the art of curing all manner of wounds, and other disorders, where the application of the hand, assisted by proper instruments, is necessary.

Of Phlebotomy.

We begin with the operation of phlebotomy; because it is of all the most general, performed in most parts of the body, and by much the most frequent in use at this present day. By phlebotomy, or bleeding, we here intend the opening a vein, by a sharp-edged and pointed instrument of steel, for extracting a proper quantity of blood, either for the preservation or recovery of a person's health.

It is commonly enough known, that the operation of bleeding in the arm is performed on the veins that lie on the internal part of the cubit. There are several things worthy the surgeon's notice in this operation; some of which regard the things which are to be done preparatory to bleeding, some in the operation itself, others immediately after the performance of it. Preparatory to bleeding you should have in readiness (1.) A linen fillet, about an ell in length, and two fingers in breadth. (2.) Two small square bolsters. (3.) Porringers or vessels to receive the blood. (4.) A sponge with warm water. (5.) Some vinegar, wine, or Hungary water, to raise the patient's spirits if he should be inclinable to faint. (6.) Two assistants, one to hold the porringers, the other to reach you anything that you shall want. (7.) You must place your patient upon a couch; or, if he is very fearful of the operation, lay him upon a bed, lest he should fall into a swoon. Lastly, the operator should be as expert in bleeding with his left hand as with his right; For, as you are readier at bleeding in the right arm with your right hand, so when you are to open the veins of the left arm, you will find it necessary to use your left hand.

Though the operation is to be performed at once, with one puncture, yet many things are to be observed in order to render it successful. First, it is necessary for the surgeon to inspect his patient's arm diligently, that he may see the course of the veins: he must then take hold of the arm, and extend it towards his breast, tucking up the sleeve about a hand's breadth above the bend of the cubit, where he must make his ligature, rolling the fillet twice round, and fastening it with a knot. The veins being compressed, and the blood being stopped in its return, they will enlarge, and lie fairer to the eye. When you have bound up the arm in this manner, you let it go for a small time till the veins grow turgid. You are then to lay hold of the arm again in the same manner as we directed before, and extend it to your breast, having an assistant ready with the vessel in his hand, at a convenient distance for receiving the blood.

You are now to examine which vein lies fairest, and is therefore most proper to be opened. For you must observe, that in the arm there usually appear three principal veins. The first is called Vena Cephalica, and is found in the external part of the arm. The second is termed Basilica, and lies on the internal part of the arm: In the right arm it is also called Hepatica; in the left, Splenitica. The third, which is obliquely situated between the former two, is called Mediana. The median and basilic veins, as they are larger than the cephalic, discharge a greater quantity of blood, but are attended with more danger in the operation. For a considerable artery and the brachial nerve lie under the basilic vein, and the tendon of the biceps muscle under the median. But as they lie fairer to the eye, and are therefore more frequently the subjects of the operations we are treating of than the cephalic vein, it is safer and more eligible for the less experienced surgeons to open the basilic, or at least the median vein.

When you have determined which vein to open, you are to perform the operation on that part which presents itself fairest to you. But if the vein has frequently been opened, and the part which appears largest and fairest is full of cicatrices, you are not to open above, but below the cicatrices, by which means the blood will discharge itself more freely: For the part above is generally straitened by the cicatrix.

Before you apply the lancet to the skin, when the veins are not risen, it will be proper to rub the arm below the bandage, which will drive the blood back towards the cubit, and render the veins more turgid. Whilst this is doing in the right arm, the surgeon should take hold of the patient's arm in such a manner that he may lay his thumb upon the vein he intends to open, to prevent the blood from flowing back, and to keep the vein from rolling. You are now to fix your eye upon that part of the vein which you intend to open, and taking the lancet with your right hand, so placed that the thumb and first finger may be fixed about the middle of the blade; the other fingers should rest gently upon the patient's arm, to prevent your hand from slipping.

Your lancet is now to be pushed lightly and carefully forward by your thumb and forefinger, till it has penetrated through the coats of the vein; and at that instant to be raised a little upwards, in order to enlarge the orifice of the wound, which will give a freer passage to the blood. The most common and convenient size of an orifice is about twice the breadth of the back of an ordinary knife. You are to keep even between the two extremes of rashness and timidity in making the puncture. For as in one case you will only divide the common integuments, and so leave your work undone; so in the other you will run the risque of wounding the artery, nerve, or tendon.

Your aperture being thus made, and the instrument drawn instantly back, the blood will then rush forth from the orifice either in a large or small stream. In the mean time the blood must be permitted to flow as long as it shall be judged useful or necessary; and if it should stop too soon, as it often may from too great a stricture of the bandage on the arm, it must be slackened a little, by which means the compressed artery being set at liberty, the blood will flow from the orifice as at first. If you find the orifice obstructed by too great a tension of the skin, or an intrusion of the membrana adiposa, you ought in that case to return the bit of fat, by pressing with the finger or a warm sponge, and to relax the skin by bending the arm a little. Lastly, if the orifice be obstructed by thick, grumous, or congealed blood, that impediment may be removed by wiping it with a sponge dipped in warm water.

But that the patient's arm may not become painful or languid, by holding it long extended, the surgeon should support it by the cubitus for a little while; and then give him a stick, or other cylindric body, to turn round in his hand, that by the contractions of the flexor and extensor muscles of the fingers, the course of the blood may be accelerated towards the cubitus: which will still be further promoted, if the patient urges a little voluntary cough.

When there seems to be a sufficient quantity of blood discharged; the ligature must then be immediately taken off from above the elbow, and the skin about the orifice must next be gently stroked or pressed together by the two forefingers of the left-hand; by which means the lips of the divided vein are more easily compressed and closed. But while the surgeon is doing this with his left hand, he takes the smallest of the two compresses, and applies it upon the incision with his right-hand: but so as to let what little blood may remain betwixt the orifice and the vein, be discharged, before he imposes the compress. Over the first or small compress he should impose another that is a little larger, pressing them both gently on the orifice with his left thumb, till the bandage is laid across.

Having applied your bandage, and drawn down the patient's sleeve over his arm; he should be ordered not to use it too early or violently, before the orifice is well closed, which might excite a fresh hemorrhage, an inflammation, suppuration, or other bad accident. And if the patient should faint away soon after the operation, it may be then convenient to wet his nostrils with Hungary water or vinegar; and to sprinkle some of the last, or else cold water, in his face; and, especially in summer-time, to let in the fresh and cool air, by opening the windows, &c. Also, if any wine or cordial water be at hand, you may give the languishing patient a small draught thereof.

Of Bleeding in the Foot.

Bleeding in the foot is an operation of very old standing: it having been an observation made by the most ancient physicians, that phlebotomy in this part proved highly serviceable in most disorders of the head and breast, and for an obstruction of the menstrual and hemorrhoidal flux; upon which discharges greatly depended the healthy state of both sexes. For these reasons they therefore denominated those veins of the foot, Saphena and Cephalica: the last of which extends itself from the internal ankle to the great toe; and the first, from the external malleolus to the smaller toes. But why one of them should be thought or denominated more cephalic than the other, there is not the least reason to be offered: since bleeding from either of them has altogether the very same effect. Therefore, the surgeon should always open that which lies fairest and most conspicuous. But if the veins upon the metatarsus, or instep of the foot, do not well appear, it may then be convenient to open one of those at the ankle, or about the calf or ham of the leg. Nor is the phlebotomist so liable to injure any of the tendons in these last parts as he is upon the metatarsus.

For the more easy and successful apertion of these veins, the patient must first wash both feet well for some time in hot water; that when the veins become sufficiently turgid, the surgeon may take his choice of that which presents fairest either in the right or left foot, without paying any deference to the distinction of right or left in any of the aforementioned disorders. Having fixed upon the particular foot and vein, your ligature must be applied about two fingers breadth above the ankle; and then the patient must return it into the warm water, while the surgeon takes out and prepares his instrument or lancet. Then kneeling down on one knee, the surgeon takes out the patient's foot from the warm water, and having wiped it dry with a napkin, places it upon his other knee, or else upon a board laid over the vessel of hot water. He now fastens or secures down the vein from slipping with his left hand. But if the veins do not appear well under the angles, the ligature must be removed higher, about two fingers' breadth above where you intend to make the apertion of the vein which best offers itself.

The blood from the vein thus opened may be received into a basin; and if it does not flow freely from the orifice, the foot should be returned into the warm water, which will either prevent or dissolve the coagulation of the blood that in this case often obstructs the aperture. When a sufficient quantity of blood has been thus drawn, which may be known partly from the time, and partly from the largeness of the stream, as also from the redness of the water, and condition or strength of the patient; the orifice is then to be closed by the finger, and after drying the foot with a napkin, to be secured by compresses and bandages.

Of Bleeding in the Veins of the Forehead, Temples, and Occiput

There are many physicians and surgeons, who think that bleeding by the veins of the forehead and temples is much more serviceable and expeditious in relieving all disorders of the head, such as violent pains, vertigo, delirium, melancholy, and raving madness, &c. than the like discharge by veins more remote from the parts affected; judging that their vicinity renders them more capable of evacuating the offending matter of the disease. 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.

Bleeding from the occipital veins, which communicate with the lateral sinuses of the dura mater, is both by reason and experience proved to be serviceable in most disorders of the brain, where that part is overcharged with blood, which may be this way diverted and evacuated. The celebrated anatomist Morgagni especially recommends it, with scarification and cupping in those parts, for all lethargic disorders.

Of Bleeding in the Jugular Veins of the Neck.

It has been a very ancient practice to bleed in the external jugular veins of the neck, for most inflammatory disorders of the adjacent parts, for a quinsy, phrenzy, madness, ophthalmia, apoplexy, inveterate head-aches, lethargy, and other disorders of the head. Nor are there wanting many among our modern surgeons and physicians to encourage the same practice, and that even from the authority of reason and experience; since the accumulated and obstructed blood and humours may be this way discharged from the parts affected, and their bad consequences prevented. Nor is the operation at all dangerous; since the jugular veins run on each side the neck from the head to the clavicles, immediately under the skin, and appearing generally very large, they may be easily perceived and opened: before which, you must make a stricture upon the lower part of the neck with a handkerchief, or the common ligature, which must be drawn tight by an assistant or the patient, to make the vein turgid and conspicuous.

When the jugular veins have been by this means rendered turgid and conspicuous, either of them which appears plaintive may be secured by the finger for incision, either in the right or left side of the neck indifferently; when the disorder lies in the whole head, or in the neck and fauces. But when only one side of the head, or one eye, is affected, the vein ought to be opened on the disordered side of the neck. The requisite quantity of the blood being taken, the ligature is next removed, and the orifice compressed with your finger, if the blood does not stop without while you wipe clean the neck, and then apply your compress and circular bandage. Thus the blood stops without any danger of a fresh hemorrhage. Lastly, it must be acknowledged, that the patient faints away as readily after bleeding in the neck, as the jugular veins are safely and easily opened; but no danger follows from thence.

Of Bleeding in the Veins, called Ranulae, under the Tongue.

It is very often found of no small service in a quinsy, or other inflammatory disorder of the neck, to bleed in the two small veins which run under the tip or end of the tongue: especially if a larger vein has been opened before, either in the neck, foot, or arm, whereby the inflamed and stagnated blood may be gradually evacuated. 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 circumflexibly open first one, and then the other on each side; because the apertions 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 Frontinum 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 hemorrhage ceases; which can never be dangerous even without such topics.

Of Phlebotomy 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.

Of Wounds.

To conceive rightly of the nature and treatment of wounds, under the variety of disorders that they are subject to, it will be proper first to learn, what are the appearances in the progress of healing a large wound, when it is made with a sharp instrument, and the constitution is pure.

In this circumstance, the blood-vessels, immediately upon their division, bleed freely, and continue bleeding till they are either stopped by art, or at length contracting and withdrawing themselves into the wound, their extremities are shut up by the coagulated blood. The hemorrhage being stopped, the next occurrence, in about twenty-four hours, is a thin serous discharge; and, a day or two after, an increase of it, though somewhat thickened, and thicker. In this state it continues two or three days without any great alteration, from which time the matter grows thicker and less offensive; and when the bottom of the wound fills up with little granulations of flesh, it diminishes in its quantity, and continues doing so till the wound is quite skinned over.

The first stage of healing, or the discharge of matter, is by surgeons called digestion; the second, or the filling up with flesh, incarnation; and the last, or skinning over, cicatrization.

It is worth observing, that the loss of any particular part of the body can only be repaired by the fluids of that distinct part; and as in a broken bone, the callus is generated from the ends of the fracture, so, in a wound, is the cicatrix from the circumference of the skin only: Hence arises the necessity of keeping the surface even, either by pressure or eating medicines, that the eminence of the flesh may not reflect the fibres of the skin in their tendency to cover the wound. This eminence is composed of little points or granulations called fungus, or proud flesh, and is frequently deemed an evil, though in truth this species of it be the constant attendant on healing wounds; for when they are smooth, and have no disposition to shoot out above their lips, there is a slackness to heal, and a cure is very difficultly effected. Since then a fungus prevents healing only by its luxuriancy, and all wounds cicatrize from their circumference, there will be no occasion to destroy the whole fungus every time it rises, but only the edges of it near the lips of the skin; which may be done by gentle echarotis, such as lint dipped in a mild solution of vitriol, or for the most part only by dry lint, and a tight bandage, which will reduce it sufficiently to a level; if applied before the fungus have acquired too much growth. In large wounds, the application of corrosive medicines to the whole surface, is of no use; because the fungus will attain but to a certain height, when lost to itself, which it will be frequently rising up to, though it be often walked; and as all the advantage to be gained from it, is only from the evenness of its margin, the purpose will be as fully answered by keeping that under only, and an infinite deal of pain avoided from the continual repetition of echarotis.

From what has been said of the progress of a wound made by a sharp instrument, where there is no indisposition of body, we see the cure is performed without any interruption, but from the fungus; so that the benefits of surgery will consist principally in a proper regard to that point, and in applications that will the least interfere with the ordinary course of nature, which in these cases will be such as act the least upon the surface of the wound; and agreeably to this we find, that dry lint only is generally the best remedy through the whole course of dressing: at first, it stops the blood with less injury than any flytack powders or waters; and afterwards, by absorbing the matter, which in the beginning of suppuration is thin and acrimonious, it becomes in effect a digestive: during incarnation it is the softest medium that can be applied between the roller and tender granulations, and at the same time is an easy compress upon the sprouting fungus.

Over the dry lint, may be applied a pledgit of some soft ointment spread upon tow, which must be renewed every day, and preserved in its situation by a gentle bandage; though in all large wounds, the first dressing, after that of the accident or operation, should not be applied in less than three days, when, the matter being formed, the lint separates more easily from the part; in the removal of which, no force should be used, but only so much be taken away as is loose and comes off without pain.

Of Inflammations and Abscesses.

As almost all abscesses are the consequences of inflammations, and these produce a variety of events, as they are differently complicated with other disorders, it will be proper first to make some inquiry into their disposition. Inflammations from all causes have three ways of terminating; either by dispersion, suppuration, or gangrene.

But though every kind of inflammation will sometimes terminate in different shapes, yet a probable conjecture of the event may be always gathered from the state of the patient's health. Thus inflammations happening in a slight degree upon colds, and, without any foregoing indisposition, will most probably be dispersed; those which follow close upon a fever, or happen to a very gross habit of body, will generally impothumate: and those which fall upon very old people, or dropsical constitutions, will have a strong tendency to gangrene.

If the state of an inflammation be such, as to make the dispersion of it safely practicable, that end will be best brought about by evacuations, such as plentiful bleeding and repeated purges: the part itself must be treated with fomentations twice a day; and if the skin be very tense, it may be embrocated with a mixture of three fourths of oil of roses, and one fourth of common vinegar, and afterwards be covered with unguent flor samb, or a soft ointment made of pine wax and tweeted, spread upon a fine rag, and rolled on gently. If after four or five days, the inflammation begin to subside, the purging-waters and manna may take place of other purges, and the embrocation of oil and vinegar be now omitted, or sooner, if it has begun to excoriate. The ointment of wax and oil may be continued to the last. During the cure a thin diet is absolutely necessary, and in the height of the inflammation the drinking of thin liquors is of great service.

Here we have supposed that the inflammation had so great a tendency to diffusion, as, by the help of proper affluence, to terminate in that manner; but when it happens that the disposition of the tumour resists all diffusive means, we must then desist from any farther evacuations, and assist nature in the bringing on a suppuration.

That matter will most likely be formed, we may judge from the increase of the symptomatic fever, and enlargement of the tumour, with more pain and pulsation; and if a small rigor come on, it is hardly to be doubted. Inflammations after a fever, and the small-pox, almost always suppurate; but these presently discover their tendency, or at least should be at first gently treated, as though we expected an impothumation. It is a maxim laid down in surgery, Surgery

That evacuations are pernicious in every circumstance of a disease, which is at last to end in suppuration: But as physicians do now acknowledge, that bleeding on certain occasions in the small-pox, is not only no impediment to the maturation, but even promotes it; so in the formation of abscesses, when the vessels have been clogged, and the suppuration has not kindly advanced, bleeding has sometimes quickened it accordingly; but, however, this practice is to be followed with caution. Purges are, no doubt, improper at this time; yet if the patient be colicky, he must be assisted with gentle clysters every two or three days.

Of all the applications invented to promote suppuration, there are none so easy as poultices; but as there are particular tumours very slow of suppuration, and almost void of pain (such, for instance, are some of the scrophulous swellings) it will be less troublesome in these cases to wear the gum-plasters, which may be renewed every four or five days only. Amongst the suppurative poultices, perhaps there is none preferable to that made of bread and milk softened with oil; at least the advantage of any other over it is not to be distinguished in practice. The abscess may be covered with the poultice twice a day, till it come to that ripeness as to require opening, which will be known by the thinness and eminence of the skin in some part of it, a fluctuation of the matter, and generally speaking, an abatement of the pain previous to these appearances.

The signs of a gangrene are these: the inflammation loses its redness, and becomes dusky and livid; the tension of the skin goes off, and feels to the touch flabby or emphysematous; vesications filled with ichor of different colours spread all over it; the tumour subsides, and, from a dusky complexion, turns black; the pulse quickens and sinks, and profuse sweats coming on, at last grow cold, and the patient dies.

To stop the progress of a mortification, the method of treatment will be nearly the same, from whatever cause it proceed, except in that arising from cold; in which case, we ought to be cautious not to apply warmth too suddenly to the part, if it be true, that in the northern countries they have daily conviction of gangrenes produced by this means, which might have been easily prevented by avoiding heat; nay, they carry their apprehension of the danger of sudden warmth so far as to cover the part with snow first, which they say seldom fails to obviate any ill consequence.

The practice of scarifying gangrenes, by several incisions, is almost universal; and with reason; since it not only lets the parts free, and discharges a pernicious ichor, but makes way for whatever efficacy there may be in topical applications. These are different with different surgeons; but the digestives softened with oil of turpentine are as good dressings as any for the scarifications; and upon them, all over the part, may be laid the theriacae Londiniensis, which should be always used in the beginning of a gangrene before the necessity of scarifying arises; or what is equally good, if not often preferable, a cataplasm made with lixivium and bran, and applied warm, which will regain its heat better than most other topicals. Medicines also given internally are beneficial, and these should consist of the cordial kind; but the bark is the sovereign remedy for this disorder: after the separation of the eschar, the wound becomes a common ulcer, and must be treated as such.

There are two ways of opening an abscess; either by incision, or cautery; 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 cautery, 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 cautery, 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 cautery usually requires in doing its office, draws such a fixation upon the skin round the eschar, as sometimes to indispose it very much for healing afterwards. In the use of cauteries, 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 cautery, 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 cauteries; 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 incarving; in which circumstance, if an incision only were made through the skin, little sinuses would often form, and burrow 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 cautery 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 scrophulous 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, yet as this inconvenience is avoided by cautery, it may on such an occasion be made use of; however, in scrophulous swellings of the neck and face, unless they are very large, cauteries are not advisable, since in that part of the body, with length of time, they heal after incision. Cauteries are of great service in destroying flabby scrophulous indurations of the glands, also venereal inductions of the glands of the groin, which will neither discolor nor suppurate; likewise in exposing carious bones, and making... making large issues. The best caustick in use is a paste made with lime and lixivium capitale, which is to be prevented from spreading, by cutting an orifice in a piece of sticking plaster, nearly as big as you mean to make the eschar; which being applied to the part, the caustick must be laid on the orifice, and preserved in its situation by a few slips of plaster laid round its edges, and a large piece over the whole. When issues are made, or bones exposed, the eschar should be cut out immediately, or the next day: for if we wait the separation, we miscarried in our design of making a deep opening; since sloughs are flung off by the sprouting new flesh underneath, which fills up the cavity at the same time that it discharges the eschar; so that we are obliged afterwards to make the opening a second time with painful escharotic medicines. To make an issue, or lay a bone bare, this caustick may lie on about four hours; to destroy a large gland, five or six; and to open abscesses, an hour and a half, two hours, or three hours, according to the thickness of the skin; and what is very remarkable, notwithstanding its strength and sudden efficacy, it frequently gives no pain where the skin is not inflamed, as in making issues, and opening some few abscesses.

When an abscess is already 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 is in almost all cases, except some fistula's 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 compass, 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 digestive 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 incarnation at the bottom; but care should be taken, not to insinuate them much deeper than the skin in this case, and that they should 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 bone, &c.

The use of vulnerary injections into abscesses has been thought to bear so near a 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 or a fluctuation 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 inclosed; and then it may be cicatrified with dry lint, or some of the cicatrific 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, as what is of greater importance than the virtue of any ointment, 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 twenty-four hours is ordinarily sufficient; but sometimes twice, or perhaps three times, is necessary.

Of Ulcers.

When a wound or abscess degenerates into so bad a state as to resist the methods of cure above laid down, and loses that complection which 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; tho' 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 meninges, dropsies, 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. Upon the whole, in both these cases, the milk-diet, and gentle purgings with manna, and the waters, seem to be most efficacious; though brisk methods may be used with more safety in the evil than in the cancer; and sometimes, particularly in young subjects, the decoction of the woods is extremely beneficial for scrophulous ulcers: but it has lately been attested by men of great skill and veracity, that sea-water is more powerful than any other remedy hitherto known, both for scrophulous ulcers, and scrophulous tumours.

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, so 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, so long will the new lips be subject to a relapse of the same kind, however often the external surface of them be destroyed: so that when we have to deal with this circumstance, 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 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 touching them a few days with the lunar caustick, 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 purposes of bringing an ulcer on to cicatrification as well as any of the others. When the ulcer is incarved, the cure may be finished as in other wounds; or if it do not cicatrify kindly, it may be washed with Ag. Calcis, or Ag. Phag. or dressed with a pledgit dipped in Tinct. Myrrhis: and if excoriations are spread round the ulcer, they may be anointed with Sperm. Cet. ointment, or Unguent. Nutritum.

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 unskilfully applied: when mixed with the Basilicon, or, what is neater, 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 twenty-four 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 escharoticks, 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, escharoticks should be applied. Those in life, the Vitriol, the Lunar Caustick, the Lapis Infernalis, and more generally the red Precipitate powder.

It is but seldom, that these inveterate fungules appear on an ulcer; but it is very usual for those of a milder kind to rise, which may often be made to subside with pressure, and the use of mild escharoticks: 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 flabby 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 escharoticks will be only a repetition of pain to the patient without any advantage.

When the excrescence is cancerous, and does not rise from a large cancer, but only from the skin itself, it has been usual to recommend the actual cautery; but it is better to cut away quite underneath, and dress afterwards with easy applications. As to the treatment of incurable cancerous ulcerations, after much trial, surgeons have at last discovered, that what gives the most ease to the sore is the most suitable application; and therefore the use of escharoticks is not to be admitted on any pretence whatsoever; nor in those parts of a cancer that are corroded into cavities, must the precipitate be made use of to procure digestion, or promote the separation of the sloughs. The best way, therefore, is to be guided by the patient what medicine to continue. Those usually prescribed are preparations from lead; but what we have found most beneficial, have been sometimes dry lint alone when it does not stick to the cancer; at other times, lint doffs spread with Basilicon or Cerat. de Lapid. Calam., and oftener than either with a Cerate made of oil and wax, or the Sperm. Cet. ointment; and over all, a pledgit of tow spread with the same. Embrocating the neighbouring skin and edges of it with milk, is of service; but the chief good is to be acquired by diet, which should be altogether of milk and things made of milk, though herbage may be admitted also. Ifuses in the shoulders or thighs do also alleviate the symptoms; and manna, with the purging waters, once, or perhaps twice a-week, will serve to keep the body cool.

When ulcers or abscesses are accompanied with inflammation and pain, they are to be assisted with fomentations made of some of the dry herbs, such as Roman wormwood, bay-leaves, and rosemary; and when they are very putrid and corrosive, which circumstances give them the name of foul phagedenic ulcers, some spirits of wine should be added to the fomentation, and the bandage be also dipped in brandy. or spirits of wine, observing in these cases where there is much pain, always to apply gentle medicines till it be removed.

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 importance 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 defend with more force, than if the body was reclined.

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 case; for the varix can only be assisted by the application of bandage, which must be continued a considerable time after the cure. The nearest bandage is the strait locking, which is particularly serviceable in this case; though also, if the legs be oedematous, 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 varicose, which when it happens, may be destroyed by tying it above and below the dilation, as in an aneurism; but this operation should only be practised where the varix is large and painful.

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 complaints, 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; but we often find it necessary to raise a salivation to effect it, though, when completed, it does not always last; so that the prospect of cure in stubborn old ulcers, at any time of life, is but indifferent. In all these cases, however, it is proper to purge once or twice a-week with calomel, if the patient can bear it, and to make an issue when the sore is almost healed, in order to continue a discharge the constitution has been so long habituated to, and prevent its falling from the cicatrix, and bursting out again in that place.

When an ulcer or abscess has any sinuses or channels opening and discharging themselves into the sore, they are called sinus ulcers. These sinuses, if they continue to drain a great while, grow hard in the surface of their cavity, and then are termed fistulae, 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 sinus ulcer, or a fistula.

The treatment of these ulcers depends upon a variety of circumstances. If the matter of the sinus be thick, strict bandages and compresses will sometimes bring the opposite sides of the sinus to a re-union; if the sinus grow turgid in any part, and the skin thinner, shewing 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 mischiefous as tents, and for nearly the same reason, since suffering the external wound to contract into a narrow orifice before the internal one be incurred, coes 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 abscesses where the counter openings are 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 scrophulous 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.

Gun-shot wounds often become sinus ulcers, and 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 terribleness is owing to the violent contusion and laceration of the parts, and often to the admission of extraneous bodies into them, as the bullet, splinters, clothes, &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. To guard against mortification in this, and all other violently contused wounds, it will be proper to bleed the patient immediately, and soon after give a clyster; the part should be dressed with soft digestives, and the compresses and roller applied very loose, being first dipped in brandy or spirits of wine. The next time the wound is opened, if it be dangerous, the spirituous fomentation may be employed, and after that continued till the danger is over. If a mortification comes on, the applications for that disorder must be used. In gun-shot wounds, it seldom happens that there is any effusion of blood, unless a large vessel be torn; but the bullet makes an eschar, which usually separates in a few days, and is followed with a plentiful discharge; but when the wound is come to this period, it is manageable by the rules already laid down.

When an ulcer with loose rotten flesh discharges more than the size of it should yield, and the discharge is oily and stinking, 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 cases 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 a caries, is by applying a cautick 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 they 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 secrete, 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 chariotick medicines; though there will be no need of either, if a regular compress be kept on the dressing; or at worst, if a flat piece of the prepared sponge, or the size of the ulcer, be rolled on with a tight bandage, it will swell 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 the evil, the bones of the carpus and tarus 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, 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 dottled with the tincture of myrrh; otherwise those of dry hurt 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 fudderly 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 excoriates, it is easiest to roll the part up gently with bandages dipped in sweet oil, or a mixture of unguent flor sanhui, with the oil: when the excoriations 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 ulcers, they may be dressed with balsamicon, 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 palteboards, to keep the part extended, are absolutely necessary, where they can be applied.

EXPLANATION of Plate CLVII. 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 forefinger, 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. Surgery.

This is used only in the suture 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 stitching 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 shoemakers 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 suture, in the suture 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.

Of Sutures.

When a wound is recent, and the parts of it are divided by a sharp instrument, without any farther violence, and in such a manner that they may be made to approach each other, by being returned with the hands, they will, if held in close contact for some time, re-unite by inoculation, and cement like one branch of a tree ingrafted on another. To maintain them in this situation, several sorts of sutures have been invented, and formerly practised; but the number of them has of late been very much reduced. Those now chiefly described, are the interrupted, the glover's, the quilled, the twisted, and the dry sutures; but the interrupted and twisted, are almost the only useful ones; for the quilled suture is never preferable to the interrupted; the dry suture is ridiculous in terms, since it is only a piece of plaster applied in many different ways to re-unite the lips of a wound; and the glover's, or uninterrupted stitch, which is advised in superficial wounds, to prevent the deformity of a scar, does rather, by the frequency of the stitches, occasion it, and is therefore to be rejected in favour of a compress and thickening plaster; the only instance where it should be used, is in a wound of the intestine.

Wounds are not fit subjects for future, when there is either a contusion, laceration, loss of substance, great inflammation, difficulty of bringing the lips into apposition, or some extraneous body introduced into them; though sometimes a lacerated wound may be assisted with one or two stitches. It has formerly been forbidden to sew up wounds of the head; but this precaution is very little regarded by the moderns.

If we stitch up a wound that has none of these obstacles, we always employ the interrupted suture, passing the needle two, three, or four times, in proportion to the length of it, though there can seldom be more than three stitches required.

The method of doing it is this: 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 them 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 suture 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.

The twisted suture being principally employed in the hare-lip, we shall reserve its description for the section on that head.

Of the Suture of Tendons.

Wounds of the tendons are not only known to heal again, but even to admit of sewing up like those of the fleshy parts, parts, though they do not re-unite in so short a time. When a tendon is partly divided, it is generally attended with an excessive pain, inflammation, &c., in consequence of the remaining fibres being stretched and forced by the action of muscle, which necessarily will contract more when some of its resistance is taken away. To obviate this mischief, it has been hitherto an indubitable maxim in surgery, to cut the tendon quite through, and immediately afterwards perform the future. But this practice is not advisable; for though the division of the tendon afford present ease, yet the mere flexion of the joint will have the same effect, if, for example, it be a wound of a flexor tendon: besides, in order to sew up the extremities of the tendon when divided, we are obliged to put the limb in such a situation, that they may be brought into contact, and even to sustain it in that posture to the finishing of the cure: if then, the posture will lay the tendon in this position, we can likewise keep it so without using the future, and are more sure of its not slipping away, which sometimes happens from any careless motion of the joint, when the stitches have almost worn through the lips of the wound; on which account, it is by all means advisable, in this case, to forbear the future, and only to favour the situation of the extremities of the tendon, by placing the limb properly.

But when the tendon is quite separated, and the ends are withdrawn from one another, having brought them together with your fingers, you may sew them with a straight triangular pointed needle, passing it from without inwards, and from within outwards in small tendons; about three tenths of an inch from their extremities, and in the tendo Achillis half an inch.

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 patteboard and bandage: the small tendons reunite in three weeks, but the tendo Achillis requires six at least.

Of the Gastroraphy.

This word signifies no more than sewing up any wound of the belly; yet in common acceptation, it implies that the wound of the belly is complicated with another of the intestine. Now the symptoms laid down for distinguishing when the intestine is wounded, do not with any certainty determine it to be wounded only in one place; which want of information makes it absurd to open the abdomen in order to come at it: if so, the operation of stitching the bowels can only take place where they fall out of the abdomen, and we can see where the wound is, or how many wounds there are: if it happens that the intestines fall out unwounded, the business of the surgeon is to return them immediately, without waiting for spirituous or emollient fomentations; and in case they puff up so as to prevent their reduction by the same orifice, you may with a knife or probe-scissors sufficiently dilate it for that purpose, or even prick them to let out the wind.

Upon the supposition of the intestine being wounded in such a manner as to require the operation, (for in small punctures it is not necessary,) the method of doing it may be this: Taking a straight needle with a small thread, you lay hold of the bowel with your left hand, and sew up the wound by the glover's stitch, that is, by passing the needle through the lips of the wound, from within outwards all the way, so as to leave a length of thread at both ends, which are to hang out of the incision of the abdomen; then carefully making the interrupted future of the external wound, you pull the bowel by the small threads into contact with the peritoneum, in order to procure an adhesion, and tie them upon a small bolster of linen. In about five days, it is said the ligature of the intestine will be loose enough to be cut and drawn away, which must be done without great force; in the interim, the wound is to be treated with superficial dressings, and the patient to be kept very still and low.

Of the Bubonocele.

When the intestine or omentum falls out of the abdomen into any part, the rumour in general is known by the name of hernia; which is farther specified either from the difference of situation, or the nature of its contents. When the intestine or omentum falls through the navel, it is called a hernia umbilicalis, or exomphalos; when through the rings of the abdominal muscles into the groin, hernia inguinalis; or if into the scrotum, scrotalis: these two last, though the first only is properly so called, are known by the name of bubonocele. When they fall under the ligamentum Falopi, through the same passage that the iliac vessels creep into the thigh, it is called hernia femoralis. The bubonocele is also sometimes accompanied with a descent of the bladder: however, the case is very rare; but when it occurs, it is known by the patient's inability to urine, till the hernia of the bladder is reduced within the pelvis. With regard to the contents characterising the swelling, it is thus distinguished: if the intestine only is fallen, it becomes an enterocele; if the omentum, (epiploa) epiplocele; and if both, entero-epiplocele. There is, besides these, another kind of hernia mentioned and described by the ancients, when the intestine or omentum is infumated between the interstices of the muscles, in different parts of the belly; this hernia has derived its name from the place affected, and is called the hernia ventralis; and lately, there have been a few instances, where the intestines or omentum have fallen thro' the great foramen of the ilium into the internal part of the thigh, between and under the two anterior heads of the triceps muscle.

All the kinds of hernias of the intestines and omentum, are owing to a preternatural dilatation of the particular orifices through which they pass, and not to a laceration of them.

The rupture of the groin, or scrotum, is the most common species of hernia, and in young children is very frequent; but it rarely happens in infancy, that any mischief arise from it. For the most part, the intestine returns of itself into the cavity of the abdomen, whenever the person lies down; at least a small degree of compression will make it. To secure the intestine when returned into its proper place, there are steel trusses now so artfully made, that by being accommodated exactly to the part, they perform the office of a bolster, without galling, or even fitting uneasily on the patient. These instruments are of so great service, that were people who are subject to ruptures always to wear them, very few would die of this distemper; since it often appears, upon inquiry, when we perform the operation for the bubonocle, that the necessity of the operation is owing to the neglect of wearing a truss.

In the application of a truss to these kinds of swellings, a great deal of judgment is sometimes necessary, and for want of it, we daily see trusses put even on buboes, indurated testicles, hydroceles, &c.

If there is a rupture of the intestine only, it is easily, when returned into the abdomen, supported by an instrument; but if of the omentum, notwithstanding it may be returned, yet the reduction seldom brings relief, unless there is only a small quantity of it; for the omentum will lie uneasily in a lump at the bottom of the belly, and, upon removal of the instrument, drop down again immediately; upon which account, seeing the little danger and pain there is in this kind of hernia, nothing need be used but a bag truss, to suspend the scrotum, and prevent possibly by that means the increase of the tumour. The difference of these tumours will be distinguished by the feel; that of the omentum feeling flaccid and rumpled, the other more even, flatulent, and springy.

Sometimes, in a rupture of both the intestine and omentum, the gut may be reduced, but the omentum will still remain in the scrotum; and when thus circumstanced, a flat-truss must be used.

We have hitherto considered the rupture as moveable; but it happens frequently, that the intestine, after it has passed the rings of the muscles, is presently inflamed, which enlarging the tumour, prevents the return of it into the abdomen, and becoming every moment more and more strangulated, it soon tends to a mortification, unless we dilate the passages through which it is fallen, with some instrument, to make room for its return; which dilatation is the operation for the Bubonocle.

It rarely happens that patients submit to this incision before the gut is mortified, and it is too late to do service; nor but that there are instances of people surviving small gangrenes, and even perfectly recovering afterwards.

In mortifications of the bowels, when fallen out of the abdomen into the navel, it is not very uncommon for the whole gangrened intestine to separate from the sound one, so that the excrement must necessarily ever after be discharged at that orifice: there are likewise a few instances, where the rupture of the scrotum has mortified, and become the anus, the patient doing well in every other respect.

Before the performance of the operation for the bubonocle, which is only to be done in the extremity of danger, the milder methods are to be tried; these are, such as will conduce to soothe the inflammation.

Perhaps except the pleurify, no disorder is more immediately relieved by plentiful bleeding than this. Clysters repeated, one after another, three or four times, if the first or second are either retained too long, or immediately returned, prove very efficacious: these are serviceable, not only as they empty the great intestines of their excrements and flatulencies, which last are very dangerous, but they likewise prove a comfortable fomentation, by passing thro' the colon all around the abdomen. The scrotum and groin must, during the stay of the clyster, be bathed with warm broths wrung out of a fomentation; and after the part has been well fomented, you must attempt to reduce the rupture: for this purpose, let your patient be laid on his back, so that his buttocks may be considerably above his head; the bowels will then retire towards the diaphragm, and give way to those which are to be pushed in. If, after endeavouring two or three minutes, you do not find success, you may still repeat the trial.

If, notwithstanding these means, the patient continues in very great torture, though not so bad as to threaten an immediate mortification, we must apply some form of poultice to the scrotum; such as equal parts of oil and vinegar made into a proper consistence with oat-meal: after some few hours, the fomentation is to be repeated, and the other directions put in practice.

After all, should the pain and tenesmus of the part continue, and hiccoughs and vomitings of the excrements succeed, the operation must take place; for if you wait until a languid pulse, cold sweats, subsiding of the tumour, and emphysematous feet come on, it will be most likely too late, as they are pretty sure symptoms of a mortification.

To conceive rightly of the occurrences in this operation, it must be remembered, that in every species of rupture, a portion of the peritoneum generally falls down with whatever makes the hernia; which, from the circumstance of containing immediately the contents of the tumour, is called the sac of the hernia. Now, the portion of the peritoneum, which usually yields to the impulsion of the descending viscera, is that which corresponds with the inmost opening of the abdominal muscles, just where the membrana cellularis peritonei begins to form the tunica vaginalis of the spermatic cord; so that the sac with the viscera infuse themselves into the tunica vaginalis of the spermatic cord, and lie upon the tunica vaginalis of the testicle: nevertheless, upon examination, the contents of the hernia are sometimes in contact with the testicle itself; that is to say, within the tunica vaginalis of the testicle. For some months during gestation, the testes of the fetus remain in the abdomen; and when they descend into the tunica vaginalis, there is an immediate communication between the cavity of the abdomen, and the cavity of the tunica vaginalis, which, in process of time, becomes obliterated by the coalition of the tunics with the cord; but if it happen, before the coalition be effected, that the intestine or the omentum fall into the scrotum, they will necessarily remain in contact with the testes.

From this description of the descent of the viscera, it is evident that the herniary sac is contained within the tunica vaginalis, and ought to give the idea of one bag inclosing another: but in the operation, this dilatation of coats does not always appear; for the herniary sac sometimes adheres so firmly to the tunica vaginalis, that together they make one thick coat: this adhesion may possibly result from the present inflammation of the parts, which has rendered the operation necessary.

The best way of laying your patient will be on a table about three feet four inches high, letting his legs hang down; then properly securing him, you begin your incision, above the rings of the muscles, beyond the extremity of the tumour, and bring it down about half the length of the scrotum, through the membrana adiposa, which will require very little trouble to separate from the tunica vaginalis, and consequently will expose the rupture for the farther processes of the operation. If a large vessel is opened by the incision, it must be taken up before you proceed further. When the tunica vaginalis is laid bare, you must cut carefully through it and the peritoneum, in order to avoid pricking the intestines.

The peritoneum being cut through, we arrive at its contents, the nature of which will determine the next process; for if it is intestine only, it must directly be reduced, but if there is any mortified omentum, it must be cut off; in order to which it is advised to make a ligature above the part wounded, to prevent an hemorrhage; but it is quite needless, and in some measure pernicious, as it puckers up the intestine, and enforces its situation, if made close to it.

When the omentum is removed, we next dilate the wound; to do which with safety, an infinite number of instruments have been invented; but there is none we can use in this case with so good management as a knife; and the finger in this operation is often a much better defence against pricking the bowels, than a director. The knife must be a little crooked and blunt at its extremity, like the end of a probe. Some surgeons perhaps may not be steady enough to cut dexterously with a knife, and may therefore perform the incision with probe-floppers. Carefully introducing one blade between the intestine and circumference of the rings, and dilating upwards, and a little obliquely outwards. When the finger and knife only are employed, the manner of doing the operation will be by pressing the gut down with the forefinger, and carrying the knife between it and the muscles, so as to dilate upwards about an inch, which will be a wound generally large enough; but if, upon examination, it shall appear that the intestine is strangulated within the abdomen, which may possibly happen from a contraction of the peritoneum near the entrance into the sac; in that case, the incision must be continued through the length of the contracted channel, or the consequence will be fatal, notwithstanding the intestine be restored into the peritoneum; on this account the operator should pass his finger up the sac into the abdomen, after the reduction of the gut, in order to discover whether it be safely returned into its proper place.

The opening being made, the intestine is gradually to be pushed into the abdomen, and the wound to be stitched up; for this purpose, some advise the quilled, and others the interrupted suture, to be passed through the skin and muscles; but as there is not so much danger of the bowels falling out when a dressing and bandage are applied, and the patient all the while kept upon his back, but that it may be prevented by one or two slight stitches through the skin only, it is by all means advisable to follow this method, since the stricture of a ligature in these tendinous parts may be dangerous.

Hitherto, in the description of the bubonocoele, we have supposed the contents to be loose, or separate in the sac; but it happens sometimes in an operation, that we find not only an adhesion of the outside of the peritoneum to the tunica vaginalis, and spermatic vessel, but likewise of some part of the intestines to its internal surface; and in this case there is so much confusion, that the operator is often obliged to extricate the intestines, in order to dislodge away and disentangle the gut; though if it can be done without castration, it ought; however, this accident happens rarely, except in those ruptures that have been a long time in the peritoneum without returning; in which case the difficulty and hazard of the operation are so great, that unless urged by the symptoms of an inflamed intestine, it should not be undertaken.

The dressing of the wound first of all may be with dry lint, and afterwards as directed under the head of wounds. The operation of the bubonocoele in women nearly resembles that performed on men, that it requires no particular description: only in them the rupture is formed by the intestine, or omentum falling down through the passage of the ligamentum rotundum into the groin, or one of the labia pudendi; where causing the same symptoms, as when obstructed in the scrotum, it is to be returned by the dilatation of that passage.

Of the Epiplocele.

There have been a few instances where so great a quantity of the omentum has fallen into the scrotum, that, by drawing the stomach and bowels downwards, it has excited vomitings, inflammation, and the same train of symptoms as happen in a bubonocoele; in which case, the operation of opening of the scrotum is necessary: the incision must be made in the manner of that for the rupture of the intestine, and the same rules observed with regard to the omentum that are laid down in the last section. It is necessary also, the rings of the muscles should be dilated; or otherwise, though you have taken away some of the mortified part of the omentum, the rest that is out of its place, and entangled in the perforation, will gangrene also. The wound is to be treated in the same manner as that after the operation of the bubonocoele.

Of the Hernia Femoralis.

This species of rupture is the same in both sexes, and formed by the falling of the omentum or intestine, or both of them, into the inside of the thigh, through the arch made by the os pubis and ligamentum Fallopii, where the iliac vessels and tendons of the psoas and iliacus internus muscles pass from the abdomen. It is very necessary surgeons should be aware of the frequency of this disorder, which creates the same symptoms as other ruptures, and must first of all be treated by the same methods: the manner of operating in the reduction is here too so exactly the same, with the difference of dilating the ligament instead of the rings of the muscles, that it would be a mere repetition of the operation for the bubonocoele to give any description of it: only it may be observed, that the spermatic cord, as it enters into the abdomen, lies nearly transverse to the incision, and close in contact with the ligament; so that unless you make the dilatation obliquely outwards, instead of perpendicularly upwards, you will probably divide those vessels.

Of the Exomphalos.

This rupture is owing to a protrusion of the intestine, or omentum, or both of them, at the navel, and rarely happens to be the subject of an operation: for though the case is common, yet most of them are gradually formed from very small beginnings; and if they do not return into the abdomen upon lying down, in all probability they adhere without any great inconvenience to the patient, till some time or other an inflammation falls upon the intestines, which soon brings on a mortification, and death; unless, by great chance, the mortified part separates from the sound one, leaving its extremity to perform the office of an anus: in this emergency, however, it is advisable to attempt the reduction, if called in at the beginning, though the universal adhesion of the sac and its contents are a great obstacle to the success: the influence in which it is most likely to answer, is, when the rupture is owing to any strain, or sudden jerk, and is attended with those disorders which follow upon the strangulation of a gut.

In this case, having tried all other means in vain, the operation is absolutely necessary; which may be thus performed: Make the incision somewhat above the tumour, on the left side of the navel, through the membrana adiposa; and then emptying the sac of its water, or mortified omentum, dilate the ring with the same crooked knife, conducted on your finger, as in the operation for the bubonocle; after this, return the intestines and omentum into the abdomen, and dress the wound without making any ligature but of the skin only.

Of the Hernia Ventralis.

The hernia ventralis, which sometimes appears between the recti muscles, is very large; but that tumour which requires the operation is seldom bigger than a walnut, and is a disease not so common as to have been observed by many; but there are cases enough known, to put a surgeon upon inquiry after it. When the patient is suddenly taken with all the symptoms of a rupture, without any appearance of one in the navel, scrotum, or thigh, the manner of dilating it will be the same as that above directed in the other hernias; after the operation in this and all hernias where the intestines have been reduced, it will be convenient to wear a truss, since the cicatrix is not always firm enough in any of them to prevent a relapse.

Explanation of Fig. 2. Plate CLVII.

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, so that it is 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 bubonocle.

Of the Hydrocele.

The hydrocele, called also hernia aquosa, hydrops scroti, and hydrops testis, is a watery tumour of the scrotum; which, notwithstanding the multiplicity of distinctions used by writers, is but of two kinds; the one when the water is contained in the tunica vaginalis, and the other when in the membrana cellularis scroti. This last is almost always complicated with an abscess; which species of dropy is an extravasation of water lodged in the cells of the membrana adiposa; and when thus circumstanced, will not be difficult to be distinguished; besides that it is sufficiently characterised by the thinning and softness of the skin, which gives way to the least impression, and remains pitted for some time. The penis is likewise sometimes enormously enlarged, by the insinuation of the fluids into the membrana cellularis; all which symptoms are absolutely wanting in the dropy of the tunica vaginalis.

In the dropy of the membrana cellularis scroti, the puncture with the trocar is recommended by some, and little orifices made here and there with the point of a lancet by others; or a small cane of silk passed by a needle through the skin, and out again at the distance of two or three inches, to be kept in the manner of a fetor, till the waters are quite drained; but the two first methods avail very little, as they open but few cells; and the last cannot be so efficacious in that respect as incisions, and will be much more apt to become troublesome, and even to gangrene.

Indeed it is not often proper to perform any operation at all upon this part, since the membrana cellularis scroti, being a continuation of the membrana adiposa, incisions made through the skin in the small of the legs will effectually empty the scrotum; and this place ought rather to be pitched upon than the other, as being more likely to answer the purpose by reason of its dependency; however, it sometimes happens, that the waters fall in to great quantities into the scrotum, as, by distending it, to occasion great pain, and threaten a mortification: the prepuce of the penis also becomes very often excessively dilated, and so twisted, that the patient cannot void his urine. In these two instances, an incision of three inches long should be made on each side of the scrotum, quite through the skin into the cells containing the water, and two or three of half an inch long, in any part of the penis, with a lancet or knife; all which may be done with great safety, and sometimes with the success of carrying off the disease of the whole body.

The dropy of the tunica vaginalis is owing to a supernatural discharge of that which is continually separating in a small quantity, on the internal surface of the tunick, for the moistening or lubricating the testicle, and which collecting too fast accumulates and forms in time a swelling of great magnitude: this is what we take to be the other species of hydrocele, and the only one besides.

The hydrocele of the tunica vaginalis is very easily to be distinguished from the hydrocele of the membrana cellularis, by the preceding description of that species of dropy. We shall now explain how it differs from the other tumours of the scrotum, viz. the bubonocle, epiplocele, and enlarged testicles. In the first place, it is seldom or never attended with pain in the beginning, and is very rarely to be imputed to any accident, as the hernia's of the omentum and intestine are. From the time it first makes its appearance, it very seldom is known to appear or diminish; but generally continues to increase, though in some much faster than in others; in one person growing to a very painful diffusion in a few months, whilst in another it shall not be troublesome in many years; nay, shall cease to swell at a certain period, and ever after continue in that state without any notable disadvantage; though this last case very rarely happens. In proportion as it enlarges, it becomes more tense, and then is said to be transparent: indeed the transparency is made the chief criterion of the distemper, it being constantly advised to hold a candle on one side of the scrotum, which it is said will shine through the other, if there be water. But this experiment does not always answer, because sometimes the tunica vaginalis is very much thickened, and sometimes the water itself is not transparent: so that to judge positively if there be a fluid, we must be guided by feeling a fluctuation; and though we do not perhaps evidently perceive it, yet we may be persuaded there is a fluid of some kind, if we are once assured that the distension of the tunica vaginalis makes the tumour; which is to be distinguished in the following manner.

If the intestine, or omentum, form the swelling, they will be soft and pliable, (unless inflamed;) uneven in their surface, particularly the omentum; and both of them extend themselves up from the scrotum quite into the very abdomen: whereas, in the hydrocele, the tumour is tense and smooth, and ceases before or at its arrival to the rings of the abdominal muscles; because the upper extremity of the tunica vaginalis terminates at some distance from the surface of the belly.

When the testicle is increased in its size, the tumour is rounder; and if not attended with an enlargement of the spermatic vessels, the cord may be easily distinguished between the swelling and abdomen; but without this rule of distinction, either the pain, or the very great hardness, will discover it to be a disease of the testicle.

As to the cure of this distemper by external applications, or internal means, little is to be expected; on which account, it is generally advisable to wait with patience until the tumour becomes troublesome, and then to tap it with a lancet or trocar. In opening with a lancet, it may possibly happen, that the orifice of the skin shall slip away from that of the tunic, and prevent the escape of the water; to obviate which inconvenience, you may introduce a probe, and by that means secure the exact situation of the wound; but if the coats are very much thickened, it will be advisable to use the trocar, rather than the lancet. It is spoken of as an easy thing, to hold the testicle with the left hand, while we make the puncture with the right; but when the tunica vaginalis is very tense, it cannot well be distinguished; however, there is no danger of wounding it, if you make the puncture in the inferior part of the scrotum. During the evacuation, the scrotum must be regularly pressed; and after the operation, a little piece of dry lint and sticking plaster are sufficient.

This method of tapping is called the palliative cure; not but that it does now and then prove an absolute one. To prevent the relapse of this disease, surgeons prescribe the making a large wound, either by incision or cautery, that upon healing it afterwards, the firmness and contraction of the cicatrix may bind up the relaxed lymphatic vessels, and obstruct the further preternatural effusion of their contents; but this practice is generally attended with so much trouble, that notwithstanding its success in the end, most surgeons prefer the palliative.

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 schirrhus, 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 sarcocoele; 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 fleshly swelling of the testicle itself, called likewise hernia canosa; or in some enlargements, such as in a clap, more frequently hernia humoralis; but generally speaking, is considered as a fleshly excrescence formed on the body of the testis, which becoming 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 sarcocoele; 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 or 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 schirrhus 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-trousers, 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 circocoele and varicocele, 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 hemorrhage is dangerous. Then pass a ligature round the cord, pretty near the abdomen, and if you have space between 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 through the skin at the upper part, in such a manner as to envelope in some degree the sound tactile, 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 hemorrhage will be much less in this case, and the operation greatly shortened, the skin by the great dilatation having been rendered very thin, will great part of it, if not taken away, sphecalate, and the rest be more prone to degenerate into a cancerous ulcer.

Of the Phymosis.

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 rent, effects a cure. But this operation is chiefly practised in venereal cases, in order to expose chances 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 scissors, 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 scissors; 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 hemorrhage; though the prepuce remains better shaped after an incision made in the upper part, and therefore 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; and 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.

Of the Paraphymosis.

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 whose 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 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 crystalliner, three or four small incisions must be made with the point of a lancet, into the stricture and crystalliner, according to the direction of the penis; which in the first case will set free the obstruction, and in the other evacuate the water: the manner of dressing afterwards must be with fomentations, digestives, and the theriac Londinensis over the pledgets.

Of the Paracentesis.

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.

There are but two kinds of dropsy: the anaesarcia, called also leucophlegmy, 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 flabby 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, hemorrhages, and diarrhoeas, to do well; whereas in such as are complicated with a scirrhus 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 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 a pint of water. This is called the encysted dropsy, and from the smallness of its cells 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 anaesarcia,) 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. 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 anaeroma 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 nothing forbids the extraction of the water, the manner of operating is this: 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 protrudes, 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 an exomphalos; 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 intimates 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, dipped in brandy or spirits of wine.

This operation, though it does not often absolutely cure, yet it sometimes preserves life a great many years, and even a pleasant one, especially if the waters have been long collecting.

Explanation of Fig. 3. Plate CLVII.

A, A trocar of the most convenient size for emptying the abdomen when the water is not gelatinous. It is here presented 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.

The handle of the trocar is generally made of wood, the canula of silver, and the perforator of steel. Great care should be taken by the makers of this instrument, that the perforator should exactly fill up the cavity of the canula; for unless the extremity of the canula lies quite close and smooth on the perforator, the introduction of it into the abdomen will be very painful. To make it slip in more easily, the edge of the extremity of the canula should be thin and sharp; and that the canula should be of steel; for the silver one being of too soft a metal, becomes jagged or bruised at its extremity with very little use.

Of the Fistula in Ano.

The fistula in ano is an abscess running upon or into the intestine rectum.

The piles, which are little tumours formed about the verge of the anus, immediately within the membrana interna of the rectum, do sometimes suppurate, and become the fore-runners of a large abscess; also external injuries here, as in every other part of the body, may produce it; but from whatever cause the abscess arise, the manner of operating upon it will be according to the nature and direction of its cavity.

If the surgeon have the first management of the abscess, and there appear an external inflammation upon 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 dressings lightly pressed in, will prevent the putrefaction of the intestine, and make the cavity fill up like imposthumations 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, in the circumstance here described, is sometimes excessive. By this method, which cannot be too much recommended, it is amazing how happy the event is likely to be; whereas, from neglecting it, and trusting only to a narrow opening, if the discharge do not destroy the patient, at least the matter, by being confined, corrupts the gut, and insinuating itself about it, forms many other channels, which running in various directions often baffle an operator, and have been the cause of a fistula being in generally esteemed very difficult of cure.

Here we have considered the imposthummation 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 passing 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, nip 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 discolouration 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 sinuses quite away, and, when it is callous, absolutely necessary, or the callousness must be waited afterwards by echafarick 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 stringent 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 (through the prostate gland) with the bladder itself. This generally takes its rise from a former gonorrhoea, and appears externally first in perineum, and afterwards increasing more towards the anus, and even sometimes into the groin, 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 obstinate indurations and foul sinuses will in consequence disappear; though there are some callous and rotten, as to demand the knife and skilful dressings, notwithstanding the urethra should be dilated by the use of bougies.

Of the Puncture of the Perineum.

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 effusion 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 intubate 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.

Of the Stone.

Stony concretions are a disease incident to several parts of the body; but we shall treat only of those formed in the kidneys and bladder.

Small stones and gravel are frequently voided without pain; but sometimes they collect and become very large in the kidneys; in which case, a fit of the stone in that part is the cure, from the inflammation and pain occasioning convulsive twitches, which at last expel them. But in this disease the patient is very much relieved by several kinds of remedies, such as the mucilaginous, the saponaceous, &c. some of which lubricate, and others both lubricate and stimulate. The sand, in passing through the ureters, is very much forwarded by the force of the urine. The ureters being very narrow as they run over the psoas muscle, and also at their entrance into the bladder, make the movement of the stone very painful and difficult in those parts; but there is seldom so much trouble after the first fit; for when once they have been dilated, they generally continue so. For the symptoms of a stone in the bladder, see Medicine, p. 122.

Of Searching.

The patient being laid on a horizontal table, with his thighs elevated and a little extended, puts the sound with the concave part towards you, until it meets with some resistance in perineum, a little above the anus; then turning it without much force, push it gently on into the bladder; and if if it meets with an obstruction at the neck, raise its extremity upwards, by inclining the handle of it towards you; or if it don't 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 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 angle 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 tincte in the vagina, which occasions the end of the found to slip a little beyond it.

Though, upon searching, we are assured of a stone in the bladder, we are not, without further inquiry, to operate immediately; since there are sometimes obstacles which forbid the operation, either absolutely, or only for a certain time; among these, that of greatest consequence, is the gravel or stone in the kidneys. The objections of less weight, and which frequently are removed, are a fit of the stone, a cough, a hectic, and being emaciated by long pain; excessive hot or cold weather are likewise hindrances: But in extremity of danger, these last considerations may be disregarded.

Difference of age makes an extreme difference of danger, infants and young people almost always recovering; but still the operation is adviseable on those advanced in years, tho' it is not attended with near the same success. This operation is performed four several ways, all which we shall describe.

Of the Lesser Apparatus, or Cutting on the Gripe.

The most ancient way of cutting for the stone, is that described by Celsus, and known by the name of cutting on the grips; though, since the time of Johannes de Romanis, it is also called cutting with the lesser apparatus, to distinguish it from his new method, which, on account of the many instruments employed in it, is called cutting with the greater apparatus. The manner of doing the operation is this: You first introduce the fore finger and middle finger of the left hand, dipped in oil, up the anus, and pressing softly with your right hand above the os pubis, endeavour to bring the stone towards the neck of the bladder; then making an incision, on the left side of the perineum, above the anus, directly upon the stone, you turn it out through the wound, either with your fingers or a scoop.

This way of cutting was attended with many difficulties, for want of proper instruments to direct the incision, and extract the stone, when it lay beyond the reach of the fingers, which in a large bladder was frequently the case.

The wound of the bladder in this operation is made in the same place as is now practised in the latest method; but it being impracticable on some subjects, and uncertain on all others, has made it universally exploded.

Of the Greater Apparatus, or the Old way.

This method of cutting, invented by Johannes de Romanis, has at different times, and with different people, varied considerably in some of its processes, and particularly with regard to the use of certain instruments. What we shall describe, will be the manner in which it is now practised with all its improvements.

Having laid the patient on a square horizontal table, three feet four inches high, with a pillow under his head, let his legs and thighs be bent, and his heels made to approach his buttocks, by tying his hands to the bottom of his feet, with a couple of strong ligatures, about two yards long; and to secure him more effectually from struggling, pass a double ligature under one of his hams, and carry the four strings round his neck to the other ham; then passing the loop underneath it, make a knot by threading one of the single ends through the loop: After this, the thighs being widened from each other, and firmly supported by proper persons, you introduce the staff, having first dipped it in oil, which must be held by your assistant, a little leaning on the left side of the seam in perineum; and beginning the external wound just below the scrotum, (which must be held out of the way,) you continue it downwards, to within two fingers breadth of the anus; then leaving that direction, you slip the knife forwards in the groove, pretty far into the bulbous part of the urethra; or, as there is some danger of wounding the rectum, in the continuation of the incision, you may turn the knife with the back towards it, and make this part of the incision from within outwards. Should a very large vessel be cut, it will be adviseable to tie it before you proceed any farther in the operation. When the wound is made, slide the gorget along the groove of the staff into the bladder; and to do it with more safety, when the beak of it is received in the groove, it will be proper to take the staff yourself in your hand: for if the assistant should, unwarily, either incline the handle of it too much towards you, or not resist enough to the force of the gorget, it is very apt to slip out of the groove, between the rectum and the bladder; which accident is not only inconvenient to the operator for the present, but is attended for the most part with very bad consequences. The gorget being passed, dilate the urethra and neck of the bladder with your fore-finger, and introduce the forceps into the bladder, keeping them shut till you touch the stone, when you must grasp it with a moderate force, and extract it by pulling downwards towards the rectum. Should you find a difficulty in laying hold of the stone, be careful to keep your forceps in such a position, that they may open upwards and downwards, (not laterally,) which will very much facilitate the embracing of the stone, in case it should happen to be thin and flat.

Of the High Operation.

This method of cutting for the stone was first published in the year 1561, by Pierre Franco. About the year 1719, it was first done in England by Mr Douglas, and after him practised by others. The manner of performing it, with the improvements made since Franco's operation, is this:

The patient being laid on a square table, with his legs hanging over, and fastened to the sides of it by a ligature passed above the knee; his head and body lifted up a little by pillows, so as to relax the abdominal muscles; and his hands held steady by some assistants; inject through a catheter into the bladder as much barley-water as he can bear, which in a man is often about eight ounces, and sometimes, twelve. For the more easily doing this, an ox's ureret may be tied to the extremity of the syringe, and handle of the catheter, which being pliable will prevent any painful motion of the instrument in the bladder.

The bladder being filled, an assistant, in order to prevent the reflux of the water, must grasp the penis the moment the catheter is withdrawn, holding it on one side, in such a manner as not to stretch the skin of the abdomen; then with a round edged knife make an incision about four inches long, between the recti and pyramidal muscles, through the membrana adiposa, as deep as the bladder, bringing its extremity almost down to the penis; after this, taking a crooked knife, continue the incision into the bladder, carrying it a little under the os pubis, and immediately upon the water's flowing out, introduce the fore-finger of your left hand, which will direct the forceps to the stone.

This method was at first received with great applause in London; but after some trial was rejected, for the following inconveniences.

It sometimes happens that the bladder, notwithstanding the injection, still continues so deep under the os pubis, that the peritoneum being necessarily wounded first, the intestine pushes out immediately at the orifice, and the urine afterwards empties into the abdomen; in which case, hardly any recover. The injection itself is exceedingly painful; and however slowly the fluid be injected, it dilates the bladder so much more suddenly than the urine from the kidneys does, and so much faster than it can well bear, that it not only is seldom dilated enough to make the operation absolutely secure, but is sometimes even burst, or at least its tone destroyed by the hasty dilatation. What adds to the danger here, is the possibility of meeting with a contracted indurated bladder; which is a circumstance sometimes attending on the stone, and indeed an exceedingly dangerous one in all the other methods; but would be frightful in this, by reason not only of the necessity of wounding the peritoneum, but of the difficulty of coming at the stone. If the stone be very small, it is hard to lay hold of it with the forceps, and in a fat man the fingers are not long enough for that purpose. If there are many little stones, it will scarce happen that more than one at a time can be extracted; and if the stone breaks, it not only is impracticable to take it all away in the operation, but also, from the supine posture of the patient, it will generally remain in the bladder; whereas, in the other methods, for the most part, it works itself out with the urine. But even supposing that the operation itself is prosperous, the consequences generally are very troublesome; for the urine issuing out at an orifice where there is no defecation, spreads itself upon the abdomen, and makes very painful excoriations; though, what is still worse, it sometimes insinuates itself into the cells between the bladder and abdominal muscles, and, together with the inflammation excited by the operation, brings on a suppuration there, which is always difficult to manage, and frequently mortal.

Of the Lateral Operation.

This method was invented by an ecclesiastic, who called himself Frere Jacquer. He came to Paris in the year 1697, bringing with him an abundance of certificates of his dexterity in opening; and making his history known to the court, and magistrates of the city, he got an order to cut at the Hotel Dieu, and the Charité, where he performed this operation on about fifty persons. His success did not answer the promises he had made.

The principal defect in his manner of cutting was the want of a groove in his staff; which made it difficult to carry the knife exactly into the bladder; nor did he take any care of his patients after the operation; so that for want of proper dressings, some of the wounds proved fistulous, and other ill consequences ensued.

Chefelden, improving Frere Jacquer's method, made use of the following, which is now the practice of most operators.

The patient being laid on a table, with his hands and feet tied, and the staff passed as in the old way, let your assistant hold it a little slanting on one side, so that the direction of it may run exactly through the middle of the left erector penis and accelerator urinae muscles; then make your incision through the skin and fat, very large, beginning on one side of the seam in perineo, a little above the place wounded in the old way, and finishing a little below the anus, between it and the tuberosity of the ilium; this wound must be carried on deeper between the muscles, until the prostate be felt; when, searching for the staff, and fixing it properly, if it has slipped, you must turn the edge of the knife upwards, and cut the whole length of that gland from within outwards, at the same time pushing down the rectum with a finger or two of the left hand; by which precautions the gut will always escape wounding; after which, the operation finishes nearly in the same manner as with the greater apparatus.

If, upon introducing the forceps, you do not perceive the stone readily, you must lift up their handle, and feel almost perpendicularly for it; since for the most part, when it is hard to come at, it lies in one of the sinuses sometimes formed on each side of the neck of the bladder, which project forward in such a manner, that if the stone lie there, the forceps pass beyond it the moment they are through the wound; so that it would be impossible to lay hold of it, or even to feel it, if not aware of this circumstance.

When the stone breaks, it is much safer to take away the fragments with the forceps, than to leave them be discharged with the urine; and if the pieces are very small, like sand, a scoop is the best instrument; though some prefer the injecting barley-water into the bladder, which suddenly returning, brings away the broken particles of the stone.

As there are hardly any instances of more stones than one, when the stone taken away is rough; so when it is smooth and polished in any part of it, it is almost a certain sign of others behind; on which account, an operator should be careful, in that case, to examine not only with his fingers, but some convenient instrument, for the remaining ones; though indeed, in all cases, it may be proper to examine the bladder after the extraction of a stone; because it is possible there may be a second stone, notwithstanding the first be rough.

The great inconvenience of the lateral operation is the hemorrhage which sometimes ensues in men; for in children the danger of it is not worth mentioning.

If in the operation any very large vessel of the external wound should be divided, it is advisable to tie it before the extraction of the stone; but the necessity of doing this, does not occur once in twenty times.

There is but one objection more of any consequence, which is the danger of wounding the rectum; and this is a very troublesome accident: But if the operator observes the rule laid down with regard to that article, it might always be avoided. In this method the remarkable parts wounded by the knife are, the muscular transversalis penis, levator ani, and prostatic gland: In the old way, the urethra only is wounded, about two inches on this side the prostate, and the instruments are forced through the rest of the passage, which is composed of the bulbous part of the urethra, the membranous part of the urethra, the neck of the bladder, and prostatic gland. This channel is so very narrow, that till it be torn to pieces, the management of the forceps is exceedingly difficult; and it happens frequently, that from the tender texture of the membranous parts, the forceps are unwarily pushed through it between the os pubis and bladder; besides that in introducing the gorget upon the staff, it is apt to slip downwards between the rectum and bladder, both which inconveniences are avoided in the lateral operation. It is true, the wound made in the lateral method will not admit of the extraction of a large stone without laceration as well as in the old way: but in the one case, the laceration is small, and made after a preparation for it by an incision; and in the other, all the parts are torn without any previous opening, and which are so very tight, that the pain of the diffusion must necessarily be excessive. However, in both these operations, the surgeon must not grasp the stone with violence; and even in extracting, must, with both hands to the branches of his forceps, retighten their shutting so tight, as the compression from the lips of such a narrow wound would otherwise make them. The extraction of very large stones is much more impracticable with the greater apparatus than by this method, because of the smallness of the angle of the bones in that part where the wound is made; so that indeed it is necessary in almost all extractions to pull the stone downward towards the rectum, which cannot be done without great violence to the membranous parts, and even the separation of one from another; whence follow abscesses and floughs about the wound, which is a circumstance not known in the lateral operation. Ecchymoses followed by suppuration and gangrene, sometimes spread themselves upon the scrotum; and in short, all the inconveniences and ill symptoms which attend upon the lateral operation, except the hemorrhage, are in a more violent degree incident to the old way.

An incontinence of urine is not common after the lateral operation, and a fistula seldom or never the consequence of it.

The manner of treating the patient after the operation, is pretty nearly this: If it happens that the vessels of the prostate bleed, dry lint, or lint dipped in some tincture water, such as aqua vitrioli, must be applied to the part, and held there with a considerable degree of pressure for a few hours; or a silver caudle of three or four inches long, covered with fine rag, may be introduced into the bladder, and left there two or three days, which seldom fails to stop the hemorrhage. The patient may also take an opiate. If the wound does not bleed, a little dry lint, or a pledgit of digestive, laid gently in it, is best. The place where the patient lies, should be moderately cool, as heat not only disposes the vessels to bleed afresh, but generally makes him low and faint. If, soon after the operation, he complains of a sickness at the stomach, or even a pain in that part of the abdomen near the bladder, it is not always a sign of a dangerous inflammation, but frequently goes off in half an hour: to afflit, however, in its removal, a fomentation put into an hog's bladder, and applied pretty warm to the part in pain, will be of great service: if the pain increases, after two or three hours, the consequence is much to be feared; and in this case, bleeding, and emollient clysters by way of fomentation to the bowels, are immediately necessary.

The first good symptom after the operation is the urine coming freely away, as we then know the lips of the bladder and prostatic gland are not much inflamed. If the patient should become languid, and continue without any appetite, blisters prove beneficial; which may be applied with great safety, and little pain, as there is seldom or never any strangury. About the third or fourth day a stool must be procured by a clyster; for it seldom comes naturally the first time, and this method must be continued as every man's discretion shall guide him. As soon as the patient comes to an appetite, he should be indulged in eating light food; with this caution, that he do not eat too much at a time.

If, during the cure, the buttocks should be excoriated by the urine, let them be anointed with nutritive: the dressing from first to last is seldom any other than a soft digestive, or dry lint.

Of the Stone in the Urethra.

If a small stone be lodged in the urethra near the glans, it may often be pushed out with the fingers, or picked away with some instrument; but if it stops in any other part of the channel, it may be cut upon without any inconvenience. The best way of doing it, is to pull the prepuce over the glans, as far as you can; and then making an incision the length of the stone, through the teguments, it may be turned out with a little hook or the point of a probe: The wound of the skin slipping back afterwards, to its proper situation, and from the orifice of the urethra, prevents the issue of the urine through that orifice, and very often heals in twenty-four hours. This is a much less painful method of extracting stones from the urethra, than by any intrusions that have hitherto been devised.

Of the extraction of the Stone in Women.

The extraction of the stone in women, will easily be understood, since the whole operation consists in placing them in the same manner as men, and, without making any wound, introducing into the bladder a straight director, upon that a gorget, and afterwards the forceps to take hold of the stone; all which may be done without difficulty, by reason of the shortness of the urethra. If the stone proves very large, and in extracting draws the bladder forwards, it is advisable to make an incision through the neck of it, upon the stone; which not only will facilitate the extraction, but also be less dangerous than a laceration which will necessarily follow. The dressings are fomentations and emollient ointments, which should be applied two or three times a day, and the patient in other respects be treated like men who have undergone the operation for the stone.

Explanation of Fig. 4. Plate CLVII.

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 found 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 inconvenience 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.

Explanations of Fig. 5. Plate CLVII.

A, A small catheter made of silver. This instrument is hollow, and serves to draw off the urine when under a suppuration. 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 prostrate 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.

Explanations of Fig. 6. Plate CLVII.

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 slanting, that they may the more readily be carried through 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, least, 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.

G, 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.

Explanation of Fig. 7. Plate CLVII.

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.

Of the Empyema.

The operation for the empyema generally 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 voided 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.

To empty the thorax, in a rupture of any vessels which open into it, bleeding is very necessary; which not only stops the hemorrhage, by abating the force of the circulation; but likewise, by unloading the vessels of their contents, makes them more fit to receive the extravasated fluid by absorption: gentle evacuations and pectorals are also very serviceable, and a low diet is absolutely necessary.

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 matter is usually spit up as fast as it is generated; and in the dissection of such who have died of this species of consump- tion, we rarely find much extravasated pus in the cavity, though a great portion of the lungs be destroyed. However, there are a few examples 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. An- other symptom of extravasated matter, is an evident un- dulation of it, so that in certain motions it may be heard to quash. For the most part too, upon careful inquiry, an edema, or at least a thickening of some portion of the inter- costal muscles, will be discovered. And lastly, if there be much fluid, it will be attended with a preternatural expan- sion of that side of the chest where it lies. When there- fore these signs appear after a previous pleuritic or pulmo- nary disorder, and the case has been attended with the symp- toms of a suppuration, it is most probably owing to a collec- tion 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 opera- tion 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 ana- phora, or even acuter, it is certainly improper; and indeed it hardly ever takes place, but where the distemper is single, and takes its rise from the same sort of disorders in the lympha- tics 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 distur- bance 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 most depending part of the thorax, which some have supposed to be between the eighth and ninth rib, and others between the ninth and tenth, at such a distance from the vertebra that the depth of the flesh may not be an impediment to the perforation. This dis- tance is determined to be about a hand's breadth: and here, with a knife, scissors, or trocar, we are ordered to make the perforation; but in doing it there are a great many diffi- culties. 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 de- rived from its dependency, the purpose of discharging the fluid will be as well answered by an opening between the sixth and seventh rib, 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 inconvenien- cies in the other method: For in this part of the thorax there is very little depth of muscles; the artery lies conceal- ed under the rib; and the diaphragm is at 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; though, 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 bubonocle) after having made a small puncture with a common knife. The treatment of the wound will be accord- ing 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 canalus, until such time as an alteration in that circumstance will give us leave to cicatrize with safety.

Of Encysted Tumours.

These tumours borrow their names from a cyst or bag, in which they are contained; and are farther distinguished by the nature of their contents: If the matter forming them resembles milk-curds, the tumour is called atheroma; if it be like honey, melicoris; and if composed of fat, or a fatty substance, fleatoma. The two first are not readily dis- tinguished from one another, but their difference from the fleatoma is easily learnt by their softness and fluctuation. These tumours appear in every part of the body, and in places where there are no glands.

The fleatoma is never painful until by its weight 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 fleatoma is irregular in its surface, with emi- nencies and depressions, it is fleshy; whereas the fat one has for the most part a uniform smooth outside. The operation for the fleatoma will be understood by the description of that for the schirrus.

The atheroma is much more common than the melicoris; at least, if all encysted tumours with matter not curdled, may, in compliance with custom, be called so: There are more frequent, and grow larger than those where the matter is curdled, being often attendant on scrophulous indispositions, which makes them more difficult of cure.

The cysts of these tumours, with the skin covering them, after a certain period of growth, resisting any further enlarge- ment, 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 pippen, 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 por- tion 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 meth- od than destroying it afterwards with echaroticks. This rule is to be observed, when the cyst runs so deep amongst the interstices of the muscles, as to make it impossible to re- move the whole of it, where, if we cut off a great quantity, the rest usually comes away in floughs and matter.

The ganglion of the tendon is an encysted tumour of the melicoris kind, but its fluid is generally like the white of an egg; when it is small, it sometimes disperses itself; pressure and sudden blows do also remove 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 carpale, 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 carpale.

The dressing in these cases does not at all differ from the general methods of treating wounds.

Of the Amputation of the Cancered and Scirrhus Breast.

The success of this operation is exceedingly precarious, from the great disposition there is in the constitution, after an amputation, to form a new cancer in the wound, or some other part of the body. 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 slippery appearance 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 varicose, at last ulcerates.

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 scirrhus tumours which appear about the lower jaw, are, generally speaking, serpulous 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 imposthume again after healing, it is for want of a good bottom, which may sometimes be procured by destroying their bad surface with a cautery. Besides these, there is another species of scirrhus in the neck, 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 moveability, want of pain, the laxness of the skin covering it, the small degree of pressure it makes on the oesophagus 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 feton may be made filulous; 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.

Of the Operation of the Trepan.

The operation of the trepan, is the making one or more orifices through the skull, to admit an instrument for raising any pieces of bone that by violence are beaten inwards upon the brain, or to give issue to blood or matter lodged in any part within the cranium.

Fractures of the skull are at all times very dangerous; not in consequence of the injury done to the cranium itself, but as the brain becomes affected either from the pressure of the fractured bone, or that of the extravasated blood and matter. If then the symptoms excited by a fracture do sometimes follow from a mere extravasation of blood, as is the case when the cranium is not beaten inwards, it must likewise happen that a rupture of the vessels of this part, without a fracture, will also occasion the same disorders: For this reason, the operation may take place where the skull is not much offended, but only the vessels of the dura mater, the pia mater, or the brain.

When the cranium is beaten inward, without any fracture, it is called a depression; when very much broken, a fracture; or if broken and beat in also, a fracture with depression; if it is only cracked without depression, though properly a fracture, it is called a fissure; if none of these disorders appear, where there is a suspicion of them, the symptoms are imputed to a concussion of the brain. These are the four distinctions in use, and which fully comprehend all the others.

The depression of the cranium without a fracture can but seldom occur, and then it happens to children whose bones are more pliable and soft than those of adults.

In blows of the cranium, requiring the use of the trepan, the marks of a fracture are generally very evident, since the scalp is often lacerated so much, as to expose it to our sight: But if the wound of the scalp be so small, as only to admit a probe, we must judge then by the feel of the surface of the bone, using the caution of not mistaking a fracture for a fracture.

If there be no wound of the scalp, you must press about the the head with your fingers, till the patient complains of some particular part, which in all likelihood is the place affected, and, if the scalp there be separated from the cranium, is almost infallibly so. The symptoms of a fracture, are, a bleeding at the ears and nose, a loss of sense, vomiting, drowsiness, delirium, incontinence of urine and excrement; but what is most to be depended upon, is a depression of the bone, or a roughness on its outside; for all the other complaints not only happen to concussions, which do well without the application of a trepan, but likewise there are fractures not attended with any of them, or at least in a slight degree; so that these symptoms alone, without examination of the part affected, are but an uncertain rule to go by.

In concussions without a fracture, that produce the symptoms here laid down, and do well afterwards, the vessels of the brain and membranes are only inflamed and dilated; or if they are ruptured, they absorb the extravasated blood again; on which account, nature should be assisted by plentiful bleedings, clysters, and other evacuations, and so in all fractures where the patient is not trepanned immediately; however, although people with violent concussions do sometimes recover, it is very seldom, that there can be no pretence, when they happen, for neglecting the trepan, but not being able to learn in what part the concussion is.

Writers dispute very much about the possibility of the central fissure, or a fissure occasioned on the part of the head opposite to that on which the blow is given, or where the inner table is fractured while the outer one remains entire; but there are histories of cases, which, if fairly stated, make it unquestionable; and this is most certain, that if the complaint be at a distance from where the blow was received, there can be no danger in scalping, and applying the trepan to that part where the pain is.

When we are assured of a fracture or depression, it is always advisable to trepan as soon as possible, in order to prevent the spreading of the abscesses, which seldom fails to follow upon the rupture of the vessels of the brain and membranes, and for the most part in a few days.

The manner of treating a fracture of the cranium, will be according to the nature of the fracture itself, and the injury of the scalp. If the wound of the head be torn into angles, perhaps cutting off the lacerated flaps will make room for the saw; if the bone be broken into several pieces, the pieces may be taken away with the forceps; or if some of the skull be also depressed, the removal of the pieces will, without perforating, make way for the elevator to raise the depressed part; but if the fracture be not complicated with a wound of the scalp, or the wound be too small to admit of the operation, which seldom fails to be the case, then the fracture must be laid bare, by taking away a large piece of the scalp.

Before the application of the trepan, it is to be remembered there are certain places on the skull where it cannot be used with so much safety as on others; the whole length of the sagittal suture, down to the nose, is always mentioned as one where the perforation is dangerous, because of the spine of the os frontis, and the course of the superior longitudinal sinus under this part, which it is supposed would necessarily be wounded by the saw, and in consequence destroy the patient by the hemorrhage; but though a perforation may, contrary to the general opinion, be made over the sinus without offending it, and, even if it was wounded, the effusion of blood would not in all probability be mortal; yet at best it would be very troublesome; and since we are not straitened in that part of the cranium for room, it is advisable to forbear operating in this place. The bony sinuses of the os frontis forbid the use of the trepan near the orbits of the eyes; therefore, if it should be desired near those cavities, the surgeon must be careful to perforate either above, or on one side of the fracture; for sawing below it will only lead into the sinus, and answer no purpose in the design either of giving a discharge to the matter from the brain, or an opportunity to elevate the depression; nay, perhaps leave an incurable fistula, if the patient escapes with life.

The os occipitis being very uneven, both in its internal and external surface, makes trepanning there almost impracticable; besides, the great sinuses run about so much of it, as hardly to afford space to perforate without danger of wounding them; but then it is so defended from injuries by its situation and strength, that fractures do not happen to it so often as to the other bones of the cranium; and when they do, for the most part they become too soon mortal, by affecting the cerebellum which it sustains, that the operation is seldom required in this case. Indeed the upper angle of this bone lies above the cerebellum, and, when fractured or depressed, is not attended with so immediate danger; but when this happens, the course of the longitudinal sinus down the middle of it, and the neighbourhood of the lateral sinuses beneath it, make it advisable to trepan at the lower part of the os parietale, or at least upon or just below the lambdoidal future, so that the perforation of the os occipitis can hardly ever be proper.

Though wounds in the cerebellum are always mortal, yet great portions of the cerebrum have been carried off, or destroyed, without any notable inconvenience.

The places then unfit to admit the saw, are the three described; that is, the sagittal suture; that part of the os frontis near the orbits of the eyes; and the os occipitis. But when a fracture happens in any other part above the ear, there is no objection to the operation. When there is only a small fissure without any depression or motion in the bone, the trepan may be applied on the fissure itself, which will more readily give vent to the blood or matter underneath, than if made at a distance. If the fissure be large, and the bone weakened or depressed, the trepan must be applied on one side of it, but so as to make it a part of the circumference of the sawed piece; if the fracture run upwards, it will be eligible always to perforate near its bottom, because the dependency of the orifice will give better issue to the matter, though the ill-grounded apprehension of the brain falling out there has made many eminent surgeons contradict this rule in their practice. If, by making one orifice, you cannot raise all the depressed part, you must make a second and a third, and continue doing so, till you have reduced the whole cranium even; there is frequently occasion to repeat it twice or thrice; and it has been done twelve times, nay oftener, with success; which shows the little danger there is, either in sawing the skull, or exposing the dura mater and brain, when the pressure is taken off. Indeed the mischief of laying the brain bare is so small, compared with a concussion of it, or an abscess from pent-up matter, that those fractures of the skull, where the bone is broken into splinters the whole extent of it, and can be taken away, much more readily do well, than a simple fissure only, where the abscess cannot discharge itself freely; for which. which reason, though the depressed fracture may be raised by the means of one orifice, yet, if it is of a considerable length, it will be almost absolutely necessary to make one or two more openings, for the convenience of discharge; since, for want of this, we see abscesses increase daily in their quantity of matter, and at the end of a few weeks carry off the patient.

In concussions of the brain without a fracture of the cranium, if the trepan be applied, and vast discharges ensue, it will be also convenient to make more perforations into the abscess and the neighbourhood of the abscess, the situation of which will be easily guessed by the direction of the stream of matter. And here it is to be observed, that abscesses which ensue from a concussion are generally more extensive and dangerous than those which accompany a fracture with depression: for in a fracture, the yielding of the bone destroys, in a great degree, the force of the striking body, and prevents any violent commotion of the brain; so that what the brain suffers results chiefly from the pressure of the incumbent bone, and the laceration of the vessels, near the fracture; whereas, when the cranium resists the shock, all, or great part of the cerebrum sustains the concussion, and is often impotumated or inflamed almost in its whole dimension.

The manner of trepanning is this: Having fixed your patient's head steady, either on the bolster of a bed, or by placing him in a low chair; with the pin of your saw, mark the center of the piece of bone to be taken out; then with the perforating trepan, make an orifice deep enough to receive the pin, which being fixed in it will prevent the saw from slipping; and thus you are to continue sawing, till the impression made will preserve the head-ends without the pin, when it is to be taken away, for fear of its wounding the brain before the saw has entered through the cranium, which it would do at last, because of its projection. In working through the bone, the teeth of the saw will begin to clog, by that time you arrive to the diploe; therefore a brush must be ready to clean it every now and then, and with a pointed probe you must clear away the dust in the circle of the trepanned bone, observing if it be deeper on one side than the other, to lean afterwards on that side where the impression is least, that the whole thickness may be sawed through at the same time. To do all this with less interruption, it will be proper to have two saws of exactly the same diameter, that an assistant may be brushing one while you operate with the other. We are advised to saw boldly till we come to the diploe, which, it is said, will always distinguish itself by the bloodiness. But, however, this is not a certain mark to go by: for though, where there is a diploe, it will manifest itself by its bloodiness, yet sometimes the skull is so very thin as not to admit of any; in which case, if an operator should push on his instrument in expectation of meeting with this substance, he would unwarily wound the brain. This is not very often the case; but, however, often enough to put a man on his guard, and make him inquire whether the bone be loose after a little sawing, which is the only rule we go by when we have passed through the diploe, and may as well be attended to before coming at it, without any considerable loss of time. When it is quite sawed through, and lies loose, it may be taken away with the forceps contrived for that use; and if the lower edges of the orifice, next to the dura mater, are splintered, they may be scraped smooth with a lenticular.

These are the chief processes of the operation of the trepan. The only thing remaining to be done, is, with an elevator introduced at the orifice, to raise the depression, or broken splinters, if they cannot otherwise be laid hold of, and to draw out the grumous blood, or any other extraneous body. If the dura mater be not wounded or torn, an incision must be made through it, to give way to the blood or matter, which almost certainly lie underneath it, if the symptoms have been bad, and none has been discharged from between the cranium and dura mater: Though it has been lately observed that an abscess will sometimes be formed in the substance of the brain; and therefore, if the puncture of the dura mater does not procure an evacuation of the matter, and the symptoms of a suppuration are still urgent, it will be advisable to make a small incision with a lancet into the brain itself.

We have used the word trepan all along, for the sake of being better understood; but the instrument here recommended is a trephine; the advantages of which, as also that of a cylindrical saw, or one nearly cylindrical, are described in the explanation of the copper-plate.

With regard to the dressings of these wounds, it is very certain, that as the greatest part of the evil proceeds from the quantity and pressure of the matter, whatever approaches towards the nature of a tent, and increases its quantity and pressure by locking it up, must be pernicious. Therefore the use of all liniments whatever should be excluded. The hasty application too of spirits of wine, which is so commonly advised, cannot be proper; as they are not only unfit for inflammations in general, but also crisp up the vessels of the dura mater and brain, and, stopping the suppuration, sometimes produce gangrene. Since then a close application is inconvenient, and, whatever good there may be in topical medicines, it cannot for the most part be communicated to the abscess, by reason of its extent beyond the orifice, the best remedy will be dry lint only, which must be laid on loosely to give vent to the matter, and be repeated twice a day till the discharge is lessened, when once in twenty-four hours will be sufficient to the finishing of the cure, which will be something retarded by the exfoliations that sometimes follow this operation. The patient afterwards may wear a plate of tin upon the face, to defend it from blows or any accidental injury.

EXPLANATION of Fig. 1. Plate CLVIII.

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 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.

Explanations of Fig. 2, Plate CLVIII.

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 butt, 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.

Of the Cataract.

The cataract, called by the Latins suffusio, is a disease of the crystalline humour, rendering the whole body of it opake, 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 cataracts adhere 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 head-ach, 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 fit 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, bleeding and other gentle evacuations are found absolutely necessary.

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 been considered as a species of blindness not to be relieved: but Mr Chefsden 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, infuse 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.

EXPLANATION OF Fig. 3. Plate CLVIII.

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 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.

Of the 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; but this is only the first and mildest stage of the disease. In the next, there is a mucus resembling matter, and afterwards matter itself discharged with the tears from the puncta lachrymalia, and sometimes from an orifice broken through the skin between the nose and angle of the eye. The last and worst degree of it is, when the matter of the abscess, by its long continuance, has not only corroded the neighbouring soft parts, but also affected the subjacent bone.

Monsieur Anell, a French surgeon, recommends in the recent fistula, to pass a small probe through one of the puncta lachrymalia into the sacculus and nose, in order to break the concretions which were supposed to make the obstruction, and with a small pipe and syringe to throw an injection through the other, in order to wash them away.

The manner of operating in those cases where perforation is not required, is this: Supposing the abscess not broken, choose a time when it is most turgid with matter; and to this end, you may shut the patient's eye the day before, and lay little slips of plaster upon one another across the lids, from about the puncta lachrymalia to the internal angle; which compressing their channels, and preventing the flux of the matter that way, will heap it up in the bag, and indicate more certainly the place to be cut. If the abscess is already open, the orifice and probe will inform you where to enlarge: then placing the patient in a seat of convenient height for the management of your hand; with a small incision-knife dilate from the upper part of the bag, down to the edge of the orbit, without any regard to the tendon of the orbicularis muscle, or fear of wounding the blood-vessels; though if you see the vessels, it is proper to shun them. The length of this incision, will be near four tenths of an inch. It has been advised, in opening the bag, to introduce a small probe through one of the puncta into its cavity, to prevent wounding the posterior part of it. But this excess of care may be more troublesome than useful; since, in so large a vessel, a very small share of dexterity is sufficient to avoid the mistake. In making this incision, care must be had, not to cut too near the joining of the eye-lids, because of the deformity of the succeeding scar; though the clear eye or uneven, contraction of the skin in that part, after the operation, is generally owing to the use of the cautery, and not to the wound of the tendon of the orbicularis muscle; for this last is necessarily from its situation always cut through, but without any inconvenience, because of the firm cicatrix afterwards that fixes it strongly to the bone.

When the bag is open, it is to be filled with dry lint, which the next day may be removed, and exchanged for a dosil dipped in a soft digestive medicine: this must be repeated every day once or twice, according to the quantity of the discharge; now and then, when the matter is not good, using the precipitate medicine, and from time to time a sponge-tent, to prevent the too sudden reunion of the upper part of the abscess. When the discharge begins to lessen, it will be proper to pass a small probe, a small bougie, or silver wire, through the nasal duct into the nose every time it is dreft, in order to dilate it a little, and make way for the tears and matter which by their drain will continue to keep it open. This method must be followed till the discharge is nearly over (which will be in a few weeks;) and then dressing superficially with dry lint, or any drying application, the wound will seldom fail of healing. After the cure, in order to prevent a relapse, it will be proper, for a few weeks, to wear the compressing instrument represented in the copperplate.

When the bone is bare, and the fistula requires perforation, the perforator is not to be carried down the ductus ad nasum, for fear of boring into the sinus maxillaris; but more internally towards the nose, which will bleed freely, if properly wounded. The wound afterwards should be dressed with dosils, in the manner above described, and the probe or silver wire be every day passed through the ductus ad nasum, left, after the cure of the abscess, it should still remain obstructed; and if, upon trial, the duct should be so filled up as not to admit the wire, it will be right to keep open the perforation into the nose with a small tent, till the discharge is almost quite ceased.

EXPLANATION OF Fig. 4. Plate CLVIII.

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 toward the nose is the tendon. 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 lacrymalia.

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 ribbon, by which it is fastened on the forehead: the button at the end of the screw is to be placed on the faccus lacrymalis, 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 plaiter 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.

Of Bronchotomy.

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 the 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.

Of the Extirpation of the Tonsils.

These glands sometimes grow so large and scirrhouss 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 bleeding, and sometimes too a mortal one; 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 fet 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. Chafelden'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 closetool, and have a crooked needle with a double ligature ready to pass through them, when by straining they are pushed out or 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 chocks the patient; the readiest cure is cutting off all but half an inch of it, which may be done at one trip with a pair of scissors (particularly curved for that purpose,) laying hold of it with a forceps, lest it should slip away.

Explanation of Fig. 5. Plate CLVIII.

A, The bent probe 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 scirrhus 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.

Of the Polypus.

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 spongiosae, 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 cells, 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 consistence, 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 consistence, 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 scirrhouss, adhering 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 oesophagus 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 thro' the puncta lacrymalia; and sometimes they grow 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 contract 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 supine two or three hours, which will bring it still farther 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 hacking, they have dropt 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 twisting 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 hemorrhage, which is an accident, that sometimes follows upon the operation, and seldom fails when the excretion is scirrhouss: 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 dipt in some flytack, will readily stop it.

After the extirpation, 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 nasty to bear.

Of the Hare Lip.

This disease 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 future. 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 it need not be advised to forbear the attempt: 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 doing it is this. You first with a knife separate the lip from the upper jaw, by dividing the frenulum between it and the gums; and if the dentes incisivi 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. For instance, if the hare lip had the shape a, Plate CLVIII. fig. 5 the incision of the edges must be continued in straight lines till they meet in the manner represented by b, ibid. 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 pins are made three fourths of their lengths of silver, and the other part towards the point of steel; the silver pin is not quite so offensive to a wound as a brass or steel one; but a steel point is necessary for their easier penetration, which indeed makes them pass so readily, that there is no need of any instrument to assist in pushing them through.

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 delist 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 frenulum 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.

Of the Wry Neck.

The 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 mastoides muscle only; as it can answer no purpose to set 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 thro' the skin and fat, something broader 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 re-uniting; 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.

Explanation of Fig. 6. Plate CLVIII.

A, The instrument called the probe razor to cut the mastoides muscle in the wry neck, and is sharp only about half its length at that end where the blade is broad.

B, The two pins with the twisted fixture, used in the hare-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.

Of the Aneurism.

This is a disease of the arteries, in which, either by a supernatural weakness of any part of them, they become excessively dilated; or by a wound through their coats, the blood is extravasated amongst the adjacent cavities. The first species of aneurism is incident to every part of the body, but does not often happen, except to the curvature of the aorta, which is subject to this disorder from the extraordinary impulse of the blood on that part: from the curvature, it runs upwards along the carotids or subclavians, generally increasing, till by its great diffusion it is ruptured, and the patient dies.

There are several histories given of aneurisms of the curvature of the aorta; in some of which, the vessel has been so excessively dilated, as to possess a great space of the upper part of the thorax; and the most curious circumstance to be gathered from them is, that the spot of the vessel which is weakest, and where the disease begins, generally gives way in such a manner to the force of the blood continually pushing it outwards, as to form a large pouch or cyst, with coats nearly as thick as those of the artery itself. However, the thickness of the coats of these cysts will last but to a certain period; for when the vessels of the coats can no longer conform to the extension, the circulation grows languid, the cyst becomes thinner at its apex, and soon after bursts.

The symptoms of this aneurism, are a strong pulsation against the sternum and ribs; every systole of the heart; and, when it extends above the sternum, a tumour with pulsation. Upon dissection, the ribs, sternum, and clavicle, are sometimes found carious, from the obstruction of the vessels of the periosteum, which are pressed by the tumour.

What we have spoken of hitherto, has been only the aneurism of the thorax from an internal disorder; aneurisms of the extremities, are for the most part owing to wounds, though when they happen of themselves, they differ very little from the description given of that in the thorax. The further symptoms of them are (besides pulsation) the tumour's being without discolouration of the skin; its subsiding when pressed by the hand, and immediately returning when the hand is taken away; though, if it be upon the point of bursting, the skin will grow inflamed, and the coagulated blood in the cyst will sometimes make the pulsation much less perceptible.

This species of aneurism may sometimes be supported a great number of years, if we resist its dilatation by proper bandage; but if we do not, there is danger of its bursting, and, if it be pretty large, of rotting the adjacent bones.

A sound artery wounded through part of its external coat would in all probability produce nearly the same appearances as where the whole coat is weakened from an internal indisposition; and this most likely is the case after bleeding in the arm, when it has not been immediately perceived that the artery was pricked, and the tumour has begun to form some days after the puncture; though the common appearance of an aneurism from the wound of a lancet, is a discharge of blood first through the orifice of the skin, and, upon being kept from bleeding outwardly, an insinuation of it among all the muscles as far as it can spread, in the shoulder and arm: here, the arm grows livid from the ecchymosis, and the blood coagulating to the consistence of flesh, prevents any sensible pulsation. The cyst which arises near the orifice of the artery is formed by the cellular capsule enveloping the vessels of that part, and a portion of the aponeurosis of the biceps muscle, which admitting of some extravasated blood underneath it, become excessively thickened and expanded. These membranes must make the cyst, otherwise we could not, upon opening the tumour in the operation, operation, discover so readily the puncture; or if the coats of the artery made it, we could not separate it distinctly from the vessel, which would be always dilated above and below the cyst, as we see in other aneurysms.

There are some few instances of small aneurysms and punctures of the artery from bleeding, doing well by bandage; but they almost all require the operation at last, which is to be performed nearly in the same manner in every part; and supposing it in the bend of the arm, is to be done after the following method.

Having applied the tourniquet near the shoulder, and laid the arm in a convenient situation, make an incision on the inside of the biceps muscle, above and below the elbow a considerable length, which, being in the course of the artery, will discover it as soon as you have taken away the coagulated blood, which must be all removed with the fingers, the wound being dilated sufficiently for that purpose. If the orifice does not readily appear, let the tourniquet be loosened, and the effusion of blood will direct you to it; then carefully carrying a crooked needle with a ligature under it, tie the vessel just above the orifice; and pulling the needle again, make a second ligature below it, to prevent the return of the blood, and leave the intermediate piece of the vessel to slough away without dividing it. To avoid wounding or tying the nerve in making the ligature, the artery may be cleared away from it first, and held up with a hook; but should the nerve be tied with the artery, no great inconvenience would ensue from it. After the operation, the arm must be laid easy, on a pillow in bed, and the wound be treated in the common method, keeping it in that posture a fortnight or three weeks, especially if it should swell much, and not digest kindly.

In doing this operation, it will be proper to have the amputating instruments ready, lest it should be impracticable to tie the artery; and even after having tied it, the arm must be carefully watched; and in case of a mortification, it may be taken off.

Of Amputation.

A spreading mortification has been always esteemed so principal a cause for amputation, that it is a fashion with writers to treat of the nature of a gangrene previous to the description of this operation. However, this operation is spoken of as frequently unsuccessful; and in length of time, its want of success has been so unquestionably confirmed by repeated experiments, that some of the most eminent practitioners make that very circumstance an exception to the operation, which so few years since was the great inducement; and the maxim is, never to extirpate till the mortification is absolutely stopped, and even advanced in its separation.

Gangrenes may be produced two ways; either by indisposition of body, or by accident in a healthful state; for as the life of a part depends upon the circulation of its fluids, whatever shall make the circulation cease, will inevitably occasion a gangrene. Thus a mere compress preventing the course of the blood, as effectually causes a mortification as any indisposition in the fluids or vessels.

It frequently happens in old age, that the arteries of the lower extremities ossify; which destroying their elasticity, must in consequence produce a gangrene in the toes first, and afterwards in the limb nearly as high as where the ossification terminates; so that in mortifications arising from this cause, we at once see why amputation, during their increase, is of so little service, unless performed above the ossification; but we have no way to judge where the ossification ends, but by the inference we make from the gangrene's stopping: Hence we may learn the propriety of our modern practice in this case.

If by any accident the limb has been injured to that violent degree as to begin to mortify, it will be no more fit to operate here till it stops, than in the other instance; because all parts that are mortified have had the disposition to become so, before the effect is produced; and cutting off a limb, half an inch above the absolute dead skin, is generally leaving a part behind, with the seeds of a mortification in it; so, unless we can be sure the vessels are not affected in the place of amputation, which will be hard to know but from the consequence, the operation will be useless.

Sometimes the fluids of the body are so vitiated, as to lose their proper nutritious qualities; and the limb becomes gangrened, not from any alteration in its vessels, but chiefly from its situation, which being at a great distance from the heart, will be more prone to feel the ill effects of bad blood than any other part, as the circulation is more languid in the extremities; and it seems not very improbable, that in some dispositions of the blood, a mortification may also be a kind of critical discharge. When therefore a gangrene arising from either of these causes, is running on, amputation above it will for the most part be useless, since it is only removing one degree of the effects of the bad juices, and leaving them in the same state to produce the like mischief in other parts. Thus we see, after amputations on this account, the gangrene sometimes falls on the bowels, or the other extremities; from which observation we may conclude it not safe to amputate, till the fluids are altered; and this alteration will presently discover itself by the stopping of the mortification.

Gunshot wounds, compound fractures, and all sudden accidents requiring amputation, are attended with the best success if immediately performed. Disorders of the joints, ulcers of long standing, and all scrophulous tumours, do sometimes return on other parts after the operation. When a leg is to be amputated, the manner of doing it is this.

Lay your patient on a table two feet six inches high, which is much better than a low seat, both for securing him steady, and giving yourself the advantage of operating without stooping, which is not only painful, but inconvenient in the other situation. While one of the assistants holds the leg, you must roll a slip of fine rag half an inch broad, three or four times round it, about four or five inches below the inferior extremity of the patella: This being pinned on, is to serve as a guide for the knife, which without it perhaps would not be directed so dexterously: The manner of rolling has always been perpendicular to the length of the leg; but having sometimes observed, that though the amputation at first be even, yet afterwards the gastrocnemius muscle contracting, draws back the inferior part of the stump more strongly than the other muscles can do the rest of it; in order to preserve the regularity of the cicatrix, allow for this excess of contraction, and make the circular incision in such a manner that the part of the wound wound which is on the calf of the leg is a little farther from the ham than that on the shin is from the middle of the patella.

In the mean time, one of your assistants must carry a strong ligature round the thigh, about three or four inches above the patella, which passing through a couple of slits in a square piece of leather, he must twist with a tourniquet, till the artery is sufficiently compressed, to prevent any great effusion of blood; and to do it more effectually, he may lay a bolster of tow or linen under the ligature, upon that part where the artery creeps. It will also be a little more easy to the patient, to carry a compass of linen three or four times double, round the thigh, on that part where the ligature is applied, in order to prevent it from cutting the skin.

The course of the blood being stopped, you must begin your incision just below the linen roller, on the under part of the limb, bringing your knife towards you, which at one sweep may cut more than the semicircle; then beginning your second wound on the upper part, it must be continued from the one extremity to the other of the first wound, making them but one line. These incisions must be made quite through the membrana adiposa, as far as the muscles; then taking off the linen roller, and an assistant drawing back the skin as far as it will go, you make your wound from the edges of it when drawn back, through the flesh to the bone, in the same manner as you did through the skin. Before you saw the bones, you must cut the ligament between them, with the point of your knife; and the assistant who holds the leg while it is sawing, must observe not to lift it upwards, which would clog the instrument; and at the same time, not to let it drop, lest the weight of the limb should fracture the bone, before it is quite sawed thro'.

In amputating below the knee, it is of advantage to stand on the inside of the leg; because the tibia and fibula lie in a position to be sawed at the same time, if the instrument be applied externally; whereas, if we lay it on the inside of the leg, the tibia will be divided first, and the fibula afterwards; which not only lengthens the operation, but is also apt to splinter the fibula when it is almost sawed thro', unless the assistant be very careful in supporting it.

When the leg is taken off, the next regard is to be had to the stopping the blood; which must be effectually done before the patient is put to bed, or there will be great danger of bleeding again, when the fever is excited, and the vessels of the stump dilated, both which happen a very little while after the operation. There is no method for this purpose to secure, as taking up the extremities of the vessels with a needle and ligature in the following manner. As soon as the amputation is performed, the assistant must loosen the tourniquet for a moment, upon which the orifices of the arteries will appear by the issue of the blood. The operator having then fixed his eye upon one of the largest vessels, passes a crooked needle through the flesh, a little more than a quarter of an inch above the orifice, and about the same depth, in such a direction as to make nearly one third of a circle round the vessel; then withdrawing the needle, he a second time passes it into the flesh and out again, in the same manner and about the same distance below the orifice of the vessel. By this means, the thread will almost encompass the vessel, and when it is tied (which should be done by the surgeon's knot) will necessarily inclose it within the striature. All the considerable arteries are to be taken up in the same manner; that is, the tourniquet is to be loosed in order to discover the vessel, and then the needle is to be passed round. This is a much better way than using the artery forceps, where the vessels are apt to slip away out of the ligature; and as to flytack applications, their want of safety is so well known, that the use of them, in hemorrhages from large vessels, is almost universally rejected; though it is thought by several surgeons who have experienced the virtue of agaric, that it will be found to be a more powerful astringent than any hitherto discovered.

It sometimes happens in a large stump, that ten or more vessels require tying; which done, you must apply loose dry lint to the wound; or in case the small vessels bleed plentifully, you may throw a handful of flour amongst the lint, which will contribute to the more effectual stopping up their orifices. Before you lay on the pledgit, you must bind the stump, and begin to roll from the lower part of the thigh down to the extremity of the stump. The use of this roller is to keep the skin forwards, which, notwithstanding the steps already taken to prevent its falling back, would in some measure do so, unless sustained in this manner. The dressing may be secured by the crofs cloth and gentle bandage; and the method of treating the wound may be learnt from what has been said with respect to recent incised wounds.

In amputating the thigh, the first incision is to be made a little more than two inches above the middle of the patella. After the operation, a roller should be carried round the body, and down the thigh, to support the skin and flesh; this is also the most proper bandage, as abcesses will sometimes form in the upper part of the thigh, which cannot discharge themselves conveniently with any other, it being almost impracticable to roll above the abcess, unless we begin from the body.

The amputation of the arm or cubit differs so little from the foregoing operations, that it will be but a repetition to describe it. However, it must be laid down as a rule, to preserve as much of the limb as possible, and, in all amputations of the upper limbs, to place your patient in a chair.

The amputation of the fingers and toes is better performed in their articulation, than by any of the other methods; for this purpose, a straight knife must be used, and the incision of the skin be made not exactly upon the joint, but a little towards the extremity of the fingers, that more of it may be preserved for the easier healing afterwards; it will also facilitate the separation in the joint, when you cut the finger from the metacarpal bone, to make two small longitudinal incisions on each side of it first. In these amputations, there is generally a vessel or two that require tying, and which often prove troublesome when the ligature is omitted.

It may happen that the bones of the toes, and part only of the metatarsal bones, are carious; in which case, the leg need not be cut off, but only so much of the foot as is disordered; a small spring-saw is better to divide with here, than a large one. When this operation is performed, the heel and remainder of the foot will be of great service, and the wound heal up safely.

Explanation of Fig. 7 Plate CLVIII.

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.

OF LUXATIONS.

A Bone is said to be luxated or dislocated, when it is moved out of its place or articulation, so as to impede its proper motion and office.

Luxation of the Nose.

It sometimes happens, that the bones of the nose are separated from each other, or distorted out of their natural places, by some violent blow or fall. When such an accident happens, it is several ways discovered: as, (1.) By the sight, when we behold the deformed position of the nose; or, (2.) By feeling; or lastly, (3.) By the ear, when perceive with what difficulty the patient draws his breath through his nostrils.

When this case happens, the patient is to be speedily placed in a high chair, that an assistant may stand behind and hold his head firm, in a proper posture: the surgeon is then to introduce with one hand, a thick probe, a goose-quill, or little stick shaped for the purpose, up the nostril internally, by which means the depressed parts of the nose may be thrust into their places: in the mean time he applies his other hand externally, to guide and direct the parts which are moved from within: this being done, there is scarce any thing else required but to let a bit of sticking plaster lie upon the nose at the same time.

Of a Dislocation of the Lower Jaw.

The lower jaw is indeed seldom luxated, because it is held so firm by strong ligaments and muscles, by whose assistance it is retained in two sinuses in the basis of the cranium: but when it is by accident forced out from thence, it may chance to be on one side only, or else on both, it being then thrust directly forwards: and this happens most frequently from opening the mouth too wide in yawning; though it has sometimes been occasioned by a violent blow or fall. If it be luxated on both sides, the chin will incline downward, and the jaw will be thrust very forward: but if only on one side, the chin will be inclined toward the opposite side; the elapsed little head of the jaw not being capable of dislocation but forward and inward; for the processes of the bones of the cranium prevent the jaw from being dislocated backwards.

The lower jaw is chiefly known to be luxated on one side, when the chin is distorted on the opposite side: for that part to which the chin inclines, is the sound; but that from whence it recedes, is the luxated one; the mouth in this case gapes wider than usual, so that the patient cannot shut it, nor eat with his teeth; the lower range of teeth being projected beyond, and on one side the upper: but when the jaw is luxated on both sides, then the mouth not only gapes wide and open, but the chin also hangs down, and is thrown directly forwards; so that the patient cannot shut his mouth, speak distinctly, or even swallow anything without much difficulty.

When the jaw is out only on one side, and the case recent, the cure is usually not so very difficult; but when both heads are dislocated, and not presently restored to their places, it always occasions the worst of symptoms, as pains, inflammations, convulsions, fevers, vomitings, and at length death itself.

When this kind of luxation happens, the patient is to be directly seated on a low stool, so that an assistant may hold his head firm back against his breast. Then the surgeon is to thrust his two thumbs as far back into the patient's mouth as he well can; but they are first wrapped round in a handkerchief, to prevent them from slipping or being hurt; and his other fingers are to be applied to the jaw externally: when he has got firm hold of the jaw, it is to be strongly pressed, first downwards, then backwards, and lastly upwards, but so as that they may be all done in one instant; by which means the elapsed heads of the jaw may be very easily shoved into their former cavities.

If the jaw be out on one side only, everything must be done in the same manner: but the luxated side of the jaw must be forced more strongly downward and backward than the sound one.

Of Luxations of the Head and Spine.

The luxations which happen in the spine and vertebrae of the back are generally imperfect ones. For it appears from an accurate consideration of the structure and articulation of these bones, that none of the vertebrae can be entirely displaced without being fractured, and also compressing or wounding the spinal marrow, which must produce danger of instant death. Even the imperfect luxations of these bones are very dangerous: which happen either between the two superior vertebrae of the neck and the head, or else between the rest of the vertebrae, when they are forced from each other.

Such as have a luxation between the head and upper vertebra, seldom escape being carried off by a speedy and sudden death: for in this case the tender medulla which joins immediately with the brain, and is lodged in the spine, the brain itself, and the nerves which arise beneath the occiput, are too much distended, compressed, or lacerated; the two condyloid processes of the occiput usually slip out of their glenoid sinus's in the first vertebra of the neck, when a person falls headlong from a high place, from off a ladder, from horseback, or when he receives a violent blow upon his neck: they dying very suddenly in this case, are vulgarly said to have broke their necks, though there is generally no more than a luxation: yet it sometimes happens that the vertebrae of the neck are really fractured. If life should remain after such a luxation, which very rarely happens, the patient's head is commonly distorted with his chin close down to his breast, so that he can neither swallow anything, nor speak, nor even move any part that is below his neck: therefore, if speedy assistance be not had, death ensues, from the compression or hurt of the medulla.

But to repulse this unwelcome messenger, the patient is to be immediately laid flat upon the ground or floor: then the surgeon kneeling down with his knees against the patient's shoulders, is to bring them together so as to contain the patient's neck between them: this done, he quickly lays hold of the patient's head with both his hands, and strongly pulling or extending it, he gently moves it from one side to the other; till he finds, by a noise, the natural posture of the neck, and the remission of the symptoms, that the dislocation is properly reduced: by this method the surgeon retains the patient firm between his knees, and per- performs the extension and reduction between his hands.

It will be proper, in order to prevent a tumor, and restore the stretched ligaments of the neck to their former vigour, to bathe it with ag. Hungar., fp. vin. camph. or some other strengthening spirit applied warm, as also compresses dipped in the same; the patient should bleed, and rest gently for some days, till the neck be found sufficiently strong and well.

With respect to the rest of the vertebrae of the back, they are seldom moved quite out of their places, unless they are fractured, they being retained, for the greatest part, by adhering to the adjacent ligaments and muscles; therefore the luxations which happen among them are usually imperfect; no more being displaced than their two upper or lower processes, and they often but on one side; and this happens sometimes to one of the spinal vertebrae, and sometimes to more. But it is here to be briefly observed, that it is usual to include among the number of luxated vertebrae, that which is found and firm, but intercepted by others which are not so; thus whenever the upper vertebrae of the loins from the last of the back, and lowermost vertebrae of the loins next the os sacrum, are luxated, we commonly say and reckon there are five vertebrae out of their places; when, strictly speaking, only the two outermost or the uppermost and lowermost of those vertebrae are disturbed, the three middle ones retaining their natural situation and connection.

The signs common to luxations in the spine dorsif are chiefly the following: the back itself is found to be crooked or unequal, after the external violence has been inflicted; the patient can neither stand nor walk, and his whole body seems to be paralytic; the parts which are beneath the luxated vertebrae are nearly without all sense and motion; the excrements and urine cannot be discharged, or else they are sometimes emitted involuntarily; the lower extremities grow dead by degrees; and, at length, death itself follows; but these symptoms vary in proportion to the degree of violence in the luxation.

Luxations of the spinal vertebrae are very difficult to reduce. The following seems to be the most suitable method of reducing luxations of the vertebrae: when the apophyses of the vertebrae are dislocated on both sides, the patient is to be laid leaning upon his belly over a cask, drum, or some other gibbous body; then two assistants are strongly to press down both the ends of the luxated spine, on each side; by which means the bones of the spine will be set free from each other, lifted or pushed up in the form of an arch, and so gradually extended. This done, the surgeon presses down the luxated vertebrae, and at the same time nimbly pushes the superior part of the body upwards; and by this means the luxated vertebrae are sometimes commodiously reduced into their right places; but, if success should not attend the first time, the method should be repeated two or three times more.

It seems proper, after the vertebrae are reduced, to bath the spine with fp. vin. or to lay on compresses dipped in fp. vin. camph. Afterwards the patient is to be laid in a soft and even bed; bleeding, and bathing the weak parts with strengthening spirits, are to be used as there may be occasion.

Of Luxations of the Os Coccyx, and Ribs.

The os coccyx may be thrust inwards by a violent fall or blow, and it is often pushed outwards in hard birth. When this happens, it is usually attended with violent pain and inflammation about the lower part of the spine, abscesses form in the intestinum rectum, and the faeces are constipated or suppressed. To discover the luxation of this bone the more readily, we have recourse to the use of our hands and eyes, as well as to the knowledge of the aforementioned symptoms; nor is the replacing this bone very difficult, if attempted by a careful and expert surgeon; for if it be thrust outwards, it must be depressed into its right place by the thumb, after which may be applied compresses dipped in warm wine, or its spirit, made broad above, and narrow below, to fill up the posterior sinus of the bones; and these may be held on by the T bandage; but that part of this bandage which comes between the thighs should be slit, and placed so that the patient may go to stool without undoing the bandage, and to prevent the bone from being by that means displaced again.

When the os coccyx happens to be luxated inwards, the first finger is to be introduced into the anus. After it has had its nail cut and been dipped in oil, it must be thrust as far as possible, that it may the more readily drive out the depressed bone; the other fingers being applied externally, are to conduct the bone into its right posture: when this has been done, it will be proper for the patient to rest some time upon the bed; and when he sits up, it should be in a chair with a hole in its bottom, lest the affected part should be otherwise compressed or disturbed.

The ribs are indeed sometimes, though but seldom, dislocated; for upon the assault of some external violence, it is not uncommon for them to be displaced either upwards, downwards, inwards, or outwards. They cannot be easily luxated outwards, because prevented by the vertebral processes, and resisted by very thick and strong muscles; but when they are drove into the cavity of the thorax, they not only lacerate the pleura, but do generally great injury to the contained parts; in consequence whereof arise most sharp pains, inflammations, difficulty of breathing, cough, ulcers, immobility, and many other dangerous symptoms of the like nature.

When the rib is dislocated either upwards or downwards, in order to replace it conveniently, the patient is to be laid on his belly upon a table, and the surgeon must strive to reduce the luxated rib into its right place with his hands; or, the arm of the disordered side may be suspended over a gate or ladder, and while the ribs are thus stretched up from each other, the heads of such as are luxated may be pushed into their former seat.

But those luxations wherein the heads of the ribs are forced into the thorax, are generally found to be much the most difficult to reduce; since neither the hand, nor any other instrument, can be applied internally to direct the luxated heads of the ribs: in this case it seems proper to lay the patient on his belly over some gibbous or cylindric body, and to move the fore part of the rib inwards towards the back, shaking it sometimes; for thus generally the head of the luxated rib slips into its former place: but if this method of cure will avail nothing, and the deplorable condition of the patient requires speedy help, we have no remedy left but incision, and endeavouring to replace the luxated head of the rib with the fingers, pliers, or little hooks. In the mean time, where the symptoms are not very urgent, and the heads of the ribs but little displaced, it is adviseable neither to cut the flesh, nor violently force the ribs; be- cause there are several instances where the luxated ribs have retained their dislocated situations without any hurt; but above all, care must be taken to lay on a compress dipped in warm Sp. Vin. or Sp. Vin. Camp.

The clavicles may be dislocated either from the top of the sternum, or processus acromion of the scapula, by some external violence, as a fall, blow, the lifting some great weight, or the like.

Of a Luxation of the Humerus.

The humerus, from the length and laxity of its ligaments, the largeness of its motion, and the shallowness of the cavity in the scapula, into which it is articulated, is thereby rendered of all bones the most subject to be luxated. The head of this bone may often be dislocated under the arm-pit, sometimes forwards, sometimes backwards, and even below the scapula; but seldom perpendicularly downwards, and never directly upwards unless the acromion and coracoide processes of the scapula should chance to be fractured at the same time; besides, as long as the strong deltoid and bicipital muscles of the humerus remain entire, they greatly resist and keep down the humerus from being luxated upwards.

When the humerus is luxated downwards, (1.) There suddenly appears a cavity, and upon pressing with the fingers you will perceive a sinus; but under the arm there must be a tumour, because the head of the bone is thrust there. (2.) The processus acromion will seem to stick out further than usual, because of the adjacent sinus. (3.) The luxated arm will be longer than the other, and it cannot be lifted up towards the head without violent pain, and sometimes it cannot be lifted up at all, or even extended. But when the humerus is luxated forwards as well as downwards, there will be observed the same sinus under the processus acromion as before, and a tumour will appear from the head of the humerus projecting towards the breast, under the axilla: the arm itself also cannot be moved without exciting the most acute pain. Lastly, When the humerus is luxated backwards, the cubitus is thrown forwards towards the praecordia, and the head of the bone makes a protuberance in the shoulder; the arm itself cannot be bent nor extended, nor even pulled outwards from the breast, without occasioning the most violent pains; but no luxation of this limb is attended with such dangerous symptoms, as when it is dislocated forwards or backwards; because the luxated head of the humerus cannot avoid injuring the large arteries and nerves of the arm; in consequence of which, various symptoms will arise.

As soon therefore as the luxation is discovered in the humerus, the safest way will be to seat the patient on the floor, or on a low stool. Two strong assistants are to be placed on each side the patient: one of which should secure his body, and, if possible, the scapula too, that it may not give way to the extension; while the other lays firm hold of the luxated arm with both his hands, a little above the cubitus, gradually and strongly extending it. But before that extension be made, the surgeon himself should have a large napkin, of a sufficient length, tied at the ends, and hung about his neck so that the knot may be behind; but the other part of the napkin must hang over his breast; then the patient's arm must be put through the napkin up to the shoulder, and the surgeon at the same time lays hold of the head of the humerus with both his hands: this done, he orders the assistant to extend the limb sufficiently, and in the mean time he himself elevates the head of the patient's humerus by the napkin about his neck, directing it with his hands, till it slip into its former cavity in the scapula.

Of a Luxation of the Cubitus.

The cubitus, consisting of two bones, the ulna and the radius, is articulated by ginglymus. The connection of these bones is such, that the ulna or cubitus, as being the largest bone, and seated in the inferior part of the arm, does of itself perform the whole flexion and extension of the arm; yet it cannot perform that motion without carrying the radius along with it; so that the radius always follows the ulna in flexion and extension; but, on the other hand, the radius may be turned along with the hand both inward and outward, without at all moving or bending the ulna; as when the pronation and supination of the hand is made thereby. Both these bones of the cubitus are so articulated with the lower head of the os humeri, that large protuberances are received into deep cavities or grooves, and the whole invested and tailed with exceeding strong ligaments; so that notwithstanding the cubitus may be luxated in all four directions, outward, inward, forward, and backward, yet it is but seldom that it suffers a perfect or entire dislocation, unless the upper part of the ulna, called olecranon, be broken, or the ligaments of the cubitus much weakened, by some very great external violence.

If the cubitus be luxated backward, which is the most frequent of all others, then the arm becomes crooked and shorter, and it cannot be extended. In the inward part of the bend of the arm, the head of the humerus may be observed to stick out; in the back part of the same, the head of the ulna or olecranon will be protuberant, and between both bones will appear a sinus or cavity. But it very seldom happens that the cubitus is luxated forward, from the largeness of the olecranon: unless that be fractured at the same time. But if this should happen, the head of the humerus will stick out behind, and that of the cubitus before; and there will be a cavity more or less in proportion to the degree of the luxation. When the cubitus is luxated externally, the protuberance appears on the outside of the cubitus; and the contrary when luxated inwards. To conclude, unless the ligaments and muscles of the cubitus are quite broken in two, it is so far from being capable of suffering a perfect dislocation, that no more can happen to it than a subluxation, i.e., it can but recede but a very little way out of its right place: but whatever of this kind happens, the case may be very easily understood, by feeling and inspecting the part, if there be no tumor; but if the joint be much swollen, it is very difficult to be discovered.

Be the luxation, however, more or less, the patient must be speedily placed in a chair; and both parts of the limb, the humerus and the cubitus, must be extended in opposite directions by two stout assistants, till the muscles are found pretty tight, with a free space between the bones: then the luxated bone must be replaced with the surgeon's bare hands, or together with bandages; and that the processes may fall into their sinuses, the cubitus must be afterwards suddenly bent. But if the tendons and ligaments are so violently strained, that they can scarce perform their office; it will not be improper to anoint them well with emollient oils, ointments, or the fat of animals, or to apply emollient fomentations and cataplasm. As soon as the reduction has been by these means effected, the articulation must be bound up with a proper bandage, and the arm is to be afterwards suspended in a napkin or sling about the neck: but care must be taken, that the bandage be not suffered to be on too long, nor the arm to be kept all the time still, without some gentle motion.

On Luxations of the Hand, Carpus, Metacarpus, and Fingers.

Notwithstanding the hand is very accurately connected to the two preceding bones, and particularly to the radius, by means of the carpus and strong ligaments, yet it sometimes suffers luxation in all four directions; but it is generally not so easy to be luxated on either side, as forward or backward, because of the two processes of the radius and ulna, which guard it on each side. The hand is said to be luxated forwards or inwards, when it recedes from the muscles which bend the fingers; to be luxated backwards, when it departs from the muscles which extend the fingers: much also in the same manner, the hand is judged to be luxated outward, when the carpus makes a tumor near the thumb, and a cavity near the little finger; to be luxated inwards, when the contrary happens.

It seems to be the safest way immediately to reduce what is displaced; and that this may succeed the better, two things are to be chiefly regarded: (1.) That the luxated hand be sufficiently extended by two assistants, one of which is to lay hold of the hand, and the other of the humerus, pulling in opposite directions: (2.) That the part of the extended hand, where the sinus is, be placed on a table, or some other flat body, that whatever sticks up may be depressed: by which method the hand, in whatever part luxated, may be very readily reduced into its natural seat.

It also sometimes happens, that one or two of the eight little bones of the carpus are luxated and distorted from their natural seat by some external violence. When this happens, there will be perceived a tumor in one part, and a cavity in another, which may be also felt by the fingers; besides, violent pains will be felt by the patient. For the rest, as this kind of luxation is very easily discovered, partly by the sight, and partly also by feeling; so, when it is recent, it is almost as readily cured, letting the hand be extended in the manner we before proposed, and the dislocated bone be afterwards forced into its place.

The four small bones, which are found in the metacarpus or palm of the hand, may be sometimes luxated from the carpus itself, to which their upper parts are connected; which usually happens from some external violence. The two bones which are seated in the middle between the two other external ones, cannot be dislocated to either side; as the two external ones which sustain the first and little fingers cannot be luxated inwards, but are more easily driven outward: though each of them may be luxated on the fore or back part of the hand. But whichever of these happens, the particular disorder may be discovered and examined by feeling and inspecting, and the cure may be carried on in altogether the same method which we directed before.

Lastly, The bones of the fingers, to which we join those of the thumbs, are liable to luxation at each of their articulations, and that in several directions. But these accidents, if recent, are both very easy to discover and cure: for the ligaments being not very robust, the fat and muscles thin, and the sinuses of the articulations shallow, render the extension very easy, and the reduction of them into their former places may be done very readily. While one hand of the surgeon extends the finger, he strives with his other to replace the bones in their natural seat.

Of a Luxation of the Thigh.

Very rare is it that the head of the thigh-bone is displaced out of its acetabulum; though formerly it was supposed to be pretty frequent, physicians taking a fracture thereof for a luxation, the reason whereof may be taken, from the articulation itself: (1.) How very deep is the foramen, called by the ancients sinus coxae; and by the moderns acetabulum, into which the head of the thigh-bone is received. (2.) With what a broad concave cartilage is almost the whole head of that bone covered. (3.) How strong are the ligaments with which it is fastened. (4.) How greatly it is defended with exceeding stout and thick muscles. (5.) But how very brittle is the neck of this bone beyond any other part thereof: from all which it appears, that the neck must be far more frequently and easily broke, especially in adults, than its head dislocated: and though something of this kind may sometimes happen, so as to make the head of the thigh-bone slip out of its acetabulum; yet that generally proceeds more from internal than external causes: for we find it has been observed by very skilful physicians, that the ligaments of the thigh-bone, though very strong, may be by various causes, and particularly by a flux of humours, so relaxed and weakened, as to let the head of that bone slip spontaneously out of its acetabulum; so that it should seem no great wonder if the thigh should be sometimes luxated even while the patient lies in bed, without any external violence, so that when they rise, one leg appears longer or shorter than the other, and seems as if it were unhinged.

But this case does not happen so easy in robust adults, as in such as are more young and tender.

Whenever the said head of the thigh-bone is thrust out, it is almost always wholly displaced, so as to make a perfect luxation. The exact roundness of this head, with the great force of the circumjacent muscles, and the narrowness of the sides of the acetabulum, will not admit the bone to be dislocated a little way only; for as soon as the head of this bone is thrust up to the edge of the acetabulum, it must unavoidably either turn quite out, or else fall back again into its right place.

The thigh is usually luxated four ways; upward, downward, backward, and forward; but it is most frequently dislocated downwards and inwards, towards the large foramen in the os pubis: for besides that the cartilaginous defense on the lower part of the acetabulum is not so high as the rest, the ligamentum rotundum is found to give way more easily in that part than any other: and lastly, the adjacent muscles are found to be weakest in their resistance on this part, being insufficient to keep the head of this bone from slipping out; and then there is a certain eminence in this edge of the acetabulum, which keeps the head of the os femoris from falling back again into its right place: but if the head of this bone be displaced outwards, it generally slips upwards at the same time; it being scarce possible but the very strong muscles of the thigh must then draw the bone upwards, and then there is no eminence there, in the edge of the acetabulum, to resist the head of the bone in that passage; but should it at any time be luxated by an external ternal force, there must certainly be a rupture of the round ligament.

When the thigh is dislocated forwards and downwards, which is what usually happens, the leg hangs straddling outward, and is longer than the other; also the knee and foot turn outwards; the head of the bone itself will be felt near the lower part of the inguen and os pubis; sometimes there is a suppression of urine in this case; when some nerve, which communicates with the bladder, is violently compressed; in the buttock may be perceived a cavity, from the trochanter major and the rest of the bone being displaced; and if the thigh-bone be not timely replaced into its acetabulum, the whole limb withers shortly afterwards; and this is the reason why the patient can bear little or no stress upon that limb, but must always incline and throw the weight of his body upon the other.

But if the thigh-bone be displaced backwards, it is usually drawn upward also at the same time; hence there will be perceived a cavity behind the inguen; but upon the haunch or buttock, a tumour; because the head and trochanter of this bone will be thrust there. The tumour in the haunch being thrust upwards, the rest of the limb will become shorter than the other, and the foot will seem to turn inwards; the heel will not touch the ground, and so the person will seem to stand upon his toes; and lastly, the luxated limb may be bent with more ease than extended.

We do not without reason judge the thigh to be luxated, (1.) When we find the ligaments of the bone have been relaxed by some preceding congestion of humours, and when no external violence has been exerted upon it, especially in young patients. (2.) When neither the symptoms, pain, tumour, or inflammation follow; and lastly, (3.) When the whole limb may be bent and turned about at the acetabulum without any crushing of the bones, which is otherwise common in fractures. The contrary of these signs are strong indications that a fracture is present; more particularly if the foot in grown persons be shorter, from the injury of any external violence, and you hear a grating of the bones in moving the limb.

The luxated bone is always to be replaced in a method agreeable to the nature and direction of the dislocation. When it is displaced forwards and downwards, the patient is to be laid flat upon his back on a table; then a linen napkin or strong sling is to be made fast over the groin about the part affected, so that one end of the sling may come over the belly, and the other over the nates and back, to be both tied together in a knot upon the spine of the os ilium, and afterwards fastened to a hook fixed in some post, or held firm by some assistants; rather the first, if we use the polyphalon or pulley, to retain the patient's body firm from giving way in the extension; in like manner, at the bottom of the thigh, a little above the knee, there must be also fastened another napkin, or sling, with a compass between it and the thigh. Both the slings being drawn tight, the thigh is to be extended, not vehemently, but only so much as is sufficient to draw the bone out of its sinus, that it may be replaced into its acetabulum by the surgeon's hands; one hand is to press the head of the thigh-bone outward, while the other conducts the knee inwards; or, the reduction may be made by napkins, fastened round the extremities of the thigh like slings, much as in a luxation of the humerus; which will be more likely to succeed if the knee be at the same time pressed inwards by the hands. When the fore-recited means are not sufficient to make the extension, it will be necessary to make use of the polyphalon or pulley. As soon as the thigh is found to be sufficiently extended, the surgeon must take particular care to restore the luxated head of the thigh-bone, with his hands from the os pubis into its former seat.

Whenever the thigh is luxated backward, the patient is to be placed flat on a table, with his face downward; and the thigh is to be extended in directly the same manner, but a little more strongly than we just now proposed; and the reduction is to be effected afterwards by the surgeon's hands, an assistant in the mean time extending the limb, and turning it inwards; by this means the head of the thigh-bone generally slips very readily again into its acetabulum.

Of a Luxation of the Patella and Knee, or Tibia and Fibula.

The patella is usually luxated mostly on the internal or external side of the joint; but whenever the knee is perfectly luxated, the patella can scarce avoid being displaced at the same time, because of its strong connection to the thigh and tibia.

The reduction of a luxated patella is usually no very great difficulty, if the patient be laid flat on his back upon a table or bed, or if he be laid in that posture upon an even floor, so as that the leg may be pulled out straight by an assistant; for then the surgeon may firmly grasp the patella with his fingers, and afterwards press it strongly into its right place; which may be also effected if the patient stands upright; when this is done, there remains nothing but carefully to bind up the disordered part; and to let the patient rest quietly for some days, sometimes gently bending and extending his leg to prevent it from growing stiff, till the pains are gone off, and the limb has recovered its former strength.

A luxation of the knee is properly so, when the tibia recedes from under the femur. The leg is sometimes luxated from the basis of the thigh-bone, either on the out or inside, or backwards; seldom or never forwards, unless it be forced and driven very violently that way; because forwards, the patella is bound against the articulation, by the very strong tendons of the muscles which extend the leg; nor is it easy for the bones of the leg to be wholly displaced from that of the thigh, so as to make a perfect luxation; by reason of the great strength of the ligaments, and the two deep sinuses which receive the head of the thigh-bone.

As this kind of luxation is very easy to discover from the thin covering of the joint, with the tumors and cavities which follow; so, when it is discovered, it is as difficult to make a perfect cure thereof, without letting the bones join together; or leaving some stiffness in the knee; which first accident is usually called an anchylosis.

When the knee is but slightly luxated, the patient is to be seated on a bed, bench, or table, and one assistant holds the thigh firm above the knee, and the other extends the leg; but the surgeon in the mean time replaces the bones by his hands and slings if necessary, or pushes it by the application of his knee into its natural place.

Sometimes the fibula is separated by some external violence from the thigh-bone, and is then distorted either upward or downward; and this generally happens, when the foot has been luxated outward; therefore, when this is the case, there is need of extension. The bone is to be first restored restored to its natural place, and then properly bound up.

Of a Luxation of the Foot and Ankle.

The ankle may be sometimes luxated either in jumping, running, or walking; and that in all four directions, inward, outward, backward, and forward. Which of these ways it happens to be luxated, may be discovered by the particular posture of the joint.

The ankle is more or less difficult to reduce, in proportion to the violence of the cause by which it is luxated. But the most ready way of reducing a luxation of the ankle is to place the patient upon a bed, seat, or table, letting the leg and foot be extended in opposite directions by two assistants, while the surgeon strives to reduce the ankle with his hands and fingers. When the foot is by this means once replaced, it is proper to bind it up carefully, after it has been well bathed with oxycate and salt, advising the patient to keep to his bed a good while, till the disorder and its symptoms quite leave him.

SUS

SURANA, in botany, a genus of the decandria pentagynia clas. The calyx consists of six leaves; and the corolla of five petals; and there are five roundish seeds. There is but one species, a native of America.

URINAM, the capital of the Dutch settlements in Guiana, in South America: W. long. 56°, and N. lat. 6° 30'.