his head, I made a third opening in the parietal bone, close to the suture. The appearance under all was the same as under the first, viz. a thin layer of grumous, or rather coagulated, blood.

"Next day (the sixth), toward the evening, the man opened his eyes; and on the seventh, in the morning, he spoke. The discharge of blood continued for several days, and at the end of about a week from this time ceased; the dura mater and the wounded scalp wearing as good an aspect as could be wished, and the patient being easy and rational.

"On the 18th day, he complained of pain all over the head; was sick, reached to vomit, and said that he was faint and chilly. On the 19th, his face was flushed, his skin hot, his pulse quick and hard. He was let blood, and ordered to have a glyster, and

to take some medicines of the febrifuge kind. A day or two more passed in this manner, his fever not violent, but rather increasing than remitting; his pain, though not acute, yet such as to deprive him of his sleep; little rigors occurring irregularly, no perspiration, and an excessive languor. At last, on the 21st day, on the upper part of the os occipitis, on the right side, where there had been a small bruise, a tumour arose, so characterized as to satisfy me that the cause of the late alteration of circumstances lay underneath it: it did not rise to any height, and contained a small quantity of sanies, but covered a portion of bone which the pericranium had quitted. I removed the scalp, and would have set on a trephine; but the man obstinately refused to submit to it.

"On the 25th day he lost the use of his left leg and arm, and was much convulsed in those of his right side; which paralysis and spasm continued until the 27th, and on the 28th he died.

"Upon examining his head, a collection of matter was found under the bare part of the occipital bone; the dura mater under this matter was sloughy and putrid; and about a desert-spoonful of matter lay between the meninges, just under the altered part of the dura mater. In the part where the bloody extravasation had been, every thing was perfectly fair and free from disease.

"In this case, there seems to have been as clear a distinction between the bloody extravasation, with its effects, and the inflammatory state of the dura mater, with its consequences, as can be desired. All the first symptoms were such as were caused by mere pressure of the extravasated blood; an obliteration of every sensible faculty, attended with the principal symptoms of an interrupted circulation. Perforation of the skull, where this extravasation had been made, did, by giving discharge to the blood, happily remove these; and the man was getting well apace, until the ills arising from another cause, viz. the inflammatory secession of the dura mater in consequence of contusion, and that in another place, began to appear: they indeed made their attack rather late, nor did they rise so high as they most frequently do; but then it must be considered what discipline the poor man had undergone, and what evacuation had been made. Notwithstanding which, they bore their true, genuine, febrile, inflammatory character, and produced their most frequent event. What perforation of the os occipitale might have done, I cannot say; I fear but little, as the matter was not only upon but underneath the dura mater, and that too diseased."

Of the caries of the cranium, mentioned n^o 129, four cases of a Caries of the cranium. examples are brought; of which only one terminated fatally, at least from the apparent injury done to the brain; although another died of a peripneumony, after every thing seemed to be in a fair way. In this last the trephine was applied upon the carious part of the bone; but in the other three it separated spontaneously.

Twelve cases are related by our author of fissures and fractures of the cranium without any depression, and fractures without depression. Of these six recovered, and as many died. The symptoms were generally the same as in contusions without fractures. In one case, indeed, where a girl of 16 had got a violent blow on the head with an iron poker, she had a large wound on the top of her head,

head, with a considerable fracture on the sagittal suture. The broken pieces were so large and so loose that they were removed without any perforation, by which the longitudinal sinus was left bare for at least two inches in length; but no hemorrhage followed from the removal of the fragments.—For three days she was bled twice a-day from one part or other, and stools were procured: but all to no purpose; she still remained quite insensible. On the fifth day an opening was made with a lancet into the longitudinal sinus, and the blood suffered to run off, until her countenance, which had been much flushed, became pale; her pulse, which till then had been full and strong, faltered considerably, and she showed all the marks of a delirium from inanition. A bit of lint was then put on the orifice, and the nurse was ordered to keep her finger on it, till Mr Pott had visited the other patients in the house. On his return, the part showed no disposition to bleed again, nor did it ever after. That afternoon she opened her eyes, and moved her arms, and the next morning was sensible enough to ask for drink. She retained her senses for some days: but a fever coming on, she became delirious and convulsed; and thus died on the 17th day. On opening the head, a considerable abscess was found on the surface of the brain, on one side of the falxiform process of the dura mater.

In another case, though the skull was fractured, none of the bad symptoms appeared till five weeks after the accident. The patient was a lad of about 22, who had fallen from a high scaffold. In his head he had suffered no apparent injury; but the radius of the right arm, the tibia and fibula of the left leg, together with one or two of the ribs, were broken. In five weeks he was permitted to get out of bed; but the first day of his rising he complained of being sick and giddy, which was imputed to weakness and confinement, and therefore disregarded. For three or four days he complained of continual pain in his head, got no sleep, and was constantly feverish. As no injury in the head was suspected, nothing was prescribed but the common antiphlogistic regimen. At the end of the sixth week he complained that his head was painful to the touch; and the day after he made this complaint, had a rigor which lasted half an hour. At last a swelling, which evidently contained a fluid, appeared on the side of the head; and upon opening it, a fracture of the parietal bone, at least three inches long, was found, through which matter issued freely. The trephine was applied, a large quantity of matter discharged, and the dura mater was found sloughy. Under this sloughy part was another collection of matter between the membranes, and below this the brain was considerably discoloured. The patient died on the 50th day after the accident.

In two cases in which the skull was fractured, the patients recovered without the least bad symptom from first to last; and though the operation was performed, Mr Pott is of opinion that they would have recovered without it: however, such cases are but rare; and it is by no means prudent to delay the operation, though no threatening symptoms occur even for a very considerable time.

When fractures are attended with a depression of the bone, they are attended with all the danger of the

foregoing classes; with this addition, that the depression is attended with some urgent symptoms, which yet may generally be removed by elevating the depressed parts: yet this ought not to prevent every possible method being used for avoiding the others which appear afterwards, and which are not the less sure on account of the cranium being fractured and depressed. The generality of writers have contented themselves with directing us to raise up the depressed parts, and thereby to endeavour to remove such symptoms as are caused by the mere pressure which the bone makes on the brain: but they have either totally neglected, or very slightly passed over, what is of full as much consequence to the patient; we mean the injury which is most frequently done to the membranes of the brain, and which, if neglected, will certainly produce that fever and those symptoms which so often baffle the whole power of medicine.

The combination of different ill effects, proceeding from the same primary violence, and concurring in the same subject, together with the great difficulty of distinguishing them from each other, is one of the principal causes of that perplexing uncertainty attending wounds of the head. When one cause of bad symptoms has been removed, another, or even several others, may still remain, each of which singly may be sufficient to destroy the patient: and therefore, although the means first made use of may have been such as have been pointed out by the earliest and most alarming symptoms, and extremely proper for the relief of such complaint, had it been the only one the patient laboured under; yet, in the case of a complication, by not being sufficient to answer every requisite intention, they very often answer none, at least not effectually; and, producing only a temporary and partial relief, prove a greater aggravation of our disappointment.

This every practitioner should know, and this the friends of every patient should be made acquainted with; lest the former, being deceived by an appearance of amendment, be induced to promise what it will not be in his power to perform; and the latter, having had their hopes exalted, should be the more severely hurt by their disappointment.

If the fracture be but small, the depression little, and the force with which it was produced not great, the elevator introduced through the perforation may be sufficient to set it to rights; and, if there be no urgent symptoms, nor any mischief done to the internal parts, may be sufficient for all purposes. But if the force was great, if the symptoms are immediate and pressing, if the fracture runs in a form inclined to a circular one, or if the depressed piece be cracked all round, the best and safest way is to remove the whole or greater part of the portion so depressed and circumscribed.

To those who are unused to things of this sort, so large an opening as such method of acting must make will have a very tremendous appearance; and they may be inclined to suspect much hazard and inconvenience from laying bare so large a portion of the dura mater: but let all such remember, that however large the quantity of membrane may be which shall be thus denuded by the operation, yet the same quantity at least, most probably a much larger, would in all

likelihood become inflamed, and generate matter on its surface; which matter, for want of a timely, ready, and sufficient outlet, would do considerably more mischief than the mere detection of the said membrane can do.

In cases where the broken pieces of a depressed fracture are widely separated from each other, and some of them a good deal loosened, the expediency and the propriety of removing such pieces is acknowledged by every body; but few people attend to the reason, or inquire why such practice is just and proper; if they did, they would also see, that the free removal of bone was equally proper in the case of great violence, as in that of loosened or widely separated pieces. In the latter, the broken parts are removed, because their re-union with the rest of the cranium, and the preservation of the attachment of the dura mater to the inner surface of them, is thought impossible, or at least highly improbable; and that therefore they must be in the way, and hinder the free discharge of matter from the suppurating membrane. And is not the same inconvenience full as likely to attend the former? Is it the violence done to the bone, and through it to the membrane, which causes the inflammation and suppuration? or is it the loosened or separated state of the broken part? If it be the former, (as it most undoubtedly must be), the same precautions, the same method of treatment, must be equally necessary in the one as the other; the reasons, the intentions, are the same in each; and if the conduct be not the same, the patient will suffer.

The peculiar circumstances of each individual case must furnish direction to the practitioner for his particular conduct. Rules to be laid down by a writer on such subject can be only general. The parts which are depressed must be elevated; such as are loose and cannot be brought to lie even, such as cannot be prevented from pressing on the membrane, or such as wound or irritate it, must at all events be taken away; the free discharge of blood or lymph in present, and of matter in future, must be provided for; and therefore every symptom and appearance must carefully and early be attended to, lest the most proper opportunity of giving assistance be not embraced.

Of four cases related by our author of fractures with depression, two recovered, and two died. The first, who was a girl of about 15, being tossed by an ox, and falling with her head against the stones, got a fracture with considerable depression. It traversed the os parietale from before backward, in its middle part between the sagittal and temporal sutures, and the depression was on the upper part of the bone. The whole was reduced to a perfect equality, the bone being trephined on the inferior and undepressed part. Her head was dressed lightly, and about 16 ounces of blood taken from her. She passed the following night very unquietly, and the next morning was still insensible. She was again freely bled, and a purge was given, which soon operated. On the third day she was bled again, on the fourth she became sensible, and on the fifth was surprisingly well: but on the ninth she began again to complain of headache, sickness, and giddiness; and, notwithstanding all the internal remedies which could be used, growing constantly worse, she died in 20 days from the time of the accident. All the internal surface of the os pa-

rietale above the fracture was detached from the dura mater, and covered with matter, which could not be discharged at the perforation, the membrane being inflamed and thrust tight up against it. On this case Mr Pott remarks, that though he will not pretend to assert that repeated perforations of the upper part of the bone would have preserved her; yet it would have been her best, if not her only chance; and that if he had at that time known as much as afterwards, he should certainly have taken away the greatest part, if not the whole, of what had been depressed.

We have already observed, that the very worst symptoms, nay, even death itself, may frequently proceed from an extravasation of the fluids within the cavity of the cranium, or from a concussion of the brain itself.—Extravasations of any kind, and wherever situated, within the cranium, are very hazardous, and much more frequently end fatally than happily: but, considered as relative to the art of surgery, that which consists of merely fluid blood situated between the cranium and dura mater is certainly the best, as it is the nearest to the surface, and admits the greatest probability of being relieved by perforation of the skull; grumous or coagulated blood, although in the same situation, by being most frequently adherent to the membrane, is not so readily discharged as the preceding, and therefore more likely to prove destructive; and all those which are either under the meninges, or within the cavities or substance of the brain, as they are very seldom within our exact knowledge, so they are also generally beyond the reach of our art.

The method of treating people under these unhappy circumstances is somewhat different, according to the supposed or most probable nature of the complaint, and according to the symptoms and appearances which it produces or which accompany it. When the symptoms which imply a pressure made on the brain or nerves have been occasioned merely by a shake or concussion, and neither blow nor other external violence 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 precise nature of the disease, or its particular situation; consequently we have no direction from what part of the head to remove the scalp, or where to apply a perforating instrument, and therefore no authority for perforating at all. In this case, the only chance of relief is from phlebotomy and an open belly; by which we may hope so to lessen the quantity of the circulating fluids as to assist nature in the dissipation or absorption of what has been extravasated. This is an effect which, although not highly improbable in itself, yet is not to be expected from a slight or trifling application of the means proposed. The use of them must be proportioned to the hazard of the case. Blood must be drawn off freely and repeatedly, and from different veins; the belly must be kept constantly open, the body quiet, and the strictest regularity of general regimen must be rigidly observed. By these means, very alarming symptoms have now and then been removed, and people in seemingly very hazardous circumstances have been recovered. Instances of these successes are not indeed so frequent as we could wish; but they have been sufficiently so to warrant the attempt, especially in cases where there are no indications to authorize the use of any other. But when the

Theory. the symptoms of extravasation are the consequence of such external violence as leaves a mark where it was inflicted, and when the scalp is so bruised or wounded as to show the place where, we then have some degree of assistance, both in forming a judgment of the most probable nature of the complaint, and in using the means most likely to prove successful in its relief. For if the effusion has been the consequence of the stroke which the head has received, and such effusion is made immediately under the part so stricken, the perforation of the cranium in this place may give discharge to the extravasated fluid; and the wound or bruise in the scalp shows us the point from whence we ought to remove a portion of it, in order to perforate the cranium. This is sometimes the case; and the consequence is sometimes so fortunate, that we save a perishing patient. But although it does now and then happen that we are so lucky, yet such success is by no means certain or to be depended upon. Every thing relative to this kind of disorder is fallible and uncertain; and though the extravasation is sometimes found immediately under the external mark, yet it often happens that it is not, and that the effusion is made in a part distant from that mark, and to which we have nothing to lead us. Upon the whole, although a bruise or wound of the scalp does not in these cases necessarily or certainly point out the seat of an extravasation; yet when bad symptoms urge, and evacuation hath been fully and unsuccessfully tried, such mark may be deemed a sufficient, though not unerring, authority for making farther inquiry, by removing the scalp and perforating the cranium: for this is a kind of case in which we are not to expect certainty, and in which we must be content with such information as we can obtain. The opportunities which we have of being serviceable are but few; we should therefore suffer none to escape, but embrace even possibility. The general advice given by Fabricius ab Aquapendente is applicable to no part of surgery more than to this; in which the loss of a very short space of time is often absolutely irretrievable.

If the extravasation be of blood, and that blood be in a fluid state, small in quantity, and lying between the skull and dura mater, immediately under or near to the place perforated, it may happily be all discharged by such perforation, and the patient's life may thereby be saved; of which many instances are producible. But if the event does not prove so fortunate, if the extravasation be so large or so situated that the operation proves insufficient, yet the symptoms having been urgent, general evacuation having been used ineffectually, and a wound or bruise of the scalp having pointed out the part which most probably received the blow; although the removal of that part of the scalp should not detect any injury done to the bone, yet the symptoms still subsisting, we cannot help thinking, that perforation of the cranium is in these circumstances so fully warranted, that the omission of it may truly be called a neglect of having done that which might have proved serviceable, and, rebus sic stantibus, can do no harm. It is very true, that no man can beforehand tell whether such operation will prove beneficial or not, because he cannot know the precise nature, degree, or situation of the mischief; but this uncer-

tainty, properly considered, is so far from being a dissuasive from the attempt, that it is generally a strong incitement to make it; it being full as impossible to know that the extravasated fluid does not lie between the skull and dura mater, and that under the part stricken, as that it does; and if the latter should be the case, and the operation be not performed, one, and most probably the only, means of relief, will have been omitted.

Of concussions and extravasations Mr Pott relates eight instances; six of whom died, and two recovered. The first was a young man who fell from a window two stories high, and pitched his head upon a sugar hog's head. He was taken up insensible, and continued so for five days; at the end of which he died, notwithstanding he had been very largely bled. No external mark of violence was observed on the head; the cranium was nowhere injured; the dura mater was every where adherent, and no fluid of any kind betwixt it and the skull. Between the dura and pia mater was a considerable quantity of blood, principally towards the lower part of the brain.

The second case was very similar; the patient expired on the third day, without having shown any signs of sense. All the space between the frontal bone and the dura mater was covered with grumous blood, firmly adherent to the membrane.—In the third, a small tumour appeared on the right side of the head, which thus indicated the seat of the mischief; and, by perforating the skull, a large quantity of blood was discharged between the dura mater and the skull; after which the patient recovered. The fourth was much the same: a tumour appeared on the right side near the sagittal suture; which indicated the application of the trephine. Thus a considerable quantity of blood was discharged, and the patient soon recovered.—The fourth case was remarkable, as showing us how very small contusions of the head will sometimes do irreparable mischief. A boy between three and four years of age, when at play with his brother, fell from a bed on a soft carpet. He pitched on his head, and immediately complained of being sick and giddy; but having vomited, was soon after so well, that no farther notice was taken of his fall. On the fourth day after this, he again became sick and giddy. The physician who prescribed for him gave him an emetic, and some of those medicines called nervous; however, his sickness and giddiness now and then returned, with a great aversion at motion of any kind. On the 11th day he lost his sight; on the 13th the use of his right arm; on the 15th he could not stand; and on the 18th he died. A considerable quantity of bloody serum was lodged between the dura and pia mater about the basis of the brain.—In the fifth case, the patient continued 12 days without any general complaint; but on the 13th became giddy and dim-sighted, and soon after died. The ventricles of the brain were full of extravasated serum, and near the origin of the medulla oblongata was a lump of firmly coagulated blood.—The seventh and eighth cases were not materially different: the patients both died comatose; and extravasations of blood, serum, or lymph, were found in both.

When the brain itself is wounded, the treatment can only be to remove all such parts of the broken skull as may continue to injure the brain or its membranes.

branes; to take away all such extraneous bodies as can easily be got at and extracted without violence; and to make such openings in the cranium as may best serve for the discharge of extravasated fluids, either immediately or at any future period. When fungi of the brain protrude, it is usual to tie a thread round their neck, upon which they drop off spontaneously.

In contusions of the head, whether attended with fractures or not, Mr Bromfield recommends the use of opium; and insinuates, that most of those patients die who are treated only with evacuations and the anti-phlogistic regimen. The medicine he recommends is Dovar's powder; and the effect expected from it is a diaphoreis. For this the warm bath is in general a good preparative, as it promotes perspiration: and should the patient be relieved, the diaphoreis is to be kept up by medicines of a similar kind; such as vinum antimoniale with the tinctura thebaica. Thus he tells us, that every symptom of concussion of the brain has in general gone off on a plentiful sweat being produced by the powder. The medicine was generally continued as the symptoms required, till the patient seemed out of danger; and where they returned again, the medicine was repeated, and the patient did well. In support of this practice, he gives the following instances.

and complained of great giddiness, with pain in his forehead and back. He was then ordered to take 10 drops of the tinctura anodyna antimoniales once in four or six hours, as the effect might indicate; a fomentation was applied to his back, a stool procured in the evening by a clyster, and Dovar's powder was repeated at bed-time. On the 10th the giddiness was gone off, the pain was abated, and his head was perfectly easy; the use of the tinctura anodyna was continued, and his body kept open by a laxative mixture. On the 11th he was free from all complaints; granulations began to appear on the wound, which looked well; and the use of the drops was discontinued. He remained well till the 16th; about which time he was seized with giddiness and a sickness at his stomach. Eight ounces of blood were then taken away, and some stools procured by a purging draught. On the 19th the giddiness and sickness entirely left him. On the 21st his sickness returned, with great pain in his head: he was then directed to take a scruple of Dovar's powder at night. On the 26th all his complaints were gone. He was then ordered to take four spoonfuls of the following medicine once in four hours: Sal. absinth. $\backslash text\{Mii.\; succ.\; limon.\; \}\; \backslash frac\{3i\}\{\backslash text\{decoct.\; cort.\; Peruvian.\; \}\; \backslash frac\{3xiv\}\{\backslash text\{\}\}\}.$ He remained without any return of his complaints, and was discharged on the 12th of June.

"A gentleman received a violent blow on the top of his head from a large weight falling on it, which fractured his skull and depressed it. I attended at the operation, when every possibility of future pressure on the brain from the fractured bone was entirely prevented by the removal of the depressed pieces. He took Dovar's sweating powder, which, he said, always relieved him when it began to operate. He had stools as often as was thought necessary, and was bled very freely before I saw him. As the wound did not begin to digest kindly at the usual period, in the intermediate time between the sweats, he took the sal absinthi neutralized with succ. limonum, and a decoction of the bark. About the fifth day he grew comatose; and the gentleman whose patient he was seemed to wish he had been bled again. I desired him to recollect how constantly we consulted the pulse when we met; and that he had always told me, that in my absence he was never induced to bleed him from fulness; and from the quiet state of his pulse whenever we met, we judged it unnecessary. This he allowed; but as the coma was great, I consented to his losing some blood from the jugular vein, which did not make his pulse flag, nor was he relieved by the bleeding. When I saw him the next day, being the sixth from the accident, he was dying. I did not see the patient after he died; but conclude, that the brain had suffered so much from the violence of the blow, that let what method soever have been followed, the event in this case would have been the same.

"Patrick Darbun, aged 26 years, was admitted into St George's hospital the 6th of July 1771, having a large wound on the fore-part of his head, and some slight bruises in different parts of his body. He had fallen from a scaffold. It was about an hour after the accident when he was brought to the hospital, where the surgeon was informed that he had continued senseless for half an hour after the fall, and had vomited twice. He had great pain in the parts that were hurt, with stupor and heaviness. Upon a careful examination of the skull, no fracture could be discovered. Some blood had been taken away before he was brought to the hospital, where a purging mixture was given him, and some stools thereby procured. He then took a scruple of Dovar's powder. He complained of great pain in his head and giddiness on the seventh, and had had but little rest. The tinctura anodyna antimoniales was given him, 10 drops of which he took once in four or six hours. He was rather easier in the evening, and the pulv. Dovari was repeated at bed-time. On the eighth he was much better; the use of the drops was continued. On the ninth the pain in his head and giddiness were quite gone. He continued to take the drops till the 12th; about which time, he being perfectly well, no more were given. Having remained in the hospital till the 31st, without any return of his complaints, and the wound being nearly healed, he was made an outpatient by his own desire, and continued perfectly well.

"John King, aged 35 years, having fallen from a scaffold, was brought to St George's hospital on the 8th of May 1771, quite senseless. He had received by the fall two large wounds; one on the anterior, the other on the posterior part of his head, and his back was violently bruised: he had bled a little at his nose. Immediately after his admission into the hospital he was let blood; and from the administration of a clyster had two stools, and took a scruple of Dovar's sweating powder. On the ninth he was more sensible,

"John Hyde, a boy about 14 years of age, was, on the 7th of June 1771, admitted into St George's hospital, on account of a hurt he had received on his head by falling backwards. The scalp was much swelled, but without any wound: he complained of giddiness, and vomited frequently. The surgeon made an incision into the tumid part, by which the skull was laid bare, and a fracture, of about an inch in length, discovered upon the superior part of the occipital bone. Some stools were procured as soon as it

¹⁷²
Theory. was possible by a purging mixture, and afterwards one scruple of Dover's powder was given. He had a pretty good night; and on the eighth the vomitings ceased, though the pain in his head and giddinefs continued. He was that day directed to take 10 drops of the tinctura anodyna antimonialis once in six hours. His giddinefs went off entirely in the evening; but he complained of a little pain in the fractured part. A stool was procured by a clyster, and the use of the antimonial anodyne was continued. On the ninth he was free from pain, and took the antimonial anodyne once in six hours till the 11th; during which time he was perfectly well, and afterwards was directed to take the neutral mixture, with a decoction of the Peruvian bark. This course he pursued for about a week, and on the 26th was made an out-patient. In about three weeks after this, the wound was healed, and the boy perfectly recovered."

¹⁷³
Theory. We shall now proceed to the treatment of gunshot wounds; in which, as the body is frequently mangled in the most dreadful manner, the surgeon must exert the utmost of his skill both with regard to external and internal remedies. In those made by a musket or pistol ball, the most immediate considerations are, To extract the ball, or any other extraneous body which may have lodged in the wounded part; and to stop the hemorrhage, if there is an effusion of blood from the rupture of some considerable artery.

¹⁷⁴
Theory. As to the first, viz. the extraction of the ball, it is frequently necessary to enlarge the wound in order to answer this purpose; and if the ball has gone quite through, both orifices are to be dilated (provided the situation of the part wounded will admit of its being done with safety); and particular care is to be taken to preserve both openings, especially that which is the most depending.

In order to get at the ball, or any other foreign matter, probing is to be used as sparingly as possible: and this must evidently appear to any one who will only consider the nature of the symptoms attendant on penetrating wounds of the breast or belly, either from a bullet or sharp instrument; the thrusting in a probe to parts under such circumstances being unavoidably a fresh stab on every repetition of such practice. In wounds of the joints, likewise, poking into them must be equally condemned, as it can never be used without very mischievous and pernicious consequences. And indeed, where probing is necessary, the finger is to be preferred as the best and truest probe, where it is practicable to do so.

If a ball, or any other foreign body, happens to be lodged near the orifice, or can be perceived by the finger to lie under the skin, though at some distance from the mouth of the wound; in the first case it is requisite immediately to remove such extraneous matter; and, on the other occasion, to cut upon it and take it out: But when it is sunk deep, and lies absolutely beyond the reach of the finger, we ought never to thrust a pair of long forceps into the wounded body, with scarce any probability of success.

To put this matter in as clear a light as possible, we will suppose a ball to be lodged in any part beyond the reach of the finger, entirely out of the way of being marked by the external touch. Now it will ap-

pear evident, upon the least restitution, that thrusting, first a long probe in quest of the bullet, and then, as has been practised likewise, a longer pair of forceps, either with or without teeth, into a wound of that kind, though with a sort of certainty to extract it, must either contuse, or irritate and inflame, the parts to a great degree; and consequently do as much, or more mischief, than the ball did at first by forcing its passage such a length of way. And should they at the same time lay hold of any nerve, artery, or even common membrane of a muscle, together with the ball (which can scarce ever fail of being the case), what shocking consequences would attend such a proceeding! Nor would attempts of this sort be less injurious in case a bullet should happen to be lodged in the cavity of the belly or breast: whereas lead, it is well known, will lie a long time in several parts of the body, without any material hurt, or even inconvenience.

A great number of instances have occurred, where balls have been quietly lodged in several parts of the body, till after many years they have worked themselves a passage towards the surface, and were very easily extracted; and many where balls have been entirely left behind.

¹⁷⁵
Theory. In case the wound be occasioned by a musket or pistol shot, and of course but small, it will be necessary to dilate it without delay, provided the nature of the part (as was before observed) will admit of this with safety: for in wounds near a joint, or in very membranous or tendinous parts, the knife, as well as forceps, should be put under some restraint; nor should any more opening be made than what is absolutely requisite for the free discharge of the matter lodged within. Wounds in the joints are always dangerous, from whatever cause they proceed, whether from a bullet or any cutting instrument: and membranous or tendinous parts, whatever sense of feeling they may be allowed, are yet known, past dispute, to suffer much from their being thus exposed to the impressions of the air.

¹⁷⁶
Theory. Whenever the wound is attended with a great effusion of blood, from the rupture of some considerable artery, it will be absolutely necessary, with all imaginable dispatch, to restrain the bleeding with the needle; and at the same time to be particularly careful that your hold be not elusive. But the bleedings from the smaller vessels, in all contused wounds, are of real service, by unloading the clogged parts, cutting off the main sources of customary inflammations, and by that means either totally preventing a fever, or at least rendering it a symptom of no threatening tendency: an event on which, in an especial manner, depends the future laudable digestion. As for styptic applications, as we have already observed, there is no thrusting to any of them, where the larger arteries are concerned. Besides, all such rather retard than promote the cure: for by obstructing the discharge of the fancies, which in all large wounds precedes digestion, the digestion is of course suspended, while the pent-up fancies become a constant additional fuel to the fever.

Where the wounded person has not suffered any great loss of blood, it will be advisable to open a vein immediately, and take from the arm a good large quantity; and to repeat bleeding as circumstances may require, the second, and even the third day. Repeated.

peated bleedings in the beginning draw after them many advantages. They prevent a good deal of pain and inflammation, lessen any feverish assaults, forward the digestion, and seldom fail to obviate imposthums, and a long train of complicated symptoms that are wont otherwise to interrupt the cure, miserably harass the poor patient, and too often endanger his life. And even where the feverish symptoms run high, and there is almost a certainty that matter is forming, bleeding, in that state, is very frequently of great advantage; the matter will be made the sooner for it, and the quantity of it will be less. The following instance, says Mr Ranby, in some measure demonstrates the necessity of bleeding freely as soon as possible.

"A young gentleman, a cornet of dragoons, was wounded by a musket-bullet just below the knee, on the inside. The ball had made a great laceration in the skin, and laid the membranes bare about four inches in length. The surgeon did not see him till two days after the injury. He was then very feverish, quite parched up with thirst, and had a full pulse, with great pain, swelling, and inflammation all round the joint. Immediate bleeding was ordered, a cooling regimen, with proper dressings, an emollient clyster, and an opiate. The next day his pain rather increased; wherefore he was let blood a second, and after that a third time. Six days were now elapsed when a miliary eruption seized him, with frequent bleedings at the nose, and a diarrhoea, which lasted about ten days. Mean while matter was formed in several places about the knee; which, on being let out, flowed in prodigious quantities. The fever declining, the bark was given him; but as that, though joined with an opiate, ran through him, it was judged necessary to lay it aside. Notwithstanding he was now very weak and low, it was thought, in a consultation, that the only chance which remained of his surviving, was the cutting off his leg. The operation was accordingly performed, but without success. Upon examining the knee, there appeared several cells full of matter communicating with the joint; which had in many places eroded the cartilages of both the great bones."

For the first twelve days it will be proper to observe a cooling regimen, both in respect of the medicines that may be prescribed, and the diet requisite for the support of nature. It is absolutely necessary, likewise, that the body be constantly kept open. Unless, therefore, nature does this office of herself, a stool should be every day procured, either by emollient clysters, or some gentle laxative taken at the mouth; and whenever there is much pain in the wounded parts, immediate recourse must be had to opium.

In respect to external applications, whatever is of a hot, spirituous nature, is remarkably injurious on these occasions; and what no wounded part can in any degree bear. Let the first dressing be with digestive, or lint moistened with a little oil; and a very light bandage made, if it can be readily got, with thin flannel: the next with a digestive warmed, and over it the bread-and-milk poultice, mixed with a sufficient quantity of oil to keep it moist; and where there is great tension, and the wound large, a fo-mentation should be used. This course is to be conti-

nued till the sore is clean.

This method will commonly promote a constant easy perspiration, abate the pain, very much facilitate the digestion, and remove all apprehensions of any approaching inflammation. The advantage of moistening the lint with oil, is the ease that is procured to a contused wound from such an application, in comparison of one of an absorbent drying disposition; which, instead of giving free liberty to the sanious blood to discharge itself, and consequently preventing an inflammation, by unloading the part, would possibly obstruct the mouths of the capillary vessels, and hinder nature from getting rid of that incumbrance which, it is observable, she very much affects to throw off. We must add here, that tents are never to be made use of where they can be possibly avoided.

Should an inflammation seize any part through the lodgment of a bullet, or any other foreign body, that could with safety have been more immediately extracted, all attempts of dislodging such extraneous matter should be postponed till the swelling has in some measure subsided, and the inflammatory disposition of the fibres is nearly vanished; unless the ball, or other extraneous body, lie at no great distance from the orifice; and there be, on that account, a certainty of removing this incumbrance without any material trouble to the patient.

"If a wound (says our author) be of such a desperate nature as to require amputation (which is always the case when it happens in any principal joint), it would certainly be of consequence could the operation be performed on the spot, even in the field of battle; lest, by deferring it, an inflammation, which one may very reasonably expect, should obstruct a work that ought rarely to be entered upon during the continuance of so calamitous a circumstance. The neglecting this critical juncture of taking off a limb, frequently reduces the patient to so low a state, and subjects the blood and juices to such an alteration, as must unavoidably render the subsequent operation, if not entirely unsuccessful, at least exceedingly dubious. And in wounds even where no amputation is required, it is equally advisable not to defer the care necessary to be taken of them; lest, by the parts being exposed to the air, there might arise a series of very dangerous symptoms.

"Wounds that border on any considerable artery, are very apt to bleed afresh upon motion, or the return of a free circulation of the blood into the part, which was interrupted at first by the violence of the injury offered it; and this is almost always the case when the slough begins to separate. For which reason, one should never attempt to remove it by force, but wait with patience till there be a perfect separation of this slough; nor be in the least shocked at the accident of arteries thus opening themselves, which a very moderate experience will convince one to be almost inevitable. The patient frequently gives warning of what is coming upon him, by complaining of great weight and fulness in the limb, which are ever accompanied with more or less pulsation in it: an infallible prognostic of the consequences. Let the wound afflict whatsoever part, if these complaints attend it, bleeding and the bark are instantly to be enjoined.

“I have known (says Mr Ranby) several instances of persons losing their lives from the starting of an artery before the surgeon could reach them; particularly where an amputation has preceded. And I dare affirm, the quantity of blood lost, especially in the case last mentioned, has not amounted to 12 ounces. I do not know how to account for this, otherwise than by the drain which had been made from the mass of blood both before and during the operation; whence a sudden gush (though but a moderate one) of blood, after the great quantity already lost, gives a check to the circulation, and causes immediate death. This reflection, I think, ought to be a lesson of instruction to every practitioner to be particularly intent on the faithful discharge of his duty in regard to tying the vessels.”

The bark extremely useful in gunshot wounds.

In all large wounds, especially those made by a cannon-ball, there is constantly a great laceration of the parts endowed with an exquisite sensation. These are ever attended with an excruciating pain, and a discharge of a gleety matter; which, if not restrained, proves often of the worst consequence, by reducing the patient almost to a skeleton; there being no possibility of receiving a supply of nourishment proportioned to the discharge. In this unhappy state, the bark (in doses of a dram each, and repeated every three hours, or oftener if the stomach will bear it) with surprising efficacy repairs the breach made in the constitution by this terrible havoc. In whatever form it be administered, whether in tincture, extract, or resin, we must ever have an eye to the proportion: for the prescribing it in less quantity is one reason why our expectations are often frustrated, and the medicine brought unreasonably into disgrace; the failure, in point of success, being generally owing to some irregularity in the giving of it, either by under-doing it, or not sufficiently persisting in its use. Elixir of vitriol, taken three times a-day in a glass of water, is of singular benefit, and proves a very good assistant to the virtues of the bark: and if the body be costive, to each dose of the bark four or five grains of rhubarb must be added, till that inconveniency be remedied. Should the bark run off by more than four or five successive stools, this effect of it will be checked by a few drops of laudanum, or two spoonfuls of the diaphorid mixture along with it, every time it is given.

Where the sore discharges a considerable quantity of gleety matter, is flabby, looks pale and glossy, (which appearances are often consequent to a loss of substance), the bark continually relieves the pain that is predominant in this case, and quite changes the complexion of the wound. Nor, in administering it, is the least attention necessary to the quickness of the pulse. And in wounds where, upon every dressing, there has been an oozing from the capillary arteries, like water squeezed from a sponge, subjecting, of course, the patient to no little hazard, the bark, by thickening the matter and lessening its quantity, procures the most surprising good effects.

Mr O'Halloran's opinion of gunshot wounds.

On the subject of gunshot wounds Mr O'Halloran observes, that of all the symptoms which attend external accidents, none is more dreaded than inflammation and fever; to guard against which, profuse bleedings, antiphlogistics, diluting liquors, and low diet, are strongly recommended. Yet, necessary as

these means are, we may go to too great excess in them. Inflammation is the natural consequence of every wound, and is absolutely necessary for bringing about the process of healing. The more violent the hurt, the greater is its concomitant inflammation. The latter therefore, so far from being an object of terror, is greatly to be wished for: its absence is always a bad sign; and where it is but slow, the act of reunion or healing is very distant. If, then, a slight inflammation is absolutely necessary to bring a trivial hurt to heal, it must of consequence follow, that a more violent one is requisite to promote a reunion of parts after a more desperate accident. Inflammation therefore should not be hastily repressed: it is a true concomitant on all all hurts; and its excess or absence are the only symptoms of this class against which we should guard.

SECT. III. Of Fractures and Dislocations.

This is one of those parts of surgery which is generally thought to be well understood, and the treatment of broken bones to be very easily learned. Hence we find it practised by those who do not attempt the practice of other parts of the science; yet, notwithstanding these pretensions, it is certain that much attention and care is necessary in reducing fractured and luxated bones, in order to prevent a deformity in the limb, or perhaps worse consequences. The general doctrine of fractures is contained under the following heads, as part of the treatment of them. Extension; counter-extension; coaptation or setting; application of medicaments; deligation or bandage; position; prevention or relief of accidents.

This is the general arrangement of the subject by most of the writers on it, and a very just and proper one it is; but, notwithstanding the parade of books under these various heads, much less alteration will be met with, since the times of Hippocrates, Galen and Celsus, than an inquirer might expect, or than the subject is capable of.

The first article in the general arrangement is extension; under which may also be comprehended the second, or counter-extension. In order to accomplish this, we are directed, if the fracture be of the thigh or leg, to place the patient in a supine posture, and the broken limb in a straight one; than having the upper part of it held firm and steady by proper assistants, we are ordered, by means of hands, ligatures, laces, or even in some cases by pieces of machinery, to make such an extension or stretching of the limb lengthwise as shall enable the surgeon to place the ends of the broken bone in as apt, that is, in as even a position, with regard to each other, as the nature of the fracture will admit.—This is a short description of what in the vulgar phrase is called setting a broken bone; and is most commonly a painful operation to the patient, a fatiguing one to the operator and his assistants, and, what is worse, is in many instances found to be inefficacious, at least not fully to answer the intention of the one or the expectation of the other.

Writers in general are very precise and formal in the directions which they have given for the due and proper accomplishment of this purpose. They have told us, that the extension should be made slowly and gradually, and should be continued till the ends of the bone

bone are separated from each other sufficiently, to admit of the fracture being set without risk of breaking off any points or inequalities, and to enable us to place them perfectly smooth and even. All this, like many other of the preceptive parts of physic and surgery, is very pretty on paper, but not often found to be practicable in the chamber. The directions to continue the extension until the ends of the bones are at a certain distance, lengthwise from each other, plainly implies a considerable degree of violence; the limb must by such force be not only made longer than its fellow, or than nature ever intended it should be; but it is ordered to be executed while the limb is in such position as to put all the muscles most on the stretch, and render them least likely to yield to it.

In order to understand the dangers of this method rightly, let us for a moment consider what is or ought to be meant by the terms extension and counter-extension, and why they become necessary: and here it is plain that neither of them can ever be necessary on account of the mere fracture considered abstractedly. The broken ends of the bone or bones are of themselves inactive; and if not acted upon by other parts, they would always remain motionless. When any attempt is made to put them into motion, they of themselves can make no possible resistance, nor can any be made on their part, save an accidental one, arising from the points of the fracture being entangled with each other; and when they have been once, by the hand of the surgeon, placed properly and evenly with regard to each other, they would of themselves for ever remain so. What then is the reason why fractured bones always suffer a greater or a less degree of displacement? why is a broken limb almost always shorter than its fellow? what creates the resistance which we always find in attempting to bring the fractured parts aptly together? whence does it proceed, that when we have done all that is in our power (according to this mode of acting), the ends of the fracture will, in many cases, become again displaced, and lameness and deformity frequently ensue? In short, what are the parts or powers which act on the bones, and which, by so acting on them, produce all these consequences?

These parts are the muscles, the only moving powers in an animal-body. By the action of these on the bones, all locomotion is performed, and cannot be performed without them: and although all bones, when broken, are in some degree displaced and shortened; yet it will always be found, that in proportion as the muscles surrounding or in connection with a bone are strong or numerous, or put into action by inadvertence or spasm, so will the displacement of the ends of such bone, when fractured, be. The even and smooth position of the fractured ends of a tibia, when the fibula of the same leg is entire and unhurt, that is, when the muscles therefore cannot act upon the former; the visible and immediate deformity when both the before-mentioned bones are broken nearly in the same place, that is, when the muscles can act upon and displace such fracture; the great difficulty frequently met with in endeavouring to get a broken os femoris to lie even tolerably smooth, and to prevent such broken limbs from being much shorter than the others; are, among others which might be produced, such strong and irrefragable proofs as need no comment.

From the muscles then, and from them only, proceeds all the difficulty which we meet with in making our extension; and by the resistance of these, and of these only, are we prevented from being always able to put the ends of a fractured bone immediately into the most apt contact.

Let us in the next place consider what it is which gives to a muscle, or to the principal muscles of a limb, the greatest power of resisting any force applied to them ab externis, in order to draw them out into greater length; for, whatever that is, the same thing will be found to be the cause of the different degrees of resistance in setting a fracture.

Does not the putting the muscles in a state of tension, or into a state approaching nearly to that of tension, almost necessarily produce this effect? or, in other words, does not that position of a limb which puts its muscles into, or nearly into, such a state, give such muscles an opportunity of exerting their greatest power either of action or of resistance? This cannot be denied. On the other hand, what is the state or position of a muscle which is most likely to prevent it from acting, and to deprive it most of its power of resistance? or what is that position of a limb, which in the case of a broken bone will most incapacitate the muscles from acting on and displacing it, and in the greatest degree remove that resistance which they have in their power to make to the attempts for the reduction of such fracture? Is it not obvious, that putting a limb into such position as shall relax the whole set of muscles belonging to or in connection with the broken bone, must best answer such purpose? Nothing surely can be more evident. If this be granted, will it not follow, that such posture of a broken limb must be the best for making the reduction? that is, it must be that in which the muscles will resist the least, and be least likely to be injured; that in which the broken bone will be most easily set, the patient suffer least pain in present; and that from which future lameness and deformity will be least likely to happen. A little attention to what frequently occurs, may perhaps serve to illustrate and confirm this doctrine better than mere assertion.

What is the reason why no man, however super- Why is it fi-
cially acquainted with his art, ever finds much trouble
in setting a fractured os humeri, and that with very
little pain, and a very small degree of extension? Is
it not because both patient and surgeon concur in
putting the arm into a state of flexion, that is, into
such a state as relaxes all the muscles surrounding the
broken bone? and is it not for the same reason that
we so very seldom see (comparatively speaking of this
bone with others) a deformity in consequence of a
fracture of it? Let the reduction be attempted with
the arm extended from the body, and the difficulty of
setting will be much increased: let the arm be depo-
sited in an extended straight position, and the fracture
will be displaced, and lie uneven.

Apply the same kind of reasoning to the os femoris; And diffi-
that bone whose fracture so often lames the patient,
cult to set
and disgraces the surgeon. Will it not be more con-
the os fe-
gent, and more conclusive, in proportion as the muscles
moris.
in connection with this bone are more numerous and
stronger? Let any man, who has been much conversant
with accidents of this kind, be asked, what is the
posture

Theory. posture which almost every person whose os femoris has been newly broken puts himself into, in order to obtain ease, until he gets proper assistance? Such people almost always bend their knee, and lay the broken thigh on its outside, because this is the most easy posture, for obvious reasons.

206 When the reduction of a fracture ought not to be attempted. It is a maxim universally taught and received, that a fractured limb may be in such state as not to admit of the extension necessary for its being set: that is, if assistance be not at hand when the accident happens; if they who bring the patient home do it so awkwardly or rudely as to bruise and hurt the part; if from drunkenness, folly, or obstinacy in the patient, it happens that the limb is so disordered that it is found to be much swollen, inflamed, and painful; it is allowed not to be in a state to admit extension.

207 Erroneous doctrine concerning fractures. This maxim is indeed founded upon very just principles; but what is the general practice in consequence of it? It is, to place the limb in an extended straight position; to secure it in that; and then by proper means, such as fomentation, poultice, &c. to endeavour to remove the tension and tumor. Now if it be considered that the swollen, indurated, and inflamed state of the muscles is the circumstance which renders extension improper, surely it must be obvious, that such position of the limb as necessarily puts these very muscles in some degree on the stretch, must be a very improper one for the accomplishment of what ought to be aimed at. Under this method of treatment, the space of time which passes in the removal of the tension is sometimes so considerable, that a happy and even coaptation becomes afterwards impracticable; and then this accident, which nine times in ten is capable of immediate relief, is urged as an excuse for unnecessary lameness and deformity.

208 Of the posture of the limb during extension. Here the nature of the complaint points out the relief. Extension is wrong; a straight position of the thigh or leg is a degree of extension, and a still greater degree of it in proportion as the muscles are in such circumstances as to be less capable of bearing it. Change of posture, then, must be the remedy; or rather the placing the limb in such a manner as to relax all its muscles, must be the most obvious and certain method of relieving all the ills arising from a tense state of them: which change of posture will be attended with another circumstance of very great consequence; which is, that the bones may in such posture be immediately set, and not one moment's time be thereby lost: a circumstance of great advantage, indeed; for, whatever may be the popular or prevailing opinion, it is demonstrably true, that a broken bone

209 Reduction ought to be performed as soon as possible. cannot be too soon put to rights; as must appear to every one who will for a moment consider the necessary state of the muscles, tendons, and membranes surrounding, and the medullary organs contained within a large bone broken and unfet; that is, lying in an uneven irregular manner. In short, if the experiment of change of posture be fairly and properly made, the objections to immediate reduction, from tension, tumor, &c. will most frequently be found to be groundless, and the fracture will be capable of being put to rights, as well at first as at any distance of time afterward.

Extension having been made, and the broken ends of the bone having been placed as smooth and as even

as the nature of the case will admit, the next circumstance to be attended to is the application of some medicament to the limb; particularly to the fractured part of it. In this, different people act differently. Some make use of an adhesive, or what they choose to call a roborant, plaster; some, of what is commonly called a cerecloth; others apply spirit of wine, with oil, vinegar, and white of egg; and others the spiritus Mindereri, the solution of crude sal ammoniac in vinegar and water, or some such kind of medicine. But let the form and composition of the application made to the limb be what it may, one thing is clear, viz. that it should be put on in such manner as that it may be renewed and shifted as often as may be necessary, without moving the limb in any manner; it being certain, that when once a broken thigh or leg has been properly put to rights, and has been deposited properly on the pillow, it ought not never to be lifted up nor moved from it again without necessity, until the fracture is perfectly united; and it is as true, that such necessity will not very often occur. This may perhaps seem strange to those who are accustomed to roll simple fractures, and consequently to lift them up every three or four days in order to renew such kind of bandage: but the necessity of this motion arises merely from the kind of bandage made use of, and not from any circumstance of the fracture itself. That the frequent motion of a fractured limb cannot possibly contribute to the ease of the patient, will be readily admitted; as also it will, that when a broken limb has been once deposited in the best position possible, it is impossible to mend that position merely by taking such limb up and laying it down again: from whence it must follow, that such kind of apparatus as necessitates the surgeon frequently to disturb the limb, cannot be so good as one that does not; provided the latter will accomplish the same kind of cure as the former.

210 Motion to be avoided as much as possible. The prevention of a flux of humours to a broken limb by bandage, is a common phrase; but if by the tight bandage points and edges of the broken bone the muscles and membranes be unavoidably wounded and torn, or if the same kind of mischief be incurred by the inadvertence or indifference of the patient, or of those who assisted in getting him home, or from the violence used in extending the limb and setting the fracture, inflammation must be excited, and pain and tumefaction will be the consequence: and these will continue for some time in every fracture; but that space will be longer or shorter in different cases and under different circumstances. Evacuation, rest, and a favourable position of the limb, will, and do in general, remove all these complaints: but bandage can contribute nothing more than by keeping the applications in their proper place; so far from it, that if the bandage be a roller, it must, by the frequent necessity of its being adjusted, and the frequent motion of the limb, in some degree counteract the proper intention of cure.

211 The old writers are in general very precise as to the number of days during which the roller should be suffered to remain without being shifted, and the number of times which such shiftings should be repeated within the first fortnight. This exactitude is by no means necessary; but if the bandage be supposed to be of any use at all, it is obvious, that it ought to be

renewed or adjusted as often as it may cease to perform the office for which it is designed, or whenever it shall be found to counteract such office, that is, as often as it shall become so slack as not to contain the fracture at all, or whenever the limb shall be so swollen that the roller makes an improper degree of stricture; the former generally occurs every four or five days, the latter is most frequent within the first week.

In most of the writers on the subject of fractures, we also find marks or signs laid down for our information concerning the due or undue effect 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 swell at all, the bandage is not sufficiently strict, and will not retain the fracture; that when the same part is considerably swollen, or tense, or inflamed, it implies that the binding is too strait; and that a moderate degree of tumefaction is a sign that the deligation is properly executed.

In consequence of these precepts, many practitioners look more anxiously after this degree of tumefaction, than after the true and exact position of the limb, and cannot be induced to believe that any thing can be wrong under this appearance: although it is plain, that even this degree of swelling is wrong; that it implies some kind of obstruction to the circulation, and cannot serve any good purpose; and consequently, that as far as it may be supposed to be the effect of bandage, so far that bandage must be faulty.

The third purpose for which the roller is said to be used, is the regulation and restraint of the callus.—If we were to form our notion of callus by what the generality of writers have said on this subject, we should suppose, that it was not only a particular juice always ready for the purpose; but that, if not restrained and regulated by art, it would always flow in such quantity, as to create trouble and deformity; that there were specific remedies for increasing or decreasing it, and that it always required the hand and art of surgery to manage it. That the callus is so far a particular juice, as that it consists 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 fractures are united, is as true; but that it requires 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 united medium does oftentimes create tumefaction and deformity, or even lameness, is true also; but the fault in these cases does not lie in the mere redundancy of such juice; it is derived from the nature of the fracture, from the inequality of it when set, and from the inapt position of the broken ends with regard to each other; nor is surgery or the surgeon any otherwise blameable in this case, than as it was or was not originally in their power to have

placed them better. It is the inequality of the fracture which makes both the real and apparent redundancy of callus, and the tumefaction in the place of union. When a bone has been broken transversely, or nearly so, and its inequalities are therefore neither many nor great; when such broken parts have been happily and properly coaptated, and proper methods have been used to keep them constantly and steadily in such state of coaptation, the divided parts unite by the intervention of the circulating juice, just as the softer parts do, allowing a different space of time for different texture and consistence. When the union of a broken bone under such circumstances has been procured, the place where such union has been made will be very little perceptible; it will be no deformity, nor will it occasion any inconvenience. It will indeed be discoverable, like a cicatrix of a wound in a softer part: but there will be no redundancy of callus, because none will be wanted; neither will there be a necessity for any particular management on the part of the surgeon, to repress or keep it in order. But when a bone has been broken very obliquely or very unequally; when the parts of a fracture are so circumstanced as not to admit of exact coaptation; when such exact coaptation as the fracture perhaps would have admitted, has not been judiciously made; when, from unmanageableness, inadvertence, or spasm, the proper position of the limb has not been attended to or preserved; in all such cases there must be considerable inequality of surface; there must be risings on one side, and depressions on another; and in such cases the juice circulating through the bone cannot accomplish the union in the same quantity, the same time, or in the same manner. The broken parts not being applied exactly to each other, there cannot be the same aptitude to unite; and according to the greater or lesser degree of exactitude in the coaptation, that is, according as the ends of the bones are or have been placed more or less even with regard to each other, will the inconvenience and the deformity be, and still must, when the fracture is not set at all; but the broken ends of the bone unite laterally, or by touching each other's sides. The periosteum covering every fracture will remain thickened for some time, and a degree of fullness or rising will be thereby caused about the place where such fracture has been united; but time, and the use of the muscles, soon in general remove this.

217
Two kinds of fracture there are which do not admit of the bent position of the joints, viz. that of the processus olecranon at the elbow, and that of the patella: in these a straight position of the arm and leg is necessary; in the former, to keep the fractured parts in contact till they are united; in the latter, to bring them as near to each other as may best serve the purpose of walking afterward (A).

With regard to the fracture of the patella, an opinion

(A) Although a straight position of the limb is necessary for the broken patella, yet this very position becomes so, upon the same principle, as renders the bent posture most advantageous in the broken tibia and femur, viz. the relaxation of the muscles and tendons attached to the fractured bone.

Whoever will for a moment attend to the disposition of the pieces in a patella which has been broken transversely, will see how little necessary or useful the many contrivances of bandages, straps, compresses, buckles, buttons, &c. to be found in writers are, especially all that part of them which are applied to the inferior fragment.

By the action of the united tendons of the extensor muscles of the leg, the superior fragment is pulled upward and

^218
219
Theory. ²²⁰
Why a fracture of the patella frequently produces a stiffness of the joint.

nion has long and generally prevailed, which seems to have no foundation in truth, or even in probability: it is, that the great degree of stiffness in the joint of the knee, which is sometimes found to be the consequence of this kind of fracture, is owing to or produced by a quantity of callus falling into it from the edges of the broken bone; and that the nearer the broken pieces are brought to each other, the more likely such consequence is. But, in the first place, the fractured bone is by no means capable of supplying such a quantity of callus as to produce this effect; in the second place, if this was the case, the most likely, and indeed the only probable way of preventing the deposition of such juice, must be by bringing the broken pieces into close contact; and, in the third place, there is no authority from the appearance of such joints after death, to suppose this to be the case, or to countenance such opinion. The cause, therefore, of this rigidity, which is now and then found to attend the broken patella, must be sought for elsewhere, viz. in the long rest and confinement of the joint, as a means used by many to procure exact union; in mischief done to the ligament, which is formed by the united tendons of the four extensor muscles of the leg, at the time of and by the fracture; and in the nature of the fracture itself, that is, the manner in which the bone shall happen to be broken.

But, be all this as it may, the fact undoubtedly is, that they walk best after such accident whose patella has been broken transversely, and that into two nearly equal fragments; whose confinement to the bed has been short, that is, no longer than while the inflammation lasted; whose knee, after such period, has been daily and moderately moved; and in whom the broken pieces are not brought into exact contact, but lie at some small distance from each other.

²²¹
What cases of this fracture are most favourable.

We cannot take leave of this subject of simple fractures without mentioning a circumstance relative to them, which, although, when rightly understood, is of little or no importance, yet, by being misunderstood, becomes frequently of considerable consequence, viz. the use of the term rising end of a broken bone.

By the expression, any one unacquainted with these things would be inclined to think, that the prominent part of a broken bone rose or was elevated from its natural place, and became by such rising superior to the other part or extremity of the fracture. This would certainly be the idea of an ignorant person, and as such would be of little consequence: but by the practice of many surgeons, it is as certainly their idea also; and this renders it a matter of great consequence. The truth is, that there is really no rising end to a broken bone, when applied, as the term usually is, to the leg, thigh, and clavicle. There is indeed a superior or prominent end or part, and an inferior or depressed one: but the former of these 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.

When a collar-bone, or femoris, or tibia and fibula, are

are broken by the action of the muscles, by the motions of the patient, and by the mere weight of the inferior part of the arm, thigh, or leg, the fractured ends of such bones are displaced, and always displaced in such manner, that the inequality occasioned necessarily by such displacement, proceeds from the inferior end of the fractured bone being retracted or drawn under the superior. This produces a tumefaction or unequal rising; and the upper extremity of the fracture is therefore called the rising end of it. Now the man who regards this rising end as that part of the fracture which has by such rising got out of its place, and not as having accidentally become the prominent part merely by the insinuation or retraction of the other part underneath it, will go to work with bolster, compress, and bandage, in order to bring and keep such end down: by which means he will give his patient considerable pain; and, while he depends on such means alone, will most certainly be frustrated in his intention and expectation, the means not being adequate to the proposed end. But the man who looks on this in the true light, that is, who looks on the superior part as being in its proper place, and the inferior as being displaced by the weight of the limb and the action of the muscles, will know, that by the mere position of such limb, he shall 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 useless apparatus.

²²²
Theory.

He will, for example, know, that the prominent part of a broken clavicle, that part of it which is next to the sternum, is just where it should be; and that the inferior part, that which is connected with the scapula, is out of its place, by being drawn down by the weight of the arm; and therefore, instead of loading, as is usual, the prominent part with quantities of compress, which never can do any service, he, by a proper elevation of the arm, will bring the lower end upward into contact with the other, and thereby with very little trouble easily accomplish what he never can do in any other manner, however operose.

The same thing will happen, from the same principles, in the leg and thigh. A prominence, or a rising end, there always will be; but that rising end is never to be brought down by any pressure from compress or bandage; the fallen or inferior one must always be brought up to it by the proper position of the rest of the limb: this will always remove the inequality as far as it is removable; and nothing else can.

²²³
We come now to speak of compound fractures, or those in which the breaking of a bone is complicated with a wound. In this case, the first object is whether the limb can be preserved or not. Many circumstances concur to make this doubtful. For instance, the bone or bones being broken into many different pieces for a considerable extent, as when a person's limbs are crushed by the wheels of heavy carriages passing over them; the skin, muscles, tendons, &c. the limbs being so much lacerated and destroyed, as to render can be preserved, gangrene and mortification the most probable consequence;

and separated from the inferior; but the latter remains nearly, if not absolutely, where it was before the accident: there is nothing to act upon it; and therefore it cannot, nor does it move.

The extension of the leg puts the muscles attached to the upper part of the broken bone into a state of relaxation, and prevents their acting; and though a small compress just above this piece, with a moderate bandage, may be useful toward retaining it, yet it is the position of the leg which must keep the broken piece down, and effect the cure.

quence; the extremities forming a joint being crushed, or, as it were, comminuted, and the ligaments connecting such bonds being torn and spoiled, with other circumstances of the same kind, are, by very eminent practitioners, reckoned sufficient reasons for performing immediate amputation. On the other hand, there are not wanting men, whose knowledge in their profession can by no means be doubted, that absolutely deny the usefulness of immediate amputation almost in any case, unless the limb is already torn off and hanging almost by the skin. Mr Boucher, of the Royal Academy of Surgery, gives twelve remarkable instances of desperate fractures in which the limbs were preserved. The first was a shot through the thigh, with a considerable fracture of the os femoris near the condyles. The patient refused to submit to the operation, and was completely cured, but with one thigh shorter than the other, in ten months, notwithstanding the frequent incisions, fever, and large splinters of bone that came away from time to time. The second had a fracture of the lower extremity of the arm, and was also cured without amputation. The third was shot in the fore-arm by a pistol ball, which wounded the internal condyle of the humerus and olecranium; yet the patient not only was cured of the wound in the space of 12 months, but recovered of the ankylosis also. The fourth and fifth were similar. In the sixth, the shot penetrated the lower part of the femur, in which the inner condyle was engaged; yet, notwithstanding a variety of bad symptoms, he obtained a cure in the space of 11 months. In the seventh case, the inferior part of the radius was fractured, with considerable laceration of the tendons; nevertheless this patient also was cured, but with a stiffness in the joint. In the eighth, the ball passed from the malleolus internus through the malleolus externus; yet the patient was completely cured in nine weeks. The ninth patient had received a ball which tore through the deltoid muscle, fractured the head of the humerus, and part of the clavicle. The extirpation of the humerus was judged absolutely necessary, which yet the patient resolutely opposed; and by that means saved his arm, being discharged only with a small fistula, which the warm bath soon cured. The tenth was a soldier, wounded by a musket-ball in the upper part of the humerus, with a fracture of this bone; yet he also got a cure without amputation. In the eleventh, a musket-ball fractured the head of the bone at the elbow. In the twelfth, a ball was lodged in the calcaneum; yet, after extraction, the wound was cured without any bad accident.

Notwithstanding this great success, however, M. Boucher is of opinion, that there are certain accidents which nothing but amputation can remove. Such, for instance, are fractures of the larger extremities, where numbers of splints stick out, and cannot be removed; when the same bone is fractured in several different places; when the extremity of one of these bones is separated from its body, and shattered in many places; when the wounded parts are seized with violent convulsions which cannot be cured; where the bone is surrounded with loose flabby flesh, and a sanious discharge with acute pain, which indicate the bone to be disordered; and where a sphacelus is formed. Where these symptoms indicate amputation, he thinks that

the sooner it is performed the better; for when it is deferred, he says, the violent irritation of the nervous and vascular systems, which in a short time succeeds the accident, puts the whole animal economy and mass of fluids into such disorder, that the pus requisite for the cure is defective, and the recovery becomes doubtful. And he attributes this want of success where the operation is delayed, not to the first cause, but to the alteration caused by the delay.

On the other hand, M. Faure, in a paper presented to the Academy, attempts to prove, that where amputation is necessary, it ought always to be deferred till the bad symptoms occasioned by the wound have abated. The reason he gives for this practice is, that nature having already sustained a violent shock, is unable to bear the succeeding one arising from amputation: and for the truth of this he appeals to the cases of about 300 persons, who underwent the operation after the battle of Fontenoy, of whom scarce one in ten escaped. Convinced, by this sad example, that amputation had been too hastily performed, he selected ten patients on whom the operation was judged unavoidable, and directed them to be let alone for a month; after which he performed the operation with success on them all. The cases were the worst that can almost be imagined. The first had the head of the os humeri fractured by a cannon-ball, while a complicated fracture of the leg was made by a musket-ball. The others were a complicated fracture of the thigh; a fracture in the articulation of the knee, through which the ball passed; a complete fracture of the forearm, which extended to the os humeri; a wound of the inferior part of the forearm, with shivering of the bones of the carpus; a wound at the upper part of the humerus, with a fracture above an inch broad; a fracture of the bones of the carpus; the os calcis shivered, and the tendo Achillis torn; a complicated fracture of the tibia; a fracture of the tibia in which the tarsus was engaged.—From all these cases, M. Faure strongly contends, that where amputation is unavoidable, it should always be delayed till the fever and other bad symptoms cease; and he exclaims against the contrary method; adding, that "we might even say, the sooner the limbs were amputated, the sooner were the patients condemned to death."

M. Boucher presented a second paper to the Academy, in which he adhered to his former opinion, and gave his reasons for immediate amputation. These were, that at the time of the hurt, or soon after it, the body must be in the best state for enduring the operation; and by neglecting this time, the efforts of nature are useless, and she becomes weaker; the melancholy effects of which, he says, he has been witness of. "For how can we expect (says he) that a body extenuated with pain and misery for five or six weeks, should then be in a better condition to support a terrible operation, than when in full vigour, as must be the case at the time of the accident?" Several instances are adduced in favour of his doctrine; but Mr O'Halloran, from whom we have taken this account, is of opinion, that his reasoning is quite unsatisfactory. "The great point," says he, "for which M. Boucher contends, is the advantage arising to the patient by having his limb taken off in the first period, or before the fever, inflammation, &c. come on, which

Theory. in themselves endanger the life of the party. But it is highly probable this gentleman never once recollected, that this fever, and all other alarming symptoms, tho' they do not immediately appear, are nevertheless the effect of the derangement in the constitution on receiving the accident: that on this account it is certainly very bad practice to amputate till at least part of these symptoms are abated, for three excessive strong and clear reasons. First, so much depends upon the habit of body, that we cannot be too cautious in our prognostics: for if the slightest hurts, happening in constitutions seemingly sound, are often attended with the most fatal symptoms, in spite of the earliest and best resources of art; how then can we, with any degree of certainty, immediately promise ourselves success, by performing a terrible operation, till we first know if the very juices themselves will not be the greatest obstacle to a re-union? Secondly, how often does it happen, in the best constitutions, that the terrible shock which the whole frame sustains on a violent gunshot wound, nay, even in a fall, without any fracture or visible hurt, that the parts can never recover their tone, and the patient in some days expires? What else are concussions of the brain, violent leaps, where, though the party comes down on his legs, and has no visible hurt, yet dies with all the appearance of a concussion of the brain? What else but the velocity of the circumambient air of a discharged cannon-ball, which, by deranging the whole animal-system, kills the party without sign of hurt? If these account for the death of the patient, will not this be a strong reason for delaying amputation, till we know whether nature is strong enough to recover from this shock, without adding to his misery that of a cruel and terrible operation? Thirdly, let us suppose, to give this gentleman and his partisans argument their utmost force, that happily for the patient, though unknown, or never reflected on by the surgeon, first, that the juices are balsamic and kind; and, secondly, that nature is strong enough to recover from the shock which every accident, more or less, subjects the constitution to: how can we possibly foresee, or at least is not the presumption very strong, that by an immediate amputation, after such a terrible violence as absolutely indicates it, we expose the constitution to the severest trials and the greatest danger possible? If in anchylosis of the tarsus, with great pain, which has reduced the patient very low, we find a severe fever and inflammation ensue, the consequence of the pain and the shock the human frame has sustained by an amputation, how much more is it to be dreaded after a terrible gunshot wound or complicated fracture; which accidents alone bring on all these symptoms in an higher degree? Justly then does M. Faure exclaim, "That the sooner their limbs were taken off, the sooner were they condemned to death!"

"The few instances advanced by M. Boucher, of the success of immediate amputation, for the reasons I have above assigned, can prove nothing for him. If any thing can be granted, it is, that, happily for the patients, their constitutions surmounted the rashness of their surgeons, as well as the severe trials of nature. Amputation, then, should never be practised after sudden accidents, till at least the violence of the symp-

toms proceeding from it are abated, for the reasons assigned, and which I again inculcate; namely, first, till by laudable suppuration we are assured that the juices are balsamic, and which becomes manifest in eight or ten days. Secondly, till we are certain that nature recovers from the shock; which we will also be certain of, by reason's becoming restored if lost, or by the state of the pulses and nervous system: this also becomes apparent about the eighth or ninth day. And, thirdly, till it becomes manifest, that the pain, fever, and inflammation, will not terminate in gangrene, sphacelus, or death. This the state of the pulse and spirits, and the nature of the suppuration, will determine.

"But besides these advantages, at least these points of knowledge gained by the delay, another and a greater also follows; namely, that the abatement of the fever, and the laudableness of the suppuration, are the highest preparations, and the most useful, the patient can possibly have previous to the operation: he is, at the time of amputation, in the same state that we could wish a patient to be in who is to suffer inoculation; and a great degree of certainty attends the recovery of the patient, especially in our method. I shall just single out one observation, which first threw me into this chain of thinking.

"A girl about 16, of a good constitution, some few years past, on Pennywell road, adjoining this city, was accidentally shot in the thigh. The swan-shot fractured the femur at the lower condyles, and the tibia rotula anteriorly, and passed through the parts with a very large wound. In this situation she lay extended on a table for about two hours, when assistance came. Her pulse was regular, she spoke sensibly, and seemed more alarmed than pained. We judged amputation absolutely unavoidable; and her thigh was taken off directly, but she died in about four hours after. Here the death of this girl was visibly hastened, by adding amputation before nature had time to recover from the first accident.

"The truth of this reasoning will appear still stronger by the following observations:

"John Quinlon, a sedan-chairman of this city, in a dispute with another chairman, received a fall by a trip, so that the tibia tore through the flesh at its articulation with the altragal, and reached down a little below the os calcis, and the fibula was consequently terribly fractured. This accident happened the latter end of August 1760. To reduce these parts was absolutely impossible; because a less force than was necessary for this must separate the foot from the leg. Amputation was the only resource left. The man was strong, and about 35 years of age; so that every thing might be expected from the constitution. However, on mature deliberation, though amputation was absolutely unavoidable, I was determined to defer it for some days. Accordingly I laid open the flesh below the protruded bone, and formed an eighteen-tailed bandage, in which, after a gentle extension, I laid the leg, bled the man, and had the parts often wet in brandy. In a few days the inflammation became violent; which was somewhat allayed by bleeding, fomentations, and poultices. In 12 days from the accident, finding the foot gangrened, I determined to amputate. The next morning I performed the operation.

tion; and though, after taking off the limb, some real pus (the remains of the inflammation) flowed from the stump spontaneously, yet did the cure go on as happily as could be wished; and in about ten weeks he was completely cured.

"Alice Blachall, about 15 years old, subject to epileptic fits, and paralytic in the right side, leg, and arm, in one of these fell into the fire, and had the diseased leg so miserably burnt, that the bones of the toes and metatarsus spontaneously dropped off, and those of the tarsus were uncovered and ready to separate. In this condition she was left at our hospital-door July 17th 1762; but with an hectic, lax, and a large discharge from the leg, which was also burnt. This accident happened about 10 days before. The sores, which were filthy, I had carefully staped, and washed with a decoction of wormwood; and finding amputation absolutely unavoidable, I performed it; and she was discharged, completely cured, in the latter end of the following month, with a firm coat of flesh to cover the extremity of the stump, notwithstanding that this whole side was completely paralytic, and of course the balsamic juices were greatly deficient.

"John Deelan, a poor man, received the fire from a musket, charged with small shot, in his right hand, and so near, that the wadding rested in the fore. Being recommended to our hospital by the reverend dean Maffy the day after the accident, he was immediately admitted. The little and ring fingers were quite tore off, and hanging by a little flesh; the two metacarpal bones that supported them were also fractured and terribly tore; and the shot was promiscuously thrown into every part of the hand. It was judged impossible to preserve the hand; but, for the reasons already specified, I was determined to defer amputation till the inflammatory state was over. However, I separated the two fingers from the hand; dilated the sores; and extracted a great deal of shot, tow, broken bones, &c. The inflammation which followed was very violent, and extended very high up the arm; but was relieved by profuse bleedings, emollient embrocations, poultices of sumnery half-boiled, nitrous medicines, &c. In about 12 days this orgasm was greatly abated; and willing to preserve part of his hand if possible, I extracted the entire remains of the two metacarpal bones, and by this means a great deal more shot, splints, &c.; and, contrary to expectation, this man was discharged with two fingers and part of his hand, with which he has been able to support his poor family since by day-labour.

"One O'Neal, returning from town much in liquor, fell into a sand-pit on the high road near this city, and a very large stone fell on his right leg with such a force, as to fracture the tibia for above three inches in a most dreadful manner, with a wound of a larger surface. Indeed the bone was broke into numberless bits; inasmuch that, considering the length of the fracture, it may be safely affirmed, that a quarter of an inch of it was not entire. He was carried to the turnpike-house, and I was sent for. On the spot I prepared an eighteen-tailed bandage, dilated the wound, extracted a great many loose bits of bone, dressed with soft lint, and bled him. Next morning he was brought to town on a door, and dressed lightly

for some days, till the state of inflammation was somewhat abated; when I determined to take off his leg, which was judged impossible to be saved: and I dare say, from this slight description of the case, every surgeon would conclude the same. Nevertheless, so bountiful was nature in this case, and so strong in her resources, that in four months from the accident, this man could use this leg, and is now a living witness of this truth. So that, besides the reasons already advanced, we have a chance for one more, and that the greatest, advantage to the patient, namely, the chance of saving the entire limb by delaying the operation.

"But as M. Faure does not absolutely determine the precise time of performing the operation after the accident, and that by the delay of six weeks, or till the symptoms cease, numbers of lives must be lost, I observe, that this is very vague and uncertain; because, by the nature of the accident, many symptoms must subsist, even after the general inflammation is passed. Such are extraneous bodies constantly irritating, splints of bones, too abundant suppuration, &c. In such cases, it will be in vain to expect an abatement of symptoms till the cause of them is removed, namely, the limb taken off. Upon maturely, then, considering the whole affair, I boldly affirm, that the shock from the general inflammation, the patient's state of blood and habit of body, &c. will be thoroughly known in about 20 days from the accident; and every symptom that continues subsequent to this must take its rise from the sore itself, and that where amputation is absolutely unavoidable. Supposing the patient to be treated all the time preceding this according to the rules of art, it should not be deferred longer, lest the patient sink under it. By this means, instead of about one in three amputated patients recovering, we should scarce lose, almost to a certainty, one in twenty."

Mr Pott seems to be an advocate for immediate amputation, or at least to dread none of those fatal consequences from amputation which we have just now mentioned. His words are, "When a surgeon says that a limb, which has just suffered a particular kind of compound fracture, ought rather to be immediately cut off, than that any attempt should be made for its preservation, he does not mean by so saying, that it is absolutely impossible for such limb to be preserved at all events; he is not to be supposed to mean so much in general, though sometimes even that will be obvious: all that he can truly and justly mean is, that from the experience of all time it has been found, that the attempts to preserve limbs so circumstanced, have most frequently been frustrated by the death of the patients in consequence of such injury; and that from the same experience it has been found, that the chance of death from amputation is by no means equal to that arising from such kind of fracture.

"Every man knows, that, apparently, desperate cases are sometimes cured; and that limbs so shattered and wounded as to render amputation the only probable means for the preservation of life, are now and then saved. This is an uncontroverted fact, but a fact which proves very little against the common opinion; because every man of experience also knows, that such escapes are very rare, much too rare to admit of being

Theory. ing made precedents, and that the majority of such attempts fail (8).

"This consideration, relative to amputation, is of the more importance, because it most frequently requires immediate determination; every minute of delay is, in many instances, to the patient's disadvantage; and a very short space of time indeed frequently makes all the difference between probable safety and fatality. If these cases in general would admit of deliberation for two or three days, and during that time such circumstances might be expected to arise as ought necessarily to determine the surgeon in his conduct, without adding to the patient's hazard, the difference would be considerable: the former would not seem to be so precipitate in his determination as he is frequently thought to be; and the latter, being more convinced of the necessity, would submit to it with less reluctance. But, unhappily for both parties, this is seldom the case; and the first 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 rashly and unnecessarily deprive his patient of a limb; nor, through a false tenderness or timidity, suffer him to perish, by endeavouring to preserve such limb. Some degree of address is also necessary upon such occasion, in order to convince the patient, that what seems to be determined upon hastily and with precipitation, will not safely admit of longer deliberation."

²³⁵ Of reducing a compound fracture. The limb being thought capable of preservation, the next consideration is the reduction of the fracture. The ease or difficulty attending this depends not only on the general nature of the case, but on the particular disposition of the bone with regard to the wound.

If the bone be not protruded forth, the trouble of reducing and of placing the fracture in a good position, will be much less than if the case be otherwise; and in the case of protrusion or thrusting forth of the bone or bones, the difficulty is always in proportion to the comparative size of the wound through which such bone has passed. In a compound fracture of the leg or thigh, it is always the upper part of the broken bone which is thrust forth. If the fracture be of the transverse kind, and the wound large, a moderate degree of extension will in general easily reduce it; but if the fracture be oblique, and terminates, as it often does, in a long sharp point, this point very often makes its way through a wound no larger than just to permit such extension. In this case, the very placing the leg in a straight position, in order to make extension, obliges the wound or orifice to gird the bone tight,

and make all that part of it which is out of such wound press hard on the skin of the leg underneath it. In these circumstances, all attempts for reduction in this manner will be found to be impracticable; the more the leg is stretched out, the tighter the bone will be begirt by the wound, and the more it will press on the skin underneath.

Upon this occasion, it is not very unusual to have recourse to the saw, and by that means to remove off the end portion of the protruded bone; but this practice is frequently erroneous.

In some few instances, and in the case of extreme sharp-pointedness of the extremity of the bone, it may be, and undoubtedly is, right, but in many instances it is totally unnecessary.

The two most proper means of overcoming this difficulty are, change of posture of the limb, and enlargement of the wound. In many cases, the former of these, under proper conduct, will be found fully sufficient; and where it fails, the latter should always be made use of. Whoever will attend to the effect which putting the leg or thigh (having a compound fracture and protruded bone) into a straight position always produces, that is, to the manner in which the wound in such position girds the bone, and to the increased difficulty of reduction thereby induced, and will then, by changing the posture of such limb from an extended one to one moderately bent, observe the alteration thereby made in both the just-mentioned circumstances, will be satisfied of the truth of what has been said, and of the much greater degree of ease and practicability of reduction in the bent than in the extended position; that is, in the relaxed, than in the stretched state of the muscles. Reduction being found impracticable either by extension or change of posture, the obvious and necessary remedy for this difficulty is enlargement of the wound. This, to some practitioners who have not seen much of this business, appears a disagreeable circumstance: but here there is neither difficulty nor danger; it is the skin only which can require division; and in making such wound there can be no possible hazard. It is needless to say, that the division should be such as to render reduction easy; or to remind the practitioner, that such enlarged opening may serve very good future purposes, by making way for the extraction of fragments, and the discharge of matter, sloughs, &c.

If the bone be broken into several pieces, and any of them be either totally separated so as to lie loose in the wound, or if they be so loosened and detached as to render their union highly improbable, all such pieces ought to be taken away; but they should be removed

41 Z

"(8) The baron Van Swieten, writing as many others have done, that is, theoretically, on surgery, advises us, in the case of very bad compound fractures, which may most probably require amputation, to defer the operation until we have tried the force of antiseptic fomentations, and applications of like kind, for two or three days; and this opinion and advice he builds, in some measure, on the remarkable success of La Motte, in a seemingly desperate case, of a man's leg mangled by the wheel of a heavy carriage.

"That De La Motte's patient escaped I make no doubt, because he has said so: but the surgeon showed much more rashness in attempting to save such a limb, than he would have done in the amputation of it; the operation would have been the more justifiable practice.—With regard to the baron's advice, to stay two or three days, I take the liberty to add, that if you do that, stay several 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 less than he would have had at the time of the accident.

"I should be very sorry to be thought a patron or an adviser of rashness or cruelty; but in what I have here said, I believe I shall have every man in the profession, who has either true humanity, or sound judgment founded on experience, on my side."

removed with all possible gentleness, without pain, violence, or laceration; without the risk of hæmorrhagy; and with as little poking into the wound as possible. If the extremities of the bone be broken into sharp points, which points wound and irritate the surrounding parts, they must be removed also. But the whole of this part of the treatment of a compound fracture should be executed with great caution. The objects of fear and apprehension in a compound fracture (that is, in the first or early state of it) are, pain, irritation, and inflammation: these are to be avoided, prevented, and appeased, by all possible means, let every thing else be as it may: and altho' certain things are always recited as necessary to be done, such as removal of fragments of bone, of foreign bodies, &c. &c. yet it is always to be understood, that such acts may be performed without prejudicial or great violence, and without adding at all to the risk or hazard necessarily incurred by the disease.

In dislocations of the joints, as well as in fractures of the bones, our great attention ought to be paid to the muscles belonging to the part affected. Tho' their action is regular and just, when the bone to which they are attached comes to be displaced, they pull and distort the limb in many different ways; and from them only arises the great difficulty in reducing luxated joints. From this consideration, Mr Pott lays down the following maxims with regard to luxated joints:

"1. Although a joint may have been luxated by means of considerable violence, it does by no means follow that the same degree of violence is necessary for its reduction.

"2. When a joint has been luxated, at least one of the bones of which it is composed is detained in that its unnatural situation, by the action of some of the muscular parts in connection with it; which action, by the immobility of the joint, becomes as it were tonic, and is not under the direction of the will of the patient.

"3. That the mere bursal ligaments of some of the joints, endowed with great mobility, are weak, diffractile, and constantly moistened: that, for these reasons, they are capable of suffering considerable violence without being lacerated; but that they are also sometimes most certainly torn.

"4. That did the laceration of the said ligaments happen much more frequently than I believe it does, yet it cannot be a matter of very great consequence, as it neither totally prevents reduction, when timely and properly attempted, nor a consequent cure (c).

"5. That supposing such accident to be frequent, yet as it is impossible to know, with any kind of certainty, whether it has happened or not, or in what part of the ligament, it cannot be admitted as a rule for our conduct, nor ought such mere conjecture to produce any deviation from what we ought to do were there no such supposition. Could we know with cer-

tainty when and where this had happened, very useful information might indeed be drawn from it.

"6. That all the force used in reducing a luxated bone, be it more or less, be it by hands, towels, ligatures, or machines, ought always to be applied to the other extremity of the said bone, and as much as possible to that only.

"7. That in the reduction of such joints as are composed of a round head received into a socket, such as those of the shoulder and hip, the whole body should be kept as steady as possible, for the same reason as in the foregoing.

"8. That in order to make use of an extending force with all possible advantage, and to excite thereby the least pain and inconvenience, it is necessary that all parts serving to the motion of the dislocated joint, or in any degree connected with it, be put into such a state as to give the smallest possible degree of resistance.

"9. That in the reduction of such joints as consist of a round head moving in an acetabulum or socket, no attempt ought to be made for replacing the said head until it has by extension been brought forth from the place where it is, and nearly to a level with the said socket.

"10. The last principle which I shall take the liberty to mention, and which I would inculcate very seriously, is, that whatever kind or degree of force may be found necessary for the reduction of a luxated joint, that such force be employed gradually; that the lesser degree be always first tried, and that it be increased gradatim."

SECT. IV. Of Abscesses and large Suppurations.

Under the article MEDICINE, n^o 154. it has been observed, that one of the ways in which inflammation terminates is by suppuration; in which case an abscess is formed. This takes place in consequence of that part of the body which was inflamed being rendered impervious to the circulating fluids; whence they are at last melted down, and converted into what is called pus or matter.—That an inflammation will terminate in an abscess, may be known from the length of time it has continued, from the remission of the pain and hardness, the greater elevation of the skin in the middle part, a change of colour from red to bluish or livid, a slight fever with shivering, and from a fluctuation of matter perceived on handling the part.

During the first stage of the inflammation, however, we ought, for the most part, to endeavour to resolve it, or prevent the formation of an abscess. Yet some cases must be excepted. For instance, those inflammatory swellings which sometimes occur in fevers, or succeed to them, ought always to be brought to suppuration; and it might be very dangerous to attempt a resolution of them. In swellings of a scrofulous nature, it is perhaps best to do nothing at all,

(c) In the accident of a dislocated tibia from a broken fibula, the strong, inelastic, tendinous ligaments, which fasten the end of the former bone to the astragalus and os calcis, are frequently torn; and as these, by proper care, almost always do well, and recover all their strength, there is the greatest reason to expect, that the more weak diffractile ones do the same. The only mischief which seems most likely to follow from a laceration of the latter, is from an effusion of the synovia; of which, Mr Pott thinks, he has seen an instance in the joint of the ankle. That the laceration of the bursal ligament of the shoulder cannot be a frequent or general impediment to reduction, appears from his never having, in more than 20 years care of an hospital, met with a single instance of its impracticability, when attempted in time.

Theory. either with a view to resolve or suppurate. Thus it might be dangerous to make use of repellent applications, at the same time that it is by no means advisable to promote their suppuration; the cure of such swellings, when opened, proving always very troublesome; while at the same time it is known, that such swellings may remain for a very long time without any risk to the patient. In the lues venerea, too, as we are possessed of a certain antidote for the disorder, it is best not to attempt the suppuration of any buboes which may appear; as the cure of them, when opened, very often proves extremely troublesome; and as their being opened cannot contribute any thing towards their cure.

Where the inflammation is but beginning, and the symptoms are not so violent as to affect the general system, topical remedies, with a due attention to regimen, often answer in resolving them. But when the inflammation runs high, with general symptoms of fever, it then becomes necessary to pay attention to these at the same time. Warm fomentations and cataplasms have generally been recommended for all inflamed parts: but these have a great tendency to promote suppuration, and are therefore very improper while the inflammation may be supposed capable of resolution. The first thing, therefore, to be attended to in the case of every inflammation, is the removal of the exciting causes, which either have brought it on originally, or which may continue it after it is begun. Such are extraneous bodies in wounds, pieces of fractured bones, luxations, &c. with whatever else may have had a tendency to foment and keep up the disease. Of all the various applications for an inflamed part, those of a sedative nature are chiefly to be depended upon; and, next to these, emollients. Of the former kind we may consider all the different preparations of lead dissolved in vinegar; together with the vegetable acid itself, which generally acts also as a sedative. Among the latter we may place, in the first class, the mild expressed oils, as also the soft ointments made with these oils and pure wax.

When we speak of sedative medicines, however, it must not be understood that all of that class are to be used indiscriminately. Thus opium, though one of the most powerful of all sedatives, yet as its application, externally, to the human body, is always attended with some degree of irritation, however useful it may at times be found in some particular species of inflammatory disorders, will never, probably, as an external application, become of general use in these cases. Warm emollient fomentations, too, though powerful sedatives, as tending more effectually to remove tension and pain than perhaps any other remedy, yet are constantly found to be improper where a resolution is to be wished for, as we have already observed. Their constant effect is, either to bring the swelling to a suppuration, or to relax the parts in such a manner as to render the removal of the disorder always exceedingly tedious.

240 The applications proper for an inflammation. 241 Of the preparations of lead. Mr Bell recommends the preparations of lead as proper applications, in cases of external inflammation, where we wish for a resolution. These medicines have lately drawn the attention of the public by the great encomiums passed upon them by M. Goulard, who thus endeavoured to pass off one of his own compositions

under the very improper name of extract of lead. This medicine, which at best can only be a saturated solution of lead in strong vinegar, Mr Bell justly observes, has not the advantages of saccharum saturni. "For (says he) although in the Extrait de Saturn of Goulard, as likewise in the Acetum Lithargirites of our dispensatories, which are both, it may be observed, very nearly the same, we may be very certain of the quantity of lead employed to the vinegar; yet we can never, but by crystallization, know exactly, or even nearly, how much of the former the menstruum may have dissolved, as that must depend on a variety of accidents; and particularly on the strength of the acid and exact degree of heat employed; which are circumstances we have not always in our power exactly to regulate. For these reasons, therefore, the salt or sugar of lead, as it is called, should, for external use, be always preferred." The best method of applying it, he says, is in the form of a watery solution; and he gives the following formula: "S. Sacchar. saturni. 3ss.; solve in acet. pur. 3iv.; et adde aq. fontan. destillat. lbij."

The addition of vinegar renders the solution much more complete than it otherwise would be; and without it, indeed, a very considerable proportion of the lead generally separates and falls to the bottom.

In making use of this solution in cases of inflammation, as it is of consequence to have the parts affected kept constantly moist with it, cataplasms prepared with it and crumb of bread, in general answer that intention exceedingly well. But when the inflamed part is so tender and painful as not easily to bear the weight of a poultice, which is frequently the case, pieces of soft linen moistened with the solution answer the purpose tolerably well: although, when there is not that objection to the use of cataplasms, as they retain the moisture longer, they should always be preferred. But whichever of the two are had recourse to, they should always be applied cold, or at least with no greater warmth than is merely necessary for preventing pain or uneasiness to the patient: they should be kept almost constantly at the part, and renewed always before turning stiff or hard.

Among the remedies recommended for external use, Of emollients in cases of inflammation, were mentioned emollients. 242 These, when the tension and irritation on the skin are considerable, are often attended with very great advantage: the parts affected being, in such a state of the disorder, gently rubbed over with any of the mild expressed oils two or three times a-day, the tension, irritation, and pain, are often very much relieved, and the dissection of the tumour thereby greatly promoted.

In every case of inflammation, indeed, emollient applications would afford some relief. But as the preparations of lead, already recommended, prove, in all such disorders, still more advantageous; and as unguents of every kind tend considerably to blunt the action of lead; these two sets of remedies should as seldom as possible be allowed to interfere with one another: and emollients should accordingly never be prescribed, but when the circumstances already mentioned, of irritation, tension, and pain, are so considerable as to render their application altogether necessary.

Unctuous substances have, too, been condemned in such cases upon a different principle, as tending to stop the pores, and consequently to obstruct the perspiration of those parts to which they are applied. It is not, however, probable, that in this way they could prove very hurtful in preventing the resolution of inflammation; which must always, it is imagined, be effected in a very different manner than by perspiration.

When the part affected with inflammation is not very tender, or lies deep, applications of the vegetable acid are then often had recourse to with considerable advantage; and the most effectual form of using it seems to be by way of cataplasm, made with the strongest vinegar and crumb of bread. In such cases, too, an alternate use of this remedy, with the saturine solution, has produced more beneficial effects than are commonly observed from a continued course of any one of them.

At the same time that these applications are continued, bleeding with leeches, or cupping and scarifying, as near as possible to the part affected, is generally of very great service; and in no case of local inflammation should ever be omitted. In all such cases, the whole body, but more especially the diseased part, should be preserved as free as possible from every kind of motion; and, for the same reason, the necessity of a low cooling diet, in every inflammatory disorder, appears obvious, as does also a total abstinence from spirituous and fermented liquors.

In slight cases of inflammation, a due perseverance in the several articles taken notice of, will, in general, be found sufficient for every purpose. But when there is likewise a full, hard, or quick pulse, with other symptoms of fever, general blood-letting becomes then always necessary; the quantity of blood taken away being always to be determined by the violence of the disorder, and by the age and strength of the patient. The use of gentle laxatives, too, together with cooling diaphoretic medicines, are always attended with very good effects.

These different evacuations being premised, the next object of consequence is to procure ease and quietness to the patient; which is often, in inflammatory cases, of more real service than any other circumstance whatever. The most effectual remedy for this purpose is opium; which, when pain and irritation are considerable, as in extensive inflammations very frequently happens, should never be omitted. In large wounds, especially after amputations and other capital operations, in punctures of all kinds, too, large doses of opium are always attended with remarkable good effects. In all such cases, however, opium, in order to have a proper influence, should, as was observed, be administered in very large doses: otherwise, instead of proving serviceable, it seems rather to have the contrary effect; a circumstance which is, perhaps, the chief reason for opiates in general having been very unjustly condemned in every case of inflammation.

By a proper attention to the different circumstances taken notice of, in the course of three or four days, and sometimes in a shorter space of time, resolution of the tumour will in general begin to take place; at least before the end of that period, it may, for the most part, be known how the disorder is to terminate.

If the heat, pain, and other attending symptoms, abate, and especially if the tumour begins to decrease, without the occurrence of any gangrenous appearances, we may then be almost certain that by a continuance of the same plan a total resolution will in time be effected.

But, on the contrary, if all the different symptoms rather increase; and especially, if the tumour turns larger, and somewhat soft, with an increase of throbbing pain; we may then, with tolerable certainty, conclude that suppuration will take place; and should therefore immediately desist from such applications as were judged proper while a cure was thought practicable by resolution, and endeavour to assist nature as much as possible in the formation of pus, or what is called maturation of the tumour.

For this reason, in every case of inflammation, the different evacuations, especially that of blood-letting, which may have been advisable while the swelling was attempted to be dissolved, should never be carried a greater length than may be merely necessary for moderating the several febrile symptoms: for by reducing the system too much, and a suppuration afterwards taking place, its progress in that case becomes always much more slow and uncertain than it would have been had a due attention been paid to these evacuations; nor will the patient be afterwards so able to bear, especially if it is considerable, the discharge that must necessarily ensue from opening the abscess.

Although it was remarked above, that if in general, in the course of three or four days, there does not some appearances of resolution occur, that suppuration will most probably take place, and that consequently a change of treatment becomes necessary; yet this, it must be observed, is only to be taken in a limited sense: for the time of desisting from one mode of treatment and commencing the other, must always depend very much on the seat of the inflammation; such disorders being, in some parts, much more apt to terminate in a speedy suppuration than in others.

Thus, in the cellular membrane, and in different soft parts, inflammatory disorders of all kinds terminate much more readily and quickly than when any of the tough membranous parts are affected. Hence, in the coats of the eye and of the testicles, very violent inflammations often continue for many days, nay, even for weeks, without either abating in the symptoms or ending in suppuration. In such cases, therefore, which go on even to a very considerable length, we need not be afraid of continuing the discutient applications for a much longer time than would in general be otherwise proper: we should never therefore be deterred from using them, unless either an evident suppuration has taken place, or there appears, from the violence of the symptoms, a certain risk either of gangrene or of some incurable obstruction; in which event, we are, no doubt, always to endeavour to procure the suppuration of the tumour.

When the means used for discussing or resolving an inflamed tumour have proved ineffectual, the next attempt of the surgeon ought to be to bring it to maturity as soon as possible; and for this purpose there is nothing better than to preserve a proper degree of heat in the parts. The method commonly had recourse

Theory. course to for the application of heat to an inflamed part, is by the means of warm fomentations and cataplasms; and when these are regularly and frequently renewed, nothing, it is probable, could more effectually answer the purpose. But in the ordinary manner in which they are applied, by the cataplasms being renewed only once, or at most twice a day, they must always, it is imagined, do more harm than good. For so soon as the degree of heat they were at first possessed of is dissipated, the moisture kept up by them, with the consequent evaporation that ensues, must always render the part a great deal colder than if it had been merely wrapped in flannel without the use of any such application.

246
common method of applying cataplasms improper.
In order to receive all the advantages of such remedies, the part affected should be well fomented with flannels pressed out of any warm emollient decoction, applied as warm as the patient can easily bear them, continued at least half an hour at once, and repeated four times a day.

Immediately after the fomentation is over, a large emollient poultice should likewise be applied warm, and renewed every second or third hour at farthest. Of all the forms recommended for emollient cataplasms, a common milk-and-bread poultice, with a proportion of butter or oil, is perhaps the most eligible; as it not only possesses all the advantages of the others, but can at all times be more easily obtained.

Roasted onions, garlic, and other acrid substances, are frequently made use of as additions to maturing cataplasms. When there is not a due degree of inflammation in the tumour, and when it appears probable that the suppuration would be quickened by having the inflammatory symptoms somewhat increased, the addition of such substances may then be of service; but when stimulants are necessary in such cases, a small proportion of strained galbanum, or of any of the warm gums, dissolved in the yolk of an egg, and added to the poultices, is not only a more elegant, but a more certain form of applying them.

Whenever the inflammation, however, takes place to a proper degree, such stimulating substances never can be necessary; and in many cases, it is apprehended, they may even do mischief.

In such tumours as, from their being possessed of little or no inflammation, are commonly said to be of a cold nature, as they are generally indolent, and proceed very slowly to suppuration, plasters composed of the warm gums are often had recourse to with considerable advantage. In such cases, they are not only of use by the stimulus and irritation they occasion, but by the heat which they tend to preserve in the part. They become particularly necessary when the patient, by being obliged to go abroad, cannot have cataplasms frequently enough renewed, or so conveniently applied; but when some such objection does not occur, the latter, for very obvious reasons, should always be preferred.

Dry cupping, as it is termed, that is, cupping without the use of the scarificator, upon or as near as possible to the part affected, is frequently had recourse to with advantage in promoting the suppuration of tumours. It is only, however, in such as these last mentioned, where there seems to be a deficiency of inflammation, that it can ever either be necessary or

useful; but in all tumours of a real indolent nature, and where there is still some probability of a suppuration being effected, I have seldom observed such effects from any other remedy.

These different applications, under the restrictions taken notice of, being continued for a longer or shorter time, according to the size of the tumour, its situation, and other circumstances, a thorough suppuration may in general at last be expected.

Matter being fully formed in a tumour, is known by a remission of all the symptoms taking place: the dolor pulsatilis, that before was frequent, now goes off, and the patient complains of a more dull, constant, heavy pain: the tumour points at some particular part, generally near to its middle; where, if the matter is not eneysted, or deep seated, a whitish yellow appearance is observed, instead of a deep red that formerly took place; and a fluctuation of a fluid underneath, is, upon pressure, very evidently discovered. Sometimes, indeed, when an abscess is thickly covered with muscular and other parts; and when, from concurring circumstances, there can be little doubt of there being even a very considerable collection of matter; yet the fluctuation cannot be readily distinguished: but it does not often happen, that matter is so very deeply lodged as not to be discovered upon proper examination.

This, however, is a circumstance of the greatest consequence in practice; and deserves, it may be remarked, more attention than is commonly given to it. In no part of the surgeon's employment, is experience in former similar cases of greater use to him than in the present; and however simple it may appear, yet nothing, it is certain, more readily distinguishes a man of observation and extensive practice, than his being able easily to detect collections of deep-seated matter; whilst nothing, on the contrary, so materially affects the character of a surgeon, as his having, in such cases, given an inaccurate or unjust prognosis; as the event, in disorders of that nature, comes generally at last to be clearly demonstrated to all concerned.

Together with the several local symptoms of the presence of pus, already enumerated, may be mentioned the frequent shiverings that patients are liable to on its first formation: these, however, seldom occur so as to be distinctly observed, unless the collection is considerable, or seated internally in some of the viscera.

After the matter is fully formed, and the abscess brought to maturity, the only remedy is to open it, and give vent to the pus it contains. In many cases, indeed, nature will do the work, and abscesses when superficially seated will certainly burst of themselves: but where the matter lies deep, we are by no means to wait for this spontaneous opening; as the pus will acquire an acrimony, before it can break through the integuments, which may prove very prejudicial to health. However, it is a general rule not to open abscesses till a thorough suppuration has taken place; for, when laid open long before that period, and while any considerable hardness remains, they commonly prove more troublesome, and seldom heal so kindly.

In some cases, however, it is necessary to deviate from this general rule, and to open them a good deal sooner; particularly in all such critical abscesses as occur.

occur in malignant fever. In the plague, too, we are commonly advised to open such tumours, so soon as they are at all tolerably advanced, and not to wait till they are fully matured; as, from experience in these disorders, it is found to be of more consequence, for the removal of the original disease, to have a quick discharge of matter produced, than any harm the patient can ever suffer from having a swelling somewhat prematurely laid open.

In abscesses, too, situated on any of the joints, or upon either of the large cavities of the breast and abdomen, and more especially when they seem to run deep, they should always be opened as soon as the least fluctuation of matter is discovered. For, when the resistance is on every side equal, they just as readily point internally as outwardly: and the consequence of a large abscess bursting into either of the large cavities especially, is well known most frequently to prove fatal: An instance of which, in the following case, with very little attention, might have been prevented.

A surgeon of eminence, and of very extensive practice, was applied to by a young healthy-looking man, with a large abscess upon the left side of his chest. A fluctuation of a fluid was, upon pressure, very evidently discovered; and it was agreed, by other two practitioners that were present, that an opening should be made to give vent to the matter. But the operator, being much engaged in business, could not fix on an earlier period for doing it than the third day from the patient's applying to him: unluckily, however, the patient died suddenly in his bed the night before the abscess was to have been opened.

On examining the body, the tumour had disappeared entirely, without any external opening being observable; and, on opening the thorax, it was found to have burst inwardly upon the lungs, and so had produced immediate suffocation.

In every other circumstance, however, except in the cases alluded to, the rule in opening abscesses, is, as was already remarked, To allow a thorough suppuration to take place, before any vent whatever be given to the matter; and it being then determined to lay the collection open, the next question that occurs, is with respect to the manner of doing it. But the consideration of this belongs to the next Part.

Under the head of abscesses, we may reckon those tumours of the joints usually called white swellings; for though they never suppurate in such a kindly manner as the common abscess, yet they certainly contain collections of a kind of pus as much as the former.—The only regular treatise which has yet appeared on white-swellings is that of Mr Bell surgeon in Edinburgh. He observes, that there are two species of the disease; the one of a mild nature, and frequently admitting a cure; which the other never does. The former, named by our author the rheumatic species of white swelling, begins with an acute pain, seemingly diffused over the whole joint, and frequently extending along the tendinous aponeuroses of the muscles which communicate with it. There is, from the beginning, an uniform swelling of the whole surrounding integuments; which in different patients is in different degrees, but always sufficient to occasion an evident disparity between the size of the diseased joint and the other. Great tension generally prevails; but

in this period of the disorder there is seldom any external change of colour. From the commencement of the disease, the motion of the joint is attended with exquisite pain, and the patient keeps it constantly in a relaxed posture, finding that the easiest. Hence the tendons become extremely stiff and rigid, till at last the joints have the appearance of complete and real anchyloses. The swelling now begins to augment, till the joint has acquired three or four times its natural size: the cuticular veins become turgid and varicose; at the same time that the muscular substance of the limb below decays, though it frequently acquires an equality in size by becoming oedematous: the pain becomes intolerable, especially when the person is warm in bed or otherwise heated: abscesses form in different parts, which, either breaking of themselves, or by being laid open, discharge considerable quantities of matter, but without any remarkable effect in reducing the size of the swelling. The pus discharged from these is at first of a tolerably good consistency, but soon degenerates into a thin ill-conditioned farnes. However, the orifices from whence it flows soon heal up, unless they are kept open by art; and new collections breaking out, they burst and heal up as before; so that in long-continued disorders of this kind, the surrounding integuments are often entirely covered with cicatrices.

In the mean time the health of the patient gradually declines; first from the violence of the pain, which often deprives him of sleep and appetite; and then from the absorption of matter into the system, which always certainly takes place in some degree from its first formation in the different abscesses; but which indeed never appear so evidently till the different abscesses have been laid open; after which a quick pulse, night-sweats, and a weakening diarrhoea, are sure to occur, and which generally carry off the patient, if the member is not either amputated, or the disease cured some other way.

On dissecting limbs which have been amputated for white swellings, the original disease appears to have been a morbid thickening of the surrounding ligaments, without any other affection of the joint whatever; the bones and cartilages always remaining perfectly sound, as likewise the synovia both in quantity and consistency. In some instances where the disease has been very violent, this thickening of the ligaments appears to have increased much more than in others where it was more mild. But in the more advanced stages of the disorder, when abscesses have formed in different parts, when the pain has been long very violent, with great addition of swelling, the thickening of the ligaments is then more considerable, and is generally, if not always, attended with an effusion, into the surrounding cellular substance, of a thick glairy matter, which gives to swellings of this kind an elastic springy feel, independent of the collections of matter above-mentioned, the fluctuation of which may also be perceived. Through this glairy matter the collections of pus are found to run in various directions, without seeming, however, to mix with it. In some instances a great many small hydatides are observed along with the collections of matter; all which form a confused mass, incapable of further dissection.

All the above-mentioned appearances have been observed

^Theory. served without any affection of the bones or cartilages, But when, by a very long continuance of the disorder the ligaments come to be corroded by the different collections of matter, the cartilages then, and in consequence thereof the bones, soon begin to suffer. The tendons of the flexor muscles, though very stiff and contracted, do not, upon dissection, show any signs of disease.

²⁵³ Of the scrofulous white-swelling; the more inveterate kind our author names the scrofulous white swelling. In this the pain is commonly very violent; more acute than in the former; and, instead of being diffused, is confined to a particular spot, commonly the very middle of the joint; so that patients will sometimes say they could cover the whole pained part with a crown-piece or less. The swelling also is commonly inconsiderable at first; in some cases that, on some occasions, even when the pain has been very violent, little difference in point of size could be observed between the diseased joint and the sound one of the opposite side. Here also the motion of the joint is attended with very great pain, and the tendons become stiff, for the same reason as in the former. As the disorder advances, the pain becomes more violent, and the swelling increases, with an evident enlargement of the ends of the bones composing the joints. The same elastic feel, together with similar abscesses, occur in this as in the last: but upon opening them they commonly discharge a thin fetid stuff; the bones are found to be carious, and pieces of them are frequently discharged at the openings.

²⁵⁴ Appearances on dissecting the amputated limbs. On the farther continuance of the disorder, the constitution comes here likewise to suffer as in the first species of the disease; and a diarrhoea with night-sweats commencing, the patient is soon reduced, from perhaps the fullest habit, to little more than skin and bone.

Upon such joints being dissected, either after death, or after amputation of the member in the first stages of the disorder, the soft parts seem very little affected: but in all, even the very slightest cases, there is constantly observed an enlargement either of the whole ends of the bones, or of their epiphyses; frequently of those on one side of the joint only; in others, again, the bones on both sides have been affected.

This enlargement sometimes occurs without any other evident disease: but in general, and always in a more advanced state of the complaint, the soft spongy parts of such bones appear dissolved into a thin, fluid, fetid matter; and that too, in some cases, without the cartilages which surround them seeming much affected. In process of time, however, the cartilages come likewise to be dissolved; and then the different matter, viz. that of the bones and softer parts, all mixing together, such swellings being in that state laid open, exhibit a still more confused collection than is generally observed even in the worst stages of the other species of the disorder.

Although it was remarked, that in the early periods of the complaint, the surrounding soft parts do not always appear much affected; yet, in its further progress, they likewise are always brought to suffer. The ligaments become thickened, and the contiguous cellular membrane stuffed with that viscous glairy kind

of matter as observed in the other species of the disorder.

Having thus given a particular account of the different appearances generally observed in both species of white swelling, we come now, in course, to the consideration of the different causes which tend to produce them. That the ligaments of the joints only are first affected in this disorder, is from the history of the dissections rendered evident; they, in the first stages of the complaint, being almost the only parts that are found diseased. The effusions, into the cellular membrane, of that thick glairy matter taken notice of, are probably occasioned by an exudation from the vessels of those ligaments that have been originally inflamed, it being known that such parts never furnish a proper fluid for the formation of purulent matter: In the course of the disease, indeed, abscesses containing real pus do always appear; but never till inflammation has been communicated to the surrounding parts, which more readily afford a fluid proper for that purpose.

Upon the whole, therefore, we may conclude, that the first species of white swelling is always occasioned by an inflammatory or rheumatic affection of the ligaments of such joints as it attacks, and that too from whatever cause such inflammation may originally have proceeded.

The other species of the disorder, from all the symptoms enumerated, and from the appearances on dissection, seems evidently to be originally an affection of the bones; the surrounding soft parts coming only to suffer in the progress of the disease, from their connection with and vicinity to these.

This last species of white swelling very seldom occurs as the consequence of any external accident; generally beginning without the patient being in the least able to account for it: And from the effects which it usually produces on the bones attacked, it would appear to be a species of the real spina ventosa; and which again is very probably a disease of the same nature in the bones, as scrofula is of the soft parts. Indeed, the appearances of the two disorders, after making allowance for their different situations, are exceedingly similar: they both begin with considerable enlargements or swellings of the parts they invade; which afterwards in both, too, generally end in evident ulcerations; and they both likewise frequently occur in the same person and at the same time.

It is likewise observed, that this species of white swelling is generally either attended with other evident symptoms of scrofula subsisting at the time; or that the patient in an early period of life has been subject to that disease; or, what is nearly the same, that he is descended from scrofulous parents, and consequently most probably has the seeds of that disease lurking in his constitution.

From all these circumstances, it may with probability be concluded, that this species of white swelling is commonly, if not always, of a scrofulous nature: and it having already been shown, that the other species of the disorder is to be considered as an inflammatory, or what we have termed a rheumatic, affection; and a thorough distinction of the two different species being, in the treatment, a matter of very great importance; it will not here be improper to give

give a short enumeration of the several diagnostic or most characteristic symptoms of each.

The pain in the white swelling from a rheumatic disposition is, as was formerly remarked, always, from the beginning, diffused over the whole joint, and on some occasions extends even a considerable way along the muscles that are attached to it; whereas, in the other species of the disorder, the pain is not only always at first, but sometimes even when the complaint has been of considerable standing, confined to a very small circumscribed space.

In the former, the swelling is always confined to the soft parts, and is from the beginning exceedingly evident; but in the latter, there is seldom for some time any perceptible swelling; and when it does more sensibly appear, the bones are found evidently to be the parts chiefly affected, the surrounding teguments coming only to suffer on a farther progress of the disease.

These are the chief local differences of the two species of this disorder; but some assistance in the distinction may likewise be obtained, from the general habit of the patient, and from the manner in which the complaint may seem to have been produced.

Thus, when such swellings occur in young, strong, plethoric people, especially in such as have formerly been subject to rheumatism, and that whether in consequence of an immediate external accident or not, such, most probably, will always prove to be of the mildest or rheumatic species of the disorder.

Whereas, when swellings of this nature appear in such patients as are otherwise evidently of scrofulous dispositions; where, together with a fine skin and delicate complexion, there are either, on examination, found hardened glands in the neck, arm-pits, or inguina; or it is discovered that the patient has, from his ancestors, a title to such complaints; when either any or all of these circumstances occur, and if the disorder has begun in the manner formerly described, without any evident external cause, we need be under very little doubt in concluding it to be of a scrofulous nature.

The great utility of properly distinguishing the two different species of white swellings, appears in no circumstance so evident as in the treatment. In the one, there being some chance, by proper remedies, of being serviceable to the patient; whereas in the other, viz. the scrofulous, it is not probable that art will ever be able to afford much assistance.

In the rheumatic white swelling, as it is always at first evidently of an inflammatory nature, considerable advantages are commonly obtained by a due attention to a proper antiphlogistic course.

The first remedy which, with this view, should be put in practice, is blood-letting; but instead of general evacuations from the arm or elsewhere, it proves always more effectual to take the blood immediately from the part affected. Cupping and scarifying is here a principal remedy. The instrument should be applied to each side of the diseased joint; on each side of the rotula, for instance, when the knee is the part affected, and at least eight or ten ounces of blood discharged; and this to be repeated at proper intervals, once, twice, or oftener, according to the violence of the symptoms and state of the patient's strength at the time.

258
Theory.
In the ordinary way of discharging only an ounce or two of blood by this operation, it has in general very little or no influence; but in the quantities mentioned, and which, by those accustomed to the practice, is commonly easily obtained, it most frequently is attended with very considerable effects.

It must here be observed, that cupping is, in these cases, much superior to leeches; which is not only a more tedious method of getting the same quantity of blood, but the swelling occasioned by the application of any considerable number of these animals proves frequently very troublesome; and, what is often of worse consequences, gives sometimes an interruption, for a time, to the use of other remedies.

Upon the anterior part of the joint, where the cupping-glasses have not been placed, a small blister should be directly applied, and the part kept open with issue-ointment, till the wounds from the scarificator are so far healed, that a vesicatory may likewise be laid on one side of the joint; and so soon as that is nearly healed, the other side should be also blistered.

By thus alternately applying them, first to the one side, and then to the other, almost a constant stimulus is kept up; which, in deep-seated inflammations, seems to have fully a greater influence than all the discharge occasioned by blisters.

Gentle cooling laxatives at proper intervals are here of use too; and the patient should, in every respect, be kept upon a strict antiphlogistic course, both as to diet and every other circumstance. From a due attention to which, with a continuance of the topical treatment already recommended, considerable advantages have frequently been observed, more indeed than from any other remedies ever used in this complaint.

It is in the first stages only, however, of the disease, that such a course can probably be of much service; and in such it has frequently been a means of curing disorders, which otherwise would probably have proceeded to the last stages of white swellings.

The original inflammatory affection being once over, these sort of drains seem to have little or no influence, and ought not then to be long persisted in, as tending to prevent the use of other remedies, which, in an advanced state of the disease, prove commonly more efficacious.

The inflammation being mostly gone, and while there are yet no appearances of the formation of matter, mercury, in these circumstances, has sometimes been known of use; not given so as to salivate, but merely to affect the mouth gently, and to keep it somewhat sore for a few weeks.

The best form of using mercury, in such cases, is certainly by way ofunction; as it allows, at the same time, of the application of friction; which, in all such swellings, may of itself be in some measure considered as a remedy. For this purpose, an ointment of quicksilver and hog's lard should be prepared; but with so small a proportion of the former, that the patient may admit of two drams of the ointment being rubbed in three times a-day. In order to rub that quantity of the medicine in with gentle friction, an hour each time is at least necessary, and which is as little as should ever be given in order to receive all the advantages that attend the practice: for however useful friction, in

Theory. in such cases, may be, when properly applied, in the ordinary way of continuing the remedy for a few minutes only, it is not probable it can ever have much influence.

Gentle mercurials, given internally, are here sometimes of service too; but as all the advantages to be derived from them in that form are obtained from theunction, together with that of the friction necessary for its application, the latter, in all such cases, should certainly be preferred.

By Le Dran, and other French writers, falls of warm water on swellings of this nature are much recommended; and there is no sort of doubt, but a long-continued and reiterated application of that remedy may, in the first stages of such complaints, be often attended with very good effects.

By a proper use of these different applications, viz. of the several topical remedies in the first or inflammatory state of the disease, and afterwards (still, however, before the formation of matter) of mercurials, friction, &c. many affections of this nature have been entirely removed. But in many instances, when, either by the use of medicines, or by an effort of nature, the swelling and pain are almost entirely, or even wholly removed, it frequently happens, by the bent position the limb has been for a long time kept in, that the use of the joint comes to be entirely lost, having often acquired such a degree of stiffness, that any attempts to move it are commonly attended with very great pain.

Unluckily, in all such cases, these affections of the joints have been constantly attributed to one or other of two different causes, which are both in their nature incurable, viz. either to the ends of such bones as compose the joints having run into one another, so as to become firmly conjoined in consequence of the surrounding cartilages being abraded; or to the inspissation, as it is termed, of the synovia of the joints, whereby their cavities are supposed to be entirely filled up, and no space thereby left for the future motion of the different bones.

Both these opinions, however, (says Mr Bell), I can, from a great number of facts, assert to be in general at least very ill founded: for although, by an abrasion of the cartilages which surround the different bones at the joints, an union of their extremities may very readily be occasioned, and is no doubt on some occasions the cause of such affections; yet from a variety of dissections, I am convinced that it is an exceeding rare occurrence, and, in cases of white swelling, never happens but in the most advanced stages of the disorder: the only causes almost of the stiffness of the joints, in such cases, being that contracted state of the flexor tendons, formerly taken notice of in the description; at least, in nineteen cases out of twenty, it probably is so.

There is nothing indeed more deceiving than the feel on such occasions: for when the disorder has been of long standing, the stiffness and immobility are generally so considerable, as, at first sight, always to appear as if a real conjunction of the bones certainly subsisted; many instances of which I have known, that had been all along considered as real anchyloses of the worst kind; but which, on dissection, were constantly

found to proceed merely from a contracted state of the flexor muscles and tendons.

With respect to the other opinion, which did formerly so universally, and with many still does, prevail, of such affections generally proceeding from an inspissated state of the synovial fluid, it has for some time, by many anatomists, been much doubted if it ever occurs; and from all the opportunities I have had of dissecting such diseased joints, I am pretty much convinced, that it either never does take place, or at least that it is an exceeding rare occurrence: for in every case of this kind, even when the disease had been of very long continuance, if the capsular ligament of the joint remained undivided, so that no matter from the surrounding soft parts got admittance, and when the ends of the bones were not become carious, the synovia always retained its natural appearances both in colour and consistency. So that it is very probable, the many causes of diseased joints, attributed to affections of that fluid, have been more founded on mere hypotheses than on facts and experience.

This stiffness of the joint, therefore, which to a certain degree always occurs in white swellings, proceeding seldom or never from either of the causes mentioned, which might probably both be considered as incurable, but merely from a preternatural contraction of the muscles and tendons, we have from that circumstance great reason to expect, that in many situations a good deal may be done towards its removal. And in fact, there is no sort of doubt but complaints of this kind, which often remain after every other symptom of white swelling has disappeared, may, on many occasions, be got the better of, merely by a long-continued use of emollients: several instances, indeed, of this I have seen, some of which had been thought to be of the worst species of anchylosis.

The best, and probably least offensive, emollient that can be used, is pure olive oil applied warm; as much of it as can be easily rubbed in by an hour's gentle friction should be regularly done at least three times a-day; and instead of confining the friction altogether to the rigid tendons, as is commonly done, it should be extended over the whole muscles, even to the insertions of their other extremities; but more especially on their fleshy muscular parts, where the principal cause of the continuance of such complaints is probably seated; these parts being chiefly, if not altogether, possessed of the contractile, and consequently of the resisting, powers.

I have known used, too, in this complaint, as Neat's-foot oil some-what inferior, an emollient, and often with advantage, an oil extracted from animal-substances, known by the name of neats-foot oil: but as it is more apt to turn rancid than olive oil, it is not therefore such a pleasant application; and not being possessed of any superior relaxing properties, the other will probably, for that reason, be commonly preferred.

The disorder now under consideration, viz. a stiff joint, is so evidently one of those which particularly require the use of emollients, that almost every old woman has some particular form or other of recommending them; one of which I cannot avoid mentioning, as I have frequently known it used, and in two cases particularly, with very evident advantages,

viz. the web or omentum of a new-killed sheep, or of any other animal, to be applied over all the diseased parts directly on being cut out of the animal.

"In the two cases alluded to, one was in the knee, and the other in the hand; and the joints, from having been totally useless, were almost perfectly restored. The application should be renewed as frequently as possible, once a-day at least, or oftener when it can be done; for on being more than four or five hours applied it becomes disagreeable; and after that time, indeed, as it commonly turns stiff, it cannot then probably be of much service. The same kind of remedy, used in somewhat a different manner, I find recommended by Lieutaud, a celebrated French practitioner.

"I have been the more particular on this part of the subject, as I have often thought, with a little attention, the use of many joints might be recovered, which, from a mistaken notion concerning their causes, have generally from the first been considered as incurable.

"The disorder has hitherto been supposed not to be so far advanced as to have occasioned the formation of matter; for when come that length, no considerable advantages can be expected from any of the remedies as yet recommended: but even in that state of the complaint, if the patient's health does not absolutely require it, amputation of the member should by no means be immediately had recourse to, as it most frequently is. For by paying attention to open the different abscesses soon after their formation, the matter may in that way be pretty certainly prevented from destroying the capsular ligaments of the joints, which, if once effected, would no doubt in time render that operation necessary.

"It may be here observed too, with respect to the most proper period of the disease for amputating such limbs, that, even in point of success from the operation, it ought never to be advised till the complaint is pretty far advanced: for though, a priori, it might be imagined, that the more early in the disease amputation of the member is had recourse to, the more successful it should prove; and although this, indeed, has been made a common argument for amputating very early in every case of white swelling, yet, however plausible the observation may appear, it will not, from experience, I am certain, be found to hold good. For in this disorder especially, I have constantly observed, that amputation has more frequently succeeded, that is, a greater proportion of such patients have recovered from it, who have previously been considerably reduced by diarrhoeas and other weakening symptoms, than of such as have still remained in a full plethoric habit of body.

"In the former, when the constitution has not been too much broken, and which practitioners have always in their power to guard against, the several symptoms of hectic which previously took place, are commonly removed in a very few days after the limb is taken off. No high inflammatory affections are ever produced; the patient daily mends in his health; and a complete cure, if the patient has not been too much reduced, is generally very soon obtained. In the latter, again, the very reverse of all these circumstances occur: the pa-

tient, from being in high health at the time of the operation, is generally thrown into a smart inflammatory fever; which is no doubt very often got the better of, but which frequently either carries off the patient immediately, or produces such effects as he never thoroughly recovers from.

"So that in no case whatever should amputation be had recourse to, until every probable means for saving the limb has been tried in vain.

"All the different observations hitherto made upon the treatment, relate particularly to the rheumatic species of the disorder; and when had recourse to in time, and duly persisted in, they will frequently be found of service: but when the disease is so far advanced as to have destroyed the capsular ligaments of the joint, and perhaps even the cartilages and bones themselves, amputation of the member is then no doubt the only resource.

"In the more fatal species of white swelling, viz. A scrofulous white-swelling no to be cured but by amputation, and even that not to be depended on.

"In the small joints, when the diseased parts of the bone begin to cast off, a cure may in that way, by assisting the efforts of nature, be sometimes obtained; but in all the large joints, as the knee, ankle, &c. it is not probable that any other resource than amputation will ever afford much relief. And even the effects of that operation can seldom be depended on as lasting; for when the general scrofulous taint still subsists in the constitution, the disorder will most probably appear again in some other part; which, however, in the advanced stages of the disease, it is sometimes necessary to run the risk of, the pain being often so tormenting as to make it more eligible to submit to any hazard rather than to bear it longer.

When, however, for some reason or other, amputation is determined against, as there being almost a certainty of the complaint soon returning, from the scrofulous disposition appearing very strong in the system, it then becomes necessary to have recourse to palliatives, so as to render the complaint as tolerable as possible; and with this view, opiates in large doses, by moderating the pain and procuring rest to the patient, will in general be found the principal remedy. In other respects, all such medicines and articles of regimen as are found beneficial in scrofula, may be had recourse to."

To the head of abscesses we may likewise refer those Of encysted tumours which are contained in cysts, and which sometimes increase to an extraordinary size. These appear on the head, the eyebrows, or other parts of the body, and are at first but of a small size. They are seated in the adipose and cellular membrane; whence it not unfrequently happens that they take place in the viscera themselves, where they are almost always mortal. The contents of these tumours are very different in consistence. Sometimes they are filled with a substance of the consistence of honey, and are then called meliceratous tumours; sometimes they are filled with an harder substance, and are then called atheromatous tumours; at other times they are filled with a substance of the consistence of fat, and are then called

^Theory. called sciatomatus. Sometimes, however, they are found to be replenished with a fluid lymph coagulable by fire, and are then called hydatids.

Tumours of this kind are easily distinguished from all others, as having neither heat, pain, nor pulsation, as is to be observed in those which incline to suppuration. Sometimes, however, they will burst like abscesses, and the matter which is in them will flow out; but unless the whole cyst which contained it be removed, the ulcer refuses to heal, and even sometimes degenerates into a cancer.

²⁷¹ Causes of these tumours. Erysipelas tumours are often the consequence of an itch, tinea capitis, or other cutaneous disorder; and sometimes they arise after ulcers have been hastily dried up: but it also frequently happens that people are born with them, or that they arise spontaneously without any apparent cause.—When they are recent, and neither very large nor hard, they may sometimes be dissipated by the application of the common topical remedies made use of for resolving inflammations. But if these should not succeed, the only method is to dissect off the bag from the parts to which it adheres, preserving it as much as possible from being wounded; because then the operation becomes more difficult. If this cannot be done, they must be consumed by caustic; and where this operation is performed in time, there is seldom any danger, though Platner instances a young man who died in consequence of a very large tumour of this kind on the scapula, which had arisen after a tinea capitis.

²⁷² Tumours in the eye-lids. Tumours akin to these frequently are met with in the eye-lids. Sometimes they are of a soft consistence, and sometimes harder: but the cure is the same in both, namely excision; carefully observing to take off all the roots, either by caustic or the knife, lest the distemper should return.

²⁷³ Of ganglions in the tendons. Ganglions of the tendons may also be taken notice of here; which though they never come to suppuration, yet sometimes break, and discharge a fetid farnes. These arise in the tendons which are most employed in the common offices of life; and hence are frequently to be met with in the tendons of those muscles which move the fingers. Platner gives an instance of a ganglion which destroyed the patient. It was situated on the tendo Achillis; and took its rise from the person's jumping out of a carriage, at which time he felt an acute pain in that part. A tumour began to arise on the inside of the tendon; which being thus compressed, swelled out on each side of it. Being situated in such a place, surrounded with membranous parts, the wounding of which would have been very dangerous, surgeons of character declined the performing of any operation upon it; but the patient having applied to some empirics, the tumour, by means of their applications, increased to the size of the man's head, and at last began to discharge an ichor, at the same time that he was seized with an hectic. Amputation was now proposed: but as the patient refused to submit to the operation, an incredible quantity of putrid farnes discharged itself daily from the place; which increasing the fever, soon destroyed him. All this time the tumour, though grown hollow by the discharge, yet increased in its circumference at the bottom; so that the two opposite sides of it almost met on the fore-part of the leg.

^Theory. In the cure of ganglions, we are never to attempt to bring them to suppuration: for of this they are incapable; and if unfortunately they should increase in size and burst, they will only discharge such an ill-conditioned farnes as that above-mentioned. The only method, therefore, is to attempt dissection. This is only be frequently accomplished by friction, and keeping a red by dissection or excision. Some commend plasters of different kinds; but as all of these are of a relaxing nature, there is great danger of their increasing the bulk of the tumour, at the same time that they render it softer. If, however, dissection shall be found impracticable, these tumours may be extirpated with the knife; but in such operations, great care is to be taken not to wound the tendon, lest the mischiefs already enumerated, arising from such wounds, should ensue.

The only other kind of tumours which can be referred to the head of abscesses, are those very malignant ones called cancers.—These most commonly arise in the glandular parts of the body, where they are occasioned by any bruise or contusion, sometimes a very slight one: and hence they are more common in the lips, and in the breasts of women, than in any other parts of the body.—Cancers have been generally distinguished into occult and open. By the former are meant such hard scirrhus swellings as are attended with frequent shooting pains, and which at last generally terminate in the latter.

By the open cancerous ulcer, is understood that species of sore which commonly succeeds to hard swellings of the glands; although in some instances it occurs without any previous hardness. The edges of the ulcer are hard, ragged, and unequal, very pain of an ulcer, and reversed in different ways, being sometimes turned upwards and backwards, and on other occasions inwards. The whole surface of the sore is commonly very unequal, there being in some parts considerable risings, and in others deep excavations. The discharge, for the most part, is a thin dark-coloured fetid ichor; and is often possessed of such a degree of acrimony as to excoriating, and even destroy, the neighbouring parts. In the more advanced stages of the disease, too, by the erosion of blood-vessels which occurs, considerable quantities of pure blood are sometimes discharged.

Patients labouring under real cancerous affections, universally complain of what they term a burning heat over the whole ulcerated surface; which in general, it may be remarked, is the most tormenting symptom that attends the disorder; and those shooting lancinating pains, which were troublesome in the more occult state of the complaint, become now a great deal more so.

These are the most frequent symptoms which attend an ulcerated cancer; but the appearances of such sores are so various, that it is almost impossible in any description to comprehend every one. When two, three, or more, however, of those enumerated, concur together in the same ulcer, we may always be pretty certain of its being of the cancerous kind.

Concerning the causes of cancers, there have been a great many conjectures, but without any solid foundation. It is of some moment, however, to determine whether they arise from some general disorder in the

Theory. system, or whether they are only to be accounted local diseases. Many of the most eminent practitioners have been of opinion that they arise from a general disorder of the system; and hence consider them as totally incurable even by extirpation, as the latent seeds of the disease, in their opinion, will not fail to bring on a return of it somewhere or other. Of this opinion the

279
Opinion of Dr Monro senior.

late Dr Monro appears to have been; and in a paper on this subject in the Edinburgh Medical Essays, declares, that "of near 60 cancers which he had been present at the extirpation of, only four patients remained free of the disease at the end of two years." From this bad success, and the violent progress of the disease, he finally concludes against the extirpation of cancers, and proposes only the palliative method of cure. But later practitioners have been a great deal more successful; and a late publication by Mr Hill surgeon at Dumfries has put the usefulness of extirpation beyond a doubt, when the operation is performed in time: though, after the disease has continued long, and the virus been absorbed, the whole system acquires a cancerous disposition, and the disease almost certainly recurs in some other part. From internal medicines we can expect little or nothing in the cure of cancers; and external applications can do no more than palliate. Great expectations were formed from the powder and extract of cicuta; but it has so universally failed, that few put much confidence in it at present. However, it has sometimes been of service in cases of a simple indurated gland; and even where the disease has been farther advanced, it has produced a better discharge, and diminished the scrotum of the sore; but as it cannot be depended upon for a radical cure, a delay of the operation is never to be recommended.

284
A portion of some of the abdominal viscera getting into the tunica vaginalis testis, forms that species of hernia to which new-born infants are liable, termed by Haller the hernia congenita. The testicle and protruded intestine being here in contact with one another, the tunica vaginalis testis forms the hernial sac.

285
The hernia congenita is usually produced in the manner now described: it is probable, however, that the same disorder may, and frequently does, occur from this passage between the abdomen and testicle, after having been once closed, being again rendered pervious, in consequence of the parts being overstretched by those violent fits of coughing, crying, and other convulsive affections to which children soon after birth are now and then liable. The intestinal canal and other viscera being on such occasions pushed with violence against all the containing parts, these will most easily give way where the least degree of firmness occurs; and this we may readily suppose will most probably happen in such parts as have been most recently united. In this manner, it is probable that the greatest proportion of those cases of hernia are produced which occur in the early months of infancy; and it is probable, that in some occasions, in more advanced periods of life, the same species of hernia may likewise occur from the same cause.

286
The causes which tend to the production of hernia in its more usual form, are as follows:

I. The containing parts of the abdomen we know to be elastic and compressible; whatever, therefore, tends to produce a diminution of capacity in the cavity of the abdomen, must occasion a proportional degree of risk of some of the contained parts being pushed from their natural situations. Violent coughing, crying, laughter, or great bodily exertion, are attended with more or less contraction of the abdominal muscles, and particularly of the diaphragm; and as the contraction of these muscles must always diminish the abdominal cavity, these causes therefore are frequently found to be productive of hernia.

II. Falls, in consequence of the derangement they produce in the abdominal viscera, from the sudden and violent shock with which they are often attended, are not unfrequently the immediate causes of hernia.

III. Persons of a preternatural laxity of frame are very liable to hernia. The containing parts of the abdomen

to be complete, and the disease obtains the name of scrotal rupture, or oschiocoele.

287
When a portion of gut alone forms the tumour, it is called an enterocoele, or intestinal hernia; when a piece of omentum only has got down, it is termed epiplocoele, or omental hernia; and if both intestine and omentum are down, it is called an entero-epiplocoele, or compound rupture.

288
If the gut, or other parts which have fallen down, be again pushed into the abdomen, and are retained there by proper bandages, or any other means, in that case the passage is soon closed up, and no return of the disorder is observed. But this being neglected, and the gut being allowed to remain long down, the parts forming the passage seem thereby in a great measure to lose that power of adhesion which naturally they are known to possess: instances of such cases having occurred where no art has been able to produce this wished-for obliteration of the opening.

289
How produced.

290
Of the causes of hernia in its usual form.

291
The containing parts of the abdomen we know to be elastic and compressible; whatever, therefore, tends to produce a diminution of capacity in the cavity of the abdomen, must occasion a proportional degree of risk of some of the contained parts being pushed from their natural situations. Violent coughing, crying, laughter, or great bodily exertion, are attended with more or less contraction of the abdominal muscles, and particularly of the diaphragm; and as the contraction of these muscles must always diminish the abdominal cavity, these causes therefore are frequently found to be productive of hernia.

292
Falls, in consequence of the derangement they produce in the abdominal viscera, from the sudden and violent shock with which they are often attended, are not unfrequently the immediate causes of hernia.

293
Persons of a preternatural laxity of frame are very liable to hernia. The containing parts of the abdomen

Theory. men, from the want of a sufficient tone and firmness, are unable in such people to resist on all occasions the weight of the different viscera; and they are therefore more particularly exposed to disorders of this kind on the slightest application of any of the causes already mentioned.

IV. Sprains are apt to induce a laxity of the part injured; and have therefore a similar influence in inducing hernia with general laxity.

V. It has been observed, that the people of those countries where oil is much used as an article of diet, are particularly liable to hernia.

In whatever parts the varieties of the abdomen happen to be weakest, these various causes will most readily operate in producing hernia; and accordingly we find, that descents of the bowels usually occur only in such parts.

The parts which from anatomy we would a priori suspect to be most liable to such protrusions, are the openings in the external oblique muscles; the arch formed by Poupart's ligament for the passage of the great blood-vessels of the thigh; and the umbilicus, where the same degree of firmness does not take place as is met with in the rest of the tendinous expansion of the abdominal muscles. Sometimes, however, it happens, that parts of the viscera are protruded between the interstices of the different muscles of the abdomen; but these are not frequent occurrences.

In whichever of these situations a protrusion of any portion of the intestines occurs, except in the case of the hernia congenita, as all the viscera are contained within the peritoneum, a portion of that membrane, it is evident, must be carried down together with the parts protruded; and in every such instance, it is this portion of the peritoneum, which goes down along with the gut, that is termed the hernial fac. The size of this fac is various in different subjects, and in different stages of the same disorder.

On the first appearance of the disease, the fac is commonly of no very considerable size, as such swellings seldom acquire any great bulk at once: but by repeated descents of the bowels, the fac comes to be pushed lower and lower, till in some instances its bulk becomes very considerable indeed; and when in this advanced period of the disorder the fac happens to be laid open, it is found to contain either large quantities of omentum or intestine, and frequently large portions of each.

As the peritoneum has this property in common with many other parts of the body, of thickening according to the degree of any gradual extension applied to it, so in many instances the thickness and firmness of the hernial fac are often really astonishing.

Although every instance of a bowel protruded from its natural situation is to be considered as a derangement, and as such ought to excite our attention for its reduction; yet daily instances occur both of recent hernia, and of those of longer standing, in which no bad symptoms are produced from such protrusions of the viscera. Thus it is well known, that hernial swellings of every kind very frequently happen, without the patient suffering in any other manner than from the inconvenience arising from the bulk of the tumours. But in general the case is otherwise; troublesome symptoms most frequently occur; and at all events,

when the reduction of a hernia can be accomplished with any kind of propriety, it ought always to be effected as quick as possible.

All the bad symptoms which are found to occur in hernia, proceed, as may be readily supposed, either from obstruction to the passage of the faeces when the intestinal canal forms the tumour, or from a stoppage of circulation occasioned by stricture on the prolapsed parts; so that the attending symptoms, it is evident, will be always more or less hazardous, according to the nature of the parts so protruded.

Thus, when omentum alone forms the substance of hernial swellings, as that organ does not appear to be so immediately necessary for life as many of the other viscera, such tumours accordingly are not so frequently productive of bad consequences, at least they are seldom in any degree so hazardous as when a part of the alimentary canal is either protruded by itself or along with omentum.

Although this, however, is in general the case; yet it does sometimes happen, that even an omental rupture is productive of no small degree of danger. When a stricture so complete upon it occurs as to occasion a stoppage of circulation in the protruded part, mortification with all its bad consequences must be the certain event: And besides, the connection between the omentum, stomach, and other viscera, is such, that a sudden descent of any considerable portion of the former sometimes brings on vomiting, hiccup, and other troublesome symptoms: And lastly, although a rupture containing omentum only, might not of itself produce any thing bad; yet as the passage through which the omentum has slipped, must of necessity continue open so long as that viscus remains protruded, and as that circumstance alone must so long as it continues render it more easy for a portion of gut likewise to get down, this of itself is a sufficient reason for even this species of hernia deserving the serious attention of practitioners.

But whatever the contents of such swellings may be, as their remaining in some instances for a considerable length of time without being productive of any bad symptoms, must proceed entirely from the circulation continuing to go freely on, notwithstanding the derangement of parts; so, whenever a stricture occurs upon the protruded viscera, sufficient to produce either a stoppage of the circulation, or of the faecal contents of the alimentary canal when a portion of gut forms the disease, the following in general are the symptoms which accrue.

An elastic colourless swelling is observed at the part affected. A slight pain is felt not only in the swelling itself, but, if part of the alimentary canal is down, an universal uneasiness is perceived over the whole abdomen; and this pain is always rendered worse by coughing, sneezing, or any violent exertion. The patient complains of nausea; frequent retching; can get no discharge by stool; becomes hot and restless; and the pulse is commonly found quick and hard. When the swelling is entirely formed by a portion of gut, if no faeces be contained in it, it has a smooth, equal surface; and is easily compressible, but instantly returns to its former size on the pressure being removed: but, in gut-ruptures of long standing, where hard faeces have collected in the protruded bowels, considerable

able inequalities are detected. When again the tumour is composed both of gut and omentum, its appearance is always unequal, it feels soft and somewhat like dough, and of course is not so elastic as when part of the intestinal tube only is down; for although, like the other, it is compressible, it does not so readily regain its former dimensions on the pressure being taken off.

It has been a received opinion, that in cases of strangulated hernia the symptoms should be less violent when the intestine is accompanied by a portion of omentum, than when gut alone is down. Little or no difference, however, is produced by this circumstance; for when a gut becomes obstructed and inflamed, the symptoms thereby induced are nearly the same whether the omentum be down with it or not.

It will be readily supposed, however, that the symptoms we have described never can happen from the presence of omentum only: For although stricture produced on a portion of omentum, even when no part of the intestinal tube is down, does now and then on the occasion a good deal of distress, such as pain in the part, sickness, vomiting, and twitching pains through the whole belly; yet no obstruction of the gut ever occurs from this, and of course none of the symptoms ever prove so alarming as when any part of the gut is affected. If these symptoms we have described as being produced by a strangulated gut, are not now obviated by a removal of the stricture which produced them, the nausea and retching terminate in frequent vomitings, first of a bilious, and afterwards of a more fetid matter; the belly becomes tense; the pain turns more violent; a distressing convulsive hiccup comes on; the fever, which before was not apparently of much consequence, now becomes very formidable; and a total want of rest, with a very disagreeable state of anxiety, continues through the whole course of the complaint.—These symptoms having gone on with violence for some time, the patient is at last commonly suddenly relieved from all manner of pain; when he flatters himself every risk is for certain over. But instead of that, the pulse, from having been hard and frequent, becomes languid and interrupted; cold sweats break out over the whole body, but especially on the extremities; the eyes acquire a kind of languor; the tenderness of the abdomen subsides, and the swelling of the part affected disappears; the teguments covering the parts, which before were either of a natural appearance, or had somewhat of a reddish inflamed cast, now acquire a livid hue, and a windy crepitous feel is distinguishable all over the course of the swelling. If the protruded parts have not of themselves gone entirely up, their return is now in general easily effected by a small degree of pressure, and the patient then discharges freely by stool; but the cold sweats increasing, the hiccup turns more violent, and death itself is at last ushered in by its usual forerunners, subultus tendinum, and other convulsive twitchings.

These are the ordinary symptoms of what is termed a strangulated or incarcerated gut-hernia: that is, when the parts protruded become so affected by stricture as to produce pain; and do not either return to their natural situations on the patient's getting into a hori-

zontal posture, or cannot even be immediately replaced by the hands of a practitioner.

In whatever situation a strangulated hernia occurs, the only rational method of cure, it is evident, must consist in the removal of that stricture which prevents the return of the protruded parts. It is that stricture which ought to be considered as the cause of all the mischief; and unless it be removed, nothing effectual can be done for the relief of the patient.

Various methods have been attempted by practitioners for the removal of stricture in these disorders; all of them, however, may be comprehended under two general heads.

I. Such as effect a reduction of the protruded parts, without the interposition of incision or any surgical operation properly so called; and,

II. A division of the parts producing the stricture, so as to admit of a replacement of the deranged viscera, constituting what is termed the operation for the hernia.

The remedies to be employed for accomplishing the first of these, are, a proper posture of the patient, with the manual assistance of a practitioner; blood-letting, stimulating glysters, opiates, the warm bath, and proper applications to the tumour itself.—If these fail, there is then no other means of cure left but the operation of dividing the integuments, and replacing the viscera in the manner afterwards to be described.

SECT. VI. Of an Erysipelas, Gangrene, and Mortification.

It has been already observed, that inflammation of a membrane produces an erysipelas, as the inflammation of a muscular or fleshy part produces a tumour and abscess. The disease is attended with a much greater fever than a common inflammation, and it is much more dangerous. The internal medicines proper in these cases have been taken notice of under the article MEDICINE, n° 324. It remains therefore to treat only of the external applications; and here we find, that till very lately there have been such strong prejudices against applying any thing cooling or emollient to parts afflicted with an erysipelas, that the most absurd practices have been adopted. Those who maintain the chimerical opinion that a volatile acid was the cause of the disease, advise chalk to be strewed upon the inflamed part; some cerning used fomentations of soap; others medicated bags filled with elder-flowers, moistened with wine and water or vinegar; some a decoction of sheep's dung in wine; while others employed epithems composed of Venice treacle and spirit of wine. Some thought lixivium and oil a better remedy, while others preferred a poultice made of oatmeal and water made without boiling.—Hoffman adhered to the method of applying dry medicated powders; and modern physicians have followed him, though they have thought proper to substitute wheat-flour, or Peruvian bark in powder, as preferable to the remedies recommended by him. Amidst all this variety of prescriptions, however, the use of cooling and emollient applications has been almost universally reprobated, from a notion of their checking perspiration and repelling the disease: but Dr Kirkland, who has treated this matter at great length, is entirely of opinion that emollients are the only remedies.

Theory. medicines to be depended upon; and recommends a cataplasma composed of four ounces of the soft crumb of bread, a quart of milk, and four ounces of hog's lard, boiled slowly together till the poultice acquire such a consistence that it will not stick to the fingers. Poultices, he says, can never be good without long boiling; but as they are at any rate inconvenient when the disease is seated in the head and face, he recommends cooling emollient ointments.

It is not very uncommon for an inflammation, whether of the common or erysipelatus kind, to terminate in a gangrene and mortification: nor is it uncommon for this disease to arise in different parts of the body from internal causes, without any external tumour appearing; or at least the tendency to gangrene is so strong, that it may be said to take place almost instantaneously. The internal causes of gangrene, according to Mr O'Halloran, are,

1. An highly vitiated disposition both of solids and fluids; and of this our author reckons four classes. 1. When the solids and fluids are so much vitiated, that all attempts to restrain the disease are vain, and only hurry on death the sooner. 2. When the whole body is vitiated, yet in a less degree than the former; in which case, by strong stimulants and cordials, the patient may survive by means of nature throwing the general vice to some particular part, by the loss of which life is preserved. 3. Where the malignity is much less, so that the patient may be cured without the loss of a limb. And, 4. Where the blood, though not highly vitiated, is yet deprived of its balsamic properties, so that all sores are healed with great difficulty and very considerable length of time.

II. Gangrene may arise from an hot, bilious, and inflammatory state of the blood; in which case the parts are endowed with a great degree of sensibility, and a slight hurt will frequently bring on the most alarming symptoms.

III. Where there is a grossness of the humours, with no great degree of activity in the blood itself, and a wound or hurt supervenes. Here the system has not sufficient power to raise the degree of inflammation necessary for producing pus; nor often, by the assistance of art, to dislodge the tumour.

IV. A concurrous disposition of the juices often brings on the most dreadful species of gangrene. In this, from the hurting of a wart, a slight itching, &c. a sharp humour will gradually form, by which the muscles, ligaments, blood-vessels, and bones, are gradually consumed; nor will it cease its advances till the injured parts are totally separated from the body.

V. Another species of gangrene, Mr O'Halloran says, is endemic to the poor of Ireland; and consists in an anchylosis and caries of the bones of the tarsus, coming with or without hurt. The cause of this he supposes to proceed either from the extreme poverty of these people, or from their working continually in bogs and marshy lands.

Signs of an approaching gangrene. A gangrene is known to be approaching, when the pain, redness, and tension of the inflamed part, together with the concomitant fever, increase, at the same time that little change is made in the size of the tumour. Mortification or sphacelus first appears by a change of colour in the part, from a bright red to a leaden or livid cast, with small vesicles containing a thin acrid

ferum dispersed over its surface. In the mean time the pain abates; the pulse sinks, but continues frequent; the tumour at last loses its tenses, and turns quite black and flaccid. This blackness is the sign of the mortification becoming complete; the part, meanwhile, losing all sensation, at the same time that it emits a considerable fetor; at last, too, a softness or flaccidity in general takes place, together with an entire dissolution of the different parts of which the organ is composed. There are, however, some instances of what is called dry gangrene, in which the parts continue totally mortified for a great length of time, without either turning very flaccid, or running into dissolution. But such cases never occur from inflammation; they happen commonly from the flow of blood to such parts being put a stop to by compression of one kind or another, as tumours, ligatures, or other similar causes, obstructing the principal arteries that used to supply them; which, when the stoppage of the circulation is complete, always occasion a very slow, tedious, mortification; and as the parts in such instances are no longer supplied with fresh quantities of fluids, while a considerable evaporation must still be going on, such a degree of humidity cannot, therefore, possibly occur as does in other cases of gangrene. So that species of the disorder has, perhaps, with propriety enough, been termed the dry gangrene.

There are many other varieties of the disease enumerated by authors, as the white gangrene; in which the parts supposed mortified do not turn black, but retain nearly their former colour, &c. Whether such complaints, however, can with propriety be denominated gangrene or not, may properly be doubted: but as it is chiefly that species of the disorder which succeeds to inflammation that is now particularly to be treated of, and in which no such varieties are ever observed, it is not here necessary to carry the inquiry farther; and that especially as nearly the whole mode of treatment, afterwards to be pointed out, applies with almost equal propriety to every variety of the disease.

Of all the inflammatory complaints to which the Erysipelas system is liable, that species of the disorder termed erysipelas is observed most frequently to terminate in gangrene; and whenever phlegmon is in any degree conjoined with an erysipelatus affection, which it not unfrequently is, it seems thereby to have acquired the same tendency, by being, as was already remarked, more difficult to bring to suppuration than the true phlegmon, and by going on more frequently to the mortified state.

The best and most effectual means of preventing mortification in every case of inflammation, is to endeavour either to obtain its resolution or suppuration; the different remedies for both which purposes have already been fully pointed out. But in some cases, the disorder is far advanced, and gangrene already begun, before the surgeon's assistance is called in: in others, the inflammation runs so high, and proceeds so quickly, that gangrene occurs notwithstanding the use of all the remedies that can be applied; in some instances, as we have already observed, so quickly, even that the inflammatory state is scarcely thoroughly discerned till mortification appears to be beginning.

This is most remarkably the case in carbuncles, what

Theory. what by the French are termed charbons; in which the inflammation proceeds so rapidly to mortification, that there is seldom any evident tumour raised, the parts turning black, and ending in real gangrene, often in the course of 24 hours from the first attack.

The quick progress usually made by this disorder renders it the worst, and perhaps the most dangerous, species of inflammation. For when it occurs internally upon any of the viscera, as it sometimes does, it must, probably in every instance, prove fatal, as no remedies we are acquainted with can ever prevent its progress towards the last stage of mortification. Externally, indeed, when not very extensive, and not seated on any of the large blood-vessels and nerves, carbuncles are frequently got the better of; that is, with the loss of the affected parts.

As carbuncles always appear without any evident external cause, they are in general most probably owing to a scorbutic or putrid state of the fluids; for when putrefaction prevails in the system, every inflammatory affection that occurs, proceeds much more readily to the mortified state than inflammation in other circumstances ever does. This opinion with respect to the cause of carbuncles depending upon a putrescent state of the system, is particularly confirmed by their occurring most frequently as a symptom in pestilential disorders; for although they are sometimes met with even in this country, where the plague is now never known, yet the real carbuncle is far from being a common occurrence.

The internal remedies proper for preventing gangrene have been already mentioned under the article MEDICINE, n° 281. In the way of external application, a variety of remedies have been pointed out, and particularly those of the antiseptic kind; such as all the warm gums and balsams, ardent spirits, and even alcohol; and to admit of their nearer application to the sound parts, with a view to the preservation of these from putrefaction, deep scarifications through the diseased and into the sound parts have been generally recommended. But although such articles may be of use in preserving dead animal-substances from corruption; yet that they will always prove serviceable in the same manner in living bodies, is probably very much to be doubted. And it is even apprehended, by the strong irritation they always occasion when applied to a living fibre, that, in such cases as the present, they may rather do mischief; it being only a very slight degree of inflammation that is required to bring on a suppuration. The incisions, too, when carried into the sound parts, with a view to facilitate the operation of such remedies, may likewise do harm; not only from the risk of wounding the blood-vessels, nerves, and tendons, that lie in the way, but also by allowing a free and farther entrance of the putrescent fluids into the parts not yet affected; and unless they are carried so deep as freely to reach the sound parts, applications of the antiseptic kind can never have any effect in answering the purpose for which they were intended.

For these reasons, and from never having observed any advantage to accrue from scarifications in mortification, the best practitioners are of opinion that they may be entirely laid aside. Theriac was in former times, and still is with some practitioners, a very

common application in every case of gangrene; but, from the best experience, it seems never to produce any evident good effects.

All the advantages commonly observed from the great variety of applications recommended for gangrene, are obtained with more ease, and generally too with more certainty, from the use of any gentle stimulating embrocation; which, by exciting a slight irritation upon the surface, and especially when assisted by a free use of the bark, at last commonly produces such a degree of inflammation as is wished for. With this view, a weak solution of sal ammoniac in vinegar and water has been known to answer exceedingly well; a dram of the salt to two ounces of vinegar and six of water, forms a mixture of a very proper strength for every purpose of this kind; but the degree of stimulus can be easily either increased or diminished, according to circumstances, by using a larger or smaller proportion of the salt.

Although, for the reasons formerly advanced, incisions may not in general be proper; yet in such cases where the mortification runs very deep, it is sometimes of service to make scarifications into the diseased parts, so as to remove part of them; which by taking off a considerable load perhaps of putrid dead flesh, not only lessens the fetor, which in such cases is always considerable, but often renders it more easy for the sound parts to free themselves from the remainder. When with this view, however, incisions are had recourse to, care should always be taken that they be not carried the length of the sound parts.

Whenever, either by the means recommended, or by the effects of a natural exertion of the system, a separation of the mortified parts appears between the diseased and sound parts, we may in general, with tolerable certainty, expect, that in due time a thorough separation will take place; and when a full suppuration is once fairly established, there can then be little doubt but that the mortified parts will be very soon and easily removed.

A separation being altogether effected, the remaining sore being then to be considered merely as a simple purulent ulcer, may be treated in the same manner as such sores generally are, with very slight easy dressings; at the same time that proper attention must always be paid to the support of the general system, by the continuance of a nourishing diet, the bark, and such quantities of wine as may seem necessary.

Although, however, such ulcers as remain after gangrenous affections that have not been very extensive, may in general be healed in the manner now mentioned; yet in mortifications seated on the extremities, and that have penetrated to the bones, it sometimes happens that the whole surrounding soft cases amputate parts come to be destroyed, so that amputation of the member is thereby rendered necessary. Amputation, however, should never be had recourse to, till a full and thorough separation of the mortified parts has taken place: for it is now, in every case of gangrene, from undoubted experience, an established maxim in surgery, That though the parts immediately contiguous to those evidently diseased may outwardly appear sound; yet as there can be no certainty of those ever directly below remaining so, till a full stop, or even till a complete separation, of the mortification has been

Theory. been produced; so, till that has evidently taken place, it is in such cases a general rule never to amputate a member; there being no other security for the disorder not returning, and that immediately too upon the remaining stump.

It must be observed, however, that so soon as an entire separation of the gangrene has occurred, no time should be unnecessarily lost in having recourse to the operation; for so long as any of the corrupted parts remain in contact with the sound, the system must still be suffering considerably by the constant absorption of putrescent particles, that so long will undoubtedly take place.

SECT. VII. Of Diseases of the Bones.

³¹³
Of exostosis. This bones, as well as the softer parts, are liable to be swelled, either throughout their whole length, or to have tumours formed on particular parts of them.

Exostosis is one species of tumour of the bone; but, according to Mr Bromfield, in strictness of definition, no swelling should be called so, but an excrecence continued from a bone, like a branch from the trunk of a tree. Under this head, therefore, is ranked the node; which may be produced by external injury, such as contusions and fractures: but in both these cases, the tumour has had the epithet of benign affixed, and can hardly be called a disease, as pain is seldom consequent to such risings from the bone; but it rather should be termed a deformity.

There are risings or tumours observable on the bones which are often the consequences of venereal virus, and are termed tophi, gummi, or nodes.—Tophus, is a soft tumour in the bone; and seems to be formed of a chalky substance, that is intermediate between the osseous fibres. These cretaceous extravasations sometimes are found on the ligaments and tendons, as well as on the bone; and when collected into a toph, may sometimes be taken out by the knife. We have many instances, where chalk stones in gouty people make their way out through the skin of the fingers and toes.

³¹⁴
Tophus.
³¹⁵
Gummi.
Gummi is likewise a soft tumour; but is on the surface of the bone, between it and the periosteum; and its contents resemble gum softened, from whence it has taken its name. Possibly, by obstruction in the nutrient vessels of the bone, a rupture of some of them occasions the serous liquor to escape, which, by making its way between the fibres of the bone, arrives at its surface; and being detained by the resistance of the periosteum, its most liquid parts being evaporated, and the remainder condensed by the inflammation, and consequently this inelastic covering being stretched, it becomes inspissated, and forms this species of exostosis, as it is generally called. When this is the cause, and the indisposition of the habit in general got the better of, pressure by a steel instrument, adapted to the part affected, is the proper cure.

³¹⁶
Nodes.
The confirmed venereal node has the appearance of a divarication of the osseous fibres, probably from some inspissated humour obstructing the nutrient vessels, but not extravasated; this occasioning an extension of the periosteum, produces a violent pain, which, when nocturnal, is the characteristic of a venereal cause. When only the periosteum is thickened, but the bone not affected, a course of mercury, by attenuating the obstructed humour, and fitting it to be carried out of the

body by the proper outlets, will often produce a perfect cure: but when the bone itself is diseased, this method will fail. But here the division of the extended periosteum has been known to give perfect ease.

The usual method, formerly, was to apply a caustic equal to the extent of the node, which being laid bare, required exfoliation before it could be cicatrized. If the incision is made early, that is, before matter be formed under the investing membrane, it seldom requires exfoliation; and, as we often find that the bone itself is not affected, but only the periosteum thickened, we may be deceived even after a careful examination: it is therefore proper that the patient should be pretty far advanced in a course of mercurialunction, before even the incision is made; for, should the tumour decrease and the pain abate during the course, chirurgical assistance, with the knife, most likely may become unnecessary.

The name exostosis may not be improper to those excrencences that are found on the surface of a bone in a spina ventosa, or in consequence of a caries from other causes; and it is not unfrequent for the ossific matter, being let loose by the separation of a caries, to flow in such quantity as even to incrust, and sometimes to form a case to a diseased bone. But where a bone is enlarged throughout its whole length, or its epiphyses become swelled, as in scrofulous cases, particularly in children, which case is in them called pararthrocace, such swellings cannot with propriety be ranked in this class; and whether scrofulous, scrofulous, or venereal leaven gives rise to these tumours of the bone, the habit of the body in general must be corrected, to give any chance of a cure.

A bone may become carious first in its internal parts; and that from external injury, as well as from a vitiated state of the animal-fluids. Authors seem not to agree as to the technical term for this kind of disease of the bones; some calling it cancer or gangrena ossis; others, spina ventosa, from the pointed extuberances usually attendant on this disorder of the bone; and some again, teredo, from the appearance of the carious bone, like wood that is worm-eaten.

It is universally allowed, that this disease takes its rise from matter being formed either in the diploe, or in the marrow: whenever obstruction is begun in the vessels expanded on, or terminating in, the medullary cysts, the consequence will be inflammation, and, if not early removed, will form matter; for this reason, this case may be called abcessus in medulla. Whenever, then, a patient complains of dull, heavy pain, of this deeply situated in the bone, possibly consequent to a temper. violent blow received on the part some time before, and though at the time the patient complains of this uneasiness, within the bone, the integuments shall appear perfectly sound, and the bone itself not in the least injured, we have great reason to suspect an abcessus in the medulla. Children of a bad habit of body, though they have not suffered any external injury, will often become lame, and complain of the limb being remarkably heavy; and though not attended with acute pain, yet the dull throbbing uneasiness is constant. If rigors happen during the time the patient labours under this indisposition, it generally implies that matter will be formed within the substance of the bone. On the age of the patient, and the

solidity of the bone, will in a great measure depend the next alarming symptoms, to those who are not acquainted thoroughly with the case and the condition of the patient. As mothers and nurses are often inattentive to children on the first complaining of pain and heaviness in a limb, if, after rubbing it with their hand a few minutes, the child, amused by some new toy or play-fellow, think himself easier, the good women, as they cannot see any thing wrong, determine it a growing-pain, as they call it; but, soon after, the extremities of the bone formerly complained of begin to swell, or, possibly throughout its whole extent, it becomes enlarged; a surgeon is then sent for, who, if a man of experience, will know this to be an abscessus in medulla, or true spina ventosa, as it is called: if neither of these symptoms should be consequent to the first complaint, the great insensibility of the bone in some subjects will prevent that acuteness of pain usual in other parts where matter is formed, though the acrid matter is eroding the bone during the whole time it is contained within it. This matter at length having made its way through, arrives at the periosteum, where it creates most violent pain, as well from its sharpness as from its increased quantity, occasioning an extension of the periosteum. The integuments then become swelled and inflamed, and have a sort of emphysematous feel. On being examined by pressure, the tumour will sometimes be lessened, from part of the matter retiring into the bone: from this appearance to the touch, most likely the name of ventosa was added to the term spina. When we are assured of matter being under the periosteum, we cannot be too early in letting it out, as it will save a considerable deal of pain to the patient, though probable it may not be of any considerable advantage in respect to the carious bone; for, where the fluids in general are vitiated, no chance of cure can be expected from topical remedies; but where the constitution is mended, nature will sometimes astonish us in her part; as the carious bone will be thrown off from the epiphyses, or the teredines will be filled up by the ossific matter that flows from the parts of the bone where some of the spinae have come away.

If proper medicines are given, the children well supported, and the parts kept clean and dry, patience and perseverance will frequently give great credit to the surgeon. In case it should have been thought advisable to apply the hand of a trephine at the upper and lower extremities of the tibia, to give free discharge to the matter, the washing it away, as well as the small crumbling of the carious bone, by means of destructive and drying injections, has been known to contribute greatly to the curing this kind of caries, after the habit of body in general had been mended.

Besides those above-mentioned, the bones are liable to two opposite diseases; the one termed frailness, the other melitties: the former peculiar to adults, the latter more frequent in infants, though sometimes seen in adults, from a vitiated state of their juices.

The bones, when deprived of their cementing liquor, by passing through fire, become friable. From repeated salivations, and in old people, they have been rendered extremely brittle; insomuch that in many subjects they have been fractured merely from their weight and the action of the muscles: but in such cases, this is not owing to the friability of the bones,

but to the loss of substance, from the erosion of the bone by an acrimonious humour thrown on it; to which cause perhaps may be attributed the disease called rickets in children. The effects of scorbutic humour in rendering the bones soft in many instances, have often been remarked.

From the observations we daily make, that the bones of rickety children become soft and flexible, in different parts of the same bones, though their shape is preserved; that the known effect on bones when soaked in an acid menstruum, is, that the cretaceous particles being destroyed, they become membranous; from these remarks, we are induced to attribute the species of the disorder to an acrimonious humour thrown on the bones, and obstructed in their internal vessels. By proper diet, gentle friction with coarse cloths, exercise, and cold bathing, these invalids will frequently get their constitution so much changed, as that by the time they arrive at the age of twenty years there shall not remain the least vestige of their former disease. The epiphyses are generally most affected in this species of the disorder.

For want of early attention to invalids of this sort, we find that their bones not only become soft, and yield to the powers of the muscles, but remain distorted the rest of their lives, though they have acquired a perfect degree of solidity. In such cases, correcting the vitiated juices only will not restore the bones to their natural state; therefore the assistance of a skilful mechanic is necessary both to support the parts improperly acted on, and to alter the line of direction of the distorted osseous fibres.

Though the curvature of the extremities, or thick-ness of the ends of the bones near their articulations, may give the first alarm to those who are constantly with children, yet there are other symptoms that give earlier notice than these, which, had they been timely discovered by proper judges, it is highly probable that the curvature of the limbs in many children might not have happened. The belly generally becomes larger in this disease, from the increased size of the contained bowels, as it is not unlikely but that the mesenteric glands are the first parts obstructed; obstructions of the liver, spleen, and pancreas soon follow; the head then becomes enlarged; then a difficulty of breathing, which is generally supposed to be the effects of taking cold, succeeds; the sternum is elevated and sharp, and the thorax becomes contracted; the spine is protruded in several parts; the pelvis altered, according to the pressure of the parts within, and habitual inclination of the patient, at times, to obtain that line of direction in which the perpendicular from the centre of gravity may fall within the common base of the body, the extremities of the cylindrical bones, and the ends of the ribs, next the sternum, become enlarged; soon after this the bones in general become soft and flexible, yielding in such directions as the strongest muscles determine by their actions.

The bones of children who die of this disorder, we observe, are not only rendered soft, but the vessels within their substance are replete with blood, whose texture is totally broken, and has more the appearance of thin chocolate than blood: the periosteum in many places is separated, and the intermediate space between

Theory. it and the bone filled with extravasated fluid; and caries is almost as frequent as the separation of the periosteum. The muscles in such bodies generally appear pale and flabby.

³³⁵ Where the affection of the mesenteric glands is evident, Mr Bromfield asserts, that after a dose or two of the pulvis basilicus to empty the intestines thoroughly, the purified crude quicksilver is by much the most efficacious medicine to remove obstructions in those glands. When the belly begins to soften and subside, the chyle passes without interruption, and the child begins to get flesh; then the cold bath becomes truly serviceable, and the decoction or cold infusion of the Peruvian bark is a proper restorative; but the cold bath used too early, or the bark given before there is a free circulation of chyle through the lacteals, would be very injurious.

The mollities ossium, in some cases, may be produced from a redundancy of the oleaginous parts of the blood, or from a laxity of the solids, by which the fluids are not sufficiently attenuated, nor properly blended and mixed: the consequence of which will be obstructed perspiration, the habit in general loaded with gross, phlegmatic, and serous humours, and the ossific matter not united or condensed as in a healthy state.

From this debility and laxity of the solids, and consequent viscosity and lentor of the fluids, the rickets are produced; and, from what has been remarked, we may account for the largeness of the brain, liver, and spleen, and the swelled belly, the distortion of the vertebrae and pelvis, contracted thorax, and curvature of the extremities.

³³⁶ The method of cure confirms us likewise in the cause of these symptoms; for, by strengthening the fibrous system, by using gentle exercise, a dry diet, good air, aromatics, and cold bathing, this kind of invalids are generally restored to health.

Of the palsy of the lower extremities with curvature of the spine. Among the diseases of the bones we may likewise take notice of that palsy of the lower extremities which takes place, as is generally supposed, in consequence of a curvature in some part of the spine. To this distemper both sexes and all ages are equally liable. When it attacks an infant of only a year or two old or under, the true cause of it is seldom discovered until some time after the effect has taken place. The child is said to be uncommonly backward in the use of his legs, or it is thought to have received some hurt in the birth. When the child is of an age sufficient to have already walked, and who has been able to walk, the loss of the use of his legs is gradual, though in general not very slow. He at first complains of being very soon tired, is languid, listless, and unwilling to move much or at all briskly. Soon after this he may be observed frequently to trip and stumble, though there be no impediment in his way; and whenever he attempts to move briskly, he finds that his legs involuntarily cross each other, by which he is frequently thrown down without stumbling; and when he endeavours to stand still in an erect posture without support, even for a few minutes, his knees give way and bend forward. As the distemper advances, it will be found that he cannot, without much difficulty and deliberation, direct either of his feet exactly to any one point; and very soon after this, both legs and thighs

lose a good deal of their natural sensibility, and become quite useless. In adults, the progress of the disease is much quicker, but the symptoms nearly the same.

Until the curvature of the spine is discovered, the complaint generally passes for a nervous one; but when the state of the back-bone is adverted to, recourse is almost always had to some previous violence to account for it. That this might have been the case in some few instances, might be admitted; but in by far the greatest number some predisposing cause must be looked for.

Mr Pott, who has written a treatise upon this disease, recommends it to our observation, that though the lower limbs are rendered almost useless, or even entirely so, yet there are some circumstances in which it differs from a common nervous palsy. The legs and thighs, though so much affected, have neither the flabby feel of a truly paralytic limb; nor have they that seeming looseness at the joints, nor the total incapacity of resistance which allows the latter to be twisted almost in all directions: on the contrary, the joints have frequently a considerable degree of stiffness, particularly the ankles; by which stiffness the feet of children are generally pointed downward, and they are prevented from setting them flat upon the ground.

³³⁸ The curvature of the spine, which is supposed to be the cause of the complaint, and with which it is always accompanied, is various in situation, extent, and degree, being either in the neck or back, and sometimes, though very seldom, in the upper part of the loins. Sometimes it comprehends only two vertebrae, sometimes three or more, by which the extent of the curve necessarily becomes more or less; but whatever may be the number of the vertebrae concerned, or whatever may be the degree of curvature, our author never saw the arms affected.

When a weak infant is the subject of this disorder, and the curvature is situated in the vertebrae of the back, it is not uncommon for the whole back to become what is called humped, at the same time that the bones of the thorax are considerably altered; whence such persons are justly said to be shortened in their stature; but in all cases where this effect has been gradually produced, the curvature of the spine is always the first of these deformities which makes its appearance.

Before the curvature of the spine is discovered, or while no attention is paid to it, the complaint is, as we have already said, looked upon to be nervous; such internals as are supposed to be proper in nervous cases are given, together with warm liniments, embrocations, and blisters, to the part affected: and when the true cause is known, recourse is always had to steel stays, the swing, screw-chair, and other pieces of machinery. But all these are productive of no real or permanent good; the patient becomes unhealthy, and, languishing for some time under a variety of complaints, dies in an emaciated state, or drags on a miserable existence, confined to a great chair or bed, totally deprived of the power of locomotion, and useless both to himself and others.

At first the general health of the patient seems not to be at all, or at least not materially, affected; but when the disease has continued for some time, and the curvature

curvature is thereby increased; many inconveniences and complaints come on; such as difficulty in respiration, indigestion, pain, and what they call tightness at the stomach, obstinate constipations, purgings, involuntary flux of urine and faeces, &c. with the addition of some nervous complaints, which are partly caused by the alterations made in the form of the cavity of the thorax, and partly by impressions made on the abdominal viscera.

Mr Pott was led to a knowledge of the true cause and cure of this distemper, from observing the case of a youth of 14, who was restored to the use of his limbs immediately after a seemingly accidental abscess near the part. From this he was inclined to think, that the curvature of the spine was not the original cause of the disorder, but that the surrounding parts were predisposed towards it by some affection of the solids and fluids there. For these suspicions he had the following reasons:

1. That he had never seen this paralytic effect on the legs from a mal-formation of the spine, however crooked such mal-formation might have rendered it, or whether such crookedness had been from the time of birth, or had come on at any time afterwards during infancy.

2. That none of those strange twists and deviations, which the majority of European women get in their shapes from the very absurd custom of dressing them in slays during their infancy, and which put them into all directions but the right, ever caused any thing of this kind, however great the deformity might be.

3. That the curvature of the spine, which is accompanied by this affection of the limbs, whatever may be its degree or extent, is at first almost always the same, that is, it is always from within, outward, and seldom or never to either side.

4. That since he had been particularly attentive to the disorder, he had remarked, that neither the degree nor the extent of the curve made any alteration in the nature or degree of the symptoms at first, nor for some time after the appearance; or, in other words, that the smallest curvature, in which only two or three of the vertebrae were concerned, was always at first attended by the same symptoms as the largest.

5. That although it sometimes happened that a smart blow, or a violent strain, had immediately preceded the appearance of the curve, and might be supposed to have given rise to it; yet in many more adults it happened that no such cause was fairly assignable, and that they began to stoop and to falter in their walking, before they thought at all of their back, or of any violence offered to it.

6. That exactly the same symptoms are found in infants, and in young children, who have not exerted themselves, nor have been injured by others, as in the adult who has strained himself or received a blow; and that the case was still the same in those grown people who have neither done nor suffered any act of violence.

7. That although it must be allowed that a dislocation of any of the vertebrae would most probably be attended with the same kind of symptoms from the

pressure it must make on the spinal marrow, yet it is also most probable, that such symptoms would be immediate, and attended with great pain in the part; neither of which is in general the case here. Theory.

"These considerations (says he) appeared to me to have much force; but what confirmed me in my opinion was the state of the parts forming the curvature, and which I had several fair opportunities of examining after death. By these examinations I found, in infants, in young children, and in those who had been afflicted with the disorder but a small space of time, that the ligaments connecting the vertebrae, which formed the curve, were in some degree altered from a natural state, by being somewhat thickened and relaxed; and that what are called the bodies of those bones, were palpably spread and enlarged in their texture, just as the bones forming the articulations are in children who are called rickety. That in those who had long laboured under the distemper, and in whom the symptoms were aggravated, whatever might be their age, the ligaments were still more thickened, relaxed, and altered; the bodies of the bones more spread, more enlarged, and more inclining to become carious; and the cartilages between the bodies of the vertebrae much compressed and lessened in size: and that in all those who had so long laboured under the disease, as to have been destroyed by it or by its consequences, the corpora vertebrae were completely carious, the intervening cartilages totally destroyed, and a quantity of sanies lodged between the rotten bones and the membranes investing the spinal marrow (A).

"All these circumstances put together, induced me, as I have already said, to suspect, that when we attribute the whole of this mischief to the mere accidental curvature of the spine, in consequence of violence, we mistake an effect for a cause; and that previous both to the paralytic state of the legs, and to the alteration of the figure of the back-bone, there is a predisposing cause of both, consisting in a distempered state of the ligaments and bones, where the curve soon after makes its appearance.

"While the subject was fresh in my mind, I happened to be at Worcester; and in a conversation on it with the late Dr Cameron of that place, I mentioned to him my opinion and my doubts. The doctor concurred with me; and at the same time mentioned a circumstance which made a strong impression on me. He said, that he remembered, some years ago, to have noted a passage in Hippocrates, in which he speaks of a paralysis of the lower limbs being cured by an abscess in the back or loins; and that, taking the hint from this, he, Dr Cameron, had, in a case of a palsy of the legs and thighs, attended by a curvature of the back-bone, endeavoured to imitate this act of nature, by exciting a discharge near the part; and that it had proved very advantageous. He also referred me to Mr Jeffrys, a surgeon of eminence at Worcester, for a farther account of the same kind of attempt. This gentleman confirmed what Dr Cameron had told me; and assured me that he had found the method equally successful.

(A) In the body of a man who died not long since of this disorder in its last and worst state, the bodies of three of the vertebrae were not only quite carious, but completely separated from, all connection with the other parts of the same vertebrae.

It may easily be supposed, that these accounts, from gentlemen of veracity, and of reputation in their profession, still added to my desire of knowing more on this subject, and determined me to lose no opportunity of getting information.

"The first that offered was an infant, whose curvature was in the middle of the neck, and who had lost the use of its legs for about two or three months. I made an issue by incision on one side of the projection, and gave strict charge to the mother to take care that the pea was kept in: the woman, who had no faith in the remedy, did not take the proper care; and consequently the discharge was not equal to what it should and might have been: but notwithstanding this neglect, at the end of about three weeks or a month the child was manifestly better, and began to make use of its legs; it was then seized with the small pox, and died. The bodies of the vertebrae concerned in the curve were larger than they should be, and than those above and below were, and their texture much more open and spongy; which difference appeared immediately, before the parts covering them were dissected off.

"Some time passed before I had another opportunity. My next patient was a tall thin man, about 35 years old, who thought that he had hurt himself by lifting a heavy weight. His legs and thighs were cold, and what he called nummy, but not absolutely useless: he could with difficulty go about the room with the help of a pair of crutches; but he could neither rise from his chair, nor get on his crutches, without the assistance of another person, nor could he without them walk at all.

"I made a feton on each side of the curve which was in his back, about the middle; and having given his wife directions how to dress them, I called on him once in three or four days. At the end of six weeks he had recovered the due degree of sensation in his limbs, and found much less necessity for the use of his crutches. He could rise from his bed and from his chair without assistance: and, by means of one crutch and an underhand stick, could walk for an hour or more without resting and without fatigue. The fetons had now, from not having been properly managed, worn their way out; and I would have converted each of them into an issue: but as neither the patient nor his wife had ever believed that the discharge had had any share in his amendment, but, on the contrary, that he would have been better without it, he would not submit to what I proposed, and I left him. At the distance of about three weeks from the time of my leaving him, I met him in the street walking very stoutly with a common cane, of which he made little or no use. I asked him what he had done: He told me that the fores had continued to discharge till within a few days; but that he had drank a great deal of comfrey-root tea with isinglass; and he supposed that had cured him.

"I believe that the cure of this man will, by all who know any thing of medicine, be thought to be so unlikely to have been effected by the comfrey and isinglass, that my inference in favour of the feton will not be thought unreasonable, and that my determination to prosecute the method, from what I had heard and seen, was well founded.

"Within the course of the last ten or twelve months,

I have had several fair opportunities of doing this, both in St. Bartholomew's hospital and out of it; and am very happy to be able to say, that it has not only always answered, but in most instances greatly exceeded, my most sanguine expectations, by restoring several most miserable and totally helpless people to the use of their limbs, and to a capacity of enjoying life themselves, as well as of being useful to others.

"I have now in the hospital a boy about 12 years old, whose case was so truly deplorable, that I made the experiment merely to avoid the appearance of inhumanity by discharging him as incurable without trying something. The curvature was in his back, and consisted of three or four vertebrae; but by means of the weakness thereby induced, the whole set of dorsal ones had so universally and gradually given way, that he was exceedingly deformed both behind and before: he was so absolutely incapable of motion, that he could neither turn himself nor sit up in his bed: his feet were pointed downwards, and his ankles so stiff, that, when he was held up under the arms, the extremities of his great toes touched the floor, nor could his feet be brought flat to the ground by any means or force whatever. In short, he was as perfectly and as totally helpless as can be supposed; and at the same time in an exceeding general bad state of health, from disorders of the thoracic and abdominal viscera. In this state he had been more than a year. It is now about three months since the caustics were applied: he is become healthy, and free from most of his general complaints: has the most perfect use of his legs while he is in bed; can walk without the assistance of any body, or any thing to hold by; and from his manner of executing this, will, I make no doubt, in a very short space, recover perfectly the use of his legs. To this I ought to add, that notwithstanding a considerable degree of deformity does, and I suppose will remain, yet the spine in general is so much strengthened, that he is some inches taller than he was four months ago.

"The remedy for this most dreadful disease consists merely in procuring a large discharge of matter, by suppuration, from underneath the membrana adiposa on each side of the curvature, and in maintaining such discharge until the patient shall have perfectly recovered the use of his legs. To accomplish this purpose, I have made use of different means, such as fetons, issues made by incision, and issues made by caustic; and although there be no very material difference, I do upon the whole prefer the last. A feton is a painful and a nasty thing: besides which, it frequently wears through the skin before the end for which it was made can be accomplished. Issues made by incision, if they be large enough for the intended purpose, are apt to become inflamed, and to be very troublesome before they come to suppuration; but openings made by caustic are not in general liable to any of these inconveniences, at least not so frequently nor in the same degree: they are neither so troublesome to make or maintain. I make the eschars about this size and shape on each side the curve, taking care to leave a sufficient portion of skin between them. In a few days, when the eschar begins to loosen and separate, I cut out all the middle, and put into

each a large kidney-bean: when the bottoms of the foies are become clean by suppuration, I sprinkle, every third or fourth day, a small quantity of finely-powdered cantharides on them, by which the foies are prevented from contracting, the discharge increased, and possibly other benefit obtained. The issues I keep open until the cure is complete; that is, until the patient recovers perfectly the use of his legs, or even for some time longer: and I should think that it would be more prudent to heal only one of them first, keeping the other open for some time; that is, not only until the patient can walk, but until he can walk firmly, briskly, and without the assistance of a stick; until he can stand quite upright, and has recovered all the height which the habit, or rather the necessity, of stooping, occasioned by the distemper, had made him lose."

SECT. VIII. Of the different Operations in Surgery, and in what Cases they are proper.

THE most simple operations are those in which there are neither arteries to tie up, fractures to reduce, nor any divided parts to conjoin by future. They are chiefly phlebotomy or blood-letting; simple incisions into abscesses in order to discharge the matter; and drawing of teeth.——Phlebotomy is useful in all cases where there is a great tendency to inflammation, or where one particular part of the body has been accidentally so much weakened that it cannot bear the impetus of the fluids moving through it with their usual velocity. Hence it is useful in all large wounds, fractures, or contusions, because the impetus of the blood and other fluids, in such cases, is too great to be borne by the weakened and distracted vessels; and if they are entirely divided, it would keep them perpetually bleeding. Hence phlebotomy is also of use in restraining profuse hemorrhages from any part of the body. On the other hand, it is exceedingly hurtful where the crasis of the fluids tends to a dissolution, or where the vital powers are so weakened that they cannot propel the humours with their usual degree of force. In cases of scurvy, therefore, bleeding is prejudicial; in mortifications, or in large suppurations; because thus the vital powers, which are already reduced, become still more weak, the scorbutic disposition is increased, or the pus cannot be formed as it ought to be. For the same reason, in the lues venerea, however it might seem to be indicated by the pain and swellings, it is entirely improper. The same may be said of all other eruptive disorders, even the itch: for though some have a notion of the good effects of bleeding in this disease, it is always evidently the worse for it; and it will constantly be found, that even this disease proceeds from such causes as weaken the vital powers, such as nastiness, damp, and poor low diet; while, on the other hand, those who keep themselves clean, and live on wholesome strengthening food, are seldom or never troubled with it.

Phlebotomy may be performed in many different parts of the body; and it is found to be more effectual when performed in the neighbourhood of an affected place than at a distance from it. Where the affection of the system is general, bleeding in the arm is most eligible; but if the head or throat are affected, bleeding in the jugular vein is preferable. In

swellings and inflammations of the throat, it will also be of service to open the sublingual veins: in suppressions of the menses, bleeding in the ankle is recommended: and it has been found in some cases necessary to perform the operation even on the veins of the penis and eyes.

Cupping, with or without scarification, is a kind of partial phlebotomy. Dry-cupping brings a flux of all the humours towards that part on which the cupping-glass is applied; and hence is useful in bringing the milk towards the breasts of women, in hastening suppuration, &c. If scarification is used, it discharges the blood not only from the small cutaneous veins, but also from the arteries. Hence it is of service in local inflammations.—In the same cases also the application of leeches is useful.

Incision, or something equivalent to it, is always necessary in the case of abscesses, or large collections of matter which cannot otherwise be discharged: tho' large incisions are to be avoided as much as possible; both on account of their evident cruelty, and because they are apt to produce an absorption of matter, and occasion an hectic. In cases of white swellings and cancerous tumours, they ought always to be avoided as much as possible, unless with a view totally to extirpate the diseased parts. On the other hand, in cases of punctured nerves and tendons, incision is not only necessary, but frequently the only means of preserving the patient from death.

Under the head of incision we may likewise reckon the putting in of issues and fetons, though the former fetons are more commonly put in by caustic. They are useful in drawing off collections of matter, when situated in such places that they cannot be opened. They are also of use in the case of palsy of the lower extremities with curvature of the spines, as has been already explained, n° 332. In apoplexies, palsies, and other disorders of the head, they are also frequently of eminent service.

Under the article MEDICINE, n° 314, it is observed, that where the teeth are carious, the only remedy is to draw them out. However, we are not therefore to imagine, that in all cases of toothach, even when the pain is very severe, that we are to have recourse to this remedy. The teeth are never known to exfoliate, and grow up again, as other bones will do; and therefore the preservation of them is well worthy our attention. But when, by the gradual putrefaction of a tooth, the patient is kept in continual pain, and there is danger of a caries, by means of the affection of the tooth, taking place in the jawbone, tooth-drawing then becomes absolutely necessary, and is generally attended with little pain to the patient, as in such cases the teeth are generally loosened in their sockets. It must be remembered, however, that the upper teeth are much worse to draw than the under ones, being not only much faster in their sockets, but connected in such a manner with the nerves of the eyes, especially those called the eye-teeth, as makes the drawing of them very dangerous.

Of the more difficult operations in surgery, the first is future; which necessarily takes place in all cases where we desire the union of parts that would otherwise remain at too great a distance, or where we want to form an adhesion which would not take place naturally. Hence

Theory. it is necessary in all wounds made in the fleshy parts, and attended with considerable gaping of the lips. It is also necessary in wounds of the abdominal viscera, where they are protruded; in wounds of the aspera arteria, of the cesophagus; in mortifications of the intestines, in order to make the edge of the intestine adhere to the wound; in the hare-lip, &c.

339
Ligation of
arteries. Under this article likewise we may include the ligation of arteries, which must necessarily take place in all cases where these vessels are wounded, either accidentally or by design, as in the amputation of limbs; and to the same we may refer the operation for aneurysms to be afterwards described, and which seems to be the only method of treating these tumours with any probability of success.

340
Reduction of
fractures,
&c. Reduction of fractured and dislocated bones ought always to be attempted in case of such accidents, unless where the bones are broken into such small pieces that there can be no hope either of their uniting or of preserving the limb.

341
Amputa-
tion. Amputation is necessary only in such cases as those already mentioned, namely, where, either by external accident, or from some internal cause, the limbs cannot by any means be preserved. Hence it is useful only in those diseases which are plainly destructive of life by the infectious matter absorbed, or where the parts are entirely mortified and useless.

342
Trepan-
ning. Trepanning of the cranium ought to take place in all cases where there are symptoms of an oppressed brain, provided we have any indication of the place under which the mischief lies, as has already been explained, n° 131. An operation of a similar kind may also upon some occasions be necessary on other bones, in order to remove a part of their carious substance.

343
Of the pa-
racentesis. In cases of dropy, of hydrocele, empyema, and hydrothorax, the operation called paracentesis, or tapping, ought to take place, if the water can be dissipated by no other means. Some collections of water, however, there are, in which this operation is highly

improper, and indeed fatal; such as the hydrocephalus and hydrorachitis, spina bifida, or collection of aqueous fluid in the cavity of the spine. In this last case the spinal marrow is compressed, and all the lower parts of the body become paralytic. The evacuation of this water is certain death; and if any hope remains, it must be by making use of such internal remedies as are mentioned under the article MEDICINE, n° 370, for the hydrocephalus.

344
Operation
for the
hernia. The operation for the bubonocoele, or strangulated hernia, is not to be performed on patients until after every method of reducing the gut has been attempted in vain. It is very fatal, in this country, but much less so in France; but whether owing to any peculiarity in the climate of that country, or to the superior dexterity of the French surgeons, is unknown. An operation of the same nature is sometimes performed in case of a volvulus of the intestines: and it has even been recommended in case of indurated faeces, or balls choking up their cavity; though, as the signs of these are at least but equivocal, we have not heard of any operators so bold as to attempt them.

345
Of lithot-
omy, &c. One of the most capital operations in surgery is that of lithotomy, or cutting for the stone. This has been practised from the early ages of medicine, but has received great improvements in modern times. Before it is attempted, all possible means should be used for dissolving the stone by the solvents proposed under the article MEDICINE, n° 486. However, the operation may be safely performed on persons of all ages; and though many have died under it, many have also survived, and been by it recovered from the most miserable state imaginable to perfect health.

Besides these, there are several other operations in surgery which are connected with particular diseases, and without which these distempers cannot be cured; such as the operation for the fistula lachrymalis, for the cataract, for the fistula in ano, for the phymosis, paraphymosis, &c. all of which shall be described under their proper heads.

PART III. PRACTICE OF SURGERY.

Practice. THIS consists in performing of the different operations in surgery, in such cases and with such intentions as are most proper; for which last the directions of a physician are often thought necessary; though, as before observed, it were much better that surgeons were themselves acquainted with the cases where manual operations are necessary, and when they are not.—We shall begin with these operations which are most simple and easily performed.

SECT. I. Of Blood-letting.

346
General
rules re-
specting
phlebotom-
my. THERE are some general rules and observations which relate equally to this operation in whatever part of the body it is practised; these we shall in the first place enumerate with as much accuracy as possible, and shall afterwards proceed to treat particularly of blood letting in the arm and other parts.

I. In this, as in every other operation, the situation of the patient, and of the operator likewise, ought to be precisely fixed. As the situation of a patient during the operation of blood-letting, has a considerable

influence on the effects produced by the evacuation upon the system, this circumstance therefore merits our particular attention. In some disorders, it is the object of this remedy, to evacuate a considerable quantity of blood without inducing fainting: When this is the case, and when from former experience it is known that the patient to be operated upon is liable during the evacuation to fall into a faintish state, a horizontal posture, either upon a bed or on a couch, ought to be preferred to every other; for every practitioner is now well acquainted with this fact, that fainting is not near so ready to occur in a horizontal as in an erect posture.

It now and then happens, however, that one material advantage expected from the operation of blood-letting, is the production of a state of deliquium; as, for instance, in cases of strangulated hernia, where a general relaxation of the system is sometimes desirable. In all such circumstances, instead of a horizontal posture, the more erect the patient is kept, the more readily will a state of fainting be induced: So that

Practice. the particular object in view from the operation must at all times determine this matter.

While we thus, however, attend particularly to the posture of the body at large, the particular position of the limb or part to be operated upon must not be neglected. In every operation it is a matter of much importance to have the patient seated in a proper light, but in none is it more material than in blood-letting. The best general rule that can be given upon this point is, that the patient ought to be so placed, as that the principal light of the apartment shall fall directly upon the part to be operated upon, so that the vein to be opened may be made as apparent as possible.

³⁴⁸ But, whatever may be the position of the part to be operated upon, and whether the patient is to be placed on a bed or on a chair, according to Mr Bell, the surgeon ought always to be seated. The operation may, no doubt, be done while the surgeon is standing; and it is most frequently indeed performed in this manner: But it can never be done either with such steadiness or neatness, as when the operator is firmly seated on a chair.

II. From the coats of veins being more flaccid than those of arteries, and from the blood not proceeding with such rapidity in the former as in the latter, an opening made in one of these will seldom discharge blood freely, unless the vein is either cut entirely across, which in general would be productive of disagreeable consequences, or that the blood be prevented from returning to the heart, by means of a ligature placed between the heart and that part of the vein in which the opening is to be made.

³⁴⁹ The patient being properly seated, the next step, in every operation of this kind, must therefore be, by means of a proper bandage, so to compress the vein intended to be opened, as to prevent the blood from returning to the heart; and, for the same reason, an equal degree of pressure, it is obvious, ought to be applied to all the other veins of the part: for if this circumstance should not be attended to, the communication preserved by the collateral corresponding branches would render the pressure upon any one particular vein of very little importance. But, independent of its producing a more free discharge of blood than could be otherwise obtained, this pressure upon the veins, by inducing an accumulation of their contents, tends to bring them more evidently into view, and consequently renders it easier for the operator to effect a proper opening than he would otherwise find it.

Although compression, however, to a certain extent, is necessary for this purpose of accumulating a quantity of blood in the veins, and for afterwards discharging it at an opening made by the lancet, it is at the same time perfectly evident, that any considerable degree of pressure, instead of forwarding these purposes, must obstruct them entirely: for if the pressure intended to be applied to the veins only, should accidentally be carried so far as to rest materially upon the arteries connected with them, all farther access of blood to the veins would be thereby cut off, so that no evacuation of importance could take place at any opening to be made in them. Whenever it is intended, therefore, to evacuate blood in this manner,

a good deal of nicety is requisite in applying this pressure upon the veins: it ought always to be carried so far as effectually to compress the veins of the part, but never to such a degree as to obstruct the circulation in the corresponding arteries. When we see that the pressure applied has the effect of raising the veins, and if at the same time the pulsation of the artery is distinctly felt in the inferior part of the member, we may then be certain that it is to a very proper degree, and that it ought not to be carried farther: for by the swelling of the veins we are sure that they are sufficiently compressed; and by the arteries continuing to beat, it is evident that a continued flow of blood may be expected.

III. The reflux of blood to the heart being in this manner prevented, the next question to be determined is, the best method of making an opening into the vein. Different instruments have been invented for this purpose; but there are two only which have been retained in use, and which are all, therefore, that here require to be mentioned. These are the lancet and the phlegm. This last, on being placed immediately on the part to be cut, is, by means of a spring, pushed suddenly into the vein, and produces an opening of the exact size of the instrument employed.

The phlegm, in many parts of Germany, has acquired some reputation, particularly in taking blood from the jugular vein: but there are various objections to the use of this instrument, which must undoubtedly prevent it from ever coming into general use; and these particularly are, that we are obliged, from the nature of the instrument, to regulate the deepness to which it is to go before it is applied. Now we know well, that in blood-letting this is a circumstance we are never by any means certain of: for we frequently, after the introduction of a lancet, find it necessary to go much deeper than was at first expected; so that when a phlegm is used, unless we employ one on every occasion of a length which cannot be frequently required, we must often meet with disappointments.

But the most material objection to this instrument is, that where there are arteries or other parts lying below the veins, and in any danger of being hurt by the operation of blood-letting, the risk is much greater with the phlegm than with the lancet. For when the lancet is used, after the vein is once opened, the orifice may be enlarged at pleasure without any additional risk, merely by carrying the instrument forward along the course of the vein in the same depth to which it was at first introduced: whereas with the phlegm, so soon as it enters the vein, it must for certain pass directly downwards to its full length; a circumstance which adds greatly to the risk of wounding the parts underneath.

Independent of this, too, by the use of the lancet, we have it much more in our power to command an orifice of a determined size than when the phlegm is used: So that, without hesitation, we may venture to pronounce the phlegm to be an instrument in no degree necessary.

The broad-shouldered lancet in ordinary use, is an instrument which ought to be laid entirely aside. For opening abscesses it is very well calculated; but for the operation of blood-letting, it ought never to be used. The capital objection to this kind of lancet is, that

Practice. that the broadness of its shoulders produces always a wound in the external teguments of perhaps three times the size of the opening made in the vein; a circumstance which adds no advantage whatever to the operation; on the contrary, it produces much unnecessary pain in the first instance; it renders it frequently a very difficult matter to command a stoppage of the blood; and the wounds produced by it are commonly so extensive, as to render them very liable to terminate in partial suppurations; an occurrence which always proves painful and disagreeable to the patient.

The spear-pointed lancet, on the contrary, is an instrument in every respect well calculated for the purpose of venesection. From the acuteness of its point, it enters the teguments and vein with very little pain; which, we may here observe, is with many patients a circumstance of no small importance. We are sure of making the opening in the vein equal, or nearly so, to the orifice in the external teguments; and the discharge of blood produced by an opening made with one of these lancets, is commonly put a stop to with great ease, immediately on removing the ligature upon the vein.

“For these reasons, therefore, (says Mr Bell), the spear-pointed lancet is highly preferable to every other. And although, with timid practitioners, the acute point of this instrument may appear to require more dexterity in using it than the broad-shouldered lancet; yet the difference in this respect is so inconsiderable, that a very little experience of its excellency must, with every practitioner who gives it a fair trial, soon counterbalance all such objections. Indeed, no surgeon ought to be trusted in letting blood with the one, whose steadiness and dexterity would be in any degree doubted with the other.”

353
Method of performing the operation.
IV. The form of lancet being thus fixed upon, we come now to speak of the method of using it. The surgeon and patient being both properly seated, and the ligature having been applied for a short space of time in order to produce some degree of swelling in the veins, that vein is to be made choice of which, at the same time that it appears conspicuously enough, is found to roll less than the others on being pressed upon by the fingers. There are some veins which roll so much, from being loose and unconnected with the cellular substance of the part, that although they may rise sufficiently, yet are much worse to operate upon than others which lie at a much greater depth. That vein therefore is to be preferred, which not only rises so as to become perfectly evident, but which appears to be connected with some degree of firmness to the contiguous parts. It is scarcely thought necessary to observe here, that when a vein appears to be so immediately connected with a contiguous artery or tendon, as evidently to produce some risk of wounding these parts in the operation, another vein not liable to such hazard, if it can be procured, ought undoubtedly to be preferred.

355
Dangers attending it.
Veins may lie directly above both arteries and tendons, and yet no manner of risk be incurred by opening them, provided the operator is sufficiently steady and attentive; but it does now and then happen, that veins are so nearly and intimately connected with these

parts, as to render it hazardous even for the most dexterous surgeon to attempt this operation.

The vein being at last made choice of, the surgeon, if he is to use his right-hand in the operation, takes a firm hold of the member from whence the blood is to be drawn with his left, and, with the thumb of the same hand, he is now to make such a degree of pressure upon the vein, about an inch and half below the ligature, as not only to render the skin and teguments somewhat tense, but at the same time to interrupt for a little all communication between the under part of the vein and that portion of it lying between the ligature and the thumb placed as thus directed.

The lancet being bent to somewhat more than right angles, the operator now takes it between the finger and thumb of his right-hand; and leaving at least one half of the blade uncovered, he rests his hand on the middle finger, ring-finger, and little finger, all placed as conveniently as possible in the neighbourhood of the vein from whence the blood is to be taken; and having pushed the point of the instrument freely through the skin and teguments into the vein, he now carries it forward in an oblique direction, till the orifice is of the size he inclines to have it; taking care, during the time of pushing on the lancet, that its point be kept in as straight a direction as possible, for fear of dipping into the parts below.

The instrument is now to be withdrawn; and the surgeon, removing the thumb of his left hand, is to allow the vein to empty itself freely into the different cups previously provided for the purpose.

356
It is here of importance to observe, that during the time the blood is discharging, the member ought to be kept in exactly the same posture it was in when the lancet was first introduced: otherwise the orifice in the skin is apt to slip over the opening in the vein; a circumstance which always proves inconvenient, and on some occasions produces a good deal of trouble by the blood from the vein insinuating itself into the surrounding cellular substance.

In taking hold of the lancet, we have directed the scales to form rather an oblique angle with the blade of the instrument. It will answer when they are even at right angles; but a farther separation proves always troublesome, by throwing the scales too much out upon the operator's hand. The length of instrument left out from between the finger and thumb is another circumstance requiring our attention; for unless a sufficient quantity of it is left uncovered, the operator cannot act with freedom. In lancets of an ordinary length, one half of the blade, or very nearly that quantity, ought always to be left out.

The entry of the lancet into the vein is the next circumstance we have desired to be attended to. By very little attention, the entrance of the instrument into the vein may be distinctly perceived: for so soon as its point has entered the cavity of the vessel, the resistance to its farther progress is evidently found to be much diminished; and immediately on the opening being in any degree enlarged, the blood begins to rush out; which is the clearest proof of the operation being so far complete. On being thus rendered sure that the lancet has got into the vein, we have also desired that it may be carried forward in an oblique direction,

direction, taking care to keep the point of the instrument in the same degree of elevation from the instant it has passed fairly through the coats of the vein; and to this part of the operation the most particular attention ought to be given. To the want of necessary caution in this matter, or rather to the improper regulations held forth upon it by every writer on this subject, much of the risk attending this operation ought to be attributed.

The propriety of an oblique direction for the course of the orifice is very obvious: for when made altogether longitudinal, the sides of the wound are apt to fall immediately together, so as not to admit of a free discharge of blood; and, on the other hand, when the vein is cut entirely across, troublesome consequences commonly ensue from the wound being very difficult to heal. An orifice somewhat oblique with respect to the course of the vein, is therefore preferable to either. But the material circumstance to be kept in view, is the direction of the point of the lancet after it has got fairly into the vein.

The reason of this last precaution is, that the internal orifice of the vein may not be farther extended upwards than the external wound in the skin and other teguments, as ecchymoses, or effusions of blood into the cellular substance, have, with the broad-shouldered lancet, been found frequently to occur from a contrary management. But when the spear-pointed lancet is used, this is an occurrence which need never happen; as, from the narrow point of the instrument, it may with safety be carried on in the cavity of the vein as far as is necessary. The orifice produced by it in the vein must, when the operation is properly done, be always of very nearly the same extent as the external wound in the teguments: and, by the same management, we avoid that capital risk which it is evident must always occur from an implicit obedience to the direction alluded to; for one certain effect of raising the heel or back-part of the lancet, is, that the point of the instrument must in the same proportion be depressed; and the consequence of lowering the point of the lancet, already perhaps sliding along the under side of the vein, must at once appear to be very hazardous: for, in such circumstances, if the point of the instrument be depressed, which must undoubtedly happen if the back-part of it be elevated, it must for certain pass through the back-part of the vein; so that if either an artery, nerve, or tendon, lie contiguous, they must of necessity be wounded: and we are perfectly convinced, that this cause alone has frequently been the origin both of wounded arteries and of pricks in the nerves and tendons. So that as the hazard of the practice, whenever it is attentively considered, must at once appear evident; and as the supposed inconvenience, arising from a contrary mode of operating, is effectually prevented by the use of the spear-pointed lancet, all such risks therefore should be carefully avoided.

With respect to the size of orifice in cases of blood-letting, this circumstance must at all times be determined by the nature of the disorder for which the evacuation is prescribed. When a sudden loss of a considerable quantity of blood is intended, either with a view to produce a state of fainting, or for any other

reason, a free large orifice is absolutely necessary; but in ordinary practice, no necessity occurs for this.

In using a spear-pointed lancet, an orifice of about an eighth part of an inch in length will in general answer every purpose: but when a lancet with broad shoulders is used, an opening of twice that size is little enough; for, with such an instrument, the orifice in the vein can seldom be above half the extent of the external opening.

After withdrawing the lancet from the orifice, we have directed the thumb of the left-hand to be removed from the place it was made to occupy. One material use of the thumb placed below the part where the lancet was directed to enter, is to keep the teguments and vein firm, so as to prevent the latter from rolling. But another advantage occurring from it is, that, by making a sufficient degree of pressure upon the vein, it thereby prevents any considerable quantity of blood from escaping between the time of removing the lancet, and the application of one of the cups for receiving the blood from the orifice in the vein. During this period, it frequently happens that a good deal of blood is discharged, to the great annoyance both of the patient, the operator, and bystanders; a circumstance which, with a little attention, may be always effectually prevented.

V. When the vein is properly cut, and the orifice is made sufficiently large, it rarely occurs that any difficulty is experienced in procuring all the blood that is wanted. But it now and then happens otherwise, either from the orifice of the skin and other parts having receded from the opening in the vein, or from the patient having become faintish; a situation always unfavourable to a free discharge of blood. When this last circumstance occurs, a stream of fresh air ought to be admitted to the apartment, wine or some other cordial should be administered, and the patient ought to be laid into a horizontal posture. By these means the faintishness will in general be soon removed: but if still the blood should not flow freely, the member ought to be put into all the variety of positions that can probably assist in bringing the openings of the skin and other teguments to correspond with that of the vein; which will soon be known to have happened by the blood beginning instantly to flow. Throwing the muscles of the part into constant action, by giving the patient a cane or any other firm substance to turn frequently round in his hand when the operation is done in the arm, will often answer in producing a constant flow of blood from a vein, when every other means has failed: And, lastly, when the pulse in the inferior part of the member is felt very feeble, or especially if it cannot be distinguished at all, we may be thereby rendered certain that the ligature is too tight, and may in general have it in our power to produce an immediate flow of blood, by removing the compression thus improperly made upon the arteries of the part.

VI. A quantity of blood proportioned to the nature of the disorder being thus discharged, the pressure upon the superior part of the vein should be immediately removed; and this being done, if the spear-pointed lancet has been used, all farther loss of blood will in general stop immediately. The contrary of this, however, sometimes occurs, and blood continues to

Practice. to flow freely even after the ligature is removed. When this is the case, the operator ought to compress the vein both above and below the orifice, by means of the finger and thumb of one hand, so as to prevent any farther loss of blood: And this being done, the limb ought to be washed, and entirely cleared of any blood that may have fallen upon it; and the orifice being also cleared of every particle of blood, the sides of it should be laid as exactly together as possible; and a piece of court or any other adhesive plaster being so applied as to retain them, it will seldom happen that any kind of bandage is necessary: but when the blood has issued with uncommon violence during the operation, and has been difficult to command after the removal of the ligature, in such instances it will be prudent to apply a small compress of linen over the plaster, and to secure the whole with a linen roller properly applied round the member.

§ 1. Of Venesection in the Arm.

In applying the ligature for the stoppage of the circulation, it ought to be placed about an inch or an inch and half above the joint of the elbow; and in order to prevent the ends of it from interfering with the lancet, the knot should be made on the outside of the arm. In general, one knot might answer; but a slip-knot being made above the first, renders it more secure, and it is very easily done.

In forming the choice of a vein from whence blood is to be taken, the general rules we have already laid down upon this point must be here particularly attended to. That vein which appears most conspicuous, at the same time that it rolls least under the skin, should in general be fixed upon; but when an artery is found to lie immediately below, and quite contiguous to such a vein, the operator, if he is not perfectly satisfied with his own readiness, ought rather to take some other. In general, however, the artery lies so low in this place, that the median basilic vein, under which it commonly runs, may be opened with perfect safety; and as this vein in general appears more conspicuous than any of the others, probably from the continued pulsation of the artery below obstructing in some measure the passage of its contents, it is in this respect, therefore, more properly calculated for this operation than any of the others. Other circumstances occur, too, which render the median basilic preferable to the cephalic or median cephalic veins for the operation of blood-letting. The former, viz. the median basilic, is less deeply covered with cellular substance; and by lying towards the inner part of the arm, it is more thinly covered with the tendinous expansion of the biceps muscle than either of the others. From these circumstances, the operation is always attended with less pain when done in this vein than in any of the others.

In blood-letting at this part of the arm, although the operation may be done with the right-hand either upon the right or left arm of the patient, yet it is much more neatly done by performing with the right-hand upon the right-arm, and with the left-hand upon the left-arm of the patient.

In very corpulent people, it sometimes happens that all the larger veins lie so deep as not to be discovered by the eye; but when they are sensibly felt by

the fingers, even although they cannot be seen, they may be always opened with freedom. In a few instances, however, they can neither be distinguished by the eye nor by the finger: in such a situation, as they may in general be met with about the wrist, or on the back-part of the hand, the ligature should be removed from the upper part of the arm; and being applied about half-way between the elbow and wrist, the veins below will thereby be brought into view; and wherever a vein can be evidently observed, there can be no danger in having recourse to the operation.

§ 2. Of Blood-letting in the jugular Vein.

THERE is only one ramification of this vein, viz. its principal posterior branch, which can easily be brought so much into view as to be with propriety opened; and even this lies deeply covered with parts, not only with the skin and cellular substance, but with the fibres of the platisma myoides muscle; so that a considerable degree of pressure becomes necessary in order to raise it to any height. With a view to produce this, the operator's thumb is commonly advised to be placed upon the vein, so as to compress it effectually about an inch or inch and half below where the opening is to be made. This, however, seldom proves sufficient for the purpose, as the blood, on being stopped in its progress through this branch, easily finds a passage to the other veins; so that unless the principal vein on the other side of the neck is also compressed, the vein to be opened can never be fully distended. In order to effect this, a firm compress of linen should be applied on the largest vein on the opposite side of the neck; and an ordinary garter, or any other proper ligature, being laid directly over it, should be tied with a firm knot below the opposite arm-pit; taking care to make such a degree of pressure, as to put an entire stop to the circulation in the vein, which in this way may be easily effected without producing any obstruction to the patient's breathing.

This being done, and the patient's head properly supported, the operator, with the thumb of his left-hand, is now to make a sufficient pressure upon the vein to be opened; and with the lancet in his right-hand is to penetrate at once into the vein; and, before withdrawing the instrument, an orifice should be made large enough for the intended evacuation. It may be proper to observe, that a more extensive opening ought always to be made here than is necessary in the arm, otherwise the quantity of blood is generally procured with difficulty: and besides, there is not the same necessity for caution on this point here that there is in the arm; for it seldom or never happens, that any difficulty occurs, in this situation, in putting a stop to the blood after the pressure is removed from the veins, all that is commonly necessary for this purpose being a slip of adhesive plaster without any bandage whatever.

In order to bring the vein more clearly into view, so as afterwards to be able to open it with more exactness, it has been recommended, that the skin, cellular substance, and muscular fibres covering the vein, should be previously divided with a scalpel before attempting to push the lancet into it. There is not, however, any necessity for this precaution, as it rarely happens

Practice. happens that any difficulty is experienced in procuring a free discharge of blood by opening the vein and teguments at once in the manner directed. And it is here, as in every instance where it is necessary to take blood by a lancet, if it is not done at once, the patient is much disappointed, and is sure to attribute the failure entirely to a fault in the operator.

364 § 3. Of Venesection in the Ankles and Feet.

WHEN blood is to be discharged from the veins of these parts, it will be readily understood, that the first step to be taken is a proper compression of the veins, so as to produce an accumulation of their contents. The ligature for this purpose being applied with a sufficient degree of tightness a little above the ankle-joint, all the branches of the vena saphena, both in the inside and outside of the foot, come at once into view; and as this vein lies every where very superficial, being in general covered with skin only, wherever a proper vein appears conspicuously it may with safety be opened.

With a view to encourage the discharge of blood, it has been a constant practice in blood-letting in these veins, to dip the feet into warm-water immediately on the orifice being made. But this is a very inaccurate method of proceeding, as the quantity of blood taken in this manner can never be ascertained with precision; for the blood being all mixed with the water, the operator can never be in any degree certain as to this point: and besides, there does not appear to be any necessity for this assistance; for when the compression of the superior part of the veins is made effectual, and the orifice is of a proper size, there is seldom more difficulty in obtaining a full discharge of blood from the veins of these parts than from any other veins of the body.

On removing the ligature, the discharge is generally stopped at once; so that a piece of adhesive plaster applied over the orifice, answers all the purpose of a bandage.

365 § 4. Of blood-letting in the Veins of the Forehead, Temples, and Occiput.

BEFORE proceeding to cut the veins, an handkerchief or neckcloth ought to be drawn tight round the neck; that, by compressing the jugular vein, those branches of it may become more turgid and conspicuous. The vein being opened, the patient must hold down his head, that the blood may not trickle from his forehead into his eyes or mouth, when the stream does not spin out with sufficient force. If the blood does not stop of itself after a due quantity is discharged, you must compress the orifice with your finger; and, after wiping the forehead and face, apply a compress or two, and then your bandage.

366 § 5. Of Blood-letting in the Veins called Ranulæ, under the Tongue.

To bleed in these veins, a stricture being made upon the neck as before, you then elevate the apex of the tongue with your left-hand, while with the lancet in your right you circumspectly open first one and then the other on each side, because the aperture of one only will hardly ever discharge blood enough to give any considerable relief. When you judge a sufficient

quantity of blood has run out of the mouth into your vessel, remove the ligature from the neck; upon which the flux usually stops of itself: but if it should still continue, let the patient take a little vinegar or Frantiac wine in his mouth; or else you may apply a bit of vitriol or alum, or a compress dipped in some styptic liquor, till the hæmorrhage ceases; which can never be dangerous even without such topicals.

367 § 6. Of Venesection in the Penis.

BLEEDING in the vena dorsalis penis usually surpasses the benefit of all remedies whatever in abating inflammatory disorders of this member. This large vein, which runs along the back or upper side of the penis, being generally pretty much distended, and conspicuous in an inflammation of this part, may be incised about the middle or back part of the penis; and kept bleeding till the member becomes flaccid, and a sufficient quantity of blood be discharged proportionable to the urgency of the symptoms. This done, you must apply a compress, and the bandage proper for the penis. But you must carefully endeavour to avoid injuring the arteries or nerves which enter the penis near this vein; as also not to make your bandage too strict; for by these means the inflammation and symptoms may turn out worse than before.

When it is found necessary to discharge blood in this manner from the penis, the veins can be easily brought into view, by producing an accumulation of their contents in the same manner as in other parts of the body, through the intervention of a ligature: but in the tongue, in the hæmorrhoidal veins about the anus, and other parts where compression cannot be applied, all that the surgeon can do, is to make an orifice of a proper size in that part of the vein which shows itself most evidently; and if a sufficient discharge of blood is not thus produced, as there is no other method of effecting it, immersing the parts in warm water may in such circumstances be a very necessary measure.

368 § 7. Of Venesection in the Eyes.

THERE are several ways of performing this operation, of which we shall here only relate the chief. First, the patient is to be seated conveniently on the bed-side or on a chair, with his head held in a proper posture by an assistant; which done, the surgeon makes a transverse incision with a lancet upon the turgid small veins in the corners of the eye, so as to open them or cut them quite asunder. Some use a small pair of scissors, instead of a lancet, to divide the vessels; but in using either of them, the eye-lids must be held apart from each other by the fingers of one hand, while the vessels are incised by those of the other. Some, again, elevate the small turgid veins with a crooked needle before they divide them, the eye-lids being in the mean time held asunder by an assistant. But it would be still better to have these crooked needles made thin and double-edged, so that they may divide the vessels of themselves in the elevation, without the use of lancet or scissors. The small veins being thus incised or divided, their discharge of blood should be promoted by fomentations of warm water frequently applied to the eye by means of a sponge or soft linen rag.

Among other methods that have been proposed for scarifying

Practice. Fearifying the blood-vessels of the eye, the beards of rough barley were at one period much extolled, and are still employed by some individuals. By drawing them over the surface of the eye, in a direction contrary to the sharp spicule with which they are furnished, a considerable discharge of blood is thereby produced: But the pain attending this operation is exquisite; and as it does not possess any superior advantage to the method with the lancet, it is now falling into general disuse.

§ 8. Of Arteriotomy.

WHATEVER particular advantages may in theory have been expected from arteriotomy, and however some of its supporters may have recommended it, not only as being in many instances preferable to venesection, but as an operation perfectly safe even in vessels of considerable size; yet the most strenuous friends to the practice have shrunk from any real attempt of this kind on the larger arteries. Instances have no doubt occurred of large arteries having been opened without any danger ensuing; but these are so exceedingly rare, that no practitioner of experience will, from that consideration, be induced coolly to proceed to open any artery of importance. The smaller branches of arteries may indeed be opened with great safety when they are not deeply covered, and especially when they lie contiguous to bones; as in such situations, so soon as the quantity of blood intended to be taken is discharged, all further loss of blood may be very easily prevented by compression: but in any of the larger arteries, the attempt must be always attended with so much hazard, and the advantages to be expected from it in preference to venesection are apparently trifling, as must in all probability prevent it from ever being carried into execution.

³⁶⁹ Few arteries can be opened with propriety. There are very few arteries, therefore, which with any propriety can be opened: the different branches of the temporal are the only arteries indeed from whence blood in ordinary practice is ever taken; but if a fanciful practitioner should at any time incline to take blood in this manner from a different part, it may be done with great safety from one of the arteries running on each side of the fingers. About the middle of the last phalanx, this artery is sufficiently large for discharging a considerable quantity of blood: in most cases it lies very superficial; and in this situation there can seldom much difficulty occur in putting a stop to the evacuation. In performing this operation on any of the temporal branches, if the artery lies superficial, it may be done with one push of the lancet, in the same manner as was directed for venesection; but when the artery lies deeply covered with cellular substance, it is always necessary to lay it fairly open to view, before making the orifice with the lancet: for in all the smaller arteries, when they are cut entirely across, there is little chance of being able to procure any considerable quantity of blood from them; as, when divided in this manner, they are sure to retract considerably within the surrounding parts, which commonly puts a stop to all further evacuation.

Some degree of nicety is also necessary in making the opening into the artery of a proper oblique direction, neither quite across nor directly longitudinal; for a longitudinal opening never bleeds so freely, ei-

ther in an artery or in a vein, as when its direction is somewhat oblique.

If the opening has been properly made, and if the artery is of any tolerable size, it will at once discharge very freely without any compression; but when the evacuation does not go on so well as could be wished, the discharge may be always assisted by compressing the artery immediately above the orifice, between it and the corresponding veins. The quantity of blood being thus discharged, it will commonly happen, that a very slight compression on these smaller arteries will suffice for putting a stop to the evacuation: and whatever pressure is found necessary, may be here applied in the same manner as was directed in venesection; first, by clearing the orifice entirely of blood; and having covered it properly with a piece of adhesive plaster, if that should not be found to answer, a compress of linen should be applied over it, the whole being then to be secured with a roller.

It happens, however, in some instances, that this does not succeed, the orifice continuing to burst out from time to time, so as to be productive of much distress and inconvenience.

³⁷⁰ In this situation there are three different methods by which we may with tolerable certainty put a stop to the farther discharge of blood. 1st, If the artery is small, as all the branches of the temporal arteries commonly are, the cutting it entirely across, exactly at the orifice made with the lancet, by allowing it to retract within the surrounding parts, generally puts an immediate stop to the discharge. 2d, When that is not consented to, we have it always in our power to secure the bleeding vessel with a ligature, as we would do an artery accidentally divided in any part of the body. And, lastly, if neither of these methods is agreed to by the patient, we can, by means of a constant regular pressure, obliterate the cavity of the artery at the place where the operation has been performed, by producing the accretion of its sides. Different bandages have been contrived for compressing the temporal artery; but none of them answer the purpose so easily and so effectually as the one figured in the Plate.

As some time, however, is required to obliterate the cavity of the artery, this method is accordingly more tedious; but to timid patients it generally proves more acceptable than either of the other two.

§ 9. Of Topical Blood-letting.

WHEN, either from the severity of a local fixed pain, or from any other cause, it is wished to evacuate blood directly from the small vessels of the part affected, instead of opening any of the larger arteries or veins, the following are the different modes proposed for effecting it, viz. by means of leeches; by slight scarifications with the shoulder or edge of a lancet; and, lastly, by means of an instrument termed a scarificator, in which any number of lancets, from one to twenty or upwards, may be placed, and are fixed in such a manner, that, when the instrument is applied to the part affected, the whole number of lancets contained in it are, by means of a strong spring, pushed suddenly into it, to the depth at which the instrument has been previously regulated. This being done, as the smaller blood-vessels only by this operation are

ever intended to be cut, and as these do not commonly discharge freely, some means or other become necessary for promoting the evacuation.

Various methods have been proposed for this purpose. Glasses fitted to the form of the affected parts, with a small hole in the bottom of each, were long ago contrived; and these being placed upon the scarified parts, a degree of suction was produced by a person's mouth sufficient for nearly exhausting the air contained in the glass: and this accordingly was a sure enough method of increasing the evacuation of blood to a certain extent. But as this was attended with a good deal of trouble, and besides did not on every occasion prove altogether effectual, an exhausting syringe was at last adapted to the glass: which did indeed answer as a very certain method of extracting the air contained in it; but the application of this instrument for any length of time is very troublesome, and it is difficult to preserve the syringe always airtight.

The application of heat to the cupping-glasses, as they are termed, has been found to rarify the air contained in them to a degree sufficient for producing a very considerable suction. And as the instrument in this simple form answers the purpose in view with very little trouble to the operator, and as it is at all times easily obtained, the use of the syringe has therefore been laid aside.

There are different methods adopted for thus applying heat to the cavity of the glass. By supporting the mouth of it for a few seconds above the flame of a taper, the air may be sufficiently rarified; but if the flame is not kept exactly in the middle, but is allowed to touch either the sides or bottom of the glass, it is very apt to make it crack. A more certain, as well as an easier, method of applying the heat, is to dip a piece of soft bibulous paper in spirit of wine; and having set it on fire, to put it into the bottom of the glass, and, on its being nearly extinguished, to apply the mouth of the instrument directly upon the scarified part. This degree of heat, which may be always regulated by the size of the piece of paper, and which it is evident ought to be always in proportion to the size of the glass, if long enough applied, proves always sufficient for rarifying the air very effectually, and at the same time, if done with any manner of caution, never injures the glass in the least.

The glass having been thus applied, if the scarifications have been properly made, they instantly begin to discharge freely: and so soon as the instrument is nearly full of blood, it should be taken away; which may be always easily done by raising one side of it, so as to give access to the external air. When more blood is wished to be taken, the parts should be bathed with warm water; and being made perfectly dry, another glass, exactly of the size of the former, should be instantly applied in the very same manner: and thus, if the scarificator has been made to push to a sufficient depth, so as to have cut all the cutaneous vessels of the part, almost any necessary quantity of blood may be obtained. It sometimes happens, however, that the full quantity intended to be discharged cannot be got at one place. In such a case, the scarificator must be again applied on a part as contiguous to the other as possible; and this being done, the ap-

plication of the glasses must also be renewed as before. Practice.

When it is wished to discharge the quantity of blood as quickly as possible, two or more glasses may be applied at once on contiguous parts previously scarified; and, on some occasions, the quantity of blood is more quickly obtained by the cupping-glasses being applied for a few seconds upon the parts to be afterwards scarified. The suction produced by the glasses may possibly have some influence in bringing the more deep-seated vessels into nearer contact with the skin, so that more of them will be cut by the scarificator.

A sufficient quantity of blood being procured, the wounds made by the different lancets should be all perfectly cleared of blood; and a bit of soft linen or charpie, dipped in a little milk or cream, applied over the whole, is the only dressing that is necessary. When dry linen is applied, it not only creates more uneasiness to the patient, but renders the wounds more apt to fester than when it has been previously wetted in the manner directed.

Although this operation is by no means difficult in the execution, yet a good deal of practice is necessary to perform it in a neat and successful manner; but, with a little attention, any operator may soon become so expert, as to be able to take any quantity of blood that it can ever be necessary to evacuate.

Dry cupping consists in the application of the cupping-glasses directly to the parts affected, without the use of the scarificator. By this means a tumour is produced upon the part; and where any advantage is to be expected from a determination of blood to a particular spot, it may probably be more easily accomplished by this means than by any other.

When the part from which it is intended to produce a local evacuation of this kind is so situated, that a scarificator and cupping-glasses can be applied, this method is greatly preferable to every other; but it now and then happens, that parts are so situated as not to admit of their application. Thus, in inflammatory affections of the eye, of the nose, and of other parts of the face, the scarificator cannot be properly applied directly to the parts affected. In such instances, leeches are commonly had recourse to, as they can be placed upon almost any spot from whence we would wish to discharge blood.

In the application of these animals, the most effectual method of making them fix upon a particular spot, is to confine them to the part by means of a small wine-glass. Allowing them to creep upon a dry cloth, or upon a dry board, for a few minutes before application, makes them fix more readily; and moistening the parts on which they are intended to fix, either with milk, cream, or blood, tends also to cause them adhere much more speedily than they otherwise would do. So soon as the leeches have separated, the ordinary method of promoting the discharge of blood, is to cover the parts with linen cloths wet in warm water. In some situations, this may probably be as effectual a method as any other; but wherever the cupping-glasses can be applied over the wounds, they answer the purpose much more effectually: wherever the figure of the part, therefore, will admit of their application, they ought undoubtedly to be employed.

THERE are two ways of opening an abscess; either by incision or caustic; but incision is preferable in most cases. In small abscesses, there is seldom a necessity for greater dilatation than a little orifice made with the point of a lancet; and in large ones, where there is not a great quantity of skin discoloured and become thin, an incision to their utmost extent will usually answer the purpose; or if there be much thin discoloured skin, a circular or oval piece of it must be cut away: which operation, if done dexterously with a knife, is much less painful than by caustic, and at once lays open a great space of the abscess, which may be dressed down to the bottom, and the matter of it be freely discharged: whereas, after a caustic, though we make incisions through the eschar, yet the matter will be under some confinement; and we cannot have the advantage of dressing properly till the separation of the slough, which often requires a considerable time, so that the cure must be necessarily delayed: besides that the pain of burning continuing two or three hours, which a caustic usually requires in doing its office, draws such a suction upon the skin round the eschar, as sometimes to indispose it very much for healing afterwards. In the use of caustics, it is but too much a practice to lay a small one on the most prominent part of a large tumour, which not giving sufficient vent to the matter, and perhaps the orifice soon after growing narrow, leads on to the necessity of employing tents; which two circumstances more frequently make fistulas after an abscess, than any malignity in the nature of the abscess itself. The event would more certainly be the same after a small incision: but surgeons, not depending so much on small openings by incision as by caustic, do, when they use the knife, generally dilate sufficiently; whereas, in the other way, a little opening in the most depending part of the tumour usually satisfies them.

From this account of the method of opening abscesses, it does not appear often necessary to apply caustics; yet they have their advantages in some respects, and are seldom so terrible to patients as the knife, though in fact they are frequently more painful to bear. They are of most use in cases where the skin is thin and inflamed, and we have reason to think the malignity of the abscess is of that nature as to prevent a quickness of incision; in which circumstance, if an incision only were made through the skin, little sinuses would often form underneath, and the lips of it, lying loose and flabby, would become callous, and retard the cure, though the malignity of the wound were corrected. Of this kind are venereal buboes; which notwithstanding they often do well by mere incision, yet, when the skin is in the state we have supposed, the caustic is always preferable: but this method should be confined to venereal buboes; for those which follow a fever or the small-pox, for the most part are curable by incision only. There are many scrofulous tumours, where the reasoning is the same as in the venereal; and even in great swellings, if the patient will not submit to cutting, and the surgeon is apprehensive of any danger in wounding a large vessel, which is often done with the knife, but

is avoided by caustic, it may on such an occasion be made use of; however, in scrofulous swellings of the neck and face, unless they are very large, caustics are not advisable, since in that part of the body, with length of time, they heal after incision.

When an abscess is ready burst, we are to be guided by the probe where to dilate, observing the same rules with regard to the degree of dilatation as in the other case. The usual method of dilating, is with the probe-scissors; and indeed, in all abscesses, the generality of surgeons use the scissors, after having first made a puncture with a lancet: but as the knife operates much more quickly, and with less violence to the parts, than scissors, which squeeze at the same time that they wound, it will be sparing the patient a great deal of pain to use the knife, wherever it is practicable; which it is in almost all cases, except some fistulas in ano, where the scissors are more convenient. The manner of opening with a knife, is by sliding it on a director, the groove of which prevents its being misguided. If the orifice of the abscess be so small as not to admit the director or the blade of the scissors, it must be enlarged by a piece of sponge-tent; which is made by dipping a dry bit of sponge in melted wax, and immediately squeezing as much out of it again as possible, between two pieces of tile or marble; the effect of which is, that the loose sponge being compressed into a small compas, if any of it be introduced into an abscess, the heat of the part melts down the remaining wax that holds it together, and the sponge sucking up the moisture of the abscess, expands, and in expanding opens the orifice wider, and by degrees, so as to give very little pain.

The usual method of dressing an abscess, the first time, is with dry lint only; or, if there be no flux of blood, with soft digestives spread on lint. If there be no danger of the upper part of the wound reuniting too soon, the dressings must be laid in loose. But if the abscess be deep, and the wound narrow, as is the case sometimes of abscesses in ano, the lint must be crammed in pretty tightly, that we may have afterwards the advantage of dressing down to the bottom without the use of tents, which, by resisting the growth of the little granulations of flesh, in process of time harden them, and in that manner produce a fistula: so that, instead of being used for the cure of an abscess, they never should be employed but where we mean to retard the healing of the external wound, except in some little narrow abscesses, where, if they be not crammed in too large, they become as dressings, admitting of incision at the bottom; but care should be taken not to insinuate them much deeper than the skin in this case, and that they be repeated twice a-day to give vent to the matter they confine. But tents do most good in little deep abscesses, whence any extraneous body is to be evacuated, such as small splinters of bones, &c.

The use of vulnerary injections into abscesses has been thought to bear so near resemblance to the use of tents, that they both fell into disrepute almost at the same time.

Over the dressings of lint may be laid a large pledget of tow spread with basilicon, which will lie softer than a defensive plaster; for this, though designed to defend the circumference of wounds against inflammation.

tion or a fluxion of humours, is often the very cause of them: so that the dressings of large wounds should never be kept on by these plasters, where there is danger of such accidents. In this manner, the dressings may be continued till the cavity is incarnated; and then it may be cicatrified with dry lint or some of the cicatrifying ointments, observing to keep the fungus down, as directed before.

In the course of dressing, it will be proper to have regard to the situation of the abscess, and as much as possible to make the patient favour the discharge by his ordinary posture: and to this end also, the discharge must be assisted by compress and bandage: the compress may be made of rags or plaster; though the latter is sometimes preferable, as it remains immovable on the part it is applied to. The frequency of dressing will depend on the quantity of discharge: once in 24 hours is ordinarily sufficient; but sometimes twice, or perhaps three times, is necessary.

319 § 2. Of making the Incision in cases of punctured Nerves and Tendons.

As, in such cases, all the contiguous parts are supposed to be much swelled and in a state of high inflammation, it is impossible to get proper access either to the nerve or tendon, but by means of a large and extensive incision; and as this cannot be effected without some risk of opening at least some large branches of arteries, the first step to be taken in this operation is, to secure the parts against the effects of such an occurrence, by the application of the tourniquet on the superior part of the member. This precaution is necessary, not only for guarding against the loss of blood which would ensue from a division of any of the large arteries, but for preventing interruption during the operation, which would otherwise occur from a constant discharge of blood from the smaller vessels. The tourniquet indeed is more particularly requisite with a view to the prevention of this last inconvenience, than for any other reason; for although it is proper by means of it to guard against the effects to be expected from a division of any of the large arteries, yet, with proper caution, such an occurrence may in most cases be very easily avoided.

The tourniquet then being properly applied, a transverse incision should be made with a common scalpel upon the parts chiefly affected; and it ought to run in a direction exactly across the original orifice in the vein.

In no operation whatever is it more necessary than in this, to act with freedom in laying the parts sufficiently open by the external incision. A small incision puts the patient to nearly the same degree of pain as a larger cut; and it has this material inconvenience, that the surgeon cannot go on with the future steps of the operation with so much ease and expedition as when an extensive opening is made at first.

The external teguments being thus freely divided, the operator is now to proceed in a gradual manner, making one slight incision after another, taking care, if possible, to avoid wounding either the larger arteries or veins: and he is to go on in this way to endeavour to detect the wounded nerve; or if there is no possibility of doing so, even by great caution and nicety

Practice. in wiping away with a sponge every particle of blood as he goes along, he must still continue to proceed in this slow gradual manner, till he has divided every part between the skin and periosteum; the tendons, larger arteries and veins, excepted.

At this time the tourniquet should be loosened; and in all probability the patient will be found to express much satisfaction at what has been done: for if the part is thus divided which originally had been pricked by the lancet, and from whence all the subsequent distress proceeded, an immediate relief will now be obtained; but, on the contrary, if the pain still continues violent, we are thereby rendered almost certain of the mischief lying altogether in one or other of the tendons. An accurate examination, therefore, must now be made, by clearing the parts effectually with a sponge; and that tendon lying most contiguous to the vein in which the orifice was made, will in all probability be found either wounded, or in an evident state of inflammation: but at all events, whether any such appearance are detected or not, no hesitation whatever should occur as to the propriety of dividing that tendon which lies most contiguous to the vein; or if two or even three tendinous extremities should happen to lie in the way, and to be all therefore equally liable to suspicion, they ought all undoubtedly to be cut entirely across. This being properly effected, it will seldom occur that much relief is not immediately derived from it: and at any rate, this being done, every attempt will have been made from which we could expect any benefit to arise.

The parts having been thus freely divided, the tourniquet must now be made as slack as possible; and whatever arteries have been wounded, must be properly secured. The parts are then to be covered with soft easy dressings, and to be afterwards treated in the same manner as a wound from any other cause.

380 § 3. Of Issues and Setons.

Both these are sometimes made by the knife; tho' the former are more frequently, and indeed more conveniently, put in by caustic. When incision is used, nothing more is necessary than with a lancet to make a small wound through the skin and cellular membranes. Into this is thrust a pea rubbed over with basilicon or some other ointment, which must be kept from slipping out of the wound by means of a proper bandage. By this extraneous body the wound is kept from healing, at the same time that, as the pea swells by the absorption of the juices of the body, the orifice is gradually enlarged, and the quantity of matter discharged from it is soon increased. This method, however, has an inconvenience, namely, that by thrusting the pea into a newly incised wound, the inflammation consequent upon even this small division of the solids is so great as to give a very considerable degree of pain.—The method of making issues by caustic is therefore preferred. The best caustic for this purpose is the causticum commune or lapis infernalis of the dispensatories, prepared from soap lees. A small bit of this is to be put upon the skin, the surrounding parts of which are to be defended from its action by a bit of adhesive plaster spread on leather. In a few hours a deep eschar is formed, part of which being im-

Practice. immediately cut out, and the opening filled with pease, the rest soon separates, and is kept running with very little difficulty.

Setons are made in any part of the body by taking up the skin and subjacent cellular membrane between the fingers, then piercing through the fold with a lancet, and drawing through a soft cotton cord dipped in ointment. By this extraneous body the wound is kept in a constant state of suppuration, and the cord is every day drawn a little farther through, in order to discharge the matter, and prevent putrefaction.

SECT. III. Of Tooth-drawing.

TOOTH-drawing, according to Cicero, (De Natura Deorum, lib. 3. cap. 22.) was first invented by Æsculapius; in whose temple the ancients hung up a pair of leaden pincers, to signify that it would be dangerous and improper to extract any teeth but such as might be removed with leaden forceps, that is, such as are loose, and almost ready to fall out: for they do not consult their own welfare who imprudently remove their teeth, without absolute necessity, whilst they are sound and entire. For evulsion of the teeth is not only a dangerous and painful operation, but has even sometimes hazarded the patient's life: at least they impede the speech, and impair the act of mastication by this means; more especially in adults, in which we can have no hopes of others growing up in their room. However, it is sometimes absolutely necessary to draw teeth, 1. In infants, for removing those deciduous or lacteal teeth, which, being loosened by the fingers, may be extracted with a thread, or a pair of crow's-bill forceps; for when these teeth are left too long in the sockets, they may displace and turn the new ones awry. 2. It will be proper to extract those teeth in infants which grow out of the palate, or some other improper part of the mouth, which both hinder their speech and sucking. 3. Extraction is often the only method of relieving the toothach, which is very intense, proceeding from a caries in the teeth, and incapable of being eased by any medicines. 4. Those teeth ought to be drawn which, by their irregular figure and position, wound and lacerate the tongue, lips, and cheeks. 5. It is often absolutely necessary to draw a tooth for curing a fistula or ulceration of the gums next the teeth. The method of drawing them is as follows: If the tooth to be drawn is in the lower jaw, the patient must be seated on a low seat or on the floor; but when in the upper jaw, he must be seated on a high stool: after which, the surgeon takes his instrument best adapted to the case, and therewith draws out the tooth, as if extracting a nail out of a piece of wood, drawing the upper teeth downward, and the lower teeth upward; yet there is a particular sleight to be used, to avoid breaking the teeth. We shall conclude this section with observing, that though it is often absolutely necessary to remove or extract the teeth, yet you ought not to perform the operation while the patient's gums and parts adjacent remain inflamed and tumid.

SECT. IV. Of Ulcers.

WHEN a wound or abscess degenerates into so bad a state as to resist the method of cure described in treating of wounds, n^o 64, &c. and loses that complexion which
VOL. X.

belongs to a healing wound, it is called an ulcer; and as the name is generally borrowed from the ill habit of the sore, it is a custom to apply it to all sores that have any degree of malignity, though they be immediately formed without any previous abscess or wound; such are the venereal ulcers of the tonsils, &c.

Ulcers are distinguished by their particular disorders, though it seldom happens that the affections are not complicated; and when we lay down rules for the management of one species of ulcer, it is generally requisite to apply them to almost all others. However, the characters of most eminence are, the callous ulcer, the sinuous ulcer, and the ulcer with caries of the adjacent bone: though there be abundance more known to surgeons, such as the putrid, the corrosive, the varicose, &c.; but as they have acquired their names from some particular affection, we shall speak of the treatment of them under the general head of ulcers.

It will be often in vain to pursue the best means of cure by topical application, unless we are assisted by internal remedies: for as many ulcers are the effects of a particular indisposition of body, it will be difficult to bring them into order, while the cause of them remains with any violence; though they are sometimes in a great degree the discharge of the indisposition itself, as in the plague, small-pox, &c. But we see it generally necessary in the pox, the scurvy, obstructions of the menses, dropies, and many other distempers, to give internals of great efficacy; and indeed, there are hardly any constitutions where ulcers are not assisted by some physical regimen. Those that are cancerous and scrophulous seem to gain the least advantage from physic: for if in their beginnings they have sometimes been very much relieved, or cured, by salivation, or any other evacuation, they are also often irritated and made worse by them; so that there is nothing very certain in the effects of violent medicines in these distempers.

1. When an ulcer becomes foul, and discharges a nasty thin ichor, the edges of it, in process of time, tuck in, and, growing skinned and hard, give it the name of a callous ulcer; which, as long as the edges continue in that state, must necessarily be prevented from healing. But we are not immediately to destroy the lips of it, in expectation of a sudden cure; for while the malignity of the ulcer remains which was the occasion of the callosity, the new lips will be subject to a relapse of the same kind, however often the external surface of them be destroyed: so that, in this case, we are to endeavour to bring the body of the ulcer into a disposition to recover by other methods. It sometimes happens to poor laborious people, who have not been able to afford themselves rest, that lying a-bed will in a short time give a diversion to the humours of the part, and the callous edges, softening, will without any great assistance shoot out a cicatrix, when the ulcer is grown clean and filled with good flesh. The effect of a salivation is generally the same; and even an issue does not sometimes dispose a neighbouring ulcer to heal. But though callosities be frequently softened by these means, yet when the surface of the ulcer begins to yield thick matter, and little granulations of red flesh shoot up, it will be proper to quicken nature by destroying the edges of it, if they remain hard. The manner of doing this, is by touch-

ing them a few days with the lunar caustic, or lapis infernalis; and some choose to cut them off with a knife: but this last method is very painful, and not more efficacious; though, when the lips do not tuck down close to the ulcer, but hang loose over it, as in some venereal buboes, where the matter lies a great way under the edges of the skin, the easiest method is cutting them off with the scissors.

To digest the ulcer, or to procure good matter from it when in a putrid state, there are an infinity of ointments invented; but the basilicon flavum alone, or softened down sometimes with turpentine, and sometimes mixed up with different proportions of red precipitate, seems to serve the purpose of bringing an ulcer on to cicatrization as well as any of the others. When the ulcer is incarned, the cure may be finished as in other wounds; or if it do not cicatrize kindly, it may be washed with aq. calcis, or aq. phag. or dressed with a pledgit dippit it tinct. myrrhe: and if excoriations are spread round the ulcer, they may be anointed with sperm. cet. ointment, or any other soft ointment.

The red precipitate has of late years acquired the credit it deserves for the cure of ulcers; but, by falling into general use, is very often unskillfully applied: when mixed with the basilicon, or, what is nearer, a cerate of wax and oil, it is most certainly a digestive, since it hardly ever fails to make the ulcer yield a thick matter in 24 hours, which discharged a thin one before the application of it.

If the ulcer should be of such a nature as to produce a spongy flesh, sprouting very high above the surface, it will be necessary to destroy it by some of the escharotics, or the knife. This fungus differs very much from that belonging to healing wounds, being more eminent and lax, and generally in one mass; whereas the other is in little distinct protuberances. It approaches often towards a cancerous complexion, and when it rises upon some glands does actually degenerate sometimes into a cancer. When these excrescences have arisen in venereal ulcers, escharotics should be applied. Those in use, are the vitriol, the lunar caustic, the lapis infernalis, and more generally the red precipitate powder.

It is but seldom that these inveterate funguses appear on an ulcer; but it is very usual for those of a milder kind to rise, which may often be made to subside by pressure and the use of mild escharotics: however, if the aspect of the sore be white and smooth, as happens in ulcers accompanied with a dropsy, and often in young women with obstructions, it will answer no purpose to waste the excrescences until the constitution is repaired, when most probably they will sink without any assistance. In ulcers also, where the subjacent bone is carious, great quantities of loose spongy flesh will grow up above the level of the skin: but as the caries is the cause of the disorder, it will be in vain to expect a cure of the excrescence until the rotten part of the bone be removed; and every attempt with escharotics will be only a repetition of pain to the patient, without any advantage.

When the pain and inflammation are excessive, bleeding and other evacuations will often be serviceable; and above all things, rest and a horizontal position; which last circumstance is of so great impor-

tance to the cure of ulcers of the legs, that unless the patient will conform to it strictly, the skill of the surgeon will often avail nothing: for as the indisposition of these sores is in some measure owing to the gravitation of the humours downwards, it will be much more beneficial to lie along than sit upright, though the leg be laid on a chair; since even in this posture they will descend with more force than if the body was reclined.

1. In ulcers of the legs, accompanied with varices or dilatations of the veins, the method of treatment will depend upon the other circumstances of the sore; for the varix can only be assisted by the application of bandage, which must be continued a considerable time after the cure. The neatest bandage is the laced stocking, which is particularly serviceable in this case; though also, if the legs be œdematous, or if, after the healing of the ulcers, they swell when the patient quits his bed, it may be worn with safety and advantage. There are instances of one vein only being varicous; which, when it happens, may be destroyed by tying it above and below the dilatation, as in an aneurysm; but this operation should only be practised where the varix is large and painful.

2. Ulcers of many years standing are very difficult of cure; and in old people the cure is often dangerous, frequently exciting an asthma, a diarrhoea, or a fever, which destroys the patient, unless the sore break out again: so that it is not altogether advisable to attempt the absolute cure in such cases; but only the reduction of them into better order, and less compass, which, if they be not malignant, is generally done with rest and proper care. The cure of those in young people may be undertaken with more safety; and in all cases of stubborn ulcers, the bark, very copiously given, will be found of the utmost service.

3. When an ulcer or abscess has any sinuses or channels opening and discharging themselves into the sore, they are called sinuous ulcers. These sinuses, if they continue to drain a great while, grow hard in the surface of their cavity; and then are termed fistule, and the ulcer a fistulous ulcer; also, if matter be discharged from any cavity, as those of the joints, abdomen, &c. the opening is called a sinuous ulcer or a fistula.

The treatment of these ulcers depends upon a variety of circumstances. If the matter of the sinus be thick, strict bandage and compress will sometimes bring the opposite sides of the sinus to a reunion: if the sinus grow turgid in any part, and the skin thinner, showing a disposition to break, the matter must be made to push more against that part, by plugging it up with a tent; and then a counter opening must be made, which proves often sufficient for the whole abscess, if it be not afterwards too much tented, which locks up the matter and prevents the healing; or too little, which will have the same effect: for dressing quite superficially, does sometimes prove as mischievous as tents, and for nearly the same reason; since suffering the external wound to contract into a narrow orifice before the internal one be incarned, does almost as effectually lock up the matter as a tent. To preserve, then, a medium in these cases, a hollow tent of lead or silver may be kept in the orifice, which, at the same time that it keeps it open, gives vent to the matter. The abscess where the counter opening is made

Practice. made most frequently, are those of compound fractures, and the breast: but the latter do oftener well without dilatation than the former; though it must be performed in both, if practicable, the whole length of the abscess, when after some trial the matter does not lessen in quantity, and the sides of it grow thinner; and if the sinuses be fistulous, there is no expectation of cure without dilatation. There are also a great many scrofulous abscesses of the neck, that sometimes communicate by sinuses running under large indurations; in which instances, counter openings are advisable, and generally answer without the necessity of dilating the whole length; and indeed there are few abscesses in this distemper which should be opened beyond the thinness of the skin. When abscesses of the joints discharge themselves, there is no other method of treating the fistula, but by keeping it open, with the cautions already laid down, till the cartilages of the extremities of the bones being corroded, the two bones shoot into one another, and form an anchylosis of the joint, which is the most usual cure of ulcers in that part.

301 Of scrofulous abscesses in the neck.

302 Of gunshot wounds de-then are to be considered in the same light as those already described: though surgeons have been always inclined to conceive there is something more mysterious in these wounds than any others: but their terrible-ness is owing to the violent contusion and laceration of of the parts, and often to the admission of extraneous bodies into them, as the bullet, splinters, bits of cloth, &c. and were any other force to do the same thing, the effect would be exactly the same as when done by fire-arms. The treatment of these wounds consists in removing the extraneous body as soon as possible; to which end the patient must be put into the same posture as when he received the wound: if it cannot be extracted by cutting upon it, which should always be practised when the situation of the blood-vessels, &c. does not forbid, it must be left to nature to work out, and the wound dressed superficially: for we must not expect that if it be kept open with tents, the bullet, &c. will return that way; and there is hardly any case where tents are more pernicious than here, because of the violent tension and disposition to gangrene which presently ensue. For dissolving of bullets, it has been recommended to inject mercury into the places where they are lodged; but this has never been known to answer any good purpose.

303 Of carious ulcers.

3. When an ulcer with loose rotten flesh discharges more than the size of it should yield, and the discharge is oily and thick, in all probability the bone is carious; which may easily be distinguished by running the probe through the flesh: and if so, it is called a carious ulcer. The cure of these ulcers depends principally upon the removal of the rotten part of the bone, without which it will be impossible to heal; as we see sometimes even in little sores of the lower jaw, which taking their rise from a rotten tooth, will not admit of cure till the tooth be drawn. Those caries which happen from the matter of abscesses lying too long upon the bone, are most likely to recover: those of the pox very often do well, because that distemper fixes ordinarily upon the middle and outside of the densest bones, which admit of exfoliation; but those produced by the evil, where the whole extremities of

spongy parts of the bone are affected, are exceedingly dangerous: though all enlarged bones be not necessarily carious; and there are ulcers sometimes on the skin that covers them, which do not communicate with the bone, and consequently do well without exfoliation: nay, it sometimes happens, though the case be rare, that, in young subjects particularly, the bones will be carious to such a degree, as to admit a probe almost through the whole substance of them; and yet afterwards admit of a cure, without any notable exfoliation.

The method of treating an ulcer with caries, is by applying a caustic of the size of the scale of the bone that is to be exfoliated; and after having laid it bare, to wait till such time as the carious part can without violence be separated, and then heal the wound. In order to quicken the exfoliation, there have been several applications devised; but that which has been most used in all ages, is the actual cautery, with which surgeons burn the naked bone every day, or every other day, to dry up, as the say, the moisture, and by that means procure the separation: but as this practice is never of great service, and always cruel and painful, it is now pretty much exploded. Indeed, from considering the appearance of a wound, when a scale of bone is taken out of it, there is hardly any question to be made, but that burning retards rather than hastens the separation; for as every scale of a carious bone is flung off by new flesh generated between it and the sound bone, whatever would prevent the growth of these granulations would also in a degree prevent the exfoliation; which must certainly be the effect of a red-hot iron applied so close to it: though the circumstances of carious bones, and their disposition to separate, are so different from one another, that it is hardly to be gathered from experience, whether they will sooner exfoliate with or without the assistance of fire; for sometimes, in both methods, an exfoliation is not procured in a twelve-month, and at other times it happens in three weeks or a month: however, if it be only uncertain whether the actual cautery be beneficial or not, the cruelty that attends the use of it should entirely banish it out of practice. It is often likewise, in these cases, employed to keep down the fungous lips that spread upon the bone: but it is much more painful than the escharotic medicines; though there will be no need of either, if a regular compress be kept on the dressings; or at work, if a flat piece of the prepared sponge, of the size of the ulcer, be rolled on with a tight bandage, it will swell on on every side, and dilate the ulcer without any pain.

Some caries of the bones are so very shallow, that they crumble insensibly away, and the wound fills up; but when the bone will neither exfoliate nor admit of granulations, it will be proper to scrape it with a rugine, or perforate it in many points with a convenient instrument down to the quick. In scrofulous cases, the bones of the carpus and tarsus are often affected; but their sponginess is the reason that they are seldom cured: so that when these, or indeed the extremities of any of the bones, are carious through their substance, it is advisable to amputate; though there are instances in the evil, but more especially in critical abscesses, where, after long dressing down, the splinters,

splinters, and sometimes the whole substance, of the small bones, have worked away, and, a healthy habit of body coming on, the ulcer has healed; but these are so rare, that no great dependence is to be laid on such an event. The dressings of carious bones, if they are stinking, may be dossils dipped in the tincture of myrrh; otherwise those of dry lint are easiest, and keep down the edges of the ulcer better than any other gentle applications.

Burns are generally esteemed a distinct kind of ulcers, and have been treated with a greater variety of applications than any other species of sore. When burns are very superficial, not raising suddenly any vesication, spirits of wine are said to be the quickest relief; but whether they be more serviceable than embrocations with linseed oil, is uncertain, though they are used very much by some persons whose trade subjects them often to this misfortune. If the burn exoriatates, it is easiest to roll the part up gently with bandages dipped in sweet oil, or a mixture of unguent. flor. sambu. with the oil. When the exoriatations are very tender, dropping warm milk upon them every dressing is very comfortable; or if the patient can bear to have flannels wrung out of it, applied hot, it may be still better. If the burn have formed eschars, they may be dressed with basilicon, though generally oil alone is easier; and, in these sores, whatever is the easiest medicine will be the best digestive. There is great care necessary to keep down the fungus of burns, and heal the wounds smooth: to which end, the edges should be dressed with lint dipped in aqua vitriol. and dried afterwards; or they may be touched with the vitriol stone, and the dressings be repeated twice a-day. There is also a greater danger of contractions from burns after the cure than from other wounds: to obviate which, embrocations of neats-foot oil, and bandage with pasteboards to keep the part extended, are absolutely necessary where they can be applied.

THE method of making the bloody-suture is as follows. The wound being emptied of the grumous blood, and your assistant having brought the lips of it together that they may lie quite even, you carefully carry your needle from without, inwards to the bottom, and so on from within, outwards; using the caution of making the puncture far enough from the edge of the wound, which will not only facilitate the passing the ligature, but will also prevent it from eating through the skin and flesh; this distance may be three or four tenths of an inch: as many more stitches as you shall make, will be only repetitions of the same process. The threads being all passed, you begin tying those in the middle of the wound; though, if the lips are held carefully together all the while, as they should be, it will be of no great consequence which is done first. The most useful kind of knot in large wounds is a single one first; over this a little linen compress, on which is to be made another single knot; and then a slip-knot, which may be loosened upon any inflammation: but in small wounds, there is no danger from the double knot alone, without any compress to tie it

upon; and this is most generally practised. If a violent inflammation should succeed, loosening the ligature only will not suffice; it must be cut through and drawn away, and the wound be treated afterwards without any future. When the wound is small, the less it is disturbed by dressing the better; but in large ones, there will sometimes be a considerable discharge; and if the threads be not cautiously carried through the bottom of it, abscesses will frequently ensue from the matter being pent up underneath, and not finding issue. If no accident happen, you must, after the lips are firmly agglutinated, take away the ligatures, and dress the orifices which they leave.

It must be remembered, that during the cure the future must be always assisted by the application of bandage, if possible, which is frequently of the greatest importance; and that sort of bandage with two heads, and a slit in the middle, which is by much the best, will in most cases be found practicable.

WOUNDS of the tendons are not only known to heal again, but even to admit of sewing up like those of the fleshy parts, though they do not reunite in so short a time.

As the wound of the skin will be nearly transverse, it should not be raised to expose more of the tendon, but rather sewed up with it, which will conduce to the strength of the future. The knot of the ligature is to be made as in other wounds, and the dressings are to be the same: there is a sort of thin crooked needle that cuts on its concave and convex sides, which is very handy in the future of large tendons, and to be preferred to the straight one. During the cure, the dressings must be superficial, and the parts kept steady with pasteboard and bandage: the small tendons reunite in three weeks, but the tendon Achillis requires six at least.

IN deep wounds, attended with much retraction, it is always a necessary precaution, to assist the operation of the ligatures by means of bandages, so applied as to afford as much support as possible to the divided parts: But, even with every assistance of this nature, it now and then happens, that the divided parts cannot be kept together, retraction occurs to a greater or lesser degree, and the ligatures of course cut asunder the soft parts they were at first made to surround.

With a view to prevent this receding of the teguments and other parts, it was long ago proposed to add to the interrupted suture what was supposed would afford an additional support, viz. quills, or pieces of plaster rolled up into the form of quills; one of which being placed on each side of the wound, the double of the ligature is made to include the one, and the knot to press directly upon the other, instead of being made immediately on the edges of the sore, as was directed for interrupted sutures.

It is at once evident, however, that the ligatures must here make the same degree of pressure on the parts through which they pass as they do in the interrupted suture; and this being the case, it is equally obvious, that

Practice. that the interposition of these substances cannot be of any use. This suture is accordingly now very rarely practiced, and it is probable that it will be soon laid entirely aside.

This suture is termed the Glover's, from being the one in common use among that set of people. As it is exceedingly simple, and very universally known, it does not here merit much description: we shall, therefore, just shortly observe, that it consists in a series of stitches all connected with one another, and continued in an oblique spiral direction along the course of the divided parts intended by it to be kept together.

This suture has hitherto been universally employed for reuniting such parts of the intestines as have been divided by wounds: but, according to Mr Bell, the same end may be more perfectly attained, and probably with less danger, by means of the interrupted suture; so that as this suture has almost never been applied to any other purpose, it will likewise, in all probability, soon fall into disuse.

By the term twisted suture, is meant that species of ligature by which parts, either naturally or artificially separated, are united together, by means of strong threads properly twisted round pins or needles pushed through the edges of the divided parts.

This suture is commonly employed for the purpose of uniting the parts in cases of bare-lip; and this indeed is almost the only use to which it has been hitherto applied: But we may here remark, that it may with great advantage be put in practice in a variety of other cases, particularly in all artificial or accidental divisions either of the lips or cheeks; and in every wound in other parts that does not run deep, and in which sutures are necessary, this suture is preferable to the interrupted or any other.

In very deep wounds, for instance in all wounds extending to a greater depth than an inch and half, the interrupted suture is the only one that is admissible; for in all such deep cuts, the pins necessary in the twisted suture cannot with propriety be employed, as they cannot be introduced to such a depth, and afterwards so twisted with ligatures as to reunite the divided parts, but with great pain to the patient. In such wounds, therefore, we must of necessity have recourse to the interrupted suture. But it may be here remarked, that wounds of this depth, requiring the aid of sutures, are very rarely met with: so that, in by much the greatest proportion of wounds where sutures are advisable, the twisted suture will be found practicable; and whenever it is so, it ought certainly to be preferred to every other, as being obviously better calculated, even than the interrupted suture, for the retention of divided parts. The pins made use of for twisting the threads upon ought to be made of a flat form, so as not to cut the parts through which they pass so readily as the ligatures employed in the interrupted suture. And thus one great objection to the latter is very effectually obviated: for every practitioner must be sensible of this being the most faulty part of the interrupted suture, that when muscular parts are divided so as to produce much retraction,

the ligatures employed for retaining them almost constantly cut them through before a reunion is accomplished; whereas the flatness of the pins used in the twisted suture, and upon which, it may be remarked, the whole pressure produced by the ligatures is made to rest, proves in general a very effectual preventative against all such occurrences.

The pins used in this operation have commonly been made of silver; and in order to make them pass with greater ease, steel points have been added to them. As gold pins, however, are capable of receiving a sufficient degree of sharpness, which renders the intervention of steel points quite unnecessary; and as gold is fully more cleanly than silver, from its not acquiring so readily that kind of crust which immersion in fluids is apt to produce upon the other; pins of this metal are therefore preferable.

The manner of performing this operation is as follows. The divided parts intended to be reunited, must, by the hands of an assistant, be brought nearly into contact; leaving just as much space between the edges of the sore as to allow the surgeon to see that the pins are carried to a proper depth. This being done, one of the pins must be introduced through both sides of the wound, by entering it on one side externally, pushing it forwards and inwards to within a little of the bottom of the wound, and afterwards carrying it outwardly through the opposite side, to the same distance from the edge of the sore that it was made to enter at on the other.

The distance at which the needle ought to enter from the edge of the sore, must be determined by the depth of the wound, and by the degree of retraction produced in the divided parts. In general, however, it is a proper regulation, in deep wounds, to carry the pins nearly to the same distance from the side of the sore as they are made to penetrate in depth: And it may be also remarked, that whatever the deepness of the wound may be, the pins ought to pass within a very little of its bottom; otherwise the parts which lie deep will run a risk of not being united, a circumstance which must always give rise to troublesome collections of matter.

In passing the pins through the different sides of the wound, if the skin and other teguments are not more firm than ordinary, it may commonly be done by the fingers alone, and particularly if the pins are made with small heads or knobs for the fingers to press upon; but when, from firmness of parts and other circumstances, much difficulty is expected to the entrance of the pins, the instrument termed Porteaguille very effectually removes this inconvenience.

The first pin being passed in this manner very near to one end of the sore, and the parts being still supported by an assistant, the surgeon, by means of a firm waxed ligature, passed three or four times round and across the pin, so as nearly to describe the figure of 8, is to draw the parts through which it has passed into immediate and close contact: and the thread being now secured with a loose knot, another pin must be introduced in the same manner at a proper distance from the former; and the thread with which the other was fixed being loosed, and in the same manner carried round this pin, others must be introduced at proper distances along the whole course of the wound and

Practice. and the same ligature ought to be of a sufficient length for securing the whole.

The number of pins to be used must be determined entirely by the extent of the wound. Whenever this future, however, is practised, whether the wound be large or of very small extent, a pin ought to be introduced very near to each end of it, otherwise the extremities of the sore are apt to separate so as not to be afterwards easily reunited. In large wounds, if the pins are introduced at the distance of three quarters of an inch from one another, it will in general be found sufficient; but in cuts of smaller extent, a greater number of pins become necessary in proportion to the dimensions of the sores.

Thus in a wound of an inch and half in length, three pins are absolutely requisite; one near to each end, and another in the middle of the sore: whereas five pins will always be found fully sufficient for a wound of three inches and a half in extent, allowing one to be within a quarter of an inch of each extremity of the wound, and the others to be placed along the course of the sore at the distance of three quarters of an inch from one another.

The pins being all introduced and secured in the manner directed, nothing remains to be done, but to apply a piece of lint wet with mucilage all along the course of the wound, with a view to exclude, as effectually as possible, every access to the external air.

In order to prevent the ends of the pins from pressing upon and hurting the skin below, it is usual to apply a small bolster of linen or charpie under each of them; but as this always does mischief, by tending to press upon the pins, so as to force them to act upon the soft parts through which they have passed, every thing of this kind ought to be omitted. When, however, the patient happens to complain of being hurt by the ends of the pins, this may be easily prevented, by introducing between them and the skin pieces of thin linen spread with any adhesive plaster.

In order to give every chance of success to this operation, it has been commonly advised, immediately after the pins are secured, to apply the uniting bandage over the whole, so as to afford as much support as possible to the contiguous parts. The least reflection, however, renders it evident, that every degree of pressure made in this manner must do mischief; for the bandage being made to rest immediately upon the pins, a considerable degree of pain and consequent inflammation must of course be produced by it: And in fact this is so much the case, that in every instance in which we have seen this bandage applied, it either did harm, by exciting inflammation in consequence of too much pressure upon the pins; or, if that effect was not produced, no advantage was received from it, from the bandage not being applied with such tightness as to afford any support whatever to the parts below.

The next point to be determined, is the time the pins should be allowed to remain. When they remain long, they generally do harm, by the unnecessary irritation and consequent retraction of parts with which they are always attended; and again, if they are not continued for a sufficient length of time, that degree of adhesion is not produced between the divided parts that is necessary for their future retention; so that the

effect of the operation comes to be in a great measure, if not entirely, lost. Practice.

In wounds of no great depth, for instance of three quarters of an inch or so, a sufficient degree of adhesion always takes place in the space of five days; and six, or at most seven days, will generally be found sufficient for wounds of the greatest depth. But with respect to this circumstance, it must always be understood, that the patient's state of health must have a considerable influence on the time necessary for producing adhesion between divided parts. In specifying the time necessary for this purpose, the operation is supposed to have been done on a constitution in a state of perfect health. When the patient labours under scurvy, or any disorder which affects the general system, it is impossible to ascertain this circumstance with precision: in such cases we must be determined by the nature and state of the disease present at the time.

So soon as the pins are withdrawn, the uniting bandage may be then applied with great advantage, in order to serve as a support to the parts newly united; but as slips of leather spread with ordinary glue, when applied to each side of the cicatrix, may, by means of ligatures properly connected with them, be made to answer this purpose in a more effectual manner, this mode of supporting the parts ought of course to be preferred.

SECT. VI. Of the Ligature of Arteries.

A surgeon being called to a person losing much blood from the division of any of the larger vessels, the first step to be taken is, by means of strong compression, to effect a temporary stoppage of the discharge, till, by the application of ligatures, a more effectual remedy is obtained.

When accidents of this nature occur in any of the extremities, and where pressure can be made with ease on the superior parts of arteries, for such cases we are in possession of a remedy, which, when skilfully applied, never fails of producing an immediate stop to all farther loss of blood. What is here meant is the tourniquet.

Till the invention of this instrument, no operation of importance could be undertaken on any of the extremities but with great hazard to the patient; and large wounds must have frequently proved mortal from the want of this assistance, which otherwise might not have been in any degree hazardous.

As the invention of the tourniquet is claimed by different people, and even by different nations, we shall not here pretend to say from whence it originally came: but whoever had the merit of it, the first instrument of this kind with which the world was made acquainted was exceedingly simple; so much indeed, that we now reflect with astonishment at the discovery having been reserved to such a very late period. A small cushion being placed upon the course of the principal artery of a limb, a circular rope or bandage was made to pass twice round it; and a small wooden handle being then introduced between one of the folds of the bandage, for the purpose of twisting it, the cushion by these means was pressed with so much force upon the artery, as to put an effectual stop to the course of the blood through the under part of the limb.

Mr

Mr Petit, an eminent surgeon of Paris, was the first who proposed a considerable improvement on this instrument, by connecting the circular bandage with a screw, which was so contrived as to produce the pressure chiefly on the principal arteries, without materially affecting the rest of the limb. It had this advantage over the other instrument, that the operator himself could manage it, without being under the necessity of employing an assistant: but it was liable to one great inconvenience, from the very circumstance which by the inventor was considered as an improvement. This instrument of Mr Petit being made to act upon the principal arteries only, the smaller vessels communicating with these, by not being properly compressed, discharge blood freely from the instant they are cut; and as this proves a very troublesome circumstance in the course of operations, different improvements have of late been made upon it.

By means of this instrument in its now improved state, the blood in any limb is very easily and effectually commanded; and as it grasps the whole member equally, all the collateral branches, as well as the principal arteries, are equally compressed by it. It has this material advantage, too, over every other instrument of this kind, that, when properly applied, a single turn, or even half a turn, of the screw, is sufficient for producing either a flow of blood, or for putting a total stop to it. The manner of using it is as follows.

Let a cushion of three inches in length by one inch and half in diameter, be prepared of a linen roller, and be made tolerably firm, but yet not so hard as to render pressure produced by it very painful. This being placed upon the course of the principal artery of the limb, is to be firmly secured in that situation by one or two turns of a circular roller, of the same breadth with the cushion itself.

The instrument, with the strap connected with it, being now placed upon the limb, with the handle of the screw on the opposite side of the member to the cushion upon the artery, the strap is to be carried round the limb directly over the cushion, and to be firmly connected on the other side to the buckle. In thus connecting the strap and buckle together, particular attention is necessary in doing it with great firmness, so as that the screw may afterwards operate with as much advantage as possible in producing a sufficient degree of pressure. When proper attention is paid to this circumstance, a single turn of the screw proves sufficient for putting an entire stop to the circulation of blood in the limb: but when the strap has not originally been made very tight, several turns of the screw become necessary; an occurrence which may be always very easily prevented, and which, when not attended to, frequently proves very embarrassing in the course of an operation.

Various methods have been invented for securing arteries by means of ligatures. The practice lately in ordinary use was, by means of a curved needle, to pass a ligature of sufficient strength round the mouth of the bleeding vessel, including a quarter of an inch all round of the surrounding parts, and afterwards to form a knot of a proper tightness upon the vessel and other parts comprehended in the noose. But this method has been found to give so much pain, that the

best practitioners have thought proper to reject it, and to tie up the blood-vessels by themselves.

In order to detect the arteries to be tied, the tourniquet, with which they are secured, must be slackened a little by a turn or two of the screw; and the moment the largest artery of the fore is discovered, the surgeon fixes his eye upon it, and immediately restrains the blood again by means of the tourniquet. An assistant now forms a noose on the ligature to be made use of; and this noose being placed immediately over the end of the artery, so as to include it with certainty, the operator then pushes the sharp point of the tenaculum through the sides of the vessel, and at the same time pulls so much of it out, over the surface of the surrounding parts, as he thinks is sufficient to be included in the knot which the assistant is now to make. In forming this ligature, the surgeon's knot, as it is termed, which consists in passing the thread twice through the first noose, is certainly preferable to every other, from its being less liable to yield or slip. And as some additional security is obtained by forming a second knot above the first, this precaution ought never to be omitted. It is easily done; and on security in this point the patient's life may in a great measure depend.

The degree of strength of the ligature must always be proportioned to the size of the vessels; but this is a circumstance to be at all times determined by the judgment of the practitioner, as must also the force to be employed in forming the knots. To what was already said upon this point, we shall just add, that a very small force is fully sufficient for securing even the largest arteries; and that after such a force has been applied as evidently restrains the farther loss of blood, a very trifling additional compression is all that is in any degree necessary.

The operator ought to be provided with needles of various sizes, and of different forms. The needles in ordinary use are, for many purposes, quite too much crooked; for, in general, they are more easily managed when their curvatures are not so considerable.

The same kinds of needles as are found necessary for the interrupted suture, answer equally well for the ligature of arteries.

The needles in common use are made triangular, with three different edges, one on each side, and a third on the concave part of the needle. There is no real necessity, however, for more than two: indeed the needle enters fully more easily with two than with three edges; and as the third edge on the concave side renders them more liable to injure arteries and other parts in the course of their introduction, this addition ought therefore to be omitted.

A needle of this shape, armed with a ligature of a size proportioned to itself and to the vessel to be taken up, is to be introduced at the distance of a sixth or eighth part of an inch from the artery, and pushed to a depth sufficient for retaining it, at the same time that it is carried fully one-half round the blood-vessel. It must now be drawn out; and being again pushed forward till it has completely encircled the mouth of the artery, it is then to be pulled out, and a knot to be tied of a sufficient firmness, as was already directed when the tenaculum is used.

In every case of aneurysm, the use of pressure has been indiscriminately recommended, not only in the incipient period of the disease, but even in its more advanced stages.

414 Of the effects of pressure in aneurysms.
In the diffused or false aneurysm, pressure has been universally advised, not only with a view to dissipate the swelling already induced, but in order to produce a reunion of the wound in the artery: however, as pressure in such cases cannot be applied to the artery alone, without at the same time affecting the refluxing veins; and as this circumstance, by producing an increased resistance to the arterial pulsations, must undoubtedly force an additional quantity of blood to the orifice in the artery; therefore no advantage is to be expected from it; but on the contrary, there is reason to suppose it has been on many occasions productive of mischief.

But although pressure ought never to be attempted in any period of the diffused aneurysm, yet in some stages of the other species of the disease, it may be often had recourse to with advantage.

In the early stages of encysted aneurysm, while the blood can be yet pressed entirely out of the sac into the artery, it often happens, by the use of a bandage of soft and somewhat elastic materials, properly fitted to the part, that much may be done in preventing the swelling from receiving any degree of increase; and on some occasions, by the continued support thus given to the weakened artery, complete cures have been at last obtained. In all such cases, therefore, particularly in every instance of the varicose aneurysm, much advantage may be expected from moderate pressure.

But although pressure to a certain degree has frequently, in cases of encysted aneurysm, proved very useful, it ought never to be carried to any great length; for tight bandages in all such affections, by producing an immoderate degree of reaction in the containing parts to which they are applied, instead of answering the purpose for which they were intended, have evidently the contrary effect. Moderate compression, therefore, is more eligible than a great degree of it; and indeed the greatest length to which pressure in such cases ought to go, should be to serve as an easy support to the parts affected, and no farther.

415 Of performing the operation for an aneurysm.
The first step in this operation ought to be to obtain a full command of the circulation in the inferior part of the member by means of the tourniquet applied above. This being done, the patient should be so placed, that the diseased limb, on being stretched on a table, is found to be of a proper height for the surgeon; who, as the operation is generally tedious, ought to be seated. The limb being in this situation properly secured by an assistant, the operator is now with a scalpel to make an incision through the skin and cellular substance along the whole course of the tumour; and as freedom in the remaining parts of the operation is here a matter of much importance, it is even of use to carry this external incision half an inch or so both above and below the farthest extremities of the swelling.

This being done, the ordinary method is to proceed

in a very slow cautious manner, dissecting away one layer of the membrane after another, till the artery itself is laid bare. In this manner the operation is always rendered exceedingly tedious, as the thickness of parts with which the artery is found covered, is often really astonishing, by one layer of a membranous substance having been formed after another, from the coagulable lymph of the blood contained in the tumour. In reality, however, there is no necessity for this degree of caution, as the operation may, in the following manner, be equally well performed in a much shorter space of time, and with much less pain to the patient.

So soon as the external incision has been made in the manner directed, so as to divide the skin and cellular substance, all the effused blood ought to be wiped off by means of a sponge; and the softest part of the tumour being discovered, an opening ought there to be made into it with a lancet, large enough for admitting a finger of the operator's left hand. This being done, and the finger introduced into the cavity of the tumour, it is now to be laid open from one extremity to the other, by running a blunt-pointed bistoury along the finger from below upwards, and afterwards from above downwards, so as to lay the whole cavity fairly open.

The cavity of the tumour being thus laid freely open, all the coagulated blood is now to be taken out. For this purpose a number of instruments, particularly scoops, have been invented by different operators: but no instrument answers this intention so effectually, and with so much ease to the patient, as the fingers of the operator; who having in this manner removed all the coagulated blood, together with a number of tough membranous filaments commonly found here, the cavity of the tumour is now to be rendered quite dry, and free from the blood which, on the first opening of the swelling, is discharged into it from the veins in the inferior part of the member: and this being effectually accomplished, the tourniquet must be made perfectly slack and easy, in order to discover, not only the artery itself, but the opening into it, from whence the blood collected in the tumour has been all along discharged. This being done, the next point to be determined, is the manner of securing this opening into the artery, so as to prevent in future any farther effusion of blood. Various means have been proposed for accomplishing this; but the effects of all of them may be comprehended under the three following heads.

I. The effects of ligature upon a large artery having on some occasions proved fatal to the inferior part of the member, it was long ago proposed, that so soon as the opening into the artery has been discovered, instead of applying a ligature round it, which for certain is to obliterate its cavity entirely, a piece of agaric, vitriol, alum, or any other astringent substance, should be applied to the orifice, in order, if possible, to produce a reunion of its sides.

II. Upon the same principle with the preceding, Mr Lambert's proposal of stitching the wound in the artery should be secured by means of the twisted suture. A small needle being pushed through the edges

Practice. edges of the wound, they are then directed to be drawn together by a thread properly twisted round the needle, as was formerly directed when treating of sutures.

Strong objections, however, occur to both of these methods. In the first place, no astringent application with which we are acquainted is possessed of such powers as to deserve much confidence; for although different articles of this kind have on various occasions proved a means of putting a temporary stop to haemorrhages, yet there are very few instances properly authenticated of their having produced any permanent advantage. In almost every instance in which they have been used, the haemorrhagy has recurred again and again, so as to prove very distressing, not only to the patient, but to the practitioner in attendance; so that, from this want of success, little or no attention is now paid to remedies of this kind in ordinary practice.

With regard to Mr. Lambert's method of stitching the orifice in the artery, it is certainly a very ingenious proposal; and would in all probability, at least in most instances, prove an effectual stop to all farther discharge of blood: but as we have yet only one instance of its success, little can yet be said about it. Two material objections, however, seem to occur to this practice. One is, that in the operation for the aneurysm, in almost every instance, a very few only excepted, the artery lies at the back-part of the tumour; so that when all the collected blood is removed, there is such a depth of wound, that it must be always a very difficult matter, and on many occasions quite impracticable, to perform this nice operation upon the artery with that attention and exactness which, in order to ensure success, it certainly requires. It has now and then happened, indeed, that in this operation the artery has been found to be on the anterior part of the tumour; and in such a situation the wound in it would no doubt prove accessible enough. This, however, is a very rare occurrence, as in almost every instance of diffused aneurysm, the artery lies at the very bottom of the tumour, by the blood being collected between it and the common teguments; and accordingly, in several instances of this disorder, in which, after the tumour was laid freely open, the artery has been found to lie so deep, as would have rendered it quite impossible to perform this operation.

But there is another very material objection which a priori evidently occurs to the practice recommended by Mr. Lambert. By introducing a needle through the sides of the orifice, and drawing these together by a ligature, the cavity of the artery must undoubtedly be at that point much diminished. Indeed Mr. Lambert, in his account of the case in which this operation was performed, acknowledges that the diameter of the artery was thereby diminished. Now the passage of the blood being thus contracted at one point, the impulse upon that particular part must be very considerable: So that the very remedy employed for the cure of one species of aneurysm, will in all probability prove a very powerful agent in inducing another; for the blood being thus obstructed in its usual course, there will be no small danger incurred of a dilatation being produced immediately above this preternatural stricture.

III. Neither of the methods we have yet been considering being found eligible for securing the orifice in the artery, we shall now proceed to describe the ordinary manner of performing this operation; which consists in obliterating the arterial cavity entirely by means of ligatures.

The artery being laid bare in the manner directed, and all the coagulated blood being carefully removed from the cavity of the tumour, on the tourniquet being now slackened so as to bring the orifice in the artery into view, a small probe is to be introduced at the opening, in order to raise the artery from the neighbouring parts, so as that the surgeon may be enabled with certainty to pass a ligature round it, without comprehending the contiguous nerves, which in general run very near to the large blood-vessels of a limb. By this precaution the nerves may be always avoided; and by doing so, a great deal of mischief may be prevented, which otherwise in all probability might supervene. When the disorder is situated either in the ham, or in the usual part of blood-letting in the arm, bending the joints of the knee or of the elbow, as it relaxes the artery a little, renders this part of the operation more easily effected than when the limbs are kept fully stretched out.

The artery being thus gently separated from the contiguous parts, a firm, broad, waxed ligature must be passed round it, about the eighth part of an inch or so above the orifice, and another must in the same manner be introduced at the same distance below it. Much harm, in all probability, has been done by passing the ligature so far distant from the orifice as is commonly practised; for the risk of losing the benefit of anastomosing branches will be always increased in proportion to the extent of artery included between the ligatures.

The easiest method of introducing the ligatures is by means of a blunt-curved needle. An ordinary sharp needle is commonly made use of for this purpose; but it does not answer the intention so well as the one here recommended: by the sharpness of its points it is apt to injure the contiguous parts; and when the common crooked needle is used with a sharp edge on its concave side, there must even be some risk of its wounding the under part of the artery, as in this situation it cannot be introduced without making this part of the needle pass quite in contact with the coats of the artery. The blunt needle is not liable to either of these objections; and besides is more easily introduced than any of the ordinary aneurysmal needles.

The ligatures being both passed in the manner directed, the upper one is now to be tied with a firm, 410
sufficient for compressing the sides of the artery. The directions formerly given for forming the knot upon bleeding-vessels in other parts, will apply with equal propriety here: the ends of the ligature ought by all means to be twice passed through the first noose, and this should again be farther secured by a single knot made above it. By many writers on this subject, a small bolster of linen is ordered to be inserted between the artery and the knot, in order to prevent the artery from being cut by it. This, however, is a very unnecessary precaution; for if the whole artery is not surrounded with the bolster, it will be just as

much exposed to be cut by the ligature at any other part as where the knot is fixed: and, besides, as we have already remarked, there is no occasion whatever for making the ligature so tight on arteries as to run any risk of dividing them; a much less degree of pressure than is either commonly applied, or than could have any influence in hurting them, being fully sufficient for compressing them in the most effectual manner.

The upper ligature being thus finished, before the knot is passed upon the other below the orifice, the tourniquet ought to be untwisted, in order to see whether any blood is now discharged by the wound in the artery or not. If blood flows in any considerable quantity, it affords a prospect of success, as it clearly shows, that the anastomosing branches from the superior part of the artery are considerable enough for carrying on at least a tolerable degree of circulation in the under part of the member. At the same time, however, although blood should not be discharged at this time by the orifice, we are by no means, from this circumstance alone, to despair of success; for it frequently happens, that the operation succeeds in a very effectual manner, although no blood whatever is discharged on the trial now recommended.

But whether any blood should be discharged by this trial or not, we are not to rest satisfied with one ligature; for unless the ligature below the orifice be also tied, there is always a risk, on the return of circulation to the under part of the artery, of blood passing out at the orifice. This precaution, therefore, should never be omitted; it is easily done, and it renders the patient quite secure against all farther evacuation of blood by the orifice. After the knots have been put upon the ligatures, these should be cut of such a length, that their ends may lie fully out over the edges of the wound; so that when necessary they may be more easily withdrawn.

By way of greater security in this operation, it has been advised to insert other two ligatures quite contiguous to the former, and to leave them untied; so that if any of the others misgive, its place may be immediately supplied.

There is not, however, any necessity for this precaution: for if the first ligatures are properly applied, there can be no doubt of their answering the purpose; and in case either one or both of them should happen to fail, they can be very easily renewed. In the mean time, too, the patient is rendered safe against any sudden loss of blood, by the tourniquet being left loose upon the upper part of the member; which it ought by all means to be for several days after the operation, so that, in the event of blood bursting from the wound, it may be secured by means of it, much more readily than if it depended on the tying of a ligature.

The ligatures being both finished in the manner directed, the tourniquet is now to be made quite loose; and if no blood is discharged at the orifice in the artery, we may then rest satisfied that the operation is so far properly completed.

The wound is now to be lightly covered with soft lint, with a pledget of any emollient ointment over the whole; and a compress of linen being applied over the dressings, all the bandage in any degree requisite, is, two or three turns of a roller above, and as many be-

low the centre of the wound, making it press with no more tightness than is absolutely necessary for retaining the applications we have just now mentioned.

The patient being now put into bed, the member should be laid in a relaxed posture upon a pillow, and ought to be so placed as to create the least possible uneasiness from the posture in which it is laid.

As the operation for the aneurysm is always tedious, and produces much pain and irritation, a full dose of laudanum should be given immediately on the patient being got into bed. In order to diminish sensibility during some of the more capital operations, different trials have been made of opiates given an hour or so before the operation. On some occasions, this proved evidently very useful; but in others it seemed to have the contrary effect; particularly in weak nervous constitutions, in which with any doses, however small, they appeared to be rendered more irritable and more susceptible of pain, than if no opiate had been given. Immediately after this operation, however, an opiate ought to be exhibited, to be repeated occasionally according to the degrees of pain and restlessness.

In some few cases of aneurysm it has happened, that the pulse in the under part of the member has been discovered immediately after the operation. This, however, is a very rare occurrence: For as this disorder is seldom met with in any other part than at the joint between the elbow as a consequence of blood-letting, and as it rarely happens that the brachial artery divides till it passes an inch or two below that place, the trunk of this artery is therefore most frequently wounded; and when, accordingly, the ligature in this operation is made to obliterate the passage of almost the whole blood that went to the under part of the arm, there cannot be the least reason to expect any pulsation at the wrist, till in a gradual manner the anastomosing branches of the artery have become so much enlarged, as to transmit such a quantity of blood to the inferior part of the member as is sufficient for acting as a stimulus to the larger branches of the artery.

Immediately after the operation, the patient complains of an unusual numbness or want of feeling in the whole member; and as it generally for a few hours becomes cold, it is therefore right to keep it properly covered with warm soft flannel; and in order to serve as a gentle stimulus to the parts below, moderate frictions appear to be of use. In the space of ten or twelve hours from the operation, although the numbness still continues, the heat of the parts generally begins to return; and it frequently happens, in the course of a few hours more, that all the inferior part of the member becomes even preternaturally warm.

Immediately after this operation, the want of feeling in the parts is often very great; and in proportion as the circulation in the under part of the member becomes more considerable, the degree of feeling also augments. If we could suppose the nerves of the parts below to be always included in the ligature with the artery, that numbness which succeeds immediately to the operation might be easily accounted for; but it has been also known to happen when nothing but the artery was secured by the ligature.

In the mean time the patient being properly attended to as to regimen, by giving him cordials and nourishing diet when low and reduced, and confining him to a low diet if his constitution is plethoric, the limb being still kept in an easy relaxed posture, towards the end of the fourth or fifth day, sometimes much sooner, a very weak feeble pulse is discovered in the under part of the member, which becoming stronger in a gradual manner, the patient in the same proportion recovers the use and feeling of the parts.

So soon as there is an appearance of matter having formed freely about the sore, which will seldom happen before the fifth or sixth day, an emollient poultice should be applied over it for a few hours, in order to soften the dressings, which may be then removed. At this time, too, the ligatures might be taken away; but as their continuance for a day or two longer can do no harm, it is better to allow them to remain till the second or third dressing, when they either drop off themselves, or may be taken away with perfect safety. The dressings, which should always be of the softest materials, being renewed every second or third day according to the quantity of matter produced, the sore is in general found to heal very easily; and although the patient may for a considerable time complain of great numbness and want of strength in the whole course of the diseased limb, yet in most instances a very free use of it is at last obtained.

It will be readily supposed, that the termination of this operation, as we have here described it, is the most favourable that can possibly happen. In some instances, the success attending it is far from being so complete: Instead of a return of circulation, and of the feeling and use of the parts, they remain cold and insensible, and no marks of returning life are perceived. From a mere want of blood, therefore, mortification at last commences; and as nature is here deprived of one of her principal agents for the removal or separation of gangrenous parts, viz. the efforts of the sanguiferous system, whenever the parts in such circumstances begin to mortify, nothing can prevent their progress to the ultimate stage of that malady.

Whenever mortification ensues, therefore, as a consequence of this operation, if the patient survives the immediate effects of it till a separation occurs between the healthy and diseased parts, amputation of the member will then be the only resource.

SECT. VIII. Of Fractures and Dislocations.

The best and most useful bandage for a simple fracture of the leg or thigh, is what is commonly known by the name of the eighteen-tailed bandages; or rather one made on the same principle, but with a little difference in the disposition of the pieces. The common method is to make it so, that the parts which are to surround the limb make a right angle with that which runs lengthwise under it; instead of which, if they are tacked on so as to make an acute angle, they will fold over each other in an oblique direction, and thereby sit more neatly and more securely, as the parts will thereby have more connection with, and more dependence on, each other.

The parts of the general apparatus for a simple

fracture, which come next in order, are the splints. These are generally made of palteboard, wood, or some resisting kind of stuff, and are ordered to be applied lengthwise on the broken limb; in some cases three, in others four, for the more steady and quiet detention of the fracture. That splints properly made and judiciously applied are very serviceable, is beyond all doubt; but their utility depends much on their size, and the manner in which they are applied. In general practice, they are made of such length as not to reach either upward or downward, so far as the roller extends; nor to comprehend either the upper or the lower joint of the broken bone, and to exceed the fracture either way not many inches: They do not, for example, in the broken leg, comprehend either the joint of the knee or the joint of the ankle, and act only on the fracture.

In this manner of application, and of this size, they are in fact neither more nor less than compresses, and compresses made of very bad materials. All the good that ever is, or that can be, done by them, when of such length, and so applied, might certainly be done in a better manner by a more proper kind of compress; and every disadvantage which a hard resisting compress, injudiciously applied, is capable of producing, is probable to result from them thus used.

The true and proper use of splints is to preserve steadiness in the whole limb, without compressing the fracture at all. By the former, they become very assistant to the curative intention; by the latter, they are very capable of causing pain and other inconveniences; at the same time that they cannot, in the nature of things, contribute to the steadiness of the limb.

In order to be of any real use at all, splints should, in the case of a broken leg, reach above the knee and below the ankle; should be only two in number; and should be so guarded with tow, rag, or cotton, that they should press only on the joints, and not at all on the fracture. By this they become really serviceable; but a short splint, which extends only a little above and a little below the fracture, and does not take in the two joints, is an absurdity. By pressing on both joints, they keep not only them but the foot steady; by pressing on the fracture only, they cannot retain it in its place, if the foot be in the smallest degree displaced; but they may, and frequently do, occasion mischief, by rudely pressing the parts covering the fracture against the edges and inequalities of it.

In the case of a fractured os femoris, if the limb be laid in an extended posture, one splint should certainly reach from the hip to the outer ankle, and another (somewhat shorter) should extend from the groin to the inner ankle. In the case of a broken tibia and fibula, there never can be occasion for more than two splints; one of which should extend from above the knee to below the ankle on one side, and the other splint should do the same on the other side.

The most essential article in the treatment of a fracture is the position of the limb. Upon the judicious or injudicious execution of this, depends the ease of limbs, the patient during his confinement, and the free use and natural appearance of his limb afterward.

"If I meant to describe (says Mr. Pott), or if I approved (pardon the phrase), the common method of placing

placing the broken leg and thigh in a straight manner, this would be the place to mention the many very ingenious contrivances and pieces of machinery which practitioners, both ancient and modern, have invented for the purpose of keeping the whole limb straight and steady; that is, of keeping all the muscles surrounding the fractured bone constantly upon the stretch, and at the same time of preventing any inequality in the union of it, and any shortening of the limb in consequence of such inequality. But as it is my intention to inculcate another, and as it appears to me a better disposition of the limb, in which such boxes, cradles, and pieces of machinery are not wanted, nor can be used, it is needless for me to say any thing about them.

“According to this plan, the fractured leg and thigh should be deposited on the pillow in the very posture in which the extension was made and the fracture set; that is, with the knee bent.

“In the case of the fractured os humeri, the only position in which it can, with any tolerable convenience to the patient, be placed, is with the elbow bent; that very position which necessarily relaxes and removes all the resistance of the surrounding muscles. Daily experience evinces the utility of this, by our very seldom meeting with lameness or deformity after it, notwithstanding the prevailing apprehension of exuberant callus.

“The deformity frequently consequent to the fracture of the bones of the cubit, particularly that of the radius only, will generally, if not always, be found to be in proportion as the muscles concerned in the pronation and supination of the hand happen to be put more or less into a state of action or tension by the position of the limb.

“In the thigh the case is still more obvious, as the muscles are more numerous and stronger. The straight posture puts the majority of them into action: by which action, that part of the broken bone which is next to the knee is pulled upward, and by passing more or less underneath that part which is next to the hip, makes an inequality or rising in the broken part, and produces a shortness of the limb.

“In the fracture of both bones of the leg, the case is still the same: a straight position puts the muscles upon endeavouring to act; a moderate flexion of the knee relaxes them, and takes off such propensity.

“The disposition, therefore, of the broken cubit ought to be that which, by putting the hand into a middle state between pronation and supination, and by bending the fingers moderately, keeps the radius superior to the ulna; or, in other words, the palm of the hand should be applied to the breast, the thumb should be superior, the little finger inferior; and the hand should be kept in this posture constantly by means of two splints, which should reach from the joint of the elbow on each side, and should be extended below the fingers: or the same purpose may be still better answered by a simple neat contrivance of the very ingenious Mr Gooch of Norfolk; of which he has given a draught, and which is preferable to a common splint, by its admitting the fingers to be more easily bent.

“The position of the fractured os femoris should be on its outside, resting on the great trochanter; the pa-

tient's whole body should be inclined to the same side; the knee should be in a middle state, between perfect flexion and extension, or half-bent; the leg and foot, lying on their outside also, should be well supported by smooth pillows, and should be rather higher in their level than the thigh: one very broad splint of deal, hollowed out, and well covered with wool, rag, or tow, should be placed under the thigh, from above the trochanter quite below the knee; and another somewhat shorter should extend from the groin below the knee on the inside, or rather in this posture on the upper side. The bandage should be of the eighteen-tail kind; and when the bone has been set, and the thigh well placed on the pillow, it should not, without necessity (which necessity in this method will seldom occur) be ever moved from it again until the fracture is united: and this union will always be accomplished in more or less time, in proportion as the limb shall have been more or less disturbed.

“In the fracture of the fibula only, the position is of the not of much consequence; because, by the tibia remaining entire, the figure of the leg is preserved, and extension quite unnecessary: but still even here the laying the leg on its side, instead of on the calf, is attended with one very good consequence, viz. that the confinement of the knee, in a moderately bent position, does not render it so incapable of flexion and use afterward, as the straight or extended position of it does; and consequently that the patient will be much sooner able to walk, whose leg has been kept in the former posture, than he whose leg has been confined in the latter.

“In the fracture of both tibia and fibula, the knee should be moderately bent; the thigh, body, and leg, in the same position as in the broken thigh. If common splints be used, one should be placed underneath the leg, extending from above the knee to below the ankle, the foot being properly supported by pillows, bolsters, &c. and another splint of the same length should be placed on the upper side, comprehending both joints in the same manner; which disposition of splints ought always to be observed, as to their length, if the leg be laid extended in the common way; only changing the nominal position of them, as the posture of the leg is changed, and calling what is inferior in one case exterior in the other, and what is superior in one in the other interior.”

Reduction of, or setting a compound fracture, is the same as in the simple; that is, the intention in both is the same, viz. by means of a proper degree of extension, to obtain as apt a position of the ends of the fracture, with regard to each other, as the nature of the case will admit; and thereby to produce as perfect and as speedy union as possible.

The dressing necessary in a compound fracture is of two kinds, viz. that for the wound, and that for the limb. By the former, we mean to maintain a proper opening for the easy and free discharge of gleet, sloughs, matter, extraneous bodies, or fragments of bone; and this in such manner, and by such means, as shall give the least possible pain or fatigue, shall neither irritate by its qualities, nor oppress by its quantity; nor by any means contribute to the detention or lodgment of what ought to be discharged. By the latter, our aim should be the prevention or removal

Practice. val of inflammation, in order, if the habit be good, and all other circumstances fortunate, that the wound may be healed by what the surgeons call the first intention; that is, without suppuration or abscess; or, that not being practicable, that gangrene and mortification, or even very large suppuration, may be prevented, and such a moderate and kindly degree of it established as may best serve the purpose of a cure. The first, therefore, or the dressing for the wound, can consist of nothing better, or indeed so good, as soft dry lint, laid on so lightly as just to absorb the fancies, but neither to distend the wound, nor be the smallest impediment or obstruction to the discharge of matter. This lint should be kept clear of the edges, and the whole of it should be covered with a pledget spread with a soft easy digestive. The times of dressing must be determined by the nature of the case; if the discharge be small or moderate, once in 24 hours will be sufficient; but if it be large, more frequent dressing will be necessary, as well to prevent offence as to remedy the inconveniences arising from a great discharge of an irritating sharp fancies.

435
Of preventing violent pain, inflammation, &c.

The method of treating the limb, with a view to the prevention of such accidents and symptoms as pain, inflammation, and laceration of parts are likely to produce, is different with different practitioners; some using from the very first relaxing greasy applications, others applying medicines of a very different nature. Both these may be right conditionally, that is, according to different circumstances in the case; but they cannot be equally so in the same circumstances.

436
Of applying relaxing cataplasms, &c.

Many practitioners are accustomed to envelope compound fractures in a soft warm relaxing cataplasm from the very first, whether the limb be in a tense swollen state or not. This seems to be injudicious. When from neglect, from length of time passed without assistance, from misconduct or drunkenness in the patient, from awkwardness and unhandiness in the assistants, or from any other cause, a tension has taken possession of the limb, and it is become tumid, swollen, and painful, a warm cataplasm is certainly the best and most proper application that can be made; and that for very obvious reasons: the state of the parts under these circumstances is such, that immediate union is impossible, and nothing but a free and plentiful suppuration can dissipate or remove impending mischief: every thing, therefore, which can tend toward relaxing the tense, swollen, and irritable state of the parts concerned, must necessarily be right; the one thing aimed at (plentiful suppuration) cannot be accomplished without it. But when the parts are not in this state, the intention seems to be very different. To relax swollen parts, and to appease pain and irritation by such relaxation, is one thing; to prevent inflammatory desluxion and tumefaction is certainly another; and they ought to be aimed at by very different means. In the former, a large suppuration is a necessary circumstance of relief, and the great means of cure; in the latter it is not, and a very moderate degree of it is all that is required. The warm cataplasm, therefore, although it be the best application that can be made use of in the one case, is certainly not so proper in the other, as applications of a more discutient kind, such as mixtures of spirit. vini, vinegar and water, with crude sal-ammoniac, spirit. Min-

dereri, acet. litharg. and medicines of this class, in whatever form the surgeon may choose. By these, in good habits, in fortunately-circumstanced cases, and with the assistance of what should never be neglected, I mean phlebotomy and the general antiphlogistic regimen, inflammation may sometimes be kept off, and a cure accomplished, without large collections or discharges of matter, or that considerable degree of suppuration which, though necessary in some cases, and almost unavoidable in others, are, and must be, rather promoted and encouraged, than retarded or prevented, by warm relaxing applications of the poultice-kind.

437
Compound fractures in general require to be dressed every day; and the wounded parts not admitting the smallest degree of motion without great pain, perfect quietude becomes as necessary as frequent dressing. The common bandage, therefore (the roller), has always in this case been laid aside, and what is called the eighteen-tailed bandage substituted, very judiciously, in its place.

Splints, that is, such short ones as are most commonly made use of in simple fractures, are by all forbid in the compound; and that for the same reason which ought to have prevented them from having ever been used in the former, viz. because the probable good to be derived from them can be but little, and the probable mischief is obvious and considerable.

But although short splints are, for many reasons, palpably improper in both cases, yet those which reach from joint to joint comprehend them both; and, applied on each side of the leg only, are very useful both in the simple and in the compound fracture, as they may, thus applied, be made to keep the limb more constantly steady and quiet than it can be kept without them.

438
With regard to luxations, many engines have been invented in order to make as strong an extension as possible; but by attending to the principles laid down n^o 238, it will be found that these extraordinary degrees of force can never be necessary. To give very particular directions concerning the reduction of luxations in all cases, would not only be very tedious, but in a great measure unnecessary; as, by comparing the joint supposed to be luxated with the sound one, every intelligent operator must know whether it is so or not; and, it being remembered always to keep the muscles of the part in as relaxed a state as possible, the business of the surgeon is, 1. To restore the luxated bone to its place, first by extension, and then by reduction with his hands. 2. To preserve and retain what is so replaced, in their natural position. And lastly, 3. To prevent and cure the several symptoms which usually attend. The reduction is used to be commodiously performed by placing the patient on a stool, table, bed, or the ground, as the surgeon shall think most suitable to the case. It is however to be observed here, that those luxations are most readily reduced on a stool, which happen in the jaw, clavicle, arm, or hand; on a table, such as happen in the vertebrae or thighs; on a bed, such as happen in the legs or feet; and lastly, those dislocations are most commodiously reduced on the floor which happen on the shoulder or vertebrae of the neck.

439
The extension is to be made much after the same manner as in fractures; viz. the outer or lower part of the

of the dislocated limb is to be extended by an assistant, till the head of the disordered bone be found to correspond exactly with the sinus from whence it was luxated. This may be done by the hands: but, if they are not so convenient, the extension seldom fails of being so well made by a napkin, as to render the machinery delineated in such an ample manner by Oribasius, Parey, Andreas a Cruce, Scultetus, and others, generally unnecessary; since they can effect scarce any thing more, unless it be to terrify and discourage the patient in the extension, by their formidable show.

To replace the luxated bone again in its natural seat, the surgeon must regulate the assistant's extension, by ordering it to be strong enough, and in a right direction; in the mean time he is to compress the articulation gently with his hands and fingers, till he find the elapated bone recover its right place.

An accurate reduction of a luxation is known to have been effected by the same signs which attend the reduction of fractures. It is a good sign, 1. If the bone be heard to snap or crack in its reduction. 2. When the disordered limb is found to be of the same length with the found one. 3. When the pains grow less. Or lastly, 4. When the limb can perform its usual motion.

In those cases where the luxation is accompanied with a fracture, the reduction must be put off till that is first set and joined; for the extension cannot be safely attempted till the fracture be well joined by a firm callus.

After the bones have been pushed into their places from whence they were forced out, the next business is carefully to retain them there. But bones that are entire are much easier retained than those that have been broken: for the latter cannot be contained in their right posture without strict bandage and rest; whereas there is in the first case seldom much occasion for bandage, or any great rest: for thus, in fresh dislocations of the jaw, bones of the fingers, hands, cubitus, and humerus, the bone may be immediately reduced without further bandage or rest; because they are generally held firm enough by their proper ligaments and muscles. It seems rather more necessary to bend, extend, and gently move the limb sometimes, than to endanger its becoming stiff and immovable by a long inactivity. But when the luxation happens in the lower extremities, it seems better to let the patient rest a few days in his bed, moving the limb gently as soon as he finds it capable, and afterwards he may rise and walk cautiously with it.

On the other hand, when the ligaments have been much stretched by a violent and long-continued distention, or have been rendered infirm by any other means, it seems altogether necessary to make use of some proper bandage, and to recommend rest to the patient, till the ligaments have regained their former strength. But here it must be also carefully observed, to let the disordered articulation sometimes have a little gentle motion, by an easy flexion and extension of the limb, to prevent any stiffness or other bad consequence from such a continued rest. In the mean time, it may not be improper to moisten the bandages and bathe the part with sp. vin. aq. hungar, or some other warm and strengthening spirit, by which means the liga-

ments are used to become very firm and strong. The Practice. bandages themselves should be neither too tight nor too loose. As for the application of plasters, which has been such a prevailing custom in these cases, it seems rather to be prejudicial than otherwise.

SECT. IX. Of the Reduction of Hernia.

THE cure of a rupture is either perfect (called also radical), or imperfect, which is called palliative.

This distinction, which is just and true, and founded both on reason and experience, has frequently been misunderstood by the generality of mankind, and has therefore been the cause of much undeserved censure on the practitioners of surgery.

The truth is, that though the events are extremely different, yet the chiralurgical means which are made use of in either case are exactly the same, viz. reduction of the protruded parts, and retention of them, when so reduced, by proper bandage. These sometimes, and in some circumstances, produce a perfect cure; at other times, and under other circumstances, prove only a palliative one: and this uncertainty of event being dependent on causes which a surgeon can neither foresee nor direct with any tolerable degree of certainty, should warn him against being too forward in making a promise.

The different treatment which ruptures may require being dependent on different circumstances attending the disease, we shall divide them into four classes; under which may be comprehended, not only all the kinds of hernias, but every particularity also with which they may happen to be distinguished.

1. Under the first, we reckon those which are capable of easy and immediate reduction, and are not attended by any troublesome or bad symptoms. 2. Under the second, those which have been so long down, that the contained parts are either so altered in form, or have contracted such adhesions and connections, as to be absolutely incapable of being reduced at all. 3. Under the third, we comprehend those in which such stricture has been made on the protruded parts, as to bring on pain, and produce such an obstruction in the intestinal canal, as to render immediate reduction necessary, but at the same time difficult. 4. And under the fourth, we shall place those in which the return of the parts by the mere hand is absolutely impracticable, and in which the patient's life can be saved only by a chiralurgical operation.

1. The first is very frequently met with in infants, and sometimes in adults, and is too often neglected in both. In the former, as the descent seldom happens but when the infant strains to cry, and the gut is either easily put up or returns as soon as the child becomes quiet, it often is either totally unattended to, or an attempt made to restrain it only by a bandage made of cloth or dimity; and which, being ineffectual for such purpose, lays the foundation of future trouble and mischief.

This is in great measure owing to a common opinion, that a young infant cannot wear a steel truss; a may be generally prevailing error, and which ought to be corrected. There is no age at which such truss may not be worn, or ought not to be applied: it is, when well made, and properly put on, not only perfectly safe and easy, but the only kind of bandage that can be depended on.

Practice. depended upon; and as a radical cure depends greatly on the thinness of the hernial sac, and its being capable of being so compressed as possibly to unite, and thereby entirely close the passage from the belly, it must therefore appear, that the fewer times the parts have made a descent, and the smaller and finer the elongation of the peritoneum is, the greater the probability of such cure must be.

The same method of acting must, for the same reasons, be good in every age in which a radical cure may reasonably be expected; that is, the prolapsed parts cannot be too soon returned, nor too carefully prevented from falling down again; every new descent rendering a cure both more distant and more uncertain.

448 Treatment of the patient after the hernia is reduced. As soon as the parts are returned, the truss should be immediately put on, and worn without remission; care being taken, especially if the patient be an infant, to keep the parts on which it presses constantly washed, to prevent galling.

It can hardly be necessary to say, that the surgeon should be careful to see that the truss fits, as his success and reputation depend on such care. A truss which does not press enough is worse than none at all, as it occasions loss of time, and deceives the patient or his friends; and one which presses too much, or on an improper part, gives pain and trouble, by producing an inflammation and swelling of the spermatic cord, and sometimes of the testicle.

449 Of the ruptures of adults. In adults, whose ruptures are of long standing, and accustomed to frequent descent, the hernial sac is generally firm and thick, and the aperture in the tendon of the abdominal muscle large. The freedom and ease with which the parts return into the belly, when the patient is in a supine posture, and the little pain which attends a rupture of this kind, often render the persons who labour under it careless: but all such should be informed, that they are in constant danger of such alteration in their complaint, as may put them into great hazard, and perhaps destroy them. The passage from the belly being open, the quantity of intestine in the hernial sac is always liable to be increased, and, when down, to be bound by a stricture. An inflammation of that portion of the gut which is down, or such obstruction in it as may distend and enlarge it, may at all times produce such complaints as may put the life of the patient into imminent danger; and therefore, notwithstanding this kind of hernia may have been borne for a great length of time, without having proved either troublesome or hazardous, yet as it is always possible to become so, and that very suddenly, it can never be prudent or safe to neglect it.

Even though the rupture should be of the omental kind (which, considered abstractedly, is not subject to that degree or kind of danger to which the intestinal is liable), yet it may be secondarily, or by accident, the cause of all the same mischief; for while it keeps the mouth of the hernial sac open, it renders the descent of a piece of intestine always possible, and consequently always likely to produce the mischief which may proceed from thence.

They who labour under a hernia thus circumstanced, that is, whose ruptures have been generally down while they have been in an erect posture, and which have either gone up of themselves or have been easily

put up in a supine one, should be particularly careful to have their truss well made and properly fitted; for the mouth of the sac, and the opening in the tendon, being both large and lax, and the parts having been used to descend through them, if the pad of the truss be not placed right, and there be not a due degree of elasticity in the spring, a piece of intestine will in some posture slip down behind it, and render the truss productive of that very kind of mischief which it ought to prevent.

II. In the second class we ranked those cases in which the parts constituting the hernia are found irreducible, but not in a state of inflammation, nor producing any troublesome or dangerous kind of symptoms.

450 This incapacity of reduction may be owing to several causes, but most frequently arises either from the largeness of the quantity of the contents, from an alteration made in their form and texture, or from connections and adhesions which they have contracted with each other, or with their containing bag.

Ruptures are sometimes rendered difficult to be reduced, by that portion of the intestinal canal which is called the cæcum, or the beginning of the colon, being contained in the hernial sac. When a hernia of this kind (viz. one containing a part of the intestinal tube) has been long neglected, and suffered to remain in the scrotum without any bandage at all to support its weight, the hernial sac being constantly dragged down, and kept in a state of distention, necessarily becomes thick, hard, and tough: by this means the diameter of its neck is lessened, and the return of the intestine back from the scrotum into the belly rendered more and more difficult, as the parts through which it is to pass become harder and less capable of yielding. This will indeed, in time, prove an obstruction sufficient to hinder any part of the intestine, or even of the omentum, from being returned; but the more the difficulty is, which proceeds from the mere figure and size of the portion of gut, the greater will be the obstruction when added to that arising from the just-mentioned cause.

An alteration produced by time, and constant, though gentle pressure, in the form and consistency or texture of the omentum, is also no infrequent cause why neglected omental ruptures become irreducible.

The cellular membrane, in all parts of the body, however loose and light its natural texture may be, is capable of becoming hard, firm, and compact, by constant pressure. Of this there are so many and so well known instances, that it is quite unnecessary to produce any.

The omentum, from its texture, is liable to the same consequence. When a portion of it has been suffered to remain for a great length of time in the scrotum, without having ever been returned into the belly, it often happens, that although that part of it which is in the lower part of the hernial sac preserves its natural soft, adipose, expandible state, yet all that part which passes through what is called the neck of the sac, is, by constant pressure, formed into a hard, firm, incompressible, caraceous kind of body, incapable of being expanded, and taking the form of the passage in which it is confined, exactly filling that passage, and rendering it impossible to push up the loose part which fills the scrotum.

The same reason for incapacity of reduction is also sometimes met with in ruptures of the intestinal kind, from an alteration produced on that part of the mesentery which has been suffered to lie quiet for a great length of time in the neck of an old hernial sac.

The other impediment to the return of old ruptures, is connection and adhesion of the parts, either with each other, or with the bag containing them. This is common to both the intestinal and omental hernia, and is produced by slight inflammations of the parts, which have been permitted to lie long in contact with each other, or perhaps, in many cases, from the mere contact only. These adhesions are more or less firm in different cases; but even the slightest will almost always be found an invincible objection to the reduction of the adherent parts by the hand only.

Many, or perhaps most, of these irreducible ruptures, become so by mere time and neglect, and might at first have been returned; but when they are got into this state, they are capable of no relief from surgery but the application of a suspensory bag, to take off or lessen the inconvenience arising from the weight of the scrotum.

People in this situation should be particularly careful not to make any attempts beyond their strength, nor aim at feats of agility; they should take care to suspend the loaded scrotum, and to keep it out of the way of all harm from pressure, bruise, &c. When the tumour is very large, a soft quilted bolster should be worn at the bottom of the suspensory to prevent excoriation, and the scrotum should be frequently washed for the same reason; a loss of skin in this part, and in such circumstances, being sometimes of the utmost importance. They ought also to be particularly attentive to the office of the intestinal canal, to see that they do not, by any irregularity of diet, disorder it, and keep themselves from being costive, for reasons too obvious to need relating. By these means, and with these cautions, many people have passed their lives for many years free from disease or complaint, with very large irreducible ruptures.

On the other hand, it is fit that mankind should be apprised, that the quiet inoffensive state of this kind of hernia is by no means to be depended upon; many things may happen to it, by which it may be so altered, as to become hazardous and even fatal: an inflammation of that part of the gut which is down, any obstruction to the passage of the aliment or feces through it, a stricture made by the abdominal tendon, either on what has been long down or on a new portion which may at any time be added to it, are always capable of so altering the state of the case, as to put the life of the patient into danger.

Indeed the hazard arising from a stricture made on a piece of intestine contained in the sac of an old irreducible hernia, is, in one respect, greater than that attending one that has been found at times reducible; since, from the nature of the case, it will hardly admit of any attempt toward relief but the operation; and that, in these circumstances, must necessarily be accompanied with additional difficulty.

Among the ruptures which have been thought not reducible, and treated as such, there have been some which, upon more judicious and more patient attempts, have been found capable of reduction.

When this is suspected to be the case, the proper method is by absolute rest, in a supine posture, for a considerable length of time, and by great abstinence and the use of evacuations, so to lessen the size of the parts in the hernial sac, as to render them capable of passing back again into the belly.

This method has now and then succeeded, and in some cases is worth the trying: but, previous to the attempt, there should be some circumstances which makes success probable; and there should also be good reason to believe, that the habit and age of the patient will bear the necessary confinement and evacuation; otherwise, even though he should get rid of his rupture, he may be much worsted by the experiment.

If such attempt succeeds, a truss should be immediately put on, and worn constantly without remission; for in these people, the largeness of the abdominal aperture, the thickness of the hernial sac, and the relaxation of the mesentery, make a new descent always to be apprehended and guarded against.

An omental rupture, which has been so long in the scrotum as to have become irreducible, is very seldom attended with any bad symptoms, considered abstractedly; but it is constantly capable of being the occasion of an intestinal hernia and all its consequences: neither is that all; for the omentum, either so altered in form and texture, or so connected as to be incapable of reduction, may by accident inflame, and either become gangrenous or suppurate, and be the occasion of a great deal of trouble.

III. Under the third division, we reckon those ruptures of hernia which are reducible, but whose reduction is difficult, and which are attended with pain, trouble, and hazard.

Difficulty of reduction may be owing to several causes. The size of the piece of omentum, or the inflamed state of it; the quantity of intestine and mesentery, an inflammation of the gut, or its distention by faeces or wind; or the smallness of the aperture of the tendon through which the hernia passes. But to whatever cause it be owing, if the prolapsed body cannot be immediately replaced, and the patient suffers pain, or is prevented thereby from going to stool, is called an incarcerated hernia, a strangulated hernia, or a hernia with stricture.

Every symptom which attends an incarcerated rupture depends on this stricture, and is justly accountable for from it. The tumour, the pain, the tension of the belly, the nausea, the vomiting, and the suppression of stools, are so many effects produced by it, and removable only by removing it. In order to effect a reduction, the patient should be laid in a supine posture, with his trunk certainly as low, if not lower, than his thighs; the thigh on the diseased side should be so elevated as to contribute as much as possible to the relaxation of the abdominal aperture; and then the surgeon, grasping the lower part of the tumour gently with his hand, in such a manner as to keep the testicle from ascending, and the intestine from descending, must endeavour to procure the return of the latter through the ring, as it is vulgarly called, by gentle continued pressure toward that opening. If the case be a bubonocoele, there will be no occasion for endeavouring to grasp the tumour, but, by continued moderate pressure on it with the fingers, to endeavour the return of the piece of gut.

Practice. This may serve for a general description of the method of performing this operation; but the exact manner of executing it is one of those manœuvres which can be learnt only by observation and practice, and of which no verbal description can convey an adequate and perfect idea: knowledge of the structure and situation of the parts will instruct any one how to go about it; and a little practice will soon make him adroit.

455
Of the posture of the body. The posture of the body, and the disposition of the lower limbs, may be made very assiduous in this operation when the difficulty is considerable: the nearer the posture approaches to what is commonly called standing on the head, the better, as it causes the whole packet of small intestines to hang, as it were, by the strangulated portion, and may thereby disengage it. A little time and pains spent in this manner will frequently be attended with success, and obtain a return of the part; but if it should not, and the handling of it (which should always be gentle) becomes painful and very fatiguing to the patient, we are advised to desist a few hours, and try the effect of other means, viz. phlebotomy, glysters, &c. But when all these have failed, there is then no other resource than in a chiralurgical operation: and perhaps there is not in the practice of surgery a point which requires more judgement, firmness, or delicacy, than to determine the precise time beyond which this operation should not be deferred, and for a surgeon to conduct himself so as to induce a patient to submit to it early enough for his preservation. The time in which a piece of gut will become gangrenous from stricture, or get into a state approaching to that of a gangrene, is extremely uncertain, and depends on circumstances which no man can foresee. There have been several instances of ruptures, attended by pressing symptoms of stricture, which have been safely returned by the hand only, at the end of several days; or the operation having been performed at the same distance of time, the parts have been found sound and unhurt: on the other hand, there are many instances producible, of the intestine having been with great difficulty replaced, or of its returning of its own accord, from being mortified, or (the operation having been submitted to) of its having been found in such state by the operator at the end of not many hours.

456
Operation not to be very much dreaded. The two principal circumstances which have most contributed to the infrequency of performing this operation, are, a dread of great hazard from the operation itself, considered abstractedly; and a fear of bringing a disgrace upon it, by having performed it too late. The first of these is vastly greater than it ought to be, and is most frequently the cause of the latter: so that if the one can justly be lessened, the other will not be so likely to happen.

457
Of the time when it should be performed. Mr Pott is of opinion, that the operation ought always to be performed as soon as possible, after it appears that all rational attempts, by large and free bleeding, the warm bath, glysters, &c. are found to be ineffectual, or that the symptoms rather increase than decrease while such means are made use of, and that the handling necessary for reduction becomes more and more painful: for if it be delayed until the inflammation has attained a certain height, though the parts, upon being laid open, are not found

quite gangrenous, that is no proof that the want of success must be set to the account of the operation merely. That state of inflammation, either of the intestine or of the hernial sac, which is just not gangrenous, is no state of safety, nor are we sure that removing the stricture will at this time appease the symptoms or abate the hazard; far from it: such an alteration may have already been made in the intestine that a mortification will ensue, though it be set free and returned into the belly. A ligature need not be continued around any part of a living animal, until it becomes quite gangrenous, in order to produce its destruction; there is a certain point of time in which the circulation is so prevented, that the same event will follow, though the ligature be then removed. It is indeed a nice, and no very easy matter, to find this precise time; but this difficulty and uncertainty are the strongest reasons for anticipating rather than waiting for it: for when, in the present case, such time arrives, or is nearly arrived, the risk of the operation becomes complicated with that arising from the diseased state of the parts within; and the chance of success is thereby much lessened.

When the operation shall be thought necessary, the manner of performing it is as follows.

458
Manner of performing it. The pubes and groin having been clean shaved, the patient must be laid on his back on a table of convenient height, with his legs hanging easily over the end of it; then with a straight dissecting knife an incision must be made through the skin and membrana adiposa, beginning just above the place where the intestine passes out from the belly, and continuing it quite down to the lower part of the scrotum. Upon dividing the adipose membrane, there generally appear a few small distinct tendinous kind of bands, which lie close upon the hernial sac, which must be divided also as well as the sac: the same knife with which the incision through the skin was made will execute this; which should be done with a steady hand and great caution, it being of very different degrees of thickness in different cases. In the bubonocoele, or that which is confined to the groin, the sac is most frequently thin, consequently more easily divided, and requires greater attention in the operator. In the oescheocele, or scrotal hernia, if it be recent, the sac is usually thin also; if ancient, it is sometimes of considerable thickness: but whatever be the state of it, if the operator has any doubt, let him, as soon as he has made a small puncture in what appears to him to be the hernial sac, endeavour to introduce a probe into it: this will give him the necessary satisfaction; for if he has not pierced the sac, the probe will be stopped by the cells of the common membrane; and if he has, it will pass in without any obstruction. The place to make the incision in the hernial sac is about an inch and half below the stricture; and the opening need not be larger than just to admit the end of the operator's fore-finger; which, considering the great dilatability of these membranes, will be a very small one. The fore-finger introduced into this aperture is the best of all directors; and upon that a narrow-bladed curved knife, with a bold probe point, will be the only instrument necessary to finish the operation. With this knife on the finger (the point of the former being

always short of the extremity of the latter) the sac must be divided quite up to the opening in the tendon, and down to the bottom of the scrotum.

Upon the first division of the sac, a fluid generally rushes out; which fluid is different in quantity, colour, and consistence, according to the date, size, and some other circumstances attending the rupture.

This fluid has sometimes been mentioned as a defence against an accident from the knife in the first division of the hernial sac, as if it kept the intestine at such a distance as thereby to lessen the hazard of its being wounded: but this is a very fallacious circumstance, and never to be trusted: the security of this operation depends entirely on a competent knowledge of the parts, a steady hand, and an attentive eye.

Different operators, especially among the French, have proposed a number of different instruments for the safe performance of this incision; as the bistouri cachée, the bistouri herniare, the winged director, the blunt scissars, &c. &c. all which are calculated for the defence and preservation of the intestine in the division of the sac and tendon: but whoever will make use of the two knives just mentioned, will find, that he will never stand in need of any other instrument, and that he will with them be able to perform the operation with more ease to himself, with less hazard to his patient, and with more (A) apparent dexterity, than with any other whatever.

"The sac being laid open, the intestine generally pushes out immediately (unless it is confined by being enveloped in the omentum), and appears to be much more in quantity than it seemed to be while it was confined within the scrotum.

459 Of dividing the tendon. This is the time to try whether, by gently drawing out a little more of the gut, its bulk cannot be so reduced as to enable the surgeon to return it back into the belly without dividing the tendon. In the case of the protrusion of a very small piece of intestine, it has been found practicable; the difficulty of returning a large portion arising principally from the quantity of mesentery engaged in the stricture: and indeed, tho' it may now and then happen that a small piece of gut may be returnable without a division of the tendon, yet if it cannot be very easily accomplished, it had better not be attempted, since, in the state in which this part must necessarily be, to require the operation thus far, any degree of force used to it will most probably be more prejudicial and hazardous than the rest of it, if performed properly with a knife.

An attention to the natural structure, figure, and direction of the parts, will give us the best informa-

tion how to make the division of the stricture to the best purpose and with the least hazard.

The tendon of the obliquus descendens muscle runs in an oblique direction from above downward; and the natural opening which is always found in it, and through which the hernia passes, is made by a kind of separation of the fibres from each other: the direction of this opening is the same as that of the tendon, that is, obliquely downward from the os ilion to the os pubis: the knife, therefore, should be so managed, as rather to continue this separation than to make any transverse section: its edge should be applied to the superior and posterior part of the oval, and carried upward and obliquely backward, until a sufficient opening is made to serve the purpose. By this means, the fibres of the tendon will be rather separated from each other than cut; and, in all probability, the risk arising from the incision will be lessened.

460 It is generally advised to make the division of the Of the size stricture free and large, as well to admit the easy re- of the inci- turn of the parts, as to prevent the inconvenience tion. which it is supposed will be more likely to attend a small wound in a tendinous body than a large one. The first intention, the easy return of the intestine, should certainly be fulfilled; and therefore the incision ought always to be large enough for that purpose, and to afford an opportunity of passing the end of the finger round on the inside in case of any adhesion: but as too large an opening may be attended with very ill consequence, it ought also to be guarded against. In the majority of cases, a small incision will be found sufficient for the purpose of reduction; and where the parts are free from adhesion, and the safe return of them is the only object of attention, a small division, made in the manner already directed, is not liable to any more pain or trouble than a large one, and may therefore be safely trusted.

461 The sac and stricture being laid open and divi- Of the state of the intestines. ded, the contained parts come into view; and, according to the different circumstances of the rupture and of the patient, will be found in different states, and require different treatment.

These states are reducible to three general heads: that is, the contained parts will be found either in a sound, healthy, loose, unconnected state, and fit for immediate reduction; or in a sound state, but, from some particular circumstances, incapable of being immediately replaced; or in an unsound diseased state, and requiring to be treated accordingly.

If the rupture consists of a piece of intestine only, and that neither mortified nor adherent, the sooner it

(A) They who are not accustomed to perform operations of such consequence as this is, are apt, from timidity, to be too sparing in making their external incision; by which means, they add considerably to their own embarrassment, and to the fatigue of the patient. A free division of the hernial sac and scrotum downwards, gives room for the more easy admission of the finger into the stricture in order to divide it, and affords an opportunity of handling the intestine or omentum more gently as well as more properly in order to return them into the belly; both which necessary parts of the operation are much impeded by a small incision.

As therefore no possible advantage can arise from a small wound, but on the contrary it may be attended with great inconvenience both to the patient and surgeon, Mr Pott advises, when such an opening is made in the hernial sac, as will admit the operator's fore-finger, and upon it his knife, that he immediately divide the sac and scrotum down to the bottom. It is true, that, upon such division, the quantity of intestine will seem to be increased; and an ignorant bystander may be alarmed at this fallacious appearance, which is produced merely by the confined compressed gut being set free, and not by the addition of any more. The advantage which will arise to the operator, and consequently to the patient, from such division, is real and great; it will enable the former to finish his work with freedom, and spare the latter a great deal of pain.

Practice. is returned, the better; and the more gently it is handled for reduction, the better also.

If the intestine be accompanied with a portion of omentum, the latter (if in a proper state) should be returned first.

In returning the intestine, care should be taken to endeavour to put in that part first which came out last, otherwise the gut will be doubled on itself, and the difficulty and trouble be thereby much increased; and in making the reduction, the fingers should be applied to that part of the intestine which is connected with the mesentery, rather than its convex part, as it will both serve the purpose better, and be less likely to do mischief.

While the reduction is making, the leg and thigh on the ruptured side should be kept elevated; as such position of the limb will much facilitate the return of the parts.

Long confinement in the scrotum will in some people produce slight adhesions by slender filaments, which are generally very easily separated by the finger, or divided by a knife or scissors, whether the adhesions be of the parts of the intestine inter se, or to the hernial sac. If the adhesion be of the former kind, and such as proves very difficult to separate, it will be better to return the gut into the belly as it is, than to run the risk of producing an inflammation by using force: if it be of the latter, that is, if the connection be with the sac, there can be no hazard in wounding that; and therefore it may be made free with.

452 SECT. X. Of the Fistula in Ano.

The fistula in ano is an abscess running upon or into the intellinum rectum.

If the surgeon have the first management of the abscess, and there appear an external inflammation upon the one side of the buttock only; after having waited for the proper maturity, let him with a knife make an incision the whole length of it; and in all probability, even though the bladder be affected, the largeness of the wound, and the proper application of dross lightly pressed in, will prevent the putrefaction of the intestine, and make the cavity fill up like impothumations of other parts.—If the sinus be continued to the other buttock, almost surrounding the intestine, the whole course of it must be dilated in like manner; since, in such spongy cavities, a generation of flesh cannot be procured but by large openings; whence also, if the skin is very thin, lying loose and flabby over the sinus, it is absolutely necessary to cut it quite away, or the patient will be apt to sink under the discharge, which is sometimes excessive.

Here we have considered the impothumation as possessing a great part of the buttock; but it more frequently happens, that the matter points with a small extent of inflammation on the skin, and the direction of the sinus is even with the gut: in this case, having made a puncture, you may with a probe learn if it has penetrated into the intestine, by pressing your finger up it, and feeling the probe introduced through the wound into its cavity; though, for the most part, it may be known by a discharge of matter from the anus. When this is the state of the fistula, there is no hesitation to be made; but immediately putting one blade of the scissors up the gut, and the other up the

wound, snip the whole length of it. This process is as advisable when the intestine is not perforated, if the sinus is narrow, and runs upon or very near it; for if the abscess be tented, which is the only way of dressing it while the external orifice is small, it will almost certainly grow callous: so that the surest means of cure will be opening the gut, that proper applications may be laid to the bottom of the wound. However, it should be well attended to, that some sinuses pretty near the intestine neither run into nor upon it; in which case, they must be opened, according to the course of their penetration. There are abundance of instances, where the intestine is so much ulcerated, as to give free issue to the matter of the abscess by the anus: but there are none where there is not, by the thinness and discoloration of the skin, or an induration to be perceived through the skin, some mark of its direction; which, if discovered, may be opened into with a lancet, and then it becomes the same case as if the matter had fairly pointed.

If the sinuses into and about the gut are not complicated with an induration, and you can follow their course, the mere opening with scissors, or a knife guided on a director, will sometimes suffice; but it is generally safer to cut the piece of flesh surrounded by these incisions quite away, and, when it is callous, absolutely necessary, or the callus must be wasted afterwards by escharotic medicines, which is a tedious and cruel method of cure.

When the fistula is of a long standing, and we have choice of time for opening it, a dose of rhubarb the day before the operation will be very convenient, as it not only will empty the bowels, but also prove an astringent for a while, and prevent the mischief of removing the dressings in order to go to stool.

It sometimes happens, that the orifices are so small, as not to admit the entrance of the scissors; in which case, sponge-tents must be employed for their dilatation.

In performing these operations on the anus, no instruments are so handy as the knife and scissors; almost all the others which have been invented to facilitate the work are not only difficult to manage, but more painful to the patient: however, in those instances where the fistula is very narrow, and opens into the intestines just within the verge of the anus, the syringotomy may be used with advantage; but where the opening into the gut is high, it cannot be employed without giving great pain.

The worst species of fistula is that communicating with the urethra, and sometimes (though the prostate gland) with the bladder itself. This generally takes its rise from a former gonorrhoea, and appears externally first in parineo: afterwards, increasing more towards the anus, and even sometimes into the groin, it bursts out in various orifices, through the skin, which soon becomes callous and rotten; and the urine passing partly through these orifices, will often excite as much pain, and of the same kind, as a stone in the bladder.

This species of fistula taking its rise from strictures of the urethra, is only manageable by the bougie: for so long as the urethra is obstructed, the cure of the fistula will be imperfect; but if the canal be opened by this application, it is amazing what oblique indurations and foul sinuses will in consequence disappear; though

Practice. though there are some so callous and rotten, as to demand the knife and skilful dressings, notwithstanding the urethra should be dilated by the use of bougies.

SECT. XI. Bronchotomy, the Extirpation of the Tonsils, &c.

§ 1. Of Bronchotomy.

463 THE operation of bronchotomy is an incision made in the aspera arteria, to make way for the air into the lungs, when respiration is obstructed by any tumour compressing the larynx, or some other disorder of the glottis and aspera arteria, without any apparent tumour.

The manner of doing it, is by making a longitudinal incision through the skin, three quarters of an inch long, opposite to the third and fourth ring of the trachea, if you have the choice of place; and when you cannot make it so high, the rule will be to wound a little below the tumour: it is always advised to pinch up the skin for this process, which, however, may be left to the discretion of the surgeon. When the skin is cut through, you must make a small transverse incision into the wind-pipe, and immediately introduce a silver crooked canula near half an inch long, with a couple of little rings at the top of it, through which a ribband may be passed round the neck, to keep it fixed in the wound.

The method of dressing will be easily understood; since, after the patient can breathe by the natural passage, if you withdraw the hollow tent, the wound will become a simple one, and, notwithstanding its penetration through a cartilage into a large cavity, require a superficial application only.

464 § 2. Extirpation of the Tonsils, and large Piles.

THE tonsils sometimes grow so large and scirrhus as to become incurable, and even to threaten suffocation, if not extirpated. The manner of doing this operation formerly, was by cutting them off: but the almost constant consequence of this wound was a violent hemorrhagy which sometimes proved mortal; on which account it is rejected in favour of the ligature, which is not only void of danger, but also seldom fails of cure.

If the basis of the tonsil is smaller than the upper part, you may pass the ligature by tying it to the end of a probe, bent into the form of an arch, and set into a handle; which being carried beyond the gland, and round it, is to be brought back again: this done, you may easily tie it by the means of an instrument of Mr Cheselden's contrivance, which holds one end of the string on the side of the tonsil next the throat, while you make the knot by pulling the other with the right-hand quite out of the mouth, as will be easily understood by the draught in the copper-plate. Should it happen that the tonsils are conical, so that the ligature will necessarily slip over its extremity when we attempt to tie; in this case, he has recommended an instrument like a crooked needle, set in a handle, with an eye near the point, threaded with a ligature, which is to be thrust through the bottom of the gland, and being laid hold of with a hook, the instrument is to be withdrawn; then, pulling the double ligature forwards, it must be divided, and one part

be tied above, and the other below the tumour; the knots are to be always double, and the ligature to be cut off pretty near them. If after four or five days they slip, or seem to have mortified the tonsil only in part, you must repeat the whole operation; and if it fail a second time, you must even repeat it again.

This kind of extirpation is more practised in large piles that are esteemed incurable. When the piles are within side of the intestine, you must place your patient over a fomentation in a close stool, and have a crooked needle with a double ligature ready to pass through them, when by straining they are pushed out of the anus (for sometimes the intestine will return suddenly), and tie above and below as in the instance of the tonsil. Sometimes the piles are of that shape as to admit a single ligature to be tied round them without the help of a needle, which is less painful. If there are several, you must only tie one or two at a time; for the pain of the ligature is excessive, and would be intolerable if many were tied at once: however, every five or six days, the operation may be repeated till all are extirpated, and the parts must be kept supple by some emollient ointments.—When the piles are small, they may safely and with much less pain be cut off.

The uvula is subject to so great a degree of relaxation sometimes, that it almost chokes the patient: the readiest cure is cutting off all but half an inch of it; which may be done at one snip with a pair of scissors (particularly curved for that purpose), laying hold of it with a forceps, lest it should slip away.

§ 3. Of the Polypus.

465 THE polypus of the nose is said to be an excrescence of flesh, spreading its branches amongst the laminae of the os ethmoides, and through the whole cavity of one or both nostrils. It happens very often to both sides of the nose at once: and in that case is very troublesome, almost suffocating the patient, at least making respiration very difficult. The intent of the operation is the removal of this obstacle.

Polypi arise from the membrane spread upon the laminae spongiose, pretty nearly in the same manner as the hydatids of the abdomen, in one kind of dropsy, do from the surface of the liver; or as ganglions from the tendons, borrowing their coats from a production of its fibres and vessels. If they appear soft, and of the colour of the serum of the blood, in all likelihood they are formed of such a sort of water contained in cysts, which, upon breaking the membrane, leaves so little hold for the instrument, that but a small part of it can be extracted afterwards. This polypus is to be left to harden, before the operation be undertaken, which in process of time it generally will do. In the next degree of consistency, they retain pretty nearly the same colour, and are often partly watery, and partly of a viscid texture, which, though not tenacious enough to admit of drawing them out by the roots, may at several attempts be taken away by bits. The next degree of consistency, is that which is neither so soft as to be squeezed to pieces, nor so hard and brittle as to crumble, or adhere to the membrane with that force as not to admit of separation: this is the most favourable one. The last is hard and scirrhus, adhering

Practice. so tight as to tear rather than separate in the extraction, and sometimes even tends to degenerate into a cancer. This polypus is very difficult of cure.

The polypus sometimes dilates to that degree, as not only to extend beyond the os palati, and hang over the œsophagus and trachea; but also spreading into the sinus maxillaris, so exactly fills up every interstice of the nose, as to obstruct the lower orifice of the ductus ad nasum, and prevent the descent of the tears, which necessarily must return through the puncta lachrymalia: and sometimes they grow so enormously large, as even to alter the shape of the bones of the face.

When the polypus appears in the throat, it is always advisable to extract it that way; it being found, by experience, more ready to loosen when pulled in that direction, than by the nose. To this end, it would be right, before undertaking the operation, to let your patient lie on his back two or three hours, which will bring it still further down; for the body of the polypus does not universally adhere, and will by its weight stretch out the fibres by which it is connected to the nose; nay, there are instances, where by a little effort, such as hawking, they have dropped quite off.

The method of extracting it is by a pair of forceps, with a slit at their extremities for the better hold; which must be introduced into the nostril about an inch and a half, to make more sure of it towards the roots; then twirling them a little from one side to the other, you must continue in that action, while you pull very gradually the body of the polypus. If it break, you must repeat the extraction as long as any remains, unless it is attended with a violent hæmorrhagy, which is an accident that sometimes follows upon the operation, and seldom fails when the excretion is scirrhus. However, the surgeon is not to be alarmed at the appearance of an immoderate effusion the moment after the separation: for, generally speaking, the vessels collapse very soon again; but if they do not, dry lint, or lint dipped in some alyptic, will readily stop it.

After the extraction, it has been usual, in order to prevent a relapse, to dress with escharotic powders, and even to burn with the actual cautery; but neither the one or the other can be of great service in this case, and both are painful and dangerous. If ever the use of corrosive medicines is advisable, it should be for destroying the remainder of a polypus which cannot all be taken away; and then the escharotics may be better conveyed to the part by a long tent, than a seton passed through the nose and mouth, which is difficult to do without hurting the patient, and very natty to bear.

§ 4. Of the Hare-lip.

This is a fissure in the upper lip, with want of substance; and is a natural defect, the patient being always born with it, at least that species of hare-lip which requires the following operation. The cure is to be performed by the twisted suture. There are many lips where the loss of substance is so great, that the edges of the fissure cannot be brought together, or at best where they can but just touch; in which case the attempt should be forborn: it

is likewise forbidden in infants, and with reason if they suck; but otherwise it may be undertaken with great safety, and even with more probability of success than in others that are older. It is not uncommon for the roof of the mouth to be fissured likewise; but this is no objection to the operation, if the skin of the lip is loose enough to admit of reunion: and it may be remarked, that the fissure of the palate, in length of years, closes surprisingly in some cases.

The manner of performing the operation is this. You first with a knife separate the lip from the upper jaw, by dividing the frænulum between it and the gums; and if the dentes incisorii project, as is usual in infants, they must be cut out with the same knife: then with a thin pair of straight scissors take off the callous edges of the fissure the whole length of it; observing the rule of making the new wound in straight lines, because the sides of it can never be made to correspond without this caution. The two lips of the wound being brought exactly together, pass a couple of pins, one pretty near the top, and the other as near the bottom, through the middle of both edges of it, and secure them in that situation by twisting a piece of waxed thread cross and round the pins seven or eight times; you must then cut off the points, and lay a small bolster of plaster underneath them, to prevent their scratching; but when the lower part only of the hare-lip can be brought into contact, it will not be proper to use more than one pin.

The practice of bolstering the cheeks forward does little or no service to the wound, and is very uneasy to the patient. The manner of dressing will be, to remove the applications, which are quite superficial, as often only as is necessary for cleanliness. The method is to defile the three first days, and afterwards to do it every day, or every other day: it is not at all requisite to dress between the jaw and lip where the frænulum was wounded, there being no danger that an inconvenient adhesion should ensue. In about eight or nine days the parts are usually united, and in children much sooner; when you must gently cut the threads, and draw out the pins, applying upon the orifices a piece of plaster and dry lint. It will be proper, in order to withdraw the pins more easily, to daub the ligatures and pins with warm water, and also moisten them with sweet oil, two or three days before you remove them; which will wash off the coagulated blood, that would otherwise fasten them so hard to the ligature as to make the extraction painful.

§ 5. Of the Wry Neck.

This operation of cutting the wry neck is very uncommon, and is never to be practised but when the disorder is owing to a contraction of the sternocleidomastoideus muscle only; as it can answer no purpose to let that muscle free by dividing it (which is all that is to be done) if the others in the neck are in the same state; and more especially if it has been of long standing from infancy, because the growth of the vertebrae will have been determined in that direction, and make it impossible to set the head upright.

When the case is fair, the operation is this. Having laid your patient on a table, make a transverse incision through the skin and fat something broader than

than the muscle, and not above half an inch from the clavicle; then passing the probed razor with care underneath the muscle, draw it out and cut the muscle. The great vessels of the neck lie underneath; but when we are aware of their situation, the danger of wounding them may be avoided. After the incision is made, the wound is to be crammed with dry lint, and always dressed so as to prevent the extremities of the muscle from reuniting; to which end, they are to be separated from each other as much as possible by the assistance of a supporting bandage for the head during the whole time of the cure, which will generally be about a month.

THE phymosis signifies no more than such a straitness of the prepuce that the glans cannot be denuded; which if it becomes troublesome, so as to prevent the egress of the urine, or conceal under it chancres or foul ulcers, quite out of the reach of application, is to be cut open. It sometimes happens that children are born imperforate; in which case, a small puncture, dressed afterwards with a tent, effects a cure. But this operation is chiefly practised in venereal cases, in order to expose chancres either on the glans or within the prepuce itself: And here, if the prepuce is not very callous and thick, a mere incision will answer; which may be made either with the scissars, or by slipping a knife between the skin and glans to the very extremity, and cutting it up. The last method is more easy than that of the scissars: but it is safer to make the wound on the side of the prepuce than upon the upper part, for sometimes the great vessels on the dorsum penis afford a terrible hæmorrhage; though as the prepuce remains better shaped after an incision made in the upper part, the upper incision is to be preferred by those who understand how to take up the vessels. In children, it sometimes happens that the prepuce becomes very much contracted; and in that case, it is accidentally subject to slight inflammations, which bring on some symptoms of the stone; but the disorder is always removed by the cure of the phymosis.

If the prepuce be very large and indurated, the opening alone will not suffice: it is more advisable to take away the callosity by circumcision, which must be performed with a knife; and if the artery bleed much, it must be taken up with a small needle and ligature.

THE paraphymosis is a disease of the penis, where the prepuce is fallen back from the glans, and cannot be brought forwards to cover it. There are many whole penis is naturally thus formed, but without any inconvenience; so that since the time of the Romans (some of whom thought it indecent to have the glans bare), it has not been usual to perform any operation upon that account; but we read the several processes of it described very particularly by Celsus, who does not speak of it as an uncommon thing. Most of the instances of this distemper are owing to a venereal cause; but there are some where the prepuce is naturally very tight, which take their rise from a sudden retraction of it, and immediate enlargement of the

glans preventing its return. Sometimes it happens that the surgeon succeeds in the reduction immediately, by compressing the extremity of the penis at the same time he is endeavouring to advance the prepuce; if he does not, let him keep it suspended, and attempt again, after having fomented and used some emollient applications: but if, from the contraction below the corona glandis, there is so great a stricture as to threaten a gangrene, or even, if the penis is much enlarged by water in the membrana reticularis, forming tumours called crystallines, three or four small incisions must be made with the point of a lancet into the stricture and crystallines, according to the direction of the penis; which, in the first case, will let free the obstruction, and in the other evacuate the water. The manner of dressing afterwards must be with fomentations, digestives, and the theriaca Londinensis over the pledgits.

THIS operation is performed, when the bladder is under such a suppression of urine as cannot be relieved by any gentler methods, nor, by reason of the obstruction in its neck or the urethra, will admit of the introduction of a catheter. The manner of doing it, as described by most writers, is by pushing a common trocar from the place where the external wound in the old way of cutting is made, into the cavity of the bladder, and so procuring the issue of the water through the canula: but others, refining upon this practice, have ordered an incision to be carried on from the same part into the bladder, and then to insinuate the canula. But both the methods are to be rejected in favour of an opening a little above the os pubis: for besides that it is not easy to guide the instrument through the prostate gland into the bladder, the necessity of continuing it, in a part already very much inflamed and thickened, seldom fails to do mischief, and even to produce a mortification.

There is another method still more easy both to the patient and the operator; which consists only in emptying the bladder with a common trocar, and stopping the canula with a little cork, which is afterwards to be taken out as often as the patient has occasion to urine. The canula is to be continued in the bladder till such time as the person finds he can void his urine by the natural passage.

In this operation the abdomen ought to be perforated about two inches above the os pubis; and if the patient be fat, the trocar should penetrate two inches, otherwise an inch and a half will be sufficient.

THE patient being laid on a horizontal table, with his thighs elevated and a little extended, pass the sound with the concave part towards you, until it meets with some resistance in perineo, a little above the anus: then turning it without much force, push it gently on into the bladder; and if it meets with an obstruction at the neck, raise its extremity upwards, by inclining the handle of it towards you; or if it do not then slip in, withdraw it a quarter of an inch, and, introducing your fore-finger into the rectum, lift it up, and it will seldom

Practice. seldom fail to enter. There is some art in turning the found in the proper place of the urethra, which surgeons not versed in this operation cannot so well execute; therefore they may pass the instrument with the concave side always towards the abdomen of the patient, observing the same rule at the entrance into the bladder as in the other method. The cause of this obstacle, besides the rugæ of the urethra, and the resistance of the verumontanum, is sometimes a small projection of the orifice of the bladder in the urethra, like that of the os tincæ in the vagina, which occasions the end of the found to slip a little beyond it.

SECT. XII. Of Lithotomy.

⁴⁷² Lithotomy reckoned exceedingly dangerous by the ancients. THE removal of the stone from the urinary bladder, by the operation called lithotomy, has been ever classed amongst the most dangerous operations in surgery, and, till lately, was attempted but by very few, who were distinguished by the title of lithotomists. And this appears probably to have been the case in the time of Hippocrates, if any thing may be concluded from the oath ascribed to him; in which he declares, "He will not cut such as have the stone, but leave that operation to those who make it their peculiar practice."

⁴⁷³ Celsus's method. The most ancient method of cutting for the stone with which we are acquainted, is described with great accuracy and elegance by Celsus, who makes an incision in perineo immediately upon the stone, though not in the same direction with that which is now made in what is called the lateral operation. He says, "A lunated incision is to be made near the anus down to the neck of the bladder, so as the horns of the incision may point towards the coxæ; and from the bottom of the wound thus made, where it is narrower, a second incision must be made transversely; by which the neck of the bladder is to be opened, and a passage made for the urine, and the stone exposed; and moreover, this wound is to be larger than the size of the stone," for reasons which he gives. The operation described by Celsus is, in contradistinction to a more modern one invented by Johannes de Romanis, in which a greater number of instruments were employed, called apparatus minor.

⁴⁷⁴ Of the high operation. Petrus Francus, finding a stone too large to be taken away through an opening in perineo, boldly made an incision through the integuments and muscles, above the ossa pubis, into the bladder, and happily extracted it. This method has since been revived, and practised by some others, under the title of the high operation.

⁴⁷⁵ Of the lateral operation. Modern practitioners have adopted that which is called the lateral operation. Frere Jaques was, without doubt, the first person who gave the hint; and though he was extremely ignorant, yet, from the knowledge of the parts concerned in the operation, many eminent surgeons were convinced of the great probability there was of its being made a very excellent method, by correcting his errors; among whom was professor Rau in Holland, and Mr Cheselden in England.

⁴⁷⁶ Of the new method. Heister seems to prefer Celsus's method (as he understands it) in lads under 14 years of age, and chiefly on account of fewer instruments being employed in this than in other methods.

The new method, or apparatus magnus, seems to be projected merely from the observation made of the

great dilatability of the cervix vesicæ, and parts adjacent, when the stone is extracted in women. Therefore, as by cutting under the scrotum, close to the raphe on the left side, in perineo, through the integuments and muscles, as low down as the upper part of the anus, then carrying the knife deeper to divide the urethra, the parts divided by these openings are brought nearly into the state of the urethra in women, those who perform this operation must depend on the dilatation of the parts in one as well as the other for the passage of the stone, when it is extracted by this method.

When it is determined that the operation shall be performed, the manner of preparing the patient depends on various circumstances. For example, if he is plethoric, a few ounces of blood should be taken away; and, at proper distances of time, the bowels must be emptied; the patient's diet should be chiefly milk and vegetables, or other light food; which regimen should be observed for some days before the operation. The opening medicines should be principally manna, or such other lenients as will best answer the purpose; if the pain should be violent, bleeding becomes as necessary sometimes as in plethorics; but opium must be employed to abate the excess of pain: nevertheless it may be advisable to try first the effect of keeping the patient on the bed with his hips raised, in order, if possible, to roll the stone from the neck of the bladder: he should not, on any account, be permitted to sit up or use motion during the preparation for this operation.

It has been frequently remarked, on a diaphoresis coming on after operations in general, that the pain abated, and other disagreeable symptoms went off. "This (says Mr Bromfield), induced me to make use of the warm bath at proper distances of time, according to the strength of the patients, as a part of the preparatory plan for this operation, and it always succeeded to my utmost expectations: for from the skin being well cleaned and softened by the warm water, an anodyne seldom failed to produce a gentle perspiration after the operation was performed, and generally prevented the usual symptomatic fever consequent to operations.

"If the patient is an adult, the perineum should be shaved and well cleaned. An hour or two before the operation is to be performed, a clyster should be given to empty the rectum; and a few minutes before he is to be cut, he should make as much water as he can.

"The patient being laid on a table covered with blankets, pillows, &c. and properly secured by ligatures and assistants, I pass the staff into the bladder, and incline the handle towards the abdomen, and obliquely to the right groin, so as to feel the groove of the staff in the perineum on the left side of the raphe, which will be in the membranous part of the urethra. I then fix it, and deliver it to my assistant, and desire him to press it gently in order to advance the sulcus of the staff in the direction in which I had given it to him; another assistant supports the scrotum. I then seat myself on a chair of a convenient height, and begin my incision of the external integuments about half an inch below the commissure of the ossa pubis on the left side of the raphe, and pursue it by a quick stroke, obliquely,

obliquely outwards and downwards, between the anus and obtuse process of the ischium, ending somewhat lower than the basis of that process. As soon as the integuments are thus divided, I introduce the fore and middle fingers of my left hand; with the last I keep back the lip of the wound next the raphe, and with the index press down the rectum. I then make a second incision, almost in the same direction with the first, but rather nearer to the raphe and anus, and sufficiently deep to divide the transversalis penis, and as much of the levator ani and ligamentous membrane as will make the prostate gland perceptible by my finger. I then with the index of my left-hand feel for the sulcus of the staff, which serves as a conductor to my knife for opening the membranous part of the urethra, and afterwards for dividing part of the prostate: the rectum is likewise by my fingers kept out of the way of the knife in the next part of the operation, which I effect in the following manner. Hitherto I held the blade of my knife like a pen, between the fore-finger and thumb, and resting on the middle finger of my right-hand, with the back of the blade uppermost; but now I take it between the fore-finger and thumb of my right, with the handle towards the palm of my hand on the inside, the back of the blade facing the inside of the index of the right hand: I then turn the back of this hand that holds the knife downwards, and convey the knife to the membranous part of the urethra, by gliding the under fingers of my right-hand on the index of my left-hand, which serves as a conductor of the knife to the gland. As soon as I perceive that, I feel for the groove of the staff with the index of my left-hand, with which I convey the convex edge of the knife into the membranous part of the urethra, as much laterally as is possible, and as nigh to the prostate. When I am clearly in the sulcus of the staff, I turn the back of my knife as much downwards as I can to avoid wounding the rectum, as I then push the blade of the knife along the groove of the staff into the body of the gland, sliding the knife on the convexity of its edge, till it has divided near half the length of that gland; and if I wish to cut a little more of it, I incline the handle of my knife a little downwards, and towards the left ischium. The point of the knife will then drop into the groove of the staff; and by drawing the knife in this situation towards me, I shall certainly make good the wound of the prostate, so as near two-thirds of it may be divided in the operation. This last stroke of my knife is what is generally called cutting from within outwards. I then introduce the beak of the common gorgeret into the groove of the staff, and press it on till it gets into the bladder, which is soon discovered by the flux of the urine. I order my assistant to withdraw the sound, and I then turn the convex part of the gorgeret towards the wound made in the prostate, and glide the fore-finger of my left-hand in the concave part of the gorgeret till it enters the bladder: by this means I easily and gradually dilate the neck of the bladder; which being done sufficiently, I withdraw my finger, and introduce the forceps. If I do not readily feel the stone with my forceps shut, I give a gentle stroke with them on the part of the bladder near its neck, which is in contact with the rectum; by which means the stone will often

drop down: if not, I rest one cheek of the forceps on the part I had before given the stroke, and, by raising the other, open the forceps: the inferior blade then becomes the axis, on which I turn the upper branch, first to one side, and then to the other, making them gradually approach each other; by which means I generally can lay hold on the stone. When I attempt to extract it, I do it very gently, till I find resistance from the adjacent parts. I then endeavour to prevent the forceps from pressing too much on the stone, by placing the thumb of my left hand as near the joint of the forceps as I can, which, unless the stone is very soft, will prevent its breaking. If any vessel of consequence should be wounded, I take it up by the needle and ligature or tenaculum; if small, I only apply a piece of dry lint to the mouth of the bleeding vessel.

"In case the bladder has not been duly emptied before the operation, great care should be taken in extracting the stone, especially if small; for there not being time for the bladder to contract itself duly, it naturally will fall into wrinkles; these will be liable to be laid hold on together with the stone, which might prove fatal. If the stone is very large, I make use of a screw I have contrived, which may be passed through a hole in one of the branches of the forceps, in which is a female screw: by turning the male screw, you may determine to the greatest exactness the degree of pressure you would choose to make to secure the stone in the forceps.

"Though I have given this rule to prevent the breaking of a stone, yet I think the hazard is greater, in respect to the patient's life, where the stone is large and hard and the incision small, if it should not break, than if it should by the resistance of parts undivided. But still in this case there is danger from some fragments remaining behind (which will probably become nuclei for the formation of other stones), as well as from the forceps being so frequently introduced as may be necessary to their extraction. But I think that when the stone is very large, the best way will be, to bring it forward with your forceps, then secure them by your screw from making too great compression: you may then make your incision on the stone laterally through the prostate gland; which is certainly preferable to risking the laceration and contusion of the parts, by extracting so large a body through an opening naturally so small. I highly disapprove of turning the stone from one side to the other when in the forceps, by way of dilating the neck of the bladder; as the points of the stone, particularly if it should prove of the mulberry form, will probably lacerate the parts, and occasion large sloughs, and frequently cause a mortification. Andreas a Cruce is so apprehensive of the ill consequences of extracting a large stone through the neck of the bladder, that he has contrived forceps with large teeth in order to break the stone to pieces: he has likewise recommended a sort of scoop or spoon in order to take out the broken pieces, as he seems extremely sensible of the ill consequences attending the smallest pieces being left in the bladder. To inform himself whether the bladder be totally free from any fragments of the stone, he has contrived an instrument he calls verruculum, with which he examines carefully every part of the bladder: he says,

Practice. says, that the most eminent operators of his time neither used dilators nor instruments to break the stone, but trusted to their fingers or the goose-bill forceps for the extraction. Should any small branches of the pudica interna be wounded in the operation, in case a large stone has been extracted, the bleeding will rather be of service than prejudicial; and I should rather encourage it, by fomenting the wound and parts adjacent with some emollient fatus, in which there is a third or fourth part vinegar. A pledget of soft digestive is to be laid on the surface of the wound, which should be frequently renewed: for the dressing being pressed down deep in the wound, with a view to obtain granulations from the bottom, is extremely likely to make the wound fistulous; which seldom happens by the superficial method of dressing. Excoriations of the buttocks may be prevented by placing a sheet under them several times doubled, so as to be in breadth about 18 or 20 inches: it must be rolled up all but as much as is necessary to be laid under the patient. At first the remainder of the roll is put by his side, which unrolls as the nurse draws the wet part from under him: by this method he is almost constantly kept dry. If excoriations should happen, or any other unfavourable symptom, surgery will direct what should be done. I generally keep the patient on a low diet for a week or ten days, as occasion may require.

"To obtain the first stool, a clyster for the most part is necessary; which I greatly prefer to purging medicines given by the mouth, as they frequently occasion more stools than one would wish. I think I have sometimes gained time, after the urine had passed a day or two by the usual channel, by applying compresses and slips of plaster on the lips of the wound to keep them in contact, assisted by the T bandage.

"Having frequently observed in several of my pupils, when they attempted to perform this operation on dead subjects, that they had great difficulty in getting at the prostate gland, so as to divide it properly; and having repeatedly remarked the embarrassment that several operators have had in effecting it on the living subject; I was induced, many years since, to show, in my courses of operations, the two following instruments: the first by the French is called bistouris caché; the method of using which is as follows.

"The incision of the external integuments being made as above directed, the membranous part of the urethra is then to be opened with the point of the knife laterally, as near to the prostate gland as possible: through this opening of the urethra, the bistouris caché is to be introduced by the groove of the staff into the bladder; as soon as that is effected, the instrument should be disengaged from the staff, which may then be withdrawn. You then place the instrument in such direction, as, when you withdraw, it to make the wound of the gland on the left side, rather obliquely downwards and outwards than horizontally lateral. When you have placed your instrument to your mind, incline the handle towards your patient's left thigh; then press on the spring, which will bring out the blade of the knife that before was concealed in the groove, and withdraw it, observing that obliquity of the handle towards the left thigh during the whole time you are dividing the neck of the bladder. There is great

Practice. nicity in making this drawing cut: for if the blade of the knife be not placed with some obliquity downwards, it will wound the erecter penis, and that branch of the hypogastric artery called pudica externa; if placed quite perpendicular, it will wound the vesiculæ feminales and intestine. If you withdraw it in a straight line towards you, the bladder will be wounded beyond its neck. These hints observed, the instrument I think will be of use to those who find a difficulty in dividing the gland with a knife.

"The other instrument I call the double gorgeret. The upper part on which the blade is fixed must be united with the under half, by means of the grooves in its upper edges receiving the lower edges of that part with the knife affixed; they then become one instrument, which, if the blade is taken off, somewhat resembles the extreme part of a cow's horn. The manner of using this instrument is as follows: The incisions of the integuments and urethra being made as directed for cutting with the bistouris caché, the beak of the gorgeret is to be introduced into the groove of the staff. I then take the staff from my assistant with my left-hand, and incline the handle to the patient's left groin; in which situation, I can pass the instrument with the blade pointing obliquely outwards and downwards, and then push it on quite into the bladder, of which I am informed by the urine running through the instrument, which serves as a direction how much farther the instrument should be pushed on, in order to divide about two-thirds of the length of the gland. I then withdraw the upper half of the instrument with the blade, the lower part that remains becoming the common gorgeret. I should have remarked, that I take the instrument, when its parts are united, in my right hand, the wooden handle resting in the palm against the ball of my thumb, and my thumb placed on the upper part of the handle: by this means the two parts of the instrument will be kept in contact when used, merely from the resilience of the prostate gland, &c. during its introduction. The remaining part of the operation is finished as usual in the lateral method; except that when you want to disengage the forceps, it will be necessary to raise the left-hand that holds the gorgeret, at the same time that the right is depressed. It is possible I may be partial to my own contrivance; but I cannot say that I have ever seen any other instrument that has been since made, formed with the same intentions with mine. The common gorgeret, if it does not cut on its edge, and the membranous part of the urethra only be opened, will probably force off the prostate gland and neck of the bladder from its continuation with the urethra; which Mr Cheselden assured me has more than once been the case, from the shoulders near the beak not being able to dilate, unless the prostate is in some measure divided at its connection with the membranous part of the urethra: therefore I find the double gorgeret, even without the blade, is more easily introduced than the common gorgeret, and without hazard, as by dilatation it prepares the parts for the introduction of the forceps; which preparatory dilatation is still of greater service when the gland is to be divided with the blade affixed; and the lower part of the gorgeret will defend the intestine and vesiculæ feminales from being wounded.

"Many who espouse the lateral operation, as it is called, conclude, that the gland should be wounded laterally and horizontally; and for that purpose have invented various instruments to cut it through its whole length, to facilitate the extraction of a large stone. The prostate gland, I believe, is very rarely entirely divided in the present method of performing the operation, and I think never horizontally laterally, as is supposed; which indeed is obvious from the situation of the groove of the staff, which must cause the opening to be in the under part of the gland, a little to the left side. When the common dissecting knife only is employed, some, as soon as they have made an opening into the urethra, in that part where the groove of the staff can be felt most sensibly, in order to avoid wounding the rectum, divide the gland obliquely upwards and outwards. From what I have seen of this method of operating, I am convinced there is not any advantage in it; but, on the contrary, that it is rather prejudicial where the stone is large: for the resistance of the gland being taken away in the upper part by the incision, and the ligamentous and muscular parts remaining undivided below, the stone is thrown up towards the symphysis of the bones of the pubis, which is the smallest part of the angle of the pelvis, through which the stone is to pass: the great force consequently requisite to extract it, under these circumstances, frequently occasions the stone to be broken, and the neighbouring parts very much contused and lacerated; which could not be the case, were all the resistance taken away below where the distance between the ischia is greatest.

"Though almost all operators would gladly wish (by what I understand) to divide the prostate gland throughout its whole length, it is what I would always choose to avoid: about two-thirds of it nearest to the membranous part of the urethra, I am convinced, will be sufficient, and attended with more advantages than the cutting it entirely through: as the only obstacle a stone meets with is in that part of the gland, and as the neck of the bladder beyond that will dilate sufficiently in most cases without laceration, and as the wounded parts will sooner heal by the muscular fibres, which act as a sphincter, recovering their tone, than they would do if the urine were constantly running through them. By this method of operating, and proper treatment of the wound afterwards, I do not recollect a single instance of a fistula remaining."

SECT. XIII. Of Castration, and the Extirpation of Encysted and Cancerous Tumours.

§ 1. Of Castration.

THIS is one of the most melancholy operations in the practice of surgery, since it seldom takes place but in disorders into which the patient is very apt to relapse, viz. those of a scirrhous or cancer: for under most of the symptoms described as rendering it necessary, it is absolutely improper; such as a hydrocele, abscess of the testes, an increasing mortification, or what is sometimes understood by a farceole; of which last it may not be amiss to say a word. In the utmost latitude of the meaning of this term, it is received as a fleshy swelling of the testicle itself, called likewise hernia carnea; or in some enlargements, such

as in a clap, more frequently hernia humoralis; but generally speaking, is considered as a fleshy excrescence formed on the body of the testis, which becomes exceedingly hard and tumefied, for the most part is supposed to demand extirpation, either by cutting or burning away the induration, or amputating the testicle. But this maxim too precipitately received, has very much misguided the practitioners of surgery.

It sometimes happens that the epididymis is tumefied, independent of the testicle; and, feeling like a large adventitious excrescence, answers very well to the idea most surgeons form of a farceole: but not being aware of the different nature and texture of the epididymis, they have frequently confounded its disorders with those of the testicle itself, and equally recommended extirpation in the induration of one and the other. But all indurations of the glandular part of the testicle not tending to inflammation and abscess, generally, if not always, lead on to scirrhous and cancers; whereas those of the epididymis seldom or never do. It is true, in spite of internal or external means, these last often retain their hardness, and sometimes suppurate, but, however, without much danger in either case.

Before castration, it is laid down as a rule to inquire whether the patient has any pain in his back; and in that case to reject the operation, upon the reasonable presumption of the spermatic vessels being likewise diseased: but we are not to be too hasty in this determination; for the mere weight of the tumour stretching the cord, will sometimes create this complaint. To learn the cause, then, of this pain in the back, when the spermatic cord is not thickened, let your patient be kept in bed, and suspend his scrotum in a bag-truss, which will relieve him, if disordered, by the weight only; but if the spermatic cord is thickened or indurated, which disease, when attended with a dilatation of the vessels of the scrotum, is known by the Greek appellations circeosele and varicosele, the case is desperate, and not to be undertaken.

But supposing no obstacle in the way to the operation, the method of doing it may be this. Lay your patient on a square-table of about three feet four inches high, letting his legs hang down, which, as well as the rest of his body, must be held firm by the assistants. Then with a knife begin your wound above the rings of the abdominal muscles, that you may have room afterwards to tie the vessels, since for want of this caution operators will necessarily be embarrassed in making the ligature: then carrying it through the membrana adiposa, it must be continued downward, the length of it being in proportion to the size of the testicle. If it is very small, it may be dissected away without taking any part of the scrotum. If the testicle, for instance, weighs twenty ounces; having made one incision about five inches long, a little circularly, begin a second in the same point as the first, bringing it with an opposite sweep to meet the other in the inferior part, in such a manner as to cut out the shape of an oval whose smallest diameter shall be two inches: after this dissect away the body of the tumour, with the piece of skin on it, from the scrotum; first taking up some of the blood-vessels, if the haemorrhagy is dangerous. Then pass a ligature round the cord, pretty near the abdomen; and, if you have space between

480
In what cases castration is advisable.

481
When the operation ought not to be performed.

482
Method of performing it.

Practice. tween the ligature and testicle, a second about half an inch lower, to make the stoppage of blood still more secure. The ligatures may be tied with what is called the surgeon's knot, where the thread is passed through the ring twice. This done, cut off the testicle a little underneath the second ligature, and pass a needle from the skin at the lower part of the wound thro' the skin at the upper part, in such a manner as to envelope in some degree the found testicle, which will greatly facilitate and quicken the cure; or if one stitch will not answer the purpose, you may repeat it in such part of the wound where the skin on each side lies most loose.

In large tumours, it is advisable to cut away great part of the skin; for besides that the hæmorrhage will be much less in this case, and the operation greatly shortened, the skin by the great distention having been rendered very thin, will great part of it, if not taken away, sphacelate, and the rest be more prone to degenerate into a cancerous ulcer.

§ 2. Of Encysted Tumours.

483 That called steatoma is never painful until by its weight
* See n^o 170 it grows troublesome, nor is it a mark of general indisposition of body; so that the extirpation seldom fails of success. The size of some of them is very large, frequently weighing five or six pounds, and there have been instances of their weighing above forty.

When the steatoma is irregular in its surface, with eminences and depressions, it is fatty; whereas the fat one has for the most part a uniform smooth outside. The operation for the steatoma will be understood by the description of that for the scirrhus.

† See n^o 170 The antheroma † is much more common than the melicercis ‡; at least, if all encysted tumours with matter not curdled, may, in compliance with custom, be called so: These are more frequent, and grow larger than those where the matter is curdled, being often attendant on serophulous indispositions, which makes them more difficult of cure.

‡ See n^o 170 The cysts of these tumours, with the skin covering them, after a certain period of growth, resisting any further enlargement, do frequently inflame and break: but this opening is not so advantageous for the cure as extirpation by the knife, which should be done in the infancy of the swelling. When the tumours are no bigger than a small golden pippin, they may be dissected away from under the skin, by making a straight incision only through it; but if they exceed this bulk, an oval piece of skin must be cut through first, to make room for the management of the knife and taking away the tumour; in which case, it will be advisable to take off the upper portion of the cyst with the skin; and then, by the help of a hook, to dissect away as much of the remainder of it as can be conveniently, which is a less painful and more secure method than destroying it afterwards with escharotics. This rule is to be observed when the cyst runs so deep amongst the interstices of the muscles, as to make it impossible to remove the whole of it, where, if we cut off a great quantity, the rest usually comes away in sloughs and matter.

The ganglion of the tendon is an encysted tumour of the melicercis kind, but its fluid is generally like the white of an egg: when it is small, it sometimes disperses of itself; pressure and sudden blows do also re-

move it; but for the most part it continues, unless it be extirpated. It is no uncommon case to meet with this species of ganglion running under the ligamentum carpalé, and extending itself both up the wrist and down to the palm of the hand. The cure of this disorder cannot be effected but by an incision through its whole length and dividing the ligamentum carpalé.

The dressing in these cases does not at all differ from the general methods of treating wounds.

§ 3. Of the Amputation of the Cancered and Scirrhous Breast.

484 WHEN a scirrhus has admitted of a long delay before the operation, the patient seems to have a better prospect of cure without danger of a relapse, than when it has increased very fast, and with acute pain.

The scirrhus may be distinguished, by its want of inflammation in the skin, its smoothness and slipperiness deep in the breast, and generally by its pricking pain; which as it is more or less, increases the danger accordingly; though there are some few with little or none in the beginning: as the tumour degenerates into a cancer, which is the worst degree of scirrhus, it becomes unequal and livid, and the vessels growing varicous, at last ulcerate.

In extirpating the scirrhus, if it be small, a longitudinal incision will dilate sufficiently for the operation; but if too large to be dissected out in that manner, an oval piece of skin must be cut through first, the size of which is to be proportioned to that of the tumour; for example, if the swelling is five inches long and three broad, the oval piece of skin cut away must be nearly of the same length, and about an inch and a half in breadth. In taking off the whole breast, the skin may be very much preserved, by making the wound of it a great deal less than the basis of the breast, which must be carefully cleared away from the pectoral muscle. This is not difficult to do, because all these scirrhuses being enlarged glands, are encompassed with their proper membranes, which make them quite distinct from the neighbouring parts, and easily separable: at least this is the case when the tumour is moveable; for sometimes it adheres to the subjacent muscle, and that muscle to the ribs; in which circumstance, the operation is impracticable. When it is attended with knots in the arm-pit, no service can be done by amputation, unless the knots be taken away; for there is no sort of dependence to be laid on their subsiding, by the discharge of the wound of the breast.

The bleeding of the large arteries is to be stopped by passing the needle twice through the flesh, almost round every vessel, and tying upon it, which will necessarily include it in the ligature. In order to discover the orifices of the vessels, the wound must be cleaned with a sponge wrung out of warm water.

The scirrhous tumours which appear about the lower jaw, are, generally speaking, serophulous disorders, that distinguish themselves almost by the circumstance of fixing on the salivary glands. These are very stubborn of cure, but not so bad as the scirrhus, since they frequently suppurate, and heal afterwards: if they impothumate again after healing, it is for want of a good bottom, which may sometimes be procured by destroying their bad surface with a caustic. Besides these, there is another species of scirrhus in the neck, that

that succeeds better after extirpation than either of the former kind; this is an enlargement of the lymphatic glands, which run close up by the jugular vein, and is distinguishable from the cancers of this part, by its moveableness, want of pain, the laxness of the skin covering it, the small degree of pressure it makes on the œsophagus and trachea, and lastly the good habit of body, as it seldom affects the constitution, which cancers here do very early, after their first appearance. This tumour, from its situation, requires great exactness in the cutting off: they sometimes extend up to the chin towards the mouth, and occasion a division of the salivary duct in operating, which proves very troublesome to heal; but, when all other methods have failed, may be cured by a perforation into the mouth, through that part of the cheek where it is wounded, which by a tent or small seton may be made fistulous; then, by properly dressing upon the outside, the oozing of the saliva that way will be prevented, and the external orifice healed without difficulty.

The treatment of all these wounds may be with dry lint first, and afterwards as in common wounds.

SECT. XIV. Of the Operation for the Empyema, Ascites, and Hydrocele.

§ 1. Of the Empyema.

The operation for the empyema implies an artificial opening made into the cavity of the thorax, by which we evacuate any fluid that lies there extravasated, and is become dangerous by its weight and quantity. The fluids described as necessary to be avoided by this operation, are blood, matter, and water.

When blood is the fluid supposed to require evacuation by this method, it is always extravasated through some wound of the vessels of the lungs or thorax; and being discharged in great quantities on the diaphragm, is said to oppress respiration, till let out by some convenient opening made in the most depending part of that cavity, which is the only kind of perforation into the thorax distinguished by the name of the operation for the empyema: But though this opening is universally recommended in the case here stated, yet we meet with few or no examples where it has been practised for a mere extravasation of blood.

The second circumstance in which this operation takes place, is a rupture of matter from the pleura, mediastinum, or lungs, into the cavity of the thorax; where accumulating, it at length proves fatal for want of a discharge. It is true, that the case occurs but very seldom where the operation is necessary; because, in most abscesses of the thorax, the matter is usually spit up as fast as it is generated; and in the dissection of those who have died of this species of consumption, we rarely find much extravasated pus in the cavity, though a great portion of the lungs be destroyed. However, there are a few cases which require the operation; and these may be distinguished by the following symptoms. The patient is obliged to lie upon the diseased side, or, in case there is matter in both cavities of the thorax, on his back; because the mediastinum can seldom support the weight of the incumbent fluid, without suffering great pain. But this rule is not certain, it sometimes happening that the patient can lie with ease on that side where

there is no fluid. Another symptom of extravasated matter, is an evident undulation of it, so that in certain motions it may be hard to quash. For the most part too, upon careful inquiry, an œdema, or at least a thickening of some portion of the intercostal muscles, will be discovered. And lastly, if there be much fluid, it will be attended with a preternatural expansion of that side of the chest where it lies. When therefore these signs appear after a previous pleuritic or pulmonary disorder, and the case has been attended with the symptoms of a suppuration, it is most probably owing to a collection of matter; though the patient will also labour under a continual low fever, and a particular anxiety from the load of fluid.

The last sort of fluid said to require issue from this operation is water, which however very seldom collects in such manner as to become the proper subject of the operation: for if the dropy of the thorax be complicated with an anasarca, or even ascites, it is certainly improper; and indeed it hardly ever takes place, but where the diaphragm is single, and takes its rise from the same sort of disorders in the lymphatics of the pleura, as the hydrocele does from those of the tunica vaginalis. The symptoms of this dropy are, a small cough without spitting; a little slow fever, from the disturbance of respiration; sometimes, too, the water, by a sudden jerk, may be heard to quash; and generally speaking, its weight upon the diaphragm and mediastinum are so troublesome as to oblige the patient to stoop forward, and to turn upon the affected side when he lies down; for the same reason, when there is water in both cavities of the thorax, he is forced to lie on his back.

The manner of operating, whether it be for the discharge of matter or water, is to pitch upon the depending part of the thorax, which some have supposed to be between the eighth and ninth ribs, and others between the ninth and tenth, at such a distance from the vertebrae that the depth of the flesh may not be an impediment to the perforation. This distance is determined to be about a hand's breadth: and here, with a knife, scissars, or trocar, we are ordered to make the perforation; but in doing it there are a great many difficulties. In fat persons, it is not easy to count the ribs, and the wound will be very deep, and troublesome to make; it is hardly possible to escape wounding the intercostal artery, which runs in this place between the ribs. But if the only advantage proposed by the situation of the wound be derived from its dependency, the purpose of discharging the fluid will be as well answered by an opening between the sixth and seventh ribs, half way from the sternum towards the spine; which, by laying ourselves down, becomes in effect as depending an orifice as the other in sitting up; and by an opening made in this manner we avoid all the inconveniences in the other method: for in this part of the thorax there is very little depth of muscles; the artery lies concealed under the rib; and the diaphragm is at a great distance. The opening is best made with a knife; and should be about an inch long through the skin, and half an inch through the subjacent muscles: tho', to make the incision with less risk of wounding the lungs, it may be advisable to dilate it with the blunt-pointed knife (as is practised in the operation for the bu-

Practice. bubonocoele), after having made a small puncture with a common knife. The treatment of the wound will be according to the nature of the discharge. If, after a few days, there appears no drain, you may let the orifice heal up; but if it continues, it may be kept open with a short silver canula, until such time as an alteration in that circumstance will give us leave to cicatrize with safety.

§ 2. Of the Paracentesis, or tapping for the Dropsy.

This operation is an opening made into the abdomen, in order to empty any quantity of extravasated water, collected in that species of dropsy called the ascites; but as there is much more difficulty in learning when to perform than how to perform it, and indeed in some instances requires the nicest judgment, we shall endeavour to specify the distinctions which render the undertaking more or less proper.

457
Of the different kinds of dropsy. There are but two kinds of dropsy: the anasarca, called also leucophlegmacy, when the extravasated water swims in the cells of the membrana adiposa; and the ascites, when the water possesses the cavity of the abdomen. In the first kind, the water is clear and limpid; but in the second, a little grosser, very often gelatinous and corrupted, and sometimes even mixed with fleshy concretions.

The operation of tapping is seldom the cure of the distemper: but dropsies, which are the consequence of a mere impoverishment of the blood, are less likely to return than those which are owing to any previous disorder of the liver; and it is not uncommon for dropsies that follow agues, hæmorrhagies, and diarrhoeas, to do well; whereas in such as are complicated with a scirrhous liver, there is hardly an example of a cure.

The water floating in the belly, is, by its fluctuation, to determine whether the operation be advisable; for if, by the laying one hand on any part of the abdomen, you cannot feel an undulation from striking on an opposite part with the other, it is to be presumed there will be some obstacle to the evacuation. It sometimes happens, that a great quantity, or almost all the water, is contained in little bladders, adhering to the liver and the surface of the peritoneum known by the name of hydatids; and the rest of it in different-sized ones, from the degree of a hydatid, to the size of a globe holding half a pint or pint of water. This is called the encysted dropsy, and from the smallness of its cysts makes the operation useless; but is not difficult to be distinguished, because there is not a fluctuation of the water, unless it is complicated with an extravasation.

When the fluctuation is hardly perceptible, (except the teguments of the abdomen are very much thickened by an anasarca), in all probability the fluid is gelatinous.

There is another kind of dropsy, which for the most part forbids the operation, and is peculiar to women, being seated in the body of one or both ovaries. There is no example of this species but what may be known by the hardness and irregularity of the tumour of the abdomen, which is nearly uniform in the other cases.

When the ovary is dropical, the water is generally deposited in a great number of cells formed in the body of it; which circumstance makes the fluctuation

insensible, and the perforation useless: though sometimes there are only one or two cells; in which case, if the ovary is greatly magnified, the undulation will be readily felt, and the operation be advisable.

When the ascites and anasarca are complicated, it is seldom proper to perform the operation, since the water may be much more effectually evacuated by scarifications in the legs than by tapping.

Upon the supposition that nothing forbids the extraction of the water, the manner of operating is this. 488
Method of tapping.

Having placed the patient in a chair of a convenient height, let him join his hands so as to press upon his stomach; then dipping the trocar in oil, you stab it suddenly through the teguments, and, withdrawing the perforator, leave the waters to empty by the canula. The abdomen being, when filled, in the circumstance of a bladder distended with a fluid, would make it indifferent where to wound; but the apprehension of hurting the liver, if it be much enlarged, has induced operators rather to choose the left side, and generally in that part which is about three inches obliquely below the navel. If the navel protuberates, you may make a small puncture with a lancet through the skin, and the waters will be readily voided by that orifice, without any danger of a hernia succeeding; but it should be carefully attended to whether the protuberance is formed by the water or rupture; in which latter case, the intestine would be wounded, and not without the greatest danger. The surgeon, neither in opening with the lancet, nor perforating with the trocar, need fear injuring the intestines, unless there is but little water in the abdomen, since they are too much confined by the mesentery to come within reach of danger from these instruments; but it sometimes happens, that when the water is almost all emptied, it is suddenly stopped by the intestine or omentum pressing against the end of the canula; in which case you may push them away with a probe. During the evacuation, your assistants must keep pressing on each side of the abdomen, with a force equal to that of the waters before contained there: for, by neglecting this rule, the patient will be apt to fall into faintings, from the weight on the great vessels of the abdomen being taken off, and the sinking of the diaphragm succeeding; in consequence of which, more blood flowing into the inferior vessels than usual, leaves the superior ones of a sudden too empty, and thus interrupts the regular progress of the circulation. To obviate this inconvenience, the compression must not only be made with the hands during the operation; but be afterwards continued, by swathing the abdomen with a roller of flannel, about eight yards long and five inches broad, beginning at the bottom of the belly, so that the intestines may be borne up against the diaphragm: you may change the roller every day till the third or fourth day, by which time the several parts will have acquired their due tone. For the dressing, a piece of dry lint and plaster suffice; but between the skin and roller it may be proper to lay a double flannel a foot square, dipp'd in brandy or spirit of wine.

This operation, though it does not often absolutely cure, yet it sometimes preserves life a great many years, and even a comfortable one, especially if the waters have been long collected.

The term hydrocele, if used in a literal sense, means any tumour produced by water; but surgeons have always confined it to those which possess either the membranes of the scrotum, or the coats of the testicle and its vessels.

The first of these, viz. that which has its seat in the membranes of the scrotum, is common to the whole bag, and to all the cellular substance which loosely envelopes both the testes. It is, strictly speaking, only a symptom of a disease, in which the whole habit is most frequently more or less concerned, and very seldom affects this part only. The latter, or those which occupy the coats immediately investing the testicle and its vessels, are absolutely local, very seldom affect the common membrane of the scrotum, generally attack one side only, and are frequently found in persons who are perfectly free from all other complaints.

⁴⁸⁹ Different kinds of hydrocele confounded together by surgical writers.

Notwithstanding the obvious and material difference between the two kinds of disease, they have by the majority of writers been confounded together; have been considered as springing from the same immediate source, and as requiring the same kind of treatment; although the one is plainly and evidently a mere symptom or attendant on a general disorder, and the others are strictly and absolutely local complaints. This one fundamental error has been the occasion of many others. The supposition, that all collections found in the membranes and coats of the scrotum and testicles are of the same general kind, has produced an infinite variety of wild conjectures concerning the particular and immediate nature and origin of them. By some they have been attributed to a particular indisposition of the liver, kidneys, or spleen; by others, to a natural and necessary connection between the spermatic vessels and those of the kidney; by many the fluid has been thought to be of the urinary kind, or at least that it ought to have passed through the kidney; but that, mistaking its right way, it gets into the membranes of the scrotum and testicles: while others have affirmed, that all complaints of this kind are really symptoms of a dropical habit; that the fluid comes from the cavity of the belly, and either passes through the peritoneum, or extends that membrane down into the scrotum. Many cautions have been laid down against attempting the cure of one species of this disease hastily, or without a previous course of medicine, upon a supposition that the defluxion is of a noxious nature, and that by falling on this part it frees the constitution from several other distempers. It has been described as frequently producing a corrupted or otherwise diseased testicle; as being nearly allied in nature to those tumours which are called encysted, whose tunics are formed out of the common membrane by mere pressure; and as being generally accompanied with a true hernia, or descent of the intestine or omentum; which last (supposed) circumstance has been gravely urged as a reason for not attempting a radical cure. The same wanton liberty has been taken in assigning different seats to these disorders, as in accounting for their origin: every part which invests or accompanies the spermatic vessels or the testicles, not only the tunica communis of the process, and the cavity of the

tunica vaginalis (the true and real seats of one or other of these disorders), have been enumerated, but several imaginary ones have been added; firm compact membranes have been split into lamellæ, and cysts and coats have been devised which never had a real existence.

If all this were matter of mere speculation, and produced no mischief in practice, it would be of no importance; but in matters of physic and surgery this seldom or never happens: erroneous ideas of the nature, origin, and seats of diseases, most commonly are followed by improper methods of treating them. In the present case, the absurdity of the conjectures concerning these circumstances in the disorder, is fully equalled by the methods of cure which have been proposed and practised.

Upon a supposition that the extravasation of fluid ⁴⁹⁰ was the consequence of a dropical habit, strong purges and powerfully diuretic medicines have been prescribed; actual cauteries have been used, and ligatures and incisions made, both on the spermatic vessels and in the groin, to hinder the descent of the water from the cavity of the belly; astringent liquors and ardent spirits have been injected, with a view to closing or folding broken lymphatics; tedious and painful operations have been practised for the eradication of imaginary cysts; directions have been given to evacuate the water at different times, lest the patient's strength should fail or his health suffer, by its being done too suddenly; and the testicles being supposed to be frequently spoiled by long lying in the water, castration has often been performed in the simple hydrocele.

⁴⁹¹ The scrotum is the common receptacle of both the testicles, and consists of the cuticula, cutis, and what tery swell-all the anatomists have now agreed to call the dartos; which is a loose cellular membrane, perfectly void of fat, and whose cells or cavities communicate with each other, with the utmost freedom through every part.

As this membrane has no immediate communication with the cavity of the abdomen within the peritoneum, it is plain, that whatever kind or quantity of fluid may be deposited in it, it cannot be derived from the said cavity, even though the patient should labour under a true ascites: but as its cells have a free intercourse with those of the general cellular membrane all over the body, they will be liable to be affected by all those disorders which have their seat in that membrane; that is, by all disorders proceeding from a low impoverished state of blood, from a deficiency of the urinary secretion, or from non-execution of the office of the absorbent vessels; and consequently, in anasarca and leucophlegmatic habits, will become the seat of a watery extravasation.

This watery swelling of the scrotum, although it is most frequently a symptom of a dropical habit, and very often accompanies both the general anasarca and the particular collection within the abdomen called the ascites; yet, even in the latter case, neither is or can be derived from the cavity of belly, but is confined to the tela cellulosa, which lies on the outside of the peritoneum: the water derived from hence diffuses the scrotum in the same manner, and for the same reasons, that it often does the legs and feet. The cells of the dartos being larger and absolutely void of fat, and the skin which covers them being extremely

Practice. extremely dilatable, and giving way for a larger influx into this part than into most others, has indeed occasioned its being taken notice of as a particular disease, though it is most properly a symptom only.

This being the case, and the true method of cure consisting in an internal medical process, it has been improperly ranked among the species of hydrocele; though the nature of the contents will certainly admit the use of the word.

492
Description of the watery swelling of the scrotum. It is an equal soft tumour, possessing every part of the cellular membrane in which both the testicles are enveloped, and consequently is generally as large on one side as on the other: it leaves the skin of its natural colour; or, to speak more properly, it does not redden or inflame it: if the quantity of water be not large, nor the distention great, the skin preserves some degree of rugosity, the tumour has a doughy kind of feel, and easily receives and for a while retains the impression of the fingers; the raphe or seam of the scrotum divides the swelling nearly equally; the spermatic process is perfectly free, and of its natural size; and the testicles seem to be in the middle of the loaded membrane. This is the appearance when the disease is in a moderate degree; but if the quantity of extravasated serum be large, or the disease farther advanced, the skin, instead of being wrinkled, is smooth, tense, and plainly shows the limpid state of the fluid underneath: it is cold to the touch, does not so long retain the impression of the finger, and is always accompanied with a similar distention of the skin of the penis; the preputium of which is sometimes so enlarged, and so twisted and distorted, as to make a very disagreeable appearance. These are the local symptoms; to which it may be added, that a yellow countenance, a loss of appetite, a deficiency of urinary secretion, swelled legs, a hard belly, and mucous stools, are its very frequent companions.

The cure of the original disease comes within the province of the physician, and requires a course of internal medicine: but sometimes the loaded scrotum and penis are so troublesome to the patient, and in such danger of mortification, that a reduction of their size becomes absolutely necessary; and at other times a derivation or discharge of the redundant extravasated serum from this part is ordered as an assistant to the internal regimen.

The surgical means in use for this end is called in general scarification: a term whose precise sense has by no means been settled; from which it has now and then happened, that a general order being given, and the particular method of executing it being left to the choice of those who have not been sufficiently acquainted with this kind of business, much hazard has been incurred, and considerable mischief done which might have been avoided.

The means of making this discharge are two, viz. puncture and incision: the former is made with the point of a lancet; the latter with the same instrument, or with a knife.

The generality of writers on this subject have spoken of the two methods in such a manner, that a practitioner who had seen but little of either, would be inclined to think that it was a matter of great importance which we should make use of, and that the

safety and utility of each were equal: which is by no means the case.

The intention of the use of either is, by a discharge of extravasated serum, to alleviate the present uneasiness; and, by reducing the size of the scrotum, to render it less troublesome, and less likely to mortify. In some few instances it has indeed happened, that this drain has proved a radical cure of the original disease; but that has been accidental, and is not in general to be expected. The intention is generally palliative; and, if the patient lives, is most likely to require repetition: therefore, if there be any difference between the two methods, with regard either to ease or safety, there can be no doubt which ought to be preferred.

All wounds of membranous parts in anasarca or dropical habits, are necessarily both painful and hazardous; they are apt to inflame, are very difficultly brought to suppuration, and will often prove gangrenous in spite of all endeavours to the contrary. But the larger and deeper the wounds are, the more probable are these bad consequences. Simple punctures with the point of a lancet are much less liable to be attended by them than any other kind of wound; they generally leave the skin easy, soft, cool, uninflamed, and in a state to admit a repetition of the same operation if necessary. Incisions create a painful, crude, hazardous sore, requiring constant care. Punctures seldom produce any uneasiness at all, and stand in need of only a superficial plied for dressing.

Now although there is so very material a difference in the symptoms and trouble attending the two methods, yet there is none in their effect: the communication of the cells of the dartos with each other is so free through every part of it, that punctures made with the fine point of a bleeding lancet into the most superficial of them, will as certainly and as freely drain off the water as a large incision, without any of its inconveniences or its hazard.

Another species of hydrocele affects the cells of the 493 Hydrocele of the cells of the tunica communis.

When the disease is simple, it is perfectly local; that is, it is confined entirely to the membrane forming the tunica communis, and does not at all affect either the dartos, the tunica vaginalis testis, or any other part.

It is a complaint which does not give a great deal of trouble, unless it arrives to a considerable size; and being by no means so frequent as either of the other two kinds of hydrocele, it is in general but little known or attended to. With some it passes for a varix of the spermatic cord; with others, for the descent of a portion of omentum, which having contracted an adhesion cannot be returned. Thus its true nature not being in general rightly understood, and it giving but little trouble or uneasiness while it is within moderate bounds, and neither hindering any necessary action or faculty, they who have it are most frequently advised to be contented with a suspensory bandage, and find very little inconvenience from it.

Sometimes it arises to so large a size, and gets into such a state, as to become an object of surgery, and to require our very serious attention.

In general, while it is of moderate size, the state of it is as follows. The scrotal bag is free from all appearance

pearance of disease, except that when the skin is not corrugated it seems rather fuller, and hangs rather lower on that side than on the other, and, if suspended lightly on the palm of the hand, feels heavier: the testicle, with its epididymis, is to be felt perfectly distinct below this fulness, neither enlarged, nor in any manner altered from its natural state: the spermatic process is considerably larger than it ought to be; and feels like a varix or like an omental hernia, according to the different size of the tumour: it has a pyramidal kind of form, broader at the bottom than at the top: by gentle and continued pressure, it seems gradually to recede or go up, but drops down again immediately upon removing the pressure, and that as freely in a supine as in an erect posture: it is attended with a very small degree of pain or uneasiness; which uneasiness is not felt in the scrotum where the tumefaction is, but in the loins.

If the extravasation be confined to what is called the spermatic process, the opening in the tendon of the abdominal muscle is not at all dilated, and the process passing through it may be very distinctly felt; but if the cellular membrane which invests the spermatic vessels within the abdomen be affected, the tendinous aperture is enlarged, and the increased size of the distended membrane passing through it produces to the touch a sensation not very unlike that of an omental rupture.

While it is small, it is hardly an object of surgery; the pain or inconvenience which it produces being so little, that few people would choose to submit to an operation to get rid of it, and it is very seldom radically curable without one: but when it is large, or affects the membrane within the cavity as well as without, it becomes an apparent deformity, is very inconvenient both from its size and weight, and the only method of cure which it admits is far from being void of hazard; as must appear to every one who will consider, or who is at all acquainted either with the nature of lymphatic extravasation or absorption, or with the frequent consequences of wounds inflicted on parts merely membranous.

The eneysted hydrocele of the tunica communis has its seat in the same part as the preceding, viz. the tunica communis or cellular membrane, which invests the spermatic vessels; with this difference, that in the former the water is diffused in general through all the cells of the membrane, whereas in this it is contained in one cavity only.

It is a complaint by no means unfrequent, especially in children. It was very well known to many of the ancients, and has been very accurately described by some of them; but later writers have often mistaken it for and represented it as a wind-rupture, or pneumatocele, a disease existing in their imaginations only. It most frequently possesses the middle part of the process, between the testicle and groin, and is generally of an oblong figure; whence it has by some people been compared to an egg, by others to a fish's bladder. Whether it be large or small, it is generally pretty tense, and consequently the fluctuation of the water within it not always immediately or easily perceptible; for which reason it has been supposed to contain air only. It gives no pain, nor (unless it be very large indeed) does it hinder any necessary action. It is

perfectly circumscribed, and has no communication either with the cavity of the belly above, or that of the vaginal coat of the testicle below. The testis and its epididymis are perfectly and distinctly to be felt below the tumour, and are absolutely independent of it. The upper part of the spermatic process in the groin is most frequently very distinguishable. The swelling does not retain the impression of the fingers; and when lightly struck upon, sounds as if it contained wind only. It undergoes no alteration from change of the patient's posture, nor is affected by his coughing, sneezing, &c. and has no effect on the discharge per anum.

Infants are much more subject to this disease than adults, though it often affects the latter. In young children it frequently dissipates in a short time; especially if assisted by warm fomentation, and an open belly. If it does not disperse, that is, if it be not absorbed, the point of a lancet will give discharge to the water, and in young children will most frequently produce a cure. In adults, the cyst formed by the pressure of the fluid does sometimes become so thick as to require division through its whole length; which operation may in general be performed with great ease and perfect safety: though even this may prove troublesome, hazardous, and fatal; of such consequence are wounds in membranous parts in some particular habits.

The third species of this disease is that which is ⁴⁹⁴ Hydrocele confined to the vaginal coat or bag which loosely envelopes the testicle. In a natural healthy state, the cavity of this bag always contains a small quantity of a fine fluid exhaled from the capillary arteries, and constantly absorbed by vessels appointed for that purpose. This fluid in the natural small quantity serves to keep the tunica albuginea moist, and to prevent a cohesion between it and the vaginalis; a consequence which almost necessarily follows any such diseased state of these parts as prevents the due secretion of it. On the contrary, if the quantity deposited be too large, or if the regular absorption of it be by any means prevented, it will be gradually accumulated, and, by distending the containing bag, will form the disease in question.

The two preceding species of hydrocele have their seat in the tunica communis of the spermatic vessels, that is, in the cellular membrane which invests them; one by a general diffusion of lymph through all its cells, the other by a collection of it in one particular cyst or bag: that which makes our present subject has no concern or connection with that membrane at all, but is absolutely confined to the tunica vaginalis testis.

It is a disease from which no time of life is exempt; not only adults are subject to it, but young children are frequently afflicted with it, and infants sometimes born with it.

From all the circumstances attending the complaint, it is pretty clear, that whatever tends to increase the secretion of the fluid into the sacculus beyond the due and necessary quantity, or to prevent its being taken up and carried off by the proper absorbent vessels, must contribute to its production; which is so slow and gradual, and at the same time so void of pain, that the patient seldom attends to it until it has arrived to some size. Not but that it sometimes is produced very sud-

Practice. suddenly, and in a very short space of time attains considerable magnitude.

The size and figure of the tumour are various in different people, and under different circumstances. In general, at its first beginning, it is rather round; but as it increases it frequently assumes a pyriform kind of figure, with its larger extremity downward: sometimes it is hard, and almost incompressible, so much so, that in some few instances it has been mistaken for an induration of the testicle; at other times it is so soft and lax, that both the testicle and the fluid surrounding it, are easily discoverable. It is perfectly indolent in itself, though its weight does sometimes produce some small degree of uneasiness in the back. The great characteristic (as it is called) of this disease, and on which almost all writers have agreed to lay the greatest stress, and to rest their proof of the nature of the disorder, viz. the transparency of the tumour, is the most fallible and uncertain sign belonging to it; it is a circumstance which does not depend upon the quantity, colour, or consistence of the fluid constituting the disease, so much as on the uncertain thickness or thinness of the containing bag, and of the common membranes of the scrotum.

If they are thin, the fluid limpid, and the accumulation made so quick as not to give the tunica vaginalis time to thicken much, the rays of light may sometimes be seen to pass through the tumour; but this is accidental, and by no means to be depended upon. Whoever would be acquainted with this disorder must learn to distinguish it by other, and those more certain, marks, or he will be apt to fall into very disgraceful as well as pernicious blunders. The colour of the fluid is very different and uncertain: sometimes it is of a pale yellow, or straw-colour; sometimes it is inclined to a greenish cast; sometimes it is dark, turbid, and bloody; and sometimes it is perfectly thin and limpid.

The methods of cure (as they are called) in this species of hydrocele, though various, are reducible to two, viz. the palliative, or that which pretends only to relieve the disease in present, by discharging the fluid; and the radical, or that which aims at a perfect cure without leaving a possibility of relapse. The end of the former is accomplished by merely opening the containing bag in such a manner as to let out the water; that of the latter cannot be obtained unless the cavity of that bag be abolished, and no receptacle for a future accumulation left. One may be practised at all times of the patient's life, and in almost any state of health and habit; the other lies under some restraints and prohibitions, arising from the circumstances of age, constitution, state of the parts, &c.

The palliative cure may be accomplished by a very simple operation. The only circumstances requiring our attention in it, are, the instrument wherewith we would perform it; and the place or part of the tumour into which such instrument should be passed. The two instruments in use, are the common bleeding lancet, and the trocar.

The former having the finer point, may possibly pass in rather the easier, (though the difference is hardly perceptible), but is, in our opinion, liable to inconveniences to which the latter is not. The trocar, by means of its canula, secures the exit of the whole

VOL. X.

fluid without a possibility of prevention; the lancet cannot. And therefore it frequently happens, when this instrument is used, either that some of the water is left behind, or that some degree of handling and squeezing is required for its expulsion; or that the introduction of a probe, or a director, or some such instrument, becomes necessary for the same purpose. The former of these may, in some habits, be productive of inflammation: the latter prolongs what would otherwise be a short operation, and multiplies the necessary instruments; which, in every operation in surgery, is wrong. To which it may be added, that if any of the fluid be left in the vaginal coat, or insinuates itself into the cells of the dartos, the patient will have reason to think the operation imperfect, and to fear that he shall not reap even the temporary advantage which he expected. The place where this puncture ought to be made, is a circumstance of much more real consequence; the success of the attempt, the ease, and even sometimes the safety, of the patient, depending upon it.

Whoever conceives, as many have done, and some still do, that the testicle hangs loose in the middle of the water within the vaginal coat, must also suppose that every part of the general tumour is equally fit and proper for this operation. The idea is erroneous, and the experiment may prove highly mischievous. All the anterior and lateral parts of the vaginal coat are loose and detached from the albuginea; in its posterior and superior part these two tunics make one; consequently the testicle is, as it were, affixed to the posterior and superior part of the cavity of the sac of an hydrocele, and consequently the water or fluid can never get quite round it. This being the state of the case, the operation ought always to be performed on that part of the tumour where the two coats are at the greatest distance from each other, and where the fluid must, therefore, be accumulated in the largest quantity; and never on that part of it where the fluid cannot possibly be. The consequence of acting otherwise must not only produce a disappointment by not reaching the said fluid, but may prove, and has proved, highly and even fatally mischievous to the patient.

It was a custom formerly, after performing this operation, to make use of fomentations and discentient applications, upon a supposition that by such means a return of the disease might be prevented. Among the old writers are to be found the forms of medicines to be applied to the groin and scrotum, to prevent a future descent of the fluid; but anatomy and experience have proved the falsehood of such supposition, and the absurdity of such applications: the present practitioners content themselves with a bit of lint and a plaster; and if the scrotum has been considerably distended, they suspend it in a bag-truss, and give the patient no farther trouble.

In most people the orifice thus made heals in a few hours, (like that made for blood-letting); but in some habits and circumstances, it inflames and festers: this festering is generally superficial only, and is soon quieted by any simple dressing; but it sometimes is so considerable, and extends so deep, as to affect the vaginal coat, and by accident produce a radical cure. It has also been known to prove still more troublesome, and

42 H

and

and even fatal; but then the circumstances both of the patient and of the case have been particular, and such as required attention.

Every other method of treating this kind of hydrocele, except the puncture, was either originally intended to obtain a radical cure, or, having been found to have been often productive of such, has been by different people ranked sometimes among the palliative, sometimes among the radical, means.

In many of the old writers are found directions for obtaining the cure of this disease by the use of a seton, a canula, a tent, a caustic, a ligature, an injection, or an incision.

Some of these are adopted or preferred by one, and some by another, according to the theory which they have entertained of the disorder, or to the benefits which they have seen to have accidentally arisen from the use of the said means.

To reduce these under some kind of method, (which the manner of their being delivered to us does in general not very easily admit), we may say, that the seton, the tent, and the canula, were either originally meant to palliate a disease of which the old practitioners had very disagreeable apprehensions, or that they were made use of upon a supposition that the fluid contained in the cyst was in itself noxious; or that the general habit of the patient was relieved, and many other disorders prevented, by the said humour falling or being deposited in that part; or from an opinion that the cure of it ought not by any means to be hastily or rashly attempted: that the caustic, cauter, and ligature, were designed to prevent the supposed descent of the water from the abdomen into the scrotum; and that the injection was calculated for the constriction of a supposed breach in the lymphatic vessels.

Some of these (happily for mankind) are now quite laid aside, the reasons for their use being found to be false and groundless; of this kind are the cauter, the ligature, and the injection. The water is now, by every body who has made any inquiry into the matter, known to be formed and collected in the part where it is found; and not to have fallen into it from the belly: and, though an obstruction in the lymphatic vessels of the spermatic cord, may in some degree prevent the regular and due absorption of the fluid from the vaginal tunic, yet no breach or rupture of such vessels can ever produce the disease in question: the extravasation, in such case, must be in another part; and may possibly cause a hydrocele of the cellular kind, in the common membrane of the spermatic vessels, but which can never be found within the tunica vaginalis.

The reasons originally given for the use of the tent and the canula, viz. the noxious quality of the fluid, and the necessity of a gradual cure, are now also known and acknowledged to be without foundation; and therefore, though these methods, or methods like these, do still continue to be used, yet it is with another view, and upon other principles: not with intention to lengthen the time of a cure, by making a gradual drain for the prevention of other disorders; but merely to abolish the cavity of the tunica vaginalis, by having excited and maintained such a degree of inflammation and suppuration as shall produce an union between that coat and the albuginea testis.

This is indeed the only rational end which can by any of these means be pursued; for the disorder being absolutely local, and the tunica vaginalis (the seat of it) most commonly somewhat altered from its natural state, by having been distended; unless the absorbent vessels can again be restored to a capacity of doing their duty, (a circumstance which does not very often happen), the arteries will continue to exhale new serum into the cavity, and the hydrocele will still remain, or be renewed in a short time after each discharge.

To obtain this end, two kinds of means are proposed. In the use of one, it is intended, by means of a small wound, to excite such a degree of inflammation, as shall occasion or be followed by a total and absolute cohesion of the tunica vaginalis with the tunica albuginea: in the other, a larger and more free incision is made, whereby the cavity of the former of these coats is converted into a hollow or open sore or ulcer, to be filled up by a new incarnation; or else a part of the said tunic being cut away, its power of again holding the extravasated fluid is equally prevented.

The first, or union of the two coats in consequence of inflammation, has sometimes been found to follow the use of such means as were intended to procure only a temporary relief: it sometimes follows the simple puncture with the trocar or lancet; the ancient method of letting out the water by a small incision frequently produced it; and the seton, the tent, and the canula, though used for another purpose, or at least for other reasons, were found to be followed by it so often, that they soon were ranked among the means for obtaining a radical cure.

They were indeed originally designed to discharge the water gradually; and to continue such a drain from the parts where it had been collected, as might prevent any of the ill consequences apprehended from the removal of the local disorder: but the inflammation which supervened, sometimes producing a cohesion of the sacculus to the surface of the testicle, what was originally calculated for a palliative remedy only, was by many adopted for a radical one.

If the event and consequence flowing from these means were as much in our power as they have been said to be, that is, if we could with any tolerable precision or certainty determine the degree of inflammation to be excited, and the effect of such inflammation on the vaginal coat, there would be no doubt of the utility of them; but this is far from being the case: for although it sometimes is sufficient for the purpose wished for, and rises no higher than just to a degree equal to that purpose, yet it also frequently happens, that either such degree and extent of it is not excited, or it rises much higher and proves much more painful and fatiguing than was promised or intended; or, after a great deal of pain and confinement, a partial cohesion only has been the consequence, and the disease has still remained, notwithstanding all the patient's and our trouble. Sometimes the pain, inflammation, and symptomatic fever, are but little; but, on the other hand, they are all three sometimes so great as to become alarming, at least to a patient who has been taught to expect a cure upon much more easy terms. The whole scrotum sometimes becomes excessively inflamed, and, after a good deal of pain and trouble, large

Practice. large sloughs are produced, and the process becomes as irksome as any of those whose event (with regard to a cure) is much more certain.

If the inflammation be but slight, the pain and tumefaction moderate, the symptomatic fever light, the suppuration small, and an universal cohesion of the two membranes is produced, the event is very fortunate, and a very troublesome complaint is thereby got rid of upon very easy terms. If either the inflammation be confined to the dartos, where it sometimes produces several superficial abscesses (of no consequence toward the cure of the disease), or if it has been so partial as only to have occasioned the cohesion between the tunics of small compass, the cavity will not by this means be abolished, nor any thing like a radical cure be obtained; consequently the patient will have undergone all the fatigue, confinement, or pain (be it more or less) for nothing: but if the inflammation rises high, if the scrotum swells considerably, and large deep sloughs are formed (as sometimes happens), the symptoms and the hazard are then fully equal to what attend those more certain methods. Which of the three will be the event, no man can say. Under the same external appearances, different people are more or less liable to inflammation and fever: the confinement of matter, in consequence of too small an opening, will in some habits make strange havoc in a very short time; and if a large opening and a plentiful suppuration must at last be submitted to, the method by a large incision at first is preferable, as the cure is more certain, and the loss of time less. Different circumstances in the patient will render one method preferable to and more likely to succeed than another; but whenever a cure is attempted by any of the before-mentioned means, the uncertainty of the event should be made known, and the patient be apprised of what may happen either with regard to trouble or disappointment.

All the methods hitherto taken notice of are calculated to produce a perfect or radical cure, without making a large wound, or bearing the appearance of a surgical operation: those of which we are now to speak, are intended for the same purpose; but by making a large and free opening into the bag containing the fluid, to render the accomplishment of such purpose more certain.

These are called the cure by caustic and the cure by incision. The cure by caustic is calculated to spare the terror which a cutting instrument always conveys, and (as the patrons of it say) to avoid the painful symptoms and hazard which frequently attend a large incision in these parts. The method is this: A piece of the common paste caustic, rather less than a finger's breadth, properly secured by plaster, is applied the whole length of the anterior part of the tumour, which will necessarily make an eschar of proportional size. When this eschar either casts off or is divided, an opening of nearly the same length and breadth is thereby intended to be made into the cavity of the tunica vaginalis testis; by which means an opportunity is given to the surgeon to apply such dressings to the inside of the said tunic as shall, by the generation of new flesh, fill up and abolish its cavity. The preference which some practitioners have given to this method before that by incision, has been upon a suppo-

sition, that a circumstance which very seldom happens will most frequently occur; we mean the penetration of the caustic through the vaginal tunic containing the fluid.

By this they hope to avoid the symptoms which are supposed to be generally excited by the division of the said bag by a cutting instrument; but this the caustic very seldom does. If the tumour be very large and full, the containing parts be very much on the stress, and the skin and dartos very thin, the caustic may now and then penetrate through to the vaginal coat: but this, whatever may be thought or pretended, very seldom happens; and when it does not, the tunica vaginalis must be divided in the same state and manner as if no caustic had been applied. All the difference between the two methods (caustic and incision) will then amount to this: That in the former, the skin being mortified, the patient is freed from a part of his apprehension at its being cut; and the surgeon, fancying that his escharotic has gone through the vaginal coat, will divide it as a part of the eschar: but a more careful examination of what he is about at the time of such operation, would generally convince him that he divides the bag unaltered by the caustic; and the symptoms which often attend this process confirm it. It has indeed been proposed to divide the eschar made in the skin down to the surface of the tunica vaginalis, and then by the application of a fresh caustic to make an eschar in that coat also. But whoever makes or submits to this experiment, will find, that of two evils he chooses the greater; and, to avoid the pain of incision, incurs a much greater degree of it by the repetition of the escharotic. The pain attending the first application of the caustic is indeed to some persons but little; but in many it is fully equal to that of the knife, and must always be of much longer duration: if it does not penetrate the tunica vaginalis, that bag must be divided by a cutting instrument, (as we have already said), in the same state as if no caustic had been applied; which incision is and must be accompanied with the same symptoms (in the same person) as in the operation by the knife only. Nor can we at all times confine the caustic, so as that it shall not cause a much larger sore than is intended or can be necessary.

Upon the whole, the cure by caustic, as it spares the terror and apprehension of a bloody operation by the knife, and as it requires no dexterity in the operator, may, on those two accounts, become preferable both to many patients and surgeons: yet whoever promises to perform, or expects to receive, a radical cure by caustic upon much easier terms than by incision, will most frequently be disappointed; that is, they will frequently find the fever and inflammatory symptoms full as high, and the sore full as painful, in the one as in the other, and consequently all their care and attention to obviate mischief full as necessary. Neither is the necessary confinement, in general, at all less in the one than in the other.

The method of performing the operation by the knife is as follows: Having appointed an assistant to grasp the upper part of the tumour, in order to render it tense below, a puncture should be made in the lower and anterior part through the skin and vaginal coat. If the operator intends to finish the incision with

with a knife, he should make this puncture large enough to admit the end of his fore-finger; which he should introduce immediately before the water is all discharged and the vaginal coat collapsed; and upon that finger so introduced, he should continue his division of the whole length of the bag and of the scrotum which covers it. If he intends to use the probe-scissors (a more tedious and a more painful method), he may make his first puncture with a lancet, and then introduce his scissors. Upon the first division, the water rushes out, and the tumour subsides. If the puncture be made small, a part of the fluid will insinuate itself into the cells of the dartos; and by the immediate collapse of the vaginal coat, the operator will find some difficulty in introducing either his finger or his instrument into the orifice made in it. If he does not do this, he will divide only the skin and dartos, and the patient must undergo a second incision for the division of the cyst: all which inconvenience may be avoided, by making the first opening large enough for the introduction of the finger; and when that is in, all the rest is upon that very easily executed.

When the vaginal tunic is divided, and the fluid thereby discharged, the testicle, covered only by its tunica albuginea, comes into view; and, if the incision was either begun or continued very low, it generally thrusts itself out from the wound. This should be gently replaced; and if the vaginal coat is not much thickened by having been long distended, nothing more need be done than to lay a small quantity of fine lint into its cavity, and then, covering the wound with a large pledget and a soft bolster, tie the scrotum up in a suspensory bag. This operation, if properly performed, may be executed in a very few seconds: it requires no other violence than the mere division of the parts; and if this division be made with a knife rather than scissors, it will require much less time, and cause much less pain.

The membranous structure of the parts on which this wound is inflicted, their continuation from the peritoneum, and the great irritability of some of those which are necessarily laid bare, and put under a necessity of receiving dressings, must occasion pain and symptomatic fever: this it is the business of art to moderate and relieve; phlebotomy, lenient aperitives, febrifuges, and opiates, will therefore become necessary. But in this case, as in many others, it will generally be found much more easy to prevent bad symptoms, than to remove them when they have been permitted to attain a considerable height. The operation is, or ought to be, confined to the young and the healthy, in whom inflammatory symptoms are most likely to occur; but (we may venture to say) to whom we have more efficacious remedies to apply in such disorders, than can be used to people of a different habit and in different circumstances.

The general induration of all the parts about, the thick tumid lips of the incision, and the general inflammatory enlargement of the scrotum, have, for the first four or five days, a disagreeable appearance; and may, if neglected or wrong treated, prove very troublesome or even hazardous; and the kind of discharge which during that time is made (a thin discoloured gleet), seems very unequal to the reduction of so much tumefaction: but when the febrile symptoms

are appeased, and a kindly suppuration is begun, let the surgeon have patience, and not by an over-officiousness, or by improper dressings, interrupt nature in what she is about: let him, by warm fomentations, keep the parts clean and perspirable; let him dress the wound with a small quantity of soft easy digestive applications, and, covering the whole scrotum with a soft warm poultice, suspend it in a proper bag, and he will in general soon see a favourable change in all the appearances; he will see the inflammation disappear, the tumour resolve, and all the tumefaction in due time subside. But if he neglects these general cautions, and, under a notion of assisting digestion, goes to work with precipitate and other irritating dressings, the face of things will not be so agreeable: the tumour will not subside; and he will continue, or rather create, a painful undigested sore, with all its consequences; but for which he only is accountable.

In about six weeks the scrotum is generally reduced to nearly its natural size; and when the wound is quite healed, the cicatrix is a mere line, correspondent to the original incision; which is a circumstance of more consequence to the patient than is imagined, especially if he be obliged to get his bread by labour.

If the tunica vaginalis containing the water, by long or frequent distention or from any other cause become thick and hard, and cannot therefore contract itself or be contracted upon the evacuation of the fluid, it will contribute considerably to the thickness of the lips of the wound, as well as to their hardness, pain, and difficulty of digestion. In this case, the best way is to remove a part of it on each side at the time of the operation. The cellular structure of the dartos easily admits this to be done; and when these sides are thus taken away, the lips of the wound consist only of the common integuments. A knife will do this with much more ease and expedition than any other instrument whatever. The method proposed by the late Mr Douglas, of doing it by repeated snips of the probe-scissors, is operose, unhandy, and unnecessarily painful and tedious; nor is the cutting away an oval piece of the scrotum, as advised by that gentleman and some others, at all necessary: on the contrary, the more loose that part of the scrotum is which is to cover the testicle (now deprived of its vaginal coat) the better, as it will be more capable of corrugation.

With these cautions, and under the proper restrictions already mentioned, this method of obtaining a radical cure is very practicable. That it is sometimes accompanied by troublesome symptoms, is beyond all doubt; and so is the method by caustic. We cannot say that we have never seen it prove fatal; nor can that be said of any operation of consequence: much depends on the choice of a proper subject, and the observance of the necessary means and cautions; without which, both this and the use of the caustic will always be troublesome, and sometimes hazardous.

When the quantity of fluid is large, and the scrotum and tunic much on the stretch, Mr Port thinks it is better to discharge the water by mere puncture, and not to perform the operation for the radical cure until a fresh accumulation has again moderately distended it. The inflammation necessarily consequent upon

Practice. upon the division of these parts, just after they have been so much on the stretch, and so suddenly let loose, may be productive of worse symptoms, and a higher degree of fever and tumefaction, than usually occurs when the same parts are divided in a less distended state.

510
Of the use of a seton. In this operation, the point to be aimed at, as Mr Pott observes, is to excite such a degree of inflammation, both in the tunica vaginalis and tunica albuginea, as shall occasion a general and perfect cohesion between them: and this, if possible, without the production of flugh or abscess, without the hazard of gangrene, and without that degree of symptomatic fever which now and then attends both the caustic and the incision; and which, when it does happen, is so alarming both to patient and surgeon.

These ends he has frequently obtained by the use of a seton. It is a method of cure mentioned by Aquapendens, as used by Guido and others before him, (though their process was somewhat different from his.) He has several times tried it on subjects of very different ages, some of them more than 50 years old. It requires confinement to bed only for a few days; after which the patient may lie on a couch to the end of the attendance, which is generally finished in about three weeks or a month at the farthest; and during all that time no other process or regimen is necessary, than what an inflammation of the same part from any other cause would require.

SECT. XV. Of Trepanning.

511
Parts of the skull not eligible for trepanning. THERE appears scarce any part of the cranium, from the frontal sinuses to the insertions of the muscles into the occipital bone, that may not be perforated with safety. There are some late instances in this kingdom, where the trepan has been successfully applied to the frontal sinuses. How far it might be practicable to separate the muscles from and apply the trepan to the inferior part of the occipital bone, almost to the foramen magnum, may be worth future consideration; as it is no unreasonable supposition, that a case may happen to be so circumstanced as to admit of no other remedy; and, according to Celsus, a doubtful one is better than none (A).

The parts of the skull not eligible for the application of the trepan are, 1. The frontal sinuses. 2. The sutures, in young subjects; for in old ones the adhesion of the dura mater to them is but little more than to other parts of the cranium. 3. The middle of the os frontis, towards the nose, where the spinal process of that bone projects considerably. 4. The anterior and inferior angles of the parietal bones, on the internal parts of which run the arteries of the dura mater. 5. The sagittal suture, on account of the longitudinal sinus running immediately under it. 6. The lambdoidal suture, under which lies the course of the lateral sinuses. 7. The occipital bone, on account of its great inequality of thickness, and irregularity of its internal surface. 8. The os temporale, as the temporal muscle must unavoidably be wounded in making room for the trepan: and lastly, we must be careful, not to apply it to a yielding fractured part of the bone, that

will not resist the necessary force in making the perforation.

512
Practice. There are, however, instances from the best authorities, of the successful application of the trepan to all these exceptionable parts, sufficient to encourage a cautious and judicious practitioner upon emergencies; to which, says Mr Gooch, I will venture to join my own experience, hoping it may have some weight in determining a matter of so much importance to surgery. The frontal sinuses have been trepanned with success in London and Paris. Perforations may be made lower down the os frontis in children than in adults, without running the hazard of falling upon the sinuses; for they gradually enlarge, extending higher up as they arrive at puberty. Mr Gooch has applied the trepan near the middle of the os frontis, without meeting with any obstacle from the spinal process: and at the anterior and inferior angles of the parietal bones, without opening the art. dura materis. The operation has been performed by Mr Warner upon the sagittal suture, when bits of bone stuck in the longitudinal sinus, which he easily extracted after enlarging the wound with his lancet, stopping the hæmorrhagy with dry lint without any difficulty.

513
Method of performing the operation. After having deliberately considered every circumstance, and resolved upon the operation, the instruments, sponges, dressings, compresses, bandage, and every necessary thing, are to be disposed in perfect good order, that the operator may have nothing to seek when he wants it. The head is to be shaved, if it has not been already, as indeed it should all over immediately after any of the preceding accidents: it is then to be rested and firmly held upon a person's knees; and, with the knife appropriated to this use and the scalprum, a piece of the scalp is to be removed, of a circular, elliptical, or other figure, as the circumstances of the case require. The scalping should be of such extent, as may give a fair opportunity of making as many perforations as shall be found necessary, as far as the surgeon's judgment and observation can direct him. He ought not to be sparing in this respect, lest he should be under the disagreeable necessity of extending the incision farther. The manner of cutting, is to apply force enough to the knife, to carry it quite through to the bone at once, not bearing too much upon the point, especially if we cut over loose fragments, which we should endeavour to avoid; the edge of the knife should be so inclined, as to cut rather more of the pericranium than the skin. When we have proceeded thus far, the pericranium is to be raised a little, with the point of the knife, quite round the incision; and then the scalprum used, which will be found the best instrument to clear the bone of that membrane, as has been found by frequent experience. Should it be thought proper to proceed immediately to trepanning, if any considerable vessels have been divided in scalping, they must be secured by needle and ligature; but when we do not intend performing the operation directly, dry lint with compress and bandage is generally sufficient to restrain the hæmorrhagy; but sometimes the pressure of an assistant's fingers upon it will serve that purpose without a ligature,

(A) Bontius, a writer of the best credit, relates a singular case of a sailor, whose head was crushed between the ship and a boat; in consequence of which dreadful accident, the greatest part of the occipital bone was taken away in fragments, almost as far as the foramen magnum, and the patient perfectly cured by him and another surgeon.

That kind of trepan called the trephine, is now in general use in all places: it is more commodious than the other, and can be better managed and regulated in the operation, as the different bearings may require; and it will cut full as fast, being worked both backwards and forwards. Before the operation is begun, the patient's head must be fixed so that the light may fall properly upon it, and in such a convenient position, that the instrument may be placed perpendicularly upon the part; and of such a height and manner, that the attitude may be easy during the operation, which often proves tedious, requiring many perforations (8).

Whether the patient has the operation performed in bed or seated in a chair, it is always found that resting his head on a pillow, with a board underneath it, upon the knees of an assistant, is preferable to any other manner; for being thus placed, the assistant will have more power to keep it steady, to resist the motion of the instrument. When the head is well adjusted, the next step is to make a hole with the perforator, deep enough to fix the central pin of the trephine, in order to prevent the saw from slipping out of its circular course, till it has formed a sulcus sufficiently deep to be wrought steadily in; and then the pin is to be taken out. If the skull is thick, the teeth of the saw must be brushed clean now and then during the terebration; and dipping it into oil as often, will greatly facilitate the motion, and expedite the operation, making it less disagreeable to the patient if he has his senses; and, in order to lose no time, it would not be amiss to be provided with two instruments of the same size.—We must remember, after having made some considerable progress in the operation, to examine the sulcus often with a picktooth, or some other proper instrument, in order to discover where the bearings are necessary to be made.—These precautions are of more consequence when we are employed in perforating a part of the skull that we know has an unequal thickness, especially after having passed the diplöe. And though we are told by writers in general, that we may saw boldly till we come at the diplöe, generally to be known by an appearance of blood, yet we should be upon our guard in this point; examining if the piece be loose, when we have sawn some away into the bone, lest we should happen through inadvertence to wound the subjacent membrane; for in some parts of the skull there is naturally very little diplöe, and in old subjects scarce any remains to afford direction to our judgment by the bloody appearance. And for the same reason, it is also to be remembered, that children's skulls are very thin.—When the piece is quite loose, it is to be taken out with the forceps contrived for this purpose; and if the lower edge of the perforation is left jagged, it is to be smoothed with the lenticular, that it may not irritate the dura mater. The next step is to raise the depressed piece or pieces of the cranium with the

elevator; or to extract the fragments of the bone, grumous blood, or any extraneous body, with proper instruments. After this, if there appears good reason to apprehend that blood, lymph, or matter, is contained under the dura mater, we should open it directly with a lancet very cautiously; endeavouring to avoid the blood-vessels ramified upon it, and those which lie immediately under it: and, on this occasion, it will be prudent to conceal the instrument as much as we can, by wrapping it all round with tow almost to the point, in order to prevent impressions being made upon the spectators to our prejudice.

When we have recourse to the trepan, on account of a fissure in which the bone will not yield, we should apply the instrument so as to include part of it, if not directly over it, as it is most likely the extravasated blood or lymph should be found directly underneath it: and when the fissure is of great extent, it may be proper to make a perforation at each end, if the whole can be conveniently brought in view; and, in some cases, more perforations may be requisite, according to the course of it, even to its full extent.

When we propose to make several perforations, in order to remove depressed fragments of the bone that are firmly fixed, and having the internal surface larger than the external, or to raise them sufficiently, it is necessary to apply the trepan as near the fractured parts as they will admit of; making the perforations adjoining, to save the trouble of cutting the intermediate spaces with the head-saw: and, as before hinted, we should invariably observe to make the perforations in the most depending parts we can, for the same reason as we endeavour to obtain depending openings in the fleshy parts. And in perforating the skull, where there is great inequality of its thickness, it appears more advisable to raise the piece before it is cut quite through in every part of it, to obviate injuring the subjacent membrane with the saw.

When the skull has suffered an injury upon a future, and it is not thought advisable to use the trepan there, especially in young subjects, in whom the dura mater adheres more strongly than in adults, as has been remarked, we should always remember to make a perforation on each side of the future; for this obvious reason, because there cannot be a free communication between the one side and the other, on account of the attachment of that membrane to the future.

After the elevation of the fragments of the bone, or the removal of them, the extraction of extraneous bodies, and the evacuation of extravasated blood, lymph, or sanies, &c. the membranes may be dressed with unguent. e gum. elemi, extolled by Franciscus Arceus, the inventor of it, made of a softer consistency with bals. e copaib. or some other natural balsam; applying it just warm with a feather, and soft lint lightly over it, dressing the other parts as we have already directed in wounds of the head: after which, it may be proper to embroicate the whole head with ol. et acet. adding a little spirit. lavend. and to apply

(8) Scultetus says, he was obliged to make 7 perforations in a fracture with great depression. Glandorpius says, his master Spigelius made the same number upon the like occasion. Dionis made 12. Philip count of Nassau had 27 made in different parts of his head by Henry Chadborn, a very eminent surgeon; and that nobleman has attested the cure under his own hand. Mr Gooch made 13 in the case of an old man, with success, as related in his Cases and Remarks on Surgery.

Practice. ply a plaster of cerat. alb. or some such easy application, with gentle compress and bandage. The proper bandages upon this occasion are what the French call the grand couvre-chef, and the capeline or reflex bandage, which require great care and exactness in their application, for the patient's ease. A bandage with six tails, or a kind of coif with lappets affixed to it, may be found very applicable in some cases; but to serve this purpose, the surgeon must occasionally exercise his invention.

After the dressing, the patient is to be placed in as easy a position in his bed as possible, with his head and shoulders elevated a little more than ordinary; and the rules we have laid down in the cure of wounds are to be duly observed. Warmer applications and bandages are required in winter than in summer. The degree of heat in the room must be regulated according to the temperature of the season; and it is necessary to exclude the light. In injuries of the head, bad symptoms are apt to come on sooner in warm, moist, sultry weather, than in a cold season, when it may be very beneficial to make the circumambient air warm, and dress the wound as expeditiously as possible, defending it from the attack of the cold air. A strict regimen and observance of the non-naturals are now of the greatest importance to be attended to; for a slight transgression therein may prove of fatal consequence, as we have amply evinced.

When the digestion of the wound proves kind, we shall soon observe granulations of flesh, of a good complexion, shooting from the extremities of the vessels, and throwing off the parts of the dura mater that may have suffered; which, by extending themselves and twisting one with another, form in the aperture a substance having the appearance of flesh. The same operation of nature, in a longer time, throws off exfoliations from the circumference of the perforation and other parts of the denudated skull, thicker or thinner, sooner or later, according to the age and constitution of the patient, the degree of injury the substance of the bone has sustained, the season of the year, &c. The granulations which arise from the different parts, uniting together, constitute the organized or vascular carnosous substance, which is called the incarnation of the wound: and this regenerated substance, in young subjects, generally acquires a perfect bony hardness in the perforation, but seldom in old persons.

⁵¹⁸ In order to remove the fungi mentioned, n^o 132. ligature, excision, and escharotics, have been recommended; and sometimes practised with fatal effects, throwing the nervous system into great disorder. And as there is so much to be apprehended from these methods, we should by all means take early care to prevent the growth of such excrescences; which, if neglected, may increase to a great size in a short time.

The best method of doing this is, first to apply to the dura mater a findon, spread with the balsam recommended, or dipped into it, moderately warm, according to the state the membrane appears in: then a plate of lead is to be exactly adjusted in the perforation upon the findon, having the ears of it turned back upon the skull; over which a compress, consisting of a few doubles of common plaster, with a

Practice. piece of very thin sheet-lead or card interposed, is to be laid; filling the wound up with even lint, rather above the level of the scalp; then a small easy compress of cloth, faced with cerat. alb. is to be applied, with a piece of card or thin stiff paper on the outside of it; over which, strips of common plaster about an inch broad are to be laid crucially, extending two or three inches beyond the compress. By this means the plate will be properly confined, and the degree of pressure may be easily regulated, without inconvenience to the patient, or interrupting the discharge at the wound; and should a greater degree of pressure be required, it may be obtained by thickening the compress, and making one of the strips of plaster pass through a slit in the other, as in the uniting bandage. After proceeding thus far, the head is to be embroached, and a large thin compress spread with cerate, applied over the crucial plasters, with easy bandage, as before directed. When the dura mater is granulated with flesh, the findon or lint, moistened with a mixture of tinct. myrrhe and aq. calcis, is a good application; and the other parts of the wound are also to be attended to, according to the rules of surgery which we have before laid down, in order to prevent the luxuriance of flesh, till the exfoliations are completed; for should this point be neglected, and loose flesh suffered to creep upon the bone from the circumference of the wound, much inconvenience and trouble, besides pain to the patient, might proceed from such inattention.

An abatement of the symptoms after the operation, with a good aspect of the wound in a healthy subject, give us reason to hope for success; but if the symptoms continue threatening, with a driness, glassy appearance, or livid colour of the wound, or a discharge of a fetid gleet from the membranes or brain, they are to be looked upon as very bad omens: however, we are to omit the use of no rational means, having instances upon record of the happy event of the most alarming cases to encourage our perseverance. The symptoms after the operation may require frequent bleeding, as well as strict regimen.

Should the patient, at any time after the cure, complain of pain or disorder in his head, with symptoms of plenitude, recourse ought to be had immediately to bleeding and gentle purging, with the observance of a spare diet; and for some time after his cure, he should also be very exact in his regimen and government of himself, both as to body and mind. It will be likewise very prudent to wear for a considerable time a thin brafs, steel, or tin plate, to defend the part against external injuries, especially if there has been any great loss of the bone; under which circumstance, in old persons, such a defence may be found necessary for life.

SECT. XVI. Of Tumours on the Heads of new-born Children.

This kind of tumour proceeds from an extravasation of blood; probably in consequence of some injury in a laborious, hasty, or injudicious delivery; as time should always be allowed for a gradual dilatation of the parts, to admit of the exclusion of the fetus with safety. It is seldom observed on any other parts of

of the head than the parietal bones; and the extravasated blood is most frequently lodged between the pericranium and the cranium.

This tumour is generally circumscribed by a ridge, when the extravasated fluid is contained between the cranium and the pericranium, and feels as if there was a depression or deficiency of the bone; but the deception is owing to the fluid in the distended pericranium yielding to the fingers, and to the ridge circumscribing the tumour, which, without very accurate examination, may be taken for the edge of the bone.

Some surgeons have looked upon this sort of tumour as an aneurysm proceeding from the inside of the skull, others as a hernia of the brain. But was either of these the case in question, it must appear between, and not upon, the bones it does; and a pulsation would be observed in it.

The surgeons of the foundling-hospital, who have had the greatest opportunities of discovering the nature of these tumours, and the best method of cure, from their large experience, say, they generally succeed by opening them, in case the children were otherwise healthy; and that they prefer this method, rather than waiting in expectation of absorption by any other, apprehending that the bad consequences they have seen may proceed from the putrid quality of the fluid contracted by its stagnation. They make an incision the whole length of the tumour; lay soft dry lint under the edges of the wound, to favour the discharge of the extravasated blood, after pressing out as much as they can without bruising the tender parts; and then apply a pledget of common digestive over the lint, with easy compress and bandage.

Some other practitioners, of experience too, are against opening these tumours; advising the application of compresses, moistened in warm austere red wine, or red wine and vinegar, to be renewed as often as they grow dry; and say they have generally observed absorption of the fluid to be the effect of this method without bad consequences. However, should there appear no diminution of the tumour by regularly pursuing this method a reasonable time, it will then certainly be advisable to open it, lest the fluid should be absorbed in a putrid state, or the bone injured by it, whence bad consequences might ensue: and if the bone received an injury originally, the necessity of opening is indisputable.

SECT. XVII. Of the Cataract, cutting the Iris, and Operation for the Fistula Lachrymalis.

§ 1. Of the Cataract.

THE cataract, called by the Latins suffuso, is a disease of the crystalline humour, rendering the whole body of it opaque; so that the rays of light which, in the natural state of its transparency, were transmitted to the tunica retina, become now totally intercepted, and produce no effect. This is pretty nearly the account delivered down to us by Hippocrates and the ancient Greeks, who likewise knew it by the name of glaucoma.

Anatomists have frequently dissected the eyes of persons under this disorder after their death; and have found it to be always an opacity of the crystalline humour, agreeably to the definition of a glaucoma: so

that by consequence we must understand the words cataract and glaucoma as synonymous terms.

The general criterion of the fitness of cataracts for the operation is taken from their colour: the pearl-coloured, and those of the colour of burnished iron, are esteemed proper to endure the needle; the white are supposed milky, the green and yellow horny, and incurable.

The depression of a cataract of any colour would be the cure, if that alone was the distemper of the eye; but it generally happens, that the yellow cataract adheres to the iris so firmly as to become immovable: besides, when they follow in consequence of a blow, which is often the case, either the cells of the vitreous humour are so much disturbed and broken, or the retina affected, that a degree of blindness will remain, though the cataract be depressed.

To judge whether the cataract adheres to the iris, if you cannot at once distinguish it by your sight, shut the patient's eye, and rub the lids a little; then suddenly opening it, you will perceive the pupil contract, if the crystalline humour does not prevent the action by its adhesion: and when this is the case in any kind of cataract, the operation can hardly be advised.

Another consideration of the greatest moment, before undertaking the cure, is to be assured of the right state of the tunica retina; which is very readily learnt, where there is no adhesion of the cataract, from the light falling between the iris and crystalline humour, which if the eye is not sensible of, it is a certain indication of another malady, and absolutely forbids the operation. Generally this cataract takes its rise from headaches, convulsions, and nervous disorders.

When none of these objections forbid the operation, it may be thus done. Having placed your patient in a convenient light, and in a chair suitable to the height of that you yourself sit in, let a pillow or two be placed behind his back, in such a manner, that the body bending forward, the head may approach near to you; then inclining the head a little backward upon the breast of your assistant, and covering the other eye so as to prevent its rolling, let the assistant lift up the superior eye-lid, and yourself depress a little the inferior one: this done, strike the needle through the tunica conjunctiva, something less than one tenth of an inch from the cornea, even with the middle of the pupil, into the posterior chamber, and gently endeavour to depress the cataract with the flat surface of it. If, after it is dislodged, it rises again, though not with much elasticity, it must again and again be pushed down. If it is membranous, after the discharge of the fluid, the pellicle must be more broke and depressed; if it is uniformly fluid, or exceedingly elastic, we must not continue to endanger a terrible inflammation by a vain attempt to succeed. If a cataract of the right eye is to be couched, and the surgeon cannot use his left-hand so dexterously as his right, he may place himself behind the patient, and use his right-hand.

We have not recommended the speculum oculi, because, upon the discharge of the aqueous humour through the puncture, the eye, being somewhat emptied, more readily admits of the depression of the crystalline humour than when pressed upon by the instrument.

As to the method of treating the succeeding inflammation,

Practice. mation, bleeding and other gentle evacuations are found absolutely necessary.

§ 2. Of cutting the Iris.

THERE are two cases where this operation may be of some service; one when the cataract is from its adhesion immovable; and the other when the pupil of the eye is totally closed up by a disorder of the muscular fibres of the iris, which gradually contracting the orifice, at last leaves the membrane quite imperforate. This last distemper has hitherto been deemed incurable. The adhesion of the cataract has also been considered as a species of blindness not to be relieved. But Mr Chefelden has invented a method of making an artificial pupil, by slitting the iris, which may relieve in both the instances here stated.

In doing this operation, the patient must be placed as for couching, and the eye kept open and fixed by the speculum oculi, which is absolutely necessary here; then introducing the knife in the same part of the conjunctiva you wound in couching, insinuate it with its blade held horizontally, and the back of it towards you, between the ligamentum ciliare and circumference of the iris, into the anterior chamber of the eye; and after it is advanced to the farther side of it, make your incision quite through the membrane; and if the operation succeeds, it will upon wounding fly open, and appear a large orifice, though not so wide as it becomes afterwards.

The place to be opened in the iris will be according to the nature of the disease: if the membrane itself be only affected with a contraction, the middle part of it, which is the natural situation of the pupil, must be cut; but if there be a cataract, the incision must be made above or below the cataract, though it is more eligible to do it above.

The contracted iris from a paralytic disorder, is so often complicated with an affection of the retina, that the success is very precarious in this case. This operation has answered best in adhesions of the crystalline humour, though but very seldom even there.

§ 3. Fistula Lachrymalis.

The fistula lachrymalis is generally understood to be such a disorder of the canals leading from the eye to the nose, as obstructs the natural progress of the tears, and makes them trickle down the cheek. Although the seat of this disease is the same in almost every subject, yet its appearance is very different in different persons, and under different circumstances. These variations depend principally on, 1. The degree of obstruction in the nasal duct; 2. The state of the cellular membrane covering the sac; 3. The state of the facculus itself; 4. That of the bone underneath; 5. The general state and habit of the patient.

Sometimes a serous kind of defluxion, by which the lining of the sac and duct are so thickened as to obstruct or prevent the passage of the fluid through them into the nose, makes the whole complaint; and the cellular membrane on the outside not being diseased, there is no appearance of inflammation. In this case the duct is stopped, and the facculus dilated, but without any alteration in the colour of the skin; a fulness appears in the corner of the eye next to the

nose; and upon the application of a finger to this tumour, a clear viscid mucus is discharged through the puncta lachrymalia: the patient feels no pain, nor finds any inconvenience, except what is produced by the discharge of this mucus, and by the trickling of the lymph down the cheek.

In some cases the mucus is not perfectly and always clear, but is sometimes cloudy, and looks as if it had a mixture of milk or cream in it: at first waking some of it is generally found in the corner of the eye; and the eye-lashes being smeared over with it during sleep, most commonly adhere together in the morning.

This is the most simple state of the disease, what the French have called the hernia, or hydrops facculi lachrymalis. It is frequently met with in children who have been rickety, or are subject to glandular obstructions: and in this state it sometimes remains for some years, subject to little alterations, as the health or habit shall happen to vary, the facculus being sometimes more sometimes less full and troublesome; the mucus which is pressed out is sometimes more sometimes less cloudy, and now and then it is attended with a slight ophthalmia, or an inflammation of the eye-lids; but which, by common care, is easily removed.

If the facculus is not much dilated, the discharge small, and produced only by pressure, the chief inconveniences are the weeping eye, and the gumming together of the lids after sleeping: but these, by being attended to, may be kept from being very troublesome; and if the disease makes no further progress, may be so regulated as to render any more painful process totally unnecessary.

If the dilatation is considerable, the swelling is more visible, and the quantity of mucus is larger; it is also in this state more frequently mixt and cloudy, and more troublesome, from the more frequent necessity of emptying the bag; but if the patient be adult, it may, even in this more dilated state of it, be kept from being very inconvenient.

If an inflammation comes on, the tumour is thereby considerably increased, the discharge is larger, as well during sleep as upon pressure; the skin covering it loses its natural whiteness and softness, becomes hard, and acquires an inflamed redness; and with the mucus a mixture of something, which in colour resembles matter, is discharged, especially if the pressure be made with any force or continued for any time. This circumstance, added to the painful sensation and inflamed appearance of the parts, has been productive of a supposition that in this state there is either an ulcer or an abscess within the facculus or duct. This opinion, though it may possibly sometimes have some foundation in truth, yet is in general entertained much too hastily, and is also the principal source whence most of the mistakes concerning this disease have sprung; but as there is a certain criterion by which we may distinguish between pus and mucus, practitioners cannot now be liable to such errors in this respect as formerly.

The inflammation of the cellular membrane covering the sac is a circumstance which makes a considerable difference both in the appearance of the disease and in its requisite treatment; in some cases it is confined

confined merely to the surface of the tumour in the corner of the eye; in others it spreads still farther, affecting the eye-lids, cheek, and side of the nose.

When the parts are in this state, the mucus within the bag has generally the appearance of being matter; that is, it wears a deep yellow colour, and is of a more thin consistence: if the puncta lachrymalia are naturally large and open, and the inflammation confined to the surface of the face, its contents will pass off pretty freely, and the skin will remain entire. This is what the ancients called the simple or imperfect, or anachylops.

But when the skin covering the lachrymal bag has been for some time inflamed, or subject to frequently returning inflammations, it most commonly happens that the puncta lachrymalia are affected by it, and the fluid, not having an opportunity of passing off through them, distends the inflamed skin, so that at last it becomes sloughy, and bursts externally. This is that state of the disease which is called perfect Aigylops or Egyllops: the discharge which used to be made thro' the puncta lachrymalia, while the skin was entire, is now made through the new opening, and, by excoriating the eye-lids and cheek, increases the inflammation, and gives the disease a much more disagreeable appearance. In some, the matter bursts through a small hole; and after it has discharged itself the tumour subsides, the neighbouring parts become cool, and though the skin covering the surface of the sacculus is sloughy and foul, yet there is no reason to believe that the face itself is much diseased below. In others the breach is large, the skin remains hard and inflamed, and, from the appearance of the sore, there is reason to suppose the whole inside of the bag to be in a diseased state; and in some cases which have been much neglected or irritated by ill treatment, the cavity of the sacculus seems to be filled with a loose ill-conditioned fungus, which gleets largely, and produces inflammation and excoriation of all the parts about.

There is also another circumstance which sometimes is found to attend this disorder, viz. a carious state of the bones. This was by our forefathers supposed to be a frequent one, and was the principal reason for their so free use of caustic, cauterizing, and scalpra, in the treatment of it; but since the disease has been more minutely examined into, this circumstance has been found to be a very rare one. When the fistula lachrymalis is a symptom of the lues venerea, as it sometimes is, the bones are indeed often carious; but then the fistula is not the original complaint, but produced secondarily, and is a consequence of the diseased state of the os ethmoides and ossa spongiosa of the nose, and is not curable by any local means or applications, but depends entirely on the cure of the disease of which it is a symptom.

An abscess after the small-pox, by falling on the lachrymal bag, has made it all slough away, and leave the bones bare; which circumstance also sometimes attends the free use of strong escharotics applied to destroy what is called the cyst; but without the accession of some other disorder producing it, or the most absurd method of treating the complaint, a caries of the bones will very seldom be met with. Indeed the combination of other diseases, either of the general habit, or affecting the same or the neighbouring parts, does

often make a very material difference, both in the appearance of the disorder, in the prognostic, and in the proper method of treating it; which therefore should always be inquired into. For instance, the patient is sometimes subject to an habitual ophthalmia or lippitudo, which will add to the deformity, and give a good deal of additional trouble during the cure: an ozæna, or some other disease of the membrane and cells of the ethmoid bone, or a polypous excrecence within the nose, are now and then combined with it. The habit is sometimes, as we have before observed, infected with the lues venerea, of which this disease may be a symptom: strumous glandular obstructions are its too frequent companions; and, what is worst of all, it is sometimes cancerous.

From what has been said, we may divide this disease into four general heads or states, under which all its lesser distinctions may be comprehended. The first consists in a simple dilatation of the sacculus and obstruction of the nasal duct, discharging upon pressure a mucus, either quite clear or a little cloudy; the skin covering the bag being entire and perfectly free from inflammation. In the second, the tumour is somewhat larger; the skin which covers it is in an inflamed state, but entire; and the discharge made through the puncta lachrymalia is of a pale yellow or purulent colour. In the third, the skin covering the sacculus is become sloughy, and bursts; by which means the swelling is in some measure lessened: but the mucus, which while the skin was entire used to be pressed out through the puncta lachrymalia, now discharges itself through the new aperture. The ductus ad nares, both in this and the preceding state, are not otherwise diseased than by the thickening of its lining. In the fourth, the passage from the sacculus lachrymalis into the nose is totally obliterated, the inside of the former being either ulcerated or filled up with a fungus, and attended sometimes with a caries of the bone underneath.

The ancients, who supposed this disorder, in its first state, to be an inflammatory defluxion from the brain on the caruncle, tending to suppurate, directed their first attention to prevent such consequence: for which purpose they employed phlebotomy, cathartics, issues, fetons, collyria, and refrigerant applications of all sorts; and these not succeeding, they had recourse to such as they thought would hasten the suppuration of the supposed abscess.

By the improper use of medicines of the latter kind, it frequently happened that the skin became inflamed and burst: the discharge which necessarily followed this accident, together with the heated appearance of the parts about, confirmed their opinion of a collection of matter within; and, according to such supposition, they attempted to obtain a cure by dilating the orifice, and endeavouring to make an incision from the bottom of the hollow. Not being acquainted with the situation or use of the nasal duct, they took no care to free it from the obstruction under which it laboured; but, dressing the sore like a common imposthuration, permitted it either to be filled up with a loose fungus, or to contract itself to a narrow fistulous orifice; which daily discharging a discoloured kind of fluid, and not healing by such means as they made use of, they concluded the bone underneath was carious.

carious, and made way down to it, either by removing the parts with a cutting instrument, or by destroying them with caustic and cauterizing, intending to procure an exfoliation, and thereby a firmer basis to heal on.

But since the use of the ductus nasalis has been known, since it has been discovered that an obstruction in this is the primary and principal cause of the disorder, and that what passed for the cavity of an abscess is really the facculus lachrymalis, both the intention of cure, and the means, have been considerably altered.

⁵⁶¹ In the first and most simple state of the disease, viz. that of mere obstruction without inflammation, much pains have been taken to restore the parts to their natural state and use, without making any wound or division at all; the introduction of a probe, the injection of a fluid, and a constant compression made on the outside of the facculus in the corner of the eye, are the principal means by which this has been attempted.

⁵⁶² Some few years ago, M. Anel made a probe of so small a size as to be capable of passing from the eyelid into the nose, being introduced at one of the puncta lachrymalis, and passing through the facculus and duct; with which probe he proposed to break thro' any small obstruction which might be found in its passage. He also invented a syringe, whose pipe is small enough to enter one of the puncta, and by that means to furnish an opportunity of injecting a liquor into the facculus and duct; and with these two instruments he pretended to be able to cure the disease whenever it consisted in obstruction merely, and the discharge was not much discoloured. The first of these, viz. the passage of a small probe through the puncta, has a plausible appearance; but will, upon trial, be found very unequal to the task assigned: the very small size of it, its necessary flexibility, and the very little resistance it is capable of making, are manifest deficiencies in the instrument; the quick sensation in the lining of the fac and duct, and its diseased state, are great objections on the side of the parts; supposing it were capable of answering any valuable end, which it most certainly is not.

That the passing a fine probe from one of the puncta lachrymalis into the nose is very practicable, is known from experience; but the pain it gives, and the inflammation it often excites, are much greater than any benefit which does or can arise from it.

It is said, that the principal use of this probe is to clear the little ducts leading from the puncta into the facculus, and the obstruction of those ducts is often mentioned as a part of this disease. Hence one would be led to suppose that it was a circumstance which frequently occurred; whereas it is seldom, if ever, met with. Nor, even if it did happen, could it ever produce the disease in question; the principal characteristic of which is a discharge into the inner corner of the eye upon pressure made in the angle. This discharge is made from the facculus through the puncta, and proves that the latter are open. The passing a probe, therefore, through these, seems to be perfectly unnecessary, since a stoppage of them would never give rise to that disease, which consists in an obstruction to the passage of any thing from the fac into the nose, and not from the eye into the fac.

The syringe, if used judiciously while the disease is

recent, the fac very little dilated, and the mucus perfectly clear, will sometimes be found serviceable; it gives no pain; and a few trials render the use of it very little troublesome.

⁵⁶³ Fabricius ab Aquapendente invented an instrument, which was so contrived, as by means of a screw to of Aqua-make a pressure externally on the lachrymal bag; from the use of which, he says, his patients received much benefit. This instrument has been considerably improved by late practitioners, and is still recommended as very useful.

All the good that can be obtained by compress and bandage, this screw is capable of procuring; but it is also subject to all the same inconveniences, arising from the impossibility of determining exactly the due degree of pressure: for if it be so great as to bring the sides of the upper part of the fac into contact, all communication between it and the puncta will be thereby stopped; if it be but slight, the accumulation will not be prevented; nor does it in either case contribute to the removal of the obstruction in the nasal duct, the primary and original cause of the disease.

If the curative intention was to procure an union of the sides of the facculus, as in the case of parts separated from each other, by the formation of matter or sloughs, and the pressure could be made uniformly and constantly, possibly it might be so managed as to answer a valuable purpose; but as that is not the intention, the pressure, whether made by an instrument, or by a common roller and compress, contributes little or nothing toward a cure.

⁵⁶⁴ Besides these means of attempting a cure without incision, the gentlemen of the French academy have tried some others, such as the introduction of a probe into the lower part of the nasal duct within the nose, the injection of a fluid by the same orifice, the passing a seton from the punctum lachrymale superius through the facculus and duct and out at the nostril, there to remain till the cure is completed: and for those purposes they have invented and given figures of a number of probes, syringes, and many other instruments, which, they say, have been very successfully used; though others have not found them to answer the purpose.

When the disease is got beyond the simple state just described, that is, when the parts round about are much or constantly inflamed, or the skin covering the tumour is burst, there is something more to be done if a cure is intended.

In this state, an opening in the upper part of the facculus lachrymalis becomes in general absolutely necessary; and as a wound made by a knife leaves a much less disagreeable scar than that which necessarily follows the bursting of the skin, one being a mere simple division, the other a loss of substance; it will always be found best to anticipate the accident of bursting, by making the opening as soon as the integuments are in such a state as to threaten it.

For the making this incision, authors have been very very particular in their directions with regard to its place, manner, and form. They have ordered it to be semilunar, having its concave part toward the eye, and that the point of union of the lids should be exactly opposite to the centre of the incision. This lunated figure was calculated to correspond with the course of the fibres of the orbicular muscle, upon a supposition

that a transverse section of them would produce an inversion of the lower lid, an effect which never follows: all that the surgeon need observe is, to take care to keep the knife at a proper distance from the juncture of the palpebræ, to begin the incision a very little above a line drawn from that juncture toward the nose, and to continue it downward; its form may full as well be straight as any other, and the best instrument to make it with is a small crooked bistory.

If the facculus is already burst, the place of opening is determined; and the orifice may be enlarged with a knife, or dilated.

The incision made, the facculus should be moderately distended, either with dry lint or a bit of prepared sponge; by which means an opportunity will be gained in two or three days of knowing the state of the inside of the fac, and of the ductus nasalis: if the former is neither sloughy nor otherwise diseased, and the obstruction in the latter but slight, it sometimes happens, that, after a free discharge has been made for some days, and the inflammation occasioned by the first operation is gone off, the fac contracts itself, a superficial dressing, with moderate pressure, heals the sore, the lachrymal fluid resumes its wonted course, and the disease disappears.

If this simple method does not succeed, or from the state of the parts seems unlikely to do so, another must be tried, which the opening already made will enable us to put in practice. The point to be aimed at is, if possible, to render the nasal duct pervious to the lachrymal fluid; and we must endeavour to obtain this end by such means as give the least pain, excite the least inflammation, and leave the parts as near as possible in their natural state; that is, we are to endeavour to dilate the passage from the fac to the nose, by some means which will gradually distend it without destroying its texture, in the same manner as the dilatation of the urethra ought to be effected in the case of stricture, by passing either a probe, or a piece of catgut, or a bougie, gently into it, as far as it will easily go, and repeating it occasionally, until it is got quite through, and the passage is free (A).

When a passage has been once obtained, it should be carefully kept open, either by a piece of catgut, a small bougie, a leaden probe, or something of that sort; and when it is thoroughly established, the sore may be permitted to contract, until it becomes no more than what serves for the introduction of the bougie into the duct; in this state it should be kept open for some time, injecting now and then a little aqua calcis, softened with mell. rosar. through from above into the nose; and when it appears that the passage is so free and so well established that there is good probability of its preserving itself, the orifice in the angle of the eye, by being covered only by a superficial bit of plaster, or pledget, will contract and close; and if during its closing moderate pressure be used on the facculus, to prevent a fresh accumulation of mucus, it will assist the cure.

The last state of this disorder is that in which the natural passage from the facculus to the nose is so dis-

eased as to be quite obliterated, or in which the bones are sometimes found to be carious. The methods hitherto described have all been calculated to preserve the natural passage, and to derive the lachrymal fluid again through it: in this attempt they are sometimes successful; but when they are not, there is no surgical means left, but to attempt the formation of an artificial one in its stead. The upper and hinder part of the facculus lachrymalis is firmly attached to the os unguis, a small and very thin bone just within the orbit of the eye; which bone is so situated, that, if it be by any means broken through or removed, the two cavities of the nose and of the orbit, communicate with each other; consequently the os unguis forms the partition between the hinder part of the lachrymal bag, and the upper part of the cavity of the nose; and it is by making a breach in this partition that we attempt the formation of an artificial passage for the lachrymal fluid.

To make this opening, many different instruments have been devised, and used; a large probe, an instrument like a common gimblet, a curved trocar, &c. each of which, if dexterously and properly applied, will do the business very well: the one necessary caution is, so to apply whatever instrument is used, that it may pierce through that part of the bone which lies immediately behind the facculus lachrymalis; and not to push up too far into the nose, for fear of injuring the os spongiosum behind, while it breaks its way.

Mr Pott prefers the curved trocar, which has served his purpose well, and from which he never experienced any inconvenience. In using it, the point should be turned obliquely downward, from the angle of the eye toward the inside of the nose; the accomplishment of the breach will be known by the discharge of blood from the nostril, and of air from the wound upon blowing the nose. The most precise direction in this part of the operation will be of but little use to him who has no idea of the natural structure and disposition of the parts concerned, and who ought therefore to get such information as soon as he can: but whoever is at all acquainted with this matter, or will attend to the situation and connection of the os unguis, knows that this bone is divided into two parts by a perpendicular ridge; that the lachrymal fac is connected to all that part which is anterior to this ridge; and that the posterior part of the bone contributes to form the orbit of the eye, and has little or no connection with the lachrymal fac. The trocar must be applied therefore to that part of the bone which is anterior to the ridge, and consequently behind the lachrymal bag; by the passage of the instrument, all this part of the bone will in all probability be broken, but from which no mischief will ensue.

As soon as the perforation is made, a tent of lint should be introduced, of such size as to fill the aperture, and so long as to pass through it into the cavity of the nose: this should be permitted to remain in two, three, or four days, till the suppuration of the parts renders its extraction easy; and after that a fresh one should be passed every day, until the clean granulating

(A) This caution is very necessary to be observed in the cure of stricture of the urethra; in which case the proper intention is, gradually to dilate the passage, and to procure an increased discharge of mucus from the lacunæ: this should always be done gently, and by means which give as little pain as possible; whatever irritates or gives pain will certainly do mischief, will add to the obstruction, and increase the dysury.

Practice. lating appearance of the sore makes it probable that the edges of the divided membrane are in the same state. The business now is to prevent the incarnation from closing the orifice, for which purpose the end of the tent may be moistened with spir. vitriol. ten.; or a piece of lunar caustic so included in a quill as to leave little more than the extremity naked, may at each dressing, or every other or every third day, be introduced, by which the granulation will be repressed, and the opening maintained: and when this has been done for some little time, a piece of bougie of proper size, or a leaden canula, may be introduced instead of the tent; and, leaving off all other dressing, the sore may be suffered to contract as much as the bougie will permit, which should be of such length that one extremity of it may lie level with the skin in the centre of the eye, and the other be within the nose.

The longer time the patient can be prevailed upon to wear the bougie, the more likely will be the continuance of the opening; and when it is withdrawn, the external orifice should be covered only by a superficial pledgit or plaster, and suffered to heal under moderate pressure.

569 Of introducing a metal canula. There is another method which has been much recommended by some French writers, to prevent the closing of the opening in the os unguis, and which is now generally approved in this country; namely, to introduce a canula either of gold or silver, or lead, into the aperture, and to permit the sore to heal over it, suffering the canula to remain, or to come away by the nose.

570 Mr Wathen's directions. Mr Wathen, who has written a treatise on this subject, generally makes use of gold; because most easy to be procured in a state of perfect purity, which is a quality first to be regarded, whatever the metal be: and he prefers this or silver to lead, chiefly on account of their firmer texture, which must render a tube made of either of them less liable to be affected by any pressure it may receive. The tube is somewhat concealed, to prevent its descent into the nose; and it is made sufficiently long, to reach from the upper portion of the bony duct, to its aperture below the os spongiosum.

To introduce it more easily, it is furnished with a style, nearly as long as a common probe; the lower end of which is rounded, so as that, passing through the tube, it may exactly fill the aperture at the small end: and it is prevented from passing further, by a shoulder of the same size with the outside of the tube.

The tube is held upon the style by a doubled thread, which passes through a small hole on the one side of its upper or larger aperture, and is continued to a ring at the upper end of the style. By fastening this thread to the ring, the style and tube become one instrument, capable of being introduced and extracted at pleasure, and possessing all the power of a probe.

By means of this, the operator may be enabled to examine the state of the disease, and to judge with the greatest precision of the diameter of the duct, and consequently of the proper size of the tube. For as the duct in persons of different ages, &c. will vary both in the diameter and length, there must on this account be a proportional difference in the tube:

and the operator should therefore be furnished with styles and tubes of several different sizes.

The necessity of paying a close attention to the size of the tube is apparent. For if it be too large, it cannot be introduced; and if too small, it will be liable to slip, if not past, through the lower aperture of the duct into the nose. If, again, it rises too high, it may press against the sides of the face, and thus close the orifice through which the tears should pass. If, on the other hand, it comes down too low, it will project beyond the inferior extremity of the duct, and may produce a very troublesome titillation. When the tube is found exactly to fit, the thread, which was passed through the ring at the upper end of the style, being tied in a knot, at about the distance of an inch from the top of the tube, the longer portion of it, above the knot, is to be cut off. By this the style will be disengaged, so that it may be extracted with ease, leaving the tube behind, with the thread hanging out of the wound.

When the tube is fixed, some simple liquor is to be passed by a syringe through it into the nose, as a proof of its being so placed that it will answer the intended purpose. The opening made in the face might be entirely closed within the space of a few days, if it was not thought proper to leave the thread in. When it has continued there about a week, if the tears absorbed by the puncta are conveyed by the tube to the nose, the thread, which is double, may then be extracted, by cutting one side of it with the scissors, and drawing the other out. The little orifice thro' which the threads passed will be closed in the space of a day. And thus a disorder, which had continued for months, and perhaps years, may be perfectly cured within the short space of a week.

SECT. XVIII. Of Amputation.

In this operation the great end to be aimed at is, the procuring of a handsome stump, in which the bone may not protrude, but be well covered with flesh; so that no excoriation or rawness may be apt to take place, as is too frequently found to be the case after amputation has been performed in the common manner. As long ago as the year 1679, it was proposed by Jacob Young, an English surgeon, in a treatise intitled Currus Triumphalis ex Terebinthino, to preserve a flap of flesh and skin, which was to be folded over the bone, and which, uniting to the parts of the wound after amputation, would effectually cover the bone, and prevent the inconveniences abovementioned. No traces of the success of this method, however, can be found till the year 1696; when a Latin dissertation was published upon it by P. Adrians Verduin, an eminent surgeon in Amsterdam. The most sanguine expectations were formed of its success; and it was even thought that the flap would prevent the necessity of tying up the blood-vessels. However, it does not appear that the method as at that time practised, either did or could succeed; and accordingly it was entirely laid aside, till lately that it has been revived with considerable improvements.

§ 1. Of Amputating the Leg.

In Verduin's method of amputation, the rule was,

to cut away the fleshy parts to the tendo achillis; and after sawing through the bone, if the flap was too big, it again suffered a second incision. To keep this flap united to the bare bone, he contrived a variety of straps and machines, highly embarrassing to the operator, and painful to the sick. But Mr O'Halloran, having demonstrated that the attempting an union of these parts before suppuration was the true cause of this operation's failing of success, and willing to determine the precise quantity of flesh necessary to be taken off in the flap-operation, found that 15 inches might be considered as a medium standard of the circumference of a man's leg; the diameter of which (supposing it a complete circle) would be about 4½ inches, which appeared to him necessary to be preserved below the amputated part, in order to form a flap sufficient to cover the stump. But as this great length of flesh would make the operation practicable but in a few cases, he began to consider of some conciser means. After sawing some tibiae at the usual place of amputation, and measuring the diameter of the two bones together, he conjectured, that about 3+½ inches, might be admitted as a general standard of adults. If, then, an oblique section be made of the skin and muscles, at about three inches, or at most three and an half, below the part to be amputated, and continued in a sloping direction till it reaches the bone, at the place of excision; by a circular incision of the remainder of the flesh and skin at this part, we shall preserve flap enough to cover the ends of the bones. By this means surgeons will be enabled to perform this operation, in every case where amputation becomes necessary; and it will be then found as expeditious as the method of the double incision, and attended with no more pain.

After a trial on a body, he found the flap a little short, on account of the thickness of the gastrocnemii muscles; but upon repeating his experiment on another body, and having first carefully drawn back as much skin as he could, a flap of 3+½ inches answered exactly, allowing for the melting down of the corpus adiposum, and cellular substance of the muscles, by suppuration, as lessening considerably the bulk of flesh, though not the length of the flap. This rule should not be deemed infallible; because, where the limb is extenuated, a less quantity of skin will suffice to cover the extremities of the bones than where the parts are turgid and full. He has since found, that besides the previous drawing up of the skin, if in the circular tour care is taken to save some skin in the anterior part of the leg, which is easily done by drawing it back during the incision, a flap of three inches will certainly answer. This operation he performed three times successfully in the course of eight months, and never measured the quantity of flesh he intended to preserve, but with the eye; however, in a week after each operation, he was curious enough to measure the particular flaps. The first measured 3+½ inches without, from the extremity of the flap to the place of the circular incision; and 2+½ from the internal edge of the flap to the bone; and this flap was found sufficient to cover the extremity of the stump, though a good-sized leg; and that the circumference of it measured 24 inches. In the second case, the flap measured from without, three inches; and internally, not quite two. This woman's leg was smaller than the first patient's,

but both bones were rather larger and much more firm. The periphery of this stump was twelve inches. In the third instance, the leg was burnt so high up, that no greater flap could be allowed than two inches and one-fourth, and from within it measured 1+½ inches; and yet this stump was also completely covered with a good cushion of flesh and skin. The limb was greatly extenuated, and the circumference of the stump was not quite ten inches. Upon the whole, then, he conjectured that the difference between 3 and 3+½ inches of a flap, will take in most legs; i. e. in adults, that it should be seldom under 3, nor ever exceed 3+½ inches.

These necessary details premised, where the necessity of taking off a leg is manifest, let the hair be shaved off from the knee to where the limb is to be taken off, which will save the patient a good deal of trouble in the dressings. The skin should then be drawn up pretty tight; and let a small band moderately rolled up, and sewed from its outside folds to the centre of an open roller, of about two inches broad and a yard long, be placed in the ham, over the artery; and with the open one going round the knee, let it be thus firmly secured. If one side of the open band is perforated, so as to make it a kind of uniting band, it will roll smoother. Then with Petit's or the common tourniquet, let the artery be sufficiently compressed. On this occasion Mr O'Halloran prefers the common one; because, by its uniform pressure round the limb, less blood is lost than in the ordinary way. The difference, nevertheless, is not of so much consequence as to give one an absolute preference to the other: the choice, therefore, may be safely left to the option of the surgeon. The patient should be placed on a chair, or low table, of about two feet high, as the leg must have some degree of elevation. All the apparatus being properly disposed, which consist of a straight edged knife, with the blade as long as that of the common cateline, and pointed at its extremity, the common amputating knife, saw, and a few needles armed with flat threads, waxed, of different sizes. Let the leg be elevated about a foot higher than if in an horizontal posture; and with strong tape of about an inch broad, let it be bound round pretty firm at the intended place of excision; and if at this time he lies in a reclining posture, the raising the leg will be the more easy.

Mark with a pen the traces where you are to commence your incision, which should be, in adults at least, three inches from where the bone is to be sawed. Then with the straight incision-knife, make an oblique section from this point almost or quite to the bone, ending at your tape: then with this same, or the common amputating knife, let the circular incision of the remainder of the flesh be expeditiously performed. To do this first part of the operation with greater ease to yourself and advantage to the patient, you must be careful, if the left leg be the part diseased, to place yourself between his legs; and if the right, to be outside the limb. The reason of these situations is very obvious; for you cannot with the right-hand command an exact sight, or commence your operation dexterously, but in these postures. This done, apply a split cloth, the two tails of which should cross over the tibia, and with the single one draw back the flap. Though some operators do not approve of the split cloth in the common

mon method, yet here it is essentially necessary: for this purpose the tape should be first removed. Any little undivided flesh may be now separated by the cateline; the periosteum divided round about, and scraped upwards, agreeable to the advice of professor Monro; and the ligamentum interosseum divided. The next thing to be done is to saw the bones; but whatever be your position in dividing the soft parts, you must be always between the legs to cut away the bones. As soon as you have marked the traces of the saw on the tibia, run it along both bones, very light and nimble; and continue this manœuvre till the bones are divided. By this means the teeth of the saw will not be entangled in the bones, nor you often obstructed in your motion; but the divided bones will be smooth, and the operation expeditious.

The limb being taken off, the tourniquet must be relaxed, and the tibialis anticus, posticus, and interosseus arteries, carefully taken up. Where the flesh was thin, and not very firm, Mr O'Halloran has sometimes made a ligature round the bone in which the artery was included: but if you use, instead of the ligature of the vessels, the agaric or lycoperdon, which, our author thinks, may be safely depended on in the leg and fore-arm, you must be careful that the fungus does firmly adhere to the vessels before you dress up the stump; as also that it be not removed during the last period. As for the vessels that spread themselves on the gastrocnemii and soleus muscles in this operation, the taking them up becomes necessary. The blood being carefully mastered, which you will know by relaxing the tourniquet for some time, and no blood spouting out, you are then to dress the stump thus. Let the tibia be covered with a pledgit of dry lint, and the rest of the stump with soft lint, loose, and strewed with fine flour. In the thigh and arm, besides the future, he generally applies some lycoperdon to the extremities of the principal vessels; the same may be also done in the present case, if the ligature has been used. He particularly recommends it to the space between the tibia and fibula; because it sometimes happens that the interosseus artery shrinks between the bones; and though no appearance of an hemorrhagy at present happens, yet in a few hours it may return. The possibility of this accident justifies the precaution. The flap is likewise to be dressed with soft loose lint, and a cloth cut in form of a double T, and covered with adhesive plaster, is to cover the dressings. Its figure is thus:

The long one is to surround the stump above the amputated part, whilst the tails, by crossing the flap, press it against the stump, and make all the dressings the more compact. This done, an hog's bladder moistened and notched is to inclose the stump; but previous to this a handful of lint is to be applied between the outside of the flap and the bladder: press this last to the stump; and the notches covering each other above make the whole dressings smooth, and the pressure soft, and such as is best calculated to prevent an hemorrhagy. Let a cross compress, moistened,

cover the bladder; and then with a band, of between eight and nine yards long, and near three inches broad, rolled up to two heads, secure your dressings thus:

After removing the tourniquet and other bands used antecedent to the operation, a handful of soft lint should be applied to the ham; which, in the circumvolutions of the band here, greatly restrains the violence of the blood; for as this is the most troublesome and alarming symptom, and the most reproachful to the surgeon, all these precautions are justifiable. With one of the heads of your band make three circulars above the knee moderately tight; then with the same descend, and make two or three turns below the knee, rather smooth than tight; and then mount obliquely till you get above the knee, and here make a circular turn. Let the other head of the band go straight down from the posterior and inferior part of the thigh over the flap, and above the knee anteriorly; which will become here secured by a circular turn of the other head over it. Let the other head again cross the stump and flap from the inside of the thigh, and ascend at its outside above the knee, and here be again secured by a fresh circular turn of the other head. Cross over the stump again between these folds, so as to form on the flap a kind of star of six points; and this fold becomes also secure by a new turn of the other. Let the remainder of both bands be then disposed of round the thigh at pleasure, or cut off.

The stump being dressed, let the patient be laid on Treatment of the patient after the operation. his bed, and a pillow put under the thigh, so as to raise that part. Let the patient be kept to a proper diet: but in this point it is impossible to fix any criterion; for regard must always be had to the patient's usual manner of living, what is high diet to one being insufficient to preserve the life of another. And on this single point the success of many a cure plainly depends. In general, young people of plethoric habits should be kept low; those advanced in years, or whose constitutions are otherwise impaired, should live freer. Some bleed on the commencement of the fever: but this ought to be avoided, except the fever is high, or the subject full of blood; because without a fever there can be no suppuration, of course no tendency to recovery. In general, the first opening of the sore should not be for four or five days, according to the season or symptoms. This should be done, by first softening the dressings in warm water, and removing only as much of the lint as comes off loose and easy. Let the whole part be then covered with pledgits, armed with proper ointment, and secured by the double T-plaster, with the compress and bandage already described. The flap and the stump, at every dressing, are to be regarded as distinct sores, and separately dressed. If the discharge is small, it may be promoted by stumping the stump with sponges pressed out of very hot water, by the common digestive, and the like. If abundant, it may be lessened by dosils of lint wet in brandy or tincture of myrrh, or by dry lint alone, which is an excellent absorbent: the bark, in substance, will also greatly restrain it; often a pill or two of calomel. In general, an abundant suppuration will promote a speedy coalition; whereas, when slow, it will be more tedious.

About the 12th day, then, that is, when inflammation is entirely passed, and suppuration effectually

established, the bare flap may be turned up against the naked stump, and so be secured by plaster, compression, and bandage. Instead of the bandage already described, our author on this occasion uses one composed of a strip of strong cloth to go round the knee; and to the centre of this is fixed another, which, crossing from under the ham, the stump is secured to the circular above the knee by means of four or five pieces of tape attached to this last. The sore should not be opened for at least two days after this, and the dressings taken off with great caution. He often bathed this part very hot; and though the flap should in part separate, yet must it again and again be returned until the parts firmly unite. The little sore which the flap does not cover should be dressed with lint and brandy. Soon after the union of the flap and stump, the former sometimes inflames; but a relaxing stupe, and a poultice of flummery, soon removes this. At every dressing of the remaining little sore of the flesh, the stump may be bathed in bran and water hot, which will greatly accelerate healing. Though after 15 or 16 days the cure may be finished by any common nurse, yet do the parts remain tender for some days longer. By the dissection of one of his patients, who died many months after this operation of a malignant small-pox, our author found it was occasioned by the extremities of the bones not being completely healed: so that what he then thought a disadvantage to this operation, appears now to be one of its greatest excellencies; namely, that the bones should be fairly covered by a firm periosteum; which at the same time accounted for this phenomenon.

§ 2. Of amputating the Thigh.

To attempt this operation, by preserving a flap of flesh in the posterior and inferior part of the thigh, must leave so large a flesh-wound, and so great a quantity of muscular flesh bare, as to require a very great length of time to bring on a firm union of the divided parts: besides, the fever, and great discharge from so large a surface, may alone endanger the patient's life. Mr O'Halloran, after a variety of trials, concluded, that a flap of flesh and skin preserved in the anterior part of the thigh, must answer our most sanguine expectations: for the quantity of flesh here is not much, the skin, corpus adiposum, and rectus muscle, being only interested in the incision; of consequence the wound not considerable, and the flap not required very large. Our author attempted to determine, on a dead body, the quantity of flap necessary to be preserved in this manner. The circumference of the thigh, at four inches from the inferior part of the rotula, measured eighteen inches. Here he drew up the flesh, and bound it by a small band. He then began a flap-incision on the rotula, bringing it up to the circular band, and here sawed through the bone, having first cut through all the intervening flesh. The preserved flap measured three inches externally, and two and an half from the circular incision of the flesh to its internal extremity. The diameter of the femur, in its lowest axis, or nearly from side to side, was exactly an inch and one-tenth; and yet this flap, besides completely covering the bone, extended an half inch beyond it. By this plain and simple experiment, it appears, that the flap-opera-

tion in the thigh, by making your incision in its anterior part, becomes less complex, less painful, and even more expeditious in its cure, than the same operation in the leg. After determining on the precise place on which the limb is to be taken off, care must be taken to have the blood-vessels mastered in the operation, either by Petit's or the common tourniquet, as in the usual manner: then let the flesh and skin be tightly drawn up from the knee, and so secured above the place of election by a circular tape or band. Mr Gooch proposes a kind of thick circular cushion to serve instead of this band, to direct the knife exactly in the circular tour; but Mr O'Halloran thinks that a thick tape will answer this purpose every bit as well, as this operation is mostly exactly even, and that the cushion rather hides the direction of the knife from the eye. With a straight knife, such as has been described in taking off the leg, commence your flap-incision at about three inches more anteriorly than where the bone is to be sawed through, supposing an adult, and so in proportion to the age and size of the limb. Let this incision be continued in an oblique direction till you reach the bone at the circular tape; then with the same, or a common amputating knife, make your circular sweep, commencing from the side of the flap and directly to the bone; observing here, as in the leg, to place yourself outside the body in taking off the right thigh, and between the legs in removing the left. But then there is no necessity here, as in the leg, of change of place in sawing the bone; because, as it is but one, wherever you place yourself to cut off the soft parts, there you may stay to finish the operation.

As soon as the circular incision is completed, the tape should be removed and the split cloth cross the divided parts, in order to draw up the skin and muscles, the single tail covering the flap; and as soon as the periosteum is separated, &c. let the bone be sawed. The femoral artery should be secured as already directed; and besides this ligature, let some agaric or lycoperdon be applied: and any other considerable branches of vessels may be taken up or stopt by the above funguses. Let the surface of the sore be covered with loose unformed lint strewed with flour, and the flap laid over this dressing covered by a double T-plaster; a handful of lint outside this, gently pressed against the flap by an hog's bladder, moistened and notched at its orifice; and the whole covered by a cross compress. Let soft lint, tow, or a linen compress, cover the direction of the artery; and secure all these dressings on by a band about three inches broad, and twelve yards long, rolled up in two even heads. Apply a large handful of loose lint or soft tow over the femoral artery near the groin; and after making a couple of circulars about this part, moderately tight, so as to break in some measure the force of the circulating fluid, let the bands cross round the body. Fix a piece of strong tape, about an inch or more broad, and a yard long, along the inside of the amputated thigh, one end of which is to be secured to the band that went round the body, and the other to hang loose over the stump: let a similar piece of tape be in like manner fixed to the outside of the thigh: then, with one of the heads of your bandages, make three or four circulars round the thigh over these tapes, gently descending;

scending; and with the other head cross directly over the anterior part of the thigh and stump, and ascend posteriorly: a couple of circulars of the other head, gently ascending, will secure it smooth and firm. Descend again over the inside of the thigh, cross the stump, and mount with your first band outside the thigh; and here another circular or two makes this second turn firm. Between the anterior and lateral turns of the band you must bring down your roller cross the stump, and ascend in the opposite direction: and here, again, a couple of circulars of the other roller will make all firm. Between the posterior and lateral parts of the band you must make a fourth turn over the stump, and secure it by another circular, and finish both heads by circulars or spiral turns round the stump; or if too long, they may be cut off. Though the stump be now apparently well bound, yet, by reason of the form of the thigh, the bands may be apt to loosen, or even drop off: to prevent this, let the tapes already mentioned be turned up at their loose extremities; the inside one to cross over the inside of the thigh, and, as it ascends, to be here and there secured by pins to the circulars, and to part of the band that went round the body; and in like manner the outside tape. By this means the circular turns, which only could loosen, will be smoothly retained in their different places, and the whole bandaging convenient, firm, and even. The bandaging, however, should be but moderately tight, as the swelling of the stump will soon make them sufficiently distended.

In winter, the stump should not be opened before the fifth, or even sixth day; nor in summer sooner than the fourth: the bone should be dressed with dry lint, or lint wet in brandy, and the soft parts with the common digestive; taking care to remove no more of the old dressings than what are loose. When suppuration is well established, the stump and flap may be dressed with dry lint, as the soft digestives at this time are apt to encourage exuberant or proud flesh. If, nevertheless, such should rise on the flap, it may be now and then sprinkled with red precipitate; but the surgeon need never be uneasy at attempting an union of the flap and stump at such time. About the 12th or 13th day, and not sooner, should the flap and stump be brought into perfect union: before this they are to be treated as distinct sores, and preserved in such situation by a bandage something like what has been recommended for the leg. But whereas that was secured above the knee, to make this a fixed point, the straps must go round the body, and the body of the band lie on the anterior part of the stump, in order gently to bring the flap and stump into an exact union. This first dressing is not to be opened for three days; and every other rule recommended in the leg is here exactly to be followed. If, in the suppurative state, the sore should have an unusual degree of pain and sensibility, the parts may be often bathed in milk and water; the sick let blood; and even opium, alone or mixed with digestives, may be successfully applied to the parts.

§ 3. Of amputating the Arm.

580 IN amputating the thigh, we have, for very obvious reasons, chosen to take the flap from its anterior part, as being a less considerable wound, having less of sub-

stance, and of course sooner covering the bone, the principal object of all. For precisely the same reasons, in taking off the arm, the flap of flesh should be taken from its posterior part, as being less fleshy, and nearer the bone: here a flap of flesh, from two and half to three inches, will be certainly sufficient to cover the bone. The bandaging here must be pretty nearly the same as in the thigh; though, as the arm is almost cylindrical, some may think it unnecessary to cross the band round the body, as it might be apt to heat and oppress the patient. But if this should be thought proper to be dispensed with, a flat tape should from the neck hang down each side of the arm, the bandaging to be performed over it, and the two extremities of it turned back, pinned to the circulars, and so firmly secured to the neck-band. The union should be attempted about the eleventh day.

§ 4. Of amputating the Fore-arm.

To take off the fore-arm, we must look for the flap in its external part, as having less to cut through; but above all, as by this means you avoid bringing in that groupe of tendons which cover the inside of the fore-arm. Here from an inch and an half to two inches will be undoubtedly sufficient to cover the bones; but then in the incision you must comprehend the full breadth of the flesh and skin on the back of the fore-arm. The dressings and bandaging will be easily comprehended from what has been already said; and about the tenth day you may attempt an union of parts.

SECT. XIX. The Method of opening a dead Body.

579 SURGEONS are often called on this occasion, in order to investigate the cause and seat of diseases and death, either by the relations of the deceased, or the magistrates, to whom report is to be made; therefore, at the time of performing this operation, minutes should be taken of what is observed. The instruments, and all things necessary, should be disposed in order, as for any other operation; as knives, a razor, a great and small saw, scissors straight and curved, elevators, needles threaded, sponges, tow, saw-dust or bran, basons with water, towels, and receivers for the viscera when they are to be taken out of their cavities; and should the body have undergone any degree of putrefaction making it offensive, it will be right to have a mixture of lavender-water and vinegar, or some such thing, to sprinkle it with, &c. The body is to be laid upon a suitable table, advantageously placed for the light, having a cloth thrown over the parts which decency demands should be concealed, especially in females.

When it is intended only to inspect the abdomen and its contents, a longitudinal incision from the xiphoid cartilage to the os pubis, intersected by a transverse one at the navel, will give a fair opportunity of answering these purposes, when the angles are reversed. Should it be required to examine all the three cavities, and the parts contained in them, we are to begin by opening the head, making an incision quite cross to the bone, from ear to ear; which section is preferable to the crucial, commonly made on this occasion: then the scalp may be easily dissected from the skull, and turned down over the face, and

and towards the neck, giving room for the saw. The head must be held very steadily by an assistant during the sawing, which should be begun on the middle of the frontal, proceeding to each temporal bone, and so to finish the circle upon the middle of the occipital bone; which may generally be done conveniently enough, by raising the head and inclining it forward, after having proceeded as far as this bone; or the body may then be turned prone, should that posture be found more convenient, to complete the circle. The cap of the skull is then to be raised with the elevator, occasionally cutting the adhesions of the dura mater: after this the encephalon is to be removed, carefully separating the other attachments of the membrane.

In order to bring the thorax and abdomen, with the parts contained in these cavities, under one view, an incision is to be made on each side the sternum, in the course of the cartilages of the ribs which are annexed to it; dissecting from thence the muscles with the teguments, the space of two or three inches towards the spine; then cutting through the cartilages, which will be seen, and easily divided with a knife a little curved near the point; then the incisions are to be continued from the sternum through the abdominal cavity, in an oblique direction, to each ilion or inguen; after which the clavicles are to be separated from the sternum, or this bone divided at its superior cartilaginous junction, with a strong knife, dissecting it from the mediastinum, and turning it downwards with the muscles, &c. of the abdomen. This is the most eligible manner of opening these cavities, and gives an opportunity of sewing them up, with a better appearance for any person's view afterwards. That kind of stitch called by sempstresses the herring-bone or flat seam, has a very pretty and neat effect upon these occasions.

If it is proposed to take out the thoracic and abdominal viscera together, for further examination, the diaphragm is first to be cut down to the spine on both sides; then, to avoid being incommoded with blood, &c. two very strong ligatures are to be passed round the oesophagus and large blood-vessels, in which the trachea may be included; tying them strait, and then dividing these parts between the ligatures: the same measures are to be taken in respect to the inferior vessels, upon the lumbar region, a little above the bifurcation of the aorta, including the vena cava; and also upon the rectum. After having observed these precautions, the viscera, with the diaphragm, are to be removed, by a wary dissection, all the way close to the spine; and gently drawing them at the same time, will greatly facilitate the separation.

When the thoracic and abdominal viscera are to be taken out separately, in the first case ligatures must be made as have been described upon the vessels, &c. just above the diaphragm, and in the other just below it, and upon the rectum.

Should we be called upon to perform this office when the body is become very putrid, it will be absolutely necessary to have such parts of it well washed with warm vinegar and brandy, and then sprinkled with lavender-water or some such odoriferous antiputrescent liquor, before the examination, in order to correct the stench, and defend us against the noxious

quality of the effluvia: a precaution, the neglect of which may be attended with very direful effects, and of which we have instances.

SECT. XX. Of Embalming dead Bodies.

In the early ages of the world, the practice of embalming dead bodies was very common, particularly among the Egyptians; but it has long been disused in almost all countries, except for great personages. See EMBALMING. The following directions are taken from Mr Gooch, to whom they were communicated by a person of great character, and well acquainted with the modern practice of embalming in this kingdom.

After evisceration, as has been directed in opening a dead body, and continuing the incision farther upwards, even into the mouth, and, if practicable, without cutting the skin of the neck, all the cavities are to be well cleansed, and the humidity sucked up with sponges, then washed with tinct. myrrhe, and filled with a species, compounded of fragrant herbs, aromatic drugs, and gums reduced to powder not very fine, first restoring the heart to its former residence, after having opened its ventricles, cleansed and washed them with the tincture, stuffed them with the species, and sewed them up; and then the cavities are to be stitched very close with the glover's or spiral suture. Large and deep incisions are also to be made in all the moist fleshy parts, cleaning and washing them with the tincture in the same manner, filling them with the antiseptic species, and stitching them up. Then the head, trunk, and limbs, are to be perfectly well covered with cerecloth; putting a piece under the chin, to be secured by sewing on the top of the head, after having well adjusted the cap of the skull, sewed the scalp together, and cleaned the mouth, as has been directed for the other parts, and putting in some of the species. The cerecloth is to be prepared, according to art, with a composition made of wax, rosin, storax, and painter's drying oil. After the application of the cerecloth, with great care and exactness, cut into suitable pieces, according to the respective parts, and closing them well every where; the face being close shaved, is to be covered with some of the above composition melted, and laid on with a brush of a proper degree of heat, and of a moderate thickness; which may have a faint flesh-colour given it with vermillion; and when it is grown cold and stiff upon this part, it may belightly struck over with hard varnish; or this varnish, applied thick, may here serve the purpose alone. A cap is to be well adapted to the head, falling down upon the neck, and to be sewed under the chin, making a few circular turns about the neck with a roller of a fit breadth. All the rest of the corpse is to be inclosed in a sheet, to be carefully cut, and sewed on very close and smooth, with the finest tape, and the flat seam mentioned in the preceding section; over which an appropriate dress is to be put, as the relations or friends think fit to direct and appoint, and then laid into the coffin, which should be in readiness: but when it is some great personage, who is to lie in state for public view before the funeral rites are solemnized, the dress must be appropriated to his dignity and character. The brain and other viscera are to be put with some of the species into a leaden box. Some-

Practice. times the heart, prepared as has been directed, to preserve it from putrefaction, is deposited in an urn by itself.

EXPLANATION of Plates CCLXXVIII. CCLXXIX. CCLXXX. CCLXXXI. CCLXXXII.

FIG. 1. A, A director by which to guide the knife in the opening of abscesses that are burst of themselves, or first punctured with a lancet. This instrument should be made either of steel, silver, or iron; but so tempered, that it may be bent and accommodated to the direction of the cavity. It is usually made quite straight; but that form prevents the operator from holding it firmly while he is cutting. The manner of using it is, by passing the thumb through the ring, and supporting it with the fore-finger, while the straight-edged knife is to slide along the groove with its edge upwards, towards the extremity of the abscess.

B, The straight-edged knife, proper for opening abscesses with the assistance of a director; but which, in few other respects, is preferable to the round-edged knife.

C, A crooked needle, with its convex and concave sides sharp: this is used only in the future of the tendon, and is made thin, that but few of the fibres of so slender a body as a tendon may be injured in the passing of it. This needle is large enough for slitting the tendo achillis.

D, The largest crooked needle necessary for the tying of any vessels, and should be used with a ligature of the size it is threaded with in taking up the spermatic vessels in castration, or the femoral and humeral arteries in amputation. This needle may also be used in sewing up deep wounds.

E, A crooked needle and ligature of the most useful size, being not much too little for the largest vessels, nor a great deal too big for the smallest; and therefore, in the taking up of the greatest number of vessels in an amputation, is the proper needle to be employed. This needle also is of a convenient size for sewing up most wounds.

F, A small crooked needle and ligature for taking up the lesser arteries, such as those of the scalp, and those of the skin that are wounded in opening abscesses.

Great care should be taken by the makers of these needles to give them a due temper: for if they are too soft, the force sometimes exerted to carry them through the flesh, will bend them; if they are too brittle, they snap; both which accidents may happen to be terrible inconveniences, if the surgeon be not provided with a sufficient number of them. It is of great importance also to give them the form of part of a circle, which makes them pass much more readily round any vessel, than if they were made partly of a circle, and partly of a straight line; and in taking up vessels at the bottom of a deep wound is absolutely necessary, it being impracticable to turn the needle with a straight handle, and bring it round the vessel when in that situation. The convex surface of the needle is flat, and its two edges are sharp. Its concave side is composed of two surfaces, rising from the edges of the needle, and meeting in a ridge or eminence, so that the needle has three sides. The best materials for making ligatures, are the flaxen thread

that shoe-makers use; which is sufficiently strong when four, six, or eight of the threads are twisted together and waxed; and is not so apt to cut the vessels as threads that are more finely spun.

G, A straight needle, such as glovers use, with a three-edged point, useful in the uninterrupted future, in the future of tendons where the crooked one C is not preferred, and in sewing up dead bodies, and is rather more handy for taking up the vessels of the scalp.

FIG. 2. A, The round-edged knife, of a convenient size for almost all operations where a knife is used: the make of it will be better understood by the figure than any other description; only it may be remarked, that the handle is made of a light wood, as indeed the handles of all instruments should be, that the resistance to the blades may be better felt by the surgeon.

B, A pair of probe-scissors, which require nothing very particular in their form, but that the lower blade should be made as small as possible, provided it be strong and has a good edge; because, being chiefly used in fistulas in ano, the introduction of a thick blade into the sinus, which is generally narrow, would be very painful to the patient.

C, The crooked knife with the point blunted, used in the operation of the bubonocoele.

FIG. 3. A, A trocar of the most convenient size for emptying the abdomen when the water is not gelatinous. It is here represented with the perforator in the canula, just as it is placed when we perform the operation.

B, The canula of a large trocar, recommended in cases where the water is gelatinous.

C, The perforator of the large trocar.

FIG. 4. A, A sound used in searching for the stone. The size represented here is but a little too large for the youngest children, and may be used upon boys till they are thirteen or fourteen years of age: a larger should be employed between that age and adulthood, when one of about ten inches, in a right line from the handle to the extremity, is proper. This should be made of steel, and its extremity be round and smooth.

B, A staff fit for the operation on boys from eight to fourteen years of age. The staff for a man must be of the size of the sound already described.

C, A staff something too big for the smallest children, but may be used upon boys from about four years of age to eight.

The staff has a groove on its convex side, which first serves as a direction where to cut, and afterwards, receiving the beak of the gorget, guides it readily to the bladder. Care should be taken, in making the groove, that the edges of it be smoothed down, so that they cannot wound in passing through the urethra. The extremity should also be open; otherwise it will be sometimes difficult to withdraw the staff when the gorget is introduced, and presses against the end of it.

These instruments are usually made with a greater bending than here represented; but this shape is more like to that of the urethra, and rather more advantageous for making the incision.

D, The yoke; an instrument to be worn by men with an incontinence of urine. It is made with iron,

but for use must be covered with velvet. It moves upon a joint at one end; and is fastened at the other by catches at different distances placed on a spring. It must be accommodated to the size of the penis, and be taken off whenever the patient finds an inclination to make water. This instrument is exceedingly useful, because it always answers the purpose, and seldom galls the part after a few days wearing.

Fig. 5. A, A small catheter made of silver. This instrument is hollow, and serves to draw off the urine when under a suppression. It is also used in the high operation to fill the bladder with water. Near its extremity are two orifices, through which the water passes into its cavity. Care should be taken that the edges of these orifices are quite smooth.

B, The knife used in cutting for the stone: it is the same already described; but it is not improper to repeat the figure with the alteration of a quantity of tow twisted round it, which makes it easier to hold when we perform the lateral operation, and turn the edge upwards to wound the prostate gland.

C, A female catheter, differing from the male catheter, it being almost straight, and something larger.

D, A silver-wire to pass into either catheter, for the removing any grumous blood or matter that clogs them up.

Fig. 6. A, The gorget used upon men in the lateral operation.

B, the gorget used upon children under five years of age in the lateral operation.

A gorget between the sizes of these two will be fit for boys from five years of age to fifteen or sixteen.

These instruments are hollow for the passage of the forceps into the bladder; and their handles lie flanking, that they may the more readily be carried thro' the wound of the prostate, which is made obliquely on the left side of it. The beak at the extremity of the gorget must be smaller than the groove of the staff which is cut upon, because it is to be received in the groove. Care should be taken that the edges of the gorget near the beak are not sharp, lest, instead of dilating the wound as it ought, it should only cut on each side when introduced; in which case, it would be difficult to carry the forceps into the bladder.

C, A gorget, with its handle exactly in the middle. This shaped instrument is used in the old way. All the gorgets should be made of steel.

Fig. 7. A, The forceps for extracting the stone. These are represented a little open, that the teeth may be better seen within-side.

This instrument must be of different sizes for different ages and stones, from the length of four inches to one of near a foot long; but the forceps of about eight inches long will be found most generally useful. The number necessary to be furnished with will be four or five.

Great care should be taken by the makers of this instrument that it move easily upon the rivet; that the extremity of the chops do not meet when they are shut; and particularly that the teeth be not too large, lest, in entering deep into the stone, they should break it. It is of consequence also that the teeth do not reach farther towards the joint than here represented; because a small stone, when received into that part,

being held fast there, would dilate the forceps excessively, and make the extraction difficult; on which account, the inside of the blades near the joint should be smooth, that the stone may slip towards the teeth.

B, A director made of steel, used for the direction of the gorget, in the extraction of the stone from women.

C, A scoop to take away the stone when it is broken into small pieces like sand. This instrument is made of steel.

Fig. 8. A, The perforator, commonly called the perforating trepan. With this instrument an orifice is usually made for the reception of the pin on the centre of the piece of bone that is to be taken away in the operation of trepanning; though, if the pin be very sharp, and project but little beyond the teeth of the saw, as in that marked with the letter B, the perforator would be needless; but as the point of the pin presently grows blunt with use, and in that case it is difficult to fix the saw, it is advisable to have this instrument in readiness. It is also handy for boring into the substance of the bones, in order to promote a granulation of flesh on their surfaces. When it is made use of, it must be received and fastened in the handle C.

B, The crown or saw of the trepan, with the pin appearing just beyond the extremities of the teeth. The shape of this saw is cylindrical.

C, The handle of the foregoing instrument, called the trephine; which is much preferable to the trepan (an instrument like a wimble used by joiners), because of the great convenience of holding it, and leaning on one side or other of the saw, as we find it necessary: The trepan, however, though allowed to be unhandy, is the instrument most used by surgeons in other parts of Europe, upon the supposition of its working quicker than the trephine.

The trephine here represented is of such a shape as to make it a convenient elevator; for which purpose the extremities of it are made rough.

D, A key to take out the pin E, when the saw has made an impression deep enough to be worked without the help of it.

Fig. 9. A, A convenient forceps to take out the circular piece of bone, when it does not stick to the saw: the contrivance by which they readily lay hold of it, is to make the extremities that are to grasp it with an arch of the same circle as the saw is made. Upon one of the handles there is added a little elevator, to lift up any small splinter of bone.

B, A lenticular: the fore-part of its blade is sharp, in order to scrape the lower edge of the orifice of the cranium, in case any splinters should remain after the operation; and the button at its extremity receives the dust, that it may not fall on the brain; but there is seldom any occasion for this instrument.

C, A rugine or raspatory, for scraping bones in order to promote granulations of flesh. The handles of these two last instruments are wood; whereas every part of the others should be made of steel.

Fig. 10. A, The couching needle; the broad part of which towards the point is flat on one side; but on the other is a little convex, to give it more substance and strength.

The handle of this instrument is white ivory, inlaid with a streak of black in that part of it lying even with

Practice. with the convex surface of the blade: The meaning of which is, that by holding the handle with the streak upwards, we may be guided to depress the membrane of a milky cataract with the flat surface, though the substance of the cataract swimming in the eye obscures the needle, and prevents its being directed in a proper position by the sight.

B, A speculum oculi, which is made to open or shut by an iron button sliding along a slit in the handle. This instrument is composed of one piece of steel, in such a manner that it would fly open by its elasticity, if the two branches of the handle were not confined by the button. The circle of it should be covered with velvet, to make it lie softer on the eye-lids.

C, The knife for cutting the iris; the blade of which has two edges, resembling a lancet, which are more advantageous than one only, in cutting the cornea for the extraction of the cataract.

Fig. 11. A, the eye, with the skin of the eye-lids denuded, in order to show the orbicularis muscle: the white streak running from the inner angle of the eye towards the nose, is the tendon of the orbicularis muscle. At a little distance from the internal angle, on the edge of the eye-lids, may be observed two black spots, which are the orifices of the lachrymal channels, and called the puncta lachrymalia.

B, the exact dimension of the lachrymal channels and bag; the pricked line represents the edge of the orbit.

C, A small incision knife, more handy than a larger for opening the bag.

D, The perforator to destroy the os unguis, if ever it should happen to be necessary.

E, An iron instrument made thin and pliable, to set even on the forehead, and for use covered with velvet: the holes at the three extremities receive two pieces of ribband, by which it is fastened on the forehead: the button at the end of the screw is to be placed on the facies lachrymalis, and the screw to be twisted till the button makes a considerable pressure on the bag: the button should be covered with velvet, and a little compress of plaster be laid on the bag before it is applied, to prevent the skin from being galled by the pressure. The little branch of iron which receives the screw must be soft enough to admit of bending, otherwise it will be difficult to place the button exactly on the bag. This instrument is for the left eye only; it should be worn night and day in the beginning of a fistula, and after a fistula has been healed by incision; but as the success depends upon the exact situation of the button upon the bag, it should be carefully looked after.

Fig. 12. A, The bent probe used in extirpating the tonsils, fixed in a handle, with the ligature made of the same thread as the ligatures for tying the blood-vessels.

B, The iron instrument for tying the tonsils. This instrument is also of great service in extirpating, by ligature, a species of scirrhous that sometimes grows from the neck or cavity of the uterus.

C, The needle with the eye towards the point, for passing the ligature through the tonsil, when the basis is larger than the extremity.

D, A canula made of silver to be used in the empyema.

E, A canula to be used in bronchotomy.

To keep the canulas in their place, small ribbands may be passed through the rings of them, and carried round the body and neck; or they may be held by a ligature run through, and fastened to a hole cut in a piece of sticking-plaster, which is to be laid on each side of them.

Fig. 13. A, The instrument called the probe raser to cut the mastoidens muscle in the wry neck; it is sharp only about half its length at that end where the blade is broad.

B, The two pins with the twisted suture, used in the bare-lip.

C, The polypus forceps, with one of the rings open for the reception of the thumb, which would be cramped in pulling the forceps with much force, if it were received in the same sort of ring as in the other handle.

Fig. 14. A, The figure of the amputating knife. The length of the blade and handle should be about thirteen inches.

B, The figure of the saw used in amputating the limbs. The length of the handle and saw should be about seventeen inches.

Fig. 15. The form of the tenaculum used for pulling out bleeding vessels to be tied up.

Fig. 16. and 17. Two needles of a different form from those in ordinary use, recommended by Mr Bell as the most convenient, particularly in deep wounds.

Fig. 18. The instrument named porte-aiguille, for pressing through the pins in making the twisted suture.

A, The handles.

B, A groove for receiving the pins used in the suture.

Fig. 19. A flat needle, sometimes useful in stitching blood-vessels that lie between contiguous bones.

Fig. 20. An improved tourniquet by Mr Bell. The manner of using it described p. 8415.

Fig. 21. An improved trocar by Mr Andre, for the purposes of tapping for the ascites or hydrocele. The roundness of its point makes it pierce more easily than the common one, which is triangular. That the instrument may be easily withdrawn after the perforation is made, the canula (fig. 22.) is composed of two pieces screwed together; by uncoiling which the instrument will easily dilate them, and they will close by the pressure of the surrounding flesh, so as to afford a passage for the liquid to be drawn off.

Fig. 23. Mr Bell's trocar for evacuating the contents of an encysted hydrocele. By the flatness of its form, and its point being of the lancet kind, this instrument penetrates the cyst with great ease; and can thereby be used with more safety than the ordinary form of this instrument.

The point of the perforator is commonly made much longer than is necessary. It ought not to pass more than the fifth or sixth part of an inch from the extremity of the canula; of this length it answers equally well as when the point is longer, and it is not so apt to wound the testis on being introduced into the cavity of the tunica vaginalis.

Fig. 24. Represents figs. 25. and 27. united, which is then called the double gorgeret, with the cutting blade g, h, affixed to it. This instrument is used in lithotomy, and recommended by Mr Bromfield; (vide supra, n^o 478, et seq).

a b, The handle of the hinder part.

c d, The grooved edge of the under gorgeret, that has received the edge of the upper gorgeret.

e, The beak of the under gorgeret.

f, The handle of the upper gorgeret, by which the instruments when united, are to be introduced into the bladder.

Fig. 25. The upper part of the double gorgeret, with the blade affixed for cutting the prostate gland; g, the cutting blade, which is blunt at h.

k, A hole or slit, through which the urine will pass as soon as the instrument enters the bladder. This observation will be a guide to the operator, as to the length of the incision he would wish to make of the prostate, by the farther introduction of the instrument when united.

l, The screw to fix the blade to the upper gorgeret.

Fig. 26. The posterior side of the double gorgeret when united for use.

e, The beak formed in the under gorgeret.

ll, Shows the hollow of the two gorgerets when united, through which the urine comes out, when the extremity is got into the bladder.

Fig. 27. The under part of the double gorgeret separated from the upper, which varies but little in shape from the common gorgeret.

a, The beak; bb, the inner edges of the concave part, grooved as far as cc to permit the edges of the upper part to glide in, by which means they become one instrument at the time of introducing it.

Fig. 28. The upper part of the double gorgeret with its convex side uppermost; f, the handle; es, the edges of the gorgeret made thin, so as to glide along the groove in the under part of the instrument.

d, The point, which, when united, forms the double gorgeret, and somewhat resembles the extreme part of a cow's horn. In this form it is a very great dilator, and a much safer instrument than the common gorgeret when the membranous part of the urethra only is wounded in the operation of lithotomy.

Fig. 29. The same instrument, only intended to show its internal or concave part.

Fig. 30. The cutting blade separated from the upper gorgeret.

l, A small hole through which a screw passes to fix it to the upper gorgeret, as is expressed by l, fig. 28.

m, A little hook-like part, which is received into a slit adapted to it in the upper gorgeret.

The space between n, o, is the only part of the blade that should cut.

N.B. Great care must be taken by the instrument-maker, to place the blade on the upper gorgeret in such direction, that its edge may incline obliquely downwards and outwards when the instrument is pushed on to divide part of the prostate gland.

Fig. 31. Mr Wathen's instruments for the cure of a fistula lachrymalis.

A, The ring at the top of the style.

B, The inferior extremity of the style rounded, so as to fit exactly the smaller end of the tube.

C, The shoulder; by means of which the style is prevented from passing further in the tube than it is designed it should.

D, The tube, with a small perforation near its upper or larger aperture for the admission of a thread.

E, The tube, with its thread in it.

F, G, H, The style, tube, and thread put together; which points out the manner in which the instrument is fitted for use.

I, The knot tied in the thread at the distance of an inch from the tube.

Fig. 32. Shows Mr Wathen's contrivance for keeping a broken limb steady. It is applicable either to the superior or inferior extremities; and in the figure is represented as applied to a compound fractured leg.

Fig. 33. Gives the skeleton of the machine which he calls a conductor, separated into two portions. The knee-band a, made of tin, a little bent; divided by four joints b, that it may fit any limb, great or small; holes c, for fixing the buckle and strap; others d, round each margin for sewing on the padding; two tin canulas e, grooved on the outside, and furnished on the inside with brass springs f, and catches g; small holes h, through which the catches pass to meet the ferræ of the upright portions, when they are within the canulas.

The figure in the middle represents the inside of the tube with the groove.

Fig. 34. The ankle-band a, constructed as the knee-band, but less; shoulders b, to support and render the serrated portions parallel to the grooved canulas; both of brass.

By compressing the springs, the catches are raised, and admit the whole length of the upright serrated portions within the canulas; reducing the conductor to near half its length: from which reduction of the instrument, by the disposition of the catches and ferræ, the canulas are retracted without difficulty, but cannot be returned the same way unless the catches are elevated by compressing the springs. By this means, when the conductor is fixed, the extension hereby given to the leg, whatever it be, is secured with the greatest certainty, tho' alterable with the utmost ease.

Fig. 35. The same instrument covered with leather, that it may fit easily on the limb.

Fig. 36. and 37. The improved splints applied upon a broken leg, so that the foot-pieces are plainly to be seen on both sides.

Fig. 38. Shows a machine invented by Mr Gooch for keeping up the hand, and allowing at the same time the motion of the fingers. This machine should be made a little concave, of light tough wood, such as beech, willow, or alder, and be covered with leather to be glued unto the wood. Its dimensions for a limb of a common size should be about ten inches long and three and a half broad. Besides the hooks shown upon the sides, it should have one in the middle. It is to be confined to the limb with fillets tied upon stiff paper.

This very simple machine has been found of signal service in luxations of the wrist, and in fractures near that joint, as well as in other cases where it is necessary to have the hand supported, and also occasionally kept in gentle motion to preserve the flexure of the joint.

Rule-joints may be used to more advantage, where there is no occasion to drop the hand, and they will allow of a little motion upwards; when they are used, no hooks are required upon the machine.

Fig. 1.

SURGERY.

Plate CCLXXVIII.

4

5

6

7

A Bell sculp.

SURGERY.

Plate CCLXXIX.

Fig. 8.

Fig. 8 shows four surgical instruments. A curved probe with a textured handle (C) is on the left. To its right is a small scraper with a wooden handle (B). Below the probe is a small hook (D). To the right of the scraper is a small scalpel (E).

9

Fig. 9 shows two surgical instruments. A long, thin probe with a wooden handle (B) is on the left. To its right is a pair of forceps with curved handles and a serrated tip (A).

10

Fig. 10 shows three surgical instruments. A small scraper with a wooden handle (C) is on the left. In the middle is a pair of forceps (B). On the right is a long, thin probe (A).

11

Fig. 11 is a diagram of a human face with surgical instruments labeled A through E. A probe (A) is inserted into the eye. A small scraper (B) is near the nose. A long probe (C) is inserted into the ear. A curved probe (D) is near the mouth. A small hook (E) is at the bottom of the face.

12

Fig. 12 shows several surgical instruments. A curved probe (A) is on the left. A long, thin probe (B) is in the middle. To the left of the long probe are several small hooks (C, D, E).

13

Fig. 13 shows three surgical instruments. A pair of forceps (C) is on the left. A small scraper (B) is in the middle. A curved probe (A) is on the right.

14

Fig. 14 shows two surgical instruments. A curved probe (A) is on the left. A saw (B) is on the right.

This anatomical plate displays a variety of surgical instruments, each labeled with a number or letter. The instruments include:

• 22: A long, thin surgical probe with a pointed tip and a handle.
• 23: A shorter version of the probe from 22.
• 20: A large, complex instrument with a central screw mechanism and a handle, labeled with B at the top and A at the base.
• 19: A thin, curved surgical instrument.
• 17: A curved surgical instrument.
• 16: A curved surgical instrument.
• 15: A long, thin surgical instrument with a handle.
• 21: A long, thin surgical probe with a handle.
• 18: A pair of surgical forceps with a handle.
• 25: A surgical instrument with a handle and a blade, labeled with k at the tip.
• 24: A pair of surgical forceps with a handle, labeled with d, g, h, k, c, b, and l.
• 26: A pair of surgical forceps with a handle, labeled with c and e.
• A, B, C, D, E, F, G, H, I, K, L: Various labels on the handles and blades of the instruments.

A. Bell's Sculp.

This plate illustrates various surgical instruments and a leg cast, labeled with figures 27 through 38.

• Figure 27: A pair of curved forceps with a long handle, labeled 'a' at the top and 'b' at the base.
• Figure 28: A straight forceps with a long handle, labeled 'd' at the tip and 'j' at the base.
• Figure 29: A straight forceps with a long handle, labeled 'j' at the base.
• Figure 30: A small triangular instrument, labeled 'm' at the top, 'n' on the left, 'o' at the bottom left, and 'l' at the bottom right.
• Figure 31: A group of instruments including a long probe (labeled 'A' at the top, 'B' at the bottom), a small probe (labeled 'D' at the top, 'H' at the bottom), a long probe (labeled 'F' at the top, 'G' at the bottom), and a thin probe (labeled 'I' at the top, 'E' at the bottom).
• Figure 32: A leg cast with a metal frame, showing a leg with a wound on the knee.
• Figure 33: A detailed view of a leg cast, showing the width from end to end, labeled 'b' at the top, 'd' in the middle, 'a' at the bottom, and 'c' on the side. A note reads: "The Width from End to End, in the View as here Drawn, 18 In."
• Figure 34: A detailed view of a leg cast, showing the width from end to end, labeled 'b' at the top, 'a' in the middle, 'a' at the bottom, and 'c' on the side. A note reads: "The Width from End to End, 14 1/2".
• Figure 35: A leg cast with a metal frame, showing a leg with a wound on the knee.
• Figure 36: A leg cast with a metal frame, showing a leg with a wound on the knee.
• Figure 37: A leg cast with a metal frame, showing a leg with a wound on the knee.
• Figure 38: A leg cast with a metal frame, showing a leg with a wound on the knee.

A Bell Sculpt.