THAT part of medicine which treats of diseases to be cured or alleviated by the hand, by instruments, or by external applications.

CHAP. I. History of Surgery.

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

Concerning the surgery practiced among the Egyptians, Jews, and Asiatic nations, we know little or nothing. The Greeks were those from whom the art descended to us, though they confessedly received it from the eastern nations. The first Greek surgeons on record are Aesculapius and his sons Podalirius and Machaon. Aesculapius flourished about 50 years before the Trojan war; and his two sons distin-

guished themselves in that war both by their valour and skill in curing wounds. This indeed is the whole of the medical skill attributed to them by Homer; for in the plague which broke out in the Grecian camp, he does not mention their being at all consulted. Nay, what is still more strange, tho' he sometimes mentions his heroes having their bones broke, he never takes notice of their being reduced or cured by any other than supernatural means; as in the case of Aeneas, whose thigh-bone was broken by a stone cast at him by Diomed. The methods which these two famous surgeons used in curing the wounds of their fellow-soldiers seems to have been the extracting or cutting out the darts which inflicted them, and applying emollient fomentations or styptics to them when necessary: and to these they undoubtedly attributed much more virtue than they could possibly possess; as appears from the following lines, where Homer describes Eurypylus as wounded and under the hands of Patroclus, who would certainly practice according to the directions of the surgeons.

Patroclus cut the forkly steel away; Then in his hands a bitter root he bruised, The wound he wash'd, the styptic juice infused. The cleaving flesh that instant ceased to glow; The wound to torture, and the blood to flow. Till the days of Hippocrates we know very little of what was the practice of the Greek surgeons. From him, however, we learn, that the practice of blood-letting, cupping, and scarification, was known to them; also the use of warm and emollient fomentations, juices made with hot irons, perfumes, injections, fumigations, &c. Hippocrates also gives directions with regard to fractures, luxations, ulcers, fistulas. He directs the extension, reduction, bandages, and splints, proper to be used in fractures and luxations of different bones, with several machines to increase the extension when necessary. He directs the laxity and tightness of the bandages; the intervals for unloosing and binding them on again; the position and repose of the fractured member, and the proper regimen; and he mentions the time when a callus is usually formed. He treats also of fractures of the skull, and the method of applying the trepan. In his treatment of ulcers, he speaks of reducing fungous flesh by means of escharotics, some of which are alum, nitre, verdigris, quicklime, &c.

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

Surgery appears not to have existed in Rome, notwithstanding the warlike genius of the people, for more than 500 years. Archagathus, a Greek, was the first professor of that art in the city; and so frequently employed the knife, hot irons, and other cruel methods of cure, that he was branded with the opprobrious title of carnifex, and expelled the city, where no physician or surgeon of eminence again made his appearance for 180 years. At this time Aesculapius undertook the profession of medicine; but seems to have dealt little in surgery. Neither have we any thing of importance on that subject till the time of Celsus, who flourished during the reigns of Augustus and Tiberius.—In his surgery, all the improvements from Hippocrates to his own days are collected; the most minute and trifling dictates are not omitted. An eminent surgeon, of the moderns, emphatically exhorts every person in that profession “to keep Celsus in his hands by day and by night.” He describes the signs of a fractured skull, the method of examining for the fracture, of laying the skull bare by an incision in the form of the letter X, and afterwards of cutting away the angles, and of applying the trepan, with the signs of danger and of recovery. He observed, that sometimes, though very rarely, a fatal concussion of the brain might happen, the blood-vessels within the skull being burst, yet the bone remaining entire. After the operation of the trepan, sponges and cloths wetted with vinegar, and several other applications, were made to the head; and, throughout, severe abstinence was enjoined. In violent fractures of the ribs, he ordered venefication; low diet; to guard against all agitation of the mind, loud speaking, motion, and everything that might excite coughing or sneezing. Cloths wetted with wine, rotes and oil, and other applications, were laid over the fracture. The cure of fractures, in the upper and lower extremities, he said were nearly alike; that fractures differ in degree of violence and danger, in being simple or compound, that is, with or without a wound of the flesh, and in being near to the joint. He directs the extension of the member by assistants; the reduction, by the surgeon’s hands, of the fractured bones into their natural situation; and to bind the fractured part with bandages of different lengths, previously dipped in wine and oil; on the third day fresh bandages are to be applied, and the fractured member fomented with warm vapour, especially during the inflammation. Splints, if necessary, are to be applied, to retain the bones in a fixed position. The fractured arm is to be suspended in a broad sling hung round the neck; the fractured leg is to be inclosed in a kind of cage, reaching above the hip, and accommodated likewise with a support to the foot, and with straps at the side, to keep the leg steady; in the fractured thigh-bone, the cage is to extend from the top of the hip to the foot. He describes the method of treating compound fractures, and of removing small fragments of splinters of bones; and the manner of extracting darts. In luxations of the shoulder, he mentions several methods of giving force to the extension, and of replacing the dislocated bone. One method similar to that of Hippocrates was, to suspend the patient by the arm; the fore-part of the shoulder, at the same time, resting upon the top of a door, or any other such firm fulcrum. Another method was to lay the patient supine, some assistants retaining the body in a fixed position, and others extending the arm in the contrary direction; the surgeon, in the mean time, attempting, by his hands, forcibly to reduce the bone into its former place.

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

He is very minute in describing diseases of the eyes, ears, and teeth, and in prescribing a multitude of remedies and applications. In inflammation of the eyes, he enjoined abstinence and low diet, rest, and a dark room: if the inflammation was violent, with great pain, he ordered venefication, and a purgative; a small poultice of fine flour, saffron, and the white of an egg, to be laid to the forehead to suppress the flow of pituita; the foot inside of warm wheat bread dipped in wine, to be laid to the eye; poppy and roses were also added to his collyrums, and various ingredients too tedious to enumerate. In chronic watery defluxions, In the year 500 flourished Aëtius, in whose works we meet with many observations omitted by Celsus and Galen, particularly on the surgical operations, the diseases of women, the causes of difficult labours, and modes of delivery. He also takes notice of the dracunculus, or Guinea worm. Aëtius, however, is greatly excelled by Paulus Egineta, who flourished in 620; whose treatise on surgery is superior to that of all the other ancients. He directs how to extract darts; to perform the operation sometimes required in dangerous cases of rupture or hernia. He treats also of aneurism. Galen, Paulus, and all the ancients, speak only of one species of aneurism, and define it to be "a tumor arising from arterial blood extravasated from a ruptured artery." The aneurism from a dilatation of the artery is a discovery of the moderns. In violent inflammations of the throat, where immediate danger of suffocation was threatened, Paulus performed the operation of bronchotomy. In obstinate dislocations upon the eyes, he opened the jugular veins. He describes the manner of opening the arteries behind the ears in chronic pains of the head. He wrote also upon midwifery. Fabricius ab Aquapendente, a celebrated surgeon of the 16th century, has followed Celsus and Paulus as text books.

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

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

From the 11th century to the middle of the 14th, the history of surgery affords nothing remarkable except the importation of that nauseous disease the leprosy into Europe. Towards the end of the 15th century the venereal disease is said to have been imported from America by the first discoverers of that continent.

At the beginning of the 16th century, surgery was held in contempt in this island, and was practised indiscriminately by by barbers, farriers, and fow-gelders. Barbers and surgeons continued, for 200 years after, to be incorporated in one company both in London and Paris. In Holland and some parts of Germany, even at this day, barbers exercise the razor and lancet alternately.

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

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

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

Since the commencement of the present century, surgery has been enriched with many valuable and important improvements, of the greatest part of which we have availed ourselves in the course of the following treatise. But as it would far exceed the limits of a work of this nature to enumerate the names and writings of such authors as have lived within the above period, and besides, as it appears very unimportant to do so, we shall at once proceed to the next part of our subject.

**Chap. II. Of Wounds.**

**Sect. I. Of Simple Wounds.**

The first thing to be considered in the inspection of a wound is, whether it is likely to prove mortal or not. This knowledge can only be had from anatomy, by which the surgeon will be able to determine what parts are injured; and, from the offices which these parts are calculated to perform, whether the human frame can subsist under such injuries. It is not, however, easy for the most expert anatomist always to prognosticate the event with certainty; but this rule he ought always to lay down to himself, to draw the most favourable prognosis the case will bear, or even more than the rules of his art will allow. This is particularly incumbent on him in sea-engagements, where the sentence of death is executed as soon as pronounced, and the miserable patient is thrown alive into the sea, upon the surgeon's declaring his wound to be mortal. There are, besides, many instances on record, where wounds have healed, which the most skilful surgeons have deemed mortal. The following wounds may be reckoned mortal.

1. Those which penetrate the cavities of the heart, and wounds all those wounds of the viscera where the large blood-vessels which are opened; because their situation will not admit of pro-mortal per applications to restrain the flux of blood.

2. Those which obstruct or entirely cut off the passage of the nervous influence through the body. Such are wounds of the brain, cerebellum, medulla oblongata, and spinal marrow; though the brain is sometimes injured, and yet the patient recovers. Wounds likewise of the small blood-vessels within the brain are attended with great danger, from the effused fluids pressing upon the brain. Nor is there less danger where the nerves which tend to the heart are wounded, or entirely divided; for, after this, it is impossible for the heart to continue its motion.

3. All wounds which entirely deprive the animal of the faculty of breathing.

4. Those wounds which interrupt the course of the chyle to the heart; such are wounds of the receptacle of the chyle, thoracic duct, and larger lacteals, &c.

5. There are other wounds which prove fatal if neglected and left to nature: such are wounds of the larger external blood-vessels, which might be remedied by ligature.

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

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

If by a wound any considerable artery happens to be divided, the blood flows out with great velocity, and by series of starts; the patient soon becomes faint with loss of blood; nor does the hemorrhagy stop until he faints away altogether, when the ends of the divided vessel close by their natural contractility; and if as much vis viva still remains as is sufficient to renew the operations of life, he recovers after some time, and the wound heals up as usual. The part of the artery which is below the wound in the mean time becomes useless, and its sides collapse, so that all the inferior part of the limb would be deprived of blood, were it not that the small branches sent off from the artery above the wounded place become enlarged, and capable of carrying on the circulation. Nature also, after a wonderful manner, often produces new vessels from the superior extremity of the divided artery, by which the circulation is carried on as formerly. However, the consequences of such a profuse hemorrhagy may be very dangerous to the patient, by inducing extreme debility, polypous concretions in the heart and large vessels, or an universal dropy. This happens especially where the artery is partially divided; because then the vessel cannot contract in such a manner as to close the orifice: however, if the wound is but small, the blood gets into the cellular substance, swelling up the member to an extreme degree, forming what is called a diffused aneurism. Thus the hemorrhagy soon stops externally, but great mischief is apt to flow from the confinement of the extravasated blood, which is found to have the power of dissolving not only the fleshy parts, but also the bones themselves; and thus not only the use of the limb is entirely lost, but the patient is brought into great danger of his life, if proper assistance be not obtained in a short time.

Wounds of the ligaments, nerves, and tendons, are likewise attended with bad consequences. When a nerve is entirely divided, the pain is but trifling, though the consequences are often dangerous. If the nerve is large, all the parts to which it is distributed below the wound immediately lose the power of motion and sensation; nor is it uncommon, in such cases, for them to be seized with gangrene. This, however, takes place only when all or the greatest part of the nerves belonging to a particular part are divided. If the spinal marrow, for instance, be divided near the head, the parts below soon lose their action irrecoverably; or if the bundle of nerves passing out of the axilla be divided or tied, sensation in the greatest part of the arm below will probably be lost. But though a nerve should be divided, and a temporary palsy be produced, it may again reunite, and perform its former functions. If a nerve be wounded only, instead of being divided, the worst symptoms frequently ensue.

Wounds which penetrate the cavities of the thorax are always exceedingly dangerous, because there is scarce a possibility of all the viscera escaping unhurt. A wound is known to have penetrated the cavity of the thorax principally by the discharge of air from it at each inspiration of the patient, by an extreme difficulty of breathing, coughing up blood, &c. Such wounds, however, are not always mortal; the lungs have frequently been wounded, and yet the patient has recovered.—Wounds of the diaphragm are almost always mortal, either by inducing fatal convulsions immediately, or by the ascent of the stomach, which the pressure of the abdominal muscles forces up through the wound into the cavity of the thorax; of this Van Swieten gives several instances.—Even though the wound does not penetrate into the cavity of the thorax, the very worst symptoms may follow. For if the wound descends deeply among the muscles, and its orifice lies higher, the extravasated humours will be therein collected, stagnate, and corrupt in such a manner as to form various fistulas; and after having eroded the pleura, it may at length pass into the cavity of the thorax. The matter having once found a vent into this cavity, will be continually augmenting from the discharge of the sinus ulcer, and the lungs will at last suffer by the surrounding matter. If, in cases of wounds in the thorax, the ribs or sternum happen to become carious, the cure will be extremely tedious and difficult. Galen relates the case of a lad who received a blow upon his sternum in the field of exercise; it was first neglected, and afterwards badly healed; but, four months afterwards, matter appeared in the part which had received the blow. A physician made an incision into the part, and it was soon after cicatrizated; but in a short time a new collection of matter made its appearance, and upon a second incision the wound refused to heal. Galen found the sternum carious; and having cut off the diseased part, the pericardium itself was observed to be corroded, so that the heart could be seen quite naked; notwithstanding which, the wound was cured in no very long time.

There is sometimes difficulty in determining whether the wound has really penetrated into the thorax or the abdomen; for the former descends much farther towards the sides than at the middle. But as the lungs are almost always wounded when the cavity of the thorax is penetrated, the symptoms arising from thence can scarcely be mistaken.—Another symptom which frequently, though not always, attends wounds of the thorax, is an emphysema. This is occasioned by the air escaping from the wounded lungs, and inflating itself into the cellular substance; which being pervious to it over the whole body, the tumour passes from one part to another, till at last every part is inflated to a surprising degree. An instance is given in the Memoirs of the Royal Academy, of a tumour of this kind, which on the thorax was eleven inches thick, on the abdomen nine, on the neck six, and on the rest of the body four; the eyes were in a great measure thrust out of their orbits by the inflation of the cellular substance; and the patient died the fifth day. This was occasioned by a stab with a sword.

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

If a large wound penetrates the cavity of the abdomen, some of the viscera will certainly be protruded through it; or if the wound is but small, and closed up with fat so that none of the intestines can be protruded, we may know that the cavity of the abdomen is pierced, and probably some of the viscera wounded, by the acute pain and fever, paleness, anxiety, faintings, hiccough, cold sweats, and weakened pulse, all of which accompany injuries of the internal parts. The mischiefs which attend wounds of this kind proceed not only from the injury done to the viscera themselves, but from the extravasation of blood and the discharge of the contents of the intestines into the cavity of the abdomen; which, being of a very putrefactive nature, soon bring on the most violent disorders. Hence wounds of the abdominal viscera are very often mortal. This, however, is not always the case, for the small intestines have been totally divided, and yet the patient has recovered. Wounds both of the small and large intestines have healed spontaneously, even when they were of such magnitude that the contents of the intestine was freely discharged through the wound in it, and after part of the intestine itself has been protruded through the wound of the integuments.

When the mesentery is injured, the danger is extreme, on account of the numerous vessels and nerves situated there. Wounds of the liver, spleen, and pancreas, are also exceedingly dangerous, although there are some instances of the spleen being cut out of living animals without any considerable injury.

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

For the cure of wounds, it has been already observed, that the ancients imagined balsams, the juice of herbs, &c., to be a kind of specifics. In after-ages, and in countries where balsams are not easily to be procured, salves have been substituted in their place; and even at this day there are many who reckon a salve or ointment essentially necessary for healing the slightest cut. It is certain, however, that the cure of wounds cannot be effected, nay, not even forwarded in the least, by ointments, unless in particular cases or by accident. That power which the human frame has of repairing the injuries done to itself, which by physicians is called vis medicatrix naturae, is the sole agent in curing external injuries; and without this the most celebrated balsams would prove ineffectual. When a wound has been made with a sharp instrument, and is not extensive, if it be immediately cleaned, and all the extravasated blood sucked (a) out, it will almost always heal by the first intention in a very short time. Indeed the cures performed by this simple process are so surprising, that they would be incredible were we not assured of their reality by eye-witnesses. When this process is either neglected or proves unsucessful, there are three stages to be observed in the cure of a wound: the first, called digglion, takes place when the ends of the wounded vessels contract themselves, and pour out the liquor which is converted into pus. As soon as this appears, the second stage, in which the flesh begins to grow up, takes place; and as this proceeds, the edges of the wound acquire a fine bluish or pearl colour, which is that of the new skin beginning to cover the wound as far as the flesh has filled it up. This process continues, and the skin advances from all sides towards the centre, which is called the cicatrizing of the wound. For the promoting of each of these processes, several ointments were formerly much in vogue. But it is now found, that no ointment whatever is capable of promoting them; and that it is only necessary to keep the wound clean, and to prevent the air from having access to it. This, indeed, nature takes care to do, by covering the wound with a cake of coagulated blood; but if a wound of any considerable magnitude should be left entirely to nature, the pus would form below the crust of coagulated blood in such quantity, that it would most probably corrupt, and the wound degenerate into a corroding ulcer. It is necessary, therefore, to cleanse the wound frequently; and for this purpose it will be proper to apply a little ointment spread on soft scraped lint. For the first dressing, dry lint is usually applied, and ought to be allowed to remain for two or three days, till the pus is perfectly formed; after which the ointment may be applied as just now directed; and, in a healthy body, the wound will heal without further trouble. As to the ointment employed, it is almost indifferent what it be, provided it has no acid or stimulating ingredient in its composition.

But though, in general, wounds thus easily admit of a cure, there are several circumstances which require a different treatment, even in simple divisions of the fleshy parts, when neither the membranous nor tendinous parts are injured. These are, 1. Where the wound is large, and gapes very much, so that, if allowed to heal in the natural way, the patient might be greatly disfigured by the scar. It is proper to bring the lips of the wound near to each other, and to join them either by adhesive plaster or by future, as the wound is more superficial, or lies deeper. 2. When foreign bodies are lodged in the wound, as when a cut is given by glass, &c., it is necessary by all means to extract them, before the wound is dressed; for it will never heal until they are discharged. When these bodies are situated in such a manner as not to be capable of being extracted without lacerating the adjacent parts, which would occasion violent pain and other bad symptoms, it is necessary to enlarge the wound, so that these offending bodies may be easily removed. This treatment, however, is chiefly necessary in gunshot wounds, of which we shall treat in the next section. 3. When the wound is made in such a manner that it runs for some length below the skin, and the bottom is much lower than the orifice, the matter collected from all parts of the wound will be lodged in the bottom of it, where, corrupting by the heat, it will degenerate into a fittulous ulcer. To prevent this, we must use compresses, applied so that the bottom of the wound may suffer a more considerable pressure than the upper part of it. Thus the matter formed at the bottom will be gradually forced upwards, and that formed at the upper part will be incapable of descending by its weight; the divided parts, in the meantime, easily uniting when brought close together. Indeed, the power which nature has of uniting different parts of the human body is very surprising; for, according to authors of credit, even if a piece of flesh be totally cut out, and applied in a short time afterwards to the place from whence it was cut, the two will unite. That a part cut out of a living body does not entirely lose its vital power for some time, is evident from the modern practice of transplanting teeth; and from an experiment of Mr Hunter's at London, he put the tettle of a cock into the belly of a living hen, which adhered to the liver, and became connected to it by means of blood-vessels *. We have therefore the greatest reason to hope, that the divided parts of blood, the human body, when closely applied to each other, will cohere without leaving any sinus or cavity between them. However, if this method should fail, and matter still be collected in the depending part of the wound, it will be necessary to make an opening in that part in order to let it out; after which the wound may be cured in the common way. 4. During the course of the cure, it sometimes happens that the wound, instead of filling up with fleshy granulations of a florid colour, shoots up into a glairy-like substance which rises above the level of the surrounding skin, while

(a) See an account of the method of sucking wounds in Mr John Bell's Discourses on Wounds, Part I. Discourse v, p. 215. at the same time, instead of laudable pus, a thin ill-coloured and fetid ichor is discharged. In this case the lips of the wound lose their beautiful pearl colour, and become callous and white, nor does the cicatrizing of the wound at all advance. When this happens in a healthy patient, it generally proceeds from some improper management, especially the making use of too many emollient and relaxing medicines, an immoderate use of ballams and ointments. Frequently nothing more is requisite for taking down this fungus than dressing with dry lint; at other times dejective powders, such as calamine, tatty, calcined alum, &c. will be necessary; and sometimes red precipitate mercury must be used. This last, however, is apt to give great pain, if sprinkled in its dry state upon the wound; it is therefore most proper to grind it with some yellow balsamic ointment, which makes a much more gentle, though at the same time an efficacious echarotic. Touching the overgrown parts with blue vitriol is also found very effectual.

Hitherto we have considered the wounded patient as otherwise in a state of perfect health; but it must be observed, that a large wound is capable of disordering the system to a great degree, and inducing dangerous diseases which did not before exist.—If the patient is strong and vigorous, and the pain and inflammation of the wound great, a considerable degree of fever may arise, which it will be necessary to check by bleeding, low diet, and other parts of the antiphlogistic regimen, at the same that the inflamed lips of the wound and parts adjacent are to be treated with emollient fomentations or cataplasm till the pain and swelling abate.

On the other hand, it may happen, when the patient is of a weak and lax habit, that the vis vitae may not be sufficient to excite such an inflammation in the wound as is absolutely necessary for its cure. In this case, the edges of the wound look pale and soft; the wound itself ichorous and bloody, without any signs of flethy granulations; or if any new flesh shoots up, it is of the fungous glairy kind above-mentioned. To such wounds all external applications are vain; it is necessary to strengthen the patient by proper internal remedies, among which the bark has a principal place, until the wound begins to alter its appearance. In such persons, too, there is some danger of a hectic fever by the absorption of matter into the body when the wound is large; and this will take place during the course of the cure, even when the appearances have been at first as favourable as could be wished. This happens generally when the wound is large, and a great quantity of matter formed; for by this discharge the patient is weakened; so that the pus is no sooner formed, than it is by the absorbent vessels re-conveyed into the body, and feverish heats immediately affect the patient. For this the best remedy is to exhibit the bark copiously, at the same time supporting the patient by proper cordials and nourishing diet. Indeed, in general, it will be found, that, in the case of wounds of any considerable magnitude, a more full and nourishing regimen is required than the patient, even in health, has been accustomed to; for the discharge of pus alone, where the quantity is considerable, proves very debilitating, if the patient is not strengthened by proper diet. And it is constantly found, that the cure of such sores goes on much more easily when the patient is kept in his usual habit of body, than when his system is much emaciated by a very low allowance; and, for the same reason, purgatives, and whatever else tends to weaken the constitution, are improper in the cure of wounds.

Haemorrhages very frequently happen in wounds, either from a division of one large artery, or of a number of small ones. In this case, the first step to be taken by the surgeon is to effect a temporary stoppage of the blood by means of compression. He is then to tie up all the vessels in the manner to be afterwards described.

When the principal arteries of a wound have been tied, and a little blood continues to be discharged, but appears to come from sundry small vessels only, an experienced surgeon is induced to think, that the necessary compression of the bandages will in all probability effect a total stoppage of the hemorrhage. In a general oozing of a small quantity of blood from the whole surface of a sore, and when no particular vessel can be distinguished, there is a necessity for trifling to this remedy; but whenever an artery can be discovered, of whatever size it may be, it ought unquestionably to be secured by a ligature. But it frequently happens, that considerable quantities of blood are discharged, not from any particular vessel, but from all the small arteries over the surface of the sore. In wounds of great extent, particularly after the extirpation of cancerous breasts, and in other operations where extensive sores are left, this species of hemorrhage often proves very troublesome by being exceedingly difficult to suppress.

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

In constitutions of perfectly healthy, on the occurrence of wounds even of the most extensive nature, as soon as the larger arteries are secured, all the small vessels which have been divided are diminished, not only in their diameters, but also in their length; in consequence of which, they recede considerably within the surface of the surrounding parts. This cause of itself would probably, in the greatest number of instances, prove sufficient for restraining all loss of blood from the smaller arteries. Another very powerful agent however is provided by nature for producing the same effect. From the extremities of the divided vessels which at first discharged red blood only, there now, in their contracted state, oozes out a more thin, though viscid fluid, containing a great proportion of the coagulable parts of the blood; and this being equally dilutated over the surface of the wound, by its balsamic agglutinating powers has a very considerable influence in restraining all such hemorrhages.

When a tedious oozing occurs in a patient young and vigorous, and where the tone of the muscular fibres is evidently great, the most effectual means of putting a stop to the discharge is to relax the vascular system, either by opening a vein in some other part, or, what gives still more immediate relief, by untying the ligature on one of the principal arteries of the part, so as to allow it to bleed freely: those violent spasmodic twitches too, so frequent after operations on any of the extremities, when they do not depend on a nerve being included in the ligature with the artery, are in this manner more effectually relieved than by any other means.

By the same means the patient, from being in a febrile heat and much confused, soon becomes very tranquil: the violent pulsation of the heart and larger arteries abates, and the blood not being propelled with such impetuosity into the smaller vessels of the part, they are thereby left at more liberty to retract. In the mean time the patient ought to be kept exceedingly cool; wine and other cordials should be rigidly avoided; cold water, acidulated either with the mineral... ral or vegetable acids, ought to be the only drink; motion of every kind, particularly of the part affected, should be guarded against; and the wound being gently covered with soft charpie, ought to be tied up with a bandage so applied as to produce a moderate degree of pressure on the extremities of the divided parts.

As soon as a sufficient quantity of blood has been discharged, the wound being dressed, and the patient laid to rest, a dose of opium proportioned to the violence of the symptoms ought to be immediately exhibited. It ought to be remarked, however, that in all such circumstances, much larger doses of the remedy are necessary than in ordinary cases requiring the use of opiates. Small doses, instead of answering any good purpose, seem frequently rather to aggravate the various symptoms; so that whenever they are here had recourse to, they ought always to be given in quantities sufficient for the intended effect.

But hemorrhages of this nature happen much more frequently in relaxed enfeebled habits, where the solids have lost part of their natural firmness, and the fluids have acquired a morbid tenacity. In this case a moderate use of generous wine ought to be immediately prescribed; for nothing tends so much, in such circumstances, to restrain hemorrhages, as a well-directed use of proper cordials. By tending to invigorate and brace the solids, they enable the arterial system to give a due resistance to the contained fluids; and have also a considerable influence in restoring to the fluids that viscosity of texture, of which in all such instances we suppose them to be deprived.

A nourishing diet also becomes proper; the patient ought to be kept cool; and the mineral acids, from their known utility in every species of hemorrhage, ought also to be prescribed. Rest of body is here also proper; and opiates, when indicated either by pain or spasmodic affections of the muscles, ought never to be omitted.

Together with these remedies adapted to the general system, particular dressings, appropriated to the state of the parts to which they are to be applied, have been found very beneficial. In healthy constitutions, soon after the discharge of blood is over, the parts are covered with a viscid coagulable effusion from the mouths of the now retracted arteries; but in constitutions of an opposite nature, where the solids are much relaxed, the blood in general is found in such an attenuated state as to afford no secretion of this nature.

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

Applications of this kind, indeed, have been used with success in all such hemorrhages, with whatever habit of body they happen to be connected; but they have always proved more particularly serviceable in relaxed constitutions, attended with an attenuated state of the blood and an enfeebled muscular system. Alcohol, or any other astringent spirits, impregnated with as great a quantity as they can dissolve of mirth, or any other of the healing viscid gums, may be here used with freedom, though in constitutions of an opposite nature they ought never to be employed. The ballamum traumaticum of the shops, a remedy of this nature, has long been famous for its influence in such cases; but that indiscriminate use of this and similar applications which has long prevailed with some practitioners, has undoubtedly done much harm; for as they are all possessed of very stimulating powers, they of course tend to aggravate every symptom in wounds connected with a tense state of fibres, when much pain, and especially when spasmodic muscular affections prevail.

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

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

Wounds of the nerves, tendons, and ligaments, are attended with much more violent symptoms than those where which even considerable arteries are divided, and frequently result every method of cure proposed by the most skilful practitioners. In the simple process of blood-letting, it frequently happens that the tendinous expansion called the aponeurosis of the biceps muscle is wounded, or even the tendon of that muscle itself is punctured, by the point of the lancet; or sometimes a nerve which happens to lie in the neighbourhood is partially divided. Any one of these wounds, though they are the smallest we can well suppose to be given, are frequently very dangerous and difficult of cure. It sometimes immediately happens on the introduction of the lancet, that the patient complains of a most exquisite degree of pain; and when this occurs, we may rest assured that either a nerve or tendon has been wounded. On some occasions, by proper management, such as evacuating a considerable quantity of blood at the orifice newly made, by keeping the part at perfect rest, and preserving the patient in a cool a state as possible, the pain at first complained of will gradually abate, and at last go off entirely, without any bad consequence whatever. At other times, however, this pain which occurs instantaneously on the introduction of the lancet, instead of abating, begins soon to increase; a fullness, or small degree of swelling, takes place in the parts contiguous to the wound; the lips of the sore become somewhat hard and inflamed; and, in the course of 24 hours or so from the operation, a thin watery serum begins to be discharged at the orifice.

If, by the means employed, relief is not soon obtained, these symptoms generally continue in nearly the same state for two or perhaps three days longer. At this time the violent pain which at first took place becomes still more distressing; but instead of being sharp and acute as before, it is now attended with the sensation of a burning heat, which still goes on to increase, and proves, during the whole course of the ailment, a source of constant distress to the patient. The fullness and hardness in the lips of the wound begin to increase, and the swelling in the neighbouring parts gradually extends over the whole members. The parts at last become exceedingly tense and hard; an erysipelas-like inflammatory colour frequently appears over the whole member; the pulse by this time has generally become very hard and quick; the pain is now intense; the patient exceedingly restless; twitchings of the tendons occur... That a partial wound of a nerve will now and then produce very distressing symptoms, no practitioner will deny; but it has been attempted to be shown, that tendons are almost totally destitute of sensibility; and it has therefore been supposed, that their being wounded can never account for the various symptoms known to occur in such cases. There is great reason however to think, that in different instances the same train of symptoms have been induced by different causes; that in one instance a wounded nerve, and in others pricks of the tendons, have given rise to them, as we have already supposed.

In order to prevent as much as possible the consequent inflammation and other symptoms which usually ensue, a considerable quantity of blood should be immediately discharged from the wound at the orifice just made: the limb, for several days at least, ought to be kept in a state of perfect rest, care being at the same time taken to keep the muscles of the part in as relaxed a state as possible: the patient should be kept cool; on a low diet; and, if necessary, gentle laxatives ought to be administered.

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

The external applications usually employed in this state of the complaint are warm emollient fomentations and poultices. In similar affections of other parts no remedies with which we are acquainted would probably be found more successful; but in the complaint now under consideration, all such applications, instead of being productive of any advantage, rather do harm. The heat of the part is here one of the most distressing symptoms; and warm emollient applications rather tend to augment this source of uneasiness. The lips of the wound also are rendered still more hard, swollen, and of course more painful; and the swelling of the contiguous parts is increased. The best external remedies are cooling astringents, especially the tannin的应用. The parts chiefly affected being alternately covered over with cloths wet with a solution of saccharum tartarum, and pledgets spread with Goulard's cerate, are kept more cool and easy than by any other remedy hitherto used. The febrile symptoms which occur must at the same time be attended to, by keeping the patient cool, on a low diet, preserving a lax state of the bowels; and, if necessary, further quantities of blood ought to be evacuated.

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

It often happens, however, either from neglecting the wound or from improper treatment, that all these remedies are had recourse to without any advantage whatever: the fever, pain, and and swelling of the parts continuing, convulsive affections of the muscles at last occur, all tending to indicate the most imminent danger. In this situation of matters, if we have not immediate recourse to some effectual means, the patient will soon fall a victim to the disorder; and the only remedy from which much real advantage is to be expected, is a free and extensive division of the parts in which the orifice producing all the mischief was at first made. We know well, from the repeated experience of ages, that much more pain and distress of every kind is commonly produced by the partial division either of a nerve or of a tendon, than from any of these parts being at once cut entirely across.

Now the intention of the operation here recommended, is to produce a complete division of the nerve or tendon we suppose to have been wounded by the point of the lancet, and which we consider as the sole cause of all the subsequent distresses.

This operation being attended with a good deal of pain, and being put in practice for the removal of symptoms from which it is perhaps difficult to persuade the patient that much danger can occur, all the remedies we have mentioned should be first made trial of before it is proposed; but at the same time, care ought to be taken that the disorder is not allowed to proceed too far before we have recourse to it; for if the patient should be previously much weakened by the feverish symptoms having continued violent for any length of time, neither this remedy nor any other with which we are acquainted would probably have much influence. So soon therefore as the course already prescribed has been fairly tried, and is found to be inadequate to the effects expected from it, we ought immediately to have recourse to a free division of the parts chiefly affected.

Wherever a wounded or ruptured tendon may be situated, the limb should be placed in such a manner as will most readily admit of the retracted ends of the tendon being brought nearly together; and when in this situation, the muscles of the whole limb in which the injury has happened must be tied down with a roller, so as to prevent them from all kinds of exertion during the cure, endeavouring at the same time to keep the parts easy and relaxed. Thus in a wound or rupture of the tendon of the rectus muscle of the thigh, the patient's leg should be kept as much as possible stretched out during the cure, while the thigh should be in some degree bent, to relax the muscle itself as far as possible.

In similar affections of the tendo Achillis, the knee should be kept constantly bent to relax the muscles of the leg, and the foot should be stretched out to admit of the ends of the ruptured tendon being brought nearly into contact. A roller should be applied with a firmness quite sufficient for securing the muscles and tendons in this situation; but care must be taken to prevent it from impeding the circulation. With this view, fine soft flannel should be preferred either to linen or cotton; for being more elastic, it more readily yields to any swelling with which the limb may be attacked.

The late Dr Monro was the first who gave any accurate directions for the treatment of rupture in the large tendons; and it is perhaps given with more precision, from his having himself experienced the effects of this misfortune in the tendo Achillis.

He used a foot-sock or slipper, made of double quilted ticking, and left open at the toe; on the heel of which a strap went up above the calf of the leg. A strong piece of the same materials went round the calf, and was fastened with a lace. On the back part of this was a buckle, through which the strap of the foot-sock was passed, by which the calf could be brought down, and the foot extended at pleasure. Besides there was a piece of tin applied to the fore part of the leg, to prevent the foot from getting into any improper posture during sleep. After propelling to walk, he put on a shoe with a heel two inches deep; and it was not till the expiration of five months that he ventured to lay aside the tin plate; and he continued the use of the high-heeled shoe for two years. The whole apparatus is represented Plate CCCCXCII. fig. 124.

From this treatment a knowledge may be formed of the treatment necessary to be followed in the laceration of tendons of other parts of the body.

In wounds of the thorax, even though none of the viscera should be wounded, we may yet reasonably expect that a considerable quantity of blood will be extravasated; and this, if very large, must be evacuated if possible. However, it ought to be particularly observed, that this extravasated blood should not be discharged before we are assured that the wounded vessels have done bleeding. When the pulse appears sufficiently strong and equal, the extremities are warm, no hiccup or convulsion appears, and the patient's strength continues, we may then know that the internal hemorrhage has ceased, and that the means for discharging the blood may now be safely used. Matter, water, blood, &c. have sometimes vanished from the cavities of the thorax, and been afterwards discharged by sweat, urine, &c. Yet this but seldom happens; and if we were to trust to nature only in these cases, it is certain that many would perish from a destruction of the vital viscera by the extravasated and putrid blood, who by an artificial extraction of the same blood might have been saved.

Wounds of the abdomen must be closed as soon as possible, and then treated as simple wounds; only they ought to be dressed with great expedition as may be. A spare diet, with other parts of the antiphlogistic regimen, is here absolutely necessary. It sometimes happens, that, thro' a large wound of the abdominal integuments, the intestine comes out without being injured; yet, if it remains for any time exposed to the air, the case is commonly very dangerous. The most certain method, in all such cases, is to return the protruded part as soon as possible; for although writers in general formerly recommended warm fomentations, &c. to be previously applied, the latest authors upon this subject consider the most natural and proper fomentation to be that which is produced by the heat and moisture of the patient's belly, and that therefore the intestines, if no mortification has taken place, are to be cleared from extraneous matter, and immediately returned.

When the wound of the abdomen is large, the intestines easily prolapse, but are as easily returned. But when part of an intestine has been forced through a narrow wound, the disorder is much more dangerous. For the prolapsed intestine being distended by flatus, or the ingested aliment driven thither by the peristaltic motion, it will be inflamed, tumefied, and incapable of being returned through the stricture of the wound; whence a stoppage of the circulation and gangrene will soon follow. In this case the utmost care is to be taken to reduce the intestine to its natural size. When this cannot be accomplished by other means, some practitioners of great eminence have even advised the puncturing of the intestine in different places in order to discharge the flatus. This practice has also been recommended in an incarcerated hernia, but is exceedingly disapproved of by Mr Pott and later writers; and it seems to be very dubious whether any good can possibly arise from it. To puncture any part that is already inflamed, must undoubtedly add to the inflammation; and it is very improbable that... the discharge of flatus procured by the punctures would at all be a recompense for the bad consequences produced by the increased inflammation. The method of Celtus is much more eligible: It is to dilate the wound so as to reduce the intestine with ease. Sometimes part of the intestine is lost either by suppuration or gangrene. In this case, all that can be done is to strike a single stitch through the wounded bowel, and to fix it to the external wound by passing the suture also through the sides of the wound. The ends of the intestine may perhaps adhere; or at any rate the wound will continue to perform the office of an anus, out of which the faeces will continue to be discharged during life.

The directions given by some surgeons about inserting the upper end of the gut into the lower, and stitching them together, are perfectly impracticable, as Mr John Bell has shown in his important Discourses on Wounds*; and even if they were practicable, would certainly produce new mortification, which could not but be fatal.

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

Such extraordinary cures are to be imputed, according to the satisfactory explanation of Mr J. Bell, to the abdomen being perfectly full, and constantly subjected to strong pressure between the diaphragm and abdominal muscles; which keeps the parts contiguous to a wound closely applied to it, prevents the discharge of faeces or even of blood in some measure, and gives an opportunity for a very speedy adhesion between the parts.

In wounds of the head, where the cellular membrane only is affected, and the aponeurosis and pericranium untouched, phlebotomy, lenient purges, and the use of the common febrifuge medicines, particularly those of the neutral kind, generally remove all the threatening symptoms. When the inflammation is gone off, it leaves on the skin a yellowish tint and a dry scurf, which continue until perspiration takes them away; and upon the removal of the disease, the wound immediately recovers a healthy aspect, and soon heals without further trouble. But in the worst kind of these wounds, that is, where a small wound passes through the tela cellulosæ and aponeurosis to the pericranium, the patient will admit of more free evacuations by phlebotomy than in the former. In both, the use of warm fomentations is required; but an emollient cataplasm, which is generally forbid in the erysipelasous swellings, may in this latter case be used to great advantage. Where the symptoms are not very pressing, nor the habit very inflammable, this method will prove sufficient; but it sometimes happens that the scalp is so tense, the pain so great, and the symptomatic fever so high, that by waiting for the slow effect of such means the patient runs a risk from the continuance of the fever; or else the injured aponeurosis and pericranium, becoming flabby, produce an abscess, and render the case both tedious and troublesome. A division of the wounded part, by a simple incision down to the bone, about half an inch or an inch in length, will most commonly remove all the bad symptoms; and if it be done in time, will render every thing else unnecessary.

The wounds penetrating into the cavities of the joints do not seem at first alarming; yet, by exposure to the air, the lining membrane of such cavities acquire such a degree of sensibility as to endanger life when they are large. As soon therefore as any extraneous body, pushed into the joint, is removed, the admission of the external air is to be guarded against as much as possible. If the wound be not too large, this may be done by pulling the skin over the wound of the joint; and, to prevent its retraction, rather adhesive plaster, with proper bandaging, is to be used. But when inflammation is come on, repeated and copious blood-letting, together with fomentations, become necessary; and as the pain, in these cases, is apt to be violent, opiates must be administered; but should matter be formed in the cavity of the joint, free vent must be given to it.

Sect. II. Of contused and lacerated Wounds.

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

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

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

Sect. Gun-shot wounds can be considered in no other light than contused wounds. In those made by a musket or pistol ball, the most immediate considerations are, to extract the ball, or any other extraneous body which may have lodged in the wounded part; and to stop the hemorrhage, if there is an effusion of blood from the rupture of some considerable artery.

It is frequently necessary to enlarge the wound in order to extract the ball; and if it has gone quite through, (provided the situation of the part wounded will admit of its being done with safety), the wound is to be laid freely open through its whole length; by which means any extraneous body will be more readily removed, and the cure facilitated.

In order to get at the ball, or any other foreign matter, probing is to be used sparingly as possible; and this must evidently appear to any one who will only consider the nature of the symptoms attendant on penetrating wounds of the breast or belly, either from a bullet or sharp instrument; the thrusting in a probe to parts under such circumstances being unavoidably a fresh stab on every repetition of such practice. Wherever probing is necessary, the finger is to be preferred as the best and truest probe, where it can be used.

If a ball, or any other foreign body, happens to be lodged near the orifice, or can be perceived by the finger to lie under the skin, though at some distance from the mouth of the wound, we should cut upon it and take it out; but when it is sunk deep, and lies absolutely beyond the reach of the finger, it must appear evident, upon the least reflection, that thrusting, first a long probe in quest of the bullet, and then, as has been practised likewise, a longer pair of forceps, either with or without teeth, into a wound of that kind, though with a fort of certainty to extract it, must either contuse, or irritate and inflame, the parts to a great degree; and consequently do as much, or more mischief, than the ball did at first by forcing its passage such a length of way. And should they at the same time lay hold of any considerable artery or nerve along with the ball (which can scarce ever fail of being the case), what shocking consequences would attend such a proceeding! Nor would attempts of this sort be less injurious in case a bullet should happen to be lodged in the cavity of the belly or breast. Such attempts are the less necessary, because a great number of instances have occurred, where balls have been quietly lodged in several parts of the body, till after many years they have worked themselves a passage towards the surface, and were very easily extracted; and many where balls have been entirely left behind.

In case the wound be occasioned by a musket or pistol shot, and of course but small, it will be necessary to dilate it without delay, provided the nature of the part will admit of this with safety: for in wounds near a joint, or in very membranous or tendinous parts, the knife, as well as forceps, should be put under some restraint; nor should any more opening be made than what is absolutely requisite for the free discharge of the matter lodged within.

Where the wounded person has not suffered any great loss of blood, and this is generally the case, it will be advisable to open a vein immediately, and take from the arm a large quantity; and to repeat bleeding as circumstances may require, the second, and even the third day. Repeated bleedings in the beginning draw after them many advantages. They prevent a good deal of pain and inflammation, lessen any feverish assaults, forward the digestion, and seldom fail to obviate imposthumations, and a long train of complicated symptoms which are wont otherwise to interrupt the cure, miserably harass the poor patient, and too often endanger his life; and even where the feverish symptoms run high, and there is almost a certainty that matter is forming, bleeding, in that state, is very frequently of great advantage.

For the first 12 days it will be proper to observe a cool regimen, both in respect of the medicines that may be prescribed, and the diet requisite for the support of nature. It is absolutely necessary likewise that the body be constantly kept open. Unless, therefore, nature does this office of herself, a stool should be every day procured, either by emollient clysters, or some gentle laxative taken at the mouth; and whenever there is much pain in the wounded parts, immediate recourse must be had to opium.

As to external applications, whatever is of a hot spirituous nature is remarkably injurious on these occasions, and what no wounded part can in any degree bear. The wound may be dressed with pledgets of any emollient ointment; the whole being covered with a common poultice, or, in some cases, the preparations of lead may be used. An opiate should now be administered; and the part affected being placed in the easiest and most convenient posture, the patient should be laid to rest. The formation of matter, in every contused wound, is an object of the first importance; for, till this takes place, there is often reason to suspect that gangrene may happen. With a view to hasten suppuration, the warm poultices should be frequently renewed, and they should be continued till the tension and swelling, with which wounds of this kind are usually attended, be removed, and till the sore has acquired a red, healthy, granulating appearance, when it is to be treated like a common ulcer.

Gun-shot wounds are commonly covered from the beginning with deep floughs, and various remedies are recommended for removing them. Every appearance, however, of this kind with which they are attended proceeds entirely from contusion; and, excepting the injury be extensive, the flough is not often perceptible, or it is so thin as to come away along with the matter at the first or second dressing. Although emollient poultices be extremely useful, they ought to be no longer continued than till the effects already mentioned are produced; otherwise they will not only relax the parts, but also produce too copious a discharge of matter, which is sometimes attended with great danger. A too copious flow of matter may proceed from different causes; but in whatever way it may have been produced, the practice to be adopted must be nearly the same. Every collection which appears must have a free outlet, and the limb laid in that posture which will most readily admit of its running off. In such circumstances, nourishing diet and Peruvian bark in considerable quantities are highly useful. When the discharge continues copious, in spite of every effort to check it, detached pieces of bone or some extraneous matter are probably the cause. In such a situation nothing will lessen the quantity of matter till such substances be removed. The wound ought therefore again to be examined, and loose bodies removed. Pieces of cloth have been known to be removed by lemons, when that method was practicable, after every other method had failed. Opium likewise is frequently useful in checking an excessive discharge, when it happens to be kept up by irritation.

Although no considerable hemorrhage may happen at first in gun-shot wounds; yet after the floughs commonly produced upon such occasions have come off, some considerable arteries may be exposed, and then a dangerous hemorrhage may ensue. The hemorrhage is often preceded by a great heat in the injured parts, and with a throbbing pulsatory pain. At this period it may frequently be prevented... Poisoned Wounds.

vented by plentiful blood-letting, particularly local. But if the hemorrhage has fairly taken place, and from arteries of considerable size, nothing will do but the proper application of ligatures. As the discharge in these cases would often prove dangerous before the surgeon could be procured, the attendants should be furnished with a tourniquet, with directions to apply it, upon the first appearance of blood.

Till of late years the scarifying of gun-shot wounds was a practice which prevailed very universally among surgeons; and it was expected by this, that the sloughs with which wounds are sometimes covered would sooner separate, and that the cure would thereby be more readily performed. It is now, however, known, that this practice, instead of being useful, very generally does harm by increasing the inflammation. It should therefore be laid entirely aside. When a gun-shot wound cannot easily or safely be laid open from one end to the other, perhaps it may be proper to introduce a cord through the flatus. This, however, should not be attempted till the first or inflammatory state of the wound is over; but when a cord cannot be properly introduced, on account of the situation or direction of the wound, compression may prove equally useful here as in cases of punctured wounds.

Mortification happening after gun-shot wounds, is to be treated in the same manner as if it had arisen from any other cause, only bark is not to be promiscuously used; as, in plethoric habits, it may prove hurtful, though in debilitated relaxed habits it will be extremely useful; but even in such it should never be given while much pain and tension continue.

Sect. IV. Of Poisoned Wounds.

Poison may be introduced into the system various ways. The effects of the poison introduced by the stings of insects poisoned by the bite of mad animals. After inflammation has come on, the most effectual remedy is the washing the parts with cold water. The bite of a viper is not always dangerous; but as we can never judge with certainty whether the wound be poisoned or not, and as the poison of this animal acts very speedily upon the system, its bad effects ought to be prevented by every possible means. The injured part ought either to be cut out immediately, or destroyed with the actual or potential cautery.

Formerly suction was much employed, and frequently with success: it should not, however, prevent the removal of the part. After the part has been removed, we should endeavour to produce a plentiful suppuration. When the poison appears to have entered the system, the application of warm oil over the whole body has been extolled; and it has been said that advantage has been derived from the internal use of it. From some late observations, however, the efficacy of this remedy is much to be doubted. Perhaps a plentiful sweat, kept up for a considerable time, is the most certain method yet discovered. Small doses of volatile alkali frequently repeated is more to be depended on for producing this effect than any other remedy.

The bite of a mad animal occasions the most formidable poisoned wound known in this country. In these wounds hydrophobia indeed does not always ensue; but when it does, death is almost certainly the consequence. A variety of nostrums for preventing and curing this disease have been held forth to the public; but there is scarcely any well attested fact of any one of them proving useful. Nothing yet known can be depended upon but the immediate removal of the injured part, either with the scalpel or the actual or potential cautery; which, together with a plentiful suppuration, has, in different instances, appeared to answer the purpose effectually; at least, patients treated in this manner have escaped, while others bit at the same time by the same animal have suffered. The sooner the operation is performed, the more effectual it is likely to prove; but it ought not to be omitted, even though some time has elapsed from the time that the wound was inflicted; for there is reason to suppose that this poison does not enter the system so quickly as several others are observed to do. Sea-bathing has been much recommended in all ages as a preventive; but there are few well attested cases of its being attended with advantage. Many practitioners depend much on mercury; and as it can be used along with any other plan of treatment, it ought not to be neglected.

When wounds are poisoned by the application of matter from certain sores, as those of the venereal or cancerous kinds, or from any of the vegetable poisons, it is better to remove the part affected immediately, than to undergo a course of medicines generally slow and often doubtful in their operations.

The metallic poisons do not fall to be considered in this place; for however deleterious they may be when taken into the stomach, they seldom appear to be otherwise hurtful, when applied to wounds, than by irritating or corroding the parts with which they come in contact.

CHAP. III. Inflammation and its Consequences.

Sect. I. Of Inflammation and Suppuration.

Inflammation of any part is accompanied with increased heat, redness, and painful tension. For the remote and proximate causes of inflammation, together with the treatment of inflammatory diseases, see Phlegmatis, article Medicine. Inflammation is commonly divided into two species, the phlegmonic and erythematic. The first is distinguished by considerable swelling, throbbing pain, and circumciliated bright red colour. The second by superficial swelling, burning pain, dull red colour, apt to spread, disappearing when pressed, and quickly returning; the part affected is frequently covered with small vesicles. The consequences of inflammation are suppuration and gangrene, unless the inflammation be checked and terminated by resolution. That an inflammation will terminate in suppuration may be known from the length of time it has continued, from the remission of the pain and hardness, the greater elevation of the skin in the middle part, a change of colour from red to bluish or livid, a slight fever with shivering, and from a fluctuation of matter perceived on handling the part.

During the first stage of the inflammation, however, we ought, for the most part, to endeavour to resolve it, or prevent the suppuration. Yet some cases must be excepted. For instance, those inflammatory swellings which sometimes occur in fevers, or succeed to them, ought always to be brought to suppuration; and it might be very dangerous to attempt a resolution of them. In swellings of a ferulous nature, it is perhaps best to do nothing at all, either with a view to resolve or suppurate. Thus it might be dangerous to make use of repellent applications, at the same time that it is by no means advisable to promote their suppuration; the cure of such swellings, when opened, proving always very troublesome; while at the same time it is known, that such swellings may remain for a very long time without any risk to the patient. In the lues venerea, too, as we are possessed of a certain antidote for the disorder, it is best not to attempt the suppuration of any buboes which may appear; remedies should as seldom as possible be allowed to interfere with one another; and emollients should accordingly never be prescribed, but when the circumstances already mentioned, of irritation, tension, and pain, are so considerable as to render their application altogether necessary.

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

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

In slight cases of inflammation, a due perseverance of the several articles taken notice of will, in general, be found sufficient for every purpose. But when there is likewise a full, hard, or quick pulse, with other symptoms of fever, general blood-letting becomes necessary; the quantity of blood taken away being always to be determined by the violence of the disorder, and by the age and strength of the patient.

Evacuation, however, should never be carried to a greater height than what is merely necessary for moderating the febrile symptoms; for if suppuration should take place after the system is too much reduced, its progress is thereby rendered much more slow and uncertain, nor will the patient be able to bear the discharge that must ensue upon opening the abscess. The use of gentle laxatives, together with cooling diaphoretic medicines, are also attended with very good effects.

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

By a proper attention to the different circumstances taken notice of, in the course of three or four days, and sometimes in a shorter space of time, resolution of the tumor will in general begin to take place; at least before the end of that period it may, for the most part, be known how the disorder is to terminate. If the heat, pain, and other attending symptoms abate, and especially if the tumor begins to decrease, without the occurrence of any gangrenous appearances, we may then be almost certain that by a continuance of the same plan a total resolution will in time be effected.

But, on the contrary, if all the different symptoms rather increase; increase; and especially if the tumor turns larger, and somewhat soft, with an increase of throbbing pain; we may then with tolerable certainty conclude, that suppuration will take place; and should therefore immediately desist from such applications as were judged proper while a cure was thought practicable by resolution, and endeavour to assist nature as much as possible in the formation of pus, or what is called maturation of the tumor. For this purpose there is nothing better than to preserve a proper degree of heat in the parts. This is commonly done by the means of warm fomentations and cataplasm; and when these are regularly and frequently renewed, nothing, it is probable, could more effectually answer the purpose. But in the ordinary manner in which they are applied, by the cataplasm being renewed only once, or at most twice a day, they must always, it is imagined, do more harm than good. For so soon as the degree of heat they were at first possessed of is dissipated, the moisture kept up by them, with the consequent evaporation which ensues, must always render the part a great deal colder than if it had been merely wrapped in flannel without the use of any such application.

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

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

Roasted onions, garlic, and other acrid substances, are frequently made use of as additions to maturing cataplasm. When there is not a due degree of inflammation in the tumor, and when it appears probable that the suppuration would be quickened by having the inflammatory symptoms somewhat increased, the addition of such substances may then be of service; but when stimulants are necessary in such cases, a small proportion of strained galbanum, or of any of the warm gums, dissolved in the yolk of an egg, and added to the poultices, is a more certain form of applying them. Whenever the inflammation, however, takes place to a proper degree, such stimulating substances never can be necessary; and in many cases, it is apprehended, they may even do mischief.

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

Dry cupping, as it is termed, that is, cupping without the use of the scarificator, upon or as near as possible to the part affected, is frequently had recourse to with advantage in promoting the suppuration of tumors. It is only, however, in such as these last mentioned, where there seems to be a deficiency of inflammation, that it can ever either be necessary or useful; but in all tumors of a real indolent nature, and where there is still some probability of a suppurative inflammation, no remedy is more effectual.

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

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

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

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

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

In some cases, however, it is necessary to deviate from this general rule, and to open them a good deal sooner; particularly in all such critical abscesses as occur in malignant fevers. In like manner, in the plague, we are commonly advised to open such tumors, so soon as they are at all tolerably advanced, and not to wait till they are fully matured; as, from experience in these disorders, it is found to be of more consequence, for the removal of the original disease, to have a quick discharge of matter produced, than any harm the patient can ever suffer from having a swelling somewhat prematurely laid open.

In abscesses, also, situated on any of the joints, or upon either either of the large cavities of the breast and abdomen, and more especially when they seem to run deep, they should always be opened as soon as the least fluctuation of matter is discovered. For, when the resistance is on every side equal, they just as readily point inwardly as outwardly; and the consequence of a large abscess bursting into either of the large cavities, is well known most frequently to prove fatal. An instance of which, in the following case, with very little attention, might have been prevented. A surgeon of eminence, and of very extensive practice, was applied to by a young healthy-looking man, with a large abscess upon the left side of his chest. A fluctuation of a fluid was, upon prelure, very evidently discovered; and it was agreed, by other two practitioners who were present, that an opening should be made to give vent to the matter. But the operator, being much engaged in business, could not fix on an earlier period for doing it than the third day from the patient's applying to him; unluckily, however, the patient died suddenly in his bed the night before the abscess was to have been opened. On examining the body, the tumor had disappeared entirely, without any external opening being observable; and, on opening the thorax, it was found to have burst inwardly upon the lungs, and produced immediate suffocation.

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

There are three ways of opening an abscess so as to give an outlet to the matter; by cautery, by incision, or by the introduction of a feton. The first is more agreeable to timid patients, who are afraid of the pain of incision, but is attended with some inconveniences which render the method of incision much preferable. Cautery acts slowly, and produces a long continued pain; besides, no kind of cautery has yet been invented, the effects of which can be confined to a certain determinate extent; hence the patient is liable to suffer much unnecessary pain, as the cauteries commonly employed are either the lapis infernalis or lunar cautery. The abscess is to have a slip of adhesive plaster applied to it, with a slit cut in it of a size somewhat less than the opening is intended to be. This slit is to be filled with cautery reduced into a powder, and wetted to make it act more quickly. It is then to be covered over with a plaster, and the whole is secured with a firm compress and bandage. The time necessary for the cautery to make a sufficient opening will depend upon the thickness of the skin and strength of the cautery; but generally it requires several hours. When we find that an effusion is made, it is to be softened with any emollient ointment until it can be readily separated; after which, the matter is to be discharged, and the abscess treated as one opened by incision.

The method of opening abscesses by the knife is, to make an incision of such a size as to give free vent to the matter. The opening is to be made in the under part of the tumor, that the matter may pass readily out. It has been a practice among surgeons either to open a large abscess from end to end, or at least through two-thirds of its length; but from the bad consequences which often attend this method, the latest practitioners have thought it better merely to give a free discharge to the matter, without exposing the part to the action of the air.

The third method, viz. that by the feton, is now frequently employed. It has the advantage of being attended with little pain, emptying the abscess in a gradual manner, and completely preventing the access of the air, which, in the other two methods, is often attended with bad consequences; and it frequently performs a cure in a much shorter time.

There are various instruments for introducing the feton; it may even frequently be done by a lancet and common probe; but the instruments represented in Plate CCCCLXXXVII. fig. 1. and 2. are more frequently employed. One of these being threaded with glover's soft silk, is to be introduced through the upper part of the tumor; but if the blunt one (fig. 2.) be employed, it will be necessary to have the assistance of a lancet; the instrument is then to be brought out at the under part of the tumor, and in this way the matter will be allowed to run gradually off.

The usual mode of dressing an abscess the first time is with dry lint. In the course of dressing, it will be proper to have regard to the situation of the abscess, and as much as possible to make the patient favour the discharge by his ordinary posture: and to this end also, the discharge must be assisted by compress and bandage: the compress may be made of soft old linen, applied according to the nature of the part and the season of the year. The frequency of dressing will depend on the quantity of discharge: once in 24 hours is ordinarily sufficient; but sometimes twice, or perhaps three times, is necessary.

Sect. II. Of Gangrene.

The other consequence of inflammation is gangrene, which may terminate in mortification. When the colour of an inflamed part changes to a dark red, when blisters arise on it containing an ichorous fluid, we know that it has become gangrenous. When it becomes black, flaccid, and infusible, when it loses heat, and acquires a putrid smell, it has proceeded to complete mortification. A gangrene seldom affects those who enjoy a good habit of body, though, even in them, it may be brought on accidentally by whatever destroys the texture of a part; as constipation, long continued prelure, or whatever deprives a part of its nourishment. In like manner, cold, by putting a stop to the circulation, may produce gangrene, and frequently does so in cold climates. This comes on suddenly, without any pain or previous inflammation; and the patient himself is frequently insensible of it, till he is informed of his situation by some other person.

A defect in the circulation, in extreme old age, frequently occasions mortification in the extremities.

There are some instances of what is called dry gangrene, Dry gangrene, in which the parts continue totally mortified for a great length of time, without either turning very flaccid, or running into dissolution. But such cases never occur from inflammation; they happen commonly from the flow of blood to such parts being put a stop to by compression of one kind or another, as tumors, ligatures, or other similar causes, obstructing the principal arteries which used to supply them; which, when the stoppage of the circulation is complete, always occasions a very slow, tedious, mortification; and as the parts in such instances are no longer supplied with fresh quantities of fluids, while a considerable evaporation must still be going on, such a degree of humidity cannot therefore possibly occur as does in other cases of gangrene. So that species of the disorder has, perhaps, with propriety enough, been termed the dry gangrene.

There is another variety of the disease termed white gangrene; in which the parts supposed mortified do not turn black, but retain nearly their former colour, &c. Whether such a complaint, however, can with propriety be denominated gangrene or not, may properly be doubted: but as it is chiefly that species of the disorder which succeeds inflammation. Gangrene. mation that is here particularly treated of, and in which no such varieties are ever observed, it is not necessary to carry the inquiry farther.

The prognosis in every case of gangrene is doubtful at first; as, even in the slightest cases, the patient may suffer from the spreading of the disease; but slight cases, from external injuries, are more favourable than those which arise from internal causes, though no person can be considered safe till the diseased parts are separated, and even entirely cast off. When inflammation happens round a mortified part, more especially if pus be formed, we may pretty certainly pronounce that the mortified part will be thrown off.

When there is reason to suspect from the violence of the fever and great heat of the inflamed part, that it will terminate in gangrene, blood-letting, and whatever may have a tendency to moderate the inflammation, may check its progress. But as the patient, in such cases, is sometimes apt to sink afterwards, nothing more ought to be done than is merely necessary to moderate the present symptoms. If an inflamed surface put on a gangrenous appearance when the patient is weak, and the pulse low, we must have recourse to whatever may invigorate the system, viz. a nourishing diet, with the free use of wine. Peruvian bark likewise is to be given in as great quantities as the stomach of the patient will permit. When the stomach cannot bear enough in substance, which is the best form of exhibiting it, it may be given either in form of tincture or joined with aromatics. External applications, such as are of a stimulating nature, may likewise be useful.

In the case of gangrene arising from cold, the part must be immersed in very cold water, or rubbed with snow; for if anything warm be applied, or the patient brought near a fire, it certainly mortifies. If the whole body has become torpid with cold, the same practice must be followed; the very cold water should be afterwards changed for some that is a little warmer, and the patient gradually brought to a proper degree of heat. Rubbing with salt is sometimes found useful. If the whole body be benumbed, cordials are not to be administered too suddenly. A glass of cold wine should first be given, afterwards warm wine by itself, or with spices. If stronger cordials be required, ardent spirits may be employed. Notwithstanding the greatest attention, however, a mortification sometimes takes place, and in some instances very suddenly; as in the case of carbuncle, where, after an inflammation has continued for scarcely 24 hours, the parts become black, and end in real mortification.

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

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

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

When by the use of external or internal remedies, a separation of the mortified part has been effected, and a discharge of pus produced, the remaining sore is then to be considered merely as a simple purulent ulcer, and may be treated in the same manner.

CHAP. IV. Of Ulcers, White Swellings, Cancers, and Burns.

Sect. I. Of Ulcers.

A solution of continuity in any of the softer parts of the body, discharging either pus, fancies, or any other vitiated matter, is termed ulcer; and when the same circumstances happen to the bones, the term caries or carious ulcer is adopted.

Ulcers are distinguished by their particular disorders; although it seldom happens that the affections are not complicated; and when we lay down rules for the management of ulcers 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 finuous ulcer, and the ulcer with caries of the adjacent bone: besides this there is the putrid, the corrosive, the varicole ulcers, &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 afflicted 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. Those which 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.

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; cer; which, as long as the edges continue in that state, must necessarily be prevented from healing. But we are not immediately to destroy the lips of it, in expectation of a sudden cure; for while the malignity of the ulcer remains which was the occasion of the callous, the new lips will be subject to a relapse of the same kind, however often the external surface of them be destroyed: 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 affluence 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 sometimes disposes a neighbouring ulcer to heal. But though callouses 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 caustic, or lapis infernalis. Some choose to cut them off with a knife: but this is very painful, and not more efficacious. When the lips do not tuck down close to the ulcer, but hang loose over it, as in some venereal buboes, the safest method is to cut 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 basilico flavum, alone, or softened down sometimes with turpentine, and sometimes mixed up with different proportions of red precipitate, seems to serve the purpose of bringing an ulcer to cicatrization 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 cicatrize kindly, it may be washed with aqua calcis, or aqua phagi, or dressed with a pledgit dipped in tinct. myrrhae: and if excoriations are spread round the ulcer, they may be anointed with sperm. cet. ointment, or any other foetid ointment.

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

If the ulcer produces a spongy flesh, sprouting very high above the surface, it will be necessary to destroy it by some of the echarotics, 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 sometimes actually degenerates into a cancer. When these excrescences have arisen in venereal ulcers, echarotics should be applied. Those in use, are the vitriol, the lunar caustic, the lapis infernalis, and more generally the red precipitate powder.

It is but seldom that these inveterate funguses appear on an ulcer; but it is very usual for those of a milder kind to rise, which may often be made to subside by pressure and the use of mild echarotics; however, if the aspect of the sore be white and smooth, as happens in ulcers accompanied with a dropfy, 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 curious, 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 echarotics will be only a repetition of pain to the patient, without any advantage.

When the pain and inflammation are excessive, bleeding and other evacuations will often be serviceable; and above all things, rest and a horizontal position; which last circumstance is of so great 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 fores is in some measure owing to the gravitation of the humours downwards, it will be much more beneficial to lie along than sit upright, though the leg be laid on a chair; since even in this posture they will descend with more force than if the body was reclined.

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 affixed by the application of bandage, which must be continued a considerable time after the cure. The nearest bandage is the laced stocking, which is particularly serviceable in this case; though also, if the legs be edematous, 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 dilatation, 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 ulcers dauer, exciting an asthma, a diarrhoea, or a fever, which destroys the patient, unless the fore break out again: so that it is not altogether advisable to attempt the absolute cure in such cases; but only the reduction of them into better order, and less compass, which, if they be not malignant, is generally done with rest and proper care. The cure of those in young people may be undertaken with more safety; and in all cases of stubborn ulcers, the bark, very copiously given, will be found of the utmost service.

When an ulcer or abscess has any sinuses or channels opening and discharging themselves into the fore, 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 bandage and compress will sometimes bring the opposite sides of the sinus to a reunion; if the sinus grows turgid in any part, and the skin thinner, showing a disposition to break, the matter must be made to push more against that part, by plugging it up with a tent; and then a counter opening must be made, which proves often sufficient for the whole abscess, if it be not afterwards too much tented, which locks up the matter and prevents the healing; or too little, which will have the same effect: for dressing quite superficially does sometimes prove as mischievous as tents, and for nearly the same reason; since suffering the external wound to contract into a narrow orifice before the internal one be incarved, does almost as effectually lock up the matter as a tent. To preserve, then, a medium in these cases, a hollow tent of lead or silver may be kept in the orifice, which, at the same time that it keeps it open, gives vent to the matter. The abscesses where the counter opening is made 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, no cure need be expected without dilatation.

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 cannot heal. Those caries which happen from the matter of abscesses lying too long upon the bone, are most likely to recover; those of lues venerea very often do well, because that temper fixes ordinarily upon the middle and outside of the densest bones, which admit of exfoliation; but those produced by scrofula, where the whole extremities of the spongy parts of the bone are affected, are exceedingly dangerous. All enlarged bones are not necessarily carious; and there are ulcers sometimes on the skin which covers them, which do not communicate with the bone, and consequently do well without exfoliation: nay, it sometimes happens, though the case be rare, that, in young subjects particularly, the bones will be carious to such a degree, as to admit a probe almost through the whole substance of them; and yet afterwards admit of a cure, without any notable exfoliation.

The method of treating an ulcer with caries, is by applying a caustic of the size of the scale of the bone which is to be exfoliated; and after having laid it bare, to wait till 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 little doubt 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 found 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.

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 scrophulous cases, the bones of the carpus and tarsus are often affected; and from their sponginess they are seldom cured; so that when these, or indeed the extremities of any of the bones, are carious through their fibilitance, it is advisable to amputate; though there are instances in the scrofula, 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 dossils dipped in the tincture of myrrh; otherwise those of dry lint are easiest, and keep down the edges of the ulcer better than any other gentle applications.

Sect. II. Of White Swellings.

There are two species of white swellings, Mr Benjamin Bell observes; the one of a mild nature, and frequently admitting of a cure; which the other never does. The former, named by our author the rheumatic species of white swelling, begins with an acute pain, seemingly diffused over the whole joint, and frequently extending along the tendinous aponeuroses of the muscles which communicate with it. There is, from the beginning, an uniform swelling of the whole surrounding integuments. Great tension generally prevails; but at first there is seldom any external change of colour. From the commencement of the disease the motion of the joint is attended with exquisite pain, and the patient keeps it constantly in a relaxed posture, finding that the easiest. Hence the tendons become extremely stiff and rigid, till at last the joints have the appearance of complete and real ankylosis. The swelling now begins to augment, till the joint has acquired three or four times its natural size; the cuticular veins become turgid and varicose; at the same time that the muscular substance of the limb below decays, though it frequently acquires an equality in size by becoming oedematous; the pain becomes intolerable, especially when the person is warm in bed or otherwise heated; abscesses form in different parts, which, either breaking of themselves, or by being laid open, discharge considerable quantities of matter, but without any remarkable effect in reducing the size of the swelling. The pus discharged from these is at first of a tolerably good consistence, but soon degenerates into a thin ill-conditioned fancies. However, the oriaces from whence it flows soon heal up, unless they are kept open by art; and new collections breaking out, they burst and heal up as before; so that in long-continued disorders of this kind, the surrounding integuments are often entirely covered with cicatrices.

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

On dissecting limbs which have been amputated for white swellings, the original disease appears to have been a morbid thickening of the surrounding ligaments, without any other affection of the joint whatever; the bones and cartilages always remaining perfectly sound, as likewise the synovia both in quantity and consistence. In the more advanced stages of the disorder, the thickness of the ligaments is more considerable, and is generally attended with an effusion, into the surrounding cellular substance, of a thick glairy matter, which gives to swellings of this kind an elastic springy feel, independent of the collections of matter the fluctuation of which may also be perceived. Through this glairy matter the collections of pus run in various directions, without seeming, however, to mix with it. In some instances also a great many small hydatides are observed; all which form a confused mass, incapable of further division.

All the above-mentioned appearances have been observed without any affection of the bones or cartilages. But when, by a very long continuance of the disorder the ligaments come to be corroded by the different collections of matter, the cartilages and in consequence thereof the bones, soon begin to suffer. The tendons of the flexor muscles, though very stiff and contracted, do not, upon diffusion, show any signs of disease.

The above is an history of the mildest species of white swelling; the more invertebrate kind our author names the ferrophilous white swelling. In this the pain is commonly very violent; more acute than in the former; and, instead of being diffused, is confined to a particular spot, commonly the very middle of the joint. The swelling is commonly inconceivable at first; insomuch that, on some occasions, even when the pain has been very violent, little difference in point of size could be observed between the diseased and the sound joint. The motion of the joint is attended with very great pain, and the tendons become stiff. As the disorder advances, the pain becomes more violent, and the swelling increases, with an evident enlargement of the ends of the bones. The same elastic feel, together with similar abscesses, occur in this as in the last; but upon opening them they commonly discharge a thin fetid fluid; the bones are found to be carious, and pieces of them are frequently discharged at the openings.

By the continuance of the disorder, the constitution suffers, as in the first species of the disease; and a diarrhoea with night-sweats commencing, the patient is soon reduced to little more than skin and bone.

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

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

In the farther progress of this disease the surrounding soft parts likewise suffer: The ligaments become thickened, and the contiguous cellular membrane is stuffed with the viscid glairy matter observed in the other species of the disorder.

We come now to the consideration of the different causes which tend to produce this disease. That the ligaments of the joints only are first affected in this disorder is rendered evident by diffusion. The thick glairy effusions into the cellular membrane are probably occasioned by an exudation from the vessels of those ligaments that have been originally inflamed, as such parts never furnish a proper fluid for the formation of purulent matter: In the course of the disease, indeed, abscesses containing real pus always appear; but never till inflammation has been communicated to the surrounding parts. We may conclude, therefore, that the first species of white swelling is always occasioned by an inflammatory or rheumatic affection of the ligaments of such joints as it attacks, from whatever cause such inflammation may originally have proceeded.

The other species of the disorder seems to be originally an affection of the bones; the surrounding soft parts coming only to suffer in the progress of the disease from their connection with and vicinity to these. This last species of white swelling generally begins without the patient being in the least able to account for it; and from the effects which it produces on the bones attacked, appears to be a species of *spina ventosa*: a disease of the bones probably of the same nature as scrophula is of the soft parts. Indeed, the appearances of the two disorders, after making allowance for their different situations, are exceedingly familiar: they both begin with considerable enlargements or swellings of the parts, which generally end in ulcerations; they both likewise frequently occur in the same person at the same time. This species of white swelling is generally either attended with other evident symptoms of scrophula; or the patient, in an early period of life, has been subject to that disease; or, which is nearly the same, he is descended from ferrophilous parents, and probably has the seeds of that disease lurking in his constitution. From all these circumstances, it may with probability be concluded, that this species of white swelling is of a ferrophilous nature: and since the other species of the disorder is to be considered as an inflammatory affection, a thorough distinction between them is of very great importance; it will not be improper therefore to give a short enumeration of the several diagnostic or most characteristic symptoms of each.

The pain in the first species is always, from the beginning, diffused over the whole joint, and sometimes extends a considerable way along the muscles that are attached to it: in the other species it is always at first, and sometimes even when the complaint has been of considerable standing, confined to a very small circumscribed space. In the former, the swelling is always confined to the soft parts, and is from the beginning exceedingly evident: but in the latter, it is generally for some time hardly perceptible; and when it appears the bones are the parts chiefly affected, the surrounding teguments coming only to suffer on a farther progress of the disease. These are the chief local differences of the two species of this disorder; but some assistance in the distinction may likewise be obtained from the general habit of the patient, and from the manner in which the complaint may seem to have been produced. Thus, when such swellings occur in young, strong, plethoric people, especially in such as have formerly been subject to rheumatism, they most probably will always prove of the mildest or rheumatic species of the disorder: But when they appear in patients of ferrophilous dispositions, we need be under very little doubt in concluding them to be of a ferrophilous nature.

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

In the rheumatic white swelling, as it is always at first evidently of an inflammatory nature, considerable advantage are commonly obtained by a due attention to a proper cooling course. The first remedy which, with this view, should be put in practice, is blood letting immediately from the part affected. Cupping and scarifying is here a principal remedy. The instrument should be applied to each side of the diseased joint; on each side of the rotula, for instance, when the knee is the part affected, and at least eight or ten ounces of blood discharged; and this to be repeated at proper intervals, once, twice, or oftener, according to the violence of the symptoms and state of the patient's strength at the time.

Cupping is, in these cases, much superior to leeches, because it is more expeditious, and because of the swelling occasioned by the application of any considerable number of these... these animals proves frequently very troublesome, and sometimes interrupts for a time the use of other remedies.

Upon the anterior part of the joint, where the cupping-glasses have not been placed, a small blister should be directly applied, and the part kept open with iuflue-ointment, till the wounds from the scarificator are so far healed that a vesicatory may likewise be laid on one side of the joint; and so soon as that is nearly healed, the other side should be also blistered. By thus alternately applying them, first to the one side and then to the other, almost a constant stimulus is kept up; which, in deep-seated inflammations, seems to have fully a greater influence than all the discharge occasioned by blisters. Gentle cooling laxatives at proper intervals are also of use; and the patient should, in every respect, be kept upon a strict antiphlogistic course, both as to diet and every other circumstance.

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

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

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

The best form of using it is by way of unction, as it allows, at the same time, the application of friction; which, in all such swellings, may of itself be in some measure considered as a remedy. For this purpose, an ointment of quicksilver and hog's lard should be prepared; but with so small a proportion of the former, that the patient may admit of two drams of the ointment being rubbed in three times a day. In order to rub that quantity of the medicine in with gentle friction, an hour each time is at least necessary; for in the ordinary way of continuing friction for a few minutes only, it can seldom have much influence.

By Le Dran, and other French writers, falls of warm water on swellings of this nature are much recommended; and there is no doubt, that a long continued and reiterated application of that remedy may, in the first stages of such complaints, be often attended with very good effects. By a proper use of these different applications, viz. of the several topical remedies in the first or inflammatory stage of the disease, and afterwards (still, however, before the formation of matter) of mercurials, friction, &c. many affections of this nature have been entirely removed.

It frequently happens, by the bent position the limb has been for a long time kept in, that the use of the joint comes to be entirely lost, having often acquired such a degree of stiffness, that any attempts to move it are commonly attended with very great pain. This has been constantly attributed to one or other of two different causes, which are both in their nature incurable, viz. either to the ends of such bones as compose the joints having run into one another, so as to become firmly conjoined in consequence of the surrounding cartilages being abraded; or to the insufflation, as it is termed, of the synovia of the joints, whereby their cavities are entirely filled up, and no space left for the future motion of the bones.

Both these opinions, however, are in general very ill founded: as the stiffness almost always proceeds from a contraction of the muscles and tendons. It may often be cured by a long continued use of emollients.

The best emollient that can be used is pure olive oil applied warm; as much of it as can be easily rubbed in by an hour's gentle friction should be regularly done at least three times a day; and instead of confining the friction altogether to the rigid tendons, it should be extended over the whole muscles, even to the insertions of their other extremities; but more especially on their fleshy muscular parts, where the principal cause of the continuance of such complaints is probably seated.

The web or omentum of a new-killed sheep, or of any other animal, applied over all the diseased parts directly on being cut out of the animal, is sometimes attended with advantage. The application should be renewed as frequently as possible, once a day at least, or oftener when it can be done; for on being more than four or five hours applied it becomes disagreeable; and after that time, indeed, as it commonly turns stiff, it cannot then probably be of much service.

The disorder has hitherto been supposed not to be so far advanced as to have occasioned the formation of matter; for when come that length, no considerable advantages can be expected from any of the remedies as yet recommended: but even in that state of the complaint, if the patient's health does not absolutely require it, amputation of the member should not be immediately had recourse to. For by opening putrid the different abscesses soon after their formation, the matter may be prevented from destroying the capsular ligaments of the joints, which, if once effected, would no doubt render that operation necessary. Even in point of success from the operation, it ought never to be advised till the complaint is pretty far advanced. For in this disorder, especially, a greater proportion of patients have recovered after amputation, who have previously been considerably reduced by diarrhoeas and other weakening symptoms, than of such as have still remained in a full plethoric habit of body."

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

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

When, however, for some reason or other, amputation is determined against, as there being almost a certainty of the complaint soon returning, from the scrophulous disposition appearing very strong in the system, it then becomes necessary to have recourse to palliatives, so as to render the complaint as tolerable as possible: and with this view, opiates in large doses, by moderating the pain and procuring rest to the patient, will in general be found the principal remedy. In other respects, all such medicines and articles of regimen as are found beneficial in scrophula, may be had recourse to. Cancers most commonly arise in the glandular parts of the body, where they are occasioned by any bruise or contusion, sometimes a very slight one; and hence they are more common in the lips, and in the breasts of women, than in any other parts of the body. Cancers have been generally distinguished into occult and open. By the former are meant such hard scirrhouss swellings as are attended with frequent shooting pains, and which at last generally terminate in the latter.

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

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

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

Concerning the causes of cancers, there have been a great many conjectures, but without any solid foundation. It is of some moment, however, to determine whether they arise from some general disorder in the system, or whether they are only to be accounted local diseases. Many of the most eminent practitioners have been of opinion that they arise from a general disorder of the system; and hence consider them as totally incurable even by extirpation, as the latent seeds of the disease, in their opinion, will not fail to bring on a return of it somewhere or other. Of this opinion the late Dr Monro appears to have been; and in a paper on this subject in the Edinburgh Medical Essays, declares, that "of near 60 cancers which he had been present at the extirpation of, only four patients remained free of the disease at the end of two years." From this bad success, and the violent progress of the disease, he finally concludes against the extirpation of cancers, and proposes only the palliative method of cure. But later practitioners have been a great deal more successful; and a late publication by Mr Hill, surgeon at Dumfries, has put the usefulness of extirpation beyond a doubt, when the operation is performed in time: though, after the disease has continued long, and the virus been absorbed, the whole system acquires a cancerous disposition, and the disease almost certainly recurs in some other part. From internal medicines we can expect little or nothing in the cure of cancers; and external applications can do no more than palliate. Great expectations were formed from the powder and extract of cicuta; but it has to universally failed, that few put much confidence in it at present. However, it has sometimes been of service in cases of a simple indurated gland; and even where the disease has been farther advanced, it has produced a better discharge, and diminished the fetor of the sore; but as it cannot be depended upon for a radical cure, a delay of the operation is never to be recommended.

No part of the body is more subject to cancer than the breasts of women. Cancer of the mamma may arise at any period of life, though it seldom appears till about the time the menes usually disappear. Tumors arising in the breast previous to this period have been considered by some practitioners as being only of a scrophulous nature; and it is probably owing to that circumstance that several cures have been of late years made on tumors of the breast by mercurial fumigations and other remedies.

Scirrhus and cancer of the breasts are distinguished by the following marks: When the tumor is first observed, it is commonly in form of a small hard knot in the glandular part of the mamma, while the skin at the same time is free from inflammation. It frequently continues in this state for several months; by degrees, however, it increases considerably in size, and at last a sharp pain is felt shooting towards the axilla. The lymphatic glands at the under edge of the pectoral muscle and in the axilla are often enlarged, and an occult cancer is now formed. By degrees the integuments over this part of the tumor in the mamma become discoloured, and at last an ulceration or open cancer breaks out. Violent hemorrhages now frequently ensue; the pain becomes still more excruciating; and, unless proper affluence be given, the patient is generally cut off in not many months after the breaking out of the cancer.

In early stages, the disease in general may be considered as entirely a local affection, and a radical cure may be of course expected; but in proportion as the skin shall afterwards be found diseased and adhering to the gland, and that to the pectoral muscle, and the lymphatic glands near the mamma and in the arm-pit swelled, the chance of a cure becomes more doubtful, as the cancerous matter may have been absorbed, and part of it carried into the system. The most unfavourable state for an operation is when there are ulcerations in the breast, large, deep, and of long standing; and particularly if there are attended with great pain, when the arm of the affected side has become oedematous, and the health of the patient is much impaired. In this last state very little is to be expected from a surgical operation.

In extirpating the mamma, which we shall first suppose is to be done where the skin is found, and where the tumor extirpating, the patient ought to be placed horizontally on a bed, or upon a table covered with a mattress, &c. The operator is to be seated, and to have proper assistants. A longitudinal incision is then to be made with a common scalpel through the skin and cellular substance along the whole extent of the tumor, and at a little distance from the nipple, which is to be saved. When the longest diameter of the tumor is across the body, instead of a longitudinal incision, a transverse one is to be made. The integuments being dissected from the mamma on both sides of the incision, the patient's arm is to be extended to save the pectoral muscle; and the whole glandular part is to be detached from the muscle, though a small portion only should be diseased, beginning at the upper side, and separating downwards. If there be any indurated glands, they are to be carefully removed. If the patient be faint, a glass of wine, or some other cordial, is to be given. After the diseased parts are removed, the wound is to be cleaned with a sponge wrung out of warm water, which will generally render the small bleeding vessels more conspicuous. The integuments are next to be closely applied. plied to the parts underneath, and retained there by the twisted future, and likewise by a few adhesive straps. A large pledget of simple ointment is now to be laid over the whole; and this is to be covered with a thick compress of lint, tow, or soft linen; and the dressings to be kept in their place, and moderate pressure made by the napkin and scapular bandage.

By this method the integuments will generally soon adhere, and a cure will be performed by the first intention. But it does not often happen that the operation is performed while this favourable mode of practising it will answer.

In general, before extirpation of a breast is recommended by the surgeon, or submitted to by the patient, a considerable portion of the external integuments are so much diseased as to render it necessary to separate them along with the glandular part of the mamma. It sometimes happens likewise that the tumor adheres to the pectoral muscle, and that again to the ribs. In either of these cases it becomes necessary to remove all the diseased parts. For this purpose, two incisions of an oval form, with sharp extremities, of a sufficient size to include the whole of the affected parts, become necessary. If again it be found, that besides the disease of the breast, the lymphatic glands in the neighbourhood are indurated, or otherwise diseased, the first incision ought to extend at once over these; and after the other parts have been removed, and the vessels secured, the whole of the diseased glands are to be extirpated; and in performing this part of the operation, considerable assistance may be given by supporting them with a hook, or a ligature passed through them, till they are entirely removed. When they lie deep in the axilla, the points of the fingers, or the end of the handle, will sometimes be safer than the edge of the knife. After having removed all the glands which are in the smallest degree affected, the cut edges of the skin are to be brought as near to each other as the nature of the case will allow, so as to heal as much as possible by the first intention. After the wound is nearly, or perhaps entirely healed, an issue, inserted into the arm of the opposite side, will be the best means of preventing a relapse.

**Sect. IV Burns.**

The immediate consequence of burns is a greater or less degree of inflammation; and the danger attending such accidents is in proportion to the extent of the injury. Burns which irritate the skin only, without destroying the cuticle, act nearly in the way of a common blistering plaster. When the cuticle is destroyed, no blister takes place; a mortified slough is observed; and when this separates, an ulcer is left. Where the cuticle is not destroyed, relief may be procured by holding the part affected a considerable time in very cold water, or sometimes by plunging it two or three times into water a little below the boiling point. Solutions of saccharum saturni, and other preparations of lead, have been recommended, as in the case of other inflammations. Vinegar is found a very effectual application, whether the skin be sound or blistered. The part may be entirely immersed in it, or linen rags dipped in the vinegar may be applied, and the parts kept constantly moist, till the pain be removed. The same application is useless where the skin is rubbed off, or otherwise destroyed. In this case, indeed, the vinegar is apt to give additional pain on its first application; but this soon ceases, and the part becomes much cooler and easier. If the patient will not suffer the vinegar to be applied immediately to the surface of the fore, a linen rag soaked in olive-oil may be previously laid on the part, covering the whole with the cloths dipped in vinegar; and these applications are to be occasionally repeated till the pain and inflammation be entirely removed; after which the parts are to be dressed in the same manner as in the case of a common blister. In extensive burns, where the irritation is great, along with external applications, opium should be prescribed, in doses adequate to the degree of pain. Even that stupor with which patients in this situation are sometimes attacked, is found to be more readily removed by opium than by any other remedy. With respect to the blisters which arise upon burns, it has been disputed whether they ought to be opened, or allowed to remain till they dry up of themselves. But, according to the opinions of the latest authors, they ought to be opened as soon as any considerable quantity of fluid is found in them. After the serum is discharged, a thin liniment of wax and oil, with a little fac charum saturni, should be applied to the part.

In cases of very severe burns, where, notwithstanding the above treatment, there is danger of a violent inflammation being induced, blood-letting, cooling purgatives, and other remedies adapted to the peculiar symptoms, must be used. When, again, burns are from the first attended with loss of substance, as commonly happens after the application of hot metallic bodies, we ought to have recourse to the vinegar, as already mentioned, or to a liniment which is now in very common use for such purposes, made of equal parts of lint, feed oil and lime-water, which, when shaken together, forms a thick white substance, which often gives speedy relief; and it may be readily applied by daubing the parts frequently over with a soft pencil well soaked in it. Though this has been considered as one of the best applications in burns yet, in some cases, more immediate relief has been procured from the application of Gouillard's cerate, or the unguentum nutritum; and a weak solution of saccharum saturni has sometimes been of service.

When burns are occasioned by the explosion of gunpowder, some of the grains of the powder are apt to be forced into the skin. At first they produce much irritation; and if they are not removed, they commonly leave dark marks which remain during life. They should, therefore, be picked out as soon as possible after the accident; and to prevent inflammation, as well as to dissolve any power which may remain, the parts afflicted should be covered, for a day or two, with emollient poultices. In other respects, injuries of this sort are to be treated like any other kind of burns.—When burnt parts are contiguous to each other, they are apt to adhere. To prevent this, pledgets covered with any proper dressing ought to be interposed between them during the course of the cure. Ulcers arising from burns are apt to become soft and fungous, and to rise above their natural level. When this is observed, the emollient ointments, which may have been previously used, should be laid aside, and those of a moderately astringent nature applied. Gentle compression with a roller is also of particular service. Advantage is likewise derived from tarragon washes, &c. One of the best ointments, in such cases, is the common calamine cerate. These will commonly answer the purpose; but when they prove insufficient, burnt alum, blue vitriol, or even lunar caustic, may be necessary.

**Chap. V. Of Inflammatory Tumors.**

Inflammatory Tumors are such as are quick in their progress when compared with those of the indolent kind, and are attended with considerable pain and other symptoms of inflammation. We have here mentioned such only whose treatment more properly belongs to the province of the surgeon, and which are placed according to their situations in the different parts of the body. Sect. I. Inflammation and Abscess of the Breasts of Women.

This disorder occurs most frequently in nurses by the stoppage of the milk, which is always occasioned by sudden or imprudent exposure to cold.

In the early stages of the affection, resolution is always to be attempted, unless the swelling appears to have an evident tendency towards suppuration. The remedies used in inflammation, in general, seem useful in every case of inflammation of the breasts. When the patient happens to be nursing, a sudden evacuation of blood is apt to diminish the quantity of milk. In such cases, therefore, blood is to be extracted in small quantities at a time. The application of cooling saturnine poultices is advisable. When suppuration has taken place, the matter is to be discharged by making an incision in the most depending part of the tumor.

Sect. II. Inflammation of the Testicles.

This disease is often owing to exposure to cold, violent exercise, &c.; but most frequently to gonorrhea virulenta, and never to matter falling down upon the testes, as was supposed by those who gave it the name of hernia humoralis. Inflammation here rarely terminates in suppuration.

The best method for discharging the inflammation is by the application of leeches; after which the penis ought to be kept constantly moistened with a solution of saccharum saturni, and the scrotum and testes supported by a proper bandage. The bowels should be kept moderately open; the patient should use a low diet, and keep as much as possible in an horizontal posture. If lues venerea be present, a cure cannot be expected without mercury. If the disease is owing to a sudden stoppage of the discharge in gonorrhea, the running ought to be restored, and promoted by bathing the penis in warm water, injecting warm oil, and the use of bougies. These means will generally discharge the inflammation. If matter form, it must be discharged.

Sect. III. Of Venereal Buboes.

A swelling of any of the lymphatic glands of the body is called a bubo; and when such a swelling proceeds from venereal poison, it is termed venereal bubo. They seldom or never appear except in the lymphatic glands of the groin, arm-pit, or extremities, and much more frequently in the groin than anywhere else.

In the treatment of buboes, a strict antiphlogistic regimen is to be used to promote a resolution; the application of leeches to the hardened gland is particularly proper. In discharging venereal buboes, the application of mercurial ointment has a considerable effect. After suppuration is completely formed, the application of caustic to open the bubo is dangerous, lest it should corrode some of the considerable blood-vessels, which generally lie contiguous to the bubo. Buboes, when opened by the knife, are said to heal with more difficulty, and generally to leave a tear behind them. To allow them to burst of themselves, is therefore for the most part proper, except when the collection is so considerable as to press upon the neighboring blood-vessels. In such a case, a small incision may be made by the lancet, taking as much care as possible to prevent the admission of the external air into the wound. When the edges of the opening grow callous, the application of lunar caustic to them becomes necessary. During the remaining part of the cure, mercury joined with opium is to be used.

Sect. IV. Lumbar Abscess.

The term lumbar may be applied to every abscess seated in the loins; but that which is here meant is such as begins about the top of the os sacrum, and is seated in the inflammatory vicinity of the great psoas muscle.

The symptoms begin with pain and tension about the loins, shooting upwards to the spine and downwards to the thigh. The disease has sometimes a strong resemblance to nephritic affections, and is sometimes mistaken for lumbar abscess. After suppuration takes place, shivering fits come on; and the pain now becoming dull, the patient imagines himself better, till matter points at the side of the anus, or in the groin. The first case is rare; and when it does occur, the tumor bursts, or is opened as a common abscess. In the other case, the matter is seated behind the tibiae of the groin, and sometimes descends as far as the knee. The teguments commonly retain their natural appearance. Fluctuation is evident, especially when the patient is in an upright posture. It is often mistaken for crural hernia; but may be easily distinguished from it, by its slow progress, by pain in the lumbar region at the commencement of the disease, by the patient allowing the tumor to be handled freely, by fluctuation being evident, by the tumor becoming flaccid when the patient is in a horizontal situation, and by the absence of all the symptoms by which hernia is distinguished. Both diseases may occur at once; but this is very rare, and a distinction is still to be made.

It is discovered that this disease has, in general, been induced by considerable injury being done to the small of the back or loins, either by twists, or severe bruises, or by sudden exposure to cold after the heat occasioned by severe exercise, particularly in scrophulous habits. Were accidents of this nature immediately treated with that attention which their importance deserves, the disease might frequently be prevented.

In the treatment the strictest antiphlogistic regimen ought to be observed. Blood-letting ought immediately to be performed, by scarifying deeply and leeching the injured part; neither are blisters, opiates, gentle purgatives, and other remedies useful in inflammations, to be neglected.

Authors have an idea that little advantage can be derived from laying open the abscess, on account of the great danger which may ensue from the admission of air. Mr Benjamin Bell, however, is of an opposite opinion, and has always given vent to matter here as elsewhere, and no bad consequences have been observed. The matter, when long lodged, has been found to destroy the joint parts and bones, and sometimes to make its way into the cavity of the abdomen; all of which might be prevented by an early evacuation. For this purpose a trocar should be used, which was tried by Mr Bell in one case with complete success.

Some other cases are lately narrated by authors, where, by the introduction of a feton, and drawing off the matter by slow degrees, and then by using compresses, and sometimes injections of gently irritating fluids, a cure has been performed in the course of a few months. If the case is doubtful, an opening should be made with the knife in the same manner as in hernia. If the flow of matter continue considerable for the space of two or three weeks, injections of a weak solution of saccharum saturni, lime water, or other gentle astringents, may be employed.

Sect. V. Paronychia or Whitloe, and Chilblains.

Whitloe is a painful and inflammatory swelling at the extremities of the fingers under the nails, terminating in an effusion of clear serum below the skin, which is sometimes so acrid as to corrode the periosteum, and render the bones carious. At other times the inflammation runs so high that the whole of the arm swells, particularly the lymphatics, and sometimes even the glands in the axilla.

When this affection arises from external violence, the remedies Chilblains are inflammatory swellings, of a purple colour, chiefly affecting the heels, and sometimes also the fingers, toes, arms, hands, or feet, or even the tips of the nose and ears, attended with a stinging pain, and a degree of itching. The swelling sometimes cracks, and discharges an acrid serum; sometimes a mortification takes place, and an ulcer follows very difficult to heal.

This disorder is owing to the weaker action of the small vessels most remote from the heart, occasioned by cold or dampness, and occurs most frequently in people of a delicate constitution.

When the patient has been for some time exposed to the cold, and the parts are frost bitten, they ought to be plunged into the coldest water and rubbed with salt; when they are only benumbed, rubbing them with camphorated spirit of wine will answer equally well; but when cracks take place, and an oozing of acrid matter ensues, poultices may be applied, but not long, as they are apt to give rise to fungous excrescences.

Sect. VI. Of Contusions and Sprains.

Contusions of the integuments and muscles produce pain, swelling, and inflammation, and these, in some cases, may extend to a considerable degree; but in general they are less violent than what take place in cases of sprains of ligaments or tendons; for in these there is frequently a total loss of motion for many weeks, and sometimes for years, if proper attention be not paid. An effusion of fluids always succeeds the injury, which seems to be, for the most part, of a serous nature, as the skin usually retains its natural colour; sometimes the tumefied parts are of a deep red, or leaden colour, owing to a rupture of some vessels conveying red blood.

In the treatment of contusions and sprains, two circumstances require attention. 1. To endeavour to prevent the swelling as far as is practicable; 2. To employ those remedies afterwards which are known to be most powerful in preventing or removing inflammation. In contusions of the cellular substance, and even of the muscles, the effused fluids are commonly soon absorbed; but in sprains of the tendons or ligaments, a very troublesome, painful thickness of the injured parts is apt to continue for a great length of time, and in some instances even for life.

It is necessary, therefore, to obviate these symptoms as soon as possible; and for this purpose, cold astringent applications, as water, vinegar, &c., are most commonly used. Others again, with a view to relax the parts fully, make use of water as hot as the patient can bear it. By immersing the injured part in these immediately after the injury is received, the effusion will at least be somewhat obviated. When the pain is excessive, opiates become necessary.

After blood has been freely discharged, a repetition of the remedies already mentioned will be found to give great relief; care should be taken, at the same time, that the injured parts be kept in a relaxed and easy posture.

Chap. VI. Of Indolent Tumors.

These are such as are slow in their progress, and may continue for a long time without being attended with either indolent pain or inflammation; though occasionally almost all of them may be inflamed, and some of them, in that state, attended with considerable pain. They are of different kinds according to the nature of their contents, and kinds of appearance in various parts of the body. They are seated in the adipose and cellular membrane; whence it often happens that they take place in the viscera themselves, where they are frequently mortal. Sometimes they are filled with a sublance of the confluence of honey, and are thence called melicercous tumors; sometimes they are filled with a harder substance, and are then called atheromatous tumors; at other times they are filled with a sublance of the confluence of fat, and are then called steatomatous. Sometimes, however, they are found to be replenished with a fluid lymph coagulable by heat, and are then called hydatids. One set are filled with matter like the synovia of the joints, and get the name of ganglions.

Tumors of this kind are easily distinguished from all others, as having neither heat, pain, nor pulsation, as is to be observed in those which incline to suppuration; and they are distinguished from each other, before they are laid open, by fluctuation being readily perceived in the melicercus: the atheroma is soft and compressible, but has no fluctuation; while the steatoma is commonly firm and rolls under the skin. But these rules are liable to considerable exceptions. The melicercus and atheroma are most commonly found upon the head, and the steatoma upon the other parts of the body; while ganglions are situated over the tendons of the muscles. These tumors must be either extirpated entirely, or laid open so as to dispose the cyst to slough off or granulate. If the matter be fluid, we may evacuate it by an opening made with a lancet, or by means of a feton; but as the matter is apt to collect again, it is better to remove the sac entirely. If large vessels or nerves prevent this from being done, then it is to be laid freely open and exposed to the air, so that the bag may granulate, or be thrown off. When the tumor is to be extirpated, a longitudinal incision is to be made through the integuments; after which the tumor may be frequently removed by the point of the finger, or by the end of a spatula, replacing the integuments with a view to heal by the first intention. In every pendulous tumor of this kind, with a narrow neck, we ought to divide the teguments near the bottom of the tumor, in an oval form, so that the wound may be afterwards properly covered with the remaining integuments. After the tumor is removed, the skin is to be replaced over the wound, and fixed with adhesive straps, covering it with a pledgit of cerate, a small compris of linen, with a bandage above all, to make a gentle pressure on the parts.

Sect. I. Of Steatomatous and Sarcomatous Tumors.

Steatomatous tumors have been ranked by authors among those of the encysted kind; but they have no other resemblance containing them than the common cellular substance, somewhat condensed; and the particles of fat composing them are found of the same size with those in a sound part of the body.

Authors formerly advised the discussion of stenoms, or the prevention of their growth, by the application of pressure; but by such means the growth is rather promoted than retarded, nor have internal remedies been of any advantage. They can be removed therefore by an operation which is the same with that for the extirpation of encysted tumors.

Sarcomatous tumors have nearly the same external appearance with those of the steatomatous kind. The term sarcoma has been applied, in a general way, to cirrhi of the glands, but Ganglions, but farcomatous tumors are likewise found in various other parts of the body, and are distinguished from iteatomas by being firmer to the touch; internally they are found of a redder colour, or approaching that of muscles, in consequence of the greater number of vessels entering into their substance.

These are to be treated in the same manner as iteatomas; but the operation ought to be performed early, as they are more apt to degenerate into cancer.

Sect. II. Of Ganglions, or Swellings of the Bursa Mucosa.

Ganglions of the tendons are likewise tumors of the encyted kind, seated in the bursa mucosa, or sheaths of the tendons which belong to the extremities. They are most frequently met with over the tendons upon the back of the wrist, and often likewise about those of the ankle and other parts of the extremities. When pressed, they are found to possess a considerable degree of elasticity, from which, and from their situation, they may generally be distinguished from other encyted tumors. They seldom arrive at any great bulk, are not often attended with pain, and commonly the skin retains its natural appearance. On being laid open, they are found to contain a tough, viscid, transparent fluid, resembling the glaire of an egg.

They are generally produced by sprains, or contusions of the joints, or by rheumatism. In many instances, they go off insensibly, without any assistance from art; but as this is often not the case, means ought to be used for removing them. For this purpose, moderate friction frequently repeated, or gentle compression applied to them by means of thin plates of lead, &c. sometimes remove them. In some instances they have been removed by the application of blisters; but the most certain method is, to make a small puncture into the sac, and to draw a cord through it; or, after the puncture is made, to press out the contents, and then inject some gently stimulating fluid, as port wine and water heated blood-warm. Sometimes, in tumors of this kind, bodies of a cartilaginous nature, and of different shapes and sizes, are found; some quite smooth, others with peduncles; by which they are supposed by Dr Monro, in his work upon the bursa mucosa, to have been attached to the bursa. As these cannot be removed by any remedy with which we are yet acquainted, it is found necessary to discharge them. But as the parts may sometimes suffer from inflammation when the tumor is laid fully open, it may be punctured at each end; and, after pressing out the contents, a small cord may be introduced; after which gentle pressure may be applied with a compress and bandage over the course of the tumor. The cord however should not be continued so long as to induce any great degree of inflammation, for it is found that a slight degree of this sufficiently answers the purpose.

Sect. III. Of Collections within the Capsular Ligaments of Joints, and of Cartilaginous Bodies contained there.

Collections here may consist of serum, blood, or pus and synovia combined. They are most frequently met with in the joint of the knee, and may be produced either by internal or external causes. These kinds of collections may in general be distinguished from each other.

Watery effusions, commonly called drophical swellings of the joints, arise chiefly in consequence of severe rheumatic complaints; and when the tumor is not very large, the fluctuation of the fluid may be felt by pressure. When a large effusion appears immediately after a violent bruise, it is probable that it consists chiefly of blood; but when it succeeds a violent sprain, attended with great pain, inflammation, and swelling, terminating in an effusion, there is every reason to think that the contained fluid consists of pus mixed with synovia.

Swellings of the joints are most apt to be confounded with collections in the bursa mucosa; or with matter effused in the adjacent cellular substance. From the first of &c., these they are generally distinguished by the contained fluid passing readily from one side of the joint to the other, and from its being diffused over the whole of it; whereas, when it is contained in the bursa, the tumor is confined to a particular part, and is seldom attended with much pain.

When such collections can safely be allowed to remain, the capsular ligament ought never to be opened, as they can often be removed by discharges. Even considerable collections arising from rheumatism may commonly be discharged by friction, fomenting the parts with warm vapour, keeping them constantly moist with saturnine solutions, covering them properly with flannel, and applying blisters. When these fail, supporting the part with a laced stocking, or with a roller, has frequently been of service. But whether a rheumatic tumor can be discharged or not, it ought not to be opened; for the inconvenience attending it is more intolerable than the pain and inflammation which may ensue. But when the matter would do mischief by lodging, it should be discharged. Effused blood and matter which succeed high degrees of inflammation are of this kind. Blood is frequently extravasated among soft parts without much detriment; but when in contact with cartilage or bone, it soon hurts them materially. The matter ought to be discharged so as most effectually to prevent the admixture of air into the cavity of the joint. For this purpose the opening should be made with a trocar; and the skin, previously drawn tight to the upper part of the tumor, should be pulled down immediately on withdrawing the canula. A piece of adhesive plaster should be directly laid over the opening, and the whole joint should be firmly supported by a flannel roller properly applied. If the patient be plethoric, he should be blooded to such an extent as his strength will bear; he should be put upon a strict antiphlogistic regimen, and in every respect should be managed with caution; for inflammation being very apt to ensue, we cannot too much guard against it.

Joints are sometimes rendered painful and stiff by the formation of different substances within the capsular ligaments. These are sometimes loose, and as firm as cartilage; and sometimes of a soft membranous nature, similar to those already observed in treating swellings of the bursa mucosa.

In some cases these substances, especially the last species, retain nearly the same situation, without being much affected either by pressure or by the motion of the joint; in that case the pain is constant, but seldom severe. The first species, however, is commonly very moveable; and on being touched, they slip with such facility that it is difficult to fix them even with the fingers. There are only painful in particular situations.

Where these concretions appear, upon examination, to be perfectly loose and detached, if the pain which they excite be not very severe, we should venture in a cautious manner to take them out, by making an incision into the joint. But if there is reason to suspect that they are connected with any part of the joint, the patient ought to be advised to submit to the pain they induce, which in general will be rendered moderate by thumping exercise; but if, notwithstanding this, it becomes intolerable, amputation is the only resource.

The limb being firmly secured by assistants, in that part which admits of the body to be taken out being felt extracting them. Surgery

Chap VI

Collections most distinctly, the surgeon should endeavour to fix it with his fingers towards the upper part of the joint; after an acicular ligament has drawn the skin as much as possible upwards from the part where the incision is to be made. The operator with a scalpel is now to make an incision through the teguments and capsular ligament, directly upon the substance itself, of such a size as will admit of its being easily taken out; which may be done either with the finger or with the end of a blunt probe. If it is found to be connected by any small filaments either to the capsular ligament or to the cartilages of the joint, they should be cautiously divided, either with a probe pointed bifurcally, or probe-pointed scissors, after drawing the substance itself as far out as it can be got.

When more concretions than one are found, they should all be taken out at the same opening, when this can be done; but when it cannot, it will be better to allow the first incision to heal before attempting the second, so as to avoid as much as possible the exciting of inflammation.

After the concretion is removed, the skin should be immediately drawn over the wound in the capsular ligament; and the lips of the opening in the skin being laid together, they should be secured in this situation by pieces of adhesive plaster, so as to prevent the air from finding access to the cavity of the joint. Till the wound be completely healed, the patient should not only be confined to bed, but the limb should be kept as much as possible in one posture, and a strict antiphlogistic regimen should be preserved.

Sect. IV. Of Spina Bifida.

Spina bifida, is a tumor which sometimes appears upon the lower part of the spine in new-born children. A fluctuation is distinctly perceived in it, and the fluid it contains can in some measure be pressed in at an opening between the vertebrae. In some cases this opening is owing to a natural deficiency of bone; in others, to the separation of the spinous processes of the vertebrae.

The disease proceeds from serum collected within the coverings of the spinal marrow. It is always fatal. Children labouring under it have been known to live for two or three years; but, in general, they linger and die in a few weeks. All that art has been able to do is to support the tumor by gentle pressure with a proper bandage. When a tumor of this kind is laid open or bursts, the child dies in a few hours. A tumor nearly of the same nature with this is sometimes met with upon different parts of the head in new-born children: it is formed by a fluid lodged beneath the membranes of the brain, which have been forced out at some unoffended part of the skull. What we have said with respect to the former is exactly applicable to this.

Sect. V. Of Scrophulous Tumors.

We shall here only mention the surgical treatment of scrophulous tumors, having spoken of scrophula in general under the article Medicine. Some practitioners have recommended poultices, &c., to bring scrophulous tumors to suppuration; but the best practitioners have laid them aside, because they increase the soft and spongy state of the parts, by which they are prevented from healing.

As external applications are ineffectual, it is better to allow scrophulous tumors to be as much exposed as possible, as this frequently renders the subsequent ulcer more easily cured. The other methods recommended for discissing these tumors are, the internal use of cicuta, burnt sponge, muriated barytes, a long continued use of the cold bath, particularly of sea-bathing, and drinking mineral or sea-water. These, to produce any effect, should be begun early, while the tumors are small, and long persisted in. When the tumors come to a state of suppuration, if they are seated up-

on the thorax or abdomen, or any of the large joints, free vent ought always to be given to the matter to prevent its bursting into these cavities; and when the abscess is large, this should be done with a trocar, or by passing a cord thro' it, in order to exclude the external air. When the tumors are not situated upon great cavities, it is better to allow them to break of themselves, as the fores commonly heal more readily, and the scar is pretty similar in both. The most proper applications to scrophulous fores seem to be those of the catarrhine kind, as they diminish inflammation, and in some measure prevent the sore from spreading. When the bones become carious, they are to be treated like carious bones from other causes; but amputation cannot here be attended with advantage, as the disease proceeds from a fault in the constitution. After the fores are healed up, the introduction of an issue may assist in preventing their return.

Tumors of a scrophulous nature are sometimes apt to be mistaken for those of the scirrhus kind, and thus may be improperly extirpated. Scrophulous tumors deeply seated commonly have a degree of firmness, which, if they happen to be seated near a suppurating part, as close by the side of a woman's breast, may give occasion to such a mistake. But they may generally be distinguished by the softness even of the firmest kind of them, when compared with scirrhus. They have always a smooth equal surface; whereas scirrhus is somewhat unequal or knotty, and seated in the real substance of the gland; and a shooting pain is commonly felt in it from time to time, even from its first appearance. They are generally accompanied, too, with other symptoms of scrophula, which is not necessarily the case with scirrhus.

Sect. V. Of Bronchocoele.

This is a tumor on the fore-part of the neck, seated between the trachea and skin, termed in French goitre. In this country it is very rare; but it is frequent among the inhabitants of the Alps, and other mountainous countries, and is supposed to be owing to the use of snow-water. It is seated most frequently in the thyroid gland; tho' in two cases examined by Mr Benjamin Bell this gland was diminished from the compression of the tumor, which was chiefly formed of condensed cellular substance, with effusions in different parts of it of a viscid brown matter. Dr Proffer considers bronchocoele as a dropical affection of the thyroid gland; and in confirmation of this, he gives an account of a dissection of a diseased gland of this kind by Dr Hunter, who found in it a great number of capsules filled with water. The swelling is at first soft, without pain or any evident fluctuation, and the skin retains its natural appearance; but as the tumor advances in size, it becomes unequally hard; the skin acquires a copper colour, and the veins of the neck become varicose; the face becomes flushed, and the patient complains of frequent headaches, as well as of stinging pains through the body of the tumor.

Calcined egg-shells have been recommended by authors as a specific for this disease; but little dependence is to be placed on such a remedy. Frequent frictions are found useful, especially when employed early; saaponaceous and mercurial plasters, too, have in some cases proved serviceable; and repeated blisters have been known to retard its progress. In the enlarged state of the tumor no remedy yet known is powerful enough to affect it. When the disease is far advanced, the removal of the tumor by an operation must be attended with great danger, on account of the enlarged state of the arteries, as well as its vicinity to the common carotids. It is therefore thought by some of the most experienced practitioners, that in such a situation it would not Sect. VI. Of Naevi Materni, Corns, and Warts.

Naevi materni are those marks which frequently appear upon the bodies of children at birth, and which are supposed to originate from impressions made on the mind of the mother during pregnancy. They are of various forms; their colour is likewise various; though most frequently resembling that of claret or red port-wine. Many of these marks are perfectly flat, and never rise above the level of the skin; they do not require the assistance of surgery; but in some cases they appear in the form of small protuberances, which frequently increase to a great size in the course of a few months. They appear to be firm and fleshy. They sometimes hang by slender attachments to the contiguous parts, but more generally they are fixed by broad bases. They may be removed with as little danger as any other tumor of the sarcomatous kind. They are supplied indeed more plentifully with blood than most other tumors are; and even sometimes they appear to be entirely formed by a concretion of small blood vessels; but the arteries which supply them may, for the most part, easily be secured by ligature. The operation should never be long delayed; for as the size of the vessels corresponds with that of the tumor, they sometimes are so large as to throw out a good deal of blood before they can be secured. In performing it, the tumor is to be cut out, the arteries taken up, and the remaining skin brought as well together as the nature of the part will allow, and kept so by adhesive plaster or future. When the tumor is pendulous, and connected only by a narrow neck, it should be extirpated by ligature.

Corns are small hard tubercles, commonly situated on the toes or other parts of the feet, and sometimes on the hands. They are of a horny nature. They proceed from a diseased state of the cuticle, occasioned by pressure. The part becomes hard and thickened, with a small white substance in the centre, which has a disposition to become prominent. It likewise forms a depression in the subjacent cutis vera, and sometimes is said to penetrate it. When corns are situated on parts much exposed to pressure, they irritate the skin, and produce an increased sensibility of the part, and thus occasion much pain. The best preventative of corns is the wearing of wide shoes, and avoiding every kind of pressure; and unless this be attended to, it will be found difficult to keep free from them. Various remedies are recommended for the cure or removal of corns. One is to bathe the part about half an hour in warm water, then to pare as much off them as possible without giving pain, and to apply over them any emollient ointment. If this treatment be frequently repeated, while pressure from shoes is prevented, they generally fall off, and do not return if pressure be afterwards avoided. Another method is to allow them to grow to some length through pieces of perforated leather, properly secured by plaster or by any other means, and afterwards to cut round their root, by which they may for the most part be easily turned out. Or if such irritating substances be applied to them as will raise a blister by separating the cuticle from the cutis, the corn will be raised along with the cuticle, and may then be readily removed by a scalpel or scissors. The surface of the cutis being now exposed, is to be healed like any other part that has been blistered.

Warts are small, hard, indolent tumors, with a rough surface, appearing on different parts of the body, chiefly the hands and face, and more commonly in young people. When they appear in advanced life they are apt to degenerate into cancer, especially when of a livid colour and with a smooth surface. If they do not prove troublesome, nothing should be done to them; as they generally either fall off or waste gradually away. When from their size or situation they require to be removed, this, if they are pendulous or have narrow necks, is easily done by ligature; but if their bases be broad, the scalpel or caustic applications will be necessary. As few, however, will submit to the former, the latter are generally employed. Caustics of a mild nature give least pain, and are least apt to excite inflammation, which in these cases it is difficult to remove, and are found to be quite sufficient for the purpose. One of the best of these is crude ial ammoniae; it should first be moistened in water, and then well rubbed upon the warts two or three times a day. Liquid salt of tartar, and sometimes spirit of hartshorn, has answered the same purpose; some recommend also the juice of onions.

Warts appearing on the penis as a symptom of venereal infection, are of the same nature, and to be cured by the same means. Mercury is of no advantage here, and commonly indeed does harm. When every other part of the disease is eradicated, the warts may generally be removed by washing them morning and evening in lime-water, or in a weak solution of saccharum saturni. They may be removed also by the knife, and the parts from whence they are cut afterwards touched with lunar caustic, to prevent them from returning; but when this method is practised, the operator ought to be certain that he has removed the wart entirely, for where part has been left the most formidable symptoms have sometimes ensued.

Sect. VII. Of Polypi.

Polypi are pendulous, fleshy, indolent tumors, so called from their supposed resemblance to the animal of that name. They may be found in different cavities of the body, and originate from the lining membrane; but those which come under surgical treatment are found in the nose, mouth, throat, and outer passage of the ear, and in the vagina and rectum. They are divided into two classes; the one soft and compressible, the other extremely firm. Both of them bleed on being fretted or roughly handled. The soft kind shrivels and contracts in a dry atmosphere, (this is particularly the case with those of the nose;) but the firm are not affected by the influence of the weather. Their colour is commonly pale and transparent, and sometimes a deep red.

The pain at the commencement of the disorder is always inconsiderable; but increases in those of a hard nature as they increase in size. Sometimes polypi of this kind become unequal, and form ulcers over the whole surface, discharging fetid matter in considerable quantity. They are apt at this time, unless extirpated, to degenerate into cancer.

Most frequently they arise from local injury, or whatever tends to produce and support an inflamed state of the part. Scrophula and lues veneris, though considered by some authors as frequently giving rise to them, seem only to be exciting causes; for in lues veneris in particular, polypi when present remain after the disease is cured.

The prognosis must depend much upon their situation and their consistence. The soft kind being seldom painful, may be removed at any period with little danger; but the hard kind are generally not only painful, but more apt to degenerate into cancer, or to return after being removed. The soft kind therefore may be removed in general with success; but when polypi of a harder nature exist, the prognosis will be much more unfavourable. With respect to the treatment.—As long as they remain stationary, they are not to be touched; but when they continue to grow, we ought to use affrangent remedies, especially a strong solution of alum, a decoction of oak bark, vinegar, ardent spirits, &c. The softer kinds of polypi may frequently be prevented for a long time from increasing in size, and sometimes they even become considerably smaller. Mercury has been found rather to make them worse; caustic and other corroding applications have been of use in the softer kind, though they have not produced a cure. Seions have likewise been used with little advantage. It is therefore found necessary to have recourse to a more effectual practice; and with this view the knife, scissors, forceps, or ligature, are more generally recommended. The knife and scissors may be used when the roots of the tumor can be readily come at; but polypi are seldom so situated as to render excision practicable; and, even when they are, the hemorrhagy may be attended with considerable danger. The removal of a polypus by tearing or twisting it with the forceps, Plate CCCCLXXXVII.fig.4, is occasionally practiced; but as ligatures are less painful, and fully as effectual, they are now more generally employed. The ligatures consist of wire, catgut, silk cord, &c. Different methods have been employed for passing these over polypi, according to their different situations.

When the ligature is to be applied, it is to be passed double over the tumor, and conducted to the root of it by means of the fingers or by slit probes, as in Plate CCCCLXXXVII.fig.5, or rings, Plate CCCCLXXXVII.fig.6, as may be best suited to the shape and size of the passage. The ends of the ligature are then to be introduced into a single or double canula, as in Plate CCCCLXXXVII.fig.7, which is to be pushed along the opposite side of the polypus till the end of the canula reach the root of it, when the ligature is to be drawn somewhat tight, and fastened to the canula which is to be left in the passage. The ligature is to be daily tightened till the tumor drop off. In this manner the largest polypus may be removed equally well with those of a smaller size. Should any part of it remain, it may be destroyed by caustic, and different instruments are contrived for conducting this to the root of the tumor.

What has been said of the treatment of polypi in general, readily applies to those seated in the nose, outer passage of the ear, the rectum, and the vagina. It likewise applies to those in the throat; only that instead of passing the ligature through the mouth, it is to be passed through one of the nostrils. The operator is then to introduce one or two of his fingers into the mouth, and open the doubling of the ligature, which he is to pass over the polypus, and having pressed it down to the root of it, to proceed as before directed.

**Chap. VII. Of Diseases of the Bones.**

The bones, as well as the softer parts, are liable to be swollen, either throughout their whole length, or to have tumors formed on particular parts of them.

Exostosis is one species of tumor of the bone. According to Mr Bromfield, no swelling should be called so, but an excrecence continued from a bone, like a branch from the trunk of a tree. Under this head therefore is ranked the benign node, which may be produced by external injury, such as contusions and fractures: it can hardly be called a disease, as pain seldom succeeds, but rather a deformity.

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

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

The confirmed venereal node has the appearance of a dislocation of the osseous fibres, probably from some infilibrated humour obstructing the nutrient vessels, but not evacuated; this occasioning an extension of the periosteum, produces a violent pain, which, when nocturnal, is the characteristic of a venereal cause. When the periosteum is thickened, but the bone not affected, a course of mercury, by attenuating the obstructed humour, and fitting it to be carried out of the body by the proper outlets, will often produce a perfect cure; but when the bone itself is diseased, this method will fail. But here the division of the extended periosteum has been known to give perfect ease.

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

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

It is universally allowed, that this disease takes its rise from matter being formed either in the diploe, or in the marrow: whenever obstruction is begun in the vessels expanded on, or terminating in, the medullary cysts, the consequence will be inflammation, and, if not early removed, matter will form; for this reason this case may be called abscessus in medulla. Whenever, then, a patient complains of dull heavy pain, deeply situated in the bone, possibly consequent to a violent blow received on the part some time before, though the integuments appear perfectly sound, and the bone itself not in the least injured, we have great reason to suspect an abscessus in the medulla. Children of a bad habit of body, though they have not suffered any external injury, will often become lame, and complain of the limb being remarkably heavy; and though not attended with acute pain, Diseases of pain, yet the dull throbbing uneasiness is constant. If rigors happen during the time the patient labours under this indisposition, it generally implies that matter will be formed within the substance of the bone. If the extremities of the bone complained of begin, or if it becomes enlarged throughout its whole extent, it may be known to be an abscessus in medulla, or true spina ventosa, as it is called; if neither of these symptoms take place, the great insensibility of the bone in some subjects will prevent that acuteness of pain usual in other parts where matter is formed, though the acid matter is eroding the bone during the whole time it is contained within it. This matter at length having made its way through, arrives at the periosteum, where it creates most violent pain, as well from its sharpness as from its increased quantity, occasioning an extension of the periosteum. The integuments then become swelled and inflamed, and have a sort of emphysematous feel. On being examined by pressure, the tumor will sometimes be lessened, from part of the matter retiring into the bone: from this appearance to the touch, most likely the name of ventosa was added to the term spina. When we are assured of matter being under the periosteum, we cannot be too early in letting it out, as it will save a considerable deal of pain to the patient, though probably it may not be of any considerable advantage in respect to the carious bone; for, where the fluids in general are vitiated, no chance of cure can be expected from topical remedies; but where the constitution is mended, nature will sometimes afford us in her part, as the carious bone will be thrown off from the epiphyses, or the teredines will be filled up by the offensive matter that flows from the parts of the bone where some of the spine have come away.

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

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

The bones, when deprived of their cementing liquor, by passing through fire, become friable. From repeated salivations, and in old people, they have been rendered extremely brittle; insomuch that in many subjects they have been fractured merely from their weight and the action of the muscles; but in such cases, this is not owing to the friability of the bones, but to the loss of substance, from the erosion of the bone by an acrimonious humour thrown on it; to which cause perhaps may be attributed the disease called rickets in children. The effects of scurvy humour in rendering the bones soft in many instances, have often been remarked.

By proper diet, gentle friction with coarse cloths, exercise, and cold bathing, rickety children will frequently get their constitution so much changed, as that, by the time they arrive at the age of 20 years, there shall not remain the least vestige of their former disease. The epiphyses are generally most affected in this species of the disorder. For want of early attention to invalids of this sort, we find that their bones not only become soft, and yield to the powers of the muscles, but remain distorted the rest of their lives, though they have acquired a perfect degree of solidity. In such cases, correcting the vitiated juices only will not restore the bones to their natural state; therefore the assistance of a skilful mechanic is necessary both to support the parts improperly acted on, and to alter the line of direction of the distorted osseous fibres.

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

The bones of children who die of this disorder, we observe, are not only rendered soft, but the vessels within their substance are replete with blood of a texture totally broken, and having more the appearance of thin chocolate than blood: the periosteum in many places is separated, and the intermediate space between it and the bone filled with extravasated fluid; and caries is almost as frequent as the separation of the periosteum. The muscles in such bodies generally appear pale and flabby.

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

The mollities ossium, in some cases, may be produced from a redundancy of the oleaginous parts of the blood, or ollium, from a laxity of the follicles, by which the fluids are not sufficiently attenuated, nor properly blended and mixed: the consequence of which will be obstructed perspiration, the habit in general loaded with gouts, phlegmatic, and febrile humours, and the offensive matter not united or condensed as in a healthy state. The method of cure confirms us in the cause of these symptoms; for, by strengthening the fibrous system, by using gentle exercise, a dry diet, good air, aromatics, and cold bathing, this kind of invalids are generally restored to health.

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

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

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

At first the general health of the patient seems not to be at all, or at least not materially affected; but when the disease has continued for some time, and the curvature is thereby increased, many inconveniences and complaints come on; such as difficulty in respiration, indigestion, pain, and what they call tightness at the stomach, obstinate constipations, purgings, involuntary flux of urine and faeces, &c. with the addition of some nervous complaints, which are partly caused by the alterations made in the form of the cavity of the thorax, and partly by impressions made on the abdominal viscera.

Mr Pott was led to a knowledge of the true cause and cure of this distemper, from observing the case of a youth of 14, who was restored to the use of his limbs immediately after a seemingly accidental abscess near the part. From this he was inclined to think, that the curvature of the spine was not the original cause of the disorder, but that the surrounding parts were predisposed towards it by some affection of the solids and fluids there; and he was confirmed in these suspicions by a variety of appearances, which he observed both in the living body and upon dissection of the subject after death; all of which are narrated at full length in his treatise upon this subject.

"The remedy (says he) for this most dreadful disease consists merely in procuring a large discharge of matter, by suppuration, from underneath the membrana adiposa on each side of the curvature, and in maintaining such discharge until the patient shall have perfectly recovered the use of his legs. To accomplish this purpose, I have made use of different means, such as setons, fistulas made by incision, and fistulas made by cautery; and although there be no very material difference, I do upon the whole prefer the last. A fistula is a painful and a nasty thing; besides which it frequently wears through the skin before the end for which it was made can be accomplished. Fistulas made by incision, if they be large enough for the intended purpose, are apt to become inflamed, and to be very troublesome before they come to suppuration; but openings made by cautery are not in general liable to any of these inconveniences, at least not so frequently nor in the same degree: they are neither so troublesome to make or maintain. I make the fistulas about this size and shape on each side the curve, taking care to leave a sufficient portion of skin between them. In a few days, when the fistula begins to loosen and separate, I cut out all the middle, and put into each a large kidney-bean: when the bottoms of the fores are become clean by suppuration, I sprinkle, every third or fourth day, a small quantity of finely powdered cantharides on them, by which the fores are prevented from contracting, the discharge increased, and possibly other benefit obtained. The fistulas I keep open until the cure is complete; that is, until the patient recovers perfectly the use of his legs, or even for some time longer: and I should think that it would be more prudent to heal only one of them first, keeping the other open for some time; that is, not only until the patient can walk, but until he can walk firmly, briskly, and without the assistance of a stick: until he can stand quite upright, and has recovered all the height which the habit or rather the necessity of stooping, occasioned by the distemper, had made him lose."

**Chap. VIII. Of Blood-letting.**

**Sect. I. Of Blood-letting in general.**

Blood-letting is performed either to lessen the quantity of circulating fluid, or to relieve a particular part; hence we have the terms of general and local blood-letting.

General blood-letting is either performed upon a vein or an artery; and from this circumstance arise the appellations of phlebotomy and arteriotomy.

Local or topical blood-letting is performed by scarificators and cupping-glasses, by leeches, or by punctures made with a lancet, as may be most suitable to the nature of the disease it is intended to remedy.

There are some general rules and observations which relate equally to this operation in whatever part of the body rules it is practised: these we shall in the first place enumerate, and shall afterwards proceed to treat particularly of blood-letting in the arm and other parts.

I. In this, as in every other operation, the situation of the patient, and of the operator likewise, ought to be precisely fixed. The situation of a patient, during the operation of blood-letting, has a considerable influence on the effects produced, and therefore merits particular attention. In some disorders, it is the object of this remedy to evacuate a considerable quantity of blood without inducing fainting: When this is the case, and when from former experience it is known that the patient is liable during the evacuation to fall into a faintish state, a horizontal posture ought to be preferred to every other; for fainting is not near to ready to occur in a horizontal as in an erect posture." It now and then happens, however, however, that one material advantage expected from the operation of blood-letting, is the production of a state of deliquium; as, for instance, in cases of strangulated hernia, where a general relaxation of the system is sometimes desirable. In all such circumstances, instead of a horizontal posture, the more erect the patient is kept, the more readily will a state of fainting be induced. The patient ought to be so placed, that the principal light of the apartment shall fall directly upon the part to be operated upon, that the vein to be opened may be made as apparent as possible.

II. The patient being properly seated, the next step is, by means of a proper bandage of silk, linen, or woollen cloth, which has more elasticity, to compress the vein intended to be opened, as to prevent the blood from returning to the heart. An equal degree of pressure ought to be applied to all the other veins of the part; for this be not attended to, the communication preferred by the collateral corresponding branches would render the pressure upon any one particular vein of very little importance. This pressure upon the veins, by inducing an accumulation of their contents, tends to bring them more evidently into view, and consequently renders it easier for the operator to effect a proper opening than he would otherwise find it. The pressure, however, ought never to be carried so far as to obstruct the circulation in the corresponding arteries, otherwise no discharge of blood can take place. When we see that it has the effect of raising the veins, while at the same time the pulsation of the artery is distinctly felt in that part of the member which lies on the side of the ligature most distant from the heart, we may be certain that it is to a very proper degree, and that it ought not to be carried farther; for by the swelling of the veins we are sure that they are sufficiently compressed; and by the arteries continuing to beat, it is evident that a continued flow of blood may be expected.

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

When it is determined to employ the lancet, which is by far the safest, the form of that instrument is next the object of attention. The broad-shouldered lancet ought to be laid entirely aside; because the broadness of its shoulders produces always a wound in the external teguments of perhaps three times the size of the opening made in the vein; a circumstance which adds no advantage whatever to the operation; on the contrary, it produces much unnecessary pain; renders it frequently a very difficult matter to command a stoppage of the blood; and the wounds produced by it are commonly so extensive as to be liable to terminate in partial suppurations.

The spear-pointed lancet, on the contrary, represented in Plate CCCCLXXXVII, fig. 8, is in every respect well calculated for the purpose of venesection. From the acuteness of its point, it enters the teguments and vein with very little pain; which is with many patients a circumstance of no small importance. We are sure of making the opening in the vein equal, or nearly so, to the orifice in the external teguments; and the discharge of blood produced by an opening made with one of these lancets, is commonly put a stop to with great ease immediately on removing the ligature upon the vein.

IV. The form of lancet being thus fixed upon, we come now to speak of the method of using it. The surgeon and patient being both properly seated, and the ligature having been applied for a short space of time in order to produce some degree of swelling in the veins, that vein is to be made choice of which, at the same time that it appears conspicuously enough, is found to roll less than the others on being pressed upon by the fingers. It is scarcely thought necessary to observe here, that when a vein appears to be so immediately connected with a contiguous artery or tendon, as evidently to produce some risk of wounding these parts in the operation, another vein not liable to such hazard, if it can be procured, ought undoubtedly to be preferred. Veins may lie directly above both arteries and tendons, and yet no manner of risk be incurred by opening them, provided the operator is sufficiently steady and attentive; but it does now and then happen, that veins are so nearly and intimately connected with these parts, as to render it hazardous even for the most dexterous surgeon to attempt this operation.

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

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

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

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

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

VI. A quantity of blood proportioned to the nature of the disorder being thus discharged, the pressure upon the superior part of the vein should be immediately removed; and this being done, if the spear-pointed lancet has been used, all farther loss of blood will in general stop immediately. The contrary of this, however, sometimes occurs, and blood continues to flow freely even after the ligature is removed. When this is the case, the operator ought to compress the vein both above and below the orifice, by means of the finger and thumb of one hand, so as to prevent any farther loss of blood. This being done, and the orifice being cleared of every particle of blood, the sides of it should be laid as closely together as possible; and a piece of court or any other adhesive plaster being so applied as to retain them, it will seldom happen that any kind of bandage is necessary: but when the blood has issued with uncommon violence during the operation, and has been difficult to command after the removal of the ligature, in such instances it will be prudent to apply a small compress of linen over the plaster, and to secure the whole with a linen roller properly applied round the member.

Sect. II. Of Venesection in different Parts of the Body.

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

In forming the choice of a vein from whence blood is to be taken, the general rules we have already laid down upon this point must be here particularly attended to. In general the artery lies so low in this place, that the median basilic vein, under which it commonly runs, may be opened with perfect safety; and as this vein in general appears more conspicuous than any of the others, probably from the continued pulsation of the artery below obstructing in some measure the passage of its contents, it is in this respect therefore more properly calculated for this operation than any of the others. Other circumstances occur too which render the median basilic preferable to the cephalic or median cephalic veins for the operation of blood-letting. The former, viz. the median basilic, is less deeply covered with cellular substance; and by lying towards the inner part of the arm, it is more thinly covered with the tendinous expansion of the biceps muscle than either of the others. From these circumstances, the operation is always attended with less pain when done in this vein than in any of the others.

In very corpulent people, it sometimes happens that all the larger veins lie too deep as not to be discovered by the eye; but when they are sensibly felt by the fingers, even although they cannot be seen, they may be always opened with freedom. In a few instances, however, they can neither be distinguished by the eye nor by the finger: in such a situation, as they may in general be met with about the wrist or on the back-part of the hand, the ligature should be removed from the upper part of the arm; and being applied about half way between the elbow and wrist, the veins below will thereby be brought into view; and wherever a vein can be evidently observed, there can be no danger in having recourse to the operation.

There is only one vein of the neck, viz. the posterior external jugular, which can easily be brought into view as to be with propriety opened; and even this lies deeply covered with parts, not only with the skin and cellular substance, but with the fibres of the platysma myoides muscle; so that a considerable degree of pressure becomes necessary in order to raise it to any height. With a view to produce this, the operator's thumb is commonly advised to be placed upon the vein, so as to compress it effectually about an inch or an inch and a half below where the opening is to be made. This, however, seldom proves sufficient for the purpose, as the blood, on being stopped in its progress through this branch, easily finds a passage to the other veins; so that unless the principal vein on the other side of the neck is also compressed, the vein to be opened can never be fully distended. In order to effect this, a firm compress of linen should be applied on the largest vein on the opposite side of the neck; and an ordinary garter, or any other proper ligature, being laid directly over it, should be tied with a firm knot below the opposite arm-pit; taking care to make such a degree of pressure, as to put an entire stop to the circulation in the vein, which in this way may be easily effected without producing any obstruction to the patient's breathing. But to prevent every inconvenience of this kind, see an instrument contrived for the purpose, Plate CCCCLXXXVII. fig. 9.

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

In order to bring the vein more clearly into view, so as afterwards to be able to open it with more exactness, it has been recommended, that the skin, cellular substance, and muscular fibres covering the vein, should be previously divided with a scalpel before attempting to push the lancet into it. There is not, however, any necessity for this precaution, as it rarely happens that any difficulty is experienced in procuring a free discharge of blood by opening the vein and teguments at once in the manner directed. And it is here, as in every instance where it is necessary to take blood by a lancet, if it is not done at once, the patient is much disappointed, and is sure to attribute the failure entirely to a fault in the operator.

When blood is to be discharged from the veins of the ankle or feet, the ligature being applied a little above the ankle-joint, all the branches of the vena saphena, both in the inside and outside of the foot, come at once into view; and as this vein lies everywhere very superficial, being in general covered with skin only, wherever a pro- per vein appears conspicuously it may with safety be opened.

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

On removing the ligature, the discharge is generally stopped at once; so that a piece of adhesive plaster applied over the orifice answers all the purpose of a bandage. The arm, neck, and ankles are the parts from whence blood is usually taken by venefaction; but on some occasions, where the contiguous parts have been particularly affected, it has been thought advisable to perform venefaction in other places.

When venefaction is to be performed in the veins called ranula under the tongue, the apex of the tongue is to be elevated, and the vein on each side opened, because the opening of one only will hardly ever discharge blood enough. After a sufficient quantity has been discharged, some cold allstringent fluid taken into the mouth will generally stop the hemorrhage.

The vena dorsalis penis, which runs along the back or upper side of this member, being generally pretty much distended, and conspicuous in an inflammation of this part, may be opened about the middle or back part of the penis; and a sufficient quantity of blood be discharged proportionable to the urgency of the symptoms. This being done, apply a compress and bandage proper for the penis. The arteries and nerves which lie on each side of the vein are to be avoided: nor ought the bandage to be too tight, otherwise the inflammation and other symptoms may turn out worse than before.

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

There are several ways of performing the operation of blood-letting in the eyes. We shall here only relate the chief: First, the patient is to be seated conveniently on the bed-side or on a chair, with his head held in a proper posture by an assistant; which done, the surgeon makes a transverse incision with a lancet upon the turgid small vessels in the corners of the eye, so as to open them or cut them quite across. Some use a small pair of scissors, instead of a lancet, to divide the vessels; but in using either of them, the eyelids must be separated from each other by the fingers of one hand, while the vessels are cut by instruments held in the other. Some, again, elevate the small turgid vessels with a crooked needle before they divide them, the eye-lids being in the mean time held asunder by an assistant. The small vessels being thus opened or divided, their discharge of blood should be promoted by fomentations of warm water frequently applied to the eye by means of a sponge or soft linen rags.

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

Sect. III. Of Arteriotomy.

Whatever particular advantages may in theory have been expected from arteriotomy, and however some of its supporters may have recommended it, not only as being in many instances preferable to venefaction, but as an operation perfectly safe even in vessels of considerable size; yet the most strenuous friends to the practice have shrunk from any real attempt of this kind on the larger arteries. In my experience, there have been opened without any danger ensuing; but these are so exceedingly rare, that no practitioner of experience will, from that consideration, be induced coolly to proceed to open any artery of importance. The smaller branches of arteries may indeed be opened with great safety, when they are not deeply covered, and especially when they lie contiguous to bones; but in any of the larger arteries, the attempt must always be attended with so much hazard, and the advantages to be expected from it, in preference to venefaction, are apparently trifling, as must in all probability prevent it from ever being carried into execution.

There are very few arteries, therefore, which, with any propriety, can be opened: the different branches of the temporal are the only arteries indeed from whence blood, in ordinary practice, is ever taken; for although the opening of some other branches of arteries has by some been proposed, yet they are situated in such a manner that they either cannot be readily come at, or being in the neighbourhood of so large nerves, the opening of them might be attended with bad consequences. In performing this operation on any of the temporal branches, if the artery lies superficial, it may be done with one push of the lancet, in the same manner as was directed for venefaction; but when the artery lies deeply covered with cellular substance, it is always necessary to lay it fairly open to view, before making the orifice with the lancet: for in all the smaller arteries, when they are cut entirely across, there is little chance of being able to procure any considerable quantity of blood from them; as, when divided in this manner, they are sure to retract considerably within the surrounding parts, which commonly puts a stop to all farther evacuation.

Some degree of nicety is also necessary in making the opening into the artery of a proper oblique direction, neither quite across nor directly longitudinal; for a longitudinal opening never bleeds so freely, either in an artery or in a vein, as when its direction is somewhat oblique.

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

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

In this situation there are three different methods by which we may with tolerable certainty put a stop to the farther discharge of blood. 1st, If the artery is small, as all the branches of the temporal arteries commonly are, the cutting it entirely across, exactly at the orifice made with the lancet, by allowing it to retract within the surrounding parts, generally puts an immediate stop to the discharge. 2d, When that is not consented to, we have it always in our power to secure the bleeding vessel with a ligature, as we would do an artery accidentally divided in any part of the body. And, lastly, if neither of these methods is agreed to by the patient, we can, by means of a constant regular pressure, obliterate the cavity of the artery at the place where the operation has been performed, by producing the accretion of its sides. Different bandages have been contrived for compressing the temporal artery; but none of them answer the purpose so easily and so effectually as the one figured in Plate CCCCLXXXVII. fig. 10. This method is more tedious; but to timid patients it generally proves more acceptable than either of the other two.

Sect. IV. Of Topical Bleeding.

When, either from the severity of a local fixed pain, or from any other cause, it is wished to evacuate blood directly from the small vessels of the part affected, instead of opening any of the larger arteries or veins, the following are the different modes proposed for effecting it, viz. by means of leeches; by slight scarifications with the shoulder or edge of a lancet; and, lastly, by means of an instrument termed a scarificator, (Plate CCCCLXXXVII. fig. 11.) in which fifteen or twenty lancets are commonly placed, in such a manner, that, when the instrument is applied to the part affected, the whole number of lancets contained in it are, by means of a strong spring, pushed suddenly into it, to the depth at which the instrument has been previously regulated. This being done, as the smaller blood-vessels only by this operation are ever intended to be cut, and as these do not commonly discharge freely, some means or other become necessary for promoting the evacuation.

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

The application of heat to the cupping-glaies, represented in Plate CCCCLXXXVII. fig. 12, has been found to rarefy the air contained in them to a degree sufficient for producing a very considerable suction. And as the instrument in this simple form answers the purpose in view with very little trouble to the operator, and as it is at all times easily obtained, the use of the syringe has therefore been laid aside.

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

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

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

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

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

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

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

**CHAP. IX. Of Issues.**

Issues are a kind of artificial ulcers formed in different parts of the body with a view to procure a discharge of purulent matter, which is frequently of advantage in different disorders.

Practitioners were formerly of opinion that issues served as drains to carry off the noxious humours from the blood, and therefore they placed them as near the affected part as possible. But as it is now known that they prove useful merely by the quantity of matter which they afford, they are generally placed where they will occasion the least inconvenience. The most proper parts for them are, the nape of the neck; the middle, outer, and fore part of the humerus; the hollow above the inner side of the knee; or either side of the spine of the back; or between two of the ribs; or wherever there is a sufficiency of cellular substance for the protection of the parts beneath: they ought never to be placed over the belly of a muscle; nor over a tendon, or thinly covered bone; nor near any large blood-vein.

The issues commonly used are, the blister-issue, the pea-issue, and the feton or cord.

When a blister-issue is to be used, after the blister is removed, a discharge of matter may be kept up by dressing the part daily with an ointment mixed with the powder of cantharides. If the discharge be too little, more of the powder may be used; if too great, or if the part be much inflamed, the issue ointment may be laid aside, and the part dressed with basilicon, or with Turner's cerate, till the discharge be diminished and the inflammation abated. It is most proper sometimes to use the issue ointment and a mild one alternately.

A pea-issue is formed either by making an incision with a lancet, or by cautile, large enough to admit one or more peas; though sometimes instead of peas, kidney-beans, Gentian root, or orange-peas, are used. When the opening is made by an incision, the skin should be pinched up and cut through, of a size sufficient to receive the substance to be put into it. But when it is to be done by cautile, the common cautile or lapis internalis of the shops answers best: it ought to be reduced to a paste with a little water or soft soap, to prevent it from spreading; and adhesive plaster, with a small hole cut in the centre of it, should be previously placed, and the cautile paste spread upon the hole in the centre. Over the whole an adhesive plaster should be placed to prevent any cautile from escaping. In ten or twelve hours, the whole may be removed, and in three or four days the cicatrix will separate, when the opening may be filled with peas, or any of the other substances already mentioned.

**CHAP. X. Of Sutures and Ligatures of Arteries.**

**Sect. I. Of Sutures.**

The intention of sutures is to unite parts which have been divided, and where the retraction of the lips of the wound has been considerable. The sutures in ordinary use at present, among surgeons, are the interrupted, the quilled, and the twisted. Besides these sutures, adhesive plasters are used for uniting the lips of wounds, which have been termed the false or dry suture, in opposition to the others which have obtained the name of true or bloody. The true suture is used in cases of deep wounds, while the false is employed in those of a superficial nature.

The interrupted suture is made as follows. The wound being emptied of the grumous blood, and the assistant taking care that the lips of it lie quite even, the surgeon is careful fully to carry the needles from the bottom outwards; using the caution of making them come out far enough from the edge of the wound, which will not only facilitate the passing the ligature, but will also prevent it from cutting through the skin and flesh; as many more stitches as may be required will be only repetitions of the same process. The threads being all passed, let those be first tied which are 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 is a single one first, and then a slip-knot, which may be loosed upon any considerable inflammation taking place. 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 suture. 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, after the lips are firmly agglutinated, the ligatures are to be removed, and the orifices which they leave drefted.

It will readily be understood, that the strength of the ligature and size of the needle ought always to be proportionable to the depth of the sore and retraction of the parts. The proper form of needles is represented in Pl. CCCCLXXXVII., fig. 14.

It must likewise be remembered, that during the cure the future must be always assisted by the application of bandage, if possible, which is frequently of the greatest importance; and that sort of bandage with two heads, and a slit in the middle, In deep wounds, attended with much retraction, it is always a necessary precaution, to assist the operation of the ligatures by means of bandages, so applied as to afford as much support as possible to the divided parts: But even with every affiance of this nature, it now and then happens, that the divided parts cannot be kept together, retraction occurs to a greater or lesser degree, and the ligatures of course cut afoul the soft parts they were at first made to surround.

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

It is at once evident, however, that the ligatures must here make the same degree of pressure on the parts through which they pass as they do in the interrupted future; and this being the case, it is equally obvious, that the introduction of these substances cannot be of any use. This future is accordingly now very rarely practised, and it is probable that it will be soon laid entirely aside.

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

This future is commonly employed for the purpose of uniting the parts in cases of hare-lip; and this indeed is almost the only use to which it has been hitherto applied: But it may with great advantage be put in practice in a variety of other cases, particularly in all artificial or accidental divisions either of the lips or cheeks; and in every wound in other parts that does not run deep, and in which futures are necessary, this future is preferable to the interrupted or any other. The pins made use of for twisting the threads upon ought to be made of a flat form, so as not to cut the parts through which they pass so readily as the ligatures employed in the interrupted future. And thus one great objection to the latter is very effectually obviated: for every practitioner must be sensible of this being the most faulty part of the interrupted future, that when muscular parts are divided so as to produce much retraction, the ligatures employed for retaining them almost constantly cut them through before a reunion is accomplished; whereas the flatness of the pins used in the twisted future, and upon which the whole pressure produced by the ligatures is made to rest, proves in general a very effectual preventative against all such occurrences.

The pins used in this operation are represented in Plate CCCCLXXXVII. fig. 15. They are commonly made of gold or silver; and in order to make them pass with greater ease, steel points are added to them. They are sometimes used, however, of gold or silver alone.

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

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

The first pin being passed in this manner very near to one end of the sore, and the parts being still supported by an assistant, the surgeon, by means of a firm waxed ligature, passed three or four times round and across the pin, so as nearly to describe the figure of 8, is to draw the parts through which it has passed into immediate and close contact: and the thread being now secured with a loose knot, another pin must be introduced in the same manner at a proper distance from the former; and the thread with which the other was fixed being loosed, and in the same manner carried round this pin, others must be introduced at proper distances along the whole course of the wound; and the same ligature ought to be of a sufficient length for securing the whole.

The number of pins to be used must be determined entirely by the extent of the wound. Whenever this future is practised, a pin ought to be introduced very near each end of the wound, otherwise the extremities of the sore are apt to separate so as not to be afterwards easily reunited. In large wounds, if the pins are introduced at the distance of three quarters of an inch from one another, it will in general be found sufficient; but in cuts of smaller extent a greater number of pins become necessary in proportion to the dimensions of the fores.

Thus in a wound of an inch and half in length, three pins are absolutely requisite; one near to each end, and another in the middle of the sore: whereas five pins will always be found fully sufficient for a wound of three inches and a half in extent, allowing one to be within a quarter of an inch of each extremity of the wound, and the others to be placed along the course of the sore at the distance of three quarters of an inch from one another.

The pins being all introduced and secured in the manner directed, nothing remains to be done, but to apply a piece of lint wet with mucilage all along the course of the wound, with a view to exclude, as effectually as possible, every access to the external air.

When the pins remain long, they generally do harm, by the unnecessary irritation and consequent retraction of parts with which they are always attended; and if they are not continued for a sufficient length of time, that degree of adhesion is not produced between the divided parts which is necessary for their future retention; so that the effect of the operation comes to be in a great measure, if not entirely, lost.

In wounds of no great depth, for instance of three quarters of an inch or so, a sufficient degree of adhesion always takes place in the space of five days; and fix, or at most seven days, will generally be found sufficient for wounds of the greatest depth. But with respect to this circumstance, it must always be understood, that the patient's state of health must have a considerable influence on the time necessary for producing adhesion between divided parts.

When the pins are withdrawn, the uniting bandage may Ligature of Arteries.

When a surgeon is called immediately to a wound of any great artery of a limb, he should clap the point of his finger upon the wounded artery, or make his assistant hold it; cut the wound so far open as to see the artery fairly; draw it out if it be cut across, and have shrunk among the flesh; or tie it like the artery of the arm in aneurism by passing ligatures under it. When, however, the wound happens in such situations that we cannot command the blood, it is better to close the lips of the wound, and try to make them adhere by means of a very steady compress and bandage. Thus an aneurism will form; the operation for the cure of which shall be afterwards described.

When accidents of this nature occur in any of the extremities, and where pressure can be made with ease on the superior part of the artery, we are possessed of an instrument which never fails to put a stop to all further loss of blood; we mean the tourniquet. See Plate CCCCLXXXVII. fig. 16.

The tourniquet has undergone many improvements; but the one here represented is considered as the best. By means of it the blood in any limb is very easily and effectually commanded; and as it grasps the whole member equally, all the collateral branches, as well as the principal arteries, are equally compressed by it. It has this material advantage too over every other instrument of this kind, that, when properly applied, a single turn, or even half a turn, of the screw, is sufficient for producing either a flow of blood, or for putting a total stop to it. The manner of using it is as follows.

Let a cushion of three inches in length by one inch and half in diameter be prepared of a linen roller, tolerably firm, but not so hard as to render pressure produced by it very painful. This being placed upon the course of the principal artery of the limb, is to be firmly secured in that situation by one or two turns of a circular roller, of the same breadth with the cushion itself.

The instrument, with the strap connected with it, being now placed upon the limb, with the handle of the screw on the opposite side of the member to the cushion upon the artery, the strap is to be carried round the limb directly over the cushion, and to be firmly connected on the other side of the buckle. In thus connecting the strap and buckle together, particular attention is necessary in doing it with great firmness, so as that the screw may afterwards operate with as much advantage as possible in producing a sufficient degree of pressure. When proper attention is paid to this circumstance, a single turn of the screw proves sufficient for putting an entire stop to the circulation of blood in the limb; but when the strap has not originally been made very tight, several turns of the screw become necessary; an occurrence which may be always very easily prevented, and which, when not attended to, frequently proves very embarrassing in the course of an operation.

Various methods have been invented for securing arteries by means of ligatures. The practice till lately in ordinary use was, by means of a curved needle, to pass a ligature of sufficient strength round the mouth of the bleeding vessel, including a quarter of an inch all round of the surrounding parts, and afterwards to form a knot of a proper tightness upon the vessel and other parts comprehended in the noose.

But this method was found to give so much pain, and in some cases to be attended with such violent convulsions, not only in the part chiefly affected, but of the whole body, that the best practitioners have thought proper to reject it, and to tie up the blood-vessels by themselves; for it is now well known that even very small arteries are possessed of much firmness; and that even in the largest arteries a slight degree of compression is sufficient not only for restraining hemorrhage, but for securing the ligature on the very spot to which it is first applied.

In order to detect the arteries to be tied, the tourniquet, with which they are secured, must be slackened a little by a turn or two of the screw; and the moment the largest artery of the fore is discovered, the surgeon fixes his eye upon it, and immediately restrains the blood again by means of the tourniquet. An assistant now forms a noose on the ligature to be made use of; and this noose being put over the point of the tenaculum, Plate CCCCLXXXVII. fig. 17, the operator pushes the sharp point of the instrument through the sides of the vessel, and at the same time pulls so much of it out, over the surface of the surrounding parts, as he thinks is sufficient to be included in the knot which the assistant is now to make upon the artery. In forming this ligature a single knot moderately drawn, and over it another single knot, is perfectly sufficient.

When from the deepness of a wound, or from any other cause, some particular artery cannot be properly secured by the tenaculum; in this case there is a necessity of employing the crooked needle, and the following is the method of using it.

A needle of the shape represented Pl. CCCC.XXXVII. fig. 14, armed with a ligature of a size proportioned to itself and to the vessel to be taken up, is to be introduced at the distance of a sixth or eighth part of an inch from the artery, and pushed to a depth sufficient for retaining it, at the same time that it is carried fully one half round the blood-vessel. It must now be drawn out; and being again pushed forward till it has completely encircled the mouth of the artery, it is then to be pulled out; and a knot to be tied of a sufficient firmness, as was already directed when the tenaculum is used.

Chap. XI. Of Aneurisms.

The term Aneurism was originally meant to signify a tumor formed by the dilatation of the coats of an artery; but by modern practitioners it is made to apply not only to tumors of this kind, but to such as are formed by blood effused from arteries into the contiguous parts. There are three species; the true or encysted, the false or diffused, and the varicose aneurism.

The true or encysted aneurism, when situated near the surface of the body, produces a tumor at first small and circumscribed; the skin retains its natural appearance; when pressed by the fingers, a pulsation is evidently diminished; and with very little force the contents of the swelling may be made to disappear; but they immediately return upon removing the pressure. By degrees the swelling increases, and becomes more prominent; but still the patient does not complain of pain: on pressure the tumor continues of an equal softness, and is compressible. After this the swelling becomes large, the skin turns paler than usual, and in more advanced stages edematous: the pulse still continues; but parts of the tumor become firm from the coagulation of the contained blood, and yield little to pressure; at last the swelling increases in a gradual manner, and is attended with a great degree of pain. The skin turns livid, and has a gangrenous appearance. An oozing of bloody Aneurisms bloody serum occurs from the integuments; and, if a real mortification do not take place, the skin cracks in different parts; and the artery being now deprived of the usual resistance, the blood bursts out with such force as to occasion the almost immediate death of the patient. Thus the disease terminates in the large cavities of the body; but in the extremities we can, by means of the tourniquet, prevent the sudden termination of the disease.

When affections of this kind happen in the larger arteries, the effects produced upon the neighbouring parts are often surprising: the soft parts not only yield to a great extent, but even the bones frequently undergo a great degree of derangement.

The false or diffused aneurism consists in a wound or rupture in an artery, producing, by the blood thrown out of it, a swelling in the contiguous parts. It is most frequently produced by a wound made directly into the artery.

The following is the usual progress of the disorder. A tumor, about the size of a horse-bean, generally rises at the orifice in the artery soon after the discharge of the blood has been stopped by compression. At first it is soft, has a strong degree of pulsation, and yields a little to pressure, but cannot be made entirely to disappear; for here the blood forming the tumor being at rest, begins to coagulate. If not improperly treated by much pressure, it generally remains nearly of the same size for several weeks. The enlargement however proceeds more rapidly in some cases than in others. Instances have occurred of the blood being diffused over the whole arm in the space of a few hours; while, on the contrary, swellings of this kind have been many months, nay even years, in arriving at any considerable size.

As the tumor becomes larger, it does not, like the true aneurism, grow much more prominent, but rather spreads and diffuses itself into the surrounding parts. By degrees it acquires a firm consistence; and the pulsation, which was at first considerable, gradually diminishes, till it is sometimes scarcely perceptible. If the blood at first thrown out proceed from an artery deeply seated, the skin preserves its natural appearance till the disorder is far advanced; but when the blood gets at first into contact with the skin, the parts become instantly livid, indicating the approach of mortification; and a real sphacelus has sometimes been induced. The tumor at first produces little uneasiness; but as it increases in size, the patient complains of severe pain, stiffness, numbness, and immobility of the whole joint; and these symptoms continuing to augment, if the artery be large, and assistance not given, the teguments at last burst, and death must ensue.

When an artery is punctured through a vein, as in blood-letting at the arm, the blood generally rushes into the yielding cellular substance, and there spreads so as to shut the sides of the vein together. But in some instances where the artery happens to be in contact with the vein, the communication opened has been preserved; and the vein not being sufficiently strong for resisting the impulse of the artery, must consequently be dilated. This is a varicose aneurism. It was first accurately described by Dr Hunter, and since that time has been frequently observed by different practitioners. Here the swelling is entirely confined to the veins. Soon after the injury the vein immediately communicating with the artery begins to swell, and enlarge gradually. If there be any considerable communications in the neighbourhood, the veins which form them are also enlarged. The tumor disappears upon pressure, the blood contained in it being chiefly pushed forwards in its course towards the heart; and when the tumor is large, there is a finger tremulous motion, attended with a perpetual hissing noise, as if air was passing into it through Aneurism's small aperture.

If a ligature be applied upon the limb immediately below the swelling, tight enough to stop the pulse in the under part of the member, the swelling disappears by pressure, but returns immediately upon the pressure being removed. If, after the swelling is removed by pressure, the finger be placed upon the orifice in the artery, the veins remain perfectly flaccid till the pressure is taken off. If the trunk of the artery be compressed above the orifice so as effectually to stop the circulation, the tremulous motion and hissing immediately cease; and if the veins be now emptied by pressure, they remain so till the compression upon the artery be removed. If the vein be compressed a little above, as well as below the tumor, all the blood may generally, though not always, be pushed through the orifice into the artery; from whence it immediately returns on the pressure being discontinued.

When the disease has continued long, and the dilatation of the veins has become considerable, the trunk of the artery above the orifice generally becomes greatly enlarged, while that below becomes proportionally small; of consequence the pulse in the under part of the member is always more feeble than in the sound limb of the opposite side.

The causes producing aneurisms, in general, are a natural disuse of the arteries. Thus a partial debility of their coats may readily produce the disease; or they may arise, especially in the internal parts of the body, from great bodily exertions. They are likewise produced by wounds of the coats of the arteries, as now and then happens in blood-letting at the arm; or from acid matter contained in a neighbouring sore; or from the destruction of surrounding parts, by which the natural support is removed.

Aneurisms have frequently been mistaken for abscesses and other collections of matter, and have been laid open by incision; on which account great attention is sometimes required to make the proper distinction. In the commencement of the disease the pulsation in the tumor is commonly so strong, and other concomitant circumstances so evidently point out the nature of the disorder, that little or no doubt respecting it can ever take place; but in the more advanced stages of the disease, when the swelling has become large and has lost its pulsation, nothing but a minute attention to the previous history of the case can enable the practitioner to form a judgment of its nature.

Aneurisms may be confounded with soft encysted tumors, phlebotomous swellings, and abscesses situated near to an artery as to be affected by its pulsation. But one symptom, when connected with strong pulsation, may always lead to a certain determination that the swelling is of the aneurismal kind, viz. the contents of the tumor being made easily to disappear upon pressure, and their returning on the compression being removed. The want of this circumstance, however, ought not to convince us that it is not of that nature; for it frequently happens, especially in the advanced stages of aneurisms, that their contents become so firm that no effect is produced upon them by pressure. Hence the propriety, in doubtful cases, of proceeding as if the disease was clearly of the aneurismal kind.

In the prognosis, three circumstances are chiefly to be attended to; the manner in which the disease appears to have been produced, the part of the body in which the swelling is situated, and the age and habit of the body of the patient.

If an aneurism has come forward in a gradual manner, without any apparent injury done to the part, and not succeeding any violent bodily exertion, there will be reason to Aneurism suppose that the disease depends upon a general affection either of the trunk in which it occurs, or of the whole arterial system. In such cases art can give little assistance; whereas if the tumor has succeeded an external accident, an operation may be attended with success.

In the varicose aneurism a more favourable prognosis may generally be given than in either of the other two species. It does not proceed so rapidly; when it has arrived at a certain length, it does not afterwards acquire much additional size; and it may be sustained without much inconvenience for a great number of years. As long as there is reason to expect this, the hazard which almost always attends the operation ought to be avoided.

In the second volume of the London Medical Observations, two cases are related by Dr Hunter of the varicose aneurism. One of them at that time was of 14 years standing, and the other had subsisted for five years, without there being any necessity for an operation. And in vol. iii. of the same work a similar case of five years duration is related by Dr Cleghorn.

In a letter afterwards from Dr Hunter to Mr Benjamin Bell, the Doctor says, "The lady in whom I first observed the varicose aneurism is now living at Bath in good health, and the arm is in no sense worse, although it is now 35 years since she received the injury;" and the Doctor farther observes, that he never heard of the operation being performed for the varicose aneurism which was known to be such.

Mr Bell says, he was informed by Dr William Cleghorn of Dublin, that the case of varicose aneurism, related in the 3d volume of the London Medical Observations, remained nearly in the same state as at the time that account of it was made out, which included a period of at least 20 years; only that the veins were rather more enlarged. The patient recovered, and the limb became nearly as strong and serviceable as the other. Mr Pott also met with three different instances of this species of aneurism; and observes, that the operation never became necessary in any of them.

Among other instances of varicose aneurism which have appeared here, a young man from Paisley was examined several years ago by different surgeons of this place. The disease was very clearly marked, and no operation was advised. He was afterwards found serving in the navy, where he underwent great fatigue without any inconvenience from the aneurism, though then of 13 years standing.

But though this aneurism, when it has arrived at a certain size, commonly remains stationary, and may be borne without much inconvenience for a long time, this is not always the case; for some instances have occurred, where the disease was attended with great uneasiness, and where the operation was performed with much difficulty.

In judging further of the probable event of aneurisms in general, the situation of the tumor next requires attention. When it is so situated that no ligature or effectual compression can be applied for stopping the circulation in the part, if the artery be large, there would be the greatest danger in opening it. In this case therefore the most fatal consequences are to be apprehended.

When aneurisms are situated near the upper parts of the extremities, surgeons have been hitherto doubtful whether, after tying up the humeral or femoral arteries, the lower parts of the limb would be supplied with blood; and tho' several successful instances of performing that operation have been published, the success has been pretty generally ascribed to unusual branching of the great arteries of those patients, on whom the operation was performed, above the aneurism. Mr John Bell, however, in his late very ingenious and important Discourses on Wounds, has proved, to our satisfaction at least, that the inoculations which take place between the internal iliac and the arteries of the leg, by Dif. 2, means of the glutaeal arteries and the profunda femoris, are in every case sufficient to supply nourishment to the limb; that the same is the case in the arm; and that therefore in every aneurism, even of the humeral or femoral artery, we ought to perform the operation. Several instances of success are there related; among others, an operation performed by Mr J. Bell himself, which, as it is perhaps the first, greatest that has hitherto been performed, we shall here abridge for the gratification of our readers. A leech-catcher fell as he was stepping out of a boat; and a pair of long-pointed scissors pierced his hip exactly over the iliac notch, where the great iliac artery comes out from the pelvis. The artery bled furiously; the patient fainted. The surgeon easily flopped up the wound, as it was very narrow and deep, and healed it. A great tumor soon formed. The man travelled from the north country in six weeks to the Edinburgh infirmary, with a prodigious tumor of the hip, the thigh rigidly contracted, the ham bent, the whole leg shrunk and cold and useless. There was no pulsation nor retrocession of blood on pressure; but the distention was attended with great pain, and the man was extremely anxious to have an operation performed. Though there was little doubt of its being aneurism, it might be a great abscess. It was resolved therefore to make a small incision, and just touch the bag with the point of a lancet, and if it contained blood, a full consultation was to be called. Mr Bell accordingly made an incision two inches and an half in length; the great fascia formed the coat of the tumor, and under it were seen the fibres of the great glutaeus muscle. As soon as it was opened at one point, great clots of blood came out; and Mr Bell, after being certain that it was an aneurism of the great artery of the thigh, clasped up the wound with a tent-like compress, put the patient to bed, and a pupil held his hand on the hip. This was done at one o'clock; at four the consultation met, and the operation was performed. On making an incision eight inches long, the blood was thrown out with a whistling noise, and with such impetuosity, that the assistants were covered with it. In a moment twenty hands were about the tumor, and the bag was filled with sponges and cloths of all kinds; the blood, however, still made its way; and the man who had supported himself on his elbow, fell down; his arms and head hung down, he uttered two or three heavy groans, and they thought him dead. At that critical moment Mr Bell ran the bistoury upwards and downwards, and at once made the wound two feet long; thrust his hand to the bottom of the tumor, felt the warm jet of blood, put his finger on the mouth of the artery, the pulse of which he felt distinctly; which first assured him that the man was alive. The artery was then tied; and when Mr Bell lifted up his finger, it was discovered to be the posterior iliac; that it had been cut fairly across, and had bled with open mouth. The patient was so low, that after dressing the wound, they were obliged to bring in a bed, and leave him to sleep in the operation room. He was cured of this great wound in less than seven months, and afterwards recovered the use of his leg completely.

In every case of aneurism, the use of pressure has been effects of indiscriminately recommended, not only in the incipient pre-pressure in riod of the disease, but even in its more advanced stages.

In the diffused or false aneurism, as pressure cannot be applied to the artery alone, without at the same time affecting the refulgent veins; and as this, by producing an increased resistance to the arterial pulsations, must force an additional quantity of blood to the orifice in the artery—no advantage Aneurism is to be expected from it, though it may be productive of mischief.

In the early stages of encysted aneurism, while the blood can be yet pressed entirely out of the sac into the artery, it often happens, by the use of a bandage of soft and somewhat elastic materials, properly fitted to the part, that much may be done in preventing the swelling from receiving any degree of increase; and on some occasions, by the continued support thus given to the weakened artery, complete cures have been at last obtained. In all such cases, therefore, particularly in every instance of the varicose aneurism, much advantage may be expected from moderate pressure.

But pressure, even in encysted aneurism, ought never to be carried to any great length; for tight bandages, by producing an immoderate degree of reaction in the containing parts to which they are applied, instead of answering the purpose for which they were intended, have evidently the contrary effect. Indeed the greatest length to which pressure in such cases ought to go, should be to serve as an easy support to the parts affected, and no farther.

In performing the operation for aneurism, the first step ought to be to obtain a full command of the circulation in the inferior part of the member by means of the tourniquet. This being done, the patient should be so placed, that the diseased limb, on being stretched on a table, is found to be of a proper height for the surgeon; who, as the operation is generally tedious, ought to be seated. The limb being properly secured by an assistant, the operator is now with the scalpel, Plate CCCCLXXXVII. fig. 18, to make an incision through the skin and cellular substance along the whole course of the tumor; and as freedom in the remaining parts of the operation is here a matter of much importance, it is even of use to carry this external incision half an inch or so both above and below the farthest extremities of the swelling.

All the effused blood ought then to be wiped off by means of a sponge; and the softest part of the tumor being discovered, an opening ought there to be made into it with the lancet, Plate CCCCLXXXVII. fig. 19, large enough for admitting a finger of the operator's left-hand. This being done, and the finger introduced into the cavity of the tumor, it is now to be laid open from one extremity to the other, by running a blunt-pointed bistoury, Plate CCCCLXXXVII. fig. 20, along the finger from below upwards, and afterwards from above downwards, so as to lay the whole cavity fairly open.

The cavity of the tumor being thus laid freely open, all the coagulated blood is to be taken out by the fingers of the operator, together with a number of tough membranous filaments commonly found here. The cavity of the tumor is now to be rendered quite dry, and free from the blood which, on the first opening of the swelling, is discharged into it from the veins in the inferior part of the member: the tourniquet is then to be slackened to discover, not only the artery itself, but the opening into it, from whence the blood collected in the tumor has been all along discharged. This being done, the next point to be determined is the manner of securing this opening into the artery, so as to prevent in future any farther effusion of blood. Various means have been proposed for accomplishing this; but the effects of all of them may be comprehended under the three following heads.

1. The effects of ligature upon a large artery having on some occasions proved fatal to the inferior part of the member, it was long ago proposed, that so soon as the opening into the artery has been discovered, instead of applying a ligature round it, which for certain is to obliterate its cavity entirely, a piece of agaric, vitriol, alum, or any other astringent substance, should be applied to the orifice, in order if possible to produce a reunion of its sides.

2. Upon the same principle with the preceding, viz. that of still preserving the circulation in the artery, it was several years ago proposed by an eminent surgeon of Newcastle, Mr Lambert, that the orifice in the artery should be secured by means of the twisted future. A small needle being pushed through the edges of the wound, they are then directed to be drawn together by a thread properly twisted round the needle, as was formerly directed when treating of futures.

Strong objections, however, occur to both of these methods. In the first place, no astringent application with which we are acquainted is possessed of such powers as to deserve much confidence. In almost every instance in which they have been used, the hemorrhagy has recurred again and again, so as to prove very distressing, not only to the patient, but to the practitioner in attendance; little or no attention is therefore to be paid to remedies of this kind in ordinary practice.

Mr Lambert's method of stitching the orifice in the artery is certainly a very ingenious proposal; and would in all probability, at least in most instances, prove an effectual stop to all farther discharge of blood: but as we have yet only one instance of its success, little can be said about it. Two material objections, however, seem to occur to this practice. One is, that in the operation for the aneurism, in almost every instance, a very few only excepted, the artery lies at the back-part of the tumor; so that when all the collected blood is removed, there is such a depth of wound, that it must be always a very difficult matter, and on many occasions quite impracticable, to perform this nice operation upon the artery with that attention and exactness which, in order to ensure success, it certainly requires. But there is another very material objection. By introducing a needle through the sides of the orifice, and drawing these together by a ligature, the cavity of the artery must undoubtedly be at that point much diminished. Indeed Mr Lambert, in his account of the case in which this operation was performed, acknowledges that the diameter of the artery was thereby diminished. Now the passage of the blood being thus contracted at one point, the impulse upon that particular part must be very considerable: So that the very remedy employed for the cure of one species of aneurism, will in all probability prove a very powerful agent in inducing another; for the blood, being thus obstructed in its usual course, there will be no small danger incurred of a dilatation being produced immediately above this preternatural stricture.

3. Neither of the methods we have yet been considering being found eligible for securing the orifice in the artery, we shall now proceed to describe the ordinary manner of performing this operation; which consists in obliterating the arterial cavity entirely by means of ligatures.

The artery being laid bare in the manner directed, and all the coagulated blood being carefully removed from the cavity of the tumor, on the tourniquet being now slackened, so as to bring the orifice in the artery into view, a small probe curved at the extremity is to be introduced at the opening, in order to raise the artery from the neighbouring parts, so that the surgeon may be enabled with certainty to pass a ligature round it, without comprehending the contiguous nerves, which in general run very near to the large blood-vessels of a limb. By this precaution the nerves may be always avoided; and by doing so, a great deal of mischief may be prevented, which otherwise might supervene. When the disorder is situated either in the ham, or in the usual part of blood-letting in the arm, bending the joints of Aneurism, the knee or of the elbow, as it relaxes the artery a little, renders this part of the operation more easily effected than when the limbs are kept fully stretched out.

The artery being thus gently separated from the contiguous parts, a firm waxed ligature must be passed round it, about the eighth part of an inch or so above the orifice, and another must in the same manner be introduced at the same distance below it.

The ligatures being both finished in the manner directed, the tourniquet is now to be made quite loose; and if no blood is discharged at the orifice in the artery, we may then rest satisfied that the operation is so far properly completed.

The wound is now to be lightly covered with soft lint, with a pledget of any emollient ointment over the whole; and a compress of linen being applied over the dressings, all the bandage in any degree requisite is two or three turns of a roller above and as many below the centre of the wound, making it press with no more tightness than is absolutely necessary for retaining the application we have just now mentioned.

The patient being now put into bed, the member should be laid in a relaxed posture upon a pillow, and ought to be so placed as to create the least possible uneasiness from the posture in which it is laid.

As the operation for the aneurism is always tedious, and produces much pain and irritation, a full dose of laudanum should be given immediately on the patient being got into bed. In order to diminish sensibility during some of the more capital operations, different trials have been made of opiates given an hour or so before the operation. On some occasions this proved evidently very useful; but in others it seemed to have the contrary effect; particularly in weak nervous constitutions, in which with any doses, however small, they appeared to be rendered more irritable and more susceptible of pain, than if no opiate had been given. Immediately after this operation, however, an opiate ought to be exhibited, to be repeated occasionally according to the degrees of pain and restlessness.

In some few cases of aneurism, it has happened that the pulse in the under part of the member has been discovered immediately after the operation. This, however, is a very rare occurrence: For as this disorder is seldom met with in any other part than at the joint of the elbow as a consequence of blood-letting, and as it rarely happens that the brachial artery divides till it passes an inch or two below that place, the trunk of this artery is therefore most frequently wounded; and when, accordingly, the ligature, in this operation, is made to obliterate the passage of almost the whole blood which went to the under part of the arm, there cannot be the least reason to expect any pulsation at the wrist, till in a gradual manner the anastomosing branches of the artery have become so much enlarged as to transmit such a quantity of blood to the inferior part of the member as is sufficient for acting as a stimulus to the larger branches of the artery.

Immediately after the operation, the patient complains of an unusual numbness or want of feeling in the whole member; and as it generally, for a few hours, becomes cold, it is therefore right to keep it properly covered with warm soft flannel; and in order to serve as a gentle stimulus to the parts below, moderate frictions appear to be of use. In the space of ten or twelve hours from the operation, although the numbness still continues, the heat of the parts generally begins to return; and it frequently happens, in the course of a few hours more, that all the inferior part of the member becomes even preternaturally warm.

Immediately after this operation, the want of feeling in the parts is often very great; and in proportion as the circulation in the under part of the member becomes more considerable, the degree of feeling also augments. If we could suppose the nerves of the parts below to be always included in the ligature with the artery, that numbness which succeeds immediately to the operation might be easily accounted for; but it has been also known to happen when nothing but the artery was secured by the ligature.

In the mean time, the patient being properly attended to as to regimen, by giving him cordials and nourishing diet when low and reduced, and confining him to a low diet if his constitution is phlegmatic, the limb being still kept in an easy relaxed posture, towards the end of the fourth or fifth day, sometimes much sooner, a very weak feeble pulse is discovered in the under part of the member, which becoming stronger in a gradual manner, the patient in the same proportion recovers the use and feeling of the parts.

So soon as there is an appearance of matter having formed freely about the sore, which will seldom happen before the fifth or sixth day, an emollient poultice should be applied over it for a few hours, in order to soften the dressings, which may be then removed. At this time the ligatures might be taken away; but as their continuance for a day or two longer can do no harm, it is better to allow them to remain till the second or third dressing, when they either drop off themselves, or may be taken away with perfect safety. The dressings, which should always be of the softest materials, being renewed every second or third day according to the quantity of matter produced, the sore is in general found to heal very easily; and although the patient may for a considerable time complain of great numbness and want of strength in the whole course of the diseased limb, yet in most instances a very free use of it is at last obtained.

Very often after the artery seems to be secured it gives way, and fatal hemorrhages ensue; nor is the patient free from this danger for a great length of time. In one of Mr. Hunter's operations the artery gave way on the 26th day. It is to this difficulty of procuring adhesion between the sides of the artery that a great part of the danger of this operation is to be ascribed.

CHAP. XII. Of Affections of the Brain from External Violence.

When the brain is compressed, a set of symptoms ensues extremely dangerous, though sometimes they do not make their appearance till after a considerable interval. But whatever time they appear, they are uniformly of the same kind, and are in general as follow: drowsiness, giddiness, and stupification, dimness of sight, dilatation of the pupil; and, where the injury done to the head is great, there is commonly a discharge of blood from the eyes, nose, and ears. Sometimes the fractured bone can be discovered through the integuments, at others it cannot. There is an irregular and oppresed pulse, and frothing or apoplectic fever in breathing. There is likewise nausea and vomiting, with an involuntary discharge of faeces and urine. Among the muscles of the extremities and other parts, there is loss of voluntary motion, convulsive tremors in some parts of the body, and palsy in others, especially in that side of the body which is opposite to the injured part of the head.

Some of the milder of these symptoms, as vertigo, stupification, and a temporary loss of sensibility, are frequently induced by slight blows upon the head, but commonly soon disappear, either by rest alone, or by the means to be afterwards pointed out. But when any other symptoms ensue, such as dilatation of the pupils, and especially when much blood is Fracture and Depression of the Cranium, &c.

The cavity of the cranium, in the healthy and natural state, is everywhere completely filled by the brain; whatever therefore diminishes that cavity, will produce a compression of the brain.

The causes producing such a diminution may be of various kinds, as fracture and depression of the bones of the cranium; the forcible introduction of any extraneous body into the cavity of the cranium; effusion of blood, serum, pus, or any other matter; the thickening of the bones of the cranium in certain diseases, as in lues venerea, rickets, or spina ventosa; or water collected in hydrocephalous cases. The first set of causes shall be considered in their order. The four last mentioned belong to the province of the physician, and have been considered in a former part of this Work.

Sect. I. Of Fracture and Depression of the Cranium producing Compression of the Brain.

Fractures of the cranium have been differently distinguished by different authors; but it seems sufficient to divide them into those attended with depression, and those which are not so.

In fracture and depression of the cranium, the treatment ought to be,—to discover the situation and extent of the fracture;—to obviate the effects of the injury done to the brain, by raising or removing all the depressed parts of the bone;—to endeavour to complete the cure by proper dressings, and attention to the after treatment.

When the integuments corresponding to the injury done to the bone are cut or lacerated, and, as is sometimes the case, entirely removed, the state of the fracture is immediately discovered; but when the integuments of the skull remain entire, even though the general symptoms of fracture be present, there is sometimes much difficulty in ascertaining it. When, however, any external injury appears, particularly a tumor from a recent contusion, attended by the symptoms already described, there can be no doubt of the existence of a fracture. But it sometimes happens that compression exists without the smallest appearance of tumor. In such cases, the whole head ought to be shaved, when an inflammatory spot may frequently be observed. Sometimes the place of the fracture has been discovered by the patient applying the hand frequently on or near some particular part of the head.

When the symptoms of a compressed brain are evidently marked, no time ought to be lost in setting about an examination of the state of the cranium, wherever appearances point out, or even lead us to conjecture, in what part a fracture may be situated. For this purpose an incision is to be made upon the spot through the integuments to the surface of the bone, which must be sufficiently exposed to admit of a free examination.

Some authors have recommended a cruciate incision; others one in form of the letter T; while many advise a considerable part of the integuments to be entirely removed. But as it is more agreeable to the present mode of practice to save as much of the skin as possible, a simple incision is generally preferred, unless the fracture run in different directions, and then the incision must vary accordingly. It will frequently happen, that a considerable part of the integuments must be separated from the skull, in order to obtain a distinct view of the full extent of the fracture; but no part of the integuments is to be entirely removed.

When blood-vessels of any considerable size are divided, either before or in time of the examination, they ought to be allowed to bleed freely, as in no case whatever is the loss of blood attended with more advantage than the present.

When, however, it appears that the patient has lost a sufficient quantity, the vessels ought to be secured.

After the integuments have been divided, if the skull be found to be fractured and depressed, the nature of the case is rendered evident; but even where there is no external appearance of fracture, tumor, discoloration, or other injury, if the patient continue to labour under symptoms of a compressed brain, if the pericranium has been separated from the bone, and especially if the bone has lost its natural appearance, and has acquired a pale white or dusky yellow hue, the trepan ought to be applied without hesitation at the place where these appearances mark the principal seat of the injury.

Again, although no mark either of fracture or of any disease underneath should appear on the outer table of the bone, yet there is a possibility that the inner table may be fractured and depressed. This indeed is not a common occurrence, but it happens probably more frequently than surgeons have been aware of; and where it does happen, the injury done to the brain is as great, and attended with as much danger, as where the whole thickness of the bone is beat in. The application of the trepan is therefore necessary.

But if, after the application of the trepan, it happens that no mark of injury appears either in the outer or inner table in that part, or in the dura mater below it, and that the symptoms of a compressed brain still continue, a fracture in some other part is to be suspected; or that kind of fracture termed by practitioners counter fissure, where the skull is fractured and sometimes depressed on the opposite side to, or at a distance from, the part where the injury was received. This is fortunately not a very frequent occurrence, and has even been doubted by some; but different instances of it have, beyond all question, been found. If therefore the operation of the trepan has been performed, and no fracture is discovered, no extravasation appears on the surface of the brain; and if blood-letting and other means usually employed do not remove the symptoms of compression, the operator is to search for a fracture on some other part. The whole head should again be examined with much accuracy; and, by pressing deliberately but firmly over every part of it, if the smallest degree of sensibility remains, the patient will show signs of pain, either by moans or by raising his hands, when pressure is made over the fractured part. In this way fractures have been frequently detected, which might otherwise have been concealed.

Having now considered every thing preparatory to the operation of the trepan, we shall next point out the means best adapted for the removal or elevation of a depressed portion of the bone.

The first thing to be done is, after shaving the head, to make an incision as deep as the bone, and directly upon the course of the fracture.

The patient ought to be laid on a table, with a mattress under him, while his head is placed upon a pillow, and secured by an assistant. When the extent of the fracture has been determined, and the bleeding from the incision stopped, the depressed bone is now to be elevated; but previous to this it is necessary to search for detached pieces. Should any be found, they ought to be removed by a pair of forceps adapted to this purpose. By the same instrument any splinters of bone which may have been beaten in may be removed; but when a part of the bone is beaten in beyond the level of the rest of the cranium, as much of the pericranium is then to be removed by a raspatory, Plate CCCCLXXXVIII. fig. 21, as will allow the trephine, Plate CCCCLXXXVIII. fig. 22, to be applied; or, if the operator incline, for the sake of dispatch, he may use the trepan. Fracture and Depres- sion of the Cranium, &c.

Plate CCCCLXXXVIII. fig. 23. and 24.; or the operation may be begun and finished with the trephine, while the trepan may perform the middle and principal part of the work. This part of the work is begun by making a hole with the perforator (fig. 24.), which is screwed on to the lower end of fig. 23., deep enough to fix the central pin of the trephine, in order to prevent the saw from slipping out of its central course, till it has formed a groove sufficiently deep to be worked steadily in; and then the pin is to be removed. If the bone be thick, the teeth of the saw must be cleaned now and then by the brush (fig. 25.) during the perforation, and dipped in oil as often as it is cleaned, which will considerably facilitate the motion, and render it more expeditions; making it at the same time much less disagreeable to the patient, if he possess his senses. That no time may be lost, the operator ought to be provided with two instruments of the same size, or at least to have two heads which can be readily fitted to the same handle.

After having made some progress in the operation, the groove ought to be frequently examined with a pick-tooth, or some such instrument, in order to discover its depth; and if one side happen to be deeper than the other, the operator ought to press more on that side which is shallowest. Precautions are more particularly necessary when the operation is performed upon a part of the skull which is of an unequal thickness, especially after the instrument has passed the diploe. And though it be said by writers in general that the instrument may be worked boldly till it comes at the diploe (which is generally known by the appearance of blood), yet the operator should be upon his guard in this point, examining from time to time if the piece be loose, lest thro' inadvertence the dura mater be wounded; for in some parts of the skull there is naturally very little diploe, and in old subjects scarcely any. It ought likewise to be remembered, that the skulls of children are very thin. When the piece begins to vacillate, it ought to be snapped off with the forceps (fig. 26.), or lever (fig. 26. a); for the sawing ought by no means to be continued till the bone be cut quite through, otherwise the instrument may plunge in upon the brain, or at least injure the dura mater. If the inner edge of the perforation be left ragged, it is to be smoothed with the lenticular (fig. 28. b), to prevent it from irritating the dura mater. Particular care is to be taken in using the instrument, lest it should press too much upon the brain.

The next step is to raise the depressed part of the bone with the levator, or to extract the fragments of the bone, grumous blood, or any extraneous body. After this, if there appear reason to apprehend that blood, lymph, or matter, is contained under the dura mater, it ought to be cautiously opened with a lancet, endeavouring to avoid the blood-vessels running upon it, or lying immediately under it.

When the trepan is to be used on account of a fissure in which the bone will not yield, the instrument should be applied so as to include part of it, if not directly over it, as it is most probable that the extravasated fluid will be found directly under it. And when the fissure is of great extent, it may be proper to make a perforation at each end, if the whole can be conveniently brought into view; and in some cases several perforations may become necessary.

When it is proposed to make several perforations to remove depressed fragments of the bone which are firmly fixed, and having the internal surface larger than the external, or to raise them sufficiently, it is necessary to apply the trepan as near the fractured parts as possible; making the perforations join each other, to prevent the trouble of cutting the intermediate spaces.

Vol. XVIII. Part I.

When the skull is injured over a fracture, and it is not thought advisable to use the trepan, a perforation ought to be made on each side of the fracture, especially in young subjects, in whom the dura mater adheres more strongly than in adults; because there cannot be a free communication between the one side and the other, on account of the attachment of that membrane to the fracture.

After the elevation of the depressed pieces, or the removal of those which are quite loose, the extraction of extravasated bodies, and the evacuation of extravasated fluids, &c., all that is necessary being to apply a pledget of fine scraped lint, covered with simple ointment, to that part of the dura mater which is laid bare by the trepan, or otherwise; after which the edges of the scalp are to be brought together or nearly so, and another pledget laid along the whole course of the wound; a piece of fine soft linen is to be laid over all, and the dressings may be retained in their place by a common night-cap applied close to the head, and properly fixed.

The patient is to be placed in as easy a position in bed as possible, with his head and shoulders elevated a little more than ordinary. If the operation be attended with success, the patient will soon begin to show favourable symptoms; he will soon show signs of increasing sensibility, and the original bad symptoms will gradually disappear. After this he ought to be kept as quiet as possible; proper laxatives are to be administered, and such as may be least of a nauseating nature. His food ought to be simple and easy of digestion, and his drink of the most diluent kind. If he complain of the wound being uneasy, an emollient poultice should be immediately applied, and renewed three or four times in the twenty-four hours. By these means there will commonly be a free suppuration from the whole surface of the fore.

Every time the wound is dressed, the purulent matter ought to be wiped off from it with a fine warm sponge; and if any degree of sloughing take place on the dura mater or parts adjacent, it will then be completely separated. Granulations will begin to form, which will continue to increase till the whole arise to a level with the surface of the cranium. The edges of the fore are now to be dressed with cerate strips, and the rest of it covered with fine soft lint, kept gently pressed on by the night-cap properly tied. In this way the cure will go on favourably; luxuriance of granulations will commonly be prevented; the parts will cicatrize kindly; and as all the skin has been preserved in making the first incision, the cicatrix will be but little observed.

But things do not always proceed in this favourable manner. Sometimes in a few hours after the operation the patient is seized with a kind of restlessness, tossing his arms, and endeavouring to move himself in bed, while the symptoms of a compressed brain remain nearly the same as formerly. In this case, especially if the pulse be quick and strong, the patient ought to be bled freely, as there will be reason to suspect some tendency to inflammation in the brain. Sometimes, though the trepan has been properly applied, the symptoms are not relieved, on account of extravasated fluids collected internally under the dura mater, or between the pia mater and brain, or in the cavity of the ventricles. The danger in these cases will be in proportion to the depth of the collection. Particular attention therefore ought always to be paid to the state of the dura mater after the perforation has been made. If blood be collected below the dura mater, this membrane will be found tense, dark coloured, elastic, and even livid; in which case, an opening becomes absolutely necessary to discharge the extravasated Fracture vatated fluid. Gentle scratches are to be made with a scalpel, till a probe (fig. 27), or directory (fig. 28.), can be introduced; upon which the membrane is to be sufficiently divided in a longitudinal, and sometimes even in a crucial direction, till an outlet to the fluid be given.

After the dura mater has been cut in this manner, there is some danger of the brain protruding at the opening; but the danger from this is not equal to the bad effects arising from effused fluids compressing the brain.

A troublesome and an alarming appearance now and then follows the operation of the trepan; namely, the excrescences called fungi; formerly supposed to grow immediately from the surface of the brain, but which, in general, originate from the surface of the dura mater or cut edge of the bone granulating too luxuriantly.

It often happens that they possess little sensibility; and then the best method to prevent their rising to any great height is to touch them frequently with lunar caustic; but some cases occur where their sensibility is so great that they cannot be touched, unless they hang by a small neck; and then a ligature may be put round them, and tightened from time to time till they drop off, which will commonly be in the course of a few days. It seldom happens, however, that there is any occasion for applying such means for the removal of these tumors, for they generally fall off as the perforations of the bone fill up.

If they do not, as the connection between them and the brain will be then in a great measure intercepted, they may be with more safety removed, either by excision, by cautery, or by ligature.

The cure being thus far completed, only a small cicatrix will remain, and in general the parts will be nearly as firm as at first; but when much of the integuments have been separated or destroyed, as they are never regenerated, the bone will be left covered only by a thin cuticle, with some small quantity of cellular substance. When this is the case, the person ought to wear a piece of lead or tin, properly fitted and lined with flannel, to protect it from the cold and other external injuries.

This is the method now commonly practised in cases of concussion; but it frequently happens, that instead of compression, such a degree of concussion takes place that no assistance from the trepan can be attended with any advantage; for the effects of concussion are totally different from those of compression, and therefore to be removed in a different manner.

**Sect. II. Of Concussion of the Brain.**

By concussion of the brain is meant such an injury, from external violence, as either obstructs or destroys its functions, without leaving behind it such marks as to allow its nature to be ascertained by dissection.

Most of the symptoms attending compression of the brain occur also in concussion; but in a compressed state of the brain they are more permanent. There is no discharge of blood from the eyes, nose, or ears, which frequently happens in compression; and instead of that apoplectic stertor in breathing which accompanies compression, the patient seems to be in a sound and natural sleep. The pulse is irregular and slow in compression, and grows stronger and fuller by blood-letting; but in concussion it is weaker, being soft and equal, and sinks by blood-letting. There are besides convulsions in compressions, which are not observed in a state of concussion. The symptoms arising from concussion come on immediately after the injury is received. In the violent degrees of these the patient remains quite insensible; the pupils are much dilated, and do not contract though the eyes be exposed to the strongest light.

In more violent symptoms, especially when the patient is rendered insensible, it is extremely difficult to distinguish between concussion and depression; for symptoms which have been supposed to arise entirely from concussion have, after death, been found to be owing to extravasation or undiscovered fracture; and extravasation has been blamed, when, on dissection, not the least morbid appearance could be discovered.

In concussion the pulse will frequently sink and become feeble, even after the discharge of eight or ten ounces of blood. In doubtful cases, therefore, blood-letting should be practised with great caution. If the pulse becomes fuller and stronger after discharging a moderate quantity, if the blood appear fizzy, and especially if the patient become more sensible, it may be concluded that the symptoms depend upon extravasation, depression of the skull, or some degree of inflammation; and as long as advantage seems to be derived from blood-letting, we may repeat it; but if, upon drawing a few ounces of blood, the pulse becomes feeble, and especially if along with this the patient become more weakly, we should immediately desist from any farther evacuation of blood; and in place of it we ought to give such remedies as may support and strengthen the patient: cordials ought to be given internally, and stimulants applied externally. Warm wine should be given in proportion to the degree of debility induced; the patient, who is apt, in this case, to become cold, should be kept warm by proper coverings; a blister ought to be put to all that part of the head in which the skin has not been injured; liniments should be applied to the feet; gentle laxatives are useful, and should be regularly given, so as to keep the body open. If the patient cannot swallow wine in sufficient quantity, volatile alkali, ardent spirits, and other cordials of a stimulating kind, should be given. In concussions of the brain, Mr Bromefield has recommended the use of opiates, and several other practitioners agree with him; though some consider it as hurtful in the early stages of the disorder, and are of opinion that even wine and other cordials ought to be given with some degree of caution. Issues, or the frequent repetition of blisters to the different parts of the head and neck, by which an almost constant stimulus is preserved, are much recommended. When patients are recovering from accidents of this kind, a liberal use of bark, steel, and mineral waters, &c., have sometimes been of service. When the stomach is loaded, gentle vomits become necessary; and white vitriol is reckoned the best in such cases. When much languor, inactivity, and loss of memory continue, electricity long applied has been attended with advantage. This remedy, however, would be hurtful where any symptoms of compression or inflammation of the brain are present.

**Sect. III. Of Inflammation of the Membranes of the Brain, or of the Brain itself, from external Violence.**

Inflammation of the brain and of its membranes is attended with symptoms which occur in inflammations affecting other parts of the body, and from similar causes, and manifest likewise with symptoms peculiar to the brain itself. This disorder differs essentially from concussion in its not appearing immediately; seldom till several days after the accident, and sometimes not till two, three, or more weeks, or even as many months, have elapsed; when the patient begins to feel an universal uneasiness over his head, attended with lightheadedness, some degree of pain in the part upon which the injury was inflicted, though of this there was perhaps no previous sensation. These symptoms gradually increase; the patient appears dull and stupid; there is now a sensation of fulness, as if the brain were girt or comprimèd; he complains of giddiness and of nausea, which sometimes terminate in vomiting; he is hot, and extremely uneasy; his sleep... Inflammation is much disturbed; neither natural sleep nor that produced by opiates affording him relief; the pulse is hard and quick; the face is flushed; the eyes inflamed, and unable to bear an exposure to much light. Sometimes, where a wound of the head accompanies these symptoms, its edges become hard and swollen, and an erysipelas inflammation spreads quickly over the whole head, and especially towards the forehead and eyelids, which frequently swell to such a degree as to shut up the eyes entirely. This swelling is soft and painful to the touch; it receives the impression of the finger, and frequently originates merely from the external wound; on which account the attending symptoms are commonly easily removed by the means best suited to erysipelas of the parts. In a few instances, however, this symptom is likewise connected with, and seems to originate from, some affection of the dura mater. Its tendency is then of the most dangerous kind, and therefore requires the greatest attention. Soon after these symptoms become formidable, the part which received the blow begins to put on a discolored appearance. If the bone has been exposed by the accident, it now loses its natural complexion, becomes pale, white, and dry, either over its whole surface or in particular spots; but when the bone has not been denuded, nor the softer parts divided, but merely contused, they now well, become puffy, and painful to the touch; and when the head is shaved, the skin over the part affected is redder than the rest of the scalp; and if the swollen part be laid open, the periosteum will probably be found to be detached from the skull, and a little bloody fetid ichor will be observed between this membrane and the bone, which will be found discoloured in nearly the same manner as it had been laid bare from the beginning.

By the application of proper remedies these symptoms are frequently entirely removed; but when neglected, or when they do not yield to the means employed, they constantly become worse. Delirium ensues; the patient becomes extremely hot; and is at times seized with flighty观念ings, which continue to increase and are attended with some degree of coma or stupor. The former symptoms now in a great measure disappear; paleness of one side is soon followed by deep coma; the pupils are dilated; the urine and faeces are passed involuntarily; subsultus tendinum and other convulsions ensue; and death certainly follows, if the patient be not speedily relieved.

Of the above symptoms, the first set point out the inflammatory, the other the suppurative stage of the disease. The remedies which are useful in the one are highly improper in the other. During the inflammatory stage, blood-letting is the principal remedy; but this is improper after the suppurative symptoms appear, for then the trepan is the only thing that can give relief.

The indications of cure are; 1. To employ the most effectual means for preventing inflammation. 2. To endeavour to procure the resolution of inflammation by general and topical remedies. 3. When the inflammation cannot be removed by resolution, and when suppuration has taken place, to give a free vent to the matter. 4. If the affected parts be attacked with gangrene, to endeavour to remove it and obviate its effects.

To answer the first indication, when the contusion is considerable, blood-letting, both general and topical, ought to be employed, and to a considerable extent; the bowels ought to be kept open by the use of laxatives; a watery solution of saccharum saturni should be applied to the part affected, and a low diet, with a total abstinence from exercise, ought to be enjoined; but if these means fail, or, as frequently happens, the practitioner has not been called in soon enough for their proper application, and if inflammation have actually commenced, the second indication ought then to be attended to. For this purpose, blood-letting, not from the feet according to the advice of old practitioners, but as near as possible to the part affected, is to be performed, by leeching, cupping, or scarifying with a lancet or scalpel.

When, instead of this, general blood-letting is thought more advisable, it is commonly reckoned best to open the external jugular vein, or the temporal artery; and the rule, with regard to the quantity to be evacuated, ought to be, to draw blood as long as the pulse continues firm; so that, in violent cases, taking away from 20 to 25 ounces at once will be found to answer the purpose better than to extract even a larger quantity, but at different intervals. A few hours afterwards, if the symptoms continue violent, it may be proper to discharge an additional quantity; but this must depend upon the strength of the patient and the fulness of the pulse.

Along with the liberal use of blood-letting, brisk purgatives should be given. The bowels should not merely be kept open; but in order to receive full advantage from the practice, a smart purging should be kept up by repeated doses of calomel, jalap, or some other neutral salt. Where the patient cannot swallow in sufficient quantity, stimulating injections should be frequently exhibited.

A moist state of the skin is useful in every case of inflammation, and ought therefore to be here particularly attended to. In general, a mild perspiration may be induced by applying warm fomentations to the feet and legs, and by laying the patient in blankets instead of linen. But when these means are insufficient, diaphoretics or even sudorifics may be given.

When much pain or reflexiveness takes place, opiates should be administered freely, which are now found to be attended with real advantage.

With respect to the external treatment of this disorder, external attention should be paid to those means which may most readily induce a free discharge of purulent matter from the feet of the injury. With this view, if the original accident be attended with a wound or division of the integuments, as the lips of the sore are commonly observed to be hard, painful, and dry, it should be covered with pledgets spread with an emollient ointment, and warm emollient poultices laid over the whole; by which means, and especially by a frequent renewal of the poultices, a free discharge of matter will commonly be induced, and the bad symptoms will generally be much mitigated, or entirely removed.

In cases unattended with a division of the integuments, as soon as it is suspected that bad symptoms may supervene, the tumor should be divided down to the periosteum; and if that membrane be found separated from the bone, it ought likewise to be divided; and by inducing a suppuration in the way already mentioned, the inflammatory symptoms will probably be removed. As matter formed here is commonly of an acrid nature, and therefore apt to affect the bone, and by communication of vessels the membranes under it, instead of waiting till fluctuation be distinctly perceived, a free incision should be made as soon as a tumor is observable. But this would be extremely improper in the treatment of tumors which immediately succeed to external injuries; for it often happens that such tumors disappear spontaneously, or by the use of astringent applications. It is only when a tumor attended with pain appears at a distant period upon the spot where the injury was received, that it ought to be opened as soon as perceived.

The next part of the practice regards the remedies to be used. The suppurative state of the disease is known by the inflammatory symptoms, instead of yielding to the remedies already advised, increasing in violence; and being succeeded by coma, dilatation of the pupils, a flow and full pulse, involuntary discharge of faeces and urine, palsy, and irregular convulsive motions, and especially when these symptoms are succeeded by fits of rigor and shivering.

The existence of matter within the cranium being ascertained, as no other remedy can be depended upon for removing it, the operation of the trepan should be immediately employed, and as many perforations ought to be made as may be sufficient for evacuating the matter. But if, after the skull is perforated, little or no matter appear between the bone and membranes; if the dura mater seem more tense than usual; this membrane is likewise to be opened, so as to give a free discharge to any matter which may be between the brain and its membranes.

When it is perceived that the dura mater has already become flabby, with some tendency to gangrene, the greatest danger is to be dreaded. If mortification has commenced, there will be much reason to think that death will soon follow; but different instances have occurred of ulcers forming upon the dura mater, and of cures being made after these have separated. All that can be attempted is to keep the fores clean, to give a free discharge to the matter, to apply nothing but light easy dressings, and to give bark in as great quantities as the stomach can bear. If there be still some tendency to inflammation, the diet should be low and cooling; the patient should drink freely of whey or other diluent liquors, and the bowels should be kept moderately open: But if, on the contrary, the system be low and the pulse feeble, wine is the most effectual cordial.

Sect. IV. Of Fissures, or Simple Fractures of the Skull.

The term is here meant to imply a mere division of one or both the tables of the skull, with or without a wound of the integuments, not attended with depression. Fractures of this kind are not dangerous as far as affects the skull only, for it frequently happens that extensive fissures heal without producing bad symptoms. But as they are frequently attended with effusions of blood or serum upon the brain or its membranes, or as they may tend to excite inflammation in these, they require particular attention.

When effusions occur, symptoms of compression immediately follow. The remedies best suited to this disease must then be applied; and the trepan is alone to be depended upon. The fissures should be traced through their whole extent, and a perforation made on the most depending part of each of them. If this be unsuccessful, the operation should be repeated along the course of the fissures as long as symptoms of a compressed brain continue; and as the effused matter will commonly be found contiguous to the fissures, they ought to be included in each perforation.

If the fissure be so large as to produce an obvious separation of the two sides of the bone, the nature of the case will be at once rendered evident; but where it is extremely small, there is difficulty in distinguishing it from the natural fissures, or from fissures surrounding small bones, which sometimes occur, and get the name of os triquetra. But this may be known by the firmer adhesion which always exists between the pericranium and fissures; whereas this membrane is always somewhat separated from that part of the bone where a fissure is formed. When the pericranium is separated by the accident for a considerable way from the surface of the bone, various means have been contrived for discovering the nature of the case; as pouring ink upon the part suspected to be fractured, which in case of a fracture cannot be wiped entirely off; or making the patient hold a hair or piece of catgut between his teeth, while the other extremity of it is drawn taut, which, when struck, is said to produce a disagreeable sensation in the fractured part. But such tests are little to be depended on; ink will penetrate the sutures; and the others are ineffectual, unless the fracture be extensive, and the pieces considerably separated from each other. The oozing of the blood from a fissure is a better mark. The ascertaining of this point, however, appears not very material; for unless alarming symptoms are present, although there should be a fissure, no operation is necessary; and if such symptoms occur, the bone ought to be perforated whether there be a fissure or not.

When a fissure is not attended with symptoms of a compressed brain, the trepan ought not to be applied, especially as the operation itself tends in some degree to increase inflammation of the part. The fissure should be treated merely as a cause which may induce inflammation. The patient should be blooded according to his strength; the bowels should be kept lax, and the fore treated with mild, easy dressing; and violent exertion should be avoided as long as there is any danger of inflammation occurring.

Chap. XIII. Diseases of the Eyes.

Sect. I. Of Wounds of the Eyelids and Eyeball.

In cases of superficial wounds of the eyelids, it will be sufficient to bring the edges of the wounds together and of wound retain them in their place by slips of adhesive plaster; but when a wound is deep, particularly when the tarsus is divided, it will be necessary to employ either the interrupted or the twisted suture, care being taken that the sutures be not carried through the inner membrane of the eyelid, otherwise the eye would be irritated and inflamed. After such an operation, the motion of both eyelids should be prevented as much as possible; else no union or the divided parts can be obtained. After the sutures are finished, the eyelids should be closed and covered with a pledget of emollient ointment, and over this should be laid a compress of soft lint, and one of a similar nature ought likewise to cover the found eye; then a napkin should be made to press equally on both eyes, and be properly fixed. Inflammation should be guarded against, or, if already present, it must be removed in the manner directed under the article Ophthalmia (see Medicine.) The sutures may be removed in about three days from their introduction, when the parts will commonly be found reunited.

When a portion of the eyelids is so much destroyed, or perhaps so completely removed, as to prevent the remaining parts from being brought together, without obstructing the motion of the eye, the best method will be to treat them with light easy dressings, trusting to nature for supplying the deficiency.

If the cornea be wounded, it will commonly be attended with partial or total blindness. If any of the other parts of the ball be wounded, the danger will generally be in proportion to the extent of the wound. The principal attention ought to be directed to the prevention or removal of inflammation. When pain occurs, it ought to be removed by opiates; and with these a strict antiphlogistic course is to be enjoined.

When the wound is large, and the humours completely evacuated... Sect. II. Of Diseases of the Eyelids.

The eyelids are subject to be infested with tumors of different kinds, which frequently require the assistance of surgery. The first of these is the hordeolum or sty, which frequently grows on the edge of the eyelid, and is attended with heat, stiffness, and pain; and unless proper means be taken to prevent it, a suppuration is frequently the consequence. It may be considered as a common abscess seated in an obstructed sebaceous duct or gland. It may generally be removed by dissective applications. Should these prove ineffectual, it ought to be brought to suppurate by a small emollient poultice, when it will commonly heal itself; but if it do not, it may be opened with the point of a lancet, that the matter may be discharged; and the part may be anointed afterwards with saturnine solution.

The eyelids are subject to encysted tumors, sebaceous warts, &c., which are to be treated like the same tumors when seated in other parts of the body; only in extirpating these tumors, should part of the eyelid be removed entirely, no dressings can be applied, as, however mild they may be, they would irritate and inflame the ball of the eye. All that can be done therefore, in such cases, is to lay the lips of the sore as nearly together as possible, and frequently to remove any matter that may form on it.

The eyelashes are sometimes so much inverted as to rub upon the eye and create much pain and inflammation. Various causes are assigned for this, such as the hairs themselves taking a wrong direction; inversion of the tarsus or cartilage of the eyelid; some cicatrices formed upon the skin of this part after wounds or abcesses; tumors pressing the hairs upon the eye; and, finally, a relaxation of the external integuments.

The treatment of this disorder must depend much upon a knowledge of the cause. When it is owing to a derangement of the cilia themselves, if they have remained long in this state, it will be extremely difficult to make them recover their proper direction. They ought therefore to be pulled out by a pair of forceps, and the part washed with some astringent lotion; and if the new hairs appear to take a similar direction, which is very apt to happen, as soon as they are long enough they ought to be turned back upon the eyelid, and kept there for several days, or even weeks, by adhesive plaster. When the disease proceeds from a contraction of the orbicular muscles, the contracted part may be cut from the inner surface of the eyelid; in which place a cut commonly soon heals. If the cause proceed from a tumor or cicatrix, this must be removed before a cure can be expected; or if it be owing to relaxation of the skin, the parts ought to be bathed with some strong astringent. If this fail, the relaxed skin should be removed, and the part healed by the first intention. Sometimes the cilia of the upper eyelid are turned in on account of dropsical swelling in that place. When this happens, the water is to be evacuated by a few punctures with a lancet; but when such means fail, and when the disease is quite local, if vision be disturbed, a sufficient part of the skin ought to be removed with a scalpel, and a cure made by adhesive plaster or the twisted future.

When the gaping eye takes place to any great degree, it is attended not only with much deformity and uneasiness, from a large portion of the lining of the eyelid being turned outwards, but likewise from too much of the eye being exposed. The disorder may arise from an enlargement of the eyeball, from dropsical swelling, or from the cicatrix Disease of an old wound or abcess; hence it is frequently produced by the small-pox, burns, or scrophula; but more frequently by a laxity of the part in old age.

When the disorder is induced by an enlargement of the ball of the eye, nothing but a removal of this swelling can be effectual. If from dropsical swelling, when this is connected with general anaemia, the affection of the system must first be cured; but if it appear to be local, nothing answers so well as punctures. When it arises from a cicatrix, the skin should be divided, and the effects of inflammation guarded against. If it be owing to inflammation, the antiphlogistic course must be used; when it arises from old age, the eyes ought to be daily bathed with cold water, or some astringent and stimulant solution.

Concretion of the eyelids sometimes arises from a high degree of ophthalmia; in which case the eyelids are not only connected by their edges to each other, but now and then grow to the surface of the eyeball. A cohesiveness is sometimes observed also in children at birth. When the adhesion is slight, it may in general be removed by the end of a blunt probe; but when it is considerable, a cure can only be effected by a cautious dissection. If the eyelids on one side be found, they will serve as a guide to direct the incision. The tarso are carefully to be divided from each other; after which, if there be no other adhesions, the eyelids may be readily opened: But if they adhere to the eye, the operator is gently to pull and separate the eyelids, while the patient is desired to move the eye in the opposite direction. When this is effected, nothing is further necessary than to drop a little oil upon the eye, and cover the eyelids with soft lint spread with some cooling emollient ointment. The oil and ointment are frequently to be repeated, and every precaution taken to prevent inflammation and irritation.

Sect. III. Of Specks, Films, or Excrements on the Eye.

Specks are sometimes formed upon the white part of the eye, but more frequently upon the cornea. In the former case they are seldom attended with much inconvenience, but in the latter they are often the cause of partial or total blindness. They are almost universally the consequence of inflammation, and seldom go much deeper than the tunica adnata. Two very different states of the disorder occur; the one from an effusion immediately under the outer layer of the cornea, and in this case the cornea does not appear to be raised; the other takes place from one or more little ulcers, which breaking, leave as many opaque spots in the centre, which are more elevated than the rest of the cornea; and the inconvenience attending either situation must always be in proportion to their extent and degree of opacity, or their vicinity to the pupil. When vision is little affected by them, they need scarcely be considered as an object of surgery; but whenever vision is materially impaired, remedies become necessary, and these should be such as are best suited for removing inflammation, promoting absorption, and restoring tone to the vessels. For the means adapted for removing inflammation, see Medicine, p. 175.

Vessels running upon the surface of the eye into the speck are to be divided, and the eye frequently bathed with some refrigerant collyrium. By these means the simplest kind of specks, when recently formed, may generally be removed; but where they have been of long standing, their removal is attended with great difficulty. Where the speck is owing to an effusion of fluids between the layers of the cornea, and where it is not attended with any prominence, local applications are of little advantage, as it Specks, &c., is impossible to remove the effused matter without injuring the eye; but considerable service is derived from the use of such remedies as are most effectual for promoting absorption; and with this view a gentle, long continued course of mercury, brisk purgatives occasionally, and influes in the neck, are found to be the most effectual remedies.

In the management of specks which are prominent upon the cornea, and where inflammation is removed and the opacity is considerable, if the cornea beneath be found, the removal of the diseased part will leave it transparent and fit for vision. The remedies proper for this purpose are elachiotics or the knife. The former are applied in the form of a powder, an ointment, or a wash; and these ought to be very finely prepared, otherwise they will be in danger of irritating and inflaming the eye; and they ought merely to be of such strength as the eye can easily bear.

The applications should be long persisted in and frequently repeated; and to make them still more useful, some of the powders or ointments may be applied evening and morning, and the solution two or three times through the course of the day. To the remedies already mentioned caustic is sometimes preferred. With this the centre of the speck is to be frequently touched, till the patient complain of considerable pain, when pure water is to be applied by a pencil, or by dipping the eye in water, with the eyelids open, till the pain occasioned by the application of the caustic be removed. The eye is then to be covered with compresses moistened in some solution, and this frequently repeated. The caustic to be repeated every second or third day, unless prevented by inflammation. When the surgeon chooses to employ the knife, which frequently may be more effectual, the eye is to be fixed by a speculum (fig. 29.), or leverator (fig. 30.); the tumor is then to be cautiously separated by means of a small knife, and every attention paid to prevent inflammation. These are the methods most likely to be of service; and when properly managed, they will frequently remove specks, which otherwise would entirely deprive the patient of the use of the eye; though it is to be regretted that cases frequently occur which baffle art.

A membranous excrescence, called pterygium, is frequently found upon the white part of the eye, which often spreads over the cornea so as entirely to destroy vision. It is sometimes owing to external injuries; at other times it arises from a general disease of the system, as lues venerea or scrofula; but inflammation is always the more immediate cause.

By a proper application of the remedies above mentioned affections of this kind may generally be prevented from becoming formidable; but when the reverse takes place, and excrescences begin to spread over the cornea, other means must be used. When the diseased part is only slightly attached, it may be freely removed by a cut of the knife; but when this cannot be done without difficulty, it is better to destroy the vessels by the extention of which this subsistence is chiefly formed. The manner of performing the operation in general is this: The patient being properly seated, the eyelids opened, and the eye secured, the operator, with a small knife, makes a scarification through the whole thickness of the excrescence, entirely round, and at a little distance from the circumference, by which the source of nourishment will be cut off; and, after the bleeding is abated, one or two incisions more may be made, in a similar manner, within the former. Some practitioners raise the excrescence with a needle and ligature before the incision is made; and, in some cases, this may be done with advantage, though not in others.

After the bleeding is over, the part is to be bathed two or three times a day with a weak tartaric solution; and the operation may be repeated occasionally till the excrescence is removed. In this way the operation commonly proves effectual; but instances sometimes occur where, instead of being useful, it increases the disease. Whenever this happens, a palliative course is the only thing to be tried; and although it will not remove the disorder, it may commonly prevent the excrescence from acquiring any additional size. With this intention it ought to be frequently bathed with the solution last mentioned, and afterwards covered with a cooling ointment. When the disorder cannot even be palliated, when vision is destroyed, and particularly when the pain attending it is severe, there is reason to suspect cancer. In this case the eye ought to be extirpated, otherwise deeper parts may suffer, and the life of the patient be endangered. The method of performing this operation will be afterwards pointed out.

Sect. IV. Of Affections in the Globe of the Eye.

Though inflammation of the eye generally terminates by resolution, instances sometimes occur in which an abscess ensues. This is owing either to improper treatment, or a bad habit of body which counteracts all remedies. The greatest danger attending these complaints is when they are situated on the cornea, as the cicatrix left by them may destroy vision. When deeply seated, a purulent matter is sometimes apt to be found in some of the chambers of the eye, the ball becomes enlarged, the humours are disturbed, and neither the iris, pupil, nor lens can be distinguished. In some rare cases again, after these appearances have continued some time, the cornea bursts, part or whole of the humours are evacuated, and the iris protrudes in a thickened distended state. This has now the appearance of an excrescence, which is called flapbyloma from a kind of resemblance to a grape. But under this term some authors include all collections like those above described. In most instances the cornea protrudes, but in others the tunica sclerotica or opaque part is affected with partial swellings or protrusions.

While the disease is forming, besides the loss of sight, the patient commonly feels great distress in the eye and head, accompanied by symptoms of fever. When no other distress is experienced than the loss of sight, the swelling is but small, and contains chiefly a watery fluid. In the treatment, as vision is seldom preserved, the principal thing is to abate the pain and remove deformity. There is another kind of abscess in the eye, termed hypopyon, where the matter is lodged in the sublance of the coats. It is sometimes produced by external injuries, but more frequently from pustules of small-pox. If this termination cannot be prevented by the remedies mentioned in the article Medicine, n° 175, the matter must be evacuated by an incision into the eye, not regarding the humours, as vision previous to this time is entirely destroyed. The proper part is the cornea or the most prominent part of the tumor.

A variety of this disorder sometimes, though rarely, happens, where the humours are absorbed; but still the same external appearances are observed. In this case the tumor is formed by a thickening of the coats, especially the iris. The only means of relief is extirpation of the prominent part by the use of the knife. After the contents of the eye have been discharged, the parts are to be covered with a compress moistened with a tartaric solution, and the antiphlogistic course followed, till a cure is perfected, or at least inflammation removed. If the ulcers discharge a thin acrid matter, they may be washed two or three times a day with a solution of corrosive sublimate, or of white vitriol, &c. Fungous excrescences, sometimes considered as a cancer of the eye, are apt to form in both these diseases after the matter is evacuated; but they may be prevented from increasing. creasing to a considerable size by burnt alum finely powdered, or by touching them occasionally with lunar caustic.

Ulcers on the eye may arise from the same causes which produce ulcers on other parts of the body, as wounds, burns, &c.; or they may arise from a general affection of the constitution, as lues or scrophula; but they are more immediately produced by inflammation. In the treatment therefore of such diseases, blood-letting, blistering, laxative and cooling applications, as already described in the case of ophthalmia, are to be employed. When the inflammatory state is removed, their management must be almost the same with that for similar affections in other parts of the body. When the disorder arises from an affection of the system, the primary disease must be attended to before a cure can be performed. With respect to the fores themselves, if acrid matter be discharged, we must have recourse to detergent ointments and washes before a cicatrix can be formed. When these have not the desired effect, and when the sore becomes soft and higher than the rest of the eye, astringent applications are most efficacious. If excrescences be present, these are to be removed by escharotics, or by the knife. In some rare instances excrescences of a fungous nature are found to be connected with the interior parts of the eye, and become so prominent as even to rest upon the cheek. When such occur, nothing but the removal of the eye itself can effect a cure.

**Sect. V. Of Dropsical Swellings of the Eye.**

The eye is sometimes enlarged by an accumulation of the aqueous humour. The symptoms are, a sense of fullness in the eyeball; by degrees the motions of the eyelids become impeded; vision gradually becomes more and more imperfect, till at last the patient can only distinguish light from darkness. As the disease increases, the ball of the eye becomes greatly enlarged, and at this time the cornea begins to protrude; when, if a puncture be not made, the eye bursts and empties itself. This disease is apt to be confounded with staphyloma. But in the dropsical swelling the patient is always sensible to the effects of light, and the pupil is observed to contract, which does not happen in staphyloma. In the early stages of this disease vision may be preserved by puncturing the under edge of the cornea, and allowing the aqueous humour to pass out by the anterior chamber; or by puncturing the tunica sclerotica a little behind the iris, by which the fluid will pass out by the posterior chamber. The puncture may be made either with a lancet, pointed knife, or with a very small flat trocar. The eye ought afterwards to be dressed with a compress made moist with a tartaric solution, guarding against excessive inflammation. When the use of the eye is somewhat recovered, tone may be restored to the parts, and a return of the disease as much as possible prevented, by frequently bathing the eye in astringent lotions; but where the cornea is destroyed, the sight cannot be restored: We can then only diminish the size of the eye, and render it somewhat more comfortable to the patient.

Blood may be effused into the chambers of the eye from various causes, as in putrid diseases, or in consequence of inflammation, but most frequently from a rupture of the blood-vessels induced by external injury. In whatever way it gets into the eye, it mixes with the aqueous humour, and renders it opaque. It is sometimes taken up by the absorbents; when it is otherwise, it ought to be discharged by a puncture.

A few instances have occurred where the blood has fallen to the under side of the eye, and remained there without mixing with the aqueous humour. In such a situation it ought to be allowed to remain.

When a puncture is necessary, it is to be made in the same manner as in cases of dropsy of the eye; only the opening may require to be somewhat larger, otherwise the blood may not pass readily out. After the operation, nothing is necessary but to apply a compress of soft lint, moistened with a weak tartaric solution.

**Sect. VI. Of the Protrusion of the Eyeball beyond its Socket.**

The eye may protrude in consequence of external violence, or from tumors forming behind it, or on account of some of the ulcers, excrescences, or dropsical swellings, already mentioned. When the eye is forced out of its socket by external violence, it the eyeball be not entirely separated from the neighbouring parts, it ought to be freed from any extraneous matter which may adhere to it, and immediately replaced; and if the optic nerve be not quite divided, the use of the eye may be recovered. With a view to prevent or moderate inflammation, every part of the antiphlogistic regimen ought to be strictly adhered to. If the protrusion is occasioned by a tumor, the cure must depend upon the removal of this; and if the disease has advanced so far that the bones are become carious, they must likewise be separated. But more frequently, instead of the bones becoming carious, they assume a gelatinous or rather cartilaginous nature. In such a situation an operation could be of little advantage. The best method to prevent the bones from being affected is an early performance of the operation.

A few instances have happened of the eye being pushed from its socket by an enlargement of the lachrymal gland. When this occurs, if the enlargement be considerable, the structure of the eye will most probably be so much injured that vision will be destroyed; but instances have occurred of this gland, in the enlarged state, having been removed without any injury being done to the eye.

**Sect. VII. Of Cancer of the Eye, and Extirpation of the Eyeball.**

Scirrhus and cancer may arise from repeated inflammations of the eye, or from staphyloma, or some of the other diseases which frequently attack this organ. The symptoms are, an enlargement, hardness, and protrusion of the ball, with a red, fungous appearance, sometimes discharging thick, yellow matter, but more frequently a thin acrid ichor. At first there is only a sensation of heat in the tumor; but this gradually increasing, changes at last into darting pains, which likewise shoot through to the opposite side of the head. In this situation blood-letting, opiates, and emollient applications, may alleviate the pain. A hemlock poultice applied to the eye, and a wash of lime-water, with a little opium dissolved in it, and applied every time the poultice is renewed, gives some relief; but although the pain be moderated by these means, it does not prevent the disease from spreading, nor can any thing else but extirpation produce a radical cure.

After the disease is discovered to be cancerous, the operation should be performed without delay, to prevent the extension of the tumour, as well as the constitution at the eye large, from suffering. In performing the operation, the patient should be placed in a proper light, and the head supported by an assistant. If the eyelids are diseased, they must be separated along with the tumor; but where they are found, they ought to be carefully preserved; and for this purpose they may be kept out of the way by two levers held by assistants. When the eyeball protrudes considerably, the operator may lay hold of it with his fingers; but if this be impracticable, a broad ligature should be introduced through the centre of it, that it may be the more readily... readily removed from the orbit. Sometimes it will be necessary to enlarge the opening of the eyelids, by cutting the external angle to allow the eyeball to be more readily removed. The whole of the diseased parts are now to be separated by a knife bent so as to correspond with the sides of the orbit, guarding at the same time against wounding the periosteum or the bones of the orbit, which are commonly extremely thin. The eye being in this manner extirpated, the hemorrhage from the ocular arteries is to be suppressed by means of astringent, or by a bit of sponge; then over this is to be laid soft lint, with a napkin to cover the whole. After suppuration takes place, the dressings are to be removed, when a little lint, applied with an emollient pledget over it, will be sufficient as long as any matter is discharged. After the wound is healed, the deformity may be in some measure obviated by wearing an artificial eye; though it is chiefly in cases where part of the humours of the eye have been evacuated that this can be used with much propriety; for when the orbit is empty the artificial eye sinks too far into it.

Sect. VIII. Of the Cataract.

The ancients, and some of the modern writers, had a confused idea of the seat of the cataract; different authors placing it in different parts of the eye. It consists of an affection of the crystalline lens or its capsule, by which the rays of light are prevented from falling upon the retina; and is therefore the same disease with the glaucoma of the ancients. It commonly begins with a dimness of sight; and this generally continues a considerable time before any opacity can be observed in the lens. As the disease advances the opacity becomes sensible, and the patient imagines there are particles of dust or motes upon the eye, or in the air. This opacity gradually increases till the person either becomes entirely blind, or can merely distinguish light from darkness. The disease commonly comes on rapidly, though sometimes its progress is slow and gradual. The opacity of the lens is found to be nearly in proportion to the degree of blindness the patient is affected with; it gradually changes from a state of transparency to a perfectly white, or light grey colour. In some very rare instances a black cataract is found. Sometimes the disease is confined to a particular spot of the lens, but generally the whole is affected. The constancy also varies, being at one time hard, at another entirely dissolved. When the eye is otherwise found, the pupil moves according to the degree of light in which it is placed. This disease is seldom attended with pain; sometimes, however, every exposure to light creates uneasiness, owing probably to inflammation in the bottom of the eye. The real cause of cataract is not yet well understood. Numbers of authors consider it as proceeding from a supernatural contraction of the vessels of the lens, arising sometimes from external violence, though more commonly from some internal and occult cause. The disease is distinguished from the gutta serena, by the pupils in the latter being never affected with light, and from no opacity being observed in the lens. It is distinguished from hypopyon, staphyloma, or any other disease in the fore part of the eye, by the evident marks which these affections produce, as well as by the pain attending their beginning. But it is difficult to determine when the opacity is in the lens or in its capsule. The lens is generally affected; when the capsule is the seat of the disease, it is termed the membranous cataract.

With respect to the treatment: If the disease be in the incipient state, mercury, particularly calomel in small doses, has been attended with some advantage. When any degree of inflammation is present, blood-letting and cooling regimen will sometimes be necessary. Electricity, extract hyoscyami, flammula Jovis, &c. have likewise been extolled; but after these or other remedies have failed, the cure must depend upon a surgical operation. For this purpose two methods are in general use. The first of these, and which was practised for a long time before the other, is called couching. It is done with a view to allow the rays of light to fall upon the retina; and it consists in removing the lens from its capsule, and lodging it in some part of the vitreous humour, where it may be entirely off the axis of the eye, and where it is supposed, in course of time, to dissolve.

The other method is termed extraction, where, after an incision has been made in the cornea, the lens is pushed through the pupil, and then entirely removed from the eye. Each of these methods has been much practised, and it is still a matter of doubt to which we ought to give the preference. The next circumstance deserving attention is the time at which the operation for couching or extracting can with most propriety be performed. Formerly it was thought necessary to wait till the lens had a certain degree of consistence, or was become ripe; but no certain marks of fluidity or firmness have been yet discovered; neither indeed is there any necessity for attending particularly to it, as the operation may be practised in every period of the disease, providing the retina be found, the iris have the power of contracting, and the cornea be transparent. The proper time for the operation is when the opacity of the lens is so considerable as to prevent the patient from following his ordinary occupation. When this is not the case, or when the patient has the use of one eye, it ought not to be performed, as it is always attended with some degree of danger.

When the operation is to be performed, the following is the method of doing it: And first, of couching the cataract. To guard as much as possible against the effects of inflammation, the patient should be confined, for several days previous to the operation, to a low regimen; and two or three doses of some cooling laxative should be given at proper intervals. After this he is to be seated with his face towards the light; but sunshine ought to be avoided. Some, however, prefer a side-light both on account of the operator and patient. One assistant is to support the head, while others secure the arms. The operator is either to be seated with his elbow resting upon a table; or, which is preferred by some, he ought to stand, resting his arm upon the side of the patient. The eye being fixed by the speculum (fig. 29.), or in such a manner as to allow the whole of the cornea and a small portion of the sclerotic coat to protrude, a couching needle (fig. 31.) is to be held in the right hand, in the manner of a writing pen, if the left eye be the subject of operation; the ring and little fingers are to be supported upon the cheek or temple of the patient: The needle is to be entered in an horizontal direction through the sclerotic coat, a little below the axis of the eye, and about one fourth of a line behind the edge of the cornea, so as to get entirely behind the iris. If the needle be of the flat form, the flat side ought to be opposed to the iris, to prevent that substance from being wounded. The point of the needle is to be carried forwards till it be discovered behind the pupil. The operator is now commonly directed to push the point into the lens, and depress it at once to the bottom of the eye; but in this way the lens either bursts through the capsule at an improper place, or it carries the capsule with it, tearing it from the parts to which it is connected. Instead of this, the needle ought first to be pushed into the lens near its under edge, as Dr. Taylor advises, and then carried some way down into the vitreous humour, so as to clear the way for the lens. It is then to be drawn a little back, and carried to the upper part. Cataract part of the capsule, when, by pressing upon it, the lens, if solid, is to be pushed down by one, or, if fluid, by several movements, to the bottom of the vitreous humour. It should then be pushed downwards and outwards, as Mr Bell directs, so as to leave it in the under and outer side of afterwards the eye; where, in case it should rise, the passage of the light would be little obstructed. The needle is then to be withdrawn, the speculum removed, and the eyelids closed; and a compress soaked in a tartarine solution is to be applied over them. Mr Pellier's method is to cover each eye with a linen bag half filled with fine wool, applied dry and fixed to a circular bandage of linen passed round the forehead; the whole is retained by a triangular napkin. The patient is then to be laid in bed, upon his back, with his head very little raised; and, to be kept in this situation for about a week in a dark room. Unless he be of a weakly habit, he ought to be bled at the neck, or leeched at the temple, a few hours after the operation. He should be kept upon low diet, and get small doses of opiates frequently repeated. His belly should be kept moderately open by gentle purgatives. The dressings should not be removed till inflammation is at least so far gone that no danger will arise from uncovering the eye, which may generally be about the eighth or tenth day. Sometimes the patient perceives light immediately on the dressings being removed, but more frequently not till some time after.

Upon removing the dressings, if the cataract has again got back to the axis of the eye, a repetition of the operation may become necessary. Some time, however, after the inflammatory symptoms are gone, should be allowed to elapse before any other operation is again attempted; for the cataract frequently dissolves, providing the aqueous humour get free access to it. Mr Pott sometimes, when he found the cataract to be of the mixed kind, did not attempt depression, but contented himself with a free laceration of the capsule; in which cases the lens hardly ever failed of dissolving to entirely as not to leave the smallest vestige of a cataract. When the operation is to be performed upon the right eye, the straight needle must either be used by the left hand, or the operator must place himself behind the patient. A needle (fig. 32.) has been contrived, however, with a large curve, by which the operation may be readily performed with the right hand, while the surgeon is placed before the patient; only the needle is entered towards the inner, instead of the outer, angle of the eye.

The first hint of extracting the lens seems to have been suggested by Mr Petit, who proposed to open the cornea and extract the lens when it was forced into the anterior chamber of the eye either by external violence or accidentally in couching. At first it was considered as a dangerous operation, and was seldom practised till about the year 1737, when Mr Daviel proposed and practised extraction in preference to couching. The operation is now performed in the following manner: The patient and operator being placed, and the eye fixed in the same manner as for couching, the speculum, when the operation is to be done upon the left eye, is to be held in the left hand of the operator. It is necessary to make as much pressure as will secure without hurting the eye. Neither ought the cornea to be pressed too near the iris, lest the latter be wounded. The operator now takes the knife (fig. 33.), and holds it in the same way as he does the needle for couching; he then enters the point of it with the edge undergoing into the cornea about the distance of half a line from its connection with the sclerotic coat, and as high as the centre of the pupil; he is then to pass it across the pupil to the inner angle in an horizontal direction, keeping the edge a little outwards to prevent the iris from being cut; the point is then to be pushed through opposite to where it entered; Cataract, the under half of the cornea is next to be cut, and at the same distance from the scleroties with the parts at which the point of the knife went into and came out from the eye.

In cutting the under half of the cornea the pressure of the speculum upon the eye should be gradually lessened; for if the eye be too much compressed, the aqueous humour, with the cataract and part of the vitreous humour, are apt to be forced suddenly out immediately after the incision is made. The operator then takes a flat probe, and raises the flap made in the cornea, while he passes the same instrument, or another probe (fig. 34.), rough at the extremity, cautiously through the pupil, to scratch an opening in the capsule of the lens. This being done, the eye should be shaded till the lens be extracted, or the eyelids are to be shut to allow the pupil to be dilated as much as possible; and while in this situation, if a gentle pressure be made upon the eyeball at either the upper or under edge of the orbit, the cataract will press through the pupil more readily than it would do when the eyelids are open.

If the lens cannot be easily pushed through the opening of the cornea, no violent force should be used, for this would tend much to increase the inflammation. The opening should be enlarged, so as to allow the lens to pass out more freely. When the cataract does not come out entire, or when it is found to adhere to the contiguous parts, the end of a small flat probe, or a scoop (fig. 35.), is to be introduced, to remove any detached pieces or adhesions that may be present. The iris sometimes either projects too much into the anterior chamber, or is pushed out through the opening of the cornea. When this happens, it is to be returned to its natural situation by means of the probe already mentioned. Sometimes the opacity is not in the body of the lens, but entirely in the capsule which contains it. The extraction of the lens alone would here answer no useful purpose. Some practitioners attempt to extract, first the lens, and then the capsule by forceps; others, the lens and capsule entire. Those who have had much practice in this branch of surgery, as Pellier, say they find such a method practicable; but others think it better to trust entirely to time and a cooling regimen for the cure, which, in some instances, has taken place. When the operation is to be performed on the right eye, the operator is either to use the left hand, to take his station behind the patient, or to employ a crooked knife (fig. 36.).

After the operation is finished, the eyelids are to be shut, and the same treatment observed as in couching. Whenceafter the operation succeeds, the wound in the cornea is generally healed in little more than eight or ten days; but previous to this time, the eye ought not to be examined; and even then it should only be done in a dull light, otherwise it may suffer considerably from the irritation which a strong light might occasion. When the eye is to be examined, if the eyelids be found adhering together, they ought to be washed with some gentle astringent. With this the eye ought also to be frequently washed afterwards, by which it will gradually recover strength and sight. About the end of the third week the dressing may be entirely removed, and a piece of green silk put over the eyes as a shade; and if every thing has succeeded, the patient may generally go out after a month from the time at which the operation was performed.

It sometimes happens, that in extracting the lens a portion of the vitreous humour is evacuated. This does not in general prevent the success of the operation. The eye soon begins to fill again, and in the course of two or three weeks... Chap. XIV. Of Fistula Lachrymalis.

By this disease is properly understood a sinuous ulcer of the lachrymal sac or duct with callous edges, though every obstruction of this passage is commonly called fistula lachrymalis.

The first and most simple state of the disease is that termed a drop of the lachrymal sac. The symptoms are, a tumor between the inner cornea of the eye and side of the nose. This disappears by pressure, the tears mixed with mucus passing partly into the nose, but chiefly back upon the eye and over the cheek.

This state of the disease is what the French have called the herine, or hydrops faculi lachrymalis. It is frequently met with in children who have been rickety, or are subject to glandular obstructions; and in this state it sometimes remains for several years, subject to little alterations, as the health or habit shall happen to vary, the facculus being sometimes more, sometimes less full and troublesome; the contents which are pressed out are sometimes more, sometimes less cloudy; and now and then the disease is attended with a slight ophthalmia, or an inflammation of the eyelids, but which, by common care, is easily removed. If the facculus be not much dilated, the discharge small, and produced only by pressure, the chief inconveniences are the weeping eye, and the gumming together of the lids after sleeping; but these, by being attended to, may be kept from being very troublesome; and if the disease makes no further progress, may be so regulated as to render any more painful process totally unnecessary. If the dilatation be considerable, the swelling is more visible, and the quantity of fluid is larger; it is also in this state more frequently mixed and cloudy, and more troublesome, from the more frequent necessity of emptying the bag; but if the patient be an adult, it may, even in this more dilated state of it, be kept from being very inconvenient.

If an inflammation comes on, the tumor is thereby considerably increased, the discharge is larger, as well during sleep as upon pressure; the skin covering it loses its natural whiteness and softness, becomes hard, and acquires an inflamed redness; and with the tears a mixture of something, which in colour resembles matter, is discharged, especially if the pressure be made with any force, or continued for any time.

When the parts are in this state, the contents of the bag have so much the appearance of purulent matter, that they are now generally considered as such, though Mr. Pott and several others have been of a different opinion, considering the fluid as merely mucus under a different form; allowing, however, that pus is sometimes discharged. If the puncta lachrymalia be naturally large and open, and the inflammation confined to the surface of the sac, its contents will pass off pretty freely, and the skin will remain entire.

But when the skin covering the lachrymal bag has been for some time inflamed, or subject to frequently returning inflammations, it most commonly happens that the puncta lachrymalia are affected by it, and the fluid, not having an opportunity of passing off through them, distends the inflamed skin; so that at last it becomes flabby, bursts externally, and forms an opening in the most prominent part of the tumor, at which the tears and matter contained in it are discharged. When the opening thus formed is small, it commonly heals again in a few days, but it bursts as soon as a considerable quantity of this fluid is collected; and it continues to collect and burst alternately, till the opening becomes sufficiently large to prevent any farther collection. This state of the disorder exhibits exactly the appearances of a fissured ulcer, with callous, and sometimes with retorted edges; and this stage forms properly the real fistula lachrymalis. Tears, mucus, and purulent matter, are now abundantly discharged from the fore. When the bone beneath is sound, this discharge is seldom either acid or offensive to the smell, for the opening being in general in the under part of the tumor, the matter is readily evacuated; but when any of the contiguous bones are carious, they are not only found to be so by the introduction of a probe, but by the appearance, smell, and effects of the matter upon the neighbouring parts. In this case it is thin, fetid, and commonly so acid as to tret and corrode the integuments most contiguous to the ulcer; and when the disorder is connected with scrophula or with lues venerea, which is by no means an unfrequent occurrence, the discharge and appearance of the fore will vary according as it happens to be combined with one or other of these diseases.

From what has been said, we may divide this disease into four general heads or states, under which all its more minute distinctions may be comprehended. The first consists in a simple dilatation of the facculus and obstruction of the nasal duct, discharging, upon pressure, a fluid either quite clear or a little cloudy; the skin covering the bag being entire and perfectly free from inflammation. In the second, the tumor is somewhat larger; the skin which covers it is in an inflamed state, but entire; and the discharge made through the puncta lachrymalia is of a pale yellow or purulent colour. In the third, the skin covering the facculus is become flabby, and bursts; by which means the swelling is in some measure lessened; but the matter which, while the skin was entire, used to be pressed out through the puncta lachrymalia, now discharges itself through the new aperture. The ductus ad nares, both in this and the preceding state, are not otherwise diseased than by the thickening of its lining. In the fourth, the passage from the facculus lachrymalis into the nose is totally obliterated, the inside of the former being either ulcerated or filled up with a fungus, and attended sometimes with a caries of the bone underneath.

In the first and most simple state of the disease, viz. that of mere obstruction without inflammation, much pains have been taken to restore the parts to their natural state and use, without making any wound or division at all. The introduction of a probe, the injection of astringent fluids, and a constant compression made on the outside of the facculus in the corner of the eye, are the principal means by which this has been attempted.

Several years ago, M. Anel made a probe (fig. 37.) of so small a size as to be capable of passing from the eyelid into the nose, being introduced at one of the puncta lachrymalia, and passing through the facculus and duct; with which probe he proposed to break through any small obstruction which might be found in its passage. He also invented a syringe (fig. 38.), the pipe of which is small enough to enter one of the puncta, and thus furnishes an opportunity of injecting a liquor into the facculus and duct; and with these two instruments he pretended to be able to cure the disease whenever it consisted in obstruction merely, and the discharge was not much discoloured. The fifth of these, viz. the passage of a small probe through the puncta, has a plausible appearance; but will, upon trial, be found of but very unequal to the task assigned: the very small size of it, etc., its necessary flexibility, and the very little resistance it is capable of making, are manifest deficiencies in the instrument; ment; the quick sensation in the lining of the sac and duct, and its diseased state, are great objections on the side of the parts, supposing it were capable of answering any valuable end, which it most certainly is not.

That the passing a fine probe from one of the puncta lachrymalia into the nose is very practicable, is known from experience; but the pain it gives, and the inflammation it often excites, are much greater than any benefit which does or can arise from it. It is said that the principal use of this probe is to clear the little ducts leading from the puncta into the facculus, and the obstruction of those ducts is often mentioned as a part of this disease. Hence one would be led to suppose that it was a circumstance which frequently occurred; whereas it is seldom, if ever, met with. Nor, even if it did happen, could it ever produce the disease in question; the principal characteristic of which is a discharge into the inner corner of the eye upon pressure made in the angle.

The syringe, if used judiciously while the disease is recent, the sac very little dilated, and the mucus perfectly clear, will sometimes be found serviceable; it gives no pain; and a few trials render the use of it by no means troublesome. There is very little occasion, however, to take much trouble, or to put the patient to so much uneasiness; for if the sac be emptied by compression, if the liquor which was to have been injected be applied to the puncta, they will absorb it as readily as the fluid which naturally passes through them.

Fabricius ab Aquapendente invented an instrument, which was so contrived as by means of a screw to make a pressure externally on the lachrymal bag; from the use of which, he says, his patients received much benefit. This instrument has been considerably improved by late practitioners, and is still recommended as very useful. See fig. 39.

All the good that can be obtained by compress and bandage, this screw is capable of procuring; but it is also subject to all the same inconveniences, arising from the impossibility of determining exactly the due degree of pressure; for if it be so great as to bring the sides of the upper part of the sac into contact, all communication between it and the puncta will be thereby stopped; if it be but slight, the accumulation will not be prevented; nor does it in either case contribute to the removal of the obstruction in the nasal duct, the primary and original cause of the disease. If the curative intention was to procure an union of the sides of the facculus, as in the case of parts separated from each other by the formation of matter or floughs, and the pressure could be made uniformly and constantly, possibly it might be so managed as to answer a valuable purpose; but, as that is not the intention, the pressure, whether made by an instrument or by a common roller and compress, contributes little or nothing toward a cure.

When the disease is only beginning to form, if the lachrymal sac be frequently pressed with the finger, the contents of it will be discharged before they become acrid, and the complaint, though seldom to be cured in this manner, may be sometimes endured without any other afflaintance. But when the disease has advanced so far as to be in a state of inflammation, considerable relief may be obtained from such remedies as are found to be useful in inflammatory affections of other parts of the body, as blood-letting, laxatives, and low diet, together with fumigations applications to the parts affected. But when these fail, and it is found that the passage of the tears to the nose is completely obstructed, as the matter, if it does not burst outwardly, may be in danger of corroding the bone underneath, a different practice is to be followed.

In this state, an opening in the upper part of the facculus lachrymalis becomes in general absolutely necessary; and as a wound made by a knife leaves a much less disagreeable fear than that which necessarily follows the bursting of the skin, one being a mere simple division, the other a lot of substance; it will always be found best to anticipate the accident of bursting, by making the opening as soon as the arguments are in such a state as to threaten it.

For making this incision, authors have been very particular in their directions with regard to its place, manner, and form. But all that the surgeon need observe is, to take care to keep the knife at a proper distance from the juncture of the palpebrae, to begin the incision a very little above a line drawn from that juncture toward the nose, and to continue it downward so as to lay the sac completely open; and the best instrument to make it with is a scalpel of the common form, but of a small size. If the facculus be already burst, the place of opening is determined; and the orifice may be enlarged with a knife, or dilated.

The incision being made, the contents of the tumor should be moderately pressed out; after which, some practitioners advise that the nasal duct should be searched for by means of a probe; and if found, that a piece of catgut, bougie, or lead, should be introduced, and kept there, its edge being bent a little downwards till the sides of the duct are skinned over and healed. In the mean time, the sore is to be dressed with simple pledgets of wax and oil, which are to be retained by means of adhesive plaster. As soon as the passage of the tears into the nose is sufficiently secured, the substance which has been left in it is to be withdrawn, and the wound healed.

The last state of this disorder is that in which the natural passage from the facculus to the nose is so diseased as to be quite obliterated, or in which the bones are sometimes found to be carious. The methods hitherto described have all been calculated to preserve the natural passage, and to drive the lachrymal fluid again through it. In this attempt they are sometimes successful; but when every trial for discovering the nasal duct has been unsuccessful, recourse must be had to an artificial opening for the tears. In performing this part of the operation, the patient should be seated opposite to a window, with his head supported by an assistant. The surgeon is to place himself immediately before him, either in a sitting or standing posture. The canula of the trocar (fig. 42) is now to be introduced to the under and back part of the lachrymal sac, and held with one hand, while the fillette is to be passed into it by the other, in a direction obliquely downwards and inwards, between the two spongy bones, till it reach the cavity of the nose, which will be known by some bloody mucus passing out at the nostril. As soon as the instrument has penetrated the nose, the opening should be made sufficiently large; then the fillette should be withdrawn, and a bit of catgut or bougie, or what is more cleanly and convenient, a leaden probe, is to be introduced, and the canula removed. One end of the probe ought to remain in the nose, and the other bent in such a way as to hang over the edge of the wound, and at the same time be in no danger of coming out. The sore is now to be covered with a pledget of lint spread with emollient ointment, and the whole retained with adhesive plaster. The probe must be removed every day or two, so as to allow it and the passage to be cleaned; and at each dressing some astringent injection should be thrown in, when the parts are to be dressed as at first. Several weeks will commonly be necessary for rendering the passage perfectly callous; but this must depend much upon the state of the parts, as well as the constitution of the patient.

After the passage is become sufficiently callous, the dressings and probe are to be withdrawn, and the parts cleared from any mucus with which they may be stuffed. sides of the wound, now already sufficiently contracted, are to be laid together, and covered with some adhesive plaster.

If this be ineffectual, the wound is to be touched with cautery, when the cure will generally be quickly completed.

To give tone to the parts, moderate pressure should frequently be made upon the face, either by the patient's finger or by the machine already mentioned, and this should be continued for a considerable time. Sometimes the disease returns after a cure has been made, owing to diseases of the constitution, curious bone contiguous to the sore, or sometimes to too small an opening having been formed. In this case a canula of gold, silver, or lead, is sometimes introduced into the artificial passage, and the skin healed over it; by which means the passage will afterwards remain completely open, and no disease of the constitution can ever affect it. We shall describe Mr. Pellier's method of performing this operation, who has made several improvements on it.

The patient is to be seated, and his head properly supported by an assistant; then the face is to be laid freely open at its inferior part; the nasal duct is to be searched for with a firm probe, or with a conductor (fig. 41.) made for the purpose; and Pellier affirms that he never fails in finding it. As soon as this is discovered, a conical tube (fig. 42.), with a projection at the top, and another in the middle for securing it in its place, must be put upon the conductor, previously furnished with a compressor (fig. 43.), and it should be of such a size that the conductor may fit it exactly. The point of the conductor is now to be passed into the lachrymal duct; and being pushed in till it reaches the nostril, which may be known either by inserting a probe into it, or by a few drops of blood falling from the nose, the conductor is to be withdrawn; leaving the compressor upon the brim of the canula, which must be firmly pressed down with the left hand, while the conductor is removed with the other. This being done, the compressor must next be taken out; and to discover whether the canula be at a proper depth, a little milk or water should be injected through it. If the injection fails, it will show that the canula is properly placed. If, on the contrary, any obstruction occurs, there will be reason to suspect that it is already pushed too far, and that it presses against the os spongiosum inferius; in which case the canula must be withdrawn, shortened, and reintroduced as before.

The sore ought to be kept open for eight or ten days after the operation with soft lint spread with emollient ointment, and the whole covered with a compress of soft linen secured with a bandage. An injection of milk and water should be daily passed through the canula; and as soon as the sore looks clean and healthy, the dressings should be entirely removed, and a piece of court plaster laid over it. In this state it is to be left to heal; but the plaster must be renewed, if matter appear to form beneath it. By this method Mr. Pellier finds, that fistula lachrymalis, not depending upon diseases of the contiguous bones or of the constitution, may commonly be completely cured in two or three weeks, which, by the usual practice, might require several months.

**Chap. XV. Of Affections of the Nose.**

**Sect. I. Of Hemorrhages from the Nose.**

When the means mentioned for this complaint in the article Medicine have failed, recourse must be had to compression. Dolls of lint introduced into the nostrils are sometimes effectual; or the gut of some small animal, tied at one end, then introduced by a probe into the nose as far as the pharynx, and filled with cold water, or that and vinegar, and secured by a ligature, by adapting itself to all the parts, and pressing equally on them, has been attended with advantage. When these remedies likewise fail in their effect, a piece of catgut or wire may be introduced through the nose into the throat, and brought out at the mouth; a piece of sponge, or a bolster of lint of a size sufficient to fill the back-part of the nostril, is then to be fixed to it; the sponge is next to be drawn back and properly applied. Another is to be applied to the anterior part of the nostril and secured. The same may be done to the other nostril, if it be necessary; or the sponge may be of such a size as to fill the ends of both nostrils at the same time. By this contrivance the blood not finding an outlet, will soon coagulate, and prevent any farther evacuation.

**Sect. II. Of Ozana.**

By this is understood an ulceration within the nose, which may be occasioned by external violence, by exposure to cold, by irritating substances, or by whatever produces inflammation in the membrane lining the nostrils. Sometimes it arises from venereal infection; and in this case the discharge becomes so acrid as to corrode, and produce caries in the bones of the nose. When the disease is local, and not depending upon any constitutional affection, astringent solutions are found to be the most useful, such as a decoction of bark or that mixed with alum. Dolls of lint dipped in these are to be introduced into the nostrils three or four times a-day, or some prefer the injection of such fluids by means of a syringe as being more effectual. If stronger astringents be necessary, a solution of tincture powder ought to be used. At bed-time an ointment prepared with zinc or with lapis calaminaris ought likewise to be applied. Upon some occasions the application of a blister to the temple has cured the disease.

Instances, however, occur, where the discharge is occasioned by a collection of matter within the antrum maxillare; and then it is apt to resist every effort till a proper outlet be given to it.

When the complaint is owing to venereal infection, the primary disease is to be attended to, and mercurial preparations are to be applied to the part; but when the bones are carious, till these are removed we need neither expect that the discharge will cease, nor the disease be otherwise completely cured.

**Sect. III. Of Imperforated Nostrils.**

Sometimes the nostrils are in part or entirely obliterated. This may be owing to burns; small-pox; different kinds of sores, especially those of a venereal nature; and sometimes it is the effect of original conformation, for it has been observed in new-born children.

When any opening appears in the obstructed nostril, it may be readily dilated by the introduction of a furrowed probe, and then cutting upon it in the course of the adhesion; but when no passage appears, the operator must endeavour, by means of a scalpel, to discover one of the nostrils; and when discovered, it must be enlarged by a director and bistoury, as in the former case. The other nostril is to be treated in the same manner. After the openings are formed, they might be preserved of a proper size by the introduction of dolls of lint, which should be frequently cleaned or renewed; but metallic tubes answer the purpose better, and allow the patient to breathe freely through them till a cure be performed. Previous to their introduction, they ought to be covered with soft leather spread with emollient ointment, and retained till the sores are completely healed. When the parotid duct is divided, the saliva which it transmits passes over the cheek instead of going into the cavity of the mouth.

When the surgeon is called to a recent division of the duct, he ought to lay the divided ends of it as exactly together as possible, and to retain them in their situation till they are united by adhesive plasters, or by the twisted future if there be considerable retraction of the parts. But when the portion of the duct next the mouth is entirely obliterated, an artificial passage must be made into the mouth, and an union formed between the opening and that part of the duct which proceeds from the parotid gland. The artificial passage ought to be as much as possible in the direction of the natural duct. For this purpose a perforation of a proper size is to be made obliquely into the mouth with the treac (fig. 44.), from the side of the wound exactly opposite and contiguous to the under extremity of the upper portion of the duct; and then a piece of leaden probe of the size of the perforator should be introduced by means of the canula, and be kept in the cheek till the sides of the opening become callous; when the lead being withdrawn, the extremities of the artificial and natural ducts are to be brought into contact, and retained there by adhesive plaster till the cure is completed. Another method has, in a few instances, been followed by Mr Latta (see his System of Surgery), of introducing one end of a bit of catgut into the artificial opening, and bringing it out at the mouth, while the other is introduced a little way into the extremity of the natural duct, and retained by adhesive plaster till the wound is healed. Whichever way the operation is done, the patient should live upon spoon-meat, and make as little motion as possible with his lips or jaws.

Sect. II. Of the Hare-lip.

The hare-lip is a fissure in the upper lip, very seldom in the under one. It is attended with want of substance, and has its name from a resemblance to the lip of a hare. In general it is only a simple fissure, though sometimes it is double; in which case it renders a cure more difficult to be executed. There are many lips where the want of substance is so great, that the edges of the fissure cannot be brought together, or at least where they can but just touch, and then the attempt should be forborne. It is likewise improper in infants, and ought not to be performed till several months after they have been weaned, when they will have acquired more strength to undergo the operation, and will be less liable to be attacked with bowel complaints, which frequently make them cry at an earlier period of infancy.

In proceeding to the operation, the patient, if a child, should be secured upon a person's knee, or rather perhaps upon a table; but if an adult, he is to be seated upon a chair, in a proper light. The frenum connecting the gums to the upper lip is to be divided; if a fore-tooth project so much as to prevent the parts from being brought properly together, it is to be extracted; or when the fissure runs through the bones of the palate, if a small portion of the bone project, this must be removed. Matters being so far adjusted, the operator is to lay hold of one side of the fissure between the thumb and fore-finger, or between the forearms (fig. 45.), then with a pair of sharp and very strong scissors (fig. 46.), or with a scalpel, to cut off a thin portion of the lip, and to repeat the same thing upon the other side of the fissure, so as to render the whole edges of the fissure completely raw; by which, if the operation be properly performed, a piece will be separated in form like an inverted V. After the incisions have been made, the vessels should be allowed to bleed freely to prevent inflammation; and when the bleeding has ceased, the sides of the wound are to be brought accurately together, and kept in that state by the twisted future. The first pin ought to be as near as possible to the under edge of the lip; another is to be inserted near the upper angle; and if the patient be an adult, a third pin will generally be necessary, half way between the other two. In padding them, they ought to go rather deeper than half through the lip, that the edges of the wound may be kept properly in contact. An assistant now keeps the parts together, while the operator applies a firm waxed ligature first to the under pin; and having made three or four turns with it in the form of an eight figure (fig. 47.), it should then be carried about the second, and in a similar way about the third, care being taken that the thread be drawn of a proper tightness. After the ligature is secured, a piece of lint, covered with some mucilage, should be laid over the wound to protect it from the air; and this is commonly all the bandage necessary. When, however, from a great want of substance, the retraction has been considerable, some advantage is derived from the use of adhesive plasters applied to the cheeks and tied between the pins. During the time of the cure the patient should be fed upon spoon-meat, and prevented from making any exertion with the lips, otherwise the cure might be considerably retarded. At the end of five or six days the pins may be taken out, when the parts will commonly be found completely united.

In the case of a double hare-lip, the operation should be first done upon one fissure; and when a cure is completed there, it may be done safely upon the other.

Sect. III. Of Extirpation of Cancerous Lips.

The under lip is much more frequently attacked with cancer than the upper, or indeed than any other part of the body: And as little dependence is to be placed upon external applications or internal remedies, recourse must be had to the knife as the only certain method of cure.

When the disease has not attacked any considerable part of the lip, the diseased part is to be cut out, and the wound cured by the twisted future. The operation ought therefore to be performed early, to allow the parts to be brought properly together. The general steps of the operation are nearly the same as in the operation for hare-lip, and therefore need not be repeated. It is only to be observed, that all the diseased parts are to be removed, taking care to make the cut in such a way as will most readily admit of the twisted or hare-lip future. When the parts can be brought together, the lip will have nearly the same appearance as in the operation for hare-lip; but, when the disease spreads over a considerable part of the lip, so as to prevent the sound parts from being united after the diseased parts have been removed, all that can be done is to remove the part affected, secure the bleeding vessels, and dress the sore like any other recent wound.

Sect. IV. Of Affections of the Teeth.

In dentition the gums inflame and swell about the parts where the teeth are afterwards to appear; the child is continually rubbing the gums with its finger; the saliva is commonly increased in quantity, though sometimes the contrary happens; sometimes the bowels are remarkably colicive, tho' more frequently the reverse: there is generally quick pulse, with heat, and other symptoms of fever; and on some occasions these symptoms are attended with convulsions. The means found to be most useful here are such as are most effectual in allaying irritation; as opiates, blistering, and especially warm-bathing. When these fail, cutting the gum by means of a flint (fig. 48), over the approaching tooth, is frequently found to remove every symptom; but this ought to be done earlier than it commonly is to have the full effect. Whenever the symptoms give reason to think that a tooth is approaching, the gums should be cut freely over that part where the teeth may be first expected. When the symptoms recur, the operation should be repeated. A crucial incision is attended with still more effect; and the bleeding which afterwards takes place is of considerable service. The incision should always be carried as far as the tooth, which ought to be somewhat exposed; and when properly done, is frequently followed with immediate relief. Sometimes the same kind of symptoms attend the cutting of the second set, particularly of the dentes saponariae. When this is owing to the thickening of the gums, scarifying gives the greatest relief; but sometimes it is for want of room in the jaw, and then the tooth should be drawn.

Derangement of the teeth happens more frequently in the second than in the first set, and more commonly in the fore than in the back teeth. This may be owing to the first set remaining in the jaw after the second have appeared. Another cause is a waste of space in the jaw; and a third is a mal-conformation of the teeth, where they are too large in proportion to the jaw, and therefore overlap each other. The remedy is the same in each of these cases, viz., to extract the teeth which stand in the way of the rest, to allow those which are out of their place to come into the row, and put on a more uniform appearance.

The usual method of moving teeth which are out of the row is, by fixing them with a ligature to the nearest teeth; or the same thing is done by metallic plates or pieces of wire. But these methods have not been found fully to answer the purpose intended, though in some cases they may be useful. When one or more front teeth are accidentally drawn out of the jaw, they ought to be immediately replaced. When the teeth are broken over or otherwise injured, they may be supplied with others transplanted from the jaws of another person; but this can only be done when the sockets have been newly emptied, for after inflammation comes on it is impracticable. In these cases the inflammation must be allowed to subside, and then artificial teeth can be readily adapted.

When the teeth are loosened by external violence, by falls and blows, or by improper use of instruments in pulling diseased teeth in the neighbourhood of sound ones, they may again be made tolerably fast by pressing them as firmly as possible into their sockets, and preserving them so with ligatures of catgut, Indian weed, or waxed silk, and keeping the patient upon spoon-meat till they are firm. When loose teeth are owing to tartar, nothing will fasten them till the cause be removed; and this ought to be done early, otherwise it will have no effect. Frequently the teeth become loose from a sponginess in the gums, often, but improperly, attributed to tenery. The best remedy is scarifying the gums deeply, and allowing them to bleed freely; this should be repeated till they are fully fastened. Mild astringents, as tincture of bark, are here attended with good effects, tho' those of a strong nature will certainly do harm. The mouth should be frequently washed with cold water strongly impregnated with these, and the patient should not use the teeth which have been loose till they become firm again. The loosening of the teeth in old age cannot be remedied, as it is owing to a wasting of their sockets, from which the teeth lose their support.

The teeth sometimes become yellow or black without any adventitious matter being observed in them; at other times they become foul, and give a taint to the breath, in consequence of the natural mucus of the mouth, or part of the food remaining too long about them. The most frequent cause of foul teeth is the substance called tartar, which seems to be a deposition from the saliva, and with which the teeth are often almost entirely incrusted. When this substance is allowed to remain, it infatuates itself between the gums and the teeth, and then gets down upon the jaw in such a manner as frequently to loosen the teeth. This indeed is by far the most common cause of loose teeth, and when they have been long covered with this or with any other matter, it is seldom they can be cleaned without the affluence of instruments. But when once they are cleaned, they may generally be kept so by rubbing them with a thin piece of soft wood made into a kind of brush, and dipped into white-wine vinegar; after which the mouth is to be washed with common water.

When the teeth are to be cleaned by instruments, the operator ought, with a linen cloth or with a glove, to press against the points of the teeth, so as to keep them firm in their sockets, with the fingers of the one hand, while he cleans them with the necessary instruments, fig. 51. No. 1, 2, 3, 4, 5, held in the other; taking care not to scrape them so hard as to loosen them, or to rub off the enamel. This being done, the teeth should be rubbed over with a small brush, or a piece of sponge dipped in a mixture of cream of tartar and Peruvian bark. The same application may be made to the teeth for a few days, after which they may be kept clean as already directed.

The teeth are sometimes covered over with a thin dark coloured scurf, which has by some been mistaken for a wasting of the enamel, but which is only an extraneous matter covering it. By perseverance this may be cleaned off as completely as where the teeth are covered with tartar; but it is apt, after some time, to appear again. When this is observed, the same operation must be repeated.

For the purpose of applying powders or washes to the teeth, a brush or a sponge is commonly employed; the latter is certainly preferable, as being less in danger of wearing down the enamel, or of separating the teeth.

The causes producing toothache may be, exposure of the tooth-nerve of a tooth, by breaking or wasting of the enamel, inflammation in or about the tooth, or from sympathy when distant parts are affected, as the eye, the ear, the stomach, or the uterus, as in time of gestation. After toothache has once been produced and removed, it is apt to return by exposure to cold, by taking hot liquids, by hard bodies pressed against the nerve in the time of chewing, by the use of a pick-tooth, &c.

With respect to the cure of this disease, no rule can be laid down which will answer with certainty upon all occasions. No remedy has yet been discovered which will at all times even moderate the pain; relief, however, is frequently obtained from acid substances applied to the tooth, so as to destroy the irritability of the nerves, such as opium, spirit of wine, camphire, and essential aromatic oils. When these fail, blisters behind the ear, or destroying the nerve by the cautious use of strong acids, or by a red hot wire frequently applied to the part, have been attended with advantage.

When a black or mortified spot appears on a tooth, if it be quite superficial, it may be removed; but if it go through the thickness of the enamel, it will be more advisable to let it remain.

When a small hole breaks out in a tooth, particular attention should be paid to prevent the admission of air. Tin, lead, or gold-lea, commonly employed for this purpose, sometimes give relief for many months, or even years; but at other times are of little advantage, and in some instances create great pain. Gum-mastic or bees-wax are frequently employed, and can be made to fill the cavity of the tooth still better than metallic substances. When stuffing is to be employed, it ought to be done in the intervals of the fits of toothache, otherwise it will give great uneasiness. When it is to be used, the whole cavity of the tooth should be filled; and this is to be done with the instruments, fig. 52.

When the remedies made use of for the removal of toothache have failed in their effect, and it is found that the complaint still continues, it will be necessary to extract the tooth. In doing this, it may be observed, that all the teeth may be pulled to either side, excepting the dentes sapientiae of the lower jaw, which ought to be pulled outwards, otherwise the jaw may be splintered. As soon as the socket is cleared of blood, if the tooth be not much spoiled, it may be immediately replaced, when it will become as useful as before. It is difficult, however, to replace the large grinders, on account of their diverging roots. The more perpendicularly the teeth are pulled, the less contusion and injury will be done to the jaws and alveoli. But as no instrument has been yet invented capable of effecting this properly, surgeons are obliged to be contented with an instrument which acts in a lateral direction. One of the best is that (fig. 53.) in form of a key, with a claw and fulcrum. Previous to the operation, this should be covered with a linen rag, to prevent the gum from suffering. After dividing the gum, or separating it from the tooth, the claw is to be fixed as deep between the teeth and gum as possible. Then the fulcrum is to be applied on the opposite side. The surgeon may now, with one turn of the handle of the instrument, pull the tooth out at once. But the turn should not be effected by a sudden jerk, but in the most cautious and slow manner. When it happens to be one of the great molars, whose roots diverge very much, and when they are firmly fixed, after only loosing it with the first pull, the claw of the instrument is to be applied to the other side of the tooth, and the turn given in a contrary direction to the first. After it has been sufficiently loosed in this manner, it is to be laid hold of by a common teeth forceps (fig. 54.), and extracted in the easiest manner. Upon extraction of the tooth, any detached splinters occurring are to be immediately removed. Should any considerable hemorrhage take place, the patient may take some cold water, vinegar, or spirit of wine into his mouth, and doffs of lint may be introduced into the socket. After all these fail, recourse must be had to the actual cautery.

When stumps occur from caries, or when the teeth have broken in time of the extracting, the common key will sometimes remove them; if that fail, the punch (fig. 55.) is to be used. The operator, having this instrument in one hand, is to place the fore finger of the other, with a piece of cloth wrapped round it, upon the inside of the jaw opposite to the stump, to protect the neighbouring parts.

Teeth can never be transplanted with propriety in childhood or in old age. The constitution must be free from those dilacres which affect the gums. The tooth to be transplanted must be taken from a person of a sound constitution; otherwise it will convey infection. To guard as much as possible against infection, it should be immersed for a few minutes in lukewarm water, and then well dried and cleaned. It ought to fit the socket exactly; if it be too large, it may be filed down, avoiding the enamel as much as possible. The surface of it should be at first on a level with the rest, or rather a little more depressed, that it may be as secure as possible in its place. If the tooth fit the socket properly, there will be no occasion for using a ligature to fix it; but if a ligature be found necessary, it may be made of threads of fine silk properly waxed. After the operation is finished, the patient ought to avoid whatever may be in danger of shaking the tooth, and this is to be attended to till the tooth is perfectly firm. He should also guard against cold and moist air, and live upon spoon-meat.

Sect. V. Of Boils and Excrencences of the Gums.

Gum boils may arise from cold or from external violence, or both; but most frequently they are the consequence of toothache. The complaint begins with pain attending a tumor on the parts affected; by degrees the side of the face swells considerably; the tumor of the gum now begins to point; and if it be not opened, it bursts and gives the patient immediate relief. When the boil is owing merely to inflammation, after the matter is evacuated, the complaint goes off; but when it proceeds from a caries of a tooth, it will continue as long as the cause remains; the tooth therefore ought to be extracted. After the abscess has burst, if the matter continue to be discharged, it may sometimes be dried up by injecting some astringent liquor; but the most effectual method is to lay the abscess fully open, and to heal it from the bottom by doffs of lint. Sometimes abscesses occur of a more obstinate nature, owing to a carious state of the jaw. In that case suppuration ought to be promoted, and the part laid open as soon as matter is formed; keeping the passage open for the discharge, being the only means for effecting a cure.

Excrencences of various degrees of firmness sometimes grow upon the gums. Some are soft and fungous, while others are of a warty nature. In general they are not attended with pain. They frequently originate from caries of the teeth, or of their sockets; in which case the removal of the spoiled teeth, and the subsequent exfoliation of the carious part of the jaw, will often accomplish a cure. But when this does not happen, the tumor should be removed as soon as it becomes troublesome, otherwise there may be danger of its ending in cancer. The removal may be effected by a ligature or knife, according as the tumor may have a narrow or broad basis. It is sometimes necessary to use a speculum or to keep the mouth open. After the tumor is extirpated, the wound should be allowed to bleed freely, to prevent subsequent inflammation. When the hemorrhagy proceeds too far, it should be restrained by the application of spirit or wine, or tincture of myrrh, or solution of alum, &c., and should these prove unsuccessful, the lunar caustic will seldom fail of having the desired effect. No dressings can be applied; but for some days after the operation, the mouth should be frequently washed with a warm emollient decoction; and the cure will be afterwards promoted by the application of some gently astringent liquor, as port wine, tincture of roses, &c.

Sect. VI. Of Alloctus, &c., in the Antrum Maxillare.

This disease is known by a pain and uneasiness beginning in the cheek, and extending upwards to the eyes, nose, and ears, together with a swelling, which in the latter stages of the disease tends to a point, most frequently in the cheek. Sometimes a discharge ensues between the roots of the back-teeth, when they happen to penetrate the antrum. Sometimes a discharge of matter from the nostrils takes place, particularly when the patient lies on the side opposite to the tumor. The disease may arise from cold, or whatever produces inflammation in general; but the most common causes are violent fits of the toothache, occasioning excessive pain and inflammation of the membranes of the nose and antrum.

The cure is performed by giving a free discharge to the

Sect. IX. Division of Frænum Lingue.

Sometimes the frænum linguae extends to the point of the tongue, and tying it down; whereas, in the natural state, it ends about one-fourth of an inch farther back. When this is the case, it is to be divided, guarding against wounding the neighbouring vessels, or the ends of the salivary ducts. The division may be made with a common scalpel, but still better with a pair of very sharp scissors with blunt points.

The child being laid across the nurse's knee, the surgeon should open the mouth, and raise the tongue with the two first fingers of the one hand, while with the other he introduces the scissors, and divides the frænum in the middle, and as far back as is necessary.

Sect. X. Of Enlargement of the Tonsils and Uvula.

The tonsils sometimes grow so large and hard as to become incurable, and even to threaten suffocation. The tumors here have been commonly considered as to be of a fibrous nature; but they are neither attended with shooting pain, nor are they apt to degenerate into cancer; neither do swellings return after the tonsils have been extirpated; hence they ought not to be removed till by their size they impede deglutition or respiration; but whenever they do this, they may be removed with safety. The only proper method of removing them is that by ligatures, which are not only void of danger, but seldom fail to perform a cure. If the base of the tonsil be smaller than the top, the ligature is to be used as for polypi in the throat; but however broad the base of it may be, much difficulty will seldom occur in fixing it, for the swelling is always very prominent.

In diseases of this kind both tonsils are generally affected; but if the removal of one of them forms a sufficient passage for the food, the other may be allowed to remain. When, however, it is necessary to extirpate them both, the inflammatory symptoms produced by the extirpation of the first should be allowed to subside before any attempt be made to remove the other.

When the form of the tonsils happens to be conical, so that the ligature would be apt to slip over their extremities, Mr Chefelden has recommended a needle (fig. 56.), with an eye near the point: a double ligature being put into the eye, the instrument is to be pushed through the centre of the base of the tumor, and the ligature being laid hold of by a hook and pulled forwards, the instrument is to be withdrawn; then it is to be divided, and so tied that each part may surround one half of the tumor. This method however is scarcely ever found to be necessary.

Enlargements of the uvula, from inflammation or from other causes, may generally be removed by the frequent use of astringent gargles, as of strong infusions of red rose-leaves or of Peruvian bark. But when these fail, and the enlargement is so considerable as to give great uneasiness by impeding deglutition, irritating the throat, and so causing cough, retching, and vomiting, extirpation is the only thing upon which any dependence can be placed. Excision is the rarest method when the uvula is only elongated; but when of the size is considerable, dangerous hemorrhages sometimes attend this method; on which account a ligature is preferable. The operation may be readily performed by those of the common kind; some prefer the curved probe-pointed bistoury.

In performing the operation, the speculum oris (fig. 57.) is necessary to keep the mouth sufficiently open, and the uvula should be laid hold of by a pair of forceps or a small hook; so as to keep it firm, and prevent it from falling into the throat. After the operation, if the bleeding be considerable, it may be checked by astringent gargles, or by touch. touching the part with linen cauticle; but this will seldom be necessary.

When a ligature is to be employed, it may be readily done according to the method recommended in the extirpation of polypi. A double canula with a ligature may be passed through the nose, or the ligature may be applied according to Chefsden's method in extirpation of the tonsils.

Sect. XI. Of Scarifying and Fomenting the Throat.

In inflammatory affections of the throat, the means commonly employed are gargles, fomentations, scarification, or top-bleeding. Gargles are useful for cleaning the faucets from thick mucus or other foreign bodies; they may likewise be useful in cases of ulceration. In relaxation of the parts, they are employed to advantage when made of astringent materials. Fomentations may be of some use when externally applied; but the steam of water, &c., drawn into the throat, by means of Mudge's inhaler (fig. c8.), is preferable. Sometimes it is necessary to draw blood from the part affected. Here recourse may be had to scarifying with a common lancet, the tongue being depressed with a spatula. It may be still more readily done by the scarificator (fig. 59). After a sufficient number of punctures have been made, the flow of blood may be promoted by the patient's frequently applying warm water to the punctures. When abscess forms, notwithstanding the use of these remedies, the matter may be discharged with the scarificator already mentioned.

Chap. XVII. Of Diseases of the Ear, and Operations performed upon it.

Sometimes a thin membrane is spread over the mouth of the external passage, while at other times a considerable part of the passage is filled up with a fleshy looking substance, occasioning deafness. When the first circumstance occurs, the skin is easily divided by a simple incision, and the accretion of its sides may be prevented by a coil of lint or a bit of bougie inserted between the edges of the wound, and daily cleaned and returned till the part be rendered callous.

When the other cause is present, the incision must be continued considerably deeper, till the resistance be removed, or till the instrument reach near to the membrane of the tympanum, when the operator should desist; lest the membrane should be wounded; then the same kind of treatment may be followed as in the former case. The proper time for performing the operation is when children usually begin to speak; for previous to this the patient may be too weakly to bear it, and after this speech would be impeded.

Sometimes the meatus externus is entirely wanting in the temporal bone. For this an opening through the mastoid process has been proposed; but the operation has not been performed, at least in this country.

Children sometimes push hard bodies into their ear, or different kinds of insects occasionally creep into it, so as to cause considerable uneasiness. Substances lying near the outer end of the passage may generally be extracted by the small forceps represented in (fig. 60); but round, hard bodies situated deeper in the passage are more readily removed by a crooked probe. When insects are deep seated in the ear, they ought first to be killed, by filling the passage with oil, or any other fluid which proves noxious to them, without hurting the tympanum. They may then be washed out by injecting warm water frequently by means of a syringe.

Wax is one of the most frequent causes of deafness, and it may be readily detected by looking into the ear in a clear sunshine.

Various methods have been proposed for removing wax from the ear; but one, not inferior to any, is to throw in frequently, by means of a syringe (fig. 61), warm milk and water, or water in which a little soap has been dissolved. Wax affluence may likewise be given here, by using along with the injection a blunt probe or fine hair pencil, by which the bottom of the passage may be cleared out. After the wax is removed, the patient ought to guard against the effects of cold by introducing a little wool for some time into the meatus.

When deafness is owing to a deficiency of wax in the ear, deficiency of wax, or even oils of a hotter nature, or of wax, soap, or galbanum &c., have been of service.

Purulent matter is now and then formed in the ears of adults, but oftener in those of children. Sometimes it is produced by ulcers situated in the lining of the meatus, ear, or upon the membrane of the tympanum. It seems to be merely a local affection, and does not, as many have supposed, originate from morbid humours of the system. The remedies best calculated for removing it are such as are of a moderately astringent nature, as a weak solution of saccharinum tartari. A little of this may be dropped in two or three times a day, but it is still better to use a syringe. If the discharge has continued long, it may be proper, in addition to the other applications, to keep open a small blister for some time in the neck, arm, or wherever it may be thought most convenient.

It sometimes happens, particularly in old people, that, from exposure to a stream of cold air, the tympanum becomes affected, and a noise is heard by the patient like the rushing of water. In other cases the patient is incapable of accurately distinguishing the words of some persons speaking in a loud tone of voice; or, in mixed companies, he hears only a confusion of sounds. Complaints of this kind frequently originate from a relaxation of the soft parts of the tympanum; and though a complete cure is not very frequently performed, yet considerable advantage is sometimes derived from the use of hot stimulating oils, and from keeping the part warm at the same time with a little wool. When deafness arises from affections of this nature, some affluence may be derived from collecting the sound, so as to make a stronger impression upon the internal ear. A variety of instruments have been invented for this purpose. Some use a convoluted tube as is represented in fig. 62, (see Trumpet); others a sort of cup, fig. 63, which is concealed under the hair, and fixed to the head with straps.

In scrophulous habits, suppurations sometimes occur in the neighbourhood of the ear, and penetrate into the external passage, or into the tympanum itself; after which it is not unusual for the small bones of the ear to lose their connecting membrane, and to be discharged along with the matter, and for caries to ensue in the tympanum; in consequence of which a high degree of deafness is produced, which can never be removed. In such a situation little else can be attempted than to preserve the parts clean and free from smell, which is readily done by injecting a little warm milk and water morning and evening by means of a syringe. If this be neglected, the matter from the carious bones is apt to become offensive; and it commonly continues till the diseased parts are either dissolved and discharged, or probably during the life of the patient.

Besides the affections which may arise in the meatus externus, and may be the cause of deafness, others may occur in or about the meatus internus or eustachian tube, which may have in part the same effect, though by no means in the same degree. Inflammation and its consequences may originate The Wry originate in the cavity of the tube, or swellings or ulcers Neck. is the throat may affect it so as to cause some degree of deafness. When this is the case, it is practicable to introduce a pipe, fig. 64., crooked at the extremity, through the mouth or nose, and then to inject into the mouth of the eustachian tube any mild fluid which may be thought fittest for the purpose, though no great dependence is to be placed upon the attempt.

Formerly piercing the lobes of the ears was sometimes recommended in complaints of the head, and was considered as a surgical operation; but it is now never practiced, unless for the sake of ornament. As the substances suspended at the ears are sometimes so heavy as to tear down the parts, the perforation should be made as high on the lobes as can be done with propriety, and care should be taken that the perforations be made exactly in the corresponding parts of the ears. Previous to the perforation the lobes may be marked with ink; then the patient being seated, the lobe of the ear should be stretched upon a piece of cork placed beneath it, and perforated with an instrument, fig. 65. The cork is then to be withdrawn with the point of the instrument sticking in it: A small piece of lead, or silver, or gold-wire, is now to be inserted into that part of the instrument which remains in the ear, and on being drawn into the perforation, the wire is to be left in it. By rubbing it with oil, and moving it daily, the passage will soon become callous, and fit for receiving the ornament intended for it.

**Chap. XVIII. Of the Wry Neck.**

Wry neck may be owing to different causes; as contraction of the skin in consequence of burns, or other kinds of forces; relaxation of the muscles of one side of the neck, particularly the mastoid, while those of the other side continue to act with vigour; premature contraction of the muscles of one side of the neck, the others having their usual power; or, a bend in the vertebrae of the neck.

When the disease is owing to a contraction of the skin, this is to be divided through the whole of the contracted part, guarding against cutting the external jugular vein.

When the contraction of the mastoid muscle is the cause of the disease, the muscle should be divided by gentle strokes, so as to run no risk of wounding the great vessels situated under it. When an incision is made either with a view to divide the muscle or the skin, the head is afterwards, by means of a machine (fig. 66.), to be kept in a proper posture during the cure until new granulations form and fill up the empty space.

When the disease is merely owing to a curve of the bones of the neck, the same kind of machinery may be useful with that recommended for cure in the other parts of the spine. But sometimes the disease arises from an affection of the bones of a more serious nature. Here the disease in the vertebrae commonly begins with a slight pain, which gradually becomes worse, and the head is turned over to the sound side. As the disease becomes worse, a fulness can be observed very painful to the touch; and moving the head becomes so distressing as to be almost impracticable. The only method which has been found to be effectual in this case, is the insertion of a pericardium on each side of the tumor, and retaining it till the pain and stiffness are entirely removed.

**Chap. XIX. Of Bronchotomy and Oesophagotomy.**

The operation of bronchotomy is an incision made in the trachea, to make way for air into the lungs, when respiration is obstructed to such a degree that life is in danger. If the patient's breathing be already stopped, the operation ought to be done with the greatest expedition; using any instrument which will most readily make an opening in the bronchus trachea, as the delay of a few moments will often put a period to the person's existence. Experience has shown, indeed, that in by much the greater number of cases, by a total stoppage of respiration for only five or six minutes, life is irrecoverably destroyed.

In performing the operation, where, from the nature of the case, sufficient time is allowed, the patient is to be laid on his back upon a table, and properly secured by afflatus. A longitudinal incision is to be made, about an inch and an half long, through the skin and cellular substance; beginning at the under edge of the thyroid cartilage; the sternohyoid and thyroid muscles are then to be separated; the thyroid gland is to be avoided as much as possible, on account of its vascularity. As soon as the trachea is laid bare, the bleeding-vessels, to prevent coughing, are to be secured; then, with a common lancet, a puncture is to be made as high as may seem practicable between two rings of the trachea, of such a size as to admit the introduction of a double canula (fig. 65.), large enough to allow the patient to breathe freely, and of such a length as neither to be in danger of slipping out, nor of irritating the back part of the trachea. Such a canula has long been recommended by Doctor Monro in his course of surgery. Previous to the introduction the canula may be put through several plies of linen compress; or these may be first slit half way down, and applied so that any of them may be removed and replaced at pleasure. This double canula is to be fixed by a strap round the neck; and when mucus obstructs the passage of the instrument, the inner tube can be withdrawn, cleared, and readily replaced; while the patient is, during this time, breathing through the outer one; and by means of a screw the tubes can be regulated according to the motions of the trachea. After the canula is fixed, it ought to be covered with a piece of muslin or crape, to prevent the admission of dust, infects, &c. As soon as the causes inducing suffocation are removed, the canula is to be withdrawn, and the skin immediately brought over the orifice, and retained there by a slip of adhesive plaster.

By oesophagotomy is understood the cutting open the oesophagus, to allow substances sticking in it, and which cannot be extracted otherwise, to be removed. It is only to be done, however, in cases of the most extreme danger, as it is attended with much hazard; and there are only two instances yet on record of its having been performed with success, though there are several instances of wounds in the oesophagus being healed. The operation may be rendered necessary, where obstructions of the oesophagus become so complete as to prevent the passage of nourishment into the stomach, or of air into the lungs. But it is evident, that when the obstructing cause is in the under end of the oesophagus, any incision becomes useless.

In performing the operation, the patient is to be secured in the same manner as for bronchotomy, and an incision made through the skin and cellular substance as directly opposite as possible to the part obstructed. If it be done with a view to remove an obstruction, the muscles over the trachea are to be pulled to one side, and the trachea to the other, by means of a blunt hook; by which the oesophagus will be brought into view. If the obstructed part now come in sight, the incision is to be made directly upon the obstructing body, which is to be extracted by a pair of small forceps; but if the obstruction happen to be farther down than we can with safety have access to the oesophagus, the incision is to be enlarged as much as possible, that the forceps may be able to reach and extract it. When the operation is performed, the wound will be difficult to heal, Sore Nipples heal, as the sides of it will be frequently separated by the action of deglutition. On this account as great a degree of abstinence as possible is to be advised; and nothing but nourishing liquids, in small quantities, are to be allowed. The patient should be prevented from moving his neck; and the wound is to be healed as soon as possible by the same methods which are used with wounds in other parts of the body. On the other hand, if the operation has been done for the purpose of conveying nourishment into the stomach, when the patient was distressed by a tumor either in the oesophagus itself or in some of the neighbouring parts, it will be necessary to keep the wound open during the continuance of the tumor, or the life of the patient.

Chap. XX. Of Sore Nipples.

Women are more generally affected with sore nipples in sucking their first child than at any period afterwards. This may, in some measure, be owing to the smallness of the nipples; but very often it arises from their being unaccustomed to the irritation of sucking. In some cases, the nipples are so flat, and so much sunk in the breast, as to render it difficult for the child to lay hold of them. Here assistance can sometimes be given, by the mother pressing back the prominent part of the breast, so as to make the nipple project between two of her fingers. Should this be insufficient, the nipple may be made to project by applying to it a stout child several months old: but when this cannot be done, breast-glasses, such as fig. 68, may answer the same purpose. By applying these to the nipple, and sucking out the air, the child will commonly be enabled to lay hold of it.

The nipples at this time are liable to excoriations, cracks, or chops; which, though not attended with a formidable appearance, are frequently more distressing than large ulcers. Mild, astringent, and drying applications are most to be depended upon in such complaints; as port wine, brandy properly diluted, or lime-water; all of which ought to be applied warm. After bathing the parts with any of these, the nipple should be covered with unguentum nutritum, or Goulard's cerate; the first of which is considered as best. Even a little soft pomatum frequently rubbed upon the part, and covered with a soft linen rag, is sometimes found to give considerable relief. But the nipple should be perfectly cleared of these applications before the child is laid to the breast; and this may be done with a little port wine, or equal parts of brandy and vinegar. If proper attention be paid to these remedies, they will commonly be found to have the desired effect; but if the contrary should happen, another remains to be mentioned, which, in different instances, has given great relief: it consists in the application of a thin skin to the nipple, as the neck and part of the body of a swine's bladder with an aperture in it; which, being properly moistened and fixed to the breast, will completely protect it in the time of sucking. As long as the nipples remain any way affected, small cups of glats or tin are useful for retaining the dressings, defending the nipples from the friction of the clothes, and receiving any milk which may fall from the breast.

Chap. XXI. Of Paracentesis of the Thorax.

When either the action of the heart or of the lungs is impeded by fluids collected in the cavity of the pleura, a discharge of these fluids by a perforation is the only chance the patient has for relief. The fluids which collect in the pleura are, serum, blood, air, or pus. A collection of water or serum is frequently found in the thorax, combined with dropsy in other parts of the body; but the affection is often local, and it is then chiefly that advantage is to be derived from an operation. Besides, in the two great cavities of the thorax, collections of water are frequently met with in the pericardium, and are said to be sometimes discovered between the layers of the anterior mediastinum. The disease is marked by the following symptoms: There is a sense of weight or oppression in the thorax, and difficulty of breathing; the patient has frequently a more uneasy sensation in one side than in the other; has sudden startings during sleep, with a sense of suffocation; is troubled with a frequent dry cough; the pulse is small and irregular; the skin dry, and the urine scanty.

With these symptoms there are commonly other marks of dropsy; and the patient sometimes, upon any sudden motion, is sensible of an undulation within the chest; and when the quantity of water is considerable, the undulation will even be heard by the bystanders, if the body be smartly agitated. For this purpose, the patient's body should be uncovered while under examination; and the surgeon should place his hand upon the breast near the sternum; then an assistant ought to raise the patient suddenly from a horizontal to an erect posture, or to stand behind the patient and make sudden jerks; when, if water be present, the undulation will be felt; but it is necessary to guard against being deceived by the noise sometimes made by the contents of the stomach.

When the water is collected in one side only, if the disease be of long standing, for the most part that side is more prominent than the other. If the water be in the pericardium, the symptoms are nearly the same as those above enumerated, with this difference, that the pain is generally felt behind, and to the left side of the sternum; and the stroke of the heart is as if buried in water, while an undulatory motion has been said to be felt opposite to the anterior extremities of the third, fourth, and fifth ribs.

In the treatment of this disease, little advantage can be derived from internal remedies. Squills, cream of tartar, medicines of mercury, and digitalis, are upon some occasions attended with advantage; but the only method from which we can expect any degree of success is the removing of the water by an operation, which should be performed as soon as there is reason to expect that danger may arise from delaying it longer. The operation is done in the same way as shall be afterwards described in the case of empyema.

Blood collected in the thorax is always extravasated through some wound or rupture of the vessels of the lungs or thorax. The breathing becomes oppressed, the motion of the heart the thorax, and arteries feeble and irregular, and all these symptoms are more distressing than collections of other fluids. As it frequently happens, in cases of this kind, that some of the vessels of the lungs are injured, part of the blood is thrown up by coughing; which, when considerable, gives a temporary relief to the lungs and heart; and while this is the case, no operation is necessary; but whenever the action of these parts becomes much impeded by a great accumulation of blood, a perforation ought to be made to discharge it. When the extravasated blood is too firmly coagulated to pass off by a perforation, the wound ought to be made considerably larger; and if this be insufficient, injections of warm water ought to be thrown in, and allowed to remain for some time, to promote the diffusion of the mass, which is afterwards to be evacuated. If the extravasation has been occasioned by a wound in the lower part of the thorax, a new perforation will be unnecessary; an enlargement of the wound will be quite sufficient. But if it be situated in the upper part of the cavity, a perforation in the middle Paracentesis of the thorax ought to be made, that the blood may be freely discharged. In case of a rib being fractured, or a vessel ruptured, the incision ought to be made as near as possible to the part affected, to allow the blood to escape, and loose pieces of bones to be removed.

The discharge of air into the cavity of the thorax produces symptoms little less alarming than those proceeding from the effusion of blood. In general they are, oppression in breathing; a tightness of the breast, attended with pain; inability to breathe in the recumbent posture; a flushing and swelling of the face; a feeble, and at last an irregular pulse. The extremities become cold, and cold sweats break out on the forehead. With these symptoms there is frequently a swelling over the external parts of the body, by air getting from the ruptured lungs into the common cellular substance; and all these complaints increasing, the patient, if not quickly relieved, soon dies; sometimes in a few hours, with marks of suffocation.

Air may be produced in the cavity of the thorax by wounds in the lungs, by mortification generating air in any of the thoracic viscera, by erosion of ulcers, by laceration in consequence of fracture in any of the bones of the thorax.

We distinguish this from other collections by the sudden oppression in breathing, by the flushing of the face, by no blood being thrown up, and by the emphysematous swelling of the chest and other parts, which has a crackling noise upon being pressed.

The treatment of this complaint consists in making small punctures in the affected part of the skin, so as to allow the air to escape from the cellular substance; and if the air shall have spread to distant parts of the body, it will escape more readily by such openings. But if this give no relief to the oppressed breathing, paracentesis ought to be performed. In former times, patients labouring under such symptoms were almost constantly left to their fate. Within these few years, however, some cases have occurred where the patients have been completely relieved by an operation being performed. This is done in the same way as in the evacuation of other fluids.

Purulent matter is more frequently collected in the thorax than any other fluid: it is much more frequently formed, however, than confined there. As the matter is usually spit up as fast as it is generated, in the disfections of those who have died of this species of consumption, much extravasated pus is rarely found in the cavity of the thorax, though a great portion of the lungs be destroyed. Cases not unfrequently occur, however, which require the operation; and these may be distinguished by the following symptoms: The patient at first generally complains of a fixed pain in some part of the thorax, attended with heat, quick pulse, and other symptoms of inflammation; respiration becomes oppressed; he is unable to lie on the sound side; or, if both sides be affected, can only lie on his back; has a constant tickling cough, clammy sweats, frequent rigors or shiverings. If these symptoms be attended with an enlargement of the affected side, or with a soft oedematous fulness there, and, along with these, if there be a sensible undulation of a fluid, it may be concluded that a collection of matter is formed. The matter is commonly first formed in the substance of the lungs, and is afterwards discharged into the cavity of the pleura, though in many instances large quantities of purulent matter have been found to originate from an inflamed state of the pleura.

The operation ought to be performed as soon as there is evidence of the collection, being the cause of the oppressed breathing, and that there are no signs of this being relieved by expectoration. The operation ought to be done upon the part where the collection is supposed to be situated; and this may be known by the seat of the previous pain, and perhaps by the matter being distinguished between two of the ribs. If no matter flows, it is probably seated in the substance of the lungs; but even in this case, Method of such an opening may be useful, by taking off the support, performing the operation, and giving the abscess an opportunity of bursting. If the undulation of the fluid be general, the operation is to be performed in the following manner: The patient is to be laid prone in an horizontal posture, with the affected side inclining a little over a table. An incision is then to be made with a scalpel through the skin and cellular substance, between the fifth and seventh ribs, and half way between the spine and sternum, from one to two inches in length, and in the direction of the ribs. The muscles are then to be cut through, keeping as near as possible to the upper edge of the inferior rib to avoid wounding the intercostal vessels and nerves. As there is no occasion for the bottom of the wound being of the same length with the external incision, it may be gradually contracted, so as at last to be only about the half. The pleura being now exposed, is to be divided by slight scratches, taking the assistance of a furrowed probe to prevent the lungs from being injured, in case they shall be found adhering to the ribs. If the contrary takes place, the fluid will rush out immediately upon a small opening being made into the cavity of the thorax; but if an adhesion appear, and if it be slight, which may be known by the introduction of a blunt probe, as much of it may probably be separated as to allow the fluid to escape. In case it be considerable, the incision is either to be continued a little nearer to the sternum, or an attempt made in some other part. After the fluid is observed to flow, it will be proper to introduce a silver canula, fig. 60, at the opening; by which means it will run more readily off, or can be more easily stopped in case the patient become faint. If the quantity of fluid be not considerable, it may generally be drawn off at once; but if it be great, partial evacuations ought to be made at different intervals, as circumstances may direct.

The canula therefore should be so formed, that by means of a trap put round the body of the patient, it can be readily secured. Its mouth is to be shut by means of a cork. A pledget of emollient ointment is to be laid over the wound; and the whole being fixed by a napkin and fascial bandage, the patient should be laid to rest. The remainder may be drawn off, probably in a day or two, or as soon as it is suppoled the patient can bear it. After the fluid is carried off, the canula is to be withdrawn and the wound healed; or in case the operator be afraid of bad effects being produced upon the lungs by irritation from the canula, though of this there will be little danger, as the lungs will generally be out of its reach, the skin may be drawn back before the first incision is made as afterwards to serve the purpose of a valve. And for some days after the operation, the incision in the integuments may be brought opposite to that in the pleura, to allow the matter to run off, or to produce a radical cure by exciting a certain degree of inflammation over the lungs and inside of the thorax.

After the matter is evacuated, the wound ought to be kept open a considerable time for the purpose of discharging the matter as fast as it is collected. If the wound be apt to heal up too soon, which will be known by the symptoms of oppression being renewed, it will be proper to keep the passage open by tents, or to introduce a bougie or silver canula a few hours occasionally, till the source of the matter be dried up; which, however, seldom happens for a considerable time, and frequently never. By attending to this circumstance, the patient may enjoy good health; where- This operation is an opening made into the abdomen, in order to empty any quantity of extravasated water collected in that species of dropy called the aficites.

A fluid in the cavity of the abdomen is discovered by the following symptoms:

1. A sense of tightness in the part affected; by laborious and difficult breathing, especially when in the horizontal posture; but particularly by a sense of fluctuation being communicated to the fingers placed on one side of the abdomen, while the swelling is forcibly struck on the opposite side. There is besides much thirst, a dry skin, scantiness of urine, &c. Whatever may be the influence of diuretics and other evacuations in the cure of general dropsical affections, they are rarely serviceable in local diseases of this kind, and even the operation of tapping seldom cures the distemper; but it commonly gives the patient ease for the present time, and is attended with very little pain.

Upon the supposition that nothing forbids the extraction of the water, the manner of operating is this: Having placed the patient in an horizontal situation, as best suited to prevent fainting, and to allow the water to run freely off, the part to be perforated ought to be marked with ink; and the most approved part for the operation seems to be at a point lying at nearly an equal distance between the umbilicus and the centre of the spine of the os ilium, this being most out of the way of any of the viscera, and sufficiently depending to allow the water to escape; and as the spleen is less frequently enlarged than the liver, the left side is generally preferred. Various means have been used for applying an equal pressure in this operation. Some apply pressure by the hands of assistants; others use a broad piece of flannel, or other kinds of cloth, slit a certain way from each end; then the ends are drawn by assistants till sufficient pressure is made. Broad belts are used by some practitioners; but one of the best contrivances for this purpose is the bandage invented by the late Dr. Monro (fig. 70.). Till very lately, a puncture was first made with a lancet, then a trepan or a round form (fig. 71.), and with a triangular point, was constantly used; but the entrance of this instrument being always attended with difficulty and pain, a flat trepan is now very frequently employed; and that invented by Mr. Andrew (fig. 72.) seems the best which has yet appeared. The bandage being new applied and drawn a little tight, the part to be punctured is to project a little over the edge of the bed. The operator fixes the head of the trepan in the palm, while the forefinger directs the point of the instrument. He is then to push it forwards till he is satisfied, by the want of resistance, that the end of the canula has reached the cavity of the abdomen. The perforator is now to be withdrawn, and the water allowed to flow as long as any of it can be taken off; the bandage being from time to time pulled to favour the discharge. But if the patient become faint, a stop for a few minutes should be put to the discharge every now and then, by placing the point of the finger upon the mouth of the canula. If any of the viscera happen to stop the flow of the water before the swelling is much diminished, a blunt probe is to be introduced, but bent at the end, lest it slip into the cavity of the abdomen. When the serum is thick and gelatinous, it may sometimes be necessary to introduce a larger trepan than the one first employed. When the water does not flow, because it is collected into cysts, the canula is to be withdrawn, and the wound covered with a pledget of simple ointment. The operation may then be renewed immediately, or on the following day, upon the opposite side of the abdomen, or in the most depending part of the tumor, in whatever part of the abdomen it may be placed.

During the operation it is necessary to keep up a pressure on the abdomen, otherwise 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 flows into the inferior vessels than usual, the superior ones are left too empty, and thus the regular progress of the circulation is interrupted. To obviate this, the pressure must not only be made during the operation, but be afterwards continued. As to the dressing, it has been already mentioned, that the wound may be covered with a pledget of simple ointment; but between the skin and the roller some recommend a piece of flannel dipped in brandy or spirit of wine to be applied. The bandaging in this manner may even have some effect in preventing a return of the disorder. When the water again collects, the operation should be repeated whenever the swelling has acquired a considerable size; and though this operation does not always effect an absolute cure, yet it sometimes preserves life a great many years, and even a comfortable one, especially if the waters have been long collected.

After the operation, practitioners advise the abdomen to be frequently rubbed with astringent spirits' applications. This cannot be done for the first two days after the operation, as it would then be improper to remove the bandages; but after that time, they may be removed daily, for about a quarter of an hour; and camphorated spirit of wine, or other applications which may have a similar effect, may be applied with strong friction over the abdomen, the body being kept, during this period, in the horizontal situation, and the bandage applied immediately after the friction is finished.

Sometimes, instead of water, we find air contained in the abdomen; and the inflation is of two kinds: First, that in which the air is contained in the intestines; in which case the patient has frequent explosions of wind, with a swelling of the belly frequently unequal. Secondly, where the air is collected in the cavity of the abdomen; and here the swelling is more equal, without any considerable emission of air. In both varieties of the disease the swelling is more tense than where water is contained, and the belly sounds when struck, and affords to the touch and pressure nearly the same sensation as is received from a bladder filled with air. Of these two disorders the former is by much the most common. Many extensive practitioners have never met with an instance of true abdominal tympanites. A few well authenticated cases, however, have occurred, where the air was collected between the containing and contained parts of the abdomen. In some of them the air was found to have escaped by a small hole in the intestines, from which it has been supposed that the other cases were of the same nature. When the symptoms become urgent, there is as much necessity for discharging the air as for drawing off the water in cases of dropy. The pressure and perforation are to be made in the same manner as directed for aficites, with this difference only, that a trepan of the very smallest size ought to be used; for by it the air can be as easily discharged, and the wound will heal more readily than where a large opening is made. After the air has been extracted, the treatment ought to be nearly the same as that recommended in cases of aficites. The name of hernia might with propriety be applied to every swelling occasioned by the dislocation of parts from those boundaries within which, in a state of health, they are contained; but the general acceptation of the term implies a tumor produced by the protrusion of some part or parts from the cavity of the abdomen.

The parts in which hernia usually appear are the groin, scrotum, labia pudendi, the upper and fore part of the thigh, umbilicus, and different points between the surfaces of the abdominal muscles. If the situation of such tumors be various, the viscera which produce them are still more so; instances having occurred of the stomach, uterus, liver, spleen, and bladder, being found to form their contents. But a part of the intestinal canal, or a portion of the omentum, are from experience known to be the most frequent cause of their formation.

From these circumstances of situation and contents, all the different appellations are derived by which hernia are distinguished. Thus they are termed inguinal, scrotal, femoral, umbilical, and ventral; from their appearing in the groin, scrotum, thigh, navel, or belly. When the tumor is confined to the groin, the hernia is said to be incomplete, and is termed bulbocele; but when the swelling reaches down to the bottom of the scrotum, the rupture is then supposed to be complete, and the disease obtains the name of scrotal rupture, or phibiocele.

Of these disorders the inguinal hernia is by much the most frequent; next to that is the femoral. The umbilical is seldom observed in men, or even in women who have not born children.

The causes which tend to the production of hernia in its more usual form are these:

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

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

III. Persons of a preternatural laxity of frame are very liable to hernia. The containing parts of the abdomen, from the want of a sufficient tone and firmness, are unable in such people to resist on all occasions the weight of the different viscera; and they are therefore more particularly exposed to disorders of this kind on the slightest application of any of the causes already mentioned.

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

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

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

In whatever situation a protrusion of any portion of the Hernia intestine occurs, except in the case of the hernia congenita, as all the viscera are contained within the peritoneum, a portion of that membrane, it is evident, must be carried down together with the parts protruded; and in every instance, if such instance, it is this portion of the peritoneum which malacia goes down along with the gut, that is termed the hernial sac. The size of this sac is various in different subjects, and in different stages of the same disorder. On the first appearance of the disease, it is commonly of no very considerable size, as such swellings seldom acquire any great bulk at once; but by repeated descents of the bowels, it comes to be pushed lower and lower, till in some instances its bulk becomes very considerable indeed; and when in this advanced period of the disorder the sac happens to be laid open, it is found to contain either large quantities of omentum or intestine, and frequently large portions of each. As the peritoneum has this property in common with many other parts of the body, of thickening according to the degree of any gradual extension applied to it, so in many instances the thickness and firmness of the hernial sac are often really astonishing.

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

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

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

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

An elastic colourless swelling is observed at the part affected; a slight pain is felt not only in the swelling itself, but, if part of the alimentary canal is down, an universal uneasiness. Hernia in general.

The patient complains of nausea; frequent retching; can get no discharge by stool; becomes hot and restless; and the pulse is commonly found quick and hard. When the swelling is formed entirely by a portion of gut, if no feces be contained in it, it has a smooth, equal surface; and is easily compressible, but instantly returns to its former size on the pressure being removed; but, in gut-ruptures of long standing, where hard feces have collected in the protruded bowels, considerable inequalities are detected. When again the tumor is composed both of gut and omentum, its appearance is always unequal, it feels soft and somewhat like dough, and of course is not so elastic as when part of the intestinal tube only is down; for although, like the other, it is compressible, it does not readily regain its former dimensions on the pressure being taken off.

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

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

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

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

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

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

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

As soon as the affluence of a practitioner is desired for the removal of symptoms in cases of hernia, the first circumstance requiring his attention is the placing of his patient in such a posture as will most probably favour the return of the protruded parts. Placing the patient's feet over the shoulders of another person, while his body is allowed to hang downwards, and causing him to be a good deal jolted about, has on some occasions answered when other means have failed.

The surgeon should at the same time endeavour to assist the return of the bowels, by means of gentle pressure with his hands and fingers. In the inguinal or scrotal hernia, this pressure should be made obliquely upwards and outwards to correspond with the opening; in the external oblique muscles; in the femoral hernia it ought to be made directly upwards; in the umbilical and ventral hernia directly backwards.—The swelling should be grasped with one hand at the bottom, while with the fingers of the other hand an attempt is made to push gently the contents of the tumor into their place, always observing that the parts last protruded be first reduced. This operation is by authors termed the taxis.

When the means now mentioned have failed, no remedy affords more relief than blood-letting. The quantity to be drawn ought chiefly to be determined by the strength of the patient. There is scarcely any disease, however, where such large quantities of blood can with propriety be taken from weak people. Blood-letting till the patient is in a state of delirium animi, is frequently known to produce a more effectual relaxation of the muscles than can be done by any other means. On that account it is sometimes advised in cases of hernia, and the practice is now and then attended with advantage.

As an obstinate coition is commonly one of the most alarming symptoms of hernia, it has been a common practice to exhibit a variety of stimulating purgatives both by the mouth and anus; but they are very seldom of much service, and in that case almost universally do injury, by increasing not only the sickness at stomach, but the tension and pain of the tumor. When they are to be employed, they ought to be thrown up by the anus. For this purpose aloes and other stimulating substances, but particularly tobacco-smoke, are employed; and although this last remedy, which is to be thrown in by double bellows, &c., does not always act as a purgative, it may be usefully employed as an anodyne. Where an evacuation by stool is wanted, it may in general be readily procured by the injection of warm water, in which a little Castile soap is dissolved, in the proportion of a drachm or a drachm and a half of the latter to a pound of the former. Warm bathing is another remedy greatly extolled, either by general immersion or local application, To diminish the size of the tumor, remedies of an opposite quality from these have been used; and though by some this practice has been considered as hazardous, yet by others, particularly by the late Dr Monro and Mr Benjamin Bell, more advantage has been found from cooling applications than from those of a different nature. Snow, ice, or cloths dipped in a recent solution of sal ammoniac in water and vinegar, or cold turpentine applications, or cold water and vinegar, have been employed with advantage. If, notwithstanding these remedies, the disease becomes worse, and no probability remains of success, the division of the parts producing the stricture can alone save the life of the patient.

To determine the exact time at which to proceed to an operation, has been considered as one of the nicest points in surgery. In general, when every attempt has failed, and no repetition of the former remedies is likely to succeed, the surgeon ought certainly to proceed to the operation. A few hours, even when affluence has been early applied, is perhaps all the time which ought ever to be consumed in trials of this nature. But however necessary this operation may be when a patient's life is in danger, as it is always attended with some degree of hazard, it ought never to be practised where symptoms of strangulation do not exist.

In that kind of hernia called chronic, the circulation of the part forming the hernia, as well as the peristaltic motion of such parts of the alimentary canal as have been protruded, go freely and regularly on. There are many instances of large herniae falling down even to the bottom of the scrotum, and continuing there for many years, without producing any interruption to the usual discharge by stool. All that can be done here is, to prevent any accumulation of feces in the intestine, by prescribing a proper diet, and the occasional use of gentle laxatives; and obviating any inconvenience which might arise from the weight of the tumor, by the application of a proper truss or suspensory bandage; to warn them of the risk to which they are constantly liable, and to caution them against violent exercise, particularly leaping, and every sudden exertion. The trusses ought to be fitted exactly to the part for which it is intended, for without the utmost nicety in this respect, it must always do more harm than good; for the sole purpose of a bandage, in cases of hernia, is to prevent effectually the falling down of such parts as have been newly replaced. If therefore the pad or bolster of the bandage does not bear properly against the opening upon which it is placed, a portion of gut may slip out, and be materially injured by the pressure of the pad. Fig. 74 represents a truss for an inguinal or femoral hernia of one side, fig. 75, a truss for the same disease in both sides, and fig. 76, a truss for an umbilical hernia.

We shall now proceed to describe the circumstances to be attended to in performing the operation for hernia in general. A table of convenient size and height being placed in a proper light, the patient must be so laid on it as to relax the diseased parts as much as possible, and then secured by proper affluence. To lessen the contents of the abdomen as much as possible, the bladder ought to be emptied previous to the operation. An incision is to be made with a common round-edged scalpel through the skin and part of the cellular substance, long enough to allow the stricture to be fully exposed. The rest of the cellular substance is then to be divided with the greatest attention. That part of the muscle forming the stricture or ring must next be laid distinctly in view. A small portion of the protruding sac must also be exposed; after which the directory (fig. 73) is to be passed between the ring and the sac. A straight probe-pointed scalpel is now to be introduced into the groove of the directory, and by it the ring is to be dilated till the point of the finger can be introduced. The finger is here considered as the safest director; for it being introduced into the aperture in the tendon immediately above the protruded parts, the point of the knife is easily introduced upon it; and by keeping the end of the finger always a little before the knife, the opening may be enlarged to any necessary extent without risk of wounding any of the contiguous parts.

By the ease with which the finger is introduced, the operator will be enabled to judge when the ring is sufficiently dilated; and if the strangulation was entirely in the ring, it will now be evident that every obstacle to the reduction must be removed, and of consequence that the prolapsed parts may be returned with little difficulty. If the patient be young, or if the disease has continued a considerable time, such a degree of inflammation frequently ensues in the neck of the sac as to produce thickening and straitness; so that, after the sac and its contents have been entirely freed from the stricture of the ring, the intestines cannot be reduced. We judge this to be the case when, after the stricture of the ring has been removed, the parts prolapsed do not expand into their natural size, and farther, when they make resistance when we attempt to return them. In this case, the neck of the sac must be opened with the utmost caution, to avoid wounding the parts within it.

If the hernial sac, under the straitened place of its neck, be thin and transparent, and there is little or no reason to suspect an adhesion of the bowels to the sac, the best method, as Dr Monro, in his publication on the Bursae Muco-ae, observes, will be to make a small hole in the sac below the stricture, and then to introduce a small furrowed probe, and to cut cautiously upon it. But if the sac be thick and dark coloured, and there is likewise a suspicion that the bowels may adhere to it, the easiest and safest manner will be to make the hole in the peritoneum above the stricture; then to introduce a common probe, bent near its point into a femurcide, with its point directed downwards through the stricture into the sac; and upon the point of it to make, with great caution, another small hole; after which we may either cut upon the probe, or introduce a furrowed probe, and divide the neck of the sac.

After this, the bowels are to be returned by pressure upon the sac, without opening it farther; and the sides of the wound in the skin are to be brought together, and kept so by means of slips of adhesive plaster, though stitches made at the distance of a finger-breadth from each other will exclude the air, and prevent the return of the bowels more effectually. Over these are to be laid several folds of chamois, and the whole is to be secured by a bandage adapted to the nature of the part.

The patient, upon being carried to bed, should be so placed as to have the part upon which the operation was performed higher than the rest of his body, or at least as high as the situation of the part operated upon will allow, in order to prevent a return of the disease. After the operation, opiates are particularly useful, and ought to be repeated as circumstances may require. It is likewise necessary that the patient be kept cool. In plethoric habits, blood-letting is proper, together with a rigid attention to low diet. A frequent use of clysters and gentle laxatives, to keep the belly moderately open, ought not to be neglected. When the constitution has been previously much reduced, instead of blood-letting and a low diet, a nourishing regimen is necessary. The dressings ought not to be removed till the third or fourth day after the operation, when the sides Hernia in sides of the wound will be found almost adhering together; and if attention be paid to the subsequent treatment, the sore will be generally healed in two or three weeks. As soon as the wound is firmly cicatrized, a truss ought to be properly fitted to the part, and should never, on any future period of life, be laid aside.

When the hernia is of long standing, and when there is reason to think adhesions have taken place between the sac and bowels, or that mortification has already begun, or that some filaments run across the sac and prevent the reduction, or that there is water in the sac, or that the gut is in danger of being entangled from a part of the omentum being down, a different method of operating becomes necessary.

The patient is to be placed as already directed. The operator is to grasp the tumor with the one hand, so as to make the skin tense on the fore part of it, while with the scalpel in the other he divides the skin from one end of the tumor to the other. The cellular substance is by gentle strokes to be divided, till not only the ring, but the whole length of the sac, is laid bare. An opening is now, in the most cautious manner, to be made into the sac by slight scratches, to avoid hurting any of its contents.

In making this perforation, which is considered as the nicest part of the operation, considerable affluence is obtained from the use of the small directory, upon the point of which the fibres of the sac are to be successively raised and divided till an opening is made. The opening is to be enlarged till it admits the forefinger of the left hand, which serves as a directory for conducting the straight probe-pointed scalpel with which the sac is to be divided through its whole length.

The sac being laid fully open, the parts contained in it ought to be examined with the nicest attention, to discover whether they are all sound or not; and if, upon an attentive inspection, it is found that they are not evidently in a gangrenous state, even although they seem considerably inflamed, they should be immediately returned into the abdomen. When adhesions take place between different parts of the protruded gut, the greatest caution is necessary in separating them. When one part of a gut adheres too firmly to another as not to be separated but with difficulty, it is much better to return the whole, even in that state, into the abdomen, than to run the risk of hurting the intestine materially by using much force. When adhesions occur between the hernial sac and the gut, or between the gut and omentum, if the filaments producing the connection cannot be otherwise removed, as there is no great hazard in wounding the omentum, and still less in hurting the sac, a very small portion of these may be dissected, and returned with the gut into the abdomen. When the bowels cannot be reduced with ease, the ring is to be dilated by the blunt-pointed scalpel in the manner already directed. After returning the contents of the sac into the cavity of the abdomen, it has been proposed by some authors to pass a ligature round the neck of the sac, with a view of procuring a reunion of its sides, so as to prevent a future descent of the bowels; and various other methods, even actual and potential cauteries, have been proposed; but as none of them yet attempted have been found sufficiently to answer the purpose, the only thing that can be recommended is a well-made truss.

When the bowels are actually in a state of gangrene, as the returning of such mortified parts might be attended with the very worst consequences, a great degree of caution is necessary. When the omentum is found in a mortified state, as the excision of a portion of this substance is not attended with much risk, it is the common practice to cut away the diseased parts, and to obviate any inconvenience which might ensue from the hemorrhage. We are advised to make a ligature on the sound parts previous to the removal of hernia in those which are mortified; whilst the ends of the ligature being left hanging out of the wound, the surgeon has it in his power to remove them when circumstances appear to render it proper. These ligatures on the omentum, however, are frequently productive of bad consequences. No hemorrhage of any importance ever occurs from a division of this membrane, even in a sound unmortified state; such parts as have become gangrenous may therefore be freely cut off, and the remaining sound parts be afterwards, without the intervention of ligatures, safely introduced into the abdomen. If a vessel of any size in the omentum has been divided, a ligature may be passed above the vessel itself, and the ends left hanging out of the wound; the threads may be afterwards pulled away at pleasure. When a rupture has been of long duration, it sometimes happens, that from the pressure made by the truss, and other circumstances, portions of the omentum are collected together into hard lumps. If these be small, they may be returned into the abdomen without producing any inconvenience; but if from their bulk and hardness they are likely to do mischief, they ought to be cut off. When part of the omentum is to be removed, it ought to be previously expanded and divided with scissors, which will be more convenient than any other instrument. When again a small portion of gut is found mortified, we are to endeavour, by means of a needle-ligature, to connect the sound part of the gut immediately above the mortified spot to the wound in the abdomen already made. By this means, when the mortified part separates, or perhaps what is better, when it has been immediately cut out, the feces are discharged by the wound; and there are different instances where, after such a discharge has continued for some time, the wound has entirely healed.

But when the mortified portion of gut is of considerable extent, and includes the whole circumference of the intestine, all that can be done is to remove it, and to draw, by means of a ligature, the upper end of the gut towards the under, and afterwards connect them to the inner edges of the wound. This at least affords a chance of the ends of the gut being brought to reunite; and if unfortunately that event should not take place, a passage of the feces will still be secured. All such mortified parts as are to be removed ought to be cut off, and the remaining sound intestine retained, before the opening in the ring can be dilated with safety, lest the gangrenous portion slip in together with the sound. The parts forming a hernia being all completely replaced, when the sac in which they were contained is found thick, hard, and much enlarged, as in such a state no good suppuration can take place, and as its preservation cannot be in any degree useful, such parts of it as can be cut away with propriety ought to be removed. All the lateral and fore parts of the sac may be cut off with safety; but as it is commonly firmly connected with the spermatic vessels behind, this part of it ought not to be touched.

Sect. II. Of Babooncele, or Inguinal and Scrotal Hernia.

This species of hernia is formed by a protrusion of some symptoms of the abdominal bowels through the rings of the external abdominal oblique muscles. It is known by the general symptoms of hernia already enumerated, and by a soft and somewhat elastic swelling, beginning in the groin, and descending by degrees into the scrotum in men, and into the labia pudendi in women. When the hernia contains omentum only, the swelling is both more soft, compressible, and more unequal than when the gut alone is down; the scrotum becomes more oblong than in the intestinal hernia; and when the quantity of omentum is large, it is also much more weighty than a gut rupture of the same size; but frequently the tu- Bubonocele mor is composed of both gut and omentum, and then the inguinal distinguishing symptoms of each can never be so clearly marked.

Hernia.

Bubonocele may be confounded with certain other diseases; but may be distinguished by the following marks which are present in these disorders, while the symptoms of hernia are absent: From venereal bubo, by the presence of that incompressible hardness with which all such swellings are at first attended, and by the fluidity of matter which in the suppurative state is always observable: From hernia humeralis, or swelling of the testes, by the absence of the hardened and enlarged state of the testis and epidydimus, and likewise of the pain, the tumor of the testicle being remarkably heavy in proportion to the bulk, the spermatic process being commonly free from the swelling. In the hernia humeralis also the intestine is unobstructed, and the general symptoms of hernia are wanting. From hydrocele of the tunica vaginalis testis, by the tumor generally feeling more smooth to the touch than in hernia, by the swelling here beginning in the under part of the scrotum and ascending, by the spermatic cord being always free and distinct, and by a fluctuation being evident. From hydrocele of the spermatic cord, sometimes with much difficulty, and therefore it requires here particular attention. In every case of tumor in the testes, where the most perfect certainty is not obtained, and when it is necessary to have recourse to an operation, the surgeon ought to proceed as in a case of real hernia.

The treatment of bubonocele is the same with that already advised in the treatment of hernia in general, only making allowance for the situation of the disease. In attempting the reduction by means of the hand, the pressure should be obliquely upwards and outwards, corresponding with the ring of the abdominal muscle. In performing the operation, the patient should be laid on a table, with his head and body almost horizontal, whilst at the same time his buttocks are somewhat elevated by pillows placed beneath them. The legs hanging over the edge of the table ought to be separated, so as to admit the operator between them; and should in that situation be firmly secured by an assistant on each side, who should take care to keep the thighs so far raised as to relax all the abdominal muscles. The parts being previously shaved, an incision must be made with a common round-edged scalpel through the skin and part of the cellular substance, beginning at least an inch above the superior end of the tumor, and continuing it down to between two and three inches below the ring.

Although in by much the greatest proportion of hernial swellings the spermatic vessels lie behind the protruded parts, yet on some occasions they have been found on the anterior part of the tumor; so that in order to avoid the risk of wounding them, as soon as the skin is divided, the remainder of the operation ought to be done in the most cautious manner, care being taken to avoid every large blood-vessel which makes its appearance. This ring must now be laid distinctly in view; a small portion of the protruding sac must also be exposed; after which the directory is to be introduced between the ring and the sac, placing the point of the instrument obliquely upwards and outwards. A blunt pointed bistoury is now to be introduced into the groove of the directory, and by it the ring is to be dilated till the point of the finger can be introduced. The directory is now to be laid aside, and the finger used in place of it through the rest of the operation. After the operation is finished, the dressings are to be applied, and the whole secured by a T bandage, or suspensory bag, properly stuffed with felt lint.

The patient, on being carried to bed, should have a pillow under the buttocks, to elevate them a little above the rest of the body, and should be treated in the manner which has been already directed. As soon as the wound is firmly cicatrized, a truss ought to be properly fitted and used through the rest of the person's life. Females are liable to this species of rupture as well as men; and as the opening in the external oblique muscles is exceedingly similar in both sexes, the treatment of this species of hernia in females is very similar to what is found to answer in men. When clysters, blood-letting, and the other remedies formerly enumerated, fail, the same operation of enlarging the opening in the tendon of the oblique muscle is here equally proper as in the other sex.

As modest women are apt to conceal disorders of this kind, they may frequently happen when the surgeon receives no information about them. Whenever, therefore, such symptoms of colic occur as give reason to suspect the existence of hernia, a particular examination ought always to be made, in order, if possible, to detect the cause of the mischief, from the removal of which alone a cure can be expected.

Sect. III. Of Hernia Congenita.

The testes in the fetus are, till near the time of delivery, lodged in the cavity of the abdomen. When they descend into the ferotum, they push before them a portion of the peritoneum, which afterwards forms the vaginal coat. The passages by which they descend are soon shut up; but sometimes the contrary happens, and then a portion of some of the abdominal viscera passing down, forms that species of hernia to which new-born infants are liable, termed by Haller the hernia congenita. The testicle and protruded intestine being here in contact with one another, the tunica vaginalis testis forms the hernial sac.

It has been affirmed by some of the latest writers, that hernia congenita cannot be distinguished from that contained in the common hernia sac; and that though there was nothing to distinguish it, it could be of no material use in practice. But Dr Monro observes, that a hernia-congenita may be distinguished in an adult by an evident external mark; which is, that the bowels push down between the sac and the forepart and sides of the testicle, so as often in a great measure to conceal it; whereas, in the common hernia, every part of the testicle can be felt distinctly; And that it is of material use to make the distinction; because in whatever manner we operate in hernia congenita, unless we take the utmost care to exclude the air, there will be a more violent inflammation and greater distress than in common cases, because the testicle will partake of the inflammation.

In the treatment of ruptures of the congenital kind, little difference occurs from the management of the common scrotal hernia; only a truss ought never to be applied to infants, unless the testicle can be felt in the scrotum, after the contents of the hernia have been reduced; as it would entirely prevent the descent of the testicle, which yet remains in the abdomen. If any operation has been performed, the testicle should, immediately after the bowels are reduced, be covered with the vaginal coat, and at each dressing care should be taken that the air be excluded. In every other respect the treatment of congenita hernia is the same with that of hernia in general.

Sect. IV. Of Femoral or Crural Hernia.

The seat of this species of hernia is upon the upper and anterior part of the thigh; the protruded bowels passing out at the same opening through which the large blood-vessels of the thigh are transmitted from the abdomen, and of consequence under that part of the tendon at the under end of hernia, the abdomen known by the name of Poupart's or Fallopian's ligament. Sometimes the bowels which protrude are situated imme- immediately over the femoral vessels, sometimes on the outside of these, but more frequently they lie upon their inner side. The disease is more frequent in women than in men, on account of the width of the female pelvis, and of consequence the length and laxity of the ligament. The femoral hernia is more in danger of being confounded with inguinal hernia than with any other; the tumor, however, is deeper, and the ring of the abdominal muscles, which lies entirely above the tumor in femoral hernia, completely surrounds the parts in that of the inguinal kind.

Treatment. In the treatment of femoral hernia, when symptoms of strangulation occur, we must use all the remedies commonly practised for hernia in general; only that here, in attempting to reduce the parts by the hand, the pressure should be made directly upwards. An incision of sufficient length is to be made through the integuments, so as to allow that part of the tendon which forms the stricture to be laid fairly in view; and after dividing the integuments, we are cautiously to cut the fascia lata of the thigh, and separate any glands which may come in the way till the stricture and part of the fascia distinctly appear. The stricture is then to be divided, by cutting fibre after fibre successively. The spermatic vessels in the male, or round ligament in the uterus in the female, may be avoided by cutting in a direction towards the umbilicus, carefully dividing the tendon transversely. Some authors, from a sense of the danger attending this part of the operation, have recommended merely to dilate the passage, instead of dividing the tendon; but in such a situation, to attempt a farther dilatation without the assistance of the knife, would probably be seldom attended with any advantage. After the parts are reduced, the wound is to be dressed as directed in the treatment of hernia in general: a piece of thin leather spread with some adhesive plaster retains the dressings better, and with much more ease, than any other bandage.

Sect. V. Of other Species of Hernia.

In umbilical hernia the parts protruded pass out at the umbilicus, and are commonly the intestines, or omentum, or both; sometimes part of the stomach, the liver, and even the spleen, have been found in the sac. Here, as in other ruptures, the peritoneum forms the sac, and in recent cases it is generally very evident; but by the size of its contents, or a long continuance of the disorder, it sometimes becomes connected with the surrounding parts, that by many its existence has been doubted, and sometimes the swelling has increased to such a degree as to burst even the skin itself. The disease occurs most frequently in infancy, soon after birth. In the adult flate corpulent people are more subject to it than those of a contrary habit; and pregnant women are particularly subject to it, on account of the size of the uterus. The diagnosis in this disease is readily made, as the disorder can scarcely be confounded with any other. If the disease be attended to in due time, a bandage properly fitted will generally effect a cure; and in such swellings as occur in pregnancy, delivery will commonly remove the disorder; but even in cases of pregnant women, a bandage early applied and properly used will give considerable relief, till a cure can be obtained by delivery. In this disease the omentum is more frequently pushed out than any other viscus; hence umbilical hernia in general are not productive of such bad symptoms as usually occur in the other kinds of rupture. When, however, the intestines protrude, the usual symptoms of a strangulated hernia are apt to be induced; and when the means usually employed for returning the gut into the abdomen do not succeed, a cure it is evident must depend entirely on a thorough removal of the stricture. In performing this operation, an incision through the integuments is the first step to be taken, so as to expose the structure of the tendon and the neck of the sac. The stricture is to be removed in the manner already described; and as the tendon completely surrounds the neck of the sac, the stricture may be cut wherever it can be most readily dilated. A radical cure similar to that for the other species has been proposed, but with as little probability of success.

Ventral rupture is a protrusion of some of the bowels through the interstices of the abdominal muscles, and is most frequently observed in some of the parts most contiguous to the linea alba. The treatment of this species of disease is exactly the same with that of exomphalos.

Hernia of the bladder of urine, though less frequent than that of the omentum or intestines, is not very uncommon. The situation in which it occurs is in the groin, through the abdominal ring, in the fore part of the thigh, under Poupart's ligament, so as to form inguinal or crural hernia. Instances have likewise occurred of the bladder being pushed into the perineum. Sometimes it occurs by itself, without any complication; at other times it is accompanied with intestines and omentum, both in inguinal and femoral herniae: when complicated with bubonocle, the protruded part of the bladder is situated between the intestine and spermatic cord.

The usual symptoms are a tumor, attended with fluctuation either in the groin, in the fore part of the thigh, or perineum, which generally subsides when the patient voids urine. When the swelling is large, before water can be made with freedom, it is commonly necessary to have recourse to pressure, at the same time that the tumor, when in the groin or thigh, is as much elevated as possible; but when the swelling is small, and especially when no stricture is as yet produced, the patient generally makes water with great ease, and without any assistance from external pressure. When the disease occurs without any complication, it is commonly owing to a suppression of urine. In the diagnosis care ought to be taken not to mistake it for a hydrocele. In recent cases, the part protruding may in general be easily reduced, especially if we attend to the suppression of urine, which probably gave rise to the disease. A proper truss ought afterwards to be worn for a considerable time. When the disease has been of long standing, adhesion takes place between the bladder and cellular substance of the scrotum. In this case, therefore, as long as no symptoms occur to render the operation necessary, a fulsome bandage, so fitted as effectually to support the prolapsed parts, is the only probable means of relief.

Sometimes the bladder, owing to a suppression of urine, at other times part of the intestines, have been found toginalis, protrude through the vagina. In the former case a fluctuation of water is perceptible to the touch.

The reduction is made by laying the patient on her back with her loins somewhat raised, and pressing with the forefinger from the vagina. Defects may in future be generally prevented, by evacuating the urine often, and by the use of a pellary introduced into the vagina. Nearly the same means are employed in reducing the intestine when it is found to protrude.

Chap. XXIV. Of Hydrocele.

Every tumor formed by a collection of water might with propriety be named hydrocele, but the chirurgical acceptation of the term implies a watery swelling situated in the scrotum or spermatic cord. Hydrocele is either anasarcaous or encyded. In the former, the serum is chiefly diffused in the cellular substance; in the latter, the water is collected in a distinct bag. The scrotum with its contents are liable Sect. I. Anaerous Hydrocele of the Scrotum.

As soon as water has collected in any considerable quantity in the scrotum, a soft, inelastic, colourless tumor is observed over the whole of it; impressions are easily received and obtained for some time; the skin at first preserves its natural appearance, and the rugae of the scrotum are not much altered; but as the swelling advances, they gradually disappear, and are at last totally obliterated. The swelling, from being at first soft, and of a consistence similar to dough, by degrees turns more firm, and the skin at last acquires an unnatural white shining appearance. The tumor at length becomes large; and though originally confined to the scrotum, it at last spreads up the groin. The penis likewise becomes affected, and often so swelled and distorted as to excite much inconvenience and distress; and although the scrotum is composed of parts which readily admit of dilatation, the tumor sometimes becomes so enormous that it bursts from one end to the other.

In the surgical treatment of this disease punctures made with the point of a lancet are most advisable, as large scarifications, in anaerous habits, are sometimes apt to produce inflammation and mortification; while simple punctures readily heal, and can be renewed with very little pain as frequently as may be necessary; and besides, punctures are equally useful with the incisions; for as the cells of the scrotum communicate freely, if the punctures be made fairly through the skin, the water drains off very readily, though not too soon as by scarification. Previous to the operation, befumigating the part with some tough ointment of an innocent nature, and afterwards keeping it as dry as possible by a frequent renewal of dry soft linen cloths, in order to imbibe the moisture, is here a necessary piece of attention. The want of this seems to be the cause of much of the mischief which frequently ensues from operations of this kind. When scarifications or punctures go wrong by beginning to inflame and turn painful, &c., a cold solution of saccharum saturni, applied upon soft linen, proves most effectual in putting a stop to the farther progress of the inflammation, and affords most immediate relief to the patient in the present distresses. Lime water, employed in the same manner, proves also a very useful application. When, however, the disorder proceeds to gain ground by a real mortification coming on, we should immediately have recourse to bark and other medicines usually employed in such affections.

Although the anaerous hydrocele, for the most part, depends upon a general droppish tendency, some instances occur of a local cause producing a mere local drop of the scrotum. Thus, it has been known to happen from swellings in the groins and in the abdomen obstructing the passage of the lymphatics. When this is the case, if tumors producing such obstructions can be extirpated, no other means will afford such effectual relief; but when they are so deeply seated as to render any attempt to removing them improper, the practice we have already pointed out of making punctures in the most depending part of the tumor must be employed with a view to palliate such symptoms as occur. It sometimes happens in suppuration of urine, whether arising from strictures in the urethra or from stones impacted in it, that the urethra bursts, and the urine in this manner getting access to the cellular texture of the scrotum, an anaerous swelling rises immediately over the whole of it; nor does it commonly diminish till the cause by which it is produced is removed.

In order to prevent the formation of sinuses, which in such circumstances will otherwise be apt to occur, an incision should be made into the tumor, and carried to such a depth as is sufficient for reaching the wound in the urethra. In this manner a free vent will not only be given to the urine already diffused, but the farther collection of it may probably be prevented. If a stone impacted in the urethra be found to be the cause of effusion, it should be cut out; and if the obstruction be produced by strictures in the urethra, they must be removed by a proper use of bougies. The cause being thus removed, if the habit of body of the patient is good, and untainted with any venereal or other general affection, by dressing the sore properly with soft easy applications, the opening into the urethra will probably heal, and a complete cure will in this manner be obtained. But when these ailments are complicated with any general affection, particularly with old venereal complaints, it frequently happens that neither mercury nor any other medicine has much influence in removing them.

Sect. II. Hydrocele of the Tunica Vaginalis Testis.

In the healthy state of the body, a small quantity of aqueous fluid is exhaled for lubricating the surface of the testicle, the superfluous part of which is absorbed by vessels appointed for that purpose. When the secretion of this fluid is either morbidly increased, or its absorption diminished, a preternatural collection of water is formed in the cavity of the vaginal coat, and hydrocele of the vaginal coat produced.

The symptoms are, a fulness at first observed about the inferior parts of the testicle, and most remarkable when the patient is erect, becoming gradually more tense as the disease advances; the tumor by degrees changing from the globular to the pyramidal form; no degree of pressure making the swelling disappear at any period of the disease. In the early part of the disease therefore, if it be not combined with hernia, or with a hydrocele of the cord, the spermatic process may be distinctly felt, because the swelling does not extend beyond the scrotum. In its more advanced state, it cannot be distinguished; the weight of the tumor now drags the skin of the neighbouring parts so much as to cause the penis almost to disappear; and in this state of the disease the testicle cannot be felt without much difficulty. On a minute examination, a hardness is always to be felt along that part of the scrotum where the testicle is situated; and at this point pressure excites some uneasiness. Fluctuation of a fluid may in general be distinguished through the whole course of the disease. In late stages, however, the appearance of a fluid is not very evident.

The transparency of the tumor has been generally supposed to be the principal criterion of this species of the disorder; but this must depend upon the nature of the contents, or thickness of the sac; so that, though the transparency of the tumor is a certain sign of the existence of water, its opacity cannot upon any account be considered as an indication of its absence. Through the whole course of the disease the tumor is not attended with pain, but some uneasiness is commonly felt in the back by the weight of the swelling of the spermatic cord. This is more particularly the case when a flaxen bandage is not used.

In the radical cure of hydrocele, in whatever way it is attempted, some degree of fever and inflammation will take place. Under the circumstances mentioned in the prognosis, the operation, if properly performed, is generally attended with the most complete success. But if the patient be very old, infirm, and diseased, an operation may be attended with such a degree of inflammation, and consequent suppuration, Various methods have been proposed for the cure of hydrocele, all of which may be reduced to two general heads: such as have in view only a temporary relief, and which is therefore termed the palliative cure; and such as are meant to effect a radical cure. When the tumor has become so large as to be inconvenient from its size, an evacuation of the water by surgical means becomes necessary. In this case, if the patient either refuses to submit to the operation for a radical cure, or if his state of health render that operation improper, the palliative treatment, or a mere evacuation of the water by puncture, is the only means which can be employed.

A lancet-pointed trocar was many years ago recommended for drawing off the water in this manner by the present Dr Monro; and since that time it has been improved (fig. 77.), but has been recommended by Mr Andrews; another (fig. 78.) has been proposed by Mr Bell. With any of these an opening may be made into the tunica vaginalis with safety.

The operator with one hand should grasp the tumor behind, to press the contained fluid to the anterior and under part of it. If a round trocar is to be used, a puncture with a lancet should be made where the trocar is to enter; but where a flat trocar is to be employed, the assistance of the lancet is unnecessary.

As soon as the instrument has pierced the vaginal coat, the fluid should be withdrawn, and the canula left in the cist. The water will now run off; and if the tumor be not uncommonly large, it may be all drawn off at once; but as the sudden discharge of it, by taking off the support, might be in danger of rupturing some of the vessels, it should be discharged by slow degrees. When the whole is evacuated, a piece of adhesive plaster should be immediately applied to the orifice; and a compress of soft linen being laid over the scrotum, the whole should be firmly supported with a suspensory bag (fig. 79.) or a T bandage.

The patient in this state being laid in bed, all kind of uneasiness is in a few minutes commonly gone, and he is able to follow his ordinary business without interruption.

The intention of every means now in use for the radical cure of this species of the disease, is to induce such a degree of inflammation on the parts in which it is seated as may obliterate entirely the cavity of the tunica vaginalis, by making it adhere to the surface of the testicle. The means at present generally employed for effecting a cure are, excision of the tunica vaginalis; the application of caustic; the use of a seton; a simple incision of the fascia; and the injection of acrid liquors into the tunica vaginalis, after drawing off the fluid which it contained. The method or cure, by the removal of the vaginal coat, is, first to lay open the vaginal coat, and then to cut it away by different snips of a pair of scissors. The fascia being removed, the parts are to be dressed and treated in the same manner as in the operation where simple incision is used.

The cure by caustic is attempted in the following manner: The scrotum being shaved, a piece of common paste caustic, properly secured with adhesive plaster, is applied, of about a finger's breadth, the whole length of the tumor; and if, on removing the caustic, it has not penetrated into the vaginal coat, an opening is made in it with a scalpel, so as to evacuate the contents, lay bare the testicle, and admit proper dressings. But Mr Elfe, one of the latest writers in favour of the method of cure by caustic, lays, that there is no necessity for such an extensive application of caustic as many have recommended; that an echar of the size of a thimble is sufficient; that this may be always fully obtained by the application of caustic paste of the size of a sixpence, which is to be laid on the anterior and under part of the scrotum, and to be properly secured by plaster, in order to prevent it from spreading. The caustic commonly produces all its effects in five or six hours, and may then be removed. At this time digestive, or an emollient poultice, must be applied over the scrotum, and the whole suspended with a bandage. Inflammation, Mr Elfe observes, is soon induced over the whole tunica vaginalis; and the febrile symptoms which succeed, he advises to be kept moderate by blood-letting, injections, emollient poultices, and a low regimen. In a few days the echar of the scrotum separates, and comes away; and in a gradual manner, in the course of four, five, or six weeks, the whole tunica vaginalis comes off; when the wound for the most part soon heals, and a complete cure is obtained.

Where it is intended to treat hydrocele by means of a seton, it may be done in the following manner: An opening is made with a scalpel, or the sharp-pointed bistoury, in the superior part of the tumor, large enough to admit with ease a thick cord of common white sewing silk. A director, with an eye at one end, in which the cord is inserted, is introduced at this opening; and its farther extremity being carried down to the most depending part of the tumor, an opening is there made, of about half an inch in length, by cutting upon the director with the bistoury; the director being now drawn till a sufficient quantity of silk is left hanging out below, the operation is in this manner finished.

Another very simple method of introducing a seton is by means of a silver canula and perforator.

In the operation for a radical cure by incision, the patient being laid upon a table of convenient height, and properly secured by assistants, with the scrotum lying nearly on the edge of the table, the operator with one hand should grasp the tumor behind, so as to keep it firm and make it somewhat tense anteriorly: With a common round edged scalpel in the other hand, he should now divide the external integuments by one continued incision from the upper to the under end of the tumor. An opening is next to be made in the vaginal coat with a large lancet, or a sharp pointed bistoury (fig. 80.), at the upper end of the first incision. This opening should be of inch a size as freely to receive the finger of the operator, which is to conduct a blunt-pointed bistoury, so as to divide the fascia down to its bottom, which is considered as being of advantage, by preventing partial adhesions and the risk of a return of the disease.

The incision being completed, the testicle is now brought fully into view; and if the tunica vaginalis be found, the dressing may be finished immediately. But if the fascia be diseased, it is to be removed, which may be readily accomplished by a scalpel or bistoury.

When the hydrocele, as sometimes happens, affects both sides at the same time, if, when the operation is done on one side, an opening be made into the vaginal coat of the opposite side, at the upper part, through the septum scroti, and the incision carried down to the bottom of the tumor, the cist can be equally well laid open, the water as completely evacuated, and a return of the disease as much prevented, as when the operation is done in the usual manner, and at different times.

In whichever way the incision is made, if the testicle be found, the wound ought to be quickly dressed; for it is found, that on this much of the success of the operation depends. For if the vaginal coat be merely applied to the testicle, or united by sutures, as some have advised, partial adhesions are apt to take place, before a degree of inflammation is produced over the whole sufficient for making a complete Hydrocele complete cure. In this manner cavities are left, which of the Tunica Vaginalis open; or they afterwards give rise to collections of water, and thereby occasion a return of the disease. The practice of stuffing the cavity of the foreskin with dressings is also a frequent cause of mischief, by exciting too great a degree of inflammation in the part. But when the dressings are properly managed, symptoms of violence almost never occur.

The latest authors advise, that in dressing the parts after the operation, two pieces of lint or soft old linen are to be dipped in oil, or in a liniment of wax and oil, and then, by the help of a probe, are to be inserted into the bottom of the sac on each side of the testicle, leaving a sufficient quantity of the pledgets hanging out of the wound, so as to admit of being easily withdrawn at the first or second dressing. The edges of the wound are next to be dressed with pledgets of cerate, and the ends of the oiled pledgets turned over on each side. Several pieces of soft lint are then to be laid over the wound, and these should be more or less numerous in proportion to the heat of the season. A compress of linen is now to be laid over the whole, and the dressings supported by a T bandage or suspensory bag properly fitted. The patient is then to be carried to bed; an anodyne should be given, especially if there be much pain; and he ought to be advised to lie as much as possible upon his back for a few days after the operation.

In the third or fourth day after the operation, all the dressings, except those between the testicle and tunica vaginalis, are to be removed; and if this cannot be done readily, as the parts are otherwise apt to become uneasy, a sponge dipped in warm water should be applied. On some occasions, at the first dressing, and always at the second or third, the pledgets inserted between the tunica vaginalis come away; and whenever this happens, they should be renewed. It is also proper to renew them daily for the first fourteen or fifteen days after the operation; not however of the same depth as the first, for during the latter part of the cure they need only to be inserted as far as to prevent the divided edges of the tunica vaginalis from adhering to the testicle, before the adhesive process has taken place in the parts more deeply seated. Particular attention however is necessary to this part of the treatment; for when the disease returns, it has been found to be chiefly owing to the edges of the vaginal coat being allowed to adhere to the testicle, before adhesion had taken place between the deeper parts.

A complete adhesion of the two coats of the testicle, the tunica vaginalis, and tunica albuginea, takes place most frequently about the third week after the operation. Previous to this time, inflammation continuing gradually to increase, the tumor becomes larger till it acquire somewhat of the size of a swollen testicle from gonorrhea; but after this period it gradually subsides, and the sore produced by the incision, and now reduced to a line, heals in some time between the fourth and eighth week, according to the habit of body, age of the patient, and other circumstances.

Having thus given an account of the methods usually employed in the cure of hydrocele, we shall now make a few observations on the comparative advantages of the three last. From the testimony of many authors of credit, it is evident, that any of these methods, in most instances, prove effectual; but every practitioner being apt to be prejudiced in favour of a particular method, he generally continues to follow that mode and no other; and finding it commonly succeed, he by degrees persuades himself, that other methods of cure, with which he has not had such opportunities of becoming acquainted, are liable to objections, which those who have practised them do not find to be the case. The result of Mr B. Bell's observations upon this subject is, that although all the three modes of operating, by cauticle, the feton, and the simple incision, are perhaps equally capable of producing a radical cure; yet, that of the three, the latter, viz. the mode by the simple incision, is liable to fewer objections, and effects a cure, both with least trouble to the operator and least risk to the patient; and of the other two, the treatment by cauticle appears to be the best. He has seen all the three produce troublesome symptoms, such as, pain and tension of the abdomen, inflammation, and fever; but he states not to lay, that the feton is more frequently productive of these effects than any of the other methods.

Besides the methods already mentioned, another has been lately revived, viz. the injecting of irritating liquors into the care by vaginal coat of the testicle. This method is particularly described by a Monsieur Lambert of the last century, and may be of much older date for anything which is known to the contrary. From some cause or other it seems to have been entirely laid aside till about the middle of the present century, when it was practised by Mr Monro (afterwards a physician-general in the West Indies), under the sanction of the late Dr Monro, and favourably received and followed by some of the first surgeons of this place. But in general, though the cure appeared complete, the disease returned.

The preference is usually given to wine, and commonly that is somewhat diluted; but where no pain is excited by the injection, the liquor should be discharged, and a stronger one used. For where no pain takes place, a cure is not to be expected.

The following is the most approved method of performing the operation: The operator should be provided with a flat trocar and canula, and with a bag of retina elastics, fitted with a stop-cock and pipe, which ought exactly to suit the canula. See fig. 81.

The patient being laid in an horizontal posture, either upon a bed or a table, the water should be drawn entirely off from the tumor by a flat trocar patted into the under and fore part of it. The operator securing the canula with the one hand, is with the other to pass the tube of the injection-bag fairly through it, and with gentle pressure to force in as much of the liquid as may reach the whole surface of the vaginal coat, as well as the whole surface of the testicle. The bag should now be removed, leaving the tube within the canula of the trocar, so that by turning the stop-cock the injection may be retained in the cavity of the tumor. The canula of the trocar ought still to be kept fixed, otherwise it might recede, by which the liquid would infuse into the cellular substance of the scrotum. The liquor should likewise be brought into contact with every part of the cavity; and after remaining about four, or at the most five, minutes in the sac, it should be entirely discharged through the canula of the trocar, after withdrawing the tube of the elastic bag.

Sometimes intense pain is felt immediately after the liquor is thrown in. When this is the case, it should be discharged as soon as it has passed over the different parts of the tunica vaginalis. Some recommend a repetition of the same kind of injection immediately after the first has been discharged, and to be retained for the same period, though this is not commonly practised.

The whole of the injection should be completely discharged, after which the scrotum should be covered with a pledget of cerate, a compress being applied over it, and retained with a suspensory bag. The patient ought to be in bed for several days, and support the scrotum in the bandage by means of a small pillow.

Though it is difficult to ascertain the proportion of those Hydrocele who are cured by the method of injections, and though it is to be regretted that hitherto the disease is found to return in a great proportion of those upon whom this operation has been performed; yet, on account of the facility with which it can be done, the comparatively small pain with which it is attended, the quickness of the cure, and chiefly because it does not, in case of a return of the disease, preclude the future operation of incision, it appears a method which, in all probability, will be more and more adopted into practice.

**Sect. III. Of Hydrocele of the Spermatic Cord.**

Anasarcaous hydrocele of the spermatic cord sometimes accompanies ascites, and at other times it is found to be confined to the cellular substance in or about the spermatic cord. The causes of this disease may be, obstructions in the lymphatics leading from the part in consequence of scirrhus affections of the abdominal viscera, or the pressure of a truss applied for the cure of hernia.

**Symptoms.**

When the affection is connected with anasarca in other parts, it is then so evident as to require no description. When it is local, it is attended with a colourless tumor in the course of the spermatic cord, soft and inelastic to the touch, and unaccompanied with fluctuation. In an erect position of the body it is of an oblong figure; but when the body is recumbent, it is flatter and somewhat round. Generally it is no longer than that part of the cord which lies in the groin, though sometimes it extends as far as the testicle, and even stretches the scrotum to an uncommon size; an instance of which is related by Mr Pott, who from a swelling of this kind discharged 11 English pints at once. By pressure a great part of the swelling can always be made to recede into the abdomen. It instantly, however, returns to its former situation on the pressure being withdrawn.

When the tumor is connected with general anasarca of the system, it can only be cured along with the rest of the disease; but when the swelling is local, the remedy is also to be locally applied. An incision is to be made of such a size as may be sufficient for discharging the whole of the water; in the performance of which, attention is necessary to guard against hurting the spermatic vessels. The contents of the tumor being discharged, the sore is to be treated like any other simple wound.

Encysted hydrocele of the spermatic cord sometimes begins in the upper, but generally at the lower part of the spermatic cord. On its first appearance it is so small as to give little or no trouble; hence it is seldom particularly attended to till it has acquired a considerable size. By degrees it extends as far as the abdominal muscles, and sometimes reaches to the bottom of the scrotum; and to a person unacquainted with the appearance of the disorder may be mistaken for a hydrocele of the tunica vaginalis. But here the tumor is always above the testicle, which is distinctly felt below; and even in the advanced stage of the disease the testicle is found in the back part of it perfectly unconnected with the swelling; whereas, in the advanced stages of hydrocele in the vaginal coat, although some hardness is discovered where the tunica vaginalis adheres to the testicle, yet when the swelling is great the testicle cannot be distinctly felt. In the encysted hydrocele of the cord, the figure and size of the penis is little altered; whereas, in cases of common hydrocele, the penis frequently disappears almost entirely. In other respects, the two diseases are nearly similar. It sometimes happens that the water is contained in two distinct cells. In that case the tumor is somewhat puckered up, or diminished in its diameter. A similar appearance also occurs, when this variety of the disease is connected with hydrocele of the tunica vaginalis, which sometimes takes place.

The only other tumors with which this one may be confounded are, the anasarcaous hydrocele of the spermatic cord, and a real hernia. But in neither of these is the fluctuation of a fluid perceptible, and to the touch they are both soft and inelastic; whereas, in this variety of hydrocele, the tumor has a springy feel, and a fluctuation is sensible to the touch; and in both the one and the other the swelling recedes somewhat upon pressure, which it never does here.

From hernia it is chiefly distinguished by the tumor beginning some way down the cord. In hernia the tumor turns less when the patient is in an horizontal posture, and is considerably affected by coughing and sneezing; but this kind of hydrocele is not altered in size by any such circumstances, nor has it the common symptoms which attend a hernia.

Infants are frequently subject to this disease, as well as to an anasarcaous swelling of the cord, and an edematous tumor of the scrotum. But here the complaint is seldom permanent; for in most instances it readily yields to gentle friction, with any stimulating or astringent application, as a strong solution of sal ammoniac in vinegar, &c. But in adults, the cleft, in every variety of encysted hydrocele, becomes so firm as not to be affected by external applications; so that when the tumor becomes large, it is necessary to use means for producing either a palliative or radical cure, in the same manner as is done for a hydrocele in the vaginal coat.

**Sect. IV. Of Hematocele Scroti.**

We shall mention in this place the disease called hematocele scroti, which is occasioned by blood extravasated in the inner substance of the scrotum, in the tunica vaginalis, or in the spermatic cord; but the usual situation is in the tunica vaginalis testis.

Tumors of this kind may be produced by anything which ruptures the blood vessels of the part, but they are commonly the consequence of external violence. In the tunica vaginalis this disorder may be produced by the point of a trocar or of a lancet in tapping for hydrocele. In such a case, we are commonly informed of the accident by blood being discharged along with the water; though sometimes it does not appear till the whole of the water is evacuated, and then a tumor of a considerable size suddenly takes place. Sometimes it happens where the quantity of water has been so uncommonly great that the sudden discharge of it, by taking away the support which the vessels have been accustomed to receive, has been the cause of their rupture; and it seems certain, that whenever a tumor is produced either in the scrotum or cord suddenly after the water of a hydrocele has been evacuated by tapping, that it is entirely owing to an extravasation of blood.

In the spermatic cord injuries of the same kind will be attended with a similar effect upon the vessels of the sac containing the water. The distinction between blood and water in the substance of the scrotum is readily made by the colour; for where the disease is produced by blood, it forms a real ecchymosis. The tumor feels heavier in the tunica vaginalis when filled with blood than where it is filled merely with water; the treatment is nearly the same with that in hydrocele. In the commencement of the anasarcaous or diffused hematocoele, when produced from slight external violence, the application of stimulating or astringent fluids will sometimes disperse it; but if this prove ineffectual, the tumor is to be laid open, and treated exactly as was directed for hydrocele; only if a ruptured vessel be discovered, it must be secured by ligature. In like manner, all collections of Varicocele, of blood either in the vaginal coat or spermatic cord are to be laid open, and treated as in hydrocele. If bleeding vessels appear, they are to be secured. Sometimes, however, these cannot be detected; an oozing takes place which it is difficult to restrain, even by the use of bark, vitriolic acid, and other means generally employed in such cases. It has been uniformly found, that local remedies prove chiefly useless here, particularly the application of ardent spirits, ether, or tincture of myrrh, to the surface of the foreskin. Pledges of soft lint, soaked in one or other of these, not only serve to check the discharge of blood, but in general tend to promote the formation of good matter.

**CHAP. XXV. Of Varicocele, Circocoele, Spermatocele, and Pneumatocele.**

**Varicocele** is a preternatural distention of the veins of the scrotum, which in this state form a tumor of hard, knotty inequalities, seldom painful, and generally attended with no inconvenience excepting what arises from its bulk. Circocoele is similar in its nature to the former, but situated in the spermatic cord, extending from the abdominal ring to the superior part of the scrotum, and produced by a varicose state of the spermatic vein. Both of these disorders are occasionally produced by obstruction in the veins; but are most frequently owing to a relaxed state of these vessels; to which we may add, that on account of the smallness of the corresponding artery, they are not sufficiently affected by its influence. The tumor produced by these disorders is sometimes so large as to appear like a hernia or hydrocele; but we distinguish it from the latter by the touch, for varicose veins are like worms filled with elastic matter. We have another mark upon which we can still more depend: "The tumor in the erect posture of the body is much increased, while in the horizontal situation it almost entirely disappears."

Another disorder is observed by late authors, where a collection of blood is sometimes found within the tunica albuginea testis, and is supposed to be a kind of haematocele, or more probably varicocele. Sometimes the collection is so considerable, that a fluctuation resembling that of an hydrocele of the vaginal coat of the testicle is observable. When this is mistaken for hydrocele, and an opening is made into it with a trocar, a discharge is produced of a dusky-colored blood, somewhat resembling thin chocolate: But though the tumor may be diminished by the evacuation thus obtained, yet the alteration is inconsiderable; nor is the patient ever relieved, but on the contrary made worse by such an operation. Castration, after this, becomes necessary; but even this has been found ineffectual; so that the patient had better be advised to trust to nature, afflicted by a proper suspensory bandage, than to suffer the attempt of a radical cure; for it has been observed, that in some instances they have remained stationary for many years, whereas they never fail to become much worse by any attempt to evacuate the fluid.

When tumors, or the pressure of a tumor, has been the cause of such complaints, a proper attention to these ought to be the first attempt towards a cure. But when a relaxed state of the veins is suspected, we ought to recommend a suspensory bandage, an horizontal posture, the cold bath, and the application of a solution of alum and other astringents. By a proper exhibition of these, the disease may at least be prevented from increasing, so as to render any operation unnecessary.

By spermatocele is understood a morbid distention of the vas deferens and epidydimis. The disease may arise from tumors, stricture, or inflammation about the vas deferens, or its termination in the penis; but more probably from inflammation there. When an inflammatory disposition is discovered, general and topical blood-letting, gentle laxatives, a low cooling diet, and rest of body, will commonly be found the best remedies. When tumors are found to press upon the vas deferens, they ought either to be brought to a state of suppuration, or entirely extirpated, if that can be properly effected. If the disease proceed from a venereal cause, nothing can be so useful as a course of mercury properly directed.

By pneumatocele is understood a distention of the scrotum from a collection of air.

The principal cause of this disease, which rarely happens, is wounds in the lungs, by which air passes through the common cellular substance into the scrotum; but from whatever cause the tumor is produced, the disease is to be treated by making small punctures with the point of a lancet, as in the case of abscesses swellings formed by water.

**CHAP. XXVI. Of Sarcocele, or Scirrhus Testicle.**

Sarcocele implies a fleshy, enlarged state of the testicle, much firmer and harder to the touch than is observed in hernia humeralis or inflamed testicle.

The symptoms vary exceedingly in different patients; but the following are the most general: The first symptom is commonly a small enlargement, without much pain, and no discoloration of the part. The tumor becomes gradually larger, and the hardness increases; but for a considerable time the surface remains smooth; and when the constitution is otherwise good, the disorder will sometimes remain in this situation for a considerable number of years; and in a few rare instances, by a moderate diet, keeping the belly open, suspending the tumor properly, and avoiding violent exercise, or anything which may considerably increase the impetus of the blood, the disorder has not only been prevented from increasing, but has in a gradual manner disappeared entirely. More commonly, however, the tumor increases in size, and becomes ragged and unequal on its surface. Smart and severe shooting pains are frequently felt through its substance. Sometimes serum is extravasated in the vaginal coat, or matter is collected in different parts of the tumor. The scrotum, now much distended, bursts, and thin, fetid, bloody matter discharging, the disease terminates in an ulcerated cancer of the worst kind.

The spermatic cord is commonly unaffected till the tumor has acquired a considerable size, and generally not till collections of matter have been formed. After this, from being at first only slightly swelled, it gradually increases in hardness and bulk; after which it becomes very painful, knotty, or unequal through its whole extent. The discharge from the scrotum still continues; but although the matter increases in quantity, the size of the tumor is not thereby diminished, but, on the contrary, continually increases; the edges of the foreskin become hard, livid, and retorted, and fungous excrescences push out from every part of it; the health of the patient becomes entirely destroyed, and he is at last carried off in great misery.

Hernia humeralis produced by venereal infection has been considered, by some authors, as a frequent cause of the worst kind of scirrhus testicle; but the fact is very much otherwise; and such an idea has this bad tendency, that it prevents the perseverance in the use of such remedies as might have removed the disease without the necessity of extirpation.

Another cause mentioned by authors as producing Sarcocele, scirrhus of the testicle, is the hydrocele of the vaginal coat; but though sarcocele is frequently combined with this disease, there is every reason to think that the primary disorder was in the testicle itself, and that the water is only a consequence of the other complaint. When the hydrocele happens to be the original disease, the testicle is also found frequently altered in its appearance. It is here paler than in its natural state. It is sometimes diminished, but more frequently enlarged. The enlargement however is soft, harmless, and free from pain; and in such a situation should never be extirpated. To this point particular attention ought to be paid, otherwise we run the risk of committing a mistake, into which practitioners have been too frequently led—the extirpation of a testicle which ought to have been saved. To keep free of this error, we ought to attend to the following circumstances.

When the disease begins in the testicle itself, especially in the body or glandular part, or when it becomes hard and enlarged previous to any collection of water in the vaginal coat, it is to be considered as of a different nature from that in which an enlargement of the part succeeds to a collection of water; or if, upon evacuating the water, the testicle be found hardened, enlarged, and attended with pain and other marks of scirrhus, especially if the surface be unequal or ulcerated, extirpation ought certainly to be performed. The symptoms above mentioned sometimes, though rarely, begin in the epididymis. In such cases, however, extirpation will seldom be advisable, as there is here always a suspicion of a venereal affection; and then we ought by all means to try the remedies commonly used in such diseases. In the prognostics, we attend to the age and habit of the body, as well as to the state of the disease and length of time it has continued.

When the patient is young and the constitution unbroken, we may always hope for a cure, although the symptoms should be very considerable; whereas, in old infirm people, and in habits attended with an emaciated look, with indigestion, and other symptoms of obstructed viscera, whatever state the disease may be in, there will be but a small chance of success.

If the disease has subsisted for a long time without considerably increasing in size, we may reasonably think it is of a milder nature than where it has made a rapid progress. As long as the testicle is only hard and free from the formation of matter, we may expect a favourable event; but where collections of matter have already formed, either in the substance or upon the surface of the testicle, there is no other chance of saving the patient than by means of extirpation. Previous to this, however, we are to attend to the state of the spermatic cord; for were any of it left in a diseased state, little advantage could be derived from extirpation; nor ought the operation ever to be performed but where we can reach the whole of the diseased parts. We are not to be prevented from performing it though the cord should be considerably enlarged, providing it do not evidently partake of the disease of the testicle; for the cord is generally somewhat enlarged in the diseased state of the testicle; but this enlargement is for the most part merely either a varicose state of the veins, or a watery disposition of the cellular substance.

But supposing no obstacle to the operation, the method of doing it may be this. The parts being previously shaved, the patient is to be laid upon 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 assistants; or, he may be laid across a bed in the same manner. Then with a knife the incision is to be begun above the rings of the abdominal muscles, that there may be room afterwards to secure the vessels; then carrying it through the membrana adiposa, it must be continued downward to the bottom of the scrotum. A firm, waxed, flat ligature, composed of small threads, is next, by means of a curved needle, to be passed round the spermatic cord, at least an inch above the diseased part, or as near the abdominal ring as possible; after which the vessels are to be secured by a running knot, and divided about a quarter or half an inch below the ligature. The cord and testicle are then to be removed from the surrounding parts by dissecting from above downwards, and no instrument is better for this purpose than the common scalpel. After the diseased parts are removed, the knot upon the cord must be slackened to discover the spermatic arteries and veins; both of which, by means of the tenaculum or a common forceps, are to be taken up. The ligature upon the spermatic cord is now to be left loose, so as to act as a tourniquet if a hemorrhage should ensue; nor is there more occasion for leaving the ligature tied than for leaving a tourniquet firmly applied to one of the extremities after amputation; besides, where patients have suffered such pain as is sometimes mentioned by authors, it has been found to be owing to the tightness of the ligature rather than to any other cause. In dividing the ligatures of the blood-vessels at the extremities of the cord, they must be left of such a length without the wound as to be readily removed, however much the cord may retract in the time of the cure.

In separating the testicle, a considerable hemorrhage sometimes ensues from the division of the scrotal arteries. In such a case, they ought always to be fixed with ligatures before proceeding in the operation. The parts being removed, and the blood-vessels secured, the wound is to be cured, if possible, by the first intention; and for this purpose the sides of the scrotum are to be brought together in the most accurate manner, beginning at the under end, and securing the parts by adhesive plaster as we proceed upwards, and in such a way that the sides of the foreskin may be kept properly together. About two inches of the ligatures of the cord are to be left out, and this part of the wound treated in the same manner as the rest; the whole to be secured by a compress of linen and a T bandage.

The patient should now be laid to rest, and an opiate administered; and if, upon the second or third day, any after-inflammatory symptoms ensue, they are to be removed by methods commonly employed upon these occasions; as, topical blood-letting, gentle laxatives, and keeping the part constantly moist with a solution of sugar of lead. The dressings ought not to be allowed to shift, else the cure will be greatly retarded. They are to be examined about four or five days after the operation; and if nothing material has happened, they may be allowed to remain two or three days longer, by which time generally the ligature can be readily removed; and the wound will be healed by the first intention, excepting some small opening in the skin, more especially where the ligatures were placed. These are to be drawn together by adhesive straps, and dressed in the same manner as formerly. In this way, if the patient be otherwise healthy, a cure may be expected in little more than a fortnight.

The method of dressing most frequently practised is to apply a quantity of soft lint to the foreskin, and then a compress of linen over it, and to secure the whole with a T bandage or a suspensory bag. The patient is then laid to rest, and an opiate given. The foreskin is not to be touched till a free suppuration takes place, which will commonly be about about the fifth or sixth day; and then the dressings are to be removed, and renewed from time to time; once every two days, or oftener, as the quantity of matter may render it necessary. Sometimes after the operation the patient complains of pain in the sore, and of tension and uneasiness in the belly. In such a case, warm fomentations should be applied to the abdomen, and the sore covered with an emollient poultice, and this repeated as often as may be necessary.

**CHAP. XXVII. Of the Stone.**

**SECT. I. Of Stone in the Bladder.**

A variety of causes have been assigned as tending to the formation of calculi in the bladder of urine; as, a decomposition of a superabundant quantity of earthy matter from the blood, on account of a sedentary life; certain articles of diet or drink, containing a greater quantity of earthy matter than others; a continued use of solid food without a sufficient quantity of drink; the peculiar action of absorbent vessels; the particular structure of the kidney; the nature of the different excretory vessels; the time the urine may remain in the kidney; the habit of retaining the water in the bladder; particles of blood getting into the kidney or bladder, and attracting the stony matter so as to form a nucleus. A certain change of the vessels of the kidney forming the urine has by some been considered as a more probable cause than any of the former. The formation of calculus sometimes begins in the kidneys, at other times in the bladder.

After a calculus has begun to be formed, it sometimes acquires a great size in a few months from the first obvious symptoms; but sometimes it remains in the bladder for many years without arriving at any considerable size.

The symptoms commonly come on gradually, and bear some kind of proportion to the size and inequalities of the stone. One of the first commonly taken notice of is an uneasy sensation at the point of the urethra, which for some time is perceptible only upon making water, or upon using violent or jolting exercise. This sensation gradually increases; and there is along with it a frequent desire to make water, which is commonly voided in small quantities, and sometimes only in drops. When running in a full stream, it often suddenly stops, though the patient is conscious that a considerable quantity still remains, and feels a strong inclination to void it. If the stone be large, the patient has a constant dull pain about the neck of the bladder, and frequent desire of going to stool. The urine is generally of a limpid colour; but it is frequently thick, depositing a mucous sediment, and when the disease is violent it is often tinged with blood. All these complaints are greatly increased by exercise, especially by riding on horseback; and from a long continuance of pain, the patient's health by degrees becomes much impaired, and unless effectual means are employed for removing the cause of the disorder, death alone puts an end to his misery.

We are rendered certain of the existence of calculus when small pieces of stone are frequently passed along with the urine. When this does not occur, we cannot be certain that the symptoms do not arise from an ulcer or tumor in the body or neck of the bladder, or from the pressure of tumors in the neighbouring parts. In doubtful cases, however, we have one mark by which we can judge with certainty, and that is by means of founding.

This is performed by introducing an instrument called a **found** (fig. 82), formed of steel finely polished, and having the natural curvature of the urethra. The patient is to be laid upon a table or across a bed, with his shoulders raised upon a pillow, to bring the stone to the neck of the bladder, and his thighs a little elevated and separated from each other. A found adapted to the size of the urethra is to be chosen; and previous to the introduction it is to be laid in warm water till it be of the heat of the body, and then wiped and rubbed over with bland oil, butter, or anxiage. The surgeon lays hold of the penis with his left hand, while with his right he introduces the found with its concave side towards the abdomen. He is now with his left hand to draw the penis gently forward upon the instrument, which is to be gradually pushed into the bladder. If any difficulty occur about the neck of the bladder, this may be obviated by introducing the finger into the anus, and raising the point of the instrument; or the same purpose is more readily answered by depressing the handle of the found. If still it does not pass with ease, much force ought by no means to be used, lest the instrument perforate the membranous part of the urethra.

As soon as the instrument enters the bladder, if it happen at once to touch the stone, a tremulous motion will be communicated to the fingers of the operator, and the business of founding is then accomplished, the nature of the disease being now ascertained. Great care, however, is here always necessary, as a few particles of sand, or a hardened flake of the bladder, have sometimes communicated the same sensation. If the stone be not soon discovered, the instrument is to be moved in all directions; and should the operator be still unsuccessful, one of the fingers of the left hand is to be introduced into the rectum, so as to raise that part of the bladder in which a stone may probably be concealed. If even this attempt prove ineffectual, the body of the patient is to be put into different positions, and perhaps one of the belt is depressing the shoulders and raising the pelvis. By this mean a stone may generally be felt, providing it is not contained in a cyst, which very rarely happens. If after all these different attempts the surgeon should fail in discovering the stone, the instrument is to be withdrawn; and if symptoms of stone be strongly marked, and it appear that neither cirrhosis nor inflammation, which might give rise to these symptoms, do exist, a second or even a third trial is to be made on the following days.

Various lithotriptics have been recommended for disolving the stone in the bladder; such as lime-water, caustic alkali, soap, &c. but none of them can be conveyed in such a state into the bladder as to be much depended upon, as they undergo the greatest change in the course of the circulation. To obviate these changes, it has been recommended to inject certain fluids of this class through the urethra into the bladder; but this has not been attended with any material advantages, and has generally been found to do injury to the bladder. The only effectual method of removing stones from the bladder is by means of a surgical operation; the success of which depends much upon the dexterity of the surgeon, as well as on the constitution of the patient.

When the constitution has been so much impaired that the patient complains greatly of sickness and oppression attending fromach, with nausea and an inclination to vomit, especially after taking food; when he has likewise a constant thirst, and the pulse is as high as a hundred strokes in the minute—an operation is improper till these symptoms are removed. The operation is improper also when the patient labours under a fever fit of the stone; for then inflammation of the bladder is apt to ensue to such a degree as to produce suppuration. By frequent attacks and continuance of these fits, the coats of the bladder are apt to be thickened and greatly contracted. This last circumstance may be known by the introduction of the found; for then it will stop after ter getting past the sphincter of the bladder, and cannot be pushed farther without considerable force, and at the same time giving the patient the most exquisite pain. Nor ought the operation to be performed when the bladder is ulcerated, especially where the patient is old and much debilitated, and where the discharge of matter is great.

Children more readily recover from the operation of lithotomy than adults; and old people from the age of 51 to that of 70, whose constitutions have not been broken, are in less danger than those in the full vigour of life, probably owing to inflammatory symptoms being more apt to proceed to a dangerous length in the extremes of age than at the middle period of life. When the constitution, however, is not much impaired by the continuance of the disease, the operation may be undertaken with a probable degree of success almost at any period of the patient's life.

Several methods have been recommended for performing this operation; but there are only two which can be practised with any propriety. One is, where the operation is to be performed immediately above the pubes, in that part of the bladder which is not covered with peritoneum; the other, where it is done in the perineum, by laying open the neck and lateral part of the bladder, so as to allow of the extraction of the stone.

Franco, a French surgeon, finding a stone in a child of two years of age too large to be extracted through an opening in perineum (the place where the operation was then performed), was induced to make an incision into the bladder above the pubes; but though the stone was extracted and the child recovered, Franco, who published the case in 1561, never attempted the operation again, and even dissuaded others from doing it. It does not appear indeed to have been much practised anywhere till some time after the commencement of the present century, about the year 1720, when it was adopted and frequently performed in Britain and other parts of Europe for the space of about 12 or 15 years. The lateral operation came then to be more generally known, and since this period the high operation has been seldom practised.

In performing the high operation, the bladder must be in performing a distended state, so as to make it rise above the os pubis, to allow an incision to be made into that part of it which is uncovered by the peritoneum, and thereby to prevent the abdomen from being opened or its contents exposed. Some days, or even weeks, previous to the operation, the patient ought to be directed to retain his urine as long as he can, so as to distend the bladder till it can hold at least a pound and a half, when the person is an adult and of an ordinary size; or the penis may be tied up to allow the urine to collect. As these methods may be attended with great difficulty, some prefer distending the bladder by injecting warm water by slow degrees till the bladder is sufficiently full, which may be easily known by relaxing the abdominal muscles and feeling above the pubes.

When the operation is to be performed, the patient is to be laid upon a table of convenient height, with the pelvis higher than the shoulders, that the parts may be fully on the stretch, and to prevent the bowels from pressing upon the bladder. The legs and arms are to be properly held by assistants. An incision is to be made through the skin, in the very middle of the under and fore part of the abdomen, from some way under the umbilicus to the symphysis pubis. The cellular substance, the tendon of the oblique muscles, the musculi recti and pyramidalis, are now to be separated; and it is better to make this separation from the pubes upwards, so as to be in no danger of cutting into the abdomen. The surface of the bladder will now appear uncovered by the peritoneum. Then the operator, with a common scalpel, or an abscess lancet, or, what is better, with a concave sharp-pointed knife, makes a perforation into the most prominent part of the bladder, till the forefinger of the left hand can be introduced. The ligature is now to be removed from the penis; then with a probe-pointed bistoury, making the finger serve as a conductor, the wound is to be made sufficiently large for the extraction of the calculus, taking particular care, however, not to carry the incision so high as to cut the peritoneum. This part of the operation being finished, the stone is to be extracted with the finger; or if that be impracticable, the forceps are to be employed. Should it unfortunately happen that the stone is broken in the extraction, the pieces are to be removed entirely by the fingers rather than by scoops, which were sometimes used. The edges of the wound in the integuments are now to be drawn together by means of the twisted future, leaving about an inch and a half immediately above the pubes for the discharge of any urine which may be there evacuated. The patient is to be laid in bed, with the pelvis still kept higher than the shoulders. Gentle laxatives are to be occasionally given, and the antiphlogistic plan strictly adhered to.

The advantages of this method are, that larger stones can be extracted by this than by the lateral operation, and that disfavourable sores are less apt to ensue. The disadvantages are, the danger of opening or wounding the peritoneum, and thereby exposing the abdominal bowels; the frequent occurrence of inflammation about the beginning of the urethra, so as to occasion the urine to be diffused in the cellular substance on the outside of the bladder, and thereby producing sinuses difficult to cure; the extreme difficulty of healing the wound, especially in bad constitutions; and, lastly, the small number of patients, after the age of thirty, who have been found to recover from this operation.

Pierre Jacques, a French priest, was the inventor of the lateral operation. He first appeared at Paris in 1697, and afterwards operated in a great number of cases.

He introduced a sound through the urethra into the bladder, with a straight bistoury, cut upon the staff, and carried Jacques's incision along the staff into the bladder. He then introduced the fore finger of the left hand into the bladder, searching for the stone, which, having withdrawn the sound, he extracted by means of forceps. The patient was now carried to bed, and the after treatment left to the attendants.

Professor Rau of Holland improved upon this method, by making a groove in the staff, which enabled him, with greater certainty, to continue his incision into the bladder; but instead of dividing the urethra and prostate gland, the latter of which he was afraid of wounding, he dissected by the side of the gland, till the convex part of the staff was felt in the bladder, where he made his incision, and extracted the stone; but this method was too difficult to perform, and attended with too many inconveniences and dangers ever to be generally received. It suggested, however, to the celebrated Chefdon the lateral method of cutting, as it is now with a few alterations very generally practised. We shall attempt to describe the different steps of this operation in its present improved state.

The manner of preparing the patient depends upon a variety of circumstances. If he be plethoric, a few ounces of blood should be taken away, and at proper intervals the patient's bowels ought to be emptied by any gentle laxative which will not gripe. The diet should consist of light food for some time previous to the operation. If the pain be violent, opium is necessary. Sometimes it is relieved by keeping the patient in bed with the pelvis raised, so as to remove the stone from the neck of the bladder. He ought not to fit up, or take any exercise, in the time of preparation. The warm bath ought to be used two or three times, and the patient should remain in it half an hour at each time. A laxative ought to be given on the day preceding the operation, and an injection a few hours before it is performed. The patient ought to drink plentifully of some diluent liquor, and to retain the urine several hours previous to the operation. If this cannot be readily affected, a slight compression, by means of a ligature, may be made upon the penis, so as to have the bladder sufficiently distended, that there may be no danger of the posterior surface being hurt by the end of the gorget. The perineum and parts about the anus should be well shaved.

A table somewhat more than three feet in height, and of sufficient strength, is now to be firmly placed, and properly covered with blankets, pillows, &c. Upon this the patient is to be laid and properly secured; and for this purpose there ought to be two pieces of broad firm tape, each about five feet in length, which are to be doubled, and a noose formed upon them. A noose is then to be put upon each wrist, and the patient desired to lay hold of the middle of his foot upon the outside. One end of the ligature is to go round the hand and foot, and the other round the ankle and hand, and cross again so as to repeat the turns in the reverse way. A running knot is then to be tied, by which the hand and foot will be properly secured. The buttocks are then to be made to project an inch or two over the table, and to be raised considerably higher than the shoulders by a couple or more pillows, and one ought to be put under his head.

The operator is now to introduce a grooved staff (fig. 81.) of proportionate size, and open to the very end, through the urethra into the bladder; and having again fully satisfied himself of the existence of a stone, he inclines the staff, if the surgeon be right-handed, obliquely over the right groin, so that the convex part of the staff may be felt in the perineum on the left side of the raphe. He then fixes it, and delivers it to his assistant, who is to hold it with his right hand, defining him to press it gently, in order to make the fulcrum of the staff project in the direction in which he received it. With his left hand the same assistant is to raise and support the scrotum.

The thighs of the patient being sufficiently separated by the assistants, and the surgeon being seated upon a chair of a proper height, and in a convenient light, he makes an incision with a common convex edged scalpel through the skin and cellular substance, immediately below the symphysis of the osa pubes, which is a little below the scrotum, and where the crus penis and bulb of the urethra meet, and on the left side of the raphe, and continues it in a slanting direction downwards and outwards to the space between the anus and tuberosity of the ilium, ending somewhat lower than the basis of that process, by which a cut will be made of three or four inches in length. This incision ought not to be shorter than is here directed, otherwise there will not be room for the rest of the operation. As soon as the integuments are thus divided, he ought to introduce two of the fingers of the left hand. With one he keeps back the lip of the wound next the raphe, and with the other he presses down the rectum. He ought likewise particularly to guard against cutting the crurae of the penis, which he can readily feel, and separate at their under part with one of the fingers. He next makes a second incision almost in the same direction with the first, but rather nearer to the raphe and anus, by which he preserves the trunk of the arteria pudica. By this incision he divides the transversalis penis, and as much of the levator ani and cellular substance within these as will make the prostate gland perceptible to the finger.

If any considerable vessel be cut, it is immediately to be secured, though this is seldom necessary. After this he will have a view of the membranous part of the urethra, which is distinguished from that covered by the bulb by being very thin. He is now to search for the groove of the staff with the forefinger of his left hand, the point of which he presses along from the bulb of the urethra to the prostate gland, which surrounds the neck of the bladder. He keeps it there; and turning the edge of the knife upwards, he cuts upon the groove of the staff, and freely divides the membranous part of the urethra, from the prostate gland to the bulb of the urethra, till the staff can be felt perfectly bare, and that there is room to admit the point of the finger; and as the finger assists in keeping the parts stretched, and effectually prevents the rectum from being hurt, the incision into the urethra may be made with perfect ease and safety.

The next part of the operation, viz. dividing the prostate gland and neck of the bladder, might, by a dextrous operator, be safely performed with a common scalpel, with the edge turned the opposite way. But to guard against accidents, a more convenient instrument, called the cutting gorget (fig. 84.), is now in general use. It was originally invented by Mr. Hawkins of London, and since his time has undergone various alterations. Fig. 85., is a double gorget invented by Dr. Monro. The inner plate, which is blunt, is made to slip forwards to protect the back part of the bladder. The membranous part of the urethra being now divided, and the forefinger still retained in its place, the point of the gorget, previously fitted to the groove, is to be directed along the nail of the finger, which will serve to conduct it into the groove of the staff; and as this is one of the nicest parts of the operation, the most particular attention is here required that the point of the gorget be distinctly heard to rub in the bare groove, and that nothing is interposed.

In the introduction of the gorget into the bladder, if the assistant could be depended upon, the staff might be allowed to remain in his hand: the operator, however, generally chooses to manage it himself. He now rises from his seat, takes the staff from the assistant, raises it to near a right angle, and presses the concave part against the symphysis of the osa pubes; satisfies himself again that the point or beak is in the groove, and then pushes on the gorget, following the direction of the groove till the beak slips from the point of the staff into the bladder. The gorget is not to be pushed farther than this, otherwise it may wound the opposite side of the bladder, &c.

The gorget having now entered the bladder, which is readily known by the discharge of urine from the wound, the staff is to be withdrawn, and the finger introduced along the gorget to search for the stone, which, when felt, will point out the direction to be given to the forceps; at any rate, the introduction of the finger serves to dilate the wound in the bladder; and this being done, a pair of forceps fig. 66., of a proper size, and with their blades as nearly together as their form will allow, are to be introduced, and the gorget withdrawn slowly, and in the same direction in which it entered, so as to prevent it from injuring the parts in its return. After the forceps are introduced, and passed till they meet with a gentle resistance, but no farther, the handles ought to be depressed till they are somewhat in an horizontal direction, as this will most correspond with the fundus of the bladder. One blade of the forceps is to be turned towards the symphysis of the pubes to defend the soft parts there, the other of consequence will guard the return. After they have distinctly touched the stone, by moving them a little in various directions, they are then to be opened, and the stone laid hold of, which may generally It frequently happens, however, that when the stone is small, it is not readily felt with the forceps; and instances may happen where the under and back part of the bladder may be so depressed as to conceal the stone. In such a situation, nothing will more readily bring it in the way of the forceps than to introduce the finger into the rectum, and elevate this part of the bladder. Straight forceps are generally used; crooked ones, in some very rare cases, however, may be necessary, and therefore the surgeon ought to be provided with them.

After the forceps have laid hold of the stone, if it be small and properly placed, it may readily be extracted; but if, on the contrary, the handles of the forceps are now observed to be greatly expanded, it is certain the stone is improperly fixed, or that it is remarkably large: in either case it should not be held fast, but allowed to move into the most favourable situation; or the finger is then to be introduced so as to place it properly for extraction. If this cannot be done with the finger, it ought to be allowed to slip out of the forceps, in order to get it more properly fixed; and as the most common form of the stone is flat and oval, or somewhat like a flattened egg, the forceps should have hold of the smallest diameter, while an end presents to the neck of the instrument. The stone should be grasped with no greater firmness than is merely sufficient to bring it fairly out. It should be extracted in a slow and gradual manner.

When a stone is broken in the bladder, all the larger pieces are to be extracted by the forceps, which are to be introduced by means of the finger serving as a director. The smaller parts are to be removed by means of a scoop (fig. 87.), or probably the finger may be more convenient; and as the least particle allowed to remain, or which is not washed off by the urine, may serve as the nucleus of another stone, a large quantity of water, properly warmed, is to be injected by a bag and pipe, or by a syringe; and for this purpose the body of the patient should approach at least to an upright posture; and to give the particles of stone an opportunity of collecting near the incision of the bladder, the wound may be stopped for a little after the injection is thrown in.

When a stone is extracted of a regular, firm, and rough surface, it seldom happens that any others remain in the bladder. On the contrary, when it is of an irregular shape, and smooth and polished, particularly in certain places, with impressions formed upon it, there is the greatest probability of others remaining. There are exceptions, however, to these rules; and therefore the operator, instead of trifling to them, should introduce his finger, which will answer the purpose without any other search.

If, after the operation, any considerable artery bleeds much, it is to be taken up with a ligature; but if this be impracticable, the hemorrhage ought to be stopped by means of pressure, and for this purpose a firm roller introduced at the wound answers sufficiently; and to prevent any stoppage to the discharge of urine, a silver canula, covered with caddis, and dusted over with hyptic powder, may be introduced into the wound with advantage.

Sometimes it happens that a considerable quantity of blood, instead of passing off by the wound, is collected in the cavity of the bladder, and may produce very dangerous symptoms. To prevent this as much as possible, immediately upon the operation being finished, the patient's pelvis should be made considerably lower than the rest of his body; by which means the wound will be kept in a depending posture, and the blood will escape more readily by the wound. But if it be found that blood is still lodged in the cavity of the bladder, it must be immediately extracted.

As soon as the bleeding is stopped, the patient is to be untied, a piece of dry soft charpee put between the hips of the wound, and often renewed, and the thighs brought together. He is then to be laid in a bed, in such a way that the pelvis may be considerably lower than the rest of the body, to give a favourable direction to any blood which may afterwards flow from the wound. A considerable dose of laudanum is now to be given. From 30 to 50 drops for an adult will commonly be necessary. From this period, unless the stone has been large and difficult to extract, the patient commonly falls asleep, or at least lies quiet for a few hours; but afterwards generally begins to complain of pain in the under part of the abdomen. Anodynes are now to be given both by the mouth and anus, and warm fomentations, by means of flannels or bladders filled with warm water, are to be applied to the region of the bladder, as the affection seems to be of the spasmodic kind.

If by a continuance of these remedies the pain abates, no anxiety needs be entertained concerning it; but if it increases, and especially if the abdomen become hard and swollen, and the pulse full and quick, and these symptoms become gradually worse, great danger is to be apprehended, as they most commonly take place in consequence of inflammation. In this situation, as much blood ought to be taken as the patient can bear. A large injection of warm water and oil, or linseed tea, should be given every six or seven hours, and the fomentations continued at the abdomen. If the symptoms continue to grow worse, the patient should be immediately put into the semicupium or half-bath.

By a proper continuance of these means, with a low diet and plenty of diluent drink, the above symptoms may frequently be removed. The reverse, however, is sometimes the case. The wound becomes sluggish and ill-conditioned; all the symptoms, in spite of every effort, continue to increase, and soon terminate in death.

But where matters end favourably, the wound by degrees puts on a better appearance; the urine passes almost from the beginning by the urethra (most frequently, however, it is discharged by the wound for the first two or three weeks); the pain in the abdomen gradually abates, the feverish symptoms are soon removed, a complete cicatrix is formed, and the wound is sometimes cured in a month; though upon other occasions three will be necessary. But it must depend greatly on the nature of the constitution.

Excoriation of the buttocks may be prevented by placing a sheet under them several times doubled, the breadth to be 18 or 20 inches, and to be all rolled up, except the part which is to be laid under the patient, the rest of the roll to be by his side, which is to be unrolled as the nurse draws the wet part from under him. If, after the use of this, excoriations should still happen, the part may be washed with cold water; or the parts round the wound, after being well dried, may be rubbed with any tough simple ointment.

In patients of a debilitated constitution incontinence of urine frequently occurs after this operation. In general, this is removed as the patient acquires strength. Nourishing diet, cold bath, the bark, and other tonics, are of much service here; but where these are afterwards found ineffectual, instruments for compressing the penis, or others for receiving the urine, have been found useful, and are now made in such a convenient way as to allow them to be constantly used so long as they may be found necessary.

An operation for stone in the bladder is much seldom required in women than in men, on account of the shortness of the urethra in the former allowing a readier passage for the small calculi which get into, or are formed in, the bladder. It is likewise in women more simple, and of course more readily performed. It might be done in the same manner... manner as in the male, but there would be the greatest probability of wounding the vagina. In a few cases the operation has been performed from the vagina itself; but it is by no means advisable, as stones would not only be extracted with greater difficulty, but, on account of the thinness of the parts, the urine would most probably form a fistulous opening, and a communication be maintained between the bladder and vagina; or cicatrices here might be attended with great inconvenience in child-labour.

In the method commonly practised, the patient being placed and secured in the same manner as in the operation upon the male, the operator introduces a short grooved staff, slightly curved (fig. 88.), into the bladder; then by means of the common gorget already mentioned, with its point passed along the groove of the staff, he lays open the whole of the urethra and the neck of the bladder. The staff is now to be removed, the finger introduced upon the gorget, and to feel for the stone, which is to be removed as already directed for the operation on the male subject. Where incontinence of urine occurs after the wound is healed, a pellary is to be used within the vagina, or a sponge applied, or a tin machine to receive the urine.

Sect. II. Of Stones in the Kidneys.

The symptoms of stone in the kidneys are, pain in the region of the kidneys, sickness, and vomiting; the urine sometimes mixed with blood, at other times with mucus or even purulent matter; but the same symptoms are often induced by other causes, especially from inflammation and suppuration of the kidney. Nephritic complaints have frequently subsisted for a long time, where stones have been blamed as being the cause of them; and yet upon dissection purulent matter alone has been detected. From this circumstance, as well as from the great depth of the parts and the large size of the blood vessels of the kidney, the operation of nephrotomy could not be performed, but with the greatest uncertainty and most imminent danger, and is therefore never attempted. A few cases indeed have appeared where inflammation induced by a stone in the kidney terminated in abscess, and the stones were taken out; but it was not till they had worked their way out of the kidneys into the cellular substance, so that it only remained to open the abscess and extract them; but otherwise the operation is never to be thought of.

Sect. III. Of Stones in the Urethra.

Those who are troubled with calculous complaints frequently pass small stones along with their urine; and when these are angular or of considerable size, they sometimes stick, and give much uneasiness. The symptoms are at first pain, then inflammation and swelling, attended with a partial, or total suppression of urine, which, if long neglected, is apt to terminate in a rupture of the urethra, when the urine will be discharged into the neighbouring parts. The greatest attention is therefore necessary to get the stone extracted as soon as possible.

When a stone is in the urethra, unless it be of a large size, or has been long impacted, and the inflammation great, attempts ought to be made with the fingers to push it out; but previous to this, the penis should be relaxed as much as possible, so as to remove a certain degree of spasm which the presence of stone here probably creates. Blood ought to be drawn by general or local means, according as the patient may be of a plethoric or emaciated habit. He should be immersed in a warm bath, and get a full dose of laudanum, and warm oil ought also to be thrown into the urethra. After these remedies have relaxed the parts as much as may be, the extraction is to be attempted.

For this purpose certain instruments have been contrived, particularly a tube containing a pair of elastic forceps (fig. 89.), to be introduced into the urethra so as to lay hold of the stone. In some cases they certainly might answer the purpose, but they have not been found very useful; and as they may increase the irritation already present in the urethra, they are seldom, if ever, employed. Instead of them, the surgeon uses gentle pressure on the penis to push the stone outwards; and as calculi larger than a field bean have sometimes been passed by the urethra, an operation ought not to be performed till gentler means have been persisted in for some time. When these means have failed, an incision ought to be made immediately upon the stone, which is then to be removed by a probe, or with a pair of small forceps. When a stone is lodged near the neck of the bladder, after the patient has been placed and secured in the same manner as for the lateral operation, while an assistant supports the scrotum and penis, the operator introduces a finger oiled into the anus, to support the stone in its place, and prevent it from slipping into the bladder. An incision is then to be made, and the stone turned out. The after treatment will be nearly the same as that after the operation of lithotomy.

When, again, a stone has advanced further in the urethra, the best method is to draw the skin strongly forwards or backwards, and then to cut upon it and turn it out, when the skin will slide back so as to cover the wound, and prevent the urine from passing through it; and by this means it will generally heal by the first intention. If part of the urine passes through the wound, and infiniate into the cellular substance, an attempt is to be made with the hand to press it back. If that prove insufficient, a cut is to be made through the skin opposite to the incision of the urethra; but this will seldom be found necessary. If a stone is fixed near the point of the urethra, it may be removed with a pair of forceps; or, if this fail, the urethra is to be dilated with a scalpel; and if this also be insufficient, an incision is to be made as above directed. When the cure is nearly completed, a tube formed of silver or elastic gum, or a hollow bougie, may be used to keep the urethra of a proper size.

The worst part of the urethra for a stone to stick in is that immediately behind the scrotum; for then the urine is apt to pass by the incision into the cellular substance of the scrotum, so as to occasion large swellings there. To prevent this, a stone so situated ought, if possible, to be pushed forwards with the fingers; or if this be impracticable, it should be pushed back into the perineum by means of a staff. If both methods fail, a cut is to be made at the under part of the scrotum, which is to be well supported, and at one side of the septum, and continued upwards till the stone is felt, when an incision is to be made into the urethra, and the stone extracted as before directed.

Chap. XXVIII. Of Incontinence and Suppression of Urine.

Incontinence of urine may arise from various causes, such as, from a loss of power in the sphincter of the bladder, insufficiency of the natural tone of that organ remains unimpaired, or from irritation about the neck of the bladder, produced by the friction of stones contained in it; or from a laceration of parts by the operation of lithotomy; or from the pressure of the uterus in a state of pregnancy.

When the disease is owing to a want of tone in the sphincter, the cure is very difficult, because the constitution in general is frequently affected. The most useful remedies are tonics, especially peruvian bark, chalybeate waters, and the the cold bath, both generally and locally applied. Cold substances applied to the perineum are perhaps of greater service than any thing else, as cloths wet with vinegar and cold water, or with a strong solution of saccharum saturni in vinegar; but the best method of applying cold is to dash water immediately from the fountain upon the anus and perineum. When it arises from the irritation of stones in the bladder, opiates and mucilaginous liquors plentifully used frequently give great relief. When incontinence of urine is owing to a laceration of parts in performing the operation of lithotomy, the disease is nearly of the same nature as that from the cause first mentioned, and therefore the same remedies are of service. When these remedies fail in either of the cases, compression of the urethra prevents any inconvenience arising from the constant dripping of the urine; and for this purpose an instrument termed jugum penis (fig. 90.) is applied to the penis; or, to press against the urethra of the female, pellaries (fig. 91.a and b) are contrived, which are made in such a way as to be introduced into the vagina, and there to press upon the urethra. They are sometimes made of sponge, but those of ivory or wood well polished are more generally preferred. A small bottle made of elastic gum, and open at both ends for the passage of the menstrual discharge, answers the purpose equally well. Certain cases however occur where pressure upon the urethra is improper, especially where there is a constant desire to pass water; and here much relief is obtained from the use of receivers, which are now suited to both sexes. Fig. 92. represents one for the male, and fig. 93. one for the female.

We shall here treat only of that species of suppression of urine where the urine is collected in the bladder, but from some obstruction cannot be prevented from being discharged. It arises from a variety of causes.

When it arises from a want of tone in the body of the bladder, it is often connected with palsy of the lower extremities; it is frequently owing also to retaining urine too long. The catheter, in this case, is commonly an effectual remedy, and ought to be employed as soon as the supposition is evidently formed, and repeated from time to time, till the tone of the system is recovered by the use of proper remedies. The method of introducing the catheter is the same that already directed for introducing for the stone. Fig. 94. a catheter for the male, fig. 95. one for the female.

When the affection arises from spasm about the neck of the bladder, opiates, warm water thrown into the rectum, and afterwards the warm bath, are the best means of producing relief. When it proceeds from feverishness of the prostate gland, or from other tumors, or from obstructions of the urethra in consequence of gonorrhea, the treatment to be afterwards described will be found best suited for such complaints. When the supposition arises from the pressure of the uterus in the latter months of pregnancy, change of posture is sometimes found to have some effect; but if this fail, immediate relief can commonly be given by the introduction of the catheter, which in women is for the most part readily done.

Suppression of urine from inflammation affecting the neck of the bladder is one of the most alarming varieties of the disease, as it produces pain, and such a degree of swelling in the parts as to render the introduction of the catheter inadmissible. It may arise from the matter in gonorrhea passing backwards along the course of the urethra. An improper use of injections has likewise frequently produced this species of the disease. The treatment is nearly the same as for inflammatory complaints in other parts of the body. Blood-letting should be employed, and particularly leeches should be applied to the perineum. Opiates ought to be given in large doses. Injections of warm water should be frequently thrown up the rectum, and the whole body should be immersed in the warm bath. If these means be properly used, they will very seldom fail of success; but when they do not prove effectual, when the bladder becomes painfully distended, and when every attempt to introduce the catheter has failed, nothing is to be depended upon but a puncture made into the body of the bladder, in order to discharge the water contained in it.

Various methods have been proposed for effecting this operation. Puncturing the bladder above the pubes has been recommended by many respectable authors. The following is the method of doing it: A lancet-pointed trocar, about two inches long, is to be at once introduced through the integuments, about an inch and half above the pubes, into the body of the bladder. The fillet is to be removed as soon as the water begins to flow through a groove formed in it, and the urine allowed to flow through the canula, which is secured to the body by means of a bandage. A cork is to be fitted to the canula, that the urine may pass off at intervals only. The canula is to be retained till the cause which produced the obstruction is so far removed that the patient can discharge the urine in the natural way. It ought to be removed every three or four days, and cleared from the fords which adhere to it, otherwise it soon becomes covered with a calculous crust, which renders the extraction exceedingly difficult. On these occasions a firm probe, of sufficient length, ought to be passed through it into the bladder, upon which it may again be easily returned as soon as it is properly cleaned.

This method of puncturing the bladder is not altogether free from objections: the bladder being suspended for a long time on the canula, its tone is sometimes destroyed; and if it happens to slip off the canula, the operation must be repeated; besides, the urine may be diffused in the surrounding cellular substance.

When the bladder is to be punctured from the perineum, the trocar, which ought to be longer than the one for puncturing above the pubes, is to be introduced at a little distance from the raphe perinei, and then passed into the body of the bladder, a little to the upper and outside of the prostate gland, carrying the point of the instrument a little upwards, to avoid wounding the ends of the ureter or seminal vessels. Puncturing from the anus, or the vagina in females, are attended with so many inconveniences that they ought never to be attempted.

**Chap. XXIX. Diseases of the Penis.**

**Sect. I. Of Obstructions of the Urethra.**

Obstructions of the urethra frequently occur after repeated or severe attacks of the venereal disease. They may be owing to carbuncles or filthy excrescences in the urethra; to tumors in the lining membrane, or parts contiguous to the urethra, in consequence of inflammation; to phimotic affections of the urethra; or to fissures properly so called.

Still of late years almost every instance of obstruction in the urethra has been attributed to carbuncles, but their occurrence is much less frequent than was formerly imagined. They are rarely found except near the point of the urethra. They are considered to be nearly of the same nature with the warts which grow upon the prepuce or root of the glans in venereal cases. Tumors obstructing the passage in the urine may be occasioned either immediately by inflammation, or in consequence of old sores within the urethra. Obstruction; or tumors, from whatever cause, may be fested in the urethra; or the corpora cavernosa contiguous to the urethra, and may press upon it in such a manner as to cause an adhesion of its sides, and thereby produce stoppage of the urine. Spasmodic strictures of the urethra sometimes arise from stone in the bladder. Sometimes in gonorrhea there is such a degree of contraction that neither staff nor bougie can enter. This variety of obstruction is known by its coming on suddenly, and going off sometimes almost completely in the space of a few hours. Of the permanent stricture, or stricture properly so called, Mr Hunter observes, that in most of the cases of this kind which he has seen the disease extends no farther in breadth than if the part had been surrounded with a piece of packthread. He has however seen the urethra irregularly contracted for above an inch in length, owing to its coats or internal membrane being irregularly thickened and forming a winding canal. He farther observes, that a stricture does not arise, in all cases, from an equal contraction of the urethra all round; but in some, from a contraction of one side, which throws the passage to the opposite side, and often makes it difficult to pass the bougie. In some few cases, he says, there are more strictures than one; he has seen half a dozen in one urethra, and finds that the bulbous part is much more subject to strictures than the whole of the urethra besides; that they are sometimes on this side of the bulb, but very seldom beyond it; and that they are often slow in forming, it being frequently years from the time they are perceived before they become very troublesome. Contrary to the opinion of others, Mr Hunter doubts very much if the stricture commonly, or even ever, arises from the effects of the venereal disease, or the method of cure; for strictures are common to other passages, and sometimes happen in the urethra where no venereal complaint had ever been.

When obstructions are occasioned by carbuncles in the urethra, bougies (fig. 96.) should be introduced rubbed over with bland oil until a resistance is met with. When a bougie cannot be introduced far enough, one with a smaller point is to be used, but not till the day following, lest the part be too much irritated. They ought not to be allowed to remain long at first, particularly when they occasion a considerable degree of pain.

When suppression of urine arises from swellings in or about the urethra, in consequence of inflammation, an attempt should be made to disperse these immediately, or bring them into a state of suppuration, and discharge the pus as soon as it is formed. But when the nature of the tumor is such as not to terminate in either of these ways, extirpation of the diseased parts, when this is found practicable, is the only probable means of relief. Bougies should at the same time be used to assist in the cure.

When spasmodic affections are present in the urethra, the remedies to be employed are, warm emollients, as rubbing the part with warm oil; anodynes, as opium given by the mouth, but more especially by the anus; blood-letting in plethoric habits, and this to be generally and locally applied; blisters put to the penis or perineum; electricity, after plethora has been removed. Some cases may be treated with bougies; but where the disease is purely spasmodical, they are generally found to be hurtful; though in other cases, when the violence of the disease is so far removed, if they can be introduced, they are of service, by relieving any obstructions which may remain after the remedies above-mentioned have been exhibited. Contagious ought likewise to be guarded against. The permanent stricture is to be cured by bougies.

Bougies act solely by pressure, and by supporting the part; hence they should be so large as to fill the passage, and sufficiently flexible to be easily introduced. They are formed of various materials, as a composition of diachylon, plaster, oil, and wax melted and put upon linen, which is afterwards properly rolled up; or they are formed of leather catgut, &c., properly prepared; but the best of any are those which are formed of elastic gum. Bougies, when properly made, can sometimes be kept in for six or eight hours together; but the length of time proper for their retention must depend much upon the feelings of the patient. At all times when they give much pain they ought to be removed, and not introduced again till the part is in a state fit for receiving them. They should be gradually increased in their size, till the passage returns to its natural dimensions. They ought to be continued for some time after, till it appear that there is no danger of a return of the complaint.

Sect. II. Of Phymosis and Paraphymosis.

In phymosis the prepuce is thickened, and contracted before the glans, so that it cannot be readily drawn behind the glans. In some people there is a constitutional phymosis from the natural strictness of the prepuce. Sometimes it arises from the matter secreted by the odoriferous glands at the root of the glands being confined and becoming acrid; sometimes from an annular swelling of the scrotum and penis; but most frequently from venereal virus.

The cure must depend upon the nature of the cause producing the disease. If the symptoms be inflammatory and of no long continuance, fomenting the parts frequently with warm emollient decoctions, or bathing them in warm milk, and then applying emollient poultices, or keeping the diseased parts constantly moist with a cold astringent solution, and turning the penis upwards and supporting it against the belly, commonly give relief. If the inflammation has arisen from a venereal cause, part of the fluid ought frequently to be injected, by means of a syringe, between the prepuce and glans, so as to wash off any matter which may there be concealed; but if the inflammation still continues to increase, blood-letting is necessary, both general and local. The veins of the penis are sometimes advised to be opened with a lancet; but this is unsafe on account of the nerves. Leeches may be applied; but care must be taken, in venereal cases, lest the bites of these animals, by absorbing venereal matter, turn into chancres. Along with the remedies already advised, gentle laxatives, low diet, and abstinence, ought to be prescribed. But if, after a due perseverance in these means, it is found that they have had little effect in removing the disorder, or perhaps that the symptoms are constantly increasing, and that chancres are confined under the prepuce; in that case it is necessary to slit open the prepuce, which is best done by a sharp-pointed bistoury, concealed in a grooved directory, fig. 98. This is to be introduced between the prepuce and glands, till the director is found by the finger to have reached the upper or back part of the prepuce. The operator is now to keep the director firm with one hand, while with the other he pushes forward the knife, till its point passes through the prepuce; then drawing the instrument towards him, he cuts the prepuce through its whole length.

The operation being performed, the parts are to be washed and cleaned with warm water, and the foreskin dressed with a little soft lint, and a compress of linen laid over it. The whole may be retained by a small bag properly adapted, and secured by two straps to a bandage put round the body. This bag may be left open at the under end, to allow the patient to make water, without removing the dressings; but if this be found impracticable, the dressings may be removed with little inconvenience. If the glans be much Phymosis much inflamed and excoriated, care should be taken to and Para- infert lint spread with emollient ointment between the phymosis, glans and prepuce, otherwise troublesome adhesions are apt to ensue. It is evident, that when this disease is of the venereal kind, the sore will not readily heal till the poison be eradicated from the constitution.

In some cases of phymosis the preputium is so remarkably long, and the contraction too much confined to the point, that a circular incision is preferable to a longitudinal one; and it is easily effected, by separating such a portion as may be found necessary of the whole circumference of the prepuce. The dressings in this case are the same as when the prepuce is slit open.

Paraphymosis is the reverse of phymosis, being formed by a retraction of the prepuce, producing stricture behind the glans of the penis. Like the former disease, it arises most frequently from a venereal infection, but may be produced from whatever preternaturally enlarges the glans or contracts the prepuce.

In the incipient state, the patient may generally be re- lieved by the surgeon pushing the glans gently back with his thumbs, while with his fingers he brings the prepuce gradually forward. But a more effectual method than this is to include the glans with one of the hands, and press gently on all sides, by which the fluids forming the enlarge- ment will be pushed into the body of the penis behind the stricture. If this method be persevered in for a consider- able time, it will generally be found to answer the purpose: but should it prove ineffectual, we may try the effects of cold applications; and the best seem to be those of the fattening kind. When the penis is evidently much swelled and inflamed, the patient should be kept cool, gentle laxa- tives and low diet should be prescribed, and a number of leeches applied to the penis. Should the disease still con- tinue to increase, and an oedematous swelling appear about the under part of the prepuce, an operation is necessary to prevent a mortification from taking place in the glans. An incision is to be made on each side of the penis immedi- ately behind the glans, so large as completely to divide the stricture. The wound ought to be allowed to bleed freely; after which a pledget spread with simple ointment is to be applied, and an emollient poultice laid over the whole.

Sect. III. Of an Incomplete Urethra.

In children, especially males, the urethra is sometimes incomplete, ending before it reaches the usual place of ter- mination. Sometimes it does so without any external open- ing, at other times it opens at a distance from the com- mon termination. In the first case, a small trocar is to be introduced in the direction the urethra ought to take, till the urine be discharged; after which, the passage is to be kept open by the use of bougies, till the sides be rendered callous and an opening preferred. In the other case, as the opening which is already found affords a temporary passage for the urine, it will be better to delay doing any opera- tion till the patient be farther advanced in life, when it is to be performed as in the former case.

After the operation, a piece of flexible catheter may be introduced, as well for the purpose of rendering the passage free and callous, as for carrying off the water till a cure is made.

Sect. IV. Of Amputating the Penis.

This operation is found necessary in certain diseases which will not yield to other remedies; as in cases of mortifica- tion and cancer. The following is the method of perform- ing it:

Vol. XVIII. Part I.

A circular incision is first to be made through the sound skin a little beyond the diseased parts; the skin is then to be drawn back by an assistant, and the body of the penis divided by one stroke of the knife (fig. 99.) immediately at the edge of the retracted skin. The principal arteries, which are two or three on each side, are next to be secured by ligatures; and if an oozing of blood still continue, the surface of the sore ought to be dusted with some styptic powder. To allow the patient to make water, a silver ca- nula (fig. 99. a) is to be introduced into the urethra, and retained there by two small ligatures fixed to the side of the canula, their other extremities being fastened to a bandage put round the body. The wound is to be dressed with soft lint, kept in its place by a piece of linen previously perfor- ated for the introduction of the canula. The dressings are to be kept on by a narrow roller passed a few times round the penis, which, by gently compressing the penis upon the instrument, will effectually prevent any farther dis- charge of blood. The after treatment of the sore should be similar to wounds in other parts of the body. But it will not be necessary to make any farther compression of the penis upon the canula, as the discharge of blood will, previ- ous to this time, be entirely stopped. The tube is to be allowed to remain in the urethra during the whole time of the cure.

Before any operation of this kind is attempted, the surgeon ought to examine attentively, whether the disease be in the penis itself, or only in the skin, as the prepuce alone is frequently so much enlarged and otherwise diseased as to give cause for suspicion that the glans and body of the penis are likewise affected. This precaution is the more necessary, as several instances have occurred where the glans and body of the penis have been removed, and, after the opera- tion, have been found perfectly sound. Previous to ampu- tation, therefore, where there is any cause for suspicion, the prepuce should be slit open, and the glans examined, so as to avoid amputating more than what is absolutely diseased.

It sometimes happens that the frenum of the penis is so short as to give considerable uneasiness in time of an erection. When this is the case, it may be safely divided by a pair of scissors, or by a sharp-pointed bistoury, and the wound dressed with a little charpie.

Sect. V. Of Fistula in Perineum.

The term implies a sinuous ulcer in the perineum, com- monly communicating with the urethra, but sometimes open- ing into the bladder. The same term is also applied to similar fores opening into the scrotum, or into any part of the penis.

The disease may arise from wounds in the bladder, and Causes of of the urethra, from external violence; from a laceration of parts when performing the operation of lithotomy; from incision into the urethra for the extraction of calculi im- pacted there; from fistulas producing matter capable of cor- roding the membranous part of the urethra; from suppura- tion in the perineum in consequence of inflammation; from the urine passing through an opening in the urethra into the perineum or other neighbouring parts, and rendering the edges of the sore callous; and most frequently the disease is occasioned by venereal complaints.

In the treatment of this disease, when it is the conse- quence of a general affection of the system, a removal of the primary disorder is necessary before a cure can be attempted. When the complaint is of a local nature, a simple incision into the sinus is all that is necessary; and for this purpose a staff is to be introduced into the urethra, so as to pass the opening at which the urine is discharged. A probe, or a small director, is now to be passed at the external opening of the

The treatment of piles has been already considered under the article Medicine; but it sometimes happens, that although the means mentioned there have been employed, the disease becomes so violent as to require the affluence of the surgeon. Where the discharge of blood is so great as to endanger the life of the patient, we ought to attempt to stop it either by compression, or by securing the bleeding vessels by a ligature; and here the tenaculum is preferable to the needle, because, when the latter is used, a portion of the rectum is apt to be included in the ligature. When piles arrive at such a size as to obstruct the passage of the feces, or to produce great irritation, the removal of them by the knife or by ligature becomes necessary. The first of these may be used when their size is of such a nature as not to threaten a dangerous hemorrhage; but when this is the case, they ought to be removed by ligature, the manner of applying which has been considered under the treatment of Polypi. The dressings are to be of a simple nature.

Sect. II. Of Condylomatous Excrencences, &c., of the Anus.

Excrencences are sometimes produced about the anus, which from their figure get the name of fic, arilie, &c.; but they are all of the same nature, and to be cured by the same means. They sometimes grow within the gut itself, but more frequently are situated at the verge of the anus. They vary considerably in their colour, figure, and consistence. Sometimes they are only one or two in number, but commonly all the skin about the anus becomes covered with them. They vary in size from that of ordinary warts to that of split garden beans. They seem originally to be productions of the skin, though at last they sometimes proceed as deep as the mucilages. They frequently remain long without producing much uneasiness. When this is the case, they ought not to be touched; but sometimes they become so troublesome as to render their removal necessary.

The softer kinds can frequently be removed by rubbing them often with gentle escharotics, as crude sal ammoniac, or pulvis tabinae; but the harder kinds are to be removed chiefly by lunar caustic, or by the knife; the latter of which is greatly preferable, and may be done with the utmost safety.

The sores are afterwards to be treated like wounds produced by any other cause. If caustic is to be used, care ought to be taken that it do not injure the rectum.

Sect. III. Of Fistula in Ano.

The fistula in ano is a finuous ulcer in the neighbourhood of the rectum. When it opens externally, and has likewise a communication with the gut, it is termed a complete fistula; but if it has no communication with the rectum, it is called incomplete. When the ulcer communicates with the gut, but has no external opening, it is named an internal or occult fistula. It is likewise distinguished into simple and compound. The first is where one or more sinuses communicate with the internal ulcer, but where the parts in the neighbourhood are sound. The compound fistula is where the parts through which the sinus runs are hard and swollen, or where the ulcer communicates with the bladder, vagina, os sacrum, and other contiguous parts.

The causes producing the disease may be, whatever tends to form matter about the anus, piles, condylomatous tumors, hardened feces, or any cause which produces irritation and inflammation, so as to end in suppuration. As soon as a swelling about the anus appears to terminate in suppuration, every thing ought to be done which can accelerate the formation of matter. A proper degree of heat, warm poultices, fomentations, and the streams of warm water, are the means best suited for this purpose; and as soon as matter is formed, it ought to be discharged by a free incision in the lowest part of the tumor. Much depends upon the proper treatment here; for if the opening be made too small, or if long delayed, the matter gets into the loose cellular substance, and instead of producing one, produces many sinuses, and these sometimes running to a great depth. The parts ought then to be covered with soft lint spread with mild ointment, and an emollient poultice kept constantly over the whole. By this any remaining hardness will be removed, the cavity will fill up like impotaneous tumors in other parts, and a complete cure will in general soon be made.

It more frequently happens, however, that the practitioner is not called in till the abscess has burst of itself, and till matter has infunuated into the surrounding cellular substance, and formed one or more real fistulas.

The first thing to be done now is to discover the real course of the different sinuses, and the probe is the best instrument for this purpose. If there be openings in the external surface, there is commonly little difficulty in this. If they run along the perineum or the muscles, the probe will generally detect them. If they follow the direction of the gut, the best method is to introduce the fore finger oiled into the rectum, while the probe is entered at the external orifice. If there be a communication between the gut and the sinus, the probe may be made to pass till its point is felt by the finger in the rectum. We discover with certainty if a sinus communicate with the gut, when air or feces are discharged, or when any mild fluid injected returns by the anus.

After the course of the sinus has been discovered, the method of cure is next to be considered. Astringent or astringent injections, pressure, and fetons, are unsupportable, on account of the violent pain which they produce. The only method therefore of bringing on a proper degree of inflammation is a free incision along the whole course of the sinus. The course of the different sinuses having been previously discovered, a laxative ought to be given on the day preceding this operation, and a clyster an hour or two before performing it. The patient is to be placed with his back back towards a window, while his body leans upon a bed, table, or chair. The finger of the surgeon is to be rubbed over with oil, and introduced into the rectum. The end of a crooked probe-pointed bistoury (fig. 100.) is then to be passed into the fistula, and pushed against the finger in the rectum, if the fistula be complete. But in cases of incomplete fistulae, the point of the instrument must be made to perforate the gut before it can reach the finger. Some make the perforation with a sharp-pointed bistoury, which can be made to slip along the side of a probe-pointed one, as at fig. 101. After the bistoury has reached the cavity of the rectum, the point of it is then to be brought out at the anus, and a cut made downwards to lay the sinus completely open. In this operation the sphincter ani muscle is commonly cut, if the sinus be high; but no inconvenience is found to arise from this circumstance. It sometimes, though rarely, happens, that the sinus goes beyond the reach of the finger, and even as high as the upper end of the sacrum. The only thing which can be done in this case is to cut as high as the finger can go, so as to give a free and easy vent to the matter.

Some practitioners, with a view to prevent troublesome hemorrhages, and others to free the patient from the dread of the knife, have proposed to open the sinuses by means of ligature (fig. 102.). By introducing one end of a piece of silver or leaden wire into the sinus, then bringing it out at the anus, and twisting the ends together, the contained parts may be so compressed as to produce a complete division of them. But this is both more painful and tedious than the scalpel, and appears to be by no means necessary.

When the presence of an occult fistula is suspected, its existence ought first to be fully ascertained, by examining whether the matter which is passed by stool proceeds from an ulcer in the bowels or from an abscess at the side of the anus. It is discovered by matter from the bowels being mixed with the faeces, and no pain about the anus. In occult fistula, a hardness, swelling, and discoloration, are observed upon some spot near the anus, and there is a sensation of considerable pain upon pressure being made upon it. The operation in this is the same with that in the other two varieties of the disorder; only that an opening is previously to be made, by a lancet or scalpel, in that spot where the matter appears to be lodged. By this the sore will be reduced to a complete fistula, and the rest of the operation will be easily performed.

In this manner the different sinuses are to be operated upon, when in a simple state; but in those of a compound nature, where the parts in the vicinity of the fores have been separated from each other by an effusion of matter into the cellular substance, and where all the under end of the rectum has, in some rare cases, been detached from the surrounding parts, two modes of operating have been recommended; either to remove a considerable portion of the external integuments, so as to give free vent to the matter; or to extirpate all the lower end of the rectum which is found to be detached from the surrounding parts. But from the pain and subsequent difficulties which they occasion, these methods are judiciously laid aside. All that is necessary to be done here is to lay the detached portion of gut completely open, as in cases of simple fistula; but if this be insufficient for allowing the gut to apply properly to the contiguous parts, another incision should be made on the opposite side. If the neighbouring bones be found sound, and the constitution in other respects be unimpaired, a complete cure will probably be obtained.

The matter sometimes infinuates itself between the skin and muscles of the perineum, or of the hip. When this is observed, the sac produced by it should be laid open from one end to the other by one or more incisions as circumstances may require. Sometimes, from neglect or improper treatment, the matter collected does not find a proper outlet, and then the parts most contiguous to it inflame, become painful, and gradually acquire such a morbid callousness as to put on a scirrhouss appearance. In such cases a cure may be effected by giving free vent to the matter, preventing every future collection, and inducing and preserving a suppuration in the substance of the parts chiefly affected. To accomplish this last circumstance, however, it may sometimes be necessary not only to lay the sinuses freely open, but to cut in upon the obdurate parts.

The different sinuses having been laid open, care must be taken to apply the necessary dressings. Upon this much of the success attending the operation depends. Dry lint, till lately, was much used by practitioners; but it has been found to produce so much irritation, especially when too much crammed in, as to be one of the causes of that diarrhoea which is frequently so troublesome after operations of this kind. Instead, therefore, of this sort of dressing, pledgets, lint, or soft old linen spread with any simple ointment, are to be preferred. After the fores have been cleared of clotted blood, the pledgets are to be gently introduced between their edges, but not to such a depth, or with such force, as to give any uneasiness. This being done, and a compress of soft linen with a T bandage being applied over the whole, the patient is to be carried to bed; and the dressings being renewed, either after every stool, or, when these are not frequent, once in the twenty-four hours, the fores will generally fill up from the bottom, and will at last cicatrize in the same manner as wounds in any other part of the body. Sometimes, however, they acquire a soft, flabby, unhealthy aspect, and the matter discharged from them is thin, fetid, and occasionally mixed with blood. These appearances may sometimes arise from some part of a sinus having been overlooked. In this case advantage may follow from the part being laid completely open. But it more usually proceeds from some affection of the general system; and till this is eradicated the fores cannot be expected to heal.

In the cure of fores in other parts of the body, practitioners have sometimes found great advantage to arise from the use of ouches. The same thing is now found to be applicable here. Wherever therefore fistulae are of long standing, while any disorder existing in the constitution is properly attended to, practitioners recommend, that an ouch, in proportion to the quantity of the matter discharged by the fores, should be immediately employed. In this way, if the bones in the neighbourhood are not diseased, there will be reason to expect that a complete cure will be obtained.

Sect. IV. Of Prolapsus Ani.

This is a protrusion of part of the rectum beyond the anus. It is often occasioned by debility of the parts, but is most frequently owing to violent exertions made in the rectum in consequence of irritation. The reduction should be effected as soon as possible; for although this part of the intestine can bear exposure to air much longer than any of the rest, yet allowing it to remain a long time out would be attended with great uneasiness, and probably with danger. In the reduction, the tumor ought to be supported with the palm of one hand, while with the fingers of the other the part of the gut last protruded is to be returned. If the gut has been long exposed previous to the reduction, veneration may become necessary, and gentle astringents may be applied to the part. The patient during the reduction is to be kept in a reclined posture. As soon as the bowels Sect. V. Of Imperforated Anus.

This disorder, though not frequent, now and then occurs; and when present, unless speedy relief be given, must prove fatal. In some cases, the end of the rectum protrudes at the usual situation of the anus, and is only covered with the common integuments; but in others, no termination of that gut is discoverable. Sometimes the rectum ends within an inch of the usual seat of the anus; at others, it reaches no farther than the top of the sacrum. In some cases it terminates in the bladder; in others, in the vagina. In the most favourable cases, where the rectum protrudes, an opening may be readily made by a scalpel or lancet; but when no direction of this kind is met with, an incision is then to be made in the place where the anus is usually situated, and is to be continued in the direction of the os coccygis and sacrum, which is the course the intestine commonly takes. The finger is to be used as a director along it; the parts are to be cut either till feces are observed, or till the incision has been made the length of the finger. If still the feces do not appear, a lancet-pointed trocar is to be pushed forward upon the finger in such a direction as the operator thinks will most probably reach the gut. An artificial anus is likewise to be attempted, where the gut terminates in the bladder or vagina. After the operation, the greatest attention is necessary to preserve the opening which has been made. Substances which irritate least are the most useful; such as doffs of lint moistened in oil, and rolls of soft bougie plaster.—We shall conclude this chapter with two short sections of imperforated hymen and prolapsus uteri, though they do not properly come under it.

Sect. VI. Of an Imperforated Hymen.

When the hymen is imperforated, the most troublesome symptoms, at a certain period of life, may be produced by the accumulation of that fluid, which ought to be discharged; for then a tumor is formed, by which the most violent bearing-down pains are occasioned. These increase in severity to such a degree, as sometimes to be mistaken for labour-pains. They disappear, however, during the intervals of the accustomed periods. In the treatment of this disease, all that is necessary is to make either a single or a crucial incision into the obstructing membrane, and then to prevent the accretion of its edges by doffs of lint spread with some emollient ointment till the parts are healed.

Sect. VII. Of Prolapsus Uteri.

This is a falling down of the uterus, occasioned by debility or by excessive straining in the time of parturition. The disorder seldom occurs before child-bearing, and is commonly met with in those who are somewhat advanced in life. The parts protruding are to be reduced by gentle pressure, while the patient is put in an horizontal posture. Peffaries (fig. 91, a and b) are to be employed, which ought to be made of the lightest materials, finely polished, and somewhat compressible; and none possess these qualities in a more perfect degree than a peffary made of the elastic gum-bottle. This, or whatever else may be used to answer the purpose, is to be retained by a proper bandage till by tonic medicines the parts recover strength to retain their natural situation.

Chap. XXXI. Of Luxations.

Sect. I. Of Luxations in general.

A bone is said to be luxated when that part of it forming a joint is moved out of its place. When the bone is forced entirely out of its cavity, the luxation is termed complete; when this is not the case, it is partial or incomplete. When there is also a wound of the soft parts communicating with the joint, it is called a compound, and when there is no wound, a simple luxation.

The common symptoms of a dislocated bone are, inability to move the injured limb; pain, tension, deformity in the part affected; and sometimes inflammation, subfultus tendinum, and fever; and these three last are greatest in partial dislocations. The swelling which first appears is always inflammatory; but afterwards a secondary swelling comes on, seemingly oedematous, and probably owing to the pressure of the lymphatics by the dislocated bone.

In judging of the practicability of reducing a luxation, we ought to attend to its nature and extent, the other circumstances with which it may be complicated, and the length of time which it has continued. When a bone is only partially dislocated, it is evident that it may be reduced with much more ease and certainty than where it is completely displaced. It is evident also that fracture attending dislocation must render reduction much more difficult and uncertain. Indeed, when both the bones forming the joint are broken, there is the greatest hazard of its remaining stiff during life, even when the greatest attention has been paid. Luxated bones are most easily reduced immediately after they are displaced; the difficulty indeed of reducing them is generally proportional to the time that has intervened since the accident happened. When a bone has been some time lodged among the contiguous muscles, it forms a socket for itself, and is firmly grasped by the surrounding soft parts. The cavity, too, from which it was dislodged may be partially filled with some of the surrounding soft parts, or at least diminished by the constant action of the contiguous muscles on its cartilaginous brim. Dissections, however, show, that inspissated synovia does not, as was formerly supposed, fill up this cavity. In delicate constitutions and advanced periods of life, when the muscles give little resistance, dislocations are more easily reduced than in the vigour of youth or in robust constitutions.

In the treatment, we ought, 1. To reduce the dislocation with as much ease and expedition as possible; 2. Retain the bone in its situation till the parts have recovered their tone; and, 3. Obviate all uneasy symptoms.

1. When the surrounding skin and muscles are much contused and inflamed, we should endeavour to remove the inflammation by local bleeding, fomenting applications, and laying the limb in an easy posture, before we attempt to reduce the bone, as considerable injury may be done by stretching a limb while the parts surrounding the joint are inflamed. The upper part of the limb should be kept steady while the surgeon endeavours to replace the under bone, which alone is commonly dislocated. This is not easily done; for the contractile power of the muscles acts strongly against every attempt, and not only draws it beyond the contiguous bone against which it should be placed, but frequently forces it out of its natural situation, and fixes it firmly in some neighbouring cavity, from which it is with difficulty removed. To prevent this resistance as much as possible, the muscles ought to be put into a state of relaxation. If this is properly done, the force necessary for reducing a luxated bone may generally be obtained from assistants alone; sometimes, however, machinery is required, and various instruments have been invented for this purpose. Freke's machine is the most generally used. The force ought always to be applied in a gradual manner, and to the dislocated bone alone, and not to any more distant parts of the limb. After the end of the dislocated bone is brought into a line with that to which it is Luxations is opposed, the reduction is easily completed either by the action of the muscles alone, or, if that is not sufficient, by gentle pressure.

2. After the reduction there is seldom any difficulty in retaining the bone in its place, unless it has often been dislocated before. All that is necessary is to place the limb in a relaxed posture, and to support the bone with a bandage till the parts have recovered their tone.

3. The most urgent symptoms which accompany dislocations are pain, inflammation, and swelling. These usually abate soon after the reduction. If any degree of inflammation remains, the use of leeches is the best remedy.

When dislocated bones are accompanied with fracture near the joint, the fracture must be allowed to heal before reduction be attempted. This, however, is not always necessary in very small bones, as those of the fingers. When the fracture is at a distance from the joint, the dislocation may generally be reduced immediately. Compound luxations are to be treated nearly as compound fractures. After the bone is replaced, leeches should be applied to abate the inflammation; after which the sore should be dressed with Goulard's cerate, or any other mild ointment, and the pain moderated by opiates and a low regimen: care ought also to be taken that no matter lodges about the joint. When luxations are produced by tumors or collections of matter in the neighborhood of the joints, they may be considered as incurable: when they proceed from too great a relaxation of the ligaments and tendons of the joint, the bone can hardly be prevented from being now and then displaced; but the inconvenience may be somewhat obviated by supporting the limb with a proper bandage, by the use of the cold bath, and by electricity.

Sect. II. Luxations of the Bones of the Head and Neck.

If the bones of the cranium be separated by external injury, all that can well be done is, to support the parts by a bandage, to prevent inflammation, to keep the patient quiet, and in a proper posture during the cure. The bones of the nose are seldom luxated without fracture: when they are, the injury is easily discovered by the touch. When one of the bones is driven inwards, it may be raised and reduced by pushing a tube of a proper size, and covered with soft lint, into the nostril; which may be afterwards retained till there is no danger of the bone being again displaced. If the bone be luxated outwards, it may be reduced by the fingers, and retained by a double-headed roller. The lower jaw is luxated most frequently when the mouth is opened widely; it can only take place forwards and downwards, which are least surrounded by the neighboring parts: both sides are generally luxated at once; and in that case the mouth is opened wide, the chin thrown forwards and towards the breast. When only one side is dislocated, the mouth is distorted, and widest on the sound side of the jaw, which is drawn a little towards the contrary side. The patient should be seated, and his head supported. The surgeon should push his thumbs, protected by a covering of strong leather, as far as possible between the jaws, and then with his fingers, applied on the outside of the angle of the jaw, endeavour to bring it forward till it move a little from its situation. He should then press it forcibly down, and the condyles will immediately slip into their place. The thumbs ought to be instantly withdrawn, as the patient is apt to bite them involuntarily. The patient should for some time avoid much speaking or opening his mouth wide.

When the head is luxated, it commonly falls forward on the breast, the patient is instantly deprived of sense and motion, and soon dies if the luxation be not quickly reduced.

In reducing the luxation, the patient should be placed on the ground, and supported by an assistant: the surgeon standing behind should gradually pull up the head, while the shoulders are pressed down by the assistant till the bones are brought into their place, which is known by a sudden crack or noise; if the patient be not dead, he immediately recovers his faculties, at least in some measure. He should then be put to bed with his head elevated and retained in one posture. He should lose a quantity of blood, and live for some time on a low diet.

Sect. III. Luxations of the Spine, Os Coccygis, Clavicle, and Ribs.

The vertebrae are sometimes partially, but hardly ever completely, dislocated without fracture. When they occur high up, they are attended with the same symptoms as dislocation of the head: when farther down, besides distortion of the spine, paralysis ensues of every part of the body situated under the luxated bone; there is commonly also either a total suppression of urine, or it is discharged involuntarily together with the feces. As luxations of this kind are generally owing to falls or violent blows, the displaced vertebra is driven either forwards or to one side; it is therefore very difficult to reduce it. The best, as well as the simplest method, is to lay the patient on his face over a cylindrical body, as a large cask, and at the same time to attempt to replace the bone with the fingers. If the bone be very much displaced, there is very little reason to hope for success. The os coccygis is more liable to dislocation than any other part of the spine. It is sometimes forced outwards in laborious births. This is discovered by the great pain which is felt at the connection of the os coccygis with the sacrum, and by the bone appearing to be displaced when examined. It may generally be easily reduced by pressure with the fingers. The best support afterwards is a compress, with the T bandage. When the coccyx is luxated inwards, the patient complains of severe pain, tenesmus, and a sense of fulness in the rectum; the feces are passed with difficulty, and in some cases a suppression of urine takes place. The injury is easily discovered by introducing the finger into the anus. In this case the bone should be pressed outwards, by introducing the fore and middle fingers of one hand dipped in oil into the rectum, and supporting the parts which correspond with it externally till the reduction is accomplished. Dislocations of these bones are apt to excite inflammation, which often terminates in dangerous abscesses; it ought therefore to be guarded against by every means in our power.

The clavicle is most frequently luxated at its junction with the sternum; because the violence which produces the injury is generally applied to the shoulder. The luxation is discovered by pain in the part, by the projection of the bone, and by the immobility of the shoulder. It is easily reduced by pushing the bone into its place with the fingers, while an assistant draws back the arms and shoulders. It is not easy to retain the bone in its place. When it is the inner extremity of the clavicle which has been dislocated, the shoulder should be kept in its natural situation, neither raised nor depressed: the fore arm should be supported, as should also the head and shoulders, and a moderate pressure should be made upon the displaced end of the bone. For this purpose the machine represented fig. 104, the invention of Mr Park of Liverpool, answers best. But when the outer extremity of the clavicle has been dislocated, the shoulder must be considerably raised, the arm supported in a sling, and the bone kept in its proper situation by a small compress placed over its end, and secured by a roller forming the figure 8; or it may be retained by the machine. Luxations at the elbow most commonly happen upwards and backwards; and then the fore-arm is shortened, the end of the ulna projects behind, and is higher than usual, while the extremity of the humerus can be felt in the bend of the elbow. The surgeon should take hold of the wrist with one hand, and the upper part of the fore-arm (which is to be moderately bent) with the other, and gradually pull the top of the fore-arm downwards, while at the same time he increases the curvature of the elbow to dis-bow.

Luxations of the Bones of the Inferior Extremities.

From the great strength of the hip joint, it was formerly believed that the head of the thigh-bone was never luxated by external violence; but it is now known that it happens by no means infrequently. The ball in starting from its socket generally passes forwards and downwards into the foramen thyroideum. When this happens, the limb symptoms is considerably lengthened, the head of the bone is lodged near the hinder and fore part of the pelvis, the large trochanter is observed on the fore part of the thigh, a vacancy is perceived where the head of the bone and the trochanter should be, and the toes are turned outwards. When the bone is dislocated upwards and backwards, the limb is shortened, the great trochanter higher than usual, the knee and foot turned inwards. When it is dislocated upwards and forwards, the leg is shortened, the ball of the bone is felt on the os pubis in the groin, and the great trochanter on the upper and lower part of the thigh; a vacancy is discovered in the corresponding part of the hip; the knee and toes are turned outwards. When the ball slips downwards and backwards, the leg is lengthened, the toes turned inwards, and the great trochanter is lower than that of the other limb. If the ball slip directly downwards, the leg is lengthened, but the knee and toes keep nearly their natural situation. It is sometimes difficult to distinguish between luxation and fracture of the neck of the bone. In fractures the bone is most frequently pulled upwards, and the leg shortened, the knee and point of the toes are turned inwards, and may be moved much more readily outwards and inwards than when the bone is dislocated.

Luxations of the Bones of the Superior Extremities.

The head of the os humeri is most frequently dislocated forwards and downwards, sometimes downwards and backwards, but never upwards without a fracture of that part of the scapula which is placed above the joint. The luxation is discovered by the patient's inability to raise his arm, by violent pain attending the attempt, by the luxated arm being of a different length from the other, by the head of the humerus being felt out of its natural situation, while a vacuity is perceived under the acromion, and by the flatness of the injured joint, while the sound one has its natural fulness. When the luxation is of long standing, the whole arm is apt to become edematous.

The patient should be seated on a chair, and his body secured by a broad belt passed round it, and held by assistants. The elbow should be bent, in order to relax the muscles on the fore part of the luxated joint. A firm leather belt four or five inches broad, with strong straps, and lined with flannel, is to be tied round the arm immediately above the elbow; assistants are to extend the arm gradually, by pulling these straps, while another assistant draws back the scapula. The surgeon stands on the outside of the arm, directs the assistants, and varies the direction of the extension, according to the situation of the head of the bone. As soon as the head of the bone has cleared the brim of the socket, the muscles draw it into its place, a crack is heard, the patient is relieved, and the anterior part of the shoulder acquires its usual fulness.

Various other methods of extending the arm have been proposed in difficult cases; as, suspending the patient by the luxated arm over the step of a ladder or the top of a door, raising him up by the arm with ropes running over pulleys fixed in the ceiling of a room, &c. The jerk produced by the body being suddenly raised and let down again on a feather bed, has sometimes succeeded when other means have failed. A gentler method is to lay the patient on the floor, while two or three stout men standing on a table lay hold of him by the arm and pull him up. But all these methods are in danger of lacerating the soft parts by the suddenness with which the force is applied, and even sometimes of breaking the end of the humerus if it be pressed against the neck of the scapula. Mr Freke's improvement on the ambé of Hippocrates has been considered as the best machine for extending the arm. But machinery is very seldom necessary; even cases of long standing may by proper management be reduced by means of assistants, provided reduction be at all practicable. Inflammation after the operation should be obviated by the usual remedies. If the bone be apt to step out again, which sometimes happens after repeated dislocations, the arm should be supported in a sling till the parts have recovered their tone. Blisters, friction, stimulating medicines applied to the shoulder, and cold water poured on it, have sometimes been useful in restoring the strength of the joint. For reduction, the patient should be laid on a mattress on the sound side, and a wooden roller covered with several folds of flannel placed between his thighs, and fixed firmly by straps to the wall. A strong bandage of buff leather, or something similar, should be applied to the under end of the thigh, with straps fixed to it to make the extension. The trunk of the body should be properly secured, and the joint of the knee bent. The extension should be made at first gently, and increased gradually, while, at the same time, the thigh is made to roll in different directions. When the extension is sufficient, two assistants should lay hold of the roller, and attempt to raise the bone; the extending force should then be slackened, and the surgeon should push the head of the bone upwards and outwards, while an assistant presses the knee forcibly inwards. The muscles themselves will then commonly bring the bone into its place; and this is done with such a jerk and noise, that it is heard by the bystanders. If the reduction be not obtained, the extension must be repeated with greater force. Instead of the roller a broad strap or table cloth is frequently used. The limb should not be used for some time after reduction, and inflammation should be prevented by the proper remedies.

The patella can neither be luxated upwards or downwards, without rupture of the tendons of the extensors muscles, or of the strong ligament which fixes it to the tibia; but it may be luxated to either side. The luxation produces lameness, and much pain on attempting to move the joint. In recent cases the injury is easily discovered; but when the surgeon is not called immediately, the swelling may be so great as to render it more difficult. For reduction, the limb should be kept extended; the surgeon, by depressing the edge of the patella most distant from the joint, is enabled to raise the other, and push the bone into its place.

It may be necessary to remain a day or two in bed till the knee recover its tone. Sometimes, after the bone has been displaced, returns of the same complaint become frequent. In such cases, proper machinery applied to the side of the tumor, where the bone is apt to start out, is used with advantage.

From the size of the joint, and the great strength of the ligaments, luxations of the tibia from the os femoris rarely occur. When it does, it is easily discovered by the pain, lameness, and deformity of the limb. The patient should be laid on a table, the muscles relaxed, and the thigh secured by assistants; the limb should then be extended, and the bones cleared of each other, when they will be easily replaced. After the reduction, the limb should remain for some time perfectly at rest; and inflammation, which is very apt to ensue, and is attended with very bad consequences, should be assiduously guarded against.

If the ankle joint be dislocated forwards, the fore part of the foot is lengthened; if backwards, the foot is shortened and the heel lengthened (this is the most common variety); if to either side, there is an uncommon vacancy on the one side, and a prominence on the other. Dislocation, however, can hardly take place outwardly without fracture of the end of the fibula.

For reduction, the limb should be firmly held by assistants, the muscles relaxed, and extension made till the bones are cleared of each other, when the astragulus will easily slip into its place.—The same rules should be observed in reducing dislocations of the bones of the foot. Luxations of the metatarsal bones and toes are reduced exactly in the same manner as the bones of the metacarpus and fingers.

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**CHAP. XXXII. Of Fractures.**

**Sect. I. Of Fractures in general.**

The term fracture is generally confined to such divisions in bones as are produced by external injury. When the integuments remain sound, the fracture is called simple; when it communicates with a wound, it is called compound.

The general symptoms of fracture are pain, swelling, and tension in the contiguous parts. A grating noise when the part is handled, distortion, and a certain degree of loss of power in the injured part, accompany almost every fracture, except when it runs longitudinally, and the divided parts are not completely separated from each other. When there is only a single bone in a limb, a fracture is easily detected; but where only one of two bones of a limb has suffered, it is often difficult to judge with certainty, especially if the contiguous soft parts be tense and painful before the practitioner is called. In that case, the opinion must be regulated, not only by the attendant symptoms, but, if possible, by the age and habit of the patient; for bones are more easily fractured in old than in young persons. Different diseases, too, induce brittleness of the bones, as the gouty rheumatism and scurvy. By the situation of the part; for bones are more apt to be fractured in the solid parts of their bodies than towards their extremities, where they are more soft and pliant. By the posture of the limb; for a weight may fracture a bone lying on an unequal surface, which it would have sustained without injury if equally supported. Fractures are sometimes attended with a great degree of ecchymosis, occasioned by the ends of the fractured bones wounding some of the contiguous blood-vessels.

In giving a prognosis of fracture, various circumstances are to be attended to. It is evident that small fractured bones are more easily healed than large ones, and that the fracture of the middle of a bone is not near so dangerous as near the extremity. A cure is effected much more readily in youth than in old age, and in good constitutions than in bad. We ought also to attend to the concomitant symptoms, and the injury which the neighbouring parts may have sustained. The more moderate the symptoms, the more favourable our prognosis may be.

The treatment of fractures consist of three particulars; Treatment, replacement, retention, and obviating bad symptoms.

1. When bones are fractured directly across the parts, they are often very little moved from their natural situation; but when the fracture is oblique, they are apt to pass over each other, and to produce much uneasiness and deformity; the contiguous muscles are severely injured, and the pain is aggravated by the slightest motion. The surgeon should put the limb into the best posture for relaxing all the muscles connected with it, according to the practice first introduced by Mr Pott. If it be properly attended to, the ends of the bones will in general be easily replaced. When any difficulty occurs, a small degree of extension may be made, taking care to keep the muscles as relaxed as possible. Much attention should be paid to replacing the bones properly, otherwise the limb will remain for ever after distorted.

2. After the bones are replaced, the limb should be laid in the safest posture, and the bones afterwards retained in their situation by proper compresses and bandages, not applied too tightly, till the cure be completed. The time necessary for this purpose depends on the size of the bone, the age and habit of the patient, the steadiness with which the limb has been retained in its place, and the violence of the... Fracture the attending symptoms. In middle-aged persons, and under favourable circumstances, a fracture of the thigh bone, or of the bones of the leg, may be cured in two months; of the arm bone, or bones of the forearm, in six weeks; of the ribs, clavicles, and bones of the hand, in three weeks. In infancy the cure will take a shorter, and in old age a longer, time than this.

3. In simple fractures the inflammatory symptoms generally subside in a few days. When they become worse, which is sometimes the case, astringent applications should be employed. If these fail, blood ought to be drawn from the parts affected. This is of so much advantage, that it ought never to be omitted where the surrounding soft parts are much injured. Friction with emollient oils, warm bathing, the use of Bath and other similar waters, are also of much service. The limb sometimes puts on a clumsy appearance from an overgrowth of callus. When this tendency appears, ardent spirits and other astringents are considered as useful; sometimes pressure on the part by a thin plate of lead fixed by a bandage may be advantageous. Many instances occur, however, where no remedies prove successful: The patient ought therefore to be acquainted beforehand with the probable event, to prevent unpleasant reflections afterwards.

Sometimes the ends of the bone remain loose long after they might have been reunited. This may be owing to some constitutional disease, to the bones not being kept steadily in contact, to some of the soft parts getting in between them, or to the bone being broken in different places, and the intermediate fractures being too small to adhere. Pregnancy has also been mentioned as a cause. By removing these obstructions, a perfect union may in recent cases be accomplished. But where the case is of long standing, callus of the bones becomes so hard and smooth as to move with the ease of a joint, so that no advantage can be derived from laying them together. In that case, an incision should be made through the soft parts, and a small portion of the ends of the bone removed with a saw. If this be properly performed, nature will supply the deficiency. When small pieces of bone remain long loose, they should be extracted by making an opening. The intervention of muscles or other soft parts is known by the very severe pain and tension, and by particular motions of the limb causing great pain and twitching of the muscles which move it. The limb should be put into all the variety of situations; and if this does not succeed, an opening must be made, and the soft parts removed. Sometimes in fractures blood-vessels are ruptured by the sharp spicule of the bone: this happens most commonly in compound fractures. When the effusion of blood is great, the part swells so much that it is necessary to lay it open, and to secure the divided vessels by a ligature. When the swelling is not great, the absorption of the blood is trusted to nature. When the blood remains long in contact with the fractured bone, it sometimes prevents the formation of callus; the periosteum separates from a considerable portion of the bone, and a thin fluid exudes is discharged at the wound. When this happens, no cure can be expected till the parts of the bone deprived of peritoneum have exfoliated, or have been separated by a law.

Sect. II. Fractures of the Bones of the Face.

Fractures of the nose may impede respiration, affect the speech and sense of smelling, give rise to polypi and tedious ulcers, and may besides be dangerous from their vicinity to the brain. When any part of the bones of the nose has been raised above the rest, it is to be pressed into its place with the fingers; if it has been pushed into the nostril, it is to be raised with the end of a spatula or other similar instrument. If any portion be almost entirely separated from the rest, it should be removed; but if it adheres with considerable firmness, it is to be replaced. If the bones, after being replaced, do not remain in their proper situation, they are to be retained either by tubes introduced into the nostrils, or by a double-headed roller, with proper compresses as the case may require. Inflammation should be prevented by the proper remedies.

Much care is necessary in replacing the fractured bones of the face, and in dressing them, in order to prevent deformity. The dressings may be retained by adhesive plasters. Inflammation, by which the eyes, nose, or antrum maxillare is apt to be injured, should be prevented. When matter collects in the antrum, it is to be removed by the methods formerly described.

For replacing fractures of the lower jaw, the patient should be seated in a proper light, with his head firmly fixed. The surgeon should press with one hand on the inside of the bone, while with the other he grasps against inequalities on the outside. If a tooth come in the way, it should be extracted; when any of the others are forced out of their sockets, they should be replaced, and tied to the neighbouring teeth till they become firm. The fractured parts being kept firm by an assistant, a thick compress of linen or cotton should be laid over the chin, and made to extend from ear to ear over it; a four-headed roller should be applied firm enough to keep the fractured parts in contact. The patient should be kept quiet during the cure, and fed upon spoon-meat. The dressings should be removed as seldom as possible. When the fracture is accompanied with an external wound, the parts should be supported by an assistant during the dressing of it.

Sect. III. Fractures of the Clavicles, Ribs, Sternum, and Spine.

A fracture of the clavicle is easily discovered by the grating noise in the fractured bone upon moving the arm freely, by the ends of the bone yielding to pressure, and by the motion of the humerus being impeded. All that can be done is to raise the arm, and support it at a proper height, either by a sling, or, which is better, by the leather case recommended in case of luxation of this bone. By this the fractured parts will be brought together, so far at least as to prevent deformity, and render the bone sufficiently strong.

Fractures of the ribs are discovered by pressures with the fingers. The symptoms are commonly moderate, and the patient soon gets well. In some cases, however, the pain is severe, the breathing becomes difficult, attended with cough, and perhaps with spitting of blood, and the pulse is quick, full, and sometimes oppressed. These symptoms arise from the ribs being bent on the lungs.

In the treatment, it is proper in every case to discharge some blood. If one end of the rib rises, it ought to be repressed by moderate pressure; and to prevent its rising again, a broad leather belt should be applied pretty tight, and continued inwards, an opening should be made over it with a scalpel, and then it should be elevated with the fingers or a forceps. When distressing symptoms proceed from air or blood collected in the cavity of the chest, these fluids ought to be discharged by an operation.

The symptoms of a fractured sternum are nearly the same with those of the ribs. It requires great attention from the vicinity of the heart and large blood-vessels. The patient ought to lose a quantity of blood, and be kept on an antiphlogistic regimen. If the pain, cough, and oppressed breathing, do not yield to these remedies, an incision should be made... Fracture of the humerus is easily discovered by the pain, the immobility of the arm, and by the touch. The parts may be replaced with greater ease if the muscles connected with them be relaxed. They are retained with difficulty. A long roller should be employed for this purpose, with which the head and shoulders are also to be supported. The arm should also be suspended to relax the muscles as much as possible, and inflammation particularly guarded against by local bloodings.

Fractures of the humerus are easily discovered by the pain, the immobility of the arm, and a grating noise on handling the parts. In reducing the fracture, the muscles should be completely relaxed by bending the arm and raising it to a horizontal posture. Extension, if necessary, may be made by one assistant grasping the arm between the fracture and the shoulder, another between the fracture and the elbow. After the reduction, one splint covered with flannel should be laid along the whole outside, and another along the whole inside of the arm; and then a flannel roller applied sufficiently tight to support the parts without interrupting the circulation. The arm may either be supported in a sling or Mr Park's leather case (fig. 104). The bandages should not be removed for several days, unless some urgent symptoms render it necessary. In about a week, however, the arm should be examined to see whether the bones have been properly set.

When both of the bones of the fore-arm are broken, the fracture is easily discovered; but when only one bone is fractured, especially if it be the radius, the firmness of the other renders the discovery more difficult; the grating noise, however, on moving the bone in different directions, will generally be a sufficient symptom that a fracture has taken place. When the fracture happens near the wrist, particular attention is necessary in order to prevent a stiff joint. In order to replace the parts, the muscles are to be relaxed by bending the joints of the elbow and wrist, and the limb extended a little above and below the fracture. After reduction, a splint reaching from the elbow to the ends of the fingers is to be applied along the radius, and another along the ulna; and both are to be secured with a roller or twelve-tailed bandage. When the splints are applied, the palms should be turned towards the breast as the most convenient posture. The arm should be hung in a sling. A partial dislocation of the bones of the wrist sometimes attends a fracture of the radius, by which a stiff joint, under the best practice, is apt to ensue, or permanent painful swellings of the fore arm. In such cases, the patient ought to be warned of the danger, that no blame may be afterwards incurred.

When the olecranon is fractured, the arm must be kept in an extended state during the cure, by applying a splint opposite to the joint of the elbow, reaching from the middle of the humerus to the points of the fingers. The arm should be hung by the patient's side, to which it should be fixed by means of straps. To prevent the consequences of a stiff joint, the dressings should be removed about the eighth or tenth day, the fore-arm for some time slowly moved backwards and forwards, and the joint rubbed with an emollient oil. By a repetition of this at proper intervals, a stiff joint may be prevented.

Anhydrosis, or stiffness of the joint, commonly succeeds fractures of the bones of the wrist, owing to the great increase of the inflammation which ensues, and to their not readily uniting from their smallness. To prevent this as much as possible, after replacing the bones, the injured parts should be leeched freely, and in proportion to the violence of the symptoms. Splints should be applied exactly as in fractures of the fore-arm, and the arm supported by a sling.

In fractures of the metacarpal bones, a firm splint should be applied over the whole palm and inside of the arm, from the points of the fingers to the elbow, in order to prevent the action of the flexors of the fingers. The best splint for a fractured finger is a piece of firm pasteboard properly fitted and softened in water till it can be readily moulded into the form of the part. This should be applied along the whole length of the finger, and secured with a narrow roller. At the same time, a large roller should be applied over the inside of the hand to prevent the parts from being moved. To prevent dislocation, the dressings should be removed about the end of the second week, and the joint cautiously bent; and this should be repeated daily till the cure be completed.

Fractures of the body of the thigh bone are readily discovered by the grating noise when the ends of the bone are forcibly rubbed together, by the shortness of the limb if the fracture be oblique, and by the limb being unable to sustain the body. But fractures of the neck of the bone are often not easily distinguished from dislocation of the joint. In general they may be distinguished by the circumstances mentioned in treating luxations of this bone. In forming a prognosis, we ought to consider that no fractures are more apt to disappoint our expectations than those of the thigh, especially when the neck of the bone is broken, owing to the difficulty of discovering the place of the fracture, and of retaining the bones even after they have been replaced. In order to reduce fracture of the thigh, the muscles are to be relaxed by moderately bending the joints of the thigh and knee; when this is done, unless there be much pain and tension, the bones are easily replaced by one assistant holding the upper part of the thigh, while another supports and gently pulls down its lower extremity, while the surgeon is employed in adjusting the fractured pieces. It is more difficult to reduce fractures of the neck of the bone, on account of the great strength and various directions of the surrounding muscles. In general, however, we shall succeed by moderate extension, if we take care previously to relax all the muscles as much as possible; if we do not succeed, we must have recourse to machinery.

The greatest difficulty is to retain the bones in their situation after they are replaced. The limb must be firmly secured by splints made of thin slips of wood glued to leather (fig. 105, a and b), or of thick pasteboard. One splint, broad enough to cover half of the thigh, should reach from the top of the hip joint to a little below the knee, and another, covering about a third part of the thigh, from the groin to a little below the knee. The splints should be lined with flannel. They are to be secured by a twelve-tailed bandage, and over all a thin pillow should be put nearly as long as Fracture of the thigh. The splints and bandages may be put on in the following manner: The patient being placed on a firm hair mattress, with his knee moderately bent, the long splint bandage and pillow are to be applied to the outside of the thigh, and the patient should be turned somewhat towards the affected side, with the knee and leg raised a little higher than the body; the short splint should then be applied along the inside of the thigh, and the bandage already placed without the other splint, applied so tight as to make an equal moderate pressure over the whole: (See fig. 106.) To make the part still more secure, it is proper to insert a long firm splint of timber under the middle of the pillow, and to fix it by two broad straps to the upper part of the limb. To prevent the limb from being affected by involuntary startings, the pillow should be fixed to the bed by straps: to keep off the weight of the bed-clothes, a frame with hoops should be placed over the thigh. The parts should be examined after some time to see that the bones be not displaced. When there is pain, swelling, and inflammation, leeches and other remedies should be applied. To render the situation of the patient as easy as possible during the cure, he may be allowed after the second week to turn a little more towards his back, and at the same time to extend the joint of the knee in a small degree: after this time a little flexion and extension of the limb may be daily repeated to preserve the use of the joint.

The method here described generally succeeds. Sometimes, however, notwithstanding all our care, the ends of the bone slip over each other. To prevent the deformity which this occasions, it has been attempted to make extension and counter-extension by machines: but the pain and irritation have always been so great that little advantage has yet been derived from such means. The invention (fig. 107.) of the late Mr Gooch of Norwich, improved by the late Dr Aitken of Edinburgh, has been recommended as one of the best machines for oblique fractures of the thigh. After endeavouring to remove the pain, swelling, and inflammation, which are sometimes so great as to preclude the application of the simple bandage, this machine may be tried. But if it be found impracticable to use it, the cure must be conducted in the usual way with the chance of the fractured pieces overlapping one another, and of course the limb being somewhat shortened.

The patella is most frequently fractured transversely, sometimes lengthwise, and sometimes into several pieces. Fractures of this bone have been laid commonly to end in a stiff joint; but this is perhaps most frequently owing to the limb being kept too long in an extended posture. In the treatment of fractures of this bone, the leg should be extended to relax as much as possible the soft parts connected with the bone. The patient should be placed on a firm mattress, and a splint be placed under the limb long enough to reach from the top of the thigh to the under end of the leg, to which the limb should be fixed by a number of straps to keep it in a state of extension. The fractured bones are then to be brought together, and such a number of leeches applied to the joint as will remove as much blood as the patient can bear; and as long as much pain and tension continue, saturnine and other astringents are to be used for removing them. When this is accomplished, and the parts properly adjusted, a large pledget of Goulard's cerate should be laid over the joint, and a hooped frame employed to keep off the bed-clothes. In a longitudinal fracture the parts are easily kept together by a common uniting bandage or adhesive plaster; but in transverse fractures more force is necessary. Various bandages have been employed for drawing the pieces together in such fractures; one of the best of these is that represented fig. 108. We need not be anxious, however, about bringing the pieces very close together, as a cure may be made though they remain at a considerable distance. The bandages, unless particular symptoms occur, should not be removed till the end of the second week; after which the joint should be cautiously bent every second day to prevent stiffness.

The leg is commonly fractured near the lower end, this being the weakest part of the bones. In the treatment of a fractured leg the same rules apply which were given for a fractured thigh-bone. The muscles should be relaxed by bending the knee; but little advantage can be derived from bending the foot, for in proportion as the muscles behind are relaxed those before are put on the stretch: the patient may be therefore allowed to keep the foot in the easiest posture. The bones are commonly replaced by the gentle extension of the upper part of the limb by an assistant, while another supports it at the ankle. The bones being replaced, and the limb laid on its outside with the knee bent, two splints (fig. 109.) are to be applied, long enough to reach from the upper part of the knee to the edge of the sole, so as to prevent the motion both of the knee and ankle. The splints are to be retained by a twelve-tailed bandage, as in the case of fractured thigh bone. See fig. 106.

If the patient be either very restless or troubled with spasmodic affections of the muscles of the leg, an additional splint, shaped to the form of the leg, should be applied along the outside of it, and fixed by a strap at the upper, and another at the under part of the leg. When the patient cannot rest when lying on either side, he may be placed on his back, and the curved state of the knees still preserved by raising the leg a little above the level of the body on a frame made for the purpose. This variety of posture may likewise be used in fractures of the thigh. The patient may from the first be laid in this posture, or he may alternately change from the one to the other. No change of posture, however, should be allowed for the first ten or twelve days. When the tibia only is fractured, it is apt to be considered as a sprain of some of the muscles; but this ought to be particularly attended to, as the mistake may be followed by bad consequences. When both the bones of the leg are broken, the portion next the foot is commonly drawn towards the back part of the leg, so that a prominence is produced by the fractured part of the upper portion of the bone; and this is improperly termed the rising end of the fractured bone. The appearance is entirely produced by the inferior portion falling back. Hence no advantage is derived from pressure being made on the upper end of the bone: the inferior portion should be raised so as to bring the parts into contact, and then by proper bandages they ought to be supported till they are perfectly united.

Fractures of the bones of the foot and toes are treated nearly in the same manner as fractures of the hand and fingers. Besides the splint which may be necessary for the particular part, a large one should be applied over the sole; nor should any motion be allowed for a considerable time either in the foot or ankle, otherwise the bones may be displaced, and a proper cure prevented.

Sect. VI. Of Compound Fractures.

By compound fracture is now generally meant a fracture whether of a bone communicating with an external wound in the integuments. They are much more dangerous than simple fractures. The generality of authors have considered amputation as indispensible in cases of compound fractures; while a few, particularly Mr Bilguer, surgeon-general to the armies of the late king of Prussia, affirm that it is scarcely ever necessary. Both seem to have carried matters too far. Some of the latest and best surgeons have recom- Compounds mended never to amputate immediately in private practice, unless when the bones are so much shattered that they cannot reunite, or the texture of the soft parts completely destroyed; because, even if amputation be at last necessary, the patient will have a greater chance of recovering than if it had been performed immediately after the accident; for the state of weakness to which he is generally reduced renders the attendant symptoms less violent. On the other hand, it has been considered as no bad rule in the army or navy, where patients cannot be kept in a proper situation, and where sufficient attention cannot be given, to amputate immediately in cases of compound fractures of the large bones of the extremities. When amputation is not performed immediately, it is not, for several days at least, admissible. It may afterwards be rendered necessary by hemorrhages, which cannot be stopped but by means more dangerous than amputation itself; by extensive mortification; or by the ends of the fractured bones remaining long disunited, while a great discharge of matter endangers the patient's life.

In treating compound fractures, all extraneous bodies should be removed, as also all those small pieces of bone which will probably not unite with the rest. For this purpose the opening, if necessary, should be enlarged with a scalpel. The next step is to replace the bones by relaxing the muscles as in simple fractures. Sometimes part of a bone projects so far through the integuments that it cannot be replaced without either sawing off the end of it, or enlarging the wound. If the fractured bone be long, sharp, and projecting much, it is best to saw it off; for though it were reduced, it would not readily reunite, and it would be apt to excite much pain and inflammation. But if it be broad at the base, and of no great length, it ought certainly to be sawed, even though it cannot be reduced without enlarging the wound. For the most part, it is only the skin which it is necessary to cut; but even the muscles ought to be divided, though as much as possible in the direction of their fibres, when the bone cannot otherwise be replaced. After the reduction, a pledget of some emollient ointment is to be laid over the wound, and the limb placed on a firm splint, and still kept in a relaxed posture. In dressing the wound, the limb ought not to be moved; the many-tailed bandage, therefore, should be used rather than a roller. Various contrivances have been fallen upon to allow the limb to be at rest while the surgeon is dressing it. The fracture box, invented by the late Mr Rae surgeon in Edinburgh, is one of the best. When the leg is laid on this, it may be dressed with tolerable facility without moving it. We are happy to have it in our power to announce to the gentlemen of the medical faculty, that another machine has lately been invented by Mr Samuel James surgeon in Hoddesden, Herts, which, we are told, will effectually relax the muscles, and retain the bones in their natural situation, without pain to the patient or the least inconvenience to the operator. See fig. 110.

It is of the greatest importance to prevent inflammation, which is apt either to produce mortification, or to give rise to extensive abscesses. The dressings should be removed once or twice daily according to the quantity of matter. The common application of warm poultices, on account of their inconvenience, may be deferred till they become necessary by the approach of inflammation, which they are to be considered as the surest means of preventing by exciting a discharge of matter. Whenever the inflammation subsides, and a free discharge of pus is produced, the poultices ought to be laid aside, lest they do harm by relaxing the parts too much, and exciting too copious a discharge. Therefore ought then to be dressed with mild astringents, and the patient kept on a nourishing diet with tonic medicines. A free passage should be given to the matter by putting the limb in a favourable posture, and by making a counter opening, if necessary, to the most depending part. But this may be frequently avoided, by covering the sore with soft lint or sponge to absorb the matter. If the discharge becomes excessive, and cannot be lessened by the means above-mentioned, it will be found to proceed from a portion of loose bone which has not been earlier noticed, by the removal of which it may be stopt. If, instead of producing matter, the inflammation terminate in gangrene, the danger is still greater than under the most extensive abscesses. For the treatment of this, the reader is referred to Chap. III. Sect. 2d.

**Chap. XXXIII. Of Distortions.**

Distortions of the bones may arise from external injuries, from diseased constitutions, from a morbid state of the distortion, bones, or a contracted state of the muscles, or both; but the affection is most frequently owing to a weakly, delicate constitution, as in rickets or scrophulous cases.

In the treatment of distortions of the spine, particular attention ought to be paid to the cause of the disorder. If distortion appear to arise from the patient continuing too long in any particular posture, every habit of this kind should be guarded against on the first appearance of the disease. If the patient has turned too much to one side, the reverse of this should be advised. He ought to sleep upon a firm hair mattress, that his body may lie upon an equal surface. He should use an invigorating diet, the cold bath, bark, and other tonics. By a strict attention to the use of these remedies the disease has sometimes been retarded in its progress. Various machines have been invented for removing distortions of the spine by pressure; but considerable caution is here required, otherwise much injury may arise from it. Some advantage, however, in certain cases, has been derived from the use of the common collar (fig. 111); or the stays and machinery adapted to them (fig. 112), invented in France, and afterwards brought into use in this country by Mr Jones of London, are found to be still better suited to this purpose.

The same causes which produce distortions of the spine may likewise produce distortions of the limbs. Sometimes limbs, the distortion takes place with the original formation of the bones, at other times it occurs in infancy, and now and then at a more advanced period of life. In early infancy the bones are so pliable as to be readily affected by the postures of the body. When a child is too soon allowed to attempt to walk, its legs are apt to become crooked from their inability to support the weight of the body. Certain diseases like rickets, soften the bones so much, that they yield to the posture of the body, and to the common action of their muscles.

When the distortion of a limb is owing to a curvature in a bone, if the case be recent, and especially if it occur in childhood, it may frequently be removed, without much difficulty, by making a gradual but constant pressure, by the use of machinery, on the convex side of the limb, till it recover its natural appearance. When the deformity occurs in the leg, a method has been used, in several instances, which is to fix a firm splint of iron, lined with leather in the shoe, on the concave side of the leg; the other end of the splint to rest against the under end of the thigh; when, if a broad strap or two be applied round the leg and splint, an easy gradual pressure may be made, and considerable advantage derived from it. See fig. 113.

Along with the curvature above mentioned, it commonly happens that the feet and ankles are affected. When the bones of the leg are bent outward, the fore part of the foot is turned inward, and the inner edge upwards; and the reverse, if the leg be bent inward. In these cases the affecti... tions of the feet are generally owing to the curvature of the bones of the leg. By removing the curvature of these, the foot will commonly regain its natural situation, and the splint above mentioned will for the most part be sufficient for the purpose. But in cases where the sole of the foot is turned much out of its natural direction, it may be necessary to fix the splint and shoe to a frame (fig. 114.), which will render the cure still more effectual.

Besides the instrument already mentioned, some have used a kind of boot, cut lengthwise, made of hardened leather or of metal, &c., which may in some cases sufficiently answer the purpose.

In cases of club foot, where the distortion is in the middle of the foot, a pair of shoes, such as are represented in fig. 115: have been found useful. After the feet are fixed in the shoes, the fore part of the feet may be separated by means of a screw in two plates, which are fixed to the sole.

**Chap. XXXIV. Of Amputation.**

**Sect. I. Of Amputation in general.**

In amputation, which in surgery signifies cutting off a limb, the great end to be aimed at is, the procuring of a handsome stump, in which the bone may not protrude, but be well covered with flesh; so that no excoriation or rawness may be apt to take place. As long ago as the year 1679, it was proposed by Jacob Young, an English surgeon, in a treatise entitled *Curus Triumphalis ex Terribilium*, to prefer a flap of flesh and skin, which was to be folded over the bone, and which, uniting to the parts of the wound after amputation, would effectually cover the bone, and prevent the inconveniences above mentioned. No traces of the success of this method, however, can be found till the year 1696; when a Latin dissertation was published upon it by P. Adrians Verduin, an eminent surgeon in Amsterdam. The most sanguine expectations were formed of its success; and it was even thought that the flap would prevent the necessity of tying up the blood-vessels. However, it does not appear that the method, as at that time practised either did or could succeed; and accordingly it was entirely laid aside; but it has been lately revived with considerable improvements.

Amputation may also be sometimes necessary when a member is so much diseased as to be useless, or when it puts life in danger.

The causes in general rendering this operation necessary are, bad compound fractures; extensive lacerated and contused wounds; part of the limb being carried off by a cannon ball or otherwise, the bones being unequally broken and not properly covered; extensive mortification; white swellings of the joints; large exostoses; ulcers attended with extensive caries; cancer or other incurable ulcers; varicose kinds of tumors; particular distortions of the bones.

Amputation may also be sometimes necessary from violent hemorrhages of some principal artery during the cure of a fractured limb, or from such a profuse discharge of matter taking place that the strength of the patient is exhausted. Lacerated and contused wounds may require amputation, on account of hemorrhage ensuing which cannot be stopped. Extensive mortification may take place, and such large quantities of matter be formed, that the patient will be unable to bear up under the discharge.

Where part of the limb is carried off, it is necessary to amputate higher up, so as to cut the bone, as well as the soft parts, in such a manner as may admit of a much speedier and safer cure. When mortification occurs, every thing ought to be done for the support of the patient till the disease be stopped; the first sign of which is, the appearance of an inflamed circle between the diseased and sound parts. As soon as the diseased begin to separate from the sound parts, amputation of the limb ought to be performed, and no time ought now to be lost, lest the patient suffer from the absorption of putrefactive matter.

No part of surgery is brought to greater perfection than the manner of performing amputation. Before the invention of the tourniquet, and the method of securing the vessels by ligature, the operation was seldom undertaken; and a great proportion of those upon whom it was performed died soon after. In the present improved method, one death does not happen in twenty, or even thirty cases. In performing the operation, particular attention is to be paid to the spot where the incision is to be made; the quantity of skin and cellular substance necessary to be saved, so as to cover the muscles and bone completely, without being stretched; cutting the muscles in such a manner that they may unite with each other and entirely cover the end of the bone; the prevention of hemorrhages during the operation; the tying of the arteries alone, without including the nerves or any of the contiguous parts; securing the integuments so as to prevent them from retracting after the operation; and a proper subsequent treatment of the case.

The following are the general steps of the operation:

The patient being properly placed, with assistants to attend, and the apparatus in proper order, the flow of the blood to the limb is to be stopped by the tourniquet (fig. 16.). The first incision is to be made through the skin and cellular substance by one, or rather by two, strokes of the amputating knife represented in fig. 116. These are next to be separated from the muscles, as far as may appear sufficient for covering the stump. The separated skin or flap should be strongly drawn up, or what perhaps answers better, turned up all round the limb, leaving this part of the muscles quite bare. The flap is to be kept in this situation by an assistant, while the operator makes the next incision at the edge of the reflected skin, and cuts till he comes to the bone. This incision should be begun on the lower side of the limb, that the blood may not prevent the eye from readily following the edge of the knife during the whole cut. The muscles are now to be separated from the bone as high as may enable them afterwards completely to cover it. The foot parts in general are then to be drawn up by retractors, which may be either of leather, as in fig. 117. or metal, as in fig. 118 a and b. The periosteum is to be divided at the place where the saw is to be applied; but no part of the bone is to be denuded of this membrane, which is afterwards to cover the stump, otherwise troublesome exfoliations may ensue. At this place the saw (fig. 119.) is to be applied, and the bone divided with long steady strokes. In this part of the operation a good deal depends upon the steadiness of the assistant who holds the limb; for if it be held too high, the motion of the saw will be impeded; while the bone may be splintered if it be not sufficiently raised. Any points or splinters which may be left should be immediately removed with the pincers (fig. 120.). The retractors are now to be laid aside, and the principal arteries separated from the nerves, and secured by the tenaculum (fig. 17.), or forceps (fig. 120. a), and ligatures.

The tourniquet should next be a little slackened, to allow the different branches to be discovered; the clotted blood is to be cleared away with a warm sponge. The patient should get some warm cordial drink, and all the arterial branches which can be discovered ought to be taken up. The ends of the ligatures are then to be cut off such a length as to allow them to hang without the lips of the wound. The muscles and skin are now to be drawn down, and brought into Sect. II. Of Amputating the Arm and Fore-arm.

Amputation of the arm is performed according to the rules already laid down. No more of it should be removed than is desirable; for the longer the stump is, the more useful it proves. The tourniquet is to be applied a little above the part where the operation is to be performed: As much of the integuments should be saved as may be perfectly sufficient for covering the fore. In taking up the artery, after the bone has been divided, the operator ought to be attentive not to include the radial nerve, which may be readily discovered and separated, as it lies close upon the fore part of the artery. The fore arm is to be amputated nearly in the same manner as the leg; only that the stump may be covered by amputating with the double incision, without the assistance of a flap, which it is necessary to form in the leg.

Sect. III. Of Amputating the Thigh.

In performing this operation, the patient ought to be placed upon a table of ordinary height, with the diseased limb supported and secured by an assistant seated before him, while other assistants take care of the other leg and the arms. The course of the blood is to be stopped by applying the tourniquet over the trunk of the femoral artery, near the upper part of the thigh. No more of the thigh ought to be removed than is rendered necessary by the disease, as the more of it is left, the more useful it will be to the patient. An assistant should grasp the limb with both hands a little above the place where the skin is to be divided, and draw it up as far as possible; while the operator, standing on the outside of the limb, makes a circular incision down to the muscles by one or two strokes of the knife. As much of the integuments is then to be dissected with a scalpel from the muscles as may cover the stump completely; and this part of the skin may either be turned back, or drawn tightly up by an assistant. The muscles may then be divided quite across to the bone by the edge of the skin, in the common way, or cut obliquely upwards, according to the method of Allanon, so as to lay the bone bare two or three fingers-breadth higher than is done in the common way. The muscles are next to be separated from the bone with a scalpel a little way, that a sufficient quantity may be left for covering the end of it. The rest of the operation is to be performed exactly according to the general rules laid down in the first section of this chapter. The muscles and integuments are to be drawn over the end of the bone, and applied closely together, that the skin may completely cover the stump, and retained in this situation by an assistant till a flannel or cotton roller, according to the season of the year, which has been previously fixed round the body, be applied in such a manner as to support and fix them. For which purpose it should be passed two or three times, in a circular direction, round the top of the thigh, and should afterwards, with spiral turns, be brought down near to the end of the stump and fastened with pins; and it should not be tighter than may be sufficient to assist the plasters in preventing retraction.

The ends of the divided muscles are now to be laid exactly over the bone; and the edges of the skin are to be brought into contact, either so as to form a straight longitudinal line, according to the method of Mr. B. Dell, &c., or they are to be placed horizontally, "that the wound may appear only in a line with the angles at each side," as advised by Allanon. The ligatures may either hang over the edges of the wound, or be brought to the angles. After the edges of the skin are in this manner exactly applied to each other, either a few slips of adhesive plaster are to be laid across the face of the stump, or two large pieces of adhesive plaster, with several pieces of tape fixed to them, are to be applied to the surface of the skin. The tapes are then to be tied with a running knot immediately over the wound; by which the parts will be kept so closely together as to prevent any collection of matter from being formed. The whole surface of the stump should next be covered with a large pledget spread with an emollient ointment, over which a compress of fine tow is to be put, and retained in its place by a broad cross strap of old linen, passing some way up the thigh, so as to be secured by the roller, which is now to be passed two or three times round the stump; and the pressure formed by the cross strap may afterwards be increased or diminished at pleasure, by drawing it with more or less tightness, and fixing it with pins to the roller. While the stump is dressing, the tourniquet is removed, but replaced again looately to enable the attendants to check any hemorrhage which may afterwards ensue.

The patient is now to be laid to rest, and the limb is to be placed upon a little tow covered with linen, or upon a thin foot pillow; and to prevent the patient from involuntarily moving the limb, and to guard against spasmodic startings, which frequently happen after this operation, it may be fixed to the bed by two straps. A basket or hooped frame ought to be placed over the stump to protect it from the bed-clothes. The patient should immediately get an antidyne draught, which will generally procure ease through the rest of the day. For this purpose, no more light should be let into the room than is merely necessary for allowing the attendants to pay attention to the stump. As hemorrhages sometimes appear several hours after the operation, the person who takes the charge of the patient should watch this circumstance with the greatest attention. If there be only a slight coozing of blood, there is no occasion for being alarmed; but whenever it appears to proceed from a large artery, it must be secured. The spasmodic affections which frequently occur after amputation are seldom troublesome, unless some nerve has been included in securing the arteries; but when they do appear, laying the limb in the easiest posture, and giving opiates, are the principal means of procuring relief.

To prevent inflammation as much as possible, the patient is to be kept upon a strict antiphlogistic regimen, and his bowels kept open by laxative clysters, till the inflammatory stage is over, which will generally be in a few days. If notwithstanding this treatment, the stump swells, and the patient complains of pain and tightness, we ought to endeavour to discover from what cause the uneasiness originates. If it be owing to the straps being too tightly fixed, they must be slackened. If the stump be found much swollen, a satyrine solution should be applied by means of several folds of linen; and if the patient be young and plethoric, he ought to lose a few ounces of blood from the arm; but if he is weak and emaciated, a different mode of treatment must be followed.

At the end of the third, or fourth day at farthest, the stump should be examined; and if it appear somewhat open and flaccid, the parts must be brought closer together and secured more firmly. After this time the dressings should be renewed every day, or every second day. In about a week week after the operation the ligatures may generally be removed with ease; but if they do not separate readily, they may be gently pulled at every dressing, when they will, in a short time, be brought away, and the wound will be soon healed by the first intention. The roller should be cleaned and renewed as often as it is found filled; nor should it be laid entirely aside till the end of the third or fourth week after the operation. When the roller is removed, we may depend upon the straps or tapes for keeping the parts together till the cure be quite accomplished. When the inflammatory symptoms are entirely gone, no medicines ought to be given which would debilitate the patient, nor is any thing more necessary than to keep the bowels gently open till a complete cure be made.

**Sect. IV. Of Amputating the Leg.**

The leg may be amputated for a disease in the foot at two different parts; the one a hand-breadth under the knee, the other a little above the ankle. The former makes a sufficient support for the body to rest upon an artificial leg; but the latter does that equally well, and likewise preserves the motions of the knee.

In performing the operation a little way under the knee, the patient is to be placed and secured in the same manner as in operating upon the thigh. The tourniquet is to be placed a little above the knee, with the cushion upon the artery in the ham. The surgeon places himself upon the inside of the leg, and makes a circular incision through the integuments down to the muscles. The place where the incision should be made must depend upon the length of the limb; but in general it may be between five and seven inches under the top of the tibia in an adult, or far enough down upon the limb to save as much integuments as will cover the stump. After the integuments are cut through in the manner already directed, as much of the muscles are to be divided by the knife as can be done by a circular incision; and the interosseous parts are to be divided by a scalpel or catline, (fig. 121.). The retractors are then to be applied, and the bone sawed off immediately below the insertion of the tendons of the flexor muscles. In sawing, the operator ought to begin upon both bones at the same time, that he may finish upon the tibia, lest splinters should be formed. The vessels are next to be secured; the soft parts drawn over the bones; the adhesive plasters and other bandages applied in the same manner as directed for amputating the thigh, only that here the roller need not be applied so high as in the former operation. Two or three turns above the knee, however, are necessary to prevent the dressings from slipping down.

In amputating upon the ankle, the operator should fix upon that spot which will leave the stump of such a length as may be most convenient for being fitted with an artificial machine resembling the other leg. Nine inches from the joint of the knee, in a leg of ordinary length, was found by Mr Wilson, a late ingenious artificial limb-maker in Edinburgh, to be the best part suited to this purpose, on account of the equal pressure it makes upon the surface of the leg, without making any upon the end of the tender stump. The operation is performed in the same manner as that a little below the knee.

**Sect. V. Of Amputating at the Joints of the Extremities.**

The circumstances most to be attended to in performing amputation at the joints are, first to stop the circulation by the tourniquet; or, where that is impracticable, to take up the trunk of the artery by a ligature; to make a circular incision in such a place as may, after the operation is over, be sufficient to cover the wound: Then a longitudinal incision is to be made upon the opposite sides of the limb, extending from the joint to the circular cut, and as deep as the bone, by which two flaps will be formed to cover that part of the joint which remains after the operation is finished. The ligaments of the joint are next to be divided, and the affected limb or part of the limb removed.

After this part of the operation, it was formerly a frequent practice to scrape off the remaining cartilage, to unite the parts more firmly together. But this is now found to be unnecessary; for when the flesh is applied properly to the bone, if it do not grow to it, the union at least is so close that it afterwards gives no inconvenience to the patient.

Any branches of arteries which may have been cut during the operation are now to be secured; clotted blood is to be removed; and the muscles and skin are to be brought into close contact with the ends of the ligatures hanging out of the wound. The parts are to be retained by adhesive plasters, or twisted sutures, or both; and proper bandages applied in such a way that a cure may be made by the first intention.

Amputating the arm at the shoulder-joint has always been considered as a dangerous as well as a difficult operation. It should never be attempted, when the same purpose can be accomplished by operating lower down. But cases occasionally occur, where the life of the patient cannot, in any other manner, be saved.

Amputation may become necessary here in consequence of abscesses of the joint; caries of the humerus reaching to the joint; compound fractures, especially those from gunshot wounds, extending to the head of the bone; and of mortification.

In performing the operation, the patient should be laid upon a table of convenient height, covered with a mattress. He is then to be brought as near to the edge of it as possible, and secured by assistants. The circulation of the blood in the arm is next to be stopped, by an assistant pressing strongly with a firm compress over the subclavian artery where it passes over the first rib; or an incision may be made along the course of the artery, which may be secured after separating from the contiguous nerves. When the artery is compressed, it will readily be known whether the compression proves effectual, by observing when the pulse at the wrist is entirely flopped. As soon as this is the case, a circular incision is to be made through the integuments at the insertion of the deltoid muscle into the humerus. An assistant then draws the skin a little back, and at the edge of the retracted skin the muscles are to be cut in a circular direction to the bone.

If the artery has not been taken up at the beginning of the operation, it is now to be secured, as well as any branches which come in the way.

The amputation-knife is now to be laid aside, and the rest of the operation finished with a strong scalpel. A perpendicular incision is next to be made at a little distance from the outside of the artery, beginning at the acromion, and terminating in the circular incision, cutting as deep as the surface of the bone. A similar incision is to be made upon the back part of the arm, so that the flaps may be nearly of an equal breadth. The arterial branches are here to be secured; the flaps are to be separated from the bone, guarding against wounding the trunk of the artery; the flaps are to be supported by an assistant; and the capsular ligament of the joint is to be cut from the scapula; and thus the arm will be entirely separated.

After the arm has been separated, any arteries which appear about the joint are to be tied, and all the ligatures brought over the edges of the wound. The parts are to be cleared of clotted blood, and the two flaps drawn over the wound, wound, and secured by the twisted suture. A pledget of any emollient should then be applied, and a sufficient cushion of lint, with a compress of old linen, put over the whole. A moderate pressure is next to be applied by a flannel roller; by which the parts will be supported, their union facilitated, and matter most likely prevented from being lodged. The treatment is then the same with that after amputation in other parts of the extremities. For two or three days after the operation, it is necessary that an afflant fit with the patient to compress the artery in case a bleeding should ensue.

When it is necessary to amputate the whole hand, the operation may be performed at the wrist, so as to leave as much of the member as possible; and the same rules hold here as in amputating at any of the rest of the joints. The tourniquet is to be applied to the artery in the arm, and the cure is to be completed by the first intention. When any of the carpal bones are affected, the sore will not heal till they either work out by suppuration, or are cut out by the knife. When the middle of any of the metacarpal bones is diseased, while their extremities are sound, the trepan may be applied, and the diseased parts removed, while the remaining sound parts are preserved. But if the whole bodies or one or two of these bones be affected, while the rest remain sound, all the affected bones ought to be removed. In performing the operation, an incision is to be made along the course of the part affected; and if the operator have it in his choice, the incision should be made upon the back part, so as to save the great vessels and nerves situated in the palm. The integuments are then to be dissected, and turned to each side; after which the diseased bones or parts of bones are to be removed, guarding as much as possible against wounding the principal arteries or nerves which lie near them.

The diseased parts are next to be separated; any arteries which happen to be cut are to be secured; and, on account of the free communication which they have with neighbouring branches, they ought to be tied at both ends. If after this a bleeding still continue, compresses, styptics, and other remedies proper for stopping blood, are immediately to be used. The sides of the wound are to be brought together, and an attempt made to cure them by the first intention.

In amputating the fingers, it was formerly the practice to operate upon the bodies of the bones in the same manner as in the larger extremities; but at present the removal at the joints is more frequently practised.

In performing the operation, it is necessary to save as much skin as may cover the stump, and this ought to be done upon the side next the palm, so as to guard against the effects of friction. The general steps of the operation are the same with those for amputation of the larger joints.

A circular incision is to be made on the finger by a crooked bistoury, about the middle of the phalanx, and it may be carried at once to the bone. Another incision is to be made with a common scalpel at each side of the finger, beginning at the circular one and continuing it to the joint, by which two flaps will be left to cover the stump. The ligaments of the joint are now to be divided, and the bone removed. The blood-vessels are to be secured by ligature, and the flaps exactly applied to each other; but in order to protect the end of the bone completely, a small portion may be cut from the uppermost flap. The flaps are to be retained by adhesive plaster, or by the twisted suture; but if the latter be used, the tendons ought to be avoided. Over the sore an emollient pledget is to be applied, and then a compress and roller. If the disease be so situated, that instead of amputating at the cavity of the joint, the surgeon shall think proper to operate upon the body of the bone, flaps are to be formed as above, and the bone is to be divided by means of a small spring saw, fig. 122.

The amputation of the thigh, at the hip joint, has always been considered as one of the most formidable operations in surgery; so much so, that very few cases appear on record of its having ever been put in practice. In the Medical Commentaries of Edinburgh, an instance is recorded where the thigh was amputated at this joint, and where the patient survived the operation 18 days, and then died from a different cause, when all risk of haemorrhage was over, and when the sore had even a favourable appearance, which shows at least that the operation has been done with safety. It certainly ought never to be done, however, unless as the last resource, and when the life of the patient is in absolute danger; and then only when as much skin and muscles can be saved as will cover the sore, and when there is also a probability of being able to stop the hemorrhage, and prevent it from returning.

When the operation is to be performed, the patient is to be laid upon his back on a table, and properly secured by assistants; one of whom should be ready with a firm cushion to press, if necessary, upon the top of the femoral artery, just after it passes from behind Poupart's ligament to the thigh. A longitudinal incision is now to be made through the skin, beginning immediately under the ligament, and continuing it downwards along the course of the artery for about six or seven inches. The aponeurosis of the thigh is then to be divided by gentle scratches till a furrowed probe can be introduced, when the opening is to be dilated by means of a scalpel, till two or three inches of the artery be laid bare. A strong ligature is now to be put under the artery by the assistance of a curved blunt-pointed needle.

The part where the ligature should be passed is immediately above the origin of the arteria profunda; for if that artery be not affected by the ligature, the patient might suffer by the loss of blood during the rest of the operation. The ligature is now to be secured by a running-knot: Another ligature is to be introduced a little below the former, and likewise secured; the artery is then to be divided between the ligatures. A circular incision is now to be made through the integuments of the thigh, about six inches from its upper end. The retracted skin is then to be pulled at least an inch upwards; and at the edges of it the amputating knife is to be applied, so as to cut the muscles down to the bone. This being done, a cut is to be made upon the posterior part of the thigh, beginning a little higher than the great trochanter, and continuing it down to the circular incision, and as deep as the joint. A similar cut is to be made on the anterior part of the thigh, at a small distance from the artery, and this reaching likewise down to the bone. The two muscular flaps are to be separated from the bone and joint, and held back by an assistant. Every artery which appears is now to be secured. Then the capsular ligament, and next the round one, are to be separated from the acetabulum; by which means the limb will be removed from the body. The acetabulum and neighbouring bone are next to be examined; and if they appear sound, the case will be more favourable; but at any rate, a cure is to be attempted by the first intention. For which purpose, after removing all the clotted blood from the surface of the wound, and bringing the ligatures over the edges of the skin, the muscles are to be placed as nearly as possible in their natural situation; and drawing the flaps together, so as to cover the wound in the most accurate manner, they are to be kept in this situation by adhesive plaster, and Removing by the twisted future and other dressings, as in amputating the Ends of the under part of the thigh. The dressings are to be retained by a broad flannel roller passed three or four times round the body, and spirally over the stump, and secured.

The patient is then to be laid in bed on the sound side, and treated as for amputation in other parts of the body; only that greater attention is necessary, as there is no advantage from a tourniquet. Uncommon attention will also be necessary to prevent inflammation, and every symptom of fever which may succeed to the operation.

When the foot is so much diseased as to require amputation, the operation might be performed at the point of the ankle; but for the reasons given, when treating of amputation of the leg, it is found better to do it above the ankle. When a considerable part remains sound, it ought to be saved. If any of the taral bones are affected, they are to be removed. When the middle or whole body of any of the metatarsal bones are diseased, they are to be removed in the same manner as directed for similar operations in bones of the hand; and if even two of them remain sound, provided they be placed as to support the toes, they ought to be preserved, as it is known that, by proper treatment, an offensive matter may a terwars fill a considerable part, if not the whole, of the void; or if any cavity remain, it may be stuffed that the use of the foot may still be enjoyed.

In performing an operation of this kind, the patient should be laid upon a table, and the tourniquet applied in the ham to prevent hemorrhage. An incision is then to be made along the affected part; and if the seat of the disease admits it, the incision should be made upon the upper side of the foot so as to save the sole. The integuments are to be separated and turned to each side, to allow the affected parts to be completely removed.

The principal vessels and nerves are to be saved as much as possible; but if any particular artery be cut, it is to be secured, and the part treated as after the removal of similar parts of the hand.

The amputation of the toes is exactly similar to that of the fingers.

Sect. V. Of removing the Ends of Carious Bones in the Joints.

In compound fractures, the ends of bones, when they protruded in such a manner that they could not otherwise be returned, have frequently been sawed through; and their place has frequently been supplied by a renewal of bone, so as to preserve the ordinary use of the limb. Many cases have likewise happened, where a large part of the body of the bone has been thrown out by suppuration, and its place supplied; and a few are upon record, where either the whole of a bone, or that end next the joint, has been thrown out, and its place filled up with callus, so that no inconvenience has been felt. From these circumstances, Mr White of Manchester was led to preserve an arm by sawing off the head of a diseased humerus; and Mr Park of Liverpool, to save a limb, by sawing off the ends of the bones, in a case of white swelling of the knee. When therefore it happens that the end of a bone is diseased, while the other parts are sound, the diseased part may be removed, and the sound one saved, so as in a great measure to preserve the free use of the limb.

In performing the operation, the first step should be, to use such means as may enable the operator to have a full management of the circulation of the part affected. Then a longitudinal incision of sufficient length, and perhaps another across it, may be necessary to be made through the soft parts of the joint; and this opening ought to be at a distance from the large blood-vessels, that they may be in no danger of being injured. After the end of the diseased bone is sufficiently laid bare, it is either to be brought out of the joint, or a spatula or some other proper substance is to be introduced between the bone and soft parts, so as to defend the latter in time of sawing the bone. After the diseased part of the bone is removed, the arterial branches are to be secured, and the wound treated like any other wound of equal size.

During the cure the limb ought to be kept in the posture most favourable for the removal of the bone, and afterwards for the preservation of the natural motion of the joint.

In this way a limb may sometimes be saved which would otherwise have been removed. But though the removal of the diseased end of one bone may be readily effected, the removal of all that part of the bones which enters into the composition of a joint must be attended with so much inconvenience, that it can seldom be useless, unless it be where the ends of bones are destroyed by external violence; for then it appears that this operation may be performed with considerable success.

Chap. XXXV. Of Diminishing Pain in Surgical Operations.

The pain induced by surgical operations may be lessened in two different ways. The first is, by diminishing the natural sensibility of the system; and for this purpose narcotics of different kinds, and particularly opium, have been used; but these are apt to induce disagreeable symptoms, especially sickness and vomiting, which might be attended with bad consequences after some operations. They are therefore seldom employed before an operation. When, however, they are given immediately after it, and repeated as circumstances may require, they often give great relief.

The other method of diminishing pain is, by lessening the sensibility of a particular part of the body. It has long been known, that the sensibility of any part may not only be lessened, but entirely suspended, by compressing the nerves which supply it. From a knowledge of this circumstance, an instrument (fig. 123) was invented some years ago by Mr James Moore of London, by which the principal nerves of a member might be so compressed as to render the parts below perfectly insensible. A difficulty, however, arises here; for as the nerves must be compressed at least an hour previous to the operation, in order to render the parts quite insensible, and as it is extremely difficult to compress the nerves without at the same time affecting the veins, the latter are therefore in danger of being burst. To prevent this inconvenience, Mr Moore proposes to open a vein; but this might be attended with bad consequences in weakly constitutions. Besides, it is said, that by compressing the nerves in this manner, although less pain may be felt in the time of the operation, it is proportionally greater after the compression is removed. In certain parts of the body, however, where sufficient compression can be made upon the nerves without acting much upon the veins, it would appear that the method may be practised with advantage; though it has not yet been done, excepting in a few instances.

Chap. XXXVI. Of Bandages.

The proper application of bandages is an object of great importance in surgery: and though dexterity is only to be acquired in this branch by practice, yet a few general rules may be found useful. Bandages are employed for the retention of dressings, for stopping hemorrhagies, for removing Chap. XXXVI.

Bandages moving deformities, and for effecting the union of divided parts. They ought to be formed of such materials as are sufficiently firm, while, at the same time, they give no uneasiness to the parts to which they are applied. They may be composed either of linen, cotton, or flannel. Of late years the two last have been preferred by many for their warmth and elasticity, on which account they are certainly most proper, especially in winter; and likewise in cases where the parts are liable to swelling and inflammation, as in wounds, luxations, and fractures. Besides, they more readily absorb any moisture which may be discharged from the fores.

When first applied, they should be clean, sufficiently strong, and as free of seams as possible. They should be so tightly applied as to answer the purpose for which they are intended, without being in danger of impeding the circulation. They should be applied in such a manner that they may be easily loosed, and the parts examined with as much accuracy as possible; and they should be laid aside as soon as the purpose for which they are intended is accomplished; for when longer continued, they frequently impede the growth of the parts upon which they are applied.

With respect to bandages for particular parts, we shall begin with the head, and then proceed to the trunk and extremities. The couvre-chef of the French, which is a square napkin folded cornerwise, is most frequently used where a bandage is wanted for the head; but a nightcap, having a band to go round the head, and another to tie under the chin, appears to be more suitable for this purpose. For making compression on any particular part of the head, as for stopping bleeding vessels, the radiated bandage may be employed.

For keeping the edges of wounds together, as in cases of longitudinal cuts of the head, or of any other parts, the uniting bandage is usually employed, and is always to be preferred to futures, where it retains the edges of the wound with sufficient exactness. For retaining dressings upon the eyes, several turns of a roller have been used, and it is termed monoculus or binocular according to its being applied to one or both eyes; but the couvre-chef, and the nightcap already mentioned, are less apt to slip, and therefore found more convenient for this purpose.

For fractures of the nose, or wounds there, or on any other part of the face, the uniting bandage answers best. And in cases of fracture of the lower jaw, a four-headed roller is most convenient: the hole in the centre of the roller receives the chin, and assists in preventing the bandage from shifting. The two upper heads are to be carried backwards; and being made to pass each other at the occiput, they are afterwards brought once or twice round the head. The two under heads of the roller being reflected over the chin, are then to be turned upwards and fixed on the upper part of the head.

The bandages necessary for the neck are, the machine already mentioned after the operation of bronchotomy, and one used in cases of wry neck. For every other purpose of bandaging a common roller may answer perfectly well.

For fractures of the scapula the application of a long roller may be of service.

For retaining dressings upon the thorax the napkin and scapular are commonly, and very properly used; and when the napkin is employed merely for retaining dressings, it need not be longer than to pass once round the body; but it be used for making pressure over a fractured rib, it ought to pass two or three times round. For both purposes its breadth ought to be six or seven inches for an adult.

The same kind of bandages is also used for making pref-

Vol. XVIII, Part I. Method of contained in these cavities, under one view, an incision is to be made on each side of the sternum, in the course of the cartilages of the ribs which are annexed to it; dissecting from thence the muscles with the teguments, the space of two or three inches towards the spine; then cutting through the cartilages, which will be seen, and easily divided with a knife a little curved near the point; then the incisions are to be continued from the sternum through the abdominal cavity, in an oblique direction, to each ilium or inguen; after which the clavicles are to be separated from the sternum, or this bone divided at its superior cartilaginous junction, with a strong knife, dissecting it from the mediastinum, and turning it downwards with the muscles, &c. of the abdomen. This is the most eligible manner of opening these cavities, and gives an opportunity of sewing them up with a better appearance for any person's view afterwards. That kind of itch called by sempitrellas the herring-bone or flat seam has a very pretty and neat effect upon these occasions.

If it is proposed to take out the thoracic and abdominal viscera together, for further examination, the diaphragm is first to be cut down to the spine on both sides; then, to avoid being incommodeed with blood, &c. two very strong ligatures are to be passed round the oesophagus and large blood-vessels, in which the trachea may be included; tying them tight, and then dividing these parts between the ligatures: the same measures are to be taken in respect to the inferior vessels upon the lumbar region, a little above the bifurcation of the aorta, including the vena cava; and also upon the rectum. After having observed these precautions, the viscera, with the diaphragm, are to be removed by a wary dissection, all the way close to the spine; and by gently drawing them at the same time, the separation will be greatly facilitated.

When the thoracic and abdominal viscera are to be taken out separately, in the first case ligatures must be made, as have been described upon the vessels, &c. just above the diaphragm, and in the other just below it, and upon the rectum.

Should we be called upon to perform this office when the body is become very putrid, it will be absolutely necessary to have such parts of it well washed with warm vinegar and brandy, and then sprinkled with lavender-water or some such odoriferous antiputrefactive liquor, before the examination, in order to correct the stench, and defend us against the noxious quality of the effluvia; a precaution, the neglect of which may be attended with very direful effects.

**Chap. XXXVIII. Of Embalming dead Bodies.**

In the early ages of the world, the practice of embalming dead bodies was very common, particularly among the Egyptians; but it has long been diluted in almost all countries, except for great personages. See **Embalming.** The following directions are taken from Mr Gooch, to whom they were communicated by a person of great character, and well acquainted with the modern practice of embalming in this kingdom.

After evicceration, as has been directed in opening a dead body, and continuing the incision farther upwards, even into the mouth, and, if practicable, without cutting the skin of the neck, all the cavities are to be well cleansed, and the humidity sucked up with sponges, then washed with tincture myrrhae, and filled with a species compounded of fragrant herbs, aromatic drugs, and gums reduced to powder not very fine, first restoring the heart to its former residence, after having opened its ventricles, cleansed and washed them with the tincture, stuffed them with the spices, and sewed them up; and then the cavities are to be stitched very close with the glover's or spiral suture. Large and deep incisions are also to be made in all the most fleshy parts, cleaning and washing them with the tincture in the same manner, filling them with the antiseptic spices, and stitching them up. Then the head, trunk, and limbs, are to be perfectly well covered with cerecloth; putting a piece under the chin, to be secured by sewing on the top of the head, after having well adjusted the cap of the skull, sewed the scalp together, and cleaned the mouth, as has been directed for the other parts, and putting in some of the spices. The cerecloth is to be prepared, according to art, with a composition made of wax, rosin, storax, and painter's drying oil. After the application of the cerecloth, with great care and exactness, cut into suitable pieces according to the respective parts, and folding them well everywhere, the face being close shaved, is to be covered with some of the above composition melted, and laid on with a brush of a proper degree of heat, and of a moderate thickness; which may have a faint flesh-colour given it with vermilion; and when it is grown cold and stiff upon this part, it may be lightly covered with hard varnish; or this varnish, applied thick, may here serve the purpose alone. A cap is to be well adapted to the head, falling down upon the neck, and to be sewed under the chin, making a few circular turns about the neck with a roller of a proper breadth. All the rest of the corpse is to be inclosed in a sheet, to be artfully cut, and sewed on very close and smooth, with the finest tape, and the flat seam mentioned in the preceding chapter; over which an appropriate dress is to be put, as the relations or friends think fit to direct and appoint, and then laid into the coffin, which should be in readiness; but when it is some great personage, who is to lie in state for public view before the funeral rites are solemnized, the dress must be appropriated to his dignity and character. The brain and other viscera are to be put with some of the spices into a leaden box. Sometimes the heart, prepared as has been directed, to preserve it from putrefaction, is deposited in an urn by itself.

**Explanation of Plates.**

Plate CCCCLXXXVII. Fig. 1. A lancet and canula for discharging the contents of an abscess by means of a tenon. See n° 53.

Fig. 2. A director for discharging the contents of an abscess. See n° 50.

Fig. 3. An abscess lancet.

Fig. 4. A forceps for extracting polypi. See n° 113.

Fig. 5. A slit probe for conducting a ligature to the root of a polypus. See n° 114.

Fig. 6. A ring for afflicting in securing a ligature upon the root of a polypus. See n° 114.

Fig. 7. A double canula for fixing a ligature upon the root of a polypus. See n° 114.

Fig. 8. The most approved form of a lancet for the operation of blood-letting. See n° 131.

Fig. 9. A jugum cervicis recommended by some practitioners in venesection in the neck. See n° 137.

Fig. 10. A bandage for making compression after performing the operation of arteriotomy at the temples. See n° 145.

Fig. 11. A scarificator with 16 lancets, used in the operation of cupping. See n° 146.

Fig. 12. A cupping-glas. See n° 147.

Fig. 13. A feton needle. See n° 153.

Fig. 14. The common crooked needle used in making sutures. See n° 154.

Fig. 15. a, b, Two pins of different forms used in the twisted twisted or hare-lip future. The first commonly made of silver, with a movable steel point; the other of gold. See n° 157.

Fig. 16. The tourniquet now most generally used. See n° 160.

Fig. 17. The tenaculum used in securing the mouths of bleeding vessels. See n° 162.

Fig. 18. A common scalpel. See n° 174.

Fig. 19. A large lancet used for opening cavities of different kinds. See n° 174.

Fig. 20. A blunt-pointed bistoury. See n° 174.

Plate CCCCLXXXVIII. fig. 21. A raspatory for removing the pericranium in the operation of the trepan. See n° 186.

Fig. 22. The trephine with all its parts connected and ready for use. a, The centre-pin, which can be raised or depressed by the slider b. c, The part where the saw is united to the handle by means of the spring d. See n° 186.

Fig. 23. Handle of the trepan into which the head of the trephine is to be inserted at a. See n° 186.

Fig. 24. A perforator, which can be joined to the handle either of the trephine or trepan. See n° 186.

Fig. 25. A brush for cleaning the teeth of the saw. See n° 186.

Fig. 26. Forceps for removing the piece of bone when nearly cut through by the trephine or the trepan. See n° 186.

Fig. 26. a, A levator also employed in removing the piece of bone. See n° 186.

Fig. 26. b, Lenticular for smoothing the ragged edge of the perforated bone. See n° 186.

Fig. 27. A common probe. See n° 187.

Fig. 28. A directory. See n° 187.

Fig. 29. A speculum used for keeping the eyelids separated, and the eye fixed, in performing various operations upon that organ. See n° 205.

Fig. 30. A flat curved hook for elevating the upper eyelid, and fixing the eye, in performing various minute operations upon its surface. See n° 205.

Fig. 31. A couching needle. See n° 216.

Fig. 32. A couching needle for the right eye, fitted for the operator's right hand. See n° 217.

Fig. 33. A knife for extracting the cataract. See n° 218.

Fig. 34. A flat probe for scratching the capsule in extracting the crystalline lens. See n° 218.

Fig. 35. A flat probe or scoop for afflicting in removing the cataract. See n° 218.

Fig. 36. A knife for extracting the cataract from the right eye. See n° 218.

Fig. 37. One of Angel's probes for removing obstructions of the lachrymal ducts. See n° 224.

Fig. 38. A syringe and pipe (by the same) for injecting a liquid into the lachrymal ducts. See n° 224.

Fig. 38. a, A crooked pipe which fits the syringe. See n° 224.

Fig. 39. An instrument for compressing the lachrymal sac. See n° 226.

Fig. 40. A trocar and canula for perforating the os unguis in the operation for fistula lachrymalis. See n° 229.

Fig. 41, 42, 43. Instruments employed by Mr Pellicier in the operation for fistula lachrymalis. Fig. 41. A conductor for clearing the nasal duct. Fig. 42. A conical tube to be left in the duct. Fig. 43. A compressor for fixing the tube in its place. See n° 230.

Fig. 44. A trocar for making an artificial parotid duct. See Chap. XVI. Sect. i.

Fig. 45. Forceps sometimes used for laying hold of the lip in the operation for hare-lip. See n° 231.

Fig. 46. A pair of strong scissors used in the operation for hare-lip. See n° 231.

Fig. 47. Pins used in the operation for hare-lip. See n° 231.

Fig. 48. Gum-phleme. See n° 232.

Fig. 49. A trocar for perforating the antrum maxillare. See Chap. XVI. Sect. vi.

Fig. 50. An instrument of a tubular form for perforating the antrum maxillare. See as directed in Fig. 49.

Plate CCCCLXXXIX. Fig. 51. n° 1, 2, 3, 4, 5, 1, A file for removing inequalities upon the teeth. 2, 3, 4, 5, Different forms of instruments for removing tartar, &c., from the teeth. See n° 235.

Fig. 52. n° 1, 2, 3. 1, 2, Instruments for stuffing a hollow tooth. 3, The handle which fits the different instruments represented by fig. 51, 52. See n° 237.

Fig. 53. Instrument termed a key for extracting teeth. See n° 338.

Fig. 54. Forceps for extracting teeth. See n° 338.

Fig. 55. A punch or lever for extracting flumps of teeth. See n° 338.

Fig. 56. Mr Chefelden's needle, with an eye near the point, for tying a knot on scirrhouss tonsils. See n° 242.

Fig. 57. A speculum oris first proposed by Mr B. Bell. See n° 244.

Fig. 58. Mr Mudge's inhaler for conveying steams of warm water, &c., to the throat and breast. See Chap. XVII. Sect. xi.

Fig. 59. A scarificator for scarifying the amygdalae, and for opening abscesses in the throat. See Chap. XVII. Sect. xi.

Fig. 60. Forceps for extracting extraneous substances from the outer passage of the ear. See n° 246.

Fig. 61. A syringe for washing the outer passage of the ear. See n° 247.

Fig. 62, 63. Instruments used for concentrating sound in cases of deafness. See n° 249.

Fig. 64. A tube by which the Eustachian tube may be washed in certain cases of deafness. See n° 250.

Fig. 65. An instrument for perforating the lobes of the ear. See n° 251.

Fig. 66. An instrument recommended by Mr B. Bell for supporting the head after the operation for wry-neck. See n° 253.

Fig. 67. An instrument invented by Dr Monro for fixing the canula after the operation of bronchotomy. See n° 254.

Fig. 68. A glass for drawing milk from the breasts of women. See Chap. XX.

Fig. 69. A silver canula for carrying off pus collected in the thorax. See n° 262.

Plate CCCCXC. Fig. 70. A bandage for the paracentesis of the abdomen, originally invented by the late Dr Monro. See n° 264.

Fig. 71. The common round trocar, with a triangular point for tapping for the ascites. See n° 264.

Fig. 72. Mr André's lancet-pointed trocar, the canula of which is made of two hollow plates of steel screwed together at the larger extremity. See n° 264.

Fig. 73. A director used in the operation for hernia. See n° 273. Fig. 74. A spring truss for an inguinal or femoral hernia of one side. See n° 277.

Fig. 75. A spring truss for an inguinal or femoral hernia of both sides. See n° 277.

Fig. 76. A spring truss for an umbilical hernia. See n° 277.

Fig. 77. Mr. André's trocar for evacuating the contents of an encysted hydrocele. See n° 299.

Fig. 78. Mr. B. Bell's trocar for operating in hydrocele. See n° 299.

Fig. 79. A suspensory bandage for the scrotum. See n° 299.

Fig. 80. A straight-edged sharp-pointed bistoury. See n° 324.

Fig. 81. A bag of resina elasticata, with a stop-cock and short pipe, which fits the canula of the trocars fig. 77, 78, for the purpose of injecting wine and other fluids into the cavity of the tunica vaginalis in the case of hydrocele. See n° 306.

Fig. 82. A sound used in searching for the stone. See n° 321.

Fig. 83. A grooved staff for the operation of lithotomy. See n° 332.

Fig. 84. A cutting gorget. See n° 332.

Fig. 85. A double gorget invented by Dr. Monro. See n° 332.

Fig. 86. Extracting forceps. See n° 332.

Fig. 87. A scoop. See n° 332.

Fig. 88. A grooved staff for the operation of lithotomy in females. See n° 334.

Fig. 89. A tube containing a pair of elastic forceps for extracting stones from the urethra. See n° 336.

Plate CCCCXCI. Fig. 90. A jucum penis used in cases of incontinence of urine in men. See n° 338.

Fig. 91. Pessaries for supporting the uterus in cases of prolapsus uteri in females. a, A pessary of wood or ivory. b, One of resina elasticata. See n° 338.

Fig. 92. A receiver, which has been lately used with advantage in cases of incontinence of urine in the male. See n° 338.

Fig. 93. A receiver, which has been lately used, in a few cases, with advantage in the female. See n° 338.

Fig. 94. A catheter for a male. See n° 340.

Fig. 95. A catheter for a female. See n° 340.

Fig. 96. A bougie. See n° 345.

Fig. 97. Mr. Hunter's caudic conductor.

Fig. 98. A bistoury used in the operation for phymosis. See n° 347.

Fig. 99. A bistoury used in amputating the penis. See Chap. XXIX, Sect. iv.

Fig. 99. a, A silver canula for conducting the urine after amputation of the penis. See Ib.

Fig. 100. A bistoury, with a probe of flexible silver joined to it, to be used in the operation for fistula in ano. See n° 355.

Fig. 101. A bistoury, which has been lately used by some practitioners in the operation for fistula in ano. See n° 355.

Fig. 102. A wire of silver or lead, with a tube of the same metal, for laying open a fistula in ano. See n° 355.

Fig. 103. A bandage for supporting the end of the rectum in cases of prolapsus ani. See Chap. XXX, Sect. vii.

Fig. 104. Mr. Park's leather-case for supporting the forearm after luxations of the joints or fractures of the bones of the superior extremities. See n° 392.

Fig. 105. a, b, Splints of wood glued to leather, and afterwards cut, as represented in the figures. They are used for fractures of the bones of the extremities, particularly for those of the fore-arm or leg. See n° 397.

Fig. 106. Represents a fractured limb dressed with an eighteen-tailed bandage, and placed in the manner recommended by Mr. Pott. See n° 397.

Fig. 107. Mr. Gooche's machine, improved by Dr. Aitken, for keeping a fractured thigh-bone properly extended. The upper circular bandage goes round the waist, the under one fixes immediately above the knee. See n° 397.

Fig. 108. A bandage for a fractured patella. See n° 398.

Fig. 109. A wooden splint for a fractured leg. See n° 399.

Plate CCCCXCII. Fig. 110. Mr. James's machine, which is an improvement upon one invented some years ago by Mr. White of Manchester for retaining fractured thighs or bones of the leg in their natural situation. See n° 402.

Fig. 111. The common collar used in distortions of the spine. See n° 404.

Fig. 112. Stays recommended by Mr. Jones for distortions of the spine. See n° 404.

Fig. 113. An apparatus for a distortion of the leg. See n° 404.

Fig. 114. An apparatus for a distorted leg, where the sole is turned much out of its natural direction. See n° 404.

Fig. 115. Shoes which have been used with advantage in cases of club-feet. See n° 474.

Fig. 116. An amputating knife. See n° 407.

Fig. 117. Retractor of cloth or leather, used in amputating the larger extremities. See Ib.

Fig. 118. Iron retractors recommended by Dr. Monro in amputation of the larger extremities. See Ib.

Fig. 119. The amputating saw now most generally used. See Ib.

Fig. 120. Pincers for nipping off any points of bone which may remain after the saw has been used. See Ib.

Fig. 121. A catline used in an amputation of the leg. See n° 411.

Fig. 122. A spring saw employed in amputating the fingers. See n° 415.

Fig. 123. An instrument invented by Mr. Moore of London for compressing the nerves, and thereby diminishing pain in performing various operations upon the extremities. See Chap. XXXV.

Fig. 124. An apparatus invented by the late Dr. Monro for the cure of a rupture of the tendo Achillis. See n° 24. INDEX.

A.

Abdomen, wounds of, n° 15, 16. How treated, 26. Collection of water in, 263, 264. Of air in, 265. Of a dead person, how to be opened, 429.

Abdominal tumor, ch. vii. sect. iv. Abdominal general, how to be treated, n° 47—50. In the globe of the eye, chap xiii. sect. iv.

Abdominal in medulla, n° 119. Achilles, tendon of, wounds of it, how cured, n° 24.

Amputation in general, ch. xxxiv. sect. i. Amputating the arm and fore-arm, sect. ii. The thigh, sect. iii. The leg, sect. iv. At the joints of the extremities, sect. v. At the shoulder joint, n° 413. At the joints of the fingers, 415.

Anel's probe and syringe, account of, n° 224, 225.

Aneurism, ch. xi. True or encysted, n° 165. False or disfigured, 166. Varicose, 167. Caules, diagnosis, prognosis, &c. 168—171. Remarkable one cured by Mr John Bell, 172. Operation for, how to be performed, 174. How the patient is to be treated afterwards, 180, &c.

Anus prolapsus, ch. xxx. sect. iv. Antrum Maxillare, abscesses in, ch. xvi. sect. vi.

Anus, diseases of, ch. xxx. Condylomatous excrements of, sect. ii. Imperforated, sect. v.

Arm, amputation of, ch. xxxiv. sect. ii.

Arteries, wounds of, n° 11. Method of tying them, 162, 163. Tumors from, ch. xi.

Arteriotomy, ch. viii. sect. iii.

B.

Bandage, ch. xxxvi. For the head, n° 419. For the face, 420. For the neck, 421. For the breast, &c. 421.

Bladder, stone in, ch. xxvii.

Blood-letting, ch. viii. Consequences which sometimes attend it, n° 18. Opinions concerning the causes of these consequences, 19—22. How to be obviated, 23.

Boils of the gums, n° 242.

Bone, diseases of, ch. vii. Carious in the joints, how the ends are to be removed, ch. xxxiv. sect. v.

Brain, affections of, from external violence, ch. xii. Compression of, sect. i. Concussions of, sect. ii. Inflammation of, sect. iii.

Breasts of women, inflammation of, ch. vi. sect. i. Cancer of, n° 76—78. See Thorax.

Brittle bone of the bones, n° 122.

Bronchocoele, or tumor on the fore part of the neck, ch. vi. sect. v.

Bronchotomy, or incision made in the wind-pipe, n° 254.

Buboes, venereal, ch. vii. sect. iii.

Bubonocoele, or rupture in the groin, ch. xxii. sect. ii.

Burns, consequences and cure of, ch. iv. sect. v.

Burse Mucosae, swellings of, ch. vi. sect. ii.

C.

Calculus. See Stone.

Cancers, ch. iv. sect. iii. Of the eye, ch. xiii. sect. vii.

Cancerous lip, how extirpated, ch. xvi. sect. iii.

Capsular ligaments, collections within, ch. vi. sect. iii.

Carious bones, how the ends of are to be removed, ch. xxxiv. sect. v.

Cataract of the eye, ch. xiii. sect. viii.

Chilblains, n° 86.

Circumcision, n° 312.

Clavicle, fractures of, n° 387.

Luxation of, 369.

Concussion of the brain, n° 180, 190.

Contusions and sprains, ch. vi. sect. vi.

Cornea, specks on, n° 204.

Cornu, n° 107.

Cranium, fracture and depression of, ch. xii. sect. i. How to open it, n° 428.

Cutting, n° 146. Dry, 45.

Cystic hernia, n° 291.

D.

Dead body, how opened, c. xxxvii. How embalmed, ch. xxxviii.

Deafness, causes and cure of, ch. xvii.

Dislocation. See Luxation.

Distortion, ch. xxxiii. Of the spine, n° 404. Of the limbs, 405.

Dropical swellings of the joints, n° 95—99. Of the eye, n° 209.

Dropy, operation for, n° 26.

Dropy of the lachrymal lacrimal, n° 220.

E.

Ear, diseases of, ch. xvii. Lobes of, how perforated, n° 251.

Fellow, luxation at, n° 374.

Embalming method of, ch. xxxviii.

Emphysema, or pus collected in the thorax, n° 261.

Eyelid, diseases of, ch. xiii. Specks, films, or excrescences on, sect. iii. Abscesses in the globe of, sect. iv. Dropical swellings of, sect. v. Cancer of, sect. vii.

Cataract of, sect. viii.

Eyeball, protrusion of, sect. vi.

Wounds of, n° 199.

Eyelids, inversion of, n° 201.

Eyelids, wounds of, n° 108. Diseases of, ch. xiii. sect. ii.

Euflachian tube, affections of, n° 250.

Excrements on the white of the eye, n° 26.

Exostosis, n° 289.

Exostosis, or excrescence from a bone, n° 115.

Extremities, superior, fractures of the bones of, ch. xxxii. sect. iv.

Inferior, fractures of the bones of, sect. v.

F.

Fabricius ab Aquapendente, screw invented by, n° 226.

Fingers, fracture of, n° 396.

Amputation at the joints of, 415.

Fistula in perineo, ch. xxix. sect. v. In ano, ch. xxx. sect. iii.

Lachrymalis, ch. xiv.

Fractures, or simple fractures of the skull, ch. xii. sect. iv.

Foot, fracture of the bones of, n° 400. Amputation at the joints of, 417.

Fore-arm, fracture of the bones of, n° 393.

Fractures in general, ch. xxxii. sect. i. Of the nose, n° 385. Of the lower jaw, 386. Of the clavicles, 387. Of the ribs, 388. Of the sternum, 389. Of the vertebrae, 390. Of the scapula, 391. Of the humerus, 392. Of the bones of the fore-arm, 393. Of the olecranon, 394. Of the bones of the wrist, 395. Of the fingers, 396. Of the thigh-bone, 397. Compound, ch. xxxii. sect. vi.

Fungi in the brain after being trepanned, n° 188.

G.

Ganglia, ch. vi. sect. ii.

Gangrene, ch. iii. sect. ii. Dry, n° 51. White, 52. Means of preventing, 54, 55. In cases of hernia, 281.

Gout, or swelling on the neck, ch. vi. sect. v.

Gummi, or soft tumor on the surface of a bone, n° 117.

Gums, boils and excrescences of, ch. xvi. sect. v.

Gunpowder, burn occasioned by, how cured, n° 81.

Gun-shot wounds, n° 30—35.

H.

Hematocoele Serosi, or collection of blood in the scrotum, ch. xxiv. sect. iv.

Hemorrhagies, n° 17.

Hemorrhoids, or piles, ch. xxx. sect. i.

Herpetic, ch. xvi. sect. ii.

Head, wounds of, n° 27. Luxation of, 365.

Hernia, or rupture of the intestines, ch. xxxiii. sect. i. Inguinal and femoral, sect. ii. Congenita, sect. iii. Femoral and crural, sect. iv. Umbilical, n° 289. Ventral, 290. Cystic, 291. Vaginalis, 293.

Hip-joint, luxation of, n° 376.

Amputation at, 416.

History of Surgery, n° 2—6.

Hydrocele, or watery swelling of the scrotum, ch. xxiv. Anaerous of the scrotum, sect. i. Of the tunica vaginalis testis, sect. ii. Of the spermatic cord, sect. iii. Anaerous of the spermatic cord, n° 307, 328. Encysted of the spermatic cord, 309, 310.

Hydrops faciei lachrymalis. See Fistula lachrymalis.

Hymen, imperforated, ch. xxx. sect. vi.

I.

Jaw, lower, luxation of, n° 365. Fracture of, 386.

Imperforated hydriis, ch. xv. sect. iii. Anus, ch. xxx. sect. v. Hymen, sect. vi.

Indolent tumors, ch. vi. Steatomatous and sarcomatous, sect. i. Serpulous, sect. v.

Inflammation and its consequences, ch. iii. Of the breasts of women, ch. v. sect. i. Of the testicles, sect. ii. Of the brain and its membranes, ch. xii. sect. iii.

Intestines, rupture of, ch. xxiii.

Instruments, surgical. See Explanation of the plates, p. 187.

Joints, wounds of, n° 28. Dropical swellings in, n° 95—98. Concretions in, 99—101. Of the extremities, amputation at, ch. xxxiv. sect. vi.

K. K.

Kidneys, stones in, ch. xxvii. sect. ii.

Knee-pan, luxation of, n° 379. Fracture of, 398.

L.

Lachrymal sac, dropy of, n° 220. Leeches, when to be used, n° 149.

Leg, fracture of, n° 399. Amputation of, ch. xxxiv. sect. iv.

Ligature of arteries, ch. x. sect. ii.

Limbs, distortion of, n° 405.

Lingue frenum, division of, ch. xvi. sect. ix.

Lip, fissure of, or hare-lip, ch. xvi. sect. ii. Cancerous, extirpation of, sect. iii.

Lithotomy in men, n° 324. In women, 334.

Lumbar abscess, ch. v. sect. iv.

Luxations in general, ch. xxxi. sect. i. Of the bones of the cranium, n° 363. Of the bones of the nose, 364. Of the lower jaw, 365. Of the head or neck, 366. Of the vertebrae, 367. Of the os coccygis, 368. Of the clavicle, 369. Of the ribs, 370. Of the head of the os humeri, 371—373. At the elbow, 374. At the wrist, 375. Of the hip-joint, 376—379. Of the patella, 379. Of the tibia at the knee, 380. Of the ankle joint, 381.

M.

Marks on the bodies of children at birth, n° 106.

Matter, signs of, formed, n° 46.

Meatus auditorius externus imperforated, n° 245.

Medulla, abscessus in, n° 119.

Mellities Ossium, n° 127.

Mortification, cases of, how to be treated, n° 56. In cases of herma, how to be treated, 280.

Mouth and throat, affections of, ch. xvi. Ulcers in, sect. viii.

Muscles, wounds of, n° 10.

N.

Nevi Materni, or marks on the bodies of children at birth, n° 106.

Neck, wry, ch. xviii. Luxation of, n° 366. Swellings in, 104, 105.

Nerves, wounds of, n° 12. How cured, n° 23.

Nipples, sore, ch. xx.

Nodes, venereal, how removed, n° 118.

Nose, affections of, ch. xv. Hemorrhagies from, sect. i. Luxation of the bones of, n° 304. Fracture of, 385.

Nasus, imperforated, ch. xv. sect. iii.

O.

Oesophagotomy, or cutting open the gullet, n° 255.

Olecranon, fracture of, n° 394.

Opening a dead body, ch. xxxvii.

Os Coccygis, luxation of, n° 368. Os Humeri, head of, dislocated, how set, n° 371.

Ossium Mollitiss, n° 127.

Oxena, or ulceration in the nose, ch. xv. sect. ii.

P.

Pain, method of alleviating, in surgical operations, ch. xxxv.

Palpy of the lower extremities, n° 128.

Paracentesis of the thorax, ch. xxi. Of the abdomen, ch. xxii.

Paraphymosis, n° 348 and 349.

Paronychia, or whitlow, n° 85.

Parotid duct, division of, ch. xvi. sect. i.

Patella, or knee-pan, luxation of, n° 379. Fracture of, n° 398.

Penis, diseases of, ch. xxix. Amputation of, sect. iv. Warts on, n° 109.

Perineo, fistula in, ch. xxix. sect. v.

Phlebotomy, ch. viii.

Phymosis, n° 346, 347.

Piles, ch. xxx. sect. i.

Pneumatocele, n° 315.

Poisoned wounds, n° 37, 38.

Polyp, or flethy tumors, ch. vi. sect. vii.

Prolapsus ani, ch. xxx. sect. iv.

Uteri, sect. vii.

Pterygium, or excrescences on the white part of the eye, n° 266.

Pus, formed, signs of, n° 46.

R.

Ranula, or tumor under the tongue, ch. xvi. sect. vii.

Rheumatic white flwelling, n° 71.

Rib, luxation of, n° 370. Fractures of, 388.

Ricketts, n° 123—126.

Rupture, or hernia, ch. xxiii.

S.

Sarcocele, or scirrhus testicle, ch. xxvi.

Sarcomatous tumors, n° 93.

Scapula, fracture of, n° 391.

Scrophulous tumors, ch. vi. sect. v. White swelling, n° 68.

Scrotal hernia, ch. xxiii. sect. ii.

Scrotum, anafarous hydrocele of, ch. xxiv. sect. i.

Seten, n° 153.

Shoulder, dislocation of, n° 371.

Shoulder-joint, amputation at, n° 413.

Skull, fractures of, ch. xii. sect. iv.

Spermatic cord, hydrocele of, ch. xxiv. sect. iii.

Specks upon the eyes, ch. xiii. sect. iii.

Spermatocoele, n° 314.

Spina bifida, ch. vi. sect. iv.

Spina ventosa, or caries of the bones, n° 119.

Spine, luxation of, n° 367. Distortion of, 404.

Sprains, ch. v. sect. vi.

Steatomatous tumors, n° 92.

Sternum, fracture of, n° 389.

Stone in the bladder, ch. xxvii. sect. i. In the kidneys, sect. ii. In the urethra, sect. iii.

Suppuration, how prevented, n° 42. Method of promoting, 44.

Surgery, history of. Among the Greeks, n° 2. Among the Romans, 3. Among the Arabians, 4. Writers on, in the 16th century, 5. In the 17th century, 6.

Sutures, ch. x. Interrupted, n° 154. Quilled, 155. Twisted, 156—159.

T.

Tapping for the dropy, ch. xxii.

Teeth, affections of, chap. xvi. sect. iv. Derangement of, how corrected, n° 233. Loose, how fastened, 234. How cleaned, 235. Extraction of, 238. Transplanting of, 239.

Tendons, when wounded, how to be treated, n° 24.

Tetanic inflammation of, ch. v. sect. ii. Scirrhus, ch. xxvi.

Thigh-bone, fracture of, n° 397.

Thigh, amputation of, ch. xxxv. sect. iii.

Thorax, wounds of, n° 13 and 25. Paracentesis of, ch. xxii.

Blood collected in, n° 259.

Air collected in, 260. Pus collected in, 261. How these are to be removed, 262. Of a dead person how to be opened, 429.

Throat, affections of, ch. xvi. Scarifying and fomenting, ch. xvi. sect. xi.

Tibia, luxation of, n° 380.

Toes, fracture of, n° 400. Amputation of, 418.

Tonifilis and woulia, enlargement of, ch. xvi. sect. x.

Toothache, n° 236, 237. See teeth.

Topbus, or soft tumor of the bones, n° 116.

Topical bleeding, ch. viii. sect. iv.

Tongue, tumor under, ch. xvi. sect. vii.

Tourniquet, manner of using, n° 160, 161.

INDEX.

Tumors, indolent, ch. vi. Steatomatous and farcomatous, ch. vi. Sect. i. Scrophulous, ch. vi. Sect. v.

Tunica vaginalis testis, hydrocele of, ch. xxiv. Sect. ii.

Tympanites, or air collected in the abdomen, n° 265.

U.

Ulcers in the mouth, ch. iv. Sect. i.

Umbilical hernia, ch. xvi. Sect. viii.

Urethra, stone in, ch. xxvii. Sect. iii. Obstructions of, ch. xxix. Sect. i. Incomplete, Sect. iii.

Urine, incontinence and suppression of, ch. xxviii.

Uteri prolapsus, ch. xxx. Sect. vii.

Uvula, enlargement and extraction of, n° 243, 244.

V.

Varicose aneurism, n° 167.

Varicocele, n° 311.

Venereal buboes, ch. v. Sect. iii.

Nodes, n° 118.

Venefication, ch. viii. Sect. ii.

Ventral hernia, n° 292.

Vertebras, luxation of, n° 367. Fracture of, 390.

W.

Warts, n° 108. On the penis, 109.

Wax, superabundance of, how removed from the ear, n° 247. Deficiency of, how supplied, 248.

White swellings, ch. iv. Sect. ii.

Rheumatic, n° 66, 67, 71.

Scrophulous, 68, 69, 72.

Cauls of, 70.

Whitlow, n° 85.

Women, operation for the stone in, n° 334.

Wounds, simple, ch. ii. Sect. i.

Mortal, 7. Of the skin and cellular substance, 9. Of the muscles, 10. Of the arteries, ligaments, nerves, and tendons, 11, 12. Of the thorax and its viscera, 13, 15. Of the abdomen and its viscera, 14. Treatment of, 15, 16, and 26. Hemorrhages from, 17. Of the head, 27. Of the joints, 28. Contused and lacerated, 29. Gun-shot, ch. ii. Sect. iii. Poisoned, proceeding from the bite of animals, n° 37, 38. Of the eyelids, 198. Of the eyeball, 199.

Wrist, luxation of the bones at, n° 378. Fracture of the bones at, 395. Amputation, 414.

SURINAM.