or CHIRURGEON, one that professes the art of SURGERY.

In England there are two distinct companies of surgeons now occupying the science or faculty of surgery; the one company called barbers, the other surgeons, which latter are not incorporated.—The two are united to sue, and be sued, by the names of masters or governors and commonalty of the mystery of barbers and surgeons of London. 32 Hen. VIII. c. 42.

No person using any barbery or shaving in London, shall occupy any surgery, letting of blood, or other matter; drawing of teeth only excepted. And no person using the mystery or craft of surgery shall occupy or exercise the feat or craft of barbery or shaving, neither by himself, nor any other for his use. 32 Hen. VIII. c. 42.

By the same statute, surgeons are obliged to have signs at their doors.

The French chirurgeons being refused to be admitted into the universities (notwithstanding that their art makes a branch of medicine), on pretence of its bordering a little on butchery or cruelty, afficiated themselves into a brotherhood, under the protection of S. Cosmus and S. Damian: on which account, according to the laws of their institution, they are obliged to dress and look to wounds gratis the first Monday of each month.

They distinguish between a chirurgeon of the long robe and a barber-chirurgeon. The first has studied physic, and is allowed to wear a gown. The skill of the other, besides what relates to the management of the beard, is supposed to be confined to the more simple and easy operations in chirurgery; as bleeding, tooth-drawing, &c.

They were formerly distinguished by badges: those of the long gown bore a cafe of instruments; the barber, a balon.

S U R G E R Y.

THE term surgery has been usually employed to signify that part of medicine which treats of the diseases of the human body which are to be cured or alleviated by the hand, by instruments, or by external applications.

INTRODUCTION.

MEDICINE and surgery, formerly regarded as one and the same science, were exercised by the same persons during the most remote ages; and their separation, such as now generally exists, is to be considered as a modern institution. If we consider their origin and end, the knowledge which the practitioner of each requires, and the connection which naturally subsists between the diseases which are supposed peculiarly to belong to each department, it is probable that the first practitioners confounded them with one another; and it is easy to conceive how the same ideas should have passed from one generation to another. At last, however, the knowledge of the healing art being greatly enlarged, it became necessary to separate it into different classes, and to form it into distinct departments in practice. Accordingly there were not only some who confined themselves to surgery, but there were lithotomists, phlebotomists, oculists, aurists, dentists, &c.

We do not propose here to enter into any detail in attempting to show how this separation was made, and still less to make mention of the puerile disputes regarding the pre-eminence of medicine to surgery. There are few we believe who in our days do not feel that such a pre-eminence does not exist in nature; that medicine and surgery are one and the same science; that they are coeval with the human race; and to those who are able to appreciate them, they must appear of equal utility and importance. The healing art is one, its principles ought to be the same throughout, and the exercise of its different branches supposes the same fundamental knowledge; but it offers in the detail such a vast field for study, that few men are able to embrace the whole, and to cultivate all the parts with equal success. It becomes, therefore, an advantage to society that each part as can be easily separated in practice be exercised by different individuals; and that a man who has acquired a general knowledge of the structure, functions, and diseases of the animal economy, practice in such departments as he finds his talents and acquirements point out.

Some have opposed surgery to medicine by qualifying the first with the name of art, and in giving to the second that of science. To pretend that surgery is nothing but the art of treating diseases by external means or by manual operations, is to rank it among the mechanical professions; and to consider as a good surgeon, the man who can dress an ulcer, apply a bandage, reduce a fracture, amputate a limb, or perform such like operations, on the living body. We have already mentioned that the healing art is the same in all its branches; the internal organs of the body in a state of health are governed by the same general laws, and many of them are analogous in structure to the external parts; and the nature of a local disease can never be understood if we are not acquainted with all the deviations from the natural state, of which the whole animal system is susceptible. If a physician be called to treat a plague, he cannot expect to do it with success unless he have a sufficiently clear idea of the nature of inflammation, or at least of the principal symptoms which characterise it; of its consequences, and of the proper mode of applying the means to remove it. This knowledge is not less necessary to the surgeon who is called to treat an wound, the management of which depends chiefly on the precautions necessary to prevent and remove inflammation in the affected parts, without at the same time weakening too much the vital powers. The knowledge of the physician does not merit more the name of science, than that of the surgeon who is well acquainted with the functions of the animal economy, with morbid structure, and with the progress and termination of diseases.

The student of surgery has therefore to acquire, not only all that knowledge necessary for the well educated physician, but he has likewise to learn the manner of performing surgical operations. This, though no doubt an essential requisite to the surgeon, is by no means so important as a competent knowledge of those diseases and states of disease which require such means; and the young surgeon should endeavour not to cherish that love of operating which is observed in some, and which arises from the eclat which a dexterous operator generally receives.

To become an intelligent and expert operator, several qualifications are necessary; and some of these fall to the lot of few individuals. There are many people, who, though they have acquired an extensive knowledge of diseases, have not that calmness of mind, that collectedness of thought, which is necessary for a good operator; and there are some who are even deficient in that mechanical dexterity, which, though not requisite in all, is yet necessary in several of the operations in surgery. These talents, however, are never given in such perfection as not to require cultivation. An early habit of being prudent, and of assisting at operations, prepares the student to act for himself; and a long and unremitting habit of using the knife, and of performing operations on the dead body, gives a facility in all the mechanical part of them, which even experience on the living body does not procure.

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 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 balms, 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 balm could not heal.

Concerning the surgery practised among the Egyptians, Jews, and Asiatic nations, we know little. The art defended from the Greeks to us, though they confessedly received it from the eastern nations. The first Greek surgeons on record are Aesculapius and his sons Pedalius and Machaon. Aesculapius flourished about 50 years before the Trojan war; and his two sons distinguished themselves in that war both by their valour and by their skill in curing wounds. This indeed is the whole of the medical skill attributed to them by Homer; for in the plague which broken out in the Grecian camp, he does not mention their being at all consulted. Nay, what is still more strange, though he sometimes mentions his heroes having their bones broke, he never takes notice of their being reduced or cured by any other than supernatural means; as in the case of 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 flyttes 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 Euryalus as wounded and under the hands of Patroclus, who would certainly practise according to the directions of the surgeons.

Patroclus cut the forked steel away; Then in his hand a bitter root he bruised, The wound he wash'd, the flytic juice infus'd. The closing flesh that infant 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; al- History. for the use of warm and emollient fomentations, fluxes made with hot irons, pessaries, injections, fumigations, &c. Hippocrates also gives directions with regard to fractures, luxations, ulcers, fistulas. He directs the extension, reduction, bandages, and splints, proper to be used in fractures and luxations of different bones, with several machines to increase the extension when necessary. He directs the laxity and 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 echarotics, some of which are alum, nitre, verdigris, quicklime, &c.

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 the art in that 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 Aelaeipades 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 work on surgery, all the improvements from Hippocrates to his own days are collected; the most minute and trifling diseases are not omitted. An eminent surgeon, of the moderns, emphatically exhorts every person in that profession "to keep Celsus in his hands by day and by night." He describes the signs of a fractured skull, the method of examining for the fracture, of laying the skull bare by an incision in the form of the letter X, and afterwards of cutting away the angles, and of applying the trepan, mentioning also the signs of danger and of recovery. He observed, that sometimes, though very rarely, a fatal concussion of the brain might happen from the blood-vessels within the skull being burst, 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 every thing that might excite coughing or sneezing. Cloths wetted with wine, roses and oil, and other applications, were laid over the fracture. The cure of fractures, in the upper and lower extremities, he said were nearly alike; that fractures differ in degree of violence and danger, in being simple or compound, that is, with or without a wound of the flesh, and in being near to the joint. He directs the extension of the member by afflatus; 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 cafe, reaching above the ham, and accommodated likewise with a support to the foot, and with straps at the side, to keep the leg steady: in the fractured thigh-bone, the cafe 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 hemorrhagy, he applied a sponge wet in vinegar, and constant prelure: If necessary, on account of the violence of the hemorrhagy, ligatures were made round the vesseis, 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 disease, 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 lightly of the method of amputating; from which, comparing his treatise with the modern systems, we might infer that the operation was then seldom practised than at present. He describes the symptoms of that dangerous inflammation the carbuncle, and directs, immediately to burn or corrode the gangrened part. To promote the suppuration of abscesses, he orders poultices of barley-meal, or of marshmallows, or the feeds of linseed and fenugreek. He also mentions the compositions of several repellent cataplains. In the erysipelas, he applies ceruse, mixed with the juice of folanum 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 flower, saffron, and the white of an egg, to be laid to the forehead to suppress the flow of pituita; the soft inside of warm wheat bread dipped in wine, to be laid to the eye; poppy and roses were also added to his collyriums, and various ingredients too tedious to enumerate. In chronic watery defluxions of the eyes, he applied astringents, cupped the temples, and burnt the veins over the temple and forehead. He couched cataracts by depressing the crystalline lens to the bottom of the orbit. Teeth, loosened by any accident, he directs, after the example of Hippocrates, to be fastened with a gold thread to those adjoining on each side. Previous to drawing a tooth, he ordered the gum to be cut round its neck; and if the tooth was hollow, it was to be filled with lead before extraction, to prevent its breaking by the forceps. He describes not only the inflammation, but likewise the elongation, of the uvula: he also describes the polypus, and some other diseases affecting the nose.

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

Celsus directed various corrosive applications and injections to fistulas; and, in the last extremity, opened them to the bottom with a knife, cutting upon a grooved instrument or conductor. In old callous ulcers, he made a new wound, by either cutting away the hard edges, or corroding them with verdigris, quicklime, alum, nitre, and with some vegetable elixiarches. He mentions the symptoms of caries in the bone; directs the bone to be laid bare, and to be pierced with several holes, or to be burnt or rasped, in order to promote an exfoliation of the corrupted part; afterwards to apply nitre and several other ingredients. One of his applications to a cancer was auripigmentum or arsenic. He directs the manner of tapping the abdomen in ascites, and of drawing blood by the lancet and cupping-glares. His cupping-glares seem not to have been so convenient as the modern: they were made either of brass or horn, and were unprovided with a pump. He cured varicose veins by suction or by incision. He gives directions for extracting the dead fetus from the womb, in whatever position it should present; and, after delivery, to apply to the private parts soft cloths wet in an infusion of vinegar and roses. In Celsus's works there is a great redundance and superfluity of plasters, ointments, elixiarchies, collyriums, of huppurating and dissecting cataplasm, and external applications of every kind, both simple and compound: Perhaps, amongst the multitude, there are a few useful remedies now laid aside and neglected.

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

In the year 500 flourished Aëtius, in whose works we meet with many observations omitted by Celsus and Galen, particularly on the surgical operations, the diseases of women, the caules of difficult labours, and modes of delivery. He also takes notice of the dracunculus, or Guinea worm. Aëtius, however, is greatly excelled by Paulus Aegineta, who flourished in 640; 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 defluxions upon the eyes, he opened the jugular veins. He describes the manner of opening the arteries behind the ears in chronic pains of the head. He wrote also upon midwifery. Fabricius ab Aquapendente, a celebrated surgeon of the 16th century, has followed Celsus and Paulus as text books.

From the time of Paulus Aegineta 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 assist 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 repoked, like the Egyptians and eastern Asiatics, great confidence in burning the part. He describes accurately the manner of tapping in afecies; mentions several kinds of instruments for drawing blood; and has left a more ample and correct delineation of surgical instru- ments than any of the ancients. He gives various obstetrical directions for extracting the fetus in cases of difficult labour. He mentions the bronchocle, 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 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 barbers, farriers, and sow-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: Illa superavit omnes, et nemo illi hunc disputat gloriae; omnibus potius quam hocce carere pejussum. 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. Miggius and L. Botellus 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. Sculletus, J. Mangetus, C. Magstus, Spigellius, F. Hildanus, T. Bartholin, P. de Marchett.

During the last century, surgery, like all the other sciences, made more rapid progress toward perfection, than during all the preceding periods. This partly arose from the assistance of governments in the different countries. They being convinced that anatomy is one of the most necessary sciences, and the groundwork of the whole healing art, but particularly of surgery, in many great cities academies were instituted for the cultivation of practical anatomy; and schools were also established for the instruction of the theoretical and practical parts of surgery.

These improvements in surgery have been chiefly made in England, France, and Germany; and in all these countries a number of very eminent men have appeared.

The English surgeons, besides possessing an accurate knowledge of anatomy, and great abilities in the operative part of their profession, were the first who endeavoured to bring the art to its present simplicity. They directed also their attention, in a particular manner, to the diet of patients; the neglect of which had caused the unfortunate issue of many operations which had been dexterously performed.

Among the surgeons of later times, we may first mention the name of Sharp. He was a scholar of Chefielden, and one of the best surgeons of his day. He wrote a Compendium of Surgical Operations, 1746; and also a Critical Inquiry into the State of Surgery; both of which works are still in high estimation.

In the year 1719, Dr Monro, after visiting the schools of London, Paris, and Leyden, where he was a pupil of the great Boerhaave, came to Edinburgh; and this may be considered as the date of the foundation of the Edinburgh medical school. He began by giving lectures on anatomy and surgery, the first which were delivered in Edinburgh; and in the year 1721 he was appointed professor of anatomy and surgery to the university. This eminent anatomist and surgeon, besides filling his chair with the greatest reputation, contributed to the advancement of our knowledge in many important parts of anatomy and surgery. His works, published by his son, besides his Treatise on Osteology, which is certainly the best description of the bones that has ever been given, will be found to contain many interesting and valuable observations on various surgical diseases.

Joseph Warner, surgeon of Guy's Hospital, in London, published his Cases and Remarks in Surgery, in the year 1754, a work which contains many very important practical remarks. He afterwards published a very good work, containing a description of the human eye and its adjacent parts, in which he particularly rejects the fathening of the eye during the operation of cataract. He also published An Account of the Tumors, their Common Coverings and Coats, &c.

Percival Pott, surgeon of St Bartholomew's Hospital, may be justly considered as one of the principal English surgeons of his time. He was not only a successful practitioner, but an industrious and excellent writer. The merits of Pott are indeed considerable. He threw much light on the doctrine of wounds of the head, by his accurate arrangement of the different kinds of injuries to which the head is subject. He also gives a good account of hydrocele and the other diseases of the testicle. For the operation of the fistula in ano, he made material improvements. He has given many useful hints on fractures and dislocations; and he was a great champion in favour of the operation for cataract by couching. He was the first person who described the chimney-sweeps History. sweeps cancer; and on hernia, polypus, and curvatures of the spine, he has made many judicious pathological and practical observations.

Charles White, surgeon in Manchester, published an excellent practical work in the year 1770, in which he recommends amputation of the foot, a little above the ankle joint, instead of under the knee, as had usually been practised. He also shows the effect of sawing off the ends of bones; and discusses several other interesting points in surgery. In the same year, Mr Elfe of St Thomas's Hospital, published his treatise on the hydrocele, in which he recommends the use of cautic in the cure of that disease.

In the year 1770, Mr Deane, of Dublin, wrote an excellent treatise on the wounds of the head. Mr Bromfield, of St George's Hospital, and Mr Hill, surgeon at Dumfries, also distinguished themselves; Mr Bromfield for his Chirurgical Observations, and Mr Hill for his Observations on Cancers.

In the year 1778, Mr Benjamin Bell published the first volume of his System of Surgery. The reputation of this work was soon such, that it was translated into the French and German languages; and it has since gone through several editions in these, and many in English.

This work presented the most complete system of surgery which had ever appeared; and in every part of it there is displayed a talent for practical observation and clearness of thought which must render it ever a useful and valuable present to surgery. Like all such extensive works, it is not without faults, and the language in which it is written is in some places prolix and diffuse; but notwithstanding its errors, it certainly must be considered as the most useful body of surgery that has ever yet appeared in this country.

Besides these, mention must be made of two other eminent surgeons, William and John Hunter; the former rendered immortal by his splendid work on the gravid uterus, and the latter by his treatise on the venereal disease, and his treatise on the blood, inflammation, and gun-shot wounds.

Many very eminent men arose, both in France and Germany, during the last century. The transactions of their academies leave a lasting monument of their zeal and industry.

In France we have the names of Petit, Arnaud, Garangeot, Morand, Le Dran, Le Cat, Louis, David Levret, Le Blanc, Da la Faye, David Chopart, Desault, Janin, Jourdain, Pouteau, André Lombard Wenfel.

In Germany, surgery has been enriched by the works of Vogel, Platner, Albert Haller, Bilguer, Weitz, Seibold, Brambilla, Theden, Smucker, Stork, Plenk, Ilenflamn, Rougemont, Conradi, and many others.

Most authors who have written systems of surgery have described diseases according to the parts of the body where they were situated; beginning with the head, and describing the parts in succession, according to their situation.

Besides this mode of arrangement being unphilosophical, it has many serious disadvantages. Diseases which have no analogy to each other, are treated of in the same place; and similar diseases are treated of separately, instead of being classed together, and considered in one general point of view. A repetition of what may be considered as the specific characters of the disease, therefore, is constantly occurring. The utility of nosological systems in practical medicine and in pathology, has been very generally acknowledged. Diseases which have common characters are thus brought together and are arranged under classes, orders, genera, and species. It is to be considered, therefore, as an important step in order to facilitate the knowledge of the diseases of the human body, and to give clear and distinct ideas of them; for it is equally important, to be able to distinguish diseases, as to point out how they should be treated.

All nosological writers have not, however, constructed their systems on similar principles; and their efforts have been often frustrated by the false theories and hypotheses with which they have set out.

The world is indebted to the ingenious and celebrated Bichat, for the first truly philosophical view of the structure of the human body. The simple division of it into its component parts, which that great anatomist and philosopher pointed out, must be considered as the groundwork of all future anatomical and pathological inquiries.

Bichat demonstrated, that most of the organs of our body are made up of a variety of elementary parts or textures; each of which, in whatever part of the body it is found, uniformly has the same physical properties, and present the same morbid phenomena. These he considers as the elementary parts; which, by the diversity of their combinations, produce all the modifications of structure and functions exhibited in the different organs of animals. This method of considering organized bodies, accords with every phenomenon with which we are acquainted, and seems to arise from the essential nature of their constitution. We may trace this view of the structure of the body in the observations of many of the older anatomists; and particularly it may be considered as the basis of some of the most ingenious philosophical theories of the late ingenious Mr John Hunter.

In order to fix the characters of the elementary textures, Bichat employed various modes of inquiry. He performed numerous experiments on living animals; persevered in tedious and minute dissections; employed chemical reagents to supply the place of the knife; and examined with minuteness all the varieties of morbid structure. Having by these means accomplished his object in tracing the character of each separate texture, he proceeded next to investigate their combinations as they are found in the different organs.

The effects of this mode of investigating the structure of the human body when diseased, must be at once obvious. We learn from it, that diseases at their commencement are generally confined to one texture of an organ; the other textures of which the organ is composed remaining sound.

There is no organ of the body from which this important truth may not be deduced. It may be readily illustrated from considering the diseases of the mucous, serous, and muscular textures, which compose the stomach and alimentary canal; of the cellular texture of the lungs; of the mucous membrane of the bronchi, the serous one of the pleura, and many others.

But diseases are not only confined to one individual texture of any organ, as in the cases just mentioned; the symptoms and morbid changes are likewise uniformly the same in textures of a similar structure, in whatever parts of the body these textures may happen to be found. Thus the serous membranes which invest the lungs, the brain, the heart, the abdominal viscera, have one common character when affected with any specific disease: so also have the mucous membranes, whether we trace them in the mouth, the nose, the vagina, the urethra, or covering the eye-ball; and the same may be observed of every individual texture which enters into the composition of our bodies.

Besides the symptoms and morbid changes which are common to all textures whose structure is similar in the natural state, there are others which are determined from the particular functions of the organ in which the diseased texture exists. For example, when any of the serous membranes are inflamed, the nature of the pain, the degree of fever, and the duration of the symptoms, are the same, in whichever one it may have taken place. But to these symptoms are added, cough, difficulty of breathing, &c. when it happens to be connected with the organs of respiration, as in the case of pleuritis; coughs, fevers, strangury, delirium, loss of vision, when the intestines, the bladder, the brain, or the eye, are involved in the disease.

This view of the subject naturally suggests a correspondent division of the symptoms. The first class are general, and characterise a whole genus of textures; the second are in a manner accessory, and depend upon the relative situation or the particular functions of the organ into the composition of which the affected texture enters.

But here we must set bounds to this theory;—the history and progress of diseases shew, that we ought not to confine our observations within such narrow limits. The principles which have been stated, indeed, account admirably well for the propagation of some affections; and for some of the sympathies which subsist between different parts of the body; but there are other disorders which advance in a very different manner. In some diseases which are termed chronic, for example, the whole structure of an organ becomes gradually altered, although the primary affection was confined to one of its component textures. This is often to be observed in cancer, scrofula, lues venerae, &c. When cancer attacks the mamma, it is at its commencement generally confined to a small portion of that gland; but if allowed to proceed, it ultimately involves the whole gland, and the adjacent cellular and cutaneous textures, in one mass of disease.

These general observations will be sufficient to give an outline of the principles of a pathological system, founded on the basis of anatomical knowledge; and in giving an account of these diseases which more properly belong to a system of surgery, we have ventured to apply these principles. We shall, in the first place, therefore, consider the diseases of the cellular membrane; the diseases of the skin; of the mucous, serous, and synovial membranes; of bone and cartilage; of the vascular and nervous systems; and of the glands. In the second place, we shall treat of diseases which occur only in particular organs, whether from the peculiarity of their structure or functions: such are the diseases of the eyes, ears, nose, teeth, mouth, and fauces, and the organs of urine and generation. In the third place, we shall take notice of malformations, distortions, and protrusions; and in the last place, of wounds, fractures, dislocations, and such operations as are occasionally necessary to be performed on different parts of the body, as amputation, sutures, &c.

CHAP. I. Of the Diseases of the Cellular Membrane.

SECT. I. General Remarks on the Pathology of the Cellular Membrane.

The cellular membrane is distinguished from other organs, by the power which it has of throwing out granulations, by its being capable of elongation, of reproduction, and of growth when it has been divided or cut by any means.*

Suppuration also takes place in the cellular membrane, with a rapidity of which we have few examples in other textures. The fluid which is the result of this suppuration, is well known. Its colour, its consistence, and all its external qualities, have become the criterion by which we form our ideas of pus; in consequence of which, all discharges which do not resemble it, have been commonly considered as pus of a bad kind, or as Janier. This opinion, however, is false; and has been formed in consequence of a too superficial view of the different circumstances attending different kinds of discharged fluids. Certainly the pus which is discharged from a bone, from a muscle, from the skin in erysipelas, from the mucous membranes in catarrh, is of a good kind whenever the inflammation runs through regularly its different periods, and notwithstanding it is quite different in all these cases from the pus produced by suppuration of the cellular membrane. As the latter is most frequently observed, from it we have formed an idea of laudable pus, and of Janier. The cutaneous pus, the mucous pus, the osseous pus, &c. have all their proper fanies; which differ from one another as much as the natural structure and functions of the organs from which they are produced.

There are few parts of the body which have a greater number of exhalents than the cellular membrane; and this exposes it to a number of alterations of structure, such as being preternaturally diffused by the different substances which it exhales; these presenting a solid appearance, and sometimes producing a lardy substance, sometimes a gelatinous matter, and sometimes a much firmer and harder mass. The numerous absorbent vessels which are also distributed on the cellular membrane, is another cause of various diseases; every small cell being a reservoir common to the exhalents which terminate in it, and to the absorbents which arise from it.

There are some diseases, too, which produce a change in the elasticity and powers of diffusion, which the cellular membrane naturally possesses. In health it has enormous powers of diffusion, as may be observed in emphysema and in anaerca; and whenever these causes are removed, it regains its natural bulk and form. In inflammations, this property is in part destroyed, and it happens also in many of the different indurations to which it is liable. Its elasticity is also less remarkable in people advanced in life, than in children. When an old man becomes rapidly thin, the skin becomes flacid, and

* Bichat. Anatomy. Description. Chap. I.

S U R G E R Y.

Of the pathology of the cellular membrane.

The cellular membrane, when diseased, becomes sometimes extremely sensible, and the seat of acute pain, though it seems to possess no sensibility in its natural state. When either blood, milk, or lymph, are effused in it, its sensibility is not altered, and these fluids are absorbed. On the contrary, the sensibility is so much altered by the contact of urine, of bile, of saliva, and of the other fluids destined to be thrown out of the body, that often the inflammation which succeeds the effusion prevents their absorption.

As the cellular membrane enters into the composition of every organ, it is often difficult to distinguish in diseases what belongs to it from what is the attribute of the parts with which it is found. These connections, however, become manifest under several circumstances: in acute and chronic diseases it is very susceptible of being influenced by the disease of the organs. We do not speak here of the alterations produced from juxtaposition and continuity, but of those which arise in parts of the cellular membrane which have no known connection with the affected organ.

In acute diseases which affect a particular organ, as the lungs, stomach, intestines, &c. often the cellular membrane becomes sympathetically affected and the seat of inflammation and abscesses, &c. The greater number of critical abscesses arise from this connection which exists between the organ affected and the cellular membrane. In acute diseases too it is commonly the function of exhalation or absorption of the cellular membrane that is affected, and hence the sudden oedema which often accompanies them. In chronic diseases their influence is no less remarkable. It is well known, that in chronic diseases of the heart, of the lungs, of the liver, of the stomach, kidneys, uterus, &c. they have for their symptom during their last stages an anaemia, more or less general, which arises from a debility produced in the cellular system.

We observe, that in all acute diseases, the skin receives with great facility the sympathetic influence of the diseased organ, and that it is alternately moist and dry frequently during the same day. It is by no means improbable that the cellular membrane undergoes alterations analogous to those of the skin; and if we could observe what passes in it, we would discover the cells more or less moist, more or less dry, according as it happened to be influenced: it is also to this that we ought to attribute the different states of the cellular membrane, in patients who have died of acute diseases: these presenting numberless varieties in the feros effusions.

The cellular system is not only influenced by its sympathy with other organs; but it also exercises a sympathy over them. In a phlegmon or inflammation of the cellular membrane, if the tumour is considerable, often various alterations take place in the functions of the brain, of the heart, of the liver, or of the stomach. The sympathetic vomiting, &c. are those phenomena in great phlegmons which are often manifested without being considered as belonging to the disease.

Art avails itself of the influence of the cellular system being affected by other organs, in the use of fetons. Often in the diseases of the eye and of joints a feton produces an effect which cannot be obtained by a blifter; and this probably arises from the connection which exists between the cellular membrane and the eye, being more active than that which exists between that organ and the skin*.

It ought also to be remarked, in considering the pathology of the cellular system, that there is a manifest difference in the properties of the cellular texture, which is composed of layers and filaments; and in that found exterior to the different mucous surfaces, to the blood-vessels and excretories, which consists of filaments alone. From this difference results the rare occurrence of inflammations and of different kinds of tumors in the latter. It often forms a barrier where the morbid affection of the former stops, and thus protects the organ which it envelopes.

The unfrequency of hemorrhagy when extensive suppurations have laid bare large arteries is a proof of what has been said. We have seen cases where the cellular membrane contiguous to the brachial and femoral arteries has been completely ulcerated, whilst the coats of the arteries remained sound. We have observed the same phenomenon in the urethra and in the intestines. In cases of suppuration of the prostrate gland and cavernous bodies of the urethra, the canal has remained untouched; and in a case of femoral hernia, where the hernial sac, and the cellular membrane covering it, all mortified, the protruded gut remained quite sound.

The cellular membrane has also a powerful influence in the production of a variety of tumors and excrescences, forming as it were their base or parenchyma of nutrition. Encysted tumors are met with alone in the cellular texture of different parts of the body, and various kinds of solid tumors and excrescences are formed by the growth of that texture on the part where the tumor is to be developed; afterwards different substances are deposited amongst it, the difference in the nature of which constitutes the difference in the tumors.

These remarks will be sufficient to give a general view of the pathology of the cellular membrane, and will enable us to form a more comprehensive and connected view of those diseases, which may be more properly considered as coming within the province of surgery.

The diseases of the cellular membrane which we shall treat of in this chapter are, 1. Inflammation of the cellular membrane, or phlegmon. 2. Panaris or whitlow. 3. Sinuses. 4. Carbuncle. 5. Encysted tumors. 6. Steatoma. 7. Sarcoma. 8. Oedema. And, 9. Emphysema.

SECT. II. Of Phlegmon.

In most accounts which surgical authors have given of inflammation, they have taken the description of its general phenomena from inflammation of the cellular membrane.

Inflammation of the cellular membrane, or phlegmon, is characterized by a tumor more or less elevated and circumscribed, visible or not visible, according to the part where it is situated. It is always accompanied with an increased sensibility of the part, and with a lancinating or beating pain, a degree of heat, greater than natural, a bright redness, which becomes more livid as the disease advances, an elevated point; and it gradually ly turns softer from the center to one part of the circumference.

These are the symptoms which are generally to be observed more or less remarkable in every species of phlegmon. When they are slight, and when the affected part is not extensive, or very important from the nature of its functions, it generally has not much influence on the general system. But when they are more considerable, and the inflammation extends far, the pulse becomes commonly full, frequent, and hard; at the same time, the patient complains of universal heat, thirst, and other febrile symptoms.

When by the efforts of nature, or by the application of proper remedies, the pain, the heat, and the tension go away, the other symptoms, which depend in a great degree or altogether on the first which have been mentioned, disappear also, and the patient quickly recovers his health. This termination, which is commonly the most desirable, is called resolution.

But if, notwithstanding the remedies used, the different symptoms augment instead of diminishing, the tumor gradually increases in size and turns soft. A small eminence is observed towards the centre of the tumor or at some particular point, and its surface becomes polished. Soon afterwards the pain diminishes, and the febrile symptoms abate; and on compressing the tumor, the fluctuation of a fluid can be perceived in it, and this constitutes the second termination of a phlegmon, or abscess.

Of the treatment of Phlegmon.—The principal object which is to be generally kept in view in the treatment of inflammatory tumors, is to obtain their resolution; this being the most prompt and most certain mode of cure. There are, however, some cases which are an exception to this general rule; such as some inflammatory tumors which precede fevers, and other internal diseases: for it is commonly supposed that in these cases, suppuration is a mode by which nature throws off certain fluids or humours, which are pernicious to remain in the system. There are other tumors which seem to arise from internal causes, where it is perhaps better neither to attempt to accelerate their suppuration nor resolution, but to trust them entirely to nature. Such are inflammatory tumors which occur in scrophulous subjects. There are few cases of this kind where suppuration ought to be promoted, for their treatment is always embarrassing whether they are opened naturally or by art. It is well known too, that such tumors often remain a long time without any danger; from whence we may conclude, that it is most prudent not to touch them.

In the venereal disease, we have a specific for its cure; and when buboes are opened, or other inflammatory venereal swellings, they generally become very difficult and embarrassing to treat. It is therefore always most prudent to attempt their resolution.

The principal means to be employed, in order to procure the resolution of an inflammatory tumor, are local and general blood-letting, the application of heat and moilfure, &c. Leeches is perhaps the best mode of bleeding the inflamed part; but should the inflammation take place in any of the extremities, or contiguous to any of the large veins, one or other of these may be opened. There is no application which tends so much to remove the tension and pain of an inflamed part as the use of poultices or warm fomentations. Applications of a sedative nature are recommended by many, such as the different preparations of lead, the sulphate of zinc, vinegar, &c.; but as far as we have been able to observe, the use of this class of medicines has by no means such powerful effects as emollients, though it has been generally supposed that emollients hasten suppuration. In applying poultices, they should generally be removed three or four times in twenty-four hours, and the part bathed with warm water each time the poultice is changed. When fomentations are to be used, many employ warm water alone, whilst others prefer a decoction of chamomile flowers, or of poppy heads. A piece of flannel of considerable size, wet with either of these in nearly the boiling heat, is to be forcibly wrung out, and applied as warm as the patient can suffer it, to the inflamed part. A second piece of flannel is to be prepared in the same manner, and whenever that which is first applied begins to cool, the second piece is to be employed; and this practice is to be continued for ten or fifteen minutes, and repeated as often as it is found to relieve the patient. The best mode of applying the sedative remedies in external inflammation, is in the form of watery solution. Half an ounce of the acetate of lead dissolved in four ounces of vinegar, with the addition of two pounds of distilled water, is a convenient form. In making use of this solution, it is of consequence to have the parts affected kept constantly moist, and cataplams prepared with it generally answer that intention exceedingly well. But when the inflamed part is so tender and painful, as not easily to bear the weight of a poultice, pieces of soft linen, moistened with the solution should be employed. Both should be applied cold, or at least with no greater warmth than is merely necessary for preventing pain or uneasiness to the patient. They should be kept constantly at the part, and always renewed before turning dry and stiff.

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

In all cases of inflammation, the whole body, but more especially the diseased part, should be preserved as free as possible from every kind of motion, and the patient should be confined to a low cooling diet, and also a total abstinence from spirituous and fermented liquors.

In slight cases of inflammation, a due perseverance in the mode of treatment which has been mentioned, will be in general sufficient to accomplish the intended purposes; but when there is likewise a full, hard, and quick pulse, with other symptoms of fever, general blood-letting becomes necessary; and the quantity of blood taken away is always to be determined by the extent and violence of the disease, and by the age and strength of the patient. Evacuations, however, should never be carried to a greater height than what is merely necessary for moderating the febrile symptoms; for should suppuration take place after the system is too much reduced, its progress becomes more slow and uncertain; nor is the patient able to support the discharge that ensues. The use of gentle laxatives, with a cooling diet, is also attended with very good effects.

Besides these different evacuations, it is of great consequence to procure ease and quietness to the patient. The most effectual remedy for this purpose is opium, and, when the pain and irritation are considerable, as in extensive inflammations very frequently happens, it should never be omitted. In all such cases, the opium should be given in full doses, otherwise, instead of proving serviceable, it seems rather to have the contrary effect, a circumstance which is perhaps the chief reason for opiates having been by some very unjustly condemned in every case of inflammation.

By a proper attention to these different circumstances, a resolution of the tumor will generally begin to take place in the course of three or four days, and sometimes in a shorter time; at least before the end of that period, it may be for the most part known how the disorder is to terminate. If the heat, pain, and redness, and other attendant circumstances abate, and especially if the tumor begins to decrease, it is probable that, by a continuance of the same plan, a total resolution will be finally effected.

But, on the contrary, if all the different symptoms rather increase, and especially if the tumor turns larger, and somewhat soft, with an increase of throbbing pain, we may with tolerable certainty conclude that suppuration will take place; and we 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 the maturation of the tumor. To effect this, nothing is more useful than warm fomentations and cataplasms; and should these not have been employed during the former stage, the cold saturnine applications should be given up, and recourse had to the emollient remedies.

Dry cupping, as it is termed, viz. using the cupping glases without the lecarifier, applied as near as possible to the part affected, is frequently had recourse to in promoting the suppuration of tumors. It is only, however, in those in which there seems to be a deficiency of inflammation, that it can ever be either necessary or useful; but in all tumors of an indolent nature, and where there is still some probability of a suppuration, no remedy is more effectual. By these different applications, continued for a longer or shorter time, according to the size of the tumor, its situation and other circumstances, a complete suppuration may generally be at last expected.

Whilst an abscess is forming, it extends according as the quantity of purulent matter is augmented in the cavity in which it is contained; and this extension takes place towards that side where there is least resistance. It is on this account that where an abscess is deep, or covered by an aponeurosis, it extends in the interstices of the neighbouring parts, and diflects, as it were, the tendons, the muscles, and the bones, whilst in common cases it makes its way towards the skin. When matter is collected very near to the surface of the body, and is only covered by the common integuments, it speedily makes its way externally; but when it is deep, and surrounded by parts which make great resistance, purulent matter infinuates itself until it arrives at some place where there is nothing to oppose its exit; and it is observed making its escape after having made, in some cases, a very great circuit. It is generally towards the inferior parts of the body that purulent matter, in consequence of its weight, makes its route. On this account we see large abscesses open themselves most frequently at their inferior part, and from thence the advantage which is found by waiting till they open of themselves, or that they indicate the place most convenient for the opening to be made. Thus, we see abscesses formed under the temporal muscles open themselves in the mouth, and those of the loins making their appearance near the ring, or upon the anterior part of the thigh. Deep abscesses, in certain parts of the body, proceed rather towards the interior than towards the surface, because the purulent matter finds less obtruction in its passage. Those, for example, which form on the surface of the lungs, find great resistance from the ribs and other parts forming the thorax, whilst they easily make their way through the spongy substance of the lungs, and open in the ramifications of the bronchiae. For the same reason, abscesses formed in the cavity of the abdomen sometimes discharge themselves into the stomach or intestines; but as the parietes of the belly yield more easily than those of the chest, we also see abscesses of the different organs contained in the belly, discharge their contents through its parietes.

When matter is fully formed in a tumor, a remission of all the symptoms takes place. The throbbing pain, which before was frequent, now goes off, and the patient complains of a more dull, heavy, and conistant pain. The tumor points at some particular part, generally near to its middle, where, if the matter be not deep seated, a whitish yellow appearance is observed, instead of the deep red that formerly took place; and a fluctuation of the fluid underneath is, upon prelure, very evidently perceived. Sometimes, indeed, when the abscess is thick, and covered with muscle and other parts, though from concurring circumstances there can be little doubt of there being 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 on proper examination.

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

In addition to 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 easily distinguished, unless the collection is considerable; but it is a symptom constantly observed in all large abscesses; and when it takes place, along with other symptoms of suppuration, it always contributes to point out the true nature of the disease.

Of the opening of Abscesses.—When abscesses come to complete maturity, the integuments gradually become thinner over the more prominent part of the tumor; and they become ulcerated in one or more points through which the pus is evacuated. In many cases it is advisable to wait for the spontaneous rupture; but, on the other hand, it is often more prudent, and is indeed absolutely necessary, to give vent to the matter by an artificial opening. It is a general rule not to have recourse to such means before suppuration is completely formed; for if an abscess be opened before this period, and a considerable hardness remain around, the treatment afterwards becomes very embarrassing and difficult. It is, however, necessary in some cases to depart from this general rule, and to open an abscess much sooner. Above all, those which are critical, and those which are the consequence of lingering fevers.

In many cases there is neither safety nor convenience to be expected from the spontaneous opening of the integuments. In abscesses situated in any of the joints, or upon either of the cavities of the breast or abdomen, and more especially when they seem to run deep, they should always be opened as soon as the least fluctuation of matter can be discovered; for when the resistance is on either side equal, it just as readily points inwardly towards the cavity, as outwardly towards the skin; and the consequence of a large abscess bursting into either of the large cavities, most frequently proves fatal.

Abscesses are sometimes formed about the face, which point externally, and these should be opened in the inside of the mouth, in order to prevent any deformity. Whenever the fluctuation is sensible, this should be immediately done. They cicatrize very rapidly, and require no dressings.

Abscesses confined under an aponeurosis, and in general under those parts which are not capable of being extended without much difficulty, ought to be opened early. Such are abscesses which are formed under the temporal muscles or fascia lata of the thigh, or those which frequently happen in the extremity of the fingers, under the arch of the palate, round the maxillary bones, behind the ear, above the mastoid processes, &c. All these ought to be opened very speedily, and in particular those last mentioned, on account of the danger of a caries of the bone in which they lie being produced.

It is also particularly necessary to open without delay abscesses in the neighbourhood of the anus, or near the urethra. This ought also to be done in large abscesses of the extremities, and in particular those which are the consequence of violent inflammation, occupying the whole member, as the thigh, the arm, &c. If in such cases the matter be allowed to remain too long, the greater part of the cellular membrane is detached from the subjacent aponeurosis, and there often follow large gangrenous sloughs, which in separating themselves lay open extensive surfaces, and often form large bags of pus, which become as many separate abscesses; and often the disorder is such that the whole of the integuments of the member sphaeciate and fall off. It is also necessary not to delay the opening of abscesses formed among the large muscles, the interstices of which are filled up with cellular texture; such are those of the thigh, the back leg, and under the arm-pit. In these situations the matter is very apt to spread, and to form ramifications of the abscess in various directions, which, if not treated with much care, are very tedious to heal,

With the exception of those cases which have been mentioned, it ought to be observed as a general rule not to open an abscess until suppuration has completely formed; for if it be true, as it is said, that pus is always sufficiently prepared to be evacuated, it is also the case, that the more we favour its formation before giving it vent, the more we are sure of diminishing and of reducing the hardenes which exist in the neighbourhood, and facilitating the cicatization of the ulcer.

Of the different Methods of opening Abscesses.

There are three different modes of opening abscesses; viz. by caustic, incision, or seton.

1. By Caustic.—The use of caustic is recommended in cases where suppuration has been slow, and has not occupied the whole tumor; in those where the integuments have suffered much, and where it was necessary to wait long before opening it, on account of some affection of the bottom of the abscess; and in general in all cases of the suppuration of glands.

But though there are circumstances which may render it necessary to employ the caustic rather than the incision, yet the latter generally deserves the preference. The pain which it occasions lasts only a moment, whilst that of caustic lasts many hours; and when the inflamed part has acquired a morbid degree of sensibility, the pain is very violent. The surgeon also can never limit precisely the extent of the action of the caustic; and whatever attention be paid to it, it often extends too far, and penetrates too deep.

To open an abscess with caustic, an adhesive plaster spread on leather is to be applied over the tumor, with a slit in it of a size somewhat less than what is intended to be made in the skin by the caustic. The slit is to be filled with the caustic reduced into powder, mixed with a small quantity of soap, and wetted, so as to make it operate more quickly. Another adhesive plaster is then to be laid over it, and the whole secured with a firm compress and bandage. The time necessary to allow the caustic to make a sufficient opening will depend on the thickness of the skin and strength of the caustic, but generally it requires two, three, or more hours. When the effusion is made, and the matter has not escaped, we ought to assist its exit with the end of a probe, or the point of a bistoury; and the separation of the effusion is to be promoted by emollient applications.

2. By the Incision.—The tumors which are not very extensive, may generally be opened by making a longitudinal incision with the lancet, see Plate DXIII. fig. 1. For this purpose, when the situation of the abscess permits it, the surgeon is to apply one hand on the base of the tumor, and press the pus towards the skin, by doing which there is no risk of wounding any artery, or important part at the bottom of the tumor, and the lancet penetrates into the cavity of the abscess with more certainty and ease, and with less pain. With the other hand an incision of the integuments is to be made in such a direction, that it terminate at the most depending part of the tumor; and should be made of such length as may appear necessary, in order that the matter may be allowed freely to escape. It is in general supposed sufficient, in cases of small abscesses, that the incision extend two thirds of the length of the tumor. Some authors have advised, that when the integuments are much defended, an incision should be made through the whole length of the tumor, even where it is of a large size; but this practice ought to be rarely adopted. The irritation and consequent inflammation, produced from such an operation, must always be very considerable; and as it scarcely ever happens that the integuments are ever so much extended as entirely to lose their contractile power, there is always reason to hope that they will recover their natural dimensions. In all very large abscesses, it is the safest practice to make at first a small incision sufficient to allow the contents to be discharged; for whenever this is done, the extent of the cavity rather diminishes; and should it be found afterwards necessary to make a more extensive opening, this can now be done with much advantage. When an abscess has been opened by either of these methods, it is reduced to the state of a simple wound or ulcer, and ought to be treated accordingly.

The mode by incision ought to be preferred to that of caustic, when the matter is collected deep; when it is in the neighbourhood of important nerves or blood-vessels; when it is necessary to make the opening large; when the skin which is to be opened has a natural appearance; and, above all, when the ulcer is wished for to be healed rapidly up, and leave little deformity.

Although surgeons generally agree in preferring the incision to the caustic, it has nevertheless its inconveniences. Whenever the incision is made, the matter contained in the tumor is suddenly evacuated; from whence it happens, when the collection is considerable, that the patient faints, or has some other disagreeable symptoms; but the principal disadvantage of this method is, that it gives free access to the air over a large extent of the ulcerated surface; a circumstance which is followed by very pernicious effects, particularly in large abscesses. A total change takes place in the nature of the matter; a laudable pus is transformed into an ichorous indigested fluid; the pulse becomes quick; colliquative sweats and other symptoms of fever come on, and commonly the patient dies in a short time. Surgeons have too often occasion to observe the dangerous effects which probably are altogether produced by the admission of the air; for we see a great number of patients have for a long time after a termination of inflammatory diseases considerable abscesses, where the pus is perfectly formed, without shewing at the same time any symptom of hectic fever. But when these abscesses exceed a certain size, and if a large incision be made into them, there always follow symptoms of fever, generally in forty-eight hours from the time that the abscess had been opened. These accidents, which we have frequently observed in private practice, are still more frequent in great hospitals, where the air is impregnated with putrid exhalations.

3. By the Feton.—From the observations which have been already made, it appears necessary that as much precaution as possible should be taken to prevent the contact of the air with the internal surface of the abscess. The feton, therefore, has the advantage, not only of being attended with little pain, and emptying the abscess in a gradual manner, but it completely prevents the access of the air. When patients are otherwise in good health, there is another advantage in employing the feton; for frequently a cure is obtained at a period much shorter than that which is usually necessary when the incision has been adopted. On the other hand, if we have reason to wish to keep up for a long time a certain degree of irritation and suppuration in the affected part, the feton ought to be preferred to every other means. There have been various instruments contrived for introducing the feton, and it may easily be done by a lancet and common probe, or by the instruments represented in Plate DXIII. fig. 15. and 16. One of these being threaded with glovers soft silk or with cotton, should be introduced into the upper part of the tumor; but if the blunt one be employed, it will be necessary to have the assistance of the lancet. The instrument is then to be brought out at the under part of the tumor, and the matter allowed to run gradually along the threads. The feton should be changed forty-eight hours after it has been introduced, and as much of it should be pulled out at the under part as is sufficient to allow the removal of that which was shut up in the abscess. The abscess is to be dressed in this manner every day as long as circumstances seem to require.

By means of the feton, we obtain a regular and slow discharge of the matter contained in the abscess; the sides of the abscess are allowed to contract in a gradual manner; the presence and friction of the feton on the surfaces, excites a slight inflammation which contributes to unite them, and to complete an adhesion, much more readily than by any other method. In proportion as the discharge diminishes, the thickness of the feton ought to be lessened; and this is easily done by taking out some of the threads of the cotton every two or three days. It ought to be entirely taken out when no more matter is discharged than what would be produced by the irritation of the feton alone; and by compressing gently the parts for some days after it has been withdrawn, with a compress and bandage, we can in general depend upon a complete cure.

When speaking of the mode of introducing the feton, we recommended that this should be done from above downwards, because, if the first opening be made at the base of the tumor, a great quantity of matter immediately escapes. Thus the boundaries of the abscess at the upper part become effaced, and the passage of the director along the abscess is much more difficult than when the abscess is opened according to the manner we have pointed out. In that way the under part of the tumor is left completely defended till the last moments, and only a very small quantity of matter escapes by the superior orifice. Another advantage is, that the part of the feton left for the future dressings, is easily kept clean and dry.

The method of opening abscesses by the feton has been found particularly useful in suppurations of the joints, and in all those glandular parts where the admission of the air is followed by very pernicious effects. Thus, when it is thought necessary to open a crouulous tumour, we may generally be able to obtain a more prompt and easy cure from the use of the feton, than by making a larger incision. Venereal buboes, too, when come to maturity, have been said to get well much sooner by this than by any other method, when the integuments have not become too thin by great diffusion long continued. On the other hand, this mode is not without its inconveniencies, for in adopting it we cannot be well assured of the state of the bottom of the abscess, which it is often important to know.

Whatever advantages these different methods of opening abscesses may possess over one another, yet there is not one of them which deserves the preference in all cases, although the caustic, as already mentioned, be the means Of Sinuses, to which we ought most rarely to have recourse. However troublesome it may be, the action of the air on the interior surface of the abscess is not always equally pernicious; and when by properly applied dressings, care is taken not to allow purulent matter to form in any particular cavity, and to prevent the access of cold air on the surface of the wound, and above all when the surrounding air, as that in hospitals, is contaminated with putrid exhalations, daily experience shews, that the method by incision is accompanied with most success. On the other hand, we have seen the seton extremely useful in gradually discharging, and without exciting much inflammation, large abscesses.

These are the general principles we have to observe in the treatment of abscesses, in whatever part of the body they are found. There are, however, some modifications, some particular details of practice, which ought to be kept in view, when the disease is seated in particular organs, as the eyes, the mamme, the cavity of the chest, the groin, the scrotum, &c. Mention will be made of these in giving an account of the diseases of the particular organs.

SECT. III. Of Sinuses (Fistulae).

When an abscess, instead of healing continues to discharge purulent matter, and when this takes place through a small orifice, it obtains the name of a fistula. The orifice has smooth and callous edges, and the fistula commonly communicates with one or more cavities of different dimensions, situated in the cellular membrane, between the common integuments and the muscles, or between the interstices of the muscles themselves.

These different cavities, which are generally known by the name of sinuses, serve as reservoirs, both for the matter which is formed in the body of the ulcer, and for that furnished by their own sides. It is thus that when by compression, the matter contained in the sinuses is pressed out through the ulcers, these discharge a much greater quantity than what might have been expected, by considering the extent of their surface alone.

This description of a fistulous ulcer indicates the most simple form of the disease; but when it has lasted for a long time, the whole internal surface frequently becomes hard and callous, acquiring the properties and structure of a mucous surface.

The most frequent cause of the formation of sinuses is, when an abscess bursts, that the purulent matter, instead of being all discharged, remains shut up in some part of the cavity. Remaining there, it naturally falls to the lower part, and gradually infinuates itself among the layers of the cellular membrane, which, from its softness, gives little resistance; it advances by degrees among the interstices of the more solid organs, which are connected by that substance alone; and at last it makes its appearance on the surface of the body, or penetrates into one of the cavities. Both recent and old fistulous ulcers are generally curable, provided that the ulcer be situated in such a manner, that the necessary remedies can be applied to it, and that the constitution be otherwise free from disorder. But when the disease has been of very long duration, and, above all, when the sinuses open into any articulating cavity, or are placed in such a manner, that one cannot practise any operation, the treatment then becomes extremely difficult, and the event very doubtful. There is no disease which reflects more frequently all the efforts of art than certain species of fistula, and particularly some of those about the anus and perineum.

Of the treatment of Fistulae.—There are several different modes which have been proposed for the treatment of this disease, all of which may be useful in particular cases.

Injections, supposed to have a cicatrizing quality, have been proposed by some; and these are no doubt useful in particular cases, in diminishing the quantity of the discharge, and in preventing the extent of the sinus from increasing. When the disease is far advanced, and the edges become perfectly callous, injections of an echarotic quality have been employed; but these remedies have seldom, if ever, produced any good effects; and their too frequent use has even rendered sinuses hard and callous, which were of a more benign nature.

In some cases, particularly when the disease is recent, great advantage may be derived from the proper application of a compress and bandage. In applying these, the compress should be placed in such a manner, and made of such a form, as to make a firm pressure from the bottom of the sinus towards its orifice; and care should be taken that no pressure be made towards the orifice itself, in order that any matter which is formed may not be allowed to collect, but be discharged from it. Indeed in whatever mode we treat sinuses, the object to be held in view, is to allow any matter which is formed to be immediately discharged.

Some have advised, that, in all fistulae of long standing, their cavities should be laid open from one end to the other, and all the parts should be dissected out which have become hard, and thus to convert the whole into an ulcer, and treat it in the ordinary manner. There is no doubt, but that by such an operation, it will often be possible to obtain a cure; but independent of the great pain, and of the large and disagreeable cicatrix which must always follow, the practice is not without danger. It cannot answer, for instance, in those fistulas which extend far up the rectum. No practitioner surely would advise the adoption of such a method in the case of fistulas which penetrate very deep, and extend, as often happens, underneath the blood-vessels, the tendons, and the nerves; and even although this practice was without danger, it ought to be adopted in no case, as we are enabled, by an operation more simple, and much less painful, always to obtain a cure with as much certainty, as by a total destruction of the parts.

In the treatment of fistulas, it is necessary to procure an agglutination of the edges of the sinuses, so as to obliterate the cavity. The means most efficacious to fulfil this indication are, to make first an opening, so as to allow the exit of the matter; and to excite a certain degree of inflammation on the internal surface of the cavity, so as to produce an adhesion between its sides.

Both of these indications may, in some cases, be fulfilled in the most convenient manner, by introducing into the orifice of the ulcer a seton which will follow the whole course of the sinus as far as its opposite extremity. The seton should be of a size proportioned to that of the sinus; and it may be diminished by degrees as the cure advances, by taking away some of the threads day after day. At last, when the cavity of the sinus is nearly Of Sinuses, nearly filled up, and consequently the discharge much moderated, the feton ought to be withdrawn. Afterwards a bandage is to be firmly applied over the part, which should be allowed to continue a convenient time, in order to obtain a complete cure. In all cases, therefore, we ought to discover the direction of the sinus, which can commonly be done by introducing a probe, or by observing the place in which the matter collects, when it has been allowed time to accumulate, and by marking the place from whence it comes, the pressure is to be made on the affected part. A feton ought then to be introduced into each sinus.

Another means of procuring the obliteration of sinuses is, by a longitudinal incision along the whole cavity. In cases where the fistula extends to parts which it is not dangerous to cut, and where the feton has inconveniences which render it inadmissible, we should not hesitate to have recourse to this means. Indeed, the longitudinal incision of the sinus is to be considered in all cases, as the only means which can be adopted with certainty in the cure of the disease; and though in many cases it may be proper to attempt the cure by the milder means which have been mentioned, yet they often fail, and the mode by incision ought always to be held in view.

We may observe here, that this part of surgery owes much to the celebrated Mr Pott, he having rendered much more simple and successful the treatment of fistulas, particularly those situated in the perineum and anus. When a fistula is to be laid open, the first thing to be done, is to determine the extent of the incision. The exact extent of the sinus should be accurately ascertained with a probe, and it is necessary to lay it open to the extreme point, in order completely to secure the filling up of the cavity. The operation may be performed by introducing a director (fig. 9, and 12.), along the whole course of the sinus, and cutting on it with a common scalpel (fig. 1); or the sharp-pointed bistoury (fig. 4.) may be introduced along the groove of the director, the point of the instrument pushed through at the bottom of the sinus, and then, by withdrawing the director, the incision may be speedily completed with the bistoury.

A still better method is one we have often adopted in cases of sinus with the greatest advantage. It consists simply in putting a small bit of wax, about the size of a pin head, upon the end of a sharp-pointed bistoury, introducing the point of the instrument thus defended along the sinus; and when it arrives at the bottom of it, the point may be pushed through the skin, and displace the wax with very little pressure. When the point has been brought through the skin, the incision may afterwards be completed with one quick motion of the knife. In laying open sinuses in this manner, it is particularly necessary to form an exact idea of the direction of the sinus, and of the extent of the incision to be made, before attempting to introduce the bistoury. For as a very slight degree of pressure is sufficient to displace the wax on its point, any untoward motion upon the side of the abscess would thus expose the point of the instrument, and render the operation more tedious and difficult, and always more painful.

The principal advantages of this mode of laying open sinuses are, that the operation can be much more speedily performed, and that it costs much less pain to the patient. The introduction of the director through a small fistulous opening, and the tedious process of cutting through the integuments with a scalpel, cannot fail of creating much distress, whereas a thin bistoury can be introduced without giving almost any uneasiness; and after the operator has conducted its point to the bottom of the sinus, it may be pushed through the integuments, and the sinus cut open with a coup de main.

All sinuses should be laid open in this manner, which can be detected by a careful examination with the probe; and if the edges of the fistulous sore are found to have acquired a great degree of callosity, it is sometimes advisable to cut them entirely away.

The sinuses are now to be dressed by placing between the edges portions of caddis dipped in oil, or simple ointment; and great care should be taken that no portion of newly divided parts be allowed to come into contact, as there will be great risk of an adhesion taking place between them, thus frustrating the very objects of the operation. After the pledges have been introduced between the edges of the wound, it is commonly directed that the whole wound be covered up with a piece of linen spread with ointment. In place of the ointment, we have generally found a poultice answer better. The poultice, by its moisture prevents any agglutination of the lips of the wound; and it has the power of diminishing the inflammation more than any other application. The wound is afterwards to be treated on the principle of the common ulcer*.

Sect. IV. Of the Whitloe (Paronichia).

The whitloe is a painful inflammatory swelling, occupying the extremities of the fingers, most frequently at the root of the nails. Several varieties of the disease have been described by authors; but these differences only consist in the depth the disease is supposed to have been feated. From what we have been able to observe, it appears to be situated chiefly in the cellular membrane immediately underneath the skin, and in the structure connected with the nails; though at the same time the pathology of this disease is not yet well understood.

The first symptom of the whitloe is an uneasy burning fenation over the point of the finger, or root of the nail. The part becomes tender and painful to the touch; and a slight degree of swelling takes place, resembling oedema, attended by little discolouration. A transparent effusion takes place below the epidermis, and forms a vesication round the root of the nail. A purulent discharge takes place round the edge of the nail, and the nail always separates. The peculiarity in this disease is, that it generally affects several fingers, one after the other, and sometimes all the fingers of both hands.

In the more severe forms of the disease, the inflammation extends to the cellular membrane underneath the skin, and even to the tendinous aponeurosis and periosteum of the fingers, producing caries. In such cases the whole hand generally swells, and the swelling even extends up the arm and affects the axillary glands.

Whitloes sometimes succeed a blow or injury of the finger; but they most usually make their appearance without any known cause.

Treatment.—In the treatment of whitloe, two sets of remedies remedies have been employed. Some use fomentations, poultices, and leeches; whilst others apply ardent spirits, vinegar, cold water, and astringents.

Local bleeding and emollients do not seem to give the same relief in this as in other species of inflammation. When, however, the inflammatory symptoms and pain are violent, it is always necessary to take away some blood; and this may be best done at the bend of the arm. The affected part should be afterwards immersed in strong brandy, spirit of wine, or alcohol or strong vinegar. We have also seen the inflammation much abated by immersing the hand, on its first commencement, in a very large vessel of cold water.

It is only, however, in the first stages of this affection that remedies of this kind can prove useful: for, when effusion has actually taken place, and suppuration begun, that state of the disease is produced which these remedies were intended to prevent. Emollient remedies should now be employed; and whenever the presence of a fluid can be ascertained, it should be discharged with a lancet.

The wound is afterwards to be treated as a common abscess; but we may remark, that here, more than in any other part of the body, it is of the greatest importance to lay open freely every sinus, which a patient use of the probe can detect. Sinuses, situated here, never heal; and, when allowed to spread, are always attended with mischief. They destroy ligaments and tendons, or at least produce a thickening of the parts around the joints, so as afterwards to interrupt their free motion.

SECT. V. Of the Carbuncle.

The carbuncle (anthrax) may be considered as a species of phlegmon, attended with a remarkable degree of malignity, and is one of the symptoms of the plague, where that disease rages, or of typhus fever in this country. It consists in a deep-leated very hard swelling, attended with an intensely painful sense of burning in the part, and considerable discolouration of the skin.

The carbuncle is often sudden in its appearance. It is of a dusky red colour at its centre, but much paler and variegated at its circumference. Vesications appear on its surface, and when these are ruptured they discharge a dark-coloured exudate. The disease sometimes commences with symptoms of general inflammation; but most commonly it is attended with rigors, sickness, great restlessness and depression of strength, fainting, delirium, &c. A miliary eruption, or even petechiae, are also sometimes found dispersed in different parts of the body.

When suppuration takes place, several openings generally form in the skin, a thin ichorous fluid is discharged, and a dark yellow slough is observed at the bottom of the sore.

The carbuncle most frequently takes place about the back, neck, and shoulders, and is generally solitary. They are usually two or three inches in diameter, though sometimes they acquire an enormous size.

The cellular membrane and skin seem to be the principal textures affected in this disease; a great part of the former is always destroyed by the formation and separation of very large sloughs, and that of the latter by the extensive ulceration.

In the treatment of this disease great attention is necessary, not only to the local applications, but also to the general remedies.

Emollient poultices, and warm anodyne fomentations, ought to be employed during the first stages of the disease; and when ulceration of the skin has taken place, the application of an ointment, composed of a considerable quantity of the powder of opium, we have found to relieve very much the pain which the ulcerative process generally creates. The use of rags, wet with diluted nitrous acid, or a solution of lunar caustic, has been found of great use in promoting the separation of the slough, and the granulation of the cavities which remain.

When the constitutional symptoms are inflammatory in their commencement, it may be necessary to employ general blood-letting; but the fever being commonly of a typhoid form, wine, bark, and opium, ought to be freely administered. It will be also proper to prefer a generous diet, and to pay great attention to keep the bowels regular.

SECT. VI. Of Encysted Tumors.

The word tumor has been the origin of much confusion in the arrangements of diseases adopted by the most celebrated nosologists; they have employed it as a term to characterise a class, and also as expressing merely a symptom of diseases. A vast variety of diseases have been thus included under the class of tumors, diseases which are totally dissimilar, and have no analogy whatever. Anaarca, bubo, encysted tumors, scrofulous and cicirrhous tumors, warts, &c. have all been included under this class, these being as different from one another as any disease with which we are acquainted, having only one common symptom, which is that of swelling.

Mr Abernethy has lately made a very laudable attempt to arrange tumors from their anatomical structure; but, like those who preceded him, he has clasped diseases together, among which no analogy can be discovered. He divides tumors into sarcomatous, encysted, and osseous. Under the sarcoma he includes the fleatom (adipose farcoma), medullary farcoma, and others, all of which have no resemblance to each other in their history or symptoms.

The word tumor ought therefore to be expunged from nomenclature, and be no longer employed to characterise a class of diseases. Its use should be synonymous with that of swelling, and be confined to express merely an enlargement of any organ of the body, or a new growth; whilst all those diseases, which have been formerly clasped among tumors, should be arranged either according to their specific nature, or to the texture of the body in which they arise. Thus tumors, connected with lues venerae or scrofula, should be included under these general names. The fleatom, being a growth of fat, and being always formed in the cellular membrane, ought to be treated of among the diseases of that texture. Encysted tumors, being also formed in the cellular membrane, ought to be arranged among its diseases; and warts, corns, and other tumors being diseases of the skin, will be with propriety clasped among them; and the fame may be said of all other diseases which have usually received the general appellation of tumor. Chap. I. SURGERY.

Of Encysted tumor. We shall, therefore, in this section, treat of those tumors only which are formed in the cellular membrane.

Under the clas of encysted tumors (tumours enkydies, loupes cyldides), are comprehended all those tumors of preternatural formation, the contents of which are surrounded by a bag or cyst.

Encysted tumors are generally formed in the cellular membrane, immediately underneath the common integuments, they are moveable, circumcised, commonly indolent, without heat or any change of colour in the skin; and they are very slow in their formation and progress. They contain a matter more or less thick in consistence; and, according to the nature and consistence of this matter, they are distinguished by different names. They have been denominated atheroma, from the contents being of a soft cheezy consistence; melicertis, when they contain a matter of the consistence of honey; and fleatoma, when formed of fat. The fleatoma, however, ought not to be classed among the encysted tumors, as the thin cellular covering in which it is contained has no analogy in its structure to the cyst of the other tumors.

It ought to be observed, that the consistence of the matter contained within the cyst varies in every species of encysted tumor. In the atheroma and melicertis they have sometimes the consistence and firmness of new cheese, and at other times they are softer than the most liquid honey. These varieties depend on the length of time which the fluids have remained in the cysts, and in the proportion of coagulable lymph and serum, which have been separated and absorbed, and also from their having been inflamed or not, and on the extent to which this inflammation may have proceeded. Sometimes an encysted tumor is composed of different cysts, each of which contains a substance of a different nature. These different circumstances render in general the diagnosis in the varieties of encysted tumors very difficult; and happily this distinction is not necessary in practice, and perhaps ought also to be omitted in our nomenclature arrangements. The sac of an encysted tumor is generally pretty firm, and composed of concentric lamellae. We have observed some of the cysts which were nearly as firm as cartilage, having small chalky concretions formed in many parts between each layer. When the contents of the tumor are washed out, the internal surface of the sac generally appears smooth and polished; but, in others, some of the matter adheres firmly to the surface of the sac. In some cases the tumor very much resembles the hydatids found in the liver and other organs; for, besides the firm sac, there is sometimes formed within it, and apparently having no adhesion with it, a thin and very easily torn whitish bag, which contains the fluid.

Encysted tumors are very small at their commencement, and grow by almost insensible degrees. They vary a good deal in their form and size. Those which are formed in the hip, are generally round and smooth; commonly of the size of a nut, and acquire rarely the bulk of a large egg. Those which are seated in other parts of the body are more irregularly formed, and sometimes become of a prodigious size, some having been found which weighed 10, 15, and even 20 lbs. They are never painful, at least at their commencement, and the skin preserves, for a long time, its natural colour; but when they become very large, the veins of the skin are large, and become varicose; and the skin on their upper part becomes polished, and acquires a reddish colour, similar to that of a part inflamed. They seldom give pain or uneasiness, except when they receive a blow. Inflammation and pain then easily come on, and the cyst becomes ruptured, if it is not previously opened by an instrument.

Such is the usual progress of encysted tumors; and although they do not come to a rapid termination, yet this sometimes happens more readily under certain circumstances, and even before they have acquired a large size. In the hip, for example, we perceive the integuments become tender and very thin, and open before the tumor has acquired any considerable size. But on other parts of the body, and particularly the back, shoulders, and thighs, the integuments preserve their natural appearance, even when the tumor has acquired a large bulk. This appears to arise from the skin being more loose in these parts.

The situation of encysted tumors also contributes much to determine the degree of adhesion which they have contracted with the neighbouring parts. In some situations they are so detached, especially while they continue small, that they readily alter their situation by very slight degrees of pressure; but in others, particularly when covered by any muscular fibre, they are more firmly fixed from their commencement. The attachment of encysted tumors is also influenced by their remaining more or less free from inflammation; for they never become inflamed, even in the slightest manner, without some degree of adhesion being produced between the cysts and contiguous parts.

It has been generally supposed that the membrane of which forms the cyst of this species of tumor is not a new formation in this part, but that it is formed by a collection of fluid in one of the cells of the cellular membrane, which by its increase dilates the cell, and brings it in close contact with the adjacent cells so as finally to obliterate them, and increase the thickness of its own coats.

The ingenious Bichat* has shown that this opinion fo generally adopted is without foundation, and that the formation of encysted tumors more probably depends on laws, analogous to those which regulate the growth of the different parts of our bodies. He has also shown that there is a great analogy between these cysts and the serous membranes.

The cysts, like serous membranes, form a species of sac without an opening; they contain the fluid which they exhale, and they have a smooth and polished surface contiguous to the fluid, whilst the other surface is unequal, and connected with the adjacent cellular membrane.

The cysts have a similar structure to serous membranes; maceration, &c. proving them both to be composed of a cellular texture. In the natural state neither of them have any sensibility, but when inflamed they both become extremely sensible. The cysts also are evidently secretory organs, exhaling the fluid with which they are filled, and their power of absorption is also very manifest from the spontaneous cures of some encysted dropsies.

These considerations led Bichat to conclude that there exists a perfect resemblance between the cysts of Of Encysted the encysted tumors and the serous membranes. An important question here presents itself, to know how these cysts are formed, how a membrane which did not exist in the natural state can be produced, can grow, and even acquire a considerable development under certain circumstances? The mechanical explanation of these phenomena which has been already mentioned, though it at first sight may appear simple and satisfactory, yet it is by no means conformable to the usual proceedings of nature. How does it happen that as the cysts and serous membranes are analogous, that these membranes are formed in a different manner, the serous membranes being never formed from a compulsion of the cellular membrane? How is it, if the cells are applied and compacted with one another so as to form a sac, that the neighbouring cellular membrane does not disappear, or even diminish, whilst the sac acquires a large bulk? These reflections would lead us to believe with Bichat, that the common manner of explaining the formation of cysts is essentially different from the manner in which nature generally follows in all her operations.

Bichat ingeniously remarks that all tumors which vegetate externally, or appear internally, are formed and grow in the same manner as the cysts, there being no difference between these two morbid productions but in the form in which each of them appears. Most tumors throw out upon their external surface the fluid which they separate. The cyst, on the contrary, exhales that fluid from its internal surface, and preserves it in its cavity. "Suppose a fungous tumor in suppuration (says Bichat), transformed in a moment into a cavity, and the suppuration to be transported from the external surface to the sides of the cavity, that cavity will then become a cyst.—Reciprocally, suppose a superficial cyst, the cavity of which is obliterated, and of which the fluid is exhaled from its external surface, you will then have a tumor in suppuration.

"If therefore the form alone establishes the difference between tumors and cysts, how does it happen that the formation of the latter is not analogous to that of the first? or has ever any one attempted to attribute the formation of external or internal tumors to compression? We ought therefore to conceive the production of cysts in the following manner: they begin to be formed in the cellular membrane by laws analogous to those which regulate the general growth of our bodies, and which appear to be deviations of these fundamental laws of which we are ignorant. When the cyst is once formed, exhalation begins to take place, and though at first in a small degree, it at last augments in proportion to its progress. The increase of the exhalent organ then always precedes the accumulation of the exhaled fluid, in such a manner that the quantity of the suppuration of a tumor is always directly in proportion to its bulk *."

This mode of explaining the formation of cysts appears much more conformable to the laws of nature than that which has been formerly mentioned and generally received. But it still remains to determine the precise mechanism of the origin and growth of cysts, and consequently of all other tumors. We ought to stop where the first causes commence; and as we do not know the mechanism of the natural growth of our organs, how ought we to guess at that of morbid productions which depend upon the same laws. It is a great deal in the economy of our organs to point out analogies, and to show the uniformity of a phenomenon not understood with one in regard to which all the world agree. Much would be done for the benefit of science, if in all its branches we could demonstrate that principle on which depends such a great number of effects, that nature, avaricious in her means, is prodigal in her results; that a few causes preside over a multitude of effects, and that the greater number of those regarding which we are uncertain, depend on the same principles as many others which appear to us evident.

Of the treatment of Encysted Tumors.—Encysted tumors, though not dangerous, are often inconvenient from their size, situation, and from the deformity which they produce, so that whenever their removal becomes necessary, this can be done alone by a surgical operation.

If the tumor be of the thin or melicris kind, which by the for the most part will be the case when a distinct fluctuation is perceived in it, it ought to be treated as a common abscess. If the tumor be small, the matter may be discharged by laying open the most dependent part of it with a common lancet, and treating it in the ordinary way till the sides of the cavity come in contact by adhesion, or by the process of granulation.* But when the tumor is more considerable, the free admission of air into the interior of its cavity is always dangerous; and we ought to be attentive to prevent its effects by making the opening in such a manner, that the wound be exposed as little as possible. When treating of abscesses, we have recommended the passing of a leton or cord through them, as the best method of opening them when they are of a large size. This method is also very convenient in the case of encysted tumors, which contain a matter of a liquid consistence. It will only be necessary here to observe, that the leton should traverse the whole tumor, from the superior part of it to the most depending point, and that the inferior opening should be sufficiently large for allowing the matter to be freely discharged. This method often answers extremely well; and cures have been performed by it which could not have been obtained in so short a time in following the ordinary method of treatment by incision. But this method cannot be employed, except in those cases in which the contents of the tumor are so liquid as to be easily discharged by a small opening. When it is of too firm a consistence to admit of the leton, the contents must be emptied, either by making an extensive opening into the cyst, or the cyst and its contents may be dissected out.

When an encysted tumor adheres so firmly to the contiguous parts, as to render its removal tedious and difficult, it is often better not to undertake the operation. In such a case it will be sufficient to lay open the tumor its whole length, and to cut away any portions of the cyst which can be easily detached. The contents of the tumor will in this manner be completely removed, and the cure will be effected, either by keeping the wound open till the cavity of the cyst is filled with granulations; or it may be attempted by drawing the divided edges of the skin together, and applying moderate pressure, so as to produce adhesion within the sides of the cavity. It sometimes happens, however, that from the adhesion being complete, the remaining portion tion of the cyst forms as it were the nucleus of a new tumor.

Operation.—When it is determined upon to remove the cyst completely, the first step of the operation is to make a free incision through the integuments covering the tumor with a common scalpel *. If the tumor be not very large, a longitudinal incision will answer the purpose; but should the tumor be of such a size, that the whole integuments covering it are too large to lie neatly upon the wound, it is much better to remove an oval portion of them †. The size of this portion must be left entirely to the judgement of the operator, who should always take care that a sufficient quantity is left, so as completely to cover the wound. After the skin is divided, the cellular membrane should be dissected back, so as distinctly to expose the surface of the sac; and as the sac will be generally found loosely attached to the adjacent parts, it may be easily separated by a very simple dissection. In removing encysted tumors, it is particularly necessary to cut fairly down upon the sac; for if this be not done, instead of the tumor being readily turned out of the sheath of loose cellular membrane which surrounds it, it can only be removed by a very tedious process of dissection. Some surgeons have recommended that the contents of the tumor should be removed, before attempting to dissect out the sac; but if the incision of the integuments be made sufficiently large, this may be generally avoided. We have often observed the operation of extirpating encysted tumors, and indeed tumors of every description, rendered extremely tedious by a want of proper attention to this step of the operation. We would therefore particularly recommend, that in the extirpation of all tumors, the incision of the integuments extend both above and below the tumor a considerable way, proportioned in all cases to its bulk and easy access.

In some cases it is advisable to open the cyst, and remove its contents, before an attempt be made to dissect it out. This practice will only be necessary in cases where, either from the shape or situation of the tumor, it is impracticable to pass the knife round it, and where, from the situation of important parts at its base, the dissection is rendered very nice and delicate. We remember a case of encysted tumor closely attached to the capsule of the knee joint, where great advantage was derived from operating in this manner. Whilst the tumor remained defended, it was impossible to separate it, without running great risk of cutting, either into it, or into the cavity of the knee joint. When, however, its contents were removed, the tumors could be readily dissected from one another, without the smallest risk of injury.

After an encysted tumor is extirpated, if any artery bleed very profusely, it ought to be secured by a ligature; but this should always be avoided as much as possible, as ligatures are apt to interfere with the adhesion of the lips of the wound. At the same time it is always necessary that the bleeding be completely stopped before the wound is dressed; for should any hemorrhagy take place after the dressings have been applied, it is very apt to displace the edges of the wound, and prevent them from adhering by adhesion.

Vol. XX. Part I.

The edges of the wound are to be placed accurately together, and kept in contact with adhesive plaster, a compress and proper bandage being applied over it. The wound is to be treated in the usual manner, removing the dressings whenever they become foiled, and the application of the adhesive plaster continued till a complete cicatrization has taken place.

SECT. VII. Of the Steatoma or Fatty Tumor (B).

This species of tumor consists of a mere accumulation of cellular membrane and fat in a particular part of the body. They occur frequently, and are formed most commonly on the front or back part of the trunk of the body, and sometimes in the extremities. They generally grow in a slow and progressive manner, and the blood-veins are neither large nor numerous. They have always a thin capsule of common cellular substance; and this capsule seems merely to be the effect of that condensation of the surrounding cellular substance which the prelude of the tumor occasions. "As the growth of adipose tumors is regularly and slowly progressive, and as nothing like inflammation in general accompanies their increase, their capsules afford a striking instance of an investment acquired, simply by a slight condensation of the surrounding cellular structure, unaffected by inflammation*." When the * Abercane, which is extremely thin, and which adheres but netky's slightly to the tumor, is removed, the tumor within consists of a mere piece of fat, more or less compacted according to its situation, in the body, and the length of time which it has remained.

Of the treatment of the Steatoma.—When a steatoma is small, when it causes little deformity, and when it does not seem to injure the functions of any organ, it is most prudent to allow it to remain. They sometimes, however, acquire a very large bulk, and from their situation are extremely inconvenient and unseemly, and they then become an object of medical treatment. No external application was ever known to be useful in discharging tumors of this kind; and the only means to be employed for removing them is by an operation. There is indeed no species of tumors that can be dissected out with so much celerity, or with such apparent dexterity. In some cases, however, if inflammation has been induced, the capsules even of these tumors are thickened, and adhere so as not to be separated without difficulty from their surface.

In dissecting out a tumor of this kind, the same general rules may be followed as we mentioned when treating of encysted tumors. The external incision should be made very free, and it is also of great importance to cut completely down to the capsule of the tumor, before attempting to dissect it out.

SECT. VIII. Of the Sarcoma or Fleshly Tumor.

Our knowledge of the pathology of tumors of the cellular membrane is yet too limited to be able to arrange them in any systematic form; and it would be foreign to our purpose to attempt in this place the investigation

(b) Steatoma, adipose sarcoma of Mr Abernethy. investigation of the subject. We have adopted the term sarcoma as very general; and include under it all those swellings or wens of a fleshy feel, which occur in the cellular membrane throughout the body.

The basis of these tumors, as we before mentioned, is the cellular membrane; and the difference in the qualities of the substances deposited in the cells gives the peculiar appearance to the tumor.

The vessels which pervade them are either larger or smaller, and more or less numerous. They are also distributed in their usual arborecent manner, without any describable peculiarity of arrangement.

When tumors of this kind have attained a considerable size, the superficial veins appear remarkably large. They have little sensibility, enduring a rough examination.

This kind of tumor generally grows till the skin is so distended that it ulcerates, and exposes the new formed substance, which floughs away. In this manner does the disease occasionally terminate; but such is the constitutional irritation attending this process, and the disgusting loath and frightful appearance of the part, that the surgeon generally recommends its removal. In some instances farcomatous tumors are composed of a number of irregular-shaped masses, which from their resemblance to the pancreas have been called by Mr Abernethy the pancreatic sarcoma, and considered as a distinct species. "This new-formed substance is made up of irregularly-shaped masses, which in colour, texture, and size, resemble the larger masses composing the pancreas. They appear also to be connected to each other like the portion of that gland, by a fibrous substance of a looser texture." Other farcomatous tumors are composed of a number of cysts, containing sometimes a transparent and sometimes a dark fluid; and have been called by Mr Abernethy, the cystic sarcomas.

The Mammary and Tuberculated Sarcomas are also other two species enumerated by Mr Abernethy. In the first the structure of the tumor has been supposed to resemble the natural structure of the mamma, and in the second the tumor "consists of an aggregation of small, firm, roundish tumors of different sizes and colours, connected together by a kind of cellular texture. The size of the tubercle is from that of a pea to that of a horse-bean, or sometimes larger; the colour of a brownish red, and some are of a yellow tint (c)."

These different terms employed to characterize the various kinds of swellings which form in the cellular membrane, are by no means adequate; and tumors will be daily met with which it is impossible to assign to one or other of these species. This subject therefore still remains open for the investigation of future inquiry.

And it is probable, that when the subject is better understood, the surgeon will not on all occasions be obliged to have recourse to the knife; and that he will be able to distinguish those which may be allowed to remain, or as harmless treated by external applications, from those whose nature is more malignant, and require an early extirpation.

Treatment.—When farcomatous tumors are painful and tender to the touch, advantage may be had by local blood-letting, either by leeches or cupping. Fomenting the parts with a decoction of chamomile flowers or poppy heads, and applying a solution of muriate of ammonia or of vinegar, and acetate of lead, are also useful in diminishing their bulk. Frictions with unctuous substances, as mercurial ointment and camphor; camphorated spirits, aqua ammonia and oil; tincture of cantharides—have been used for the discussion of indolent swellings: Soap and mercurial plasters have been also much commended by some; but all of these remedies perhaps there is none more useful than friction with the dry hand. The mode by which this practice is to be conducted is particularly mentioned under Swellings of the Joint. While we employ these applications to the tumor, we ought also to prescribe purgative medicines every second or third day, enjoin an abstemious diet and rest. An alterative course of medicine is also supposed to be useful. Small doses of calomel or corrosive sublimate are given for this purpose. The extract of hyoscyamus and calomel, or calomel and the extract of cicuta, has been much extolled by some.

By caustic.—Some surgeons (and it is a favourite practice with all itinerants) have attempted to remove tumors with caustic; and though this mode is much more painful and more clumsy than the knife, yet there are some cases, where, either from the tumor being situated, or from the patient being timorous, this practice may be referred to.

Where a tumor is to be removed by caustics, the common caustic potash will answer the purpose extremely well. This is to be placed over a sufficient bulk of the skin, and allowed to remain longer or shorter according to the depth of the tumor, and the portion of it intended to be removed. After the dead portion has separated by the assistance of poultices, &c. the caustic may be again renewed until the whole mass is destroyed. Equal parts of red precipitate and burnt alum forms a very active caustic, and is used by some; but it creates great pain. By mixing opium with the caustic, the pain has been alleviated.

By incision.—When a farcomatous tumor is to be removed by incision, the surgeon should always keep in remembrance, that whilst the tumor is growing, the contiguous cellular membrane is generally condensed, and is formed into a kind of capsule. A knowledge of this not only renders the extirpation of the tumor much easier, but tumors may be cut out from a depth, and from connexions, apparently dangerous. The integuments are to be freely divided, and the incision carried down to the capsule of the tumor, before we attempt to dissect it from the contiguous parts; if this be not done, the dissection becomes more tedious and difficult, and more blood is lost than what was necessary, from vessels being divided which might have been saved; and if the tumor happen to be deeply seated, its extirpation even becomes impracticable. The general directions given for the extirpation and after treatment of encysted tumors may also be applied to the farcomatous tumors.

(c) Another species of sarcoma has been termed the oftea sarcoma, from bony matter being formed in the tumor. Sect. IX. Of Oedema.

Oedema consists in the effusion of a watery fluid in the cellular membrane of any part of the body.

The swelling in oedema is not circumcised. The skin of the swollen part retains its natural colour, and sometimes becomes paler than natural, having a gloomy hue. The part has a cold feeling; and pressure made by the point of the finger forms an impression or dimple, which remains for some time after the finger is removed, and disappears slowly. There is no acute pain, but there is an uneasiness or sense of weight and tightness in the part. If a limb be oedematous, the magnitude of the swelling is always increased or diminished, according as it is placed in a depending or horizontal posture. Oedema always arises from the want of proper balance in the functions of the exhalent and absorbent systems, and it appears both in a constitutional and local form. Contusions, sprains, the long use of relaxing poultices and washes, are often local causes of oedema. More or less oedema is conjointly with erysipelas inflammation, and this sometimes terminates in gangrene. A part which has been acutely inflamed often remains oedematous for some time afterwards. It is also often owing to some impediment which prevents the return of the blood to the heart. Pressure of the gravid uterus on the iliac veins often renders the lower extremities oedematous. Aneurisms and other tumors, by compressing the veins of the extremity, often produce this affection. It also accompanies afecites, hydrothorax, &c. &c.

Treatment.—As an oedematous swelling is generally the effect of some other disease, the cure must depend upon the original disease being removed.

If the limb be the part affected, it should be kept in a horizontal position. Frictions made on the part with flannel, and a moderately tight roller, applied from the toes upwards, have a powerful effect in diminishing the swelling. The operation of these means is to be assisted by giving purgatives and diaphoretics. See Medicine.

If the tumor become so tense as to create much pain and inflammation of the skin, these are better moderated by the discharge of the fluid by means of a small puncture, than to allow the integuments to burst. A puncture is, however, not void of danger, for wounds in droppical constitutions generally excite a great degree of inflammation, and are apt to become gangrenous. The puncture should be made upon the most prominent parts of the swelling with the point of a lancet; and as the fluid which oozes out is apt to create great irritation of the tender skin over which it flows, it is a proper and very useful precaution to keep the skin always covered with some unctuous adhesive substance. For this purpose the unguentum resinosum is very well calculated.

Sect. X. Of Emphysema.

Emphysema consists in an effusion of air into the cellular membrane of any part of the body.

The swelling is without pain, and colourless; and it is easily distinguished from oedema, by the noise and particular feeling it has when pressed upon. It then makes a crackling noise, and resembles the feeling created by pressing a dry thin bladder half filled with air. The swelling is not heavy. At its commencement, it only affects one part; but it soon spreads over the body, and distends the whole skin.

Emphysema generally arises from a wound of the lungs; often from a spicula of a broken rib*. It has * See also been known to arise from an ulceration in the Wounds of lungs; but this seldom happens, as the inflammation attending the formation of the matter condenses the contiguous vesicles, and produces adhesions between the lungs and cavity of the thorax.

Emphysema has also been sometimes observed in some putrid diseases. Dr Huxham has recorded a case of this kind in a tailor who was attacked with putrid fever and sore throat †.

A partial emphysema has also been observed in cases of gangrene. Dr William Hunter has mentioned a case of that kind.

The treatment of emphysema must always depend on the nature of the original disease. It may be here, however, remarked, that the effused air is readily absorbed, and creates no inflammation or any change in the cellular structure where it had been effused.

Chap. II.

Of the Diseases of the Skin.

Sect. I. General Remarks on the Pathology of the Skin.

There are a considerable number of diseases which arise in the different parts which compose the skin; and there are others which seem to be the effect of that sympathy which the skin has with most organs of the body.

Of the diseases which attack the skin, there are five classes. In the first, the papillae are affected; in the second, the cellular membrane contained in the areola of the skin; in the third, the rete mucosum or capillary net-work, from which the exhalents arise; in the fourth, the cutis vera or chorion; and in the fifth, the epidermis or scarf skin.

1. Under the diseases of the first class, or those of the papillae, may be considered all those in which an alteration in the sensibility of the skin takes place. Whenever inflammation affects the skin, this alteration of sensibility is perceptible; and in some of the nervous diseases of women it is very remarkable; for on touching the skin a little roughly, convulsions are produced. It is also well known the effect of titillation on the skin; and perhaps an application of this knowledge might be extremely useful in the treatment of some diseases.

2. We have examples of the second class of diseases of the skin, where the areola of the cellular membrane of the cutis vera becomes inflamed, in boils and perhaps also in smallpox, and in some of those tumors commonly called pimples of the skin.

3. The rete mucosum, from its vascularity, is probably the seat of erysipelas, measles, scarlatina, and that multiplicity of eruptions to which the skin is subject.

4. In elephantiasis, cancer, &c. and in general in all chronic cutaneous diseases, the cutis vera is affected; it appears, however, to be seldom primarily affected in acute diseases.

5. The epidermis is passive in all the diseases of the skin, and is only affected by its continuity. Its sensibili- Disease of the Skin is never increased, nor is it susceptible of being inflamed, and consequently it never forms adhesions. Its internal surface, too, raised by a blister or any other means, and applied to the parts below, never reunites. The excrescences which form on it, such as corns, &c. are dry and inert, and without circulation; if they are painful, it arises alone from their pressure on the nerves of the subjacent parts.

From all these different affections of the skin, a number of sympathetic affections arise which it is worth while here to remark, though only a few of the diseases of this organ come properly within the limits of a system of surgery.

1. Every time that the papillae are much excited in irritable people, as in titillation, various organs are sympathetically affected by it. Sometimes it is the heart; hence follows fainting. Sometimes the stomach, and in two cases mentioned by Bichat, the persons vomited. Sometimes it is the brain, as is observed in people, where tickling brings on laughter, and even violent convulsions.

* Bichat Anatomie Generale, tom. iv. p. 73.

"Medical men," says Bichat*, "are often astonished at the extraordinary effects which quacks produce on the body from the knowledge they have acquired of the sympathies of the skin produced by titillation. But how should we be more astonished at this, than by vomiting produced by diseases of the womb, than by diseases of the liver being brought on from a injury of the brain, or by headaches arising from a disordered state of the gastric viscera?" The influence of titillation of the skin may be of much use in the treatment of some diseases. In hemiplegia, &c. would not the excitement of the foles of the feet, which have so much sensibility, as every one knows, not answer much better repeated ten or twelve times a day, than the application of a blister, the irritation of which continues only during a short time.

From this sympathy which the skin has with the distant organs, we may be perhaps able to explain satisfactorily the influence which friction has been lately found to have in some diseases. Mr. ________, an ingenious surgeon at Oxford, has employed this remedy to a very great extent in diseases of the joints; and he has experienced from it the best effects†.

2. Whenever the exhalents of the skin, or the exterior capillary system from whence they arise, are affected in any manner, a number of other parts participate, and thence arises a second order of sympathies of the skin.

There are few organs which have more sympathy with the skin than the stomach. The bath, which acts upon the skin, during digestion affects sympathetically the stomach, and disturbs its functions. When that organ is spasmodically affected, it often is referred to a state of health, by the influence it receives from the bath. Bichat mentions a case of a woman who was troubled with constant vomiting, in consequence of suppressed menses; and who was immediately relieved by the warm bath after other remedies had failed.

The action of cold on the skin produces a variety of sympathetic effects; above all when that action takes place during perspiration. It is also well known what a number of phenomena result from a sudden disappearance of many eruptions of the skin.

3. When the cellular membrane contained in the areola of the skin, becomes inflamed, as in boils, pustules, &c. a number of sympathies ensue, which may be referred to the cellular system in general *.

4. The diseases of the cutis vera and epidermis being all of a chronic nature, their sympathetic affections have the same character, little more being known of them.

We have also mentioned, that besides diseases of the skin, arising from a change of structure in that organ, there were also others which arose from the sympathy it has with other organs. Whenever a cold body enters the stomach whilst there is a perspiration on the skin, the perspiration instantly stops. The entry of warm drinks into the stomach, and an augmentation of the cutaneous exhalation, are two phenomena which coincide at the same moment, in such a manner, that one cannot attribute the second to the absorption of the drink, to its passage to the venous blood through the lungs, and then to the arteries. The production of perspiration is, therefore, analogous to the suppression of it in the former instance. Hence will be found a great variety of phenomena in different diseases, arising from the sympathy existing between the skin and the other organs, various degrees of dryness, of moisture, and of perspiration. Sometimes these phenomena are chronic. In many organic diseases, different kinds of tumors are formed on the skin, in the same manner as we observe petechiae, miliary eruptions, &c. &c. produced in acute fevers; the difference being merely in the duration of the periods of the sympathetic affections.

The diseases of the skin form a very important class in a system of nology. There are, however, only a few which ought properly to be considered in a system of surgery.

It is the seat of all eruptions, as smallpox, measles, and a vast number of other diseases. It is liable to inflammation, suppuration, and gangrene. It is also subject to diseases and injuries from its exposure to the action of external bodies, and from serving as a defence to the internal parts. It is also subject to cancer, warts, and other excrescences, the treatment of which more properly belong to the surgeon.

SECT. II. Of the Erysipelas, or the Rose.

The rose is sometimes a local disease; at other times it is merely a symptom of some other affection. It differs from all other inflammations in the peculiar shade of red colour, and it is also remarkable for the disorder which it generally creates throughout the whole system. The part of the skin which is affected becomes of a bright scarlet colour, with a tinge of yellow; and towards the termination of the complaint, the yellow becomes more discernible. Besides the difference in the shade of red, the swelling is neither so hard, so elevated, nor so circumcised as that of phlegmion. The skin has a glossy smooth appearance, a burning heat, and on its being touched with the finger, the scarlet colour disappears where the pressure is made, leaving a white spot, which, however, is almost immediately replaced when the finger is removed. The pain attending the disease is sometimes very great; there is also always more or less swelling of the parts affected and those in the immediate vicinity; and this seems chiefly to arise from a watery effusion in the cellular membrane.

The rose is very apt to spread rapidly to a great extent; Chap. II.

S U R G E R Y.

Erysipelas, tent; and it frequently changes its situation, growing gradually well in one side, and extending itself on the other. Sometimes it disappears entirely at one place, and attacks some other. As the disease gets well, the cuticle peels off from the affected part.

Erysipelas may be combined with phlegmon (erysipelas phlegmonoides), in which case the inflammation is of a deeper red colour; the swelling is also greater and deeper, and the pain is more acute. There is also a throbbing in the part, and the pulse is full and hard.

There is also a particular species of erysipelas called St Anthony's fire, in which small vesicles are formed on different parts of the skin. These burst, and discharge a thin fluid which forms a scab, and beneath the scab suppuration sometimes takes place.

The true erysipelatous inflammation seldom suppurates, but generally terminates by resolution; very violent cases sometimes cause gangrene.

When erysipelas is accompanied with inflammation of the cellular membrane, as there are no distinct limits of the disease, the matter which is formed in those cases which advance to suppuration, often extends very far in every direction, and sometimes produces very considerable floughing, not only of the cellular substance, but of the fasciae and tendons beneath the skin. Erysipelas is generally accompanied with all the symptoms of general fever, and these occur in a very considerable degree, even where the external inflammation is extremely slight. Languor, lassitude, weakness in the limbs, headache, loss of appetite, oppression about the stomach, precede the appearance of the local complaint. The most violent form of erysipelas is most frequently seen attacking the face, producing a great deal of general fever, often accompanied with delirium; and in a few cases we have known it to proceed so far as to inflame and suppurate the membranes of the brain. Erysipelas seems to be intimately connected with the state of the general constitution. Persons in the habit of drunkennels and other species of intemperance, and who, when in a state of intoxication meet with local injuries, often have erysipelatous inflammation in consequence of these. In general, erysipelas has its principal source in a disordered state of the chylopoetic vasa, and the wrong state of the bilious secretion. It seems also to be often connected with a suppression of perpiration, for it never recedes until that symptom is relieved.

Of the treatment of Erysipelas.—The mild erysipelas is to be relieved by the exhibition of gentle diaphoretics. A few doses of nitre, in order to promote the ordinary evacuations, and the general attention to the antiphlogistic regimen.

It is also of great importance to attend to the state of the bowels, and to give purgative medicines, both with a view of removing any feculent matter contained in them, and as a general evacuant.

When the case is conjoined with phlegmon, and when there are strong symptoms of inflammatory fever, venesection becomes necessary; and this is particularly the case when the face is the seat of the disease. Copious bleeding, however, is generally hurtful, and no blood ought ever to be taken away when the functions of the abdominal viscera are much disordered.

When the patient has a very foul tongue, a bitter taste in his mouth, and a propensity to vomit; if these symptoms cannot be removed, purgatives and emetics become necessary. Indeed, in almost all severe cases, Erysipelas, an emetic is indicated, and ought even to be repeated, should the symptoms remain severe.

There has been a great variety of opinions with regard to the external treatment of erysipelas; some recommending the part to be kept dry, of a moderate warmth, and excluded from the air: others have used warm or cold moist applications. The practice of Default is perhaps the most judicious. In those cases of erysipelas which were produced from an internal cause, no topical application is to be employed, except, perhaps, dusting the part with flour; but when any species of erysipelas succeeds a contusion, a wound or an ulcer, the regimen and internal medicines are insufficient, if proper topical remedies are not at the same time employed to alleviate the local irritation. In this point of view Default employed poultices, the good effects of which in these sort of cases were confirmed by numerous observations. He considered it, however, as an essential precaution not to extend this topical application further than the bruised part, or the edge of the wound or ulcer. If any application is made to the erysipelatous surface, it ought to consist merely of a weak astringent solution: that which was always employed at the Hotel Dieu, consisted of a scruple of the extract of lead in a pint of water.

SECT. III. Of the Farunculus or Boil.

The farunculus appears to be an inflammation of the cellular membrane of the areola of the chorion; the other inflammations of the skin and cutaneous eruptions being seated on the corpus reticulare. The farunculus is a circumscribed, very prominent, and hard tumor, of a deep red colour; and they vary, from the size of a pea to that of a pigeon's egg. They are extremely painful, and are seldom attended with fever. They are also most frequent in young people. Boils generally pass into a more or less perfect kind of suppuration; a small white spot is formed on the apex of the tumor, which, when it has reached the skin, discharges but a small quantity of pus in proportion to the bulk of the swelling. Before the tumor begins to subside, a yellow flough, formed by a portion of dead cellular membrane, comes out.

As swellings of this kind almost always suppurate, and as induration constantly remains after an incomplete resolution of them, we ought to promote suppuration by using emollient applications. Emollient poultices are best for this purpose. When a quantity of matter is collected, it is sometimes advantageous to open the boil with the point of a lancet, then to allow it to remain until the skin ulcerates. Gentle aperients and antiphlogistic regimen ought not to be omitted.

SECT. IV. Of the Chilblain.

The chilblain is a painful, and very often an extremely itchy swelling of the skin of an extreme part of the body, in consequence of exposure to extreme cold, or sudden change from a very cold to a warmer atmosphere.

Chilblains are most frequent in young people of sanguineous constitutions, and in this country the disease is most prevalent during the winter months. It appears most commonly on the toes and heels, and sometimes also on the fingers, and parts where the circulation is most languid.

The first symptoms of the disease are a paleness of the part, which is quickly succeeded by more or less redness, a very troublesome itching, and sometimes pain. The skin gradually acquires a purple hue; the part swells, and the cuticle separates from a serous effusion which takes place below it. Beneath the cuticle an ulcer appears of a very irritable appearance, and accompanied with great pain. This ulcer spreads rapidly, has very acute edges, and its surface is of a dark or rather dirty yellow colour. Sometimes the ulceration penetrates as low as the tendons, or even exposes the surface of the bones, producing a sphacelation of an extremity.

In the treatment of chilblains, before the skin has ulcerated, the principal attention ought to be paid in keeping the affected part of an equal temperature, and to rub it over with stimulating applications. Camphorated spirit, spirit of turpentine, &c. have been generally recommended for this purpose; but we have found the tincture of catharides, properly diluted, to be much more efficacious. A drachm of this tincture to an ounce of the tincture of soap, will be generally found to answer extremely well; and this is to be rubbed on the part once or twice a day.

When vesications begin to appear, and ulceration has taken place, emollient poultices should be employed; but after this process has gone on a certain time, and the pain and irritation abated, much benefit will be experienced by the application of the red precipitate ointment to the ulcers. Under this treatment we have repeatedly observed large ulcers of this kind heal with unusual rapidity.

Rest and a plain nourishing diet will be commonly best suited to people with chilblains; and should symptoms of debility and a floughing of the sore ensue, it may be even necessary to give freely wine and bark.

SECT. V. Of Cancer of the Skin.

The skin is frequently attacked with cancer. That of the face is more particularly exposed to it; and this no doubt arises from its delicacy, from the great number of vessels which penetrate it, and perhaps also from its more frequent exposure than any other part of the body to external irritations. Cancer, however, is not confined to the skin of the face; it frequently appears on the back of the hands, and on the feet. Wifeman has seen it on the cranium, Gooch on the inside of the thigh, Richter at the umbilicus; and we have seen an example of it in the skin above the pubes.

When cancer affects the skin, it begins in the form of a small, hard, and dark-coloured wart, which increases very slowly in size; the contiguous skin becomes hardened, forming a stool or button around the wart. The progress of the disease in the skin has been always observed to be more slow than cancer in any other part; so that it often remains in the form of a black scab for many years. The scab at last separates, and then an ulcer of the skin is exposed, having all the characters of the true cancerous sore. It has a pale colour, ragged hard edges, and unequal surface; and it gradually extends in an irregular manner along the skin; the hard tumor which forms its basis, at the same time increasing in size. Instead of pus, the ulcer discharges a thin ichor, which reddens and excoriates the adjacent skin. The disease which, when in the form of a scab gave little uneasiness, now becomes painful; and the patient feels more or less frequently sharp lancinating pains darting through the tumor, and extending from it to the adjacent soft parts.

When a cancerous affection of the skin is examined after it is removed from the body, it has all the leading characters we have described in our general observations on cancer*. The great degree of hardness of the morbid mass, is produced from the formation of the hard fibrous-looking matter observed in all cicrhorous tumors; and the direction of its fibres will be generally found extending from the base of the tumor to the surface of the skin.

Cancer of the skin follows the same progress as cancerous affections of other textures; the contiguous glands become enlarged and ulcerate; and both the ulcers which these form, and the primary one, spread over whatever parts they meet, till they destroy the patient.

Treatment.—The success which has been attributed to various medicines, particularly to arsenic and strong corrosive applications, in the cure of cancer, has been chiefly from the use of these medicines in cancerous affections of the skin. From the disease being observed in the skin before it has far advanced, from its slow progress in that part, and the ready application of remedies, it affords better opportunities of experiment than other parts of the body when affected with that disease. Past experience, however, leaves us but little room to hope for a cure of cancer in the skin by any external application with which we are as yet acquainted; and we know of no remedy to be trusted to but the complete excision of the diseased parts.

The more early the diseased skin is removed, the greater is the chance of a permanent cure of the disease. And in whatever part of the body the skin is affected, it is of the utmost importance to remove every part where there is the least suspicion of contamination. In the face, we have often observed the surgeon too anxious to save skin, with a view of lessening the blemish of an extensive scar; but in a disease so deplorable as cancer, no object of this kind can in any degree compensate for being exposed to the smallest risk of its return; the more so, especially as we have often remarked that a second operation is seldom if ever attended with permanent advantage. The surgeon, therefore, ought to lay it down as a general rule, to include in his incision a considerable portion of the sound skin surrounding the diseased parts.

The particular cases wherein an operation is advisable, must be left entirely to the judgement of the surgeon. The operation may be performed in all cases where the diseased parts appear to be within the reach of the knife; or if there are any glands affected, if these can be safely removed, it may be even under these circumstances undertaken, though no doubt the chance of a return of the disease in such cases is greater.

Whenever the periosteum and parts surrounding any of the bones is affected, there is little chance from any affluence of art, except when the disease occurs in the extremities of the body, as in the hands or feet; for in such cases, amputation of the whole member may be performed. When When cancerous fores appear about the eyelids, and spread along the conjunctiva, covering the eyeball, it is the only safe practice to remove the whole contents of the orbit. The different parts which compose the eyeball and its appendages, seem to have such a close connection with one another, that it is difficult, perhaps impossible, to mark the boundaries of the diseased action which is going on; and as the loss of any part of the organ prevents the others from performing their functions, it becomes no material object to save any particular part.

It is generally remarked, that the lips are particularly subject to cancer, at least in men; and that the under lip is more fo than the upper one. The diseased part may be removed in this part of the body with great neatness upon the general principles of the operation of harelip. This can only be done when the diseased portion is small, and may be included by two incisions forming an angle, inclining towards the chin. See HARELIP. When, however, the disease has spread over a considerable portion of the lip, fo 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 parts affected, secure the bleeding vessels, and dress the sore like any other recent wound.

By a little ingenuity and contrivance, much may be sometimes done in making the incision in such a manner as to allow the sound parts to be afterwards brought together and united; so that in all cases of extensive disease, the surgeon should consider of all the different modes by which the diseased parts may be removed with most advantage.

The operation is performed by some with a common scalpel, by others with scissors. When the scalpel is used, the lip is to be held firmly with forceps by an assistant, and the second incision made along their edge; but when the disease extends beyond the adhesion of the lip to the jaw, no forceps are necessary.

The scissors are, however, the preferable instrument; they divide the lip with much less pain, and with a mathematical precision. When they are used for this purpose, it is necessary they be made thick and strong; and as in some people the lip is extremely thick, and apt to flip through the blades, instead of being divided. Giving the cutting edge of the blades a circular form will be found to be an improvement on the common straight edge. It is evident, however, that the scissors can only be employed in those cases where the forceps could be used to aid the knife. All wounds of the lip heal best and most accurately with the twisted sutures; so that the edges should be brought together in the same manner as has been recommended in the case of harelip, and the same mode of after-treatment is also to be pursued.

SECT. VI. Of Warts.

There are two kinds of warts which grow upon the surface of the body; the one species is connected with the skin by a broad base; is of a hard, firm texture, unequal in the surface, and free from pain. Warts of this description are frequent in young people, and are generally found on the hands.

The other species of wart is attached to the skin by a slender pedicle; they have a very unequal surface, appearing as if composed of an aggregate of small tumors. Warts of this kind seldom attain any very considerable size, the largest scarcely exceeding that of a pea. They are seldom troublesome; but in some situations they become extremely irritable, and produce, especially when injured, very disagreeable sensations.

This species of wart is most frequently met with on the prepuce and glans of the penis; on the labiae; around the anus, and also frequently upon the hairy scalp. In these situations they sometimes acquire a very large size, numerous warts arising over the whole surface, and forming a mass of a cauliflower appearance. They are most frequent in people advanced in life, and are often connected with the venereal disease.

Besides these, there are varieties of small warts which occur in different parts of the body, which have not been accurately described by authors. There is one variety where a number of small, whitish tumors appear in some parts of the face of children; these contain an opaque white fluid, which when discharged, and allowed to remain upon the contiguous skin, contaminates it, and produces warts of the same description.

Of the treatment of Warts.—A variety of local remedies have been applied, both by medical men and the vulgar, for the curing of warts; and these generally possess a corrosive quality.

Lunar caustic is one of those which generally answers best, and is most easily managed for destroying the first species of warts which we have described. A faturnine solution applied to the warts three or four times a day, or aqua ammonia, and tincture of cantharides, have also been found beneficial in promoting their absorption.

In the second species, when the excrescences are very large, they should always be removed along with a portion of the adjacent skin, by the knife. In those cases where the warts are very numerous, and where, from their situation, it becomes impossible to remove them with the knife, equal portions of ergo ergis and favi powder, or favi powder alone, will be found sometimes to succeed in removing them. In some cases, particularly where the warts are situated about the glans of the penis, we have found a saturated solution of the muriate of mercury in spirit of wine, completely answer the purpose. In those cases connected with syphilis, besides local applications, it is necessary to use mercury. Sometimes, indeed, the warts drop off whenever the mercury begins to affect the constitution.

SECT. VII. Of Corns.

A corn is a peculiar hardness of the epidermis, which sometimes extends to the subjacent skin. In the first case, the diseased part is removable; in the second case it is more fixed. It frequently elevates itself above the skin, and is not unlike one species of wart. It is hard, dry, and insensible, except when pressed upon the contiguous parts; and it resembles in colour and appearance the thickened cuticle on the hands of workmen. Corns commonly are formed on the toes and sides of the feet, and they are generally owing to the wearing of tight shoes. Sometimes corns do not occasion the least inconvenience; but in other instances they occasion so much much pain, that the patient can walk with difficulty. Corns are generally more painful in warm than in cold weather. The pain seems to arise from an inflamed state of the parts in the circumference of the corn, which state is excited and kept up by the pressure of the induration, and not from any sensibility in the corn itself. They are more painful in dry than in moist weather, because they become much more hard and dry.

Treatment of Corns.—The pain and difficulty of walking produced by corns, may be alleviated by immersing them in warm water, and with a sharp instrument cutting off their external layers; much relief will also be found by covering the part with a piece of adhesive plaster, and by being careful not to wear shoes which are too tight. But what we have found a most complete cure for corns, is the application of one or other of those corrosive substances which were mentioned for the treatment of warts. The lunar caustic, or the saturated solution of muriate of mercury in spirit of wine, ought to be preferred. They may be applied once every second or third day, until the absorption of the corn be completed; and before using them, it will be found proper to pare off some of the external hard layers of the corn.

Some corn-operators extirpate the corn by a sharp instrument; but this only proves a palliative treatment, for sooner or later a hard substance is again deposited.

SECT. VIII. Of Naevi Materni.

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 port-wine. Many of these marks are perfectly flat, and never rise above the level of the skin; these 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 soft and fleshy; of a cellular texture, the cells containing liquid blood. They may be removed with little danger when not involving any important organ. They are supplied indeed more plentifully with blood than most other tumors are; and even sometimes they appear to be entirely formed of a congeries of small blood-vessels; but the arteries which supply them may be, for the most part, easily secured by ligature. An 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.

If the whole tumor be removed, little hemorrhage generally follows; but if the smallest portion of the diseased vessels remain, not only a troublesome bleeding follows, but the tumor is quickly reproduced by an increased exuberance. Tumors of this kind have been also removed by ulceration excited by the application of corrosive substances; and a knowledge of this circumstance might be in some cases of practical application.

Chap. III. On the Diseases of Mucous Membranes.

SECT. I. General Remarks on the Pathology of the Mucous Membranes.

THOUGH at first sight it may appear that the mucous membranes are very considerable in number, yet when they are viewed more generally, they appear much more limited; and we will find that in whatever part of the body they be found, they are subject to the same morbid alterations of structure.

The ingenious Bichat has shewn that there are two general mucous surfaces, of which the others are all portions. The one penetrates into the interior of the mouth, the nose, and the anterior surface of the eye. After lining these two first cavities, it is prolonged into the excretory ducts of the parotids, and submaxillary glands. It passes into all the sinuses, forms the conjunctiva, enters the lacrimal points, the nasal canal, the lachrymal sac, and is continued into the nose. It lines the pharynx and eustachian tube, the trachea and bronchiae. It goes down the oesophagus into the stomach, and passes along the whole intestinal canal till it joins with the skin at the extremity of the rectum. This he calls the gastro-pulmonary mucous surface.

The other general mucous surface, the genito-urinary, begins in the male at the urethra; passes along that canal into the bladder, lines the bladder, vesiculae seminales, and vasa deferentia, along with their numerous branches. It also extends into the excretories of the prostatic gland, the ureters, and the pelvis of the kidneys.

In the female it begins at the vulva, penetrates the ureter, and passes as in the male over the urinary organs. It also enters the vagina, lines the womb and fallopian tubes, and is then continued with the peritoneum. This is the only example of a communication established between the mucous and serous surfaces.

This view of the extension of the mucous membranes is strongly exemplified by an examination of their diseases; for it will appear that there is not only an analogy between the different portions of the first, by an affection of the whole parts over which it extends, but there is also a line of demarkation between the two, from the one remaining found whilst the other is affected throughout. This last circumstance is confirmed in the history of many epidemic catarrhs; one of these membranes having been observed affected throughout, whilst the other remained unchanged. The epidemic observed at Paris in the year 1780 had this character. "This epidemic (says Pinel*) which was very general in Paris, * Nofogra- and with which I was myself attacked, was remarkable &phie Philo- for it affected almost the whole mucous membranes, &phique, that of the trachea and bronchiae, the conjunctiva, the tom. ii. pituitary membrane, the palate, the pharynx, and the ali- mentary canal." The epidemic catarrh of 1752, de- scribed in the Memoirs of the Medical Society of Edin- burgh, is an example of the same kind; for in all these, the mucous membrane lining the urinary and genital organs remained unaffected.

We also observe that an irritation of any part of a mucous membrane frequently creates a pain on a part of the membrane which was not irritated. Thus a cal- cules in the urinary bladder produces the chief pain at the point of the penis, and the prehure of worms in the intestines produces an itching at the nose.

Among these phenomena, which are purely sympathetic, it is seldom that a partial irritation of one of the mucous surfaces produces pain in any part of the other. The singular connection which subsists between the membranes of the uterus and bronchise in mucous hemorrhages, however, is an example of this kind. If the blood accidentally cease to flow from the one during menstruation, the other frequently supplies the functions of the first, and exhales it. In cases of fracture, or thickening and disorganization of the mucous membranes of the urethra, the stomach is sometimes affected: this may also arise from the sympathy of the two mucous membranes.

Mucous membranes, from being constantly exposed to the action of the external air, or to the contact of extraneous substances, do not suffer, when displaced, like other parts of the animal economy. In a prolapsus of the uterus or rectum, their mucous surfaces serve all the purposes of skin; and surrounding bodies do not produce more pain on them than on common skin. This is very different from the effects produced on opening a serous cavity or a capsule of any joint. The cellular, muscular, nervous, glandular, and other systems, when laid open, present also very different phenomena.

The mucous membrane, like the skin, is organized in such a manner as to endure with impunity the contact of external bodies; these merely producing an increased secretion of thin mucus. A sound introduced and retained in the bladder produces no alteration in the structure of the mucous membrane of the urethra; and for the same reason, a style or tube can be kept in the lachrymal duct without causing any irritation.

Most of the diseases of mucous membranes come within the province of the surgeon; the others have been already treated of under the article MEDICINE.

SECT. II. Inflammation of Mucous Membranes.

The contact of extraneous and irritating substances, acrid vapours, or the sudden exposure to cold air of any mucous surface, is often followed by some degree of inflammation.

A preternatural degree of redness is a constant symptom of inflammation in most parts of the body; but the most remarkable character of inflammation in mucous membranes, and that which distinguishes it from all others, is the secretion of a puriform fluid. The mucus, which in the natural state is nearly transparent, and merely moistens the surface, becomes of a yellow colour, and the quantity is so abundant as to form a purulent discharge. It is from the susceptibility of the mucous glands to be acted upon by any irritation which is applied to the extremities of their ducts, that the stone or any tumor in the bladder, polypi of the nose or vagina, are always accompanied by a profuse discharge.

The inflammation is accompanied with a more or less degree of thickening of the membrane; and sometimes this remains after all the inflammatory symptoms cease. The abatement of the inflammation is marked by an increase in the thickness of the discharge and a diminution in its quantity.

VOL. XX. Part I.

We have an example of inflammation affecting the mucous membrane of the nose in coryza, the ear in otitis, the urethra and vagina in gonorrhoea, the bladder in a catarrhus vesicae, and the eye in the puriform ophthalmia, the lachrymal sac or duct in fistula lacrymalis. In all these diseases the symptoms have a striking analogy, and are varied only from the difference in the functions of the particular organ, the mucous covering of which has been affected.

During life, mucous membranes become gangrenous much more seldom than the skin. This is proved from the consequences of catarrh, compared with those of erysipelas. There are, however, cases where this texture dies, whilst those adjacent continue to live; as in malignant angina.

SECT. III. Of the Inflammation of the Mucous Membrane of the Urethra.

The term gonorrhoea is employed to signify a dif. Gonorrhoea charge of puriform matter from the orifice of the ure- (Ecoule- thra or prepuce in men, and from the vagina in women; Mu- whether it proceed from a syphilitic or any other irritat- teus).

The gonorrhoea may be defined a discharge of a con- tagious, puriform fluid, which comes from the mucous glands of the urethra, and membrane which lines that canal; or from the glans in men, and the interior of the genital organs in women. The disease seems to be pro- duced by a virus sui generis.

This disease generally makes its appearance in three or four days, sometimes in fix, but rarely later, after im- pure coition, with the following symptoms. The patient finds a particular itching and disagreeable sensation at the point of the yard, and a sort of flight itching also at the part of the urethra placed immediately under the frenum. This lasts one or two days, and on the fol- lowing days the orifice of the urethra becomes sensitive and red; it also swells, and a limpid matter of a clear yellow colour flows from it, which tinges the linen. Whilst the flow of this matter continues, the titillation becomes stronger and more painful, particularly in mak- ing water; for this leaves a burning impression and sharp pain in the affected part. In some individuals the first symptom presenting itself is the discharge of a thick mucus. In these cases the patient feels from the com- mencement a burning and painful sensation in making water. These symptoms generally increase in three or four days. Sometimes, however, that does not fen- sibly happen till after eight or twelve days. The glans acquires a deep red livid colour; the discharge through it increases, and the matter becomes of a yellow, or greenish yellow colour, resembling pus diluted. The swelling of the glans, and also of the whole penis, be- comes considerable; the patient has frequently a desire to make water, and he finds, particularly when he has remained for some time in bed lying on his back, fre- quent and involuntary erections, and so painful that they disturb his sleep, and oblige him to rise out of bed.

Such is usually the progress of the disease when the in- flammation is simple, slight, and superficial; but in many cases the inflammation extends farther and penetrates more deeply, affecting the reticular substances of the cavernous Gonorrhoea cavernous bodies of the urethra. Then the pain becomes excessive during erections, and the frenum of the glans is drawn downwards as by a cord, in such a manner that the body of the penis is forced upwards by the violence of the erection. It is this which is called cordic. It sometimes happens, that in this state the vessels of the urethra are torn, and thus occasion considerable hemorrhage. At other times, the discharged matter is mixed with streaks of blood; the prepuce is also so much inflamed and swelled that it cannot be pulled back over the glans, or if it has been pulled back, it cannot be again brought forward. In some cases the strangulation which accompanies this last accident, produces a mortification of the glans, and even occasions the death of the patient; this, however, seldom happens.

In some persons one or more of the inguinal glands swell, become painful, and are attended with symptomatic fever. Often the glands of the penis swell also, a cord or knots can be felt on the back of the penis, and the skin is also swelled and painful. Besides these symptoms, the patient often feels, either from his own fault, or on account of bad treatment, a particular uneasy aching sensation, with tension and swelling of the spermatic cord and testicles, accompanied with a diminution, or even a complete suppression of the discharge by the urethra. In other cases the disease makes greater progress; the irritation and inflammation stretching along the canal of the urethra. All the symptoms then become more violent, the pain which is felt in the perineum or behind it, in making water, is so violent, that the patient is afraid to make the attempt, at the same time that he is frequently solicited by the fatiguing distillation at the neck of the bladder and anus. There is a perpetual desire to let off the water, whilst he can make no more than a few drops at a time with a burning pain. The whole canal of the urethra is swelled, and in a state of tension; the patient has frequent erections, and lancinating pains along the whole length of the canal, through the perineum and anus. He cannot lie down for a long time, nor can he rest seated. In this state the swelling of the glands of the urethra, and the spasmodic contraction of its internal membrane, obstruct the free passage of the urine, and allow it to flow in a very thin bifurcated stream, or drop by drop; and if at the same time the discharge diminishes considerably, or totally stops, a complete suppression of urine sometimes succeeds, occasioned by the inflammation and stricture of the neck of the bladder, or by the inflammation and swelling of the prostate gland and adjacent parts.

It sometimes happens that the inflammation of the urethra becomes so violent, that its internal surface, and the orifices of the glands which line it, secrete nothing; the same as we observe sometimes happens in inflammation of the mucous membrane of the nose and of the lungs. It is this state of the disease which some authors have described under the name of gonorrhoea seceta.

After these symptoms have continued with more or less violence, or when they have increased during one, two, or three weeks, or even during fix or seven, according to the treatment employed, they begin gradually to diminish. The difficulty and the frequent desire to make water cease; the erections are no longer painful; the matter acquires more consistence, and forms into threads between the fingers, and at last the discharge entirely disappears. In other cases, and these the most frequent, the inflammatory symptoms disappear by degrees; but the discharge remains during weeks, months, or even years. It is this form of the disease which is called gleet, or simply blennorrhea.

Sometimes the inflammatory symptoms disappear by degrees, and leave behind them in the urethra an ulcer, from which there is a malignant and purulent discharge, and which occasions an affection of the system. This is what has been called gonorrhoea complicata or ulcerosa; but it occurs rarely.

In other cases a contraction remains in the urethra; sometimes a paraphymosis continues, and sometimes there is a tumor of the testicles, a hardening of these parts or of some of the glands of the urethra, an inflammation of the prostate gland, with a more or less complete suppression of urine; at other times, though very rarely, the discharge, when suppressed, produces suddenly a perfect deafness, or most violent ophthalmia*.

The exciting cause of syphilitic gonorrhoea is always the application of the specific virus to some part of the mucous membrane lining the urethra. The contagious fluid, applied to any part of the body of a found person, acts with more or less difficulty, according to the difference in the structure, the greater or less debility of the part, and also according to the particular constitution of the individual; for we see people who are exposed to every danger of infection, without ever having the disease even during their whole life. Perhaps also the more or less violence of the action of the virus depends sometimes on the greater or less degree of acrimony of the virus itself.

The seat of gonorrhoea, when it immediately proceeds from impure coition, is always at a small distance from the orifice of the urethra, under the frenum, at that part of the canal where we observe a dilatation, called fossa navicularis. All gonorrhoeas which are situated more anteriorly on the curvature of the penis, in the very montanum, the neck of the bladder, or in the bladder itself, arise from bad treatment, or from some cause which has stopped or suppressed the primary discharge.

Sometimes by the natural progress of the disease, and more frequently from faults committed by the patient, or by the effects of improper remedies, the inflammation and irritation are apt to change their place. They often occupy the orifice of a mucous gland which opens at the first turn of the penis. At other times they affect the two glands of Cowper. Sometimes they occupy the protuberances which cover the orifices of the seminal vesicles; and they also sometimes takes place in the prostate gland, or in the neck of the bladder.

In some rare cases the contagious virus does not penetrate during the inflammation into the urethra, but applied to the extremity of the penis, it fixes itself upon the coronet of the glans, and irritating the excretory ducts of the sebaceous glands there, produces a discharge which has been called the gonorrhoea of the glans.

When the urethra of a person who has laboured under gonorrhoea is laid open, no ulcer is almost ever found upon the surface of the internal membrane; and in those who have suffered much in consequence of the disease, there is merely a thickening and contraction of one or more Chap. III.

Gonorrhoea parts of the urethra. Sometimes, though very rarely, excrencences are formed within it. The ducts of the mucous glands are obliterated, and the prostate gland and bladder changed in their structure.

It has been a matter of great dispute among those who have written on the venereal disease, whether the gonorrhoeal and venereal virus are the same. In this controversy a number of very futile arguments have been brought forward. It is a striking fact, however, which the practical man must have always in view, that the venereal disease is never cured without mercury; whilst a gonorrhoea, however virulent, never requires that remedy. This difference in the treatment of the diseases some authors have attempted to explain, from the difference in the structure of the parts affected. It is remarkable, however, that the matter from the gonorrhoea never affects the skin, producing chancres; but that when its virus is applied to the vagina, or to the urethra of another person, gonorrhoea is the consequence. When it affects the prepuce too, it produces, in place of chancres, a morbid discharge from the sebaceous glands of that organ. It is also a striking fact, in the history of gonorrhoea, that however long it may remain, it never produces any constitutional affection. All these circumstances in the history of the disease, in its progress and symptoms, and in its cure, being so different from those of the venereal disease, are fully sufficient grounds to consider gonorrhoea and syphilis as two distinct morbid affections, and different from one another as much as any two diseases of the animal economy.

Treatment.—All the forms of the venereal disease, when they are left to themselves, undermine and destroy the constitution; but gonorrhoea ceases without the resources of art, particularly if during its course the patient live a sober and regular life. The irritability of the urethra, the constitution of the patient, the faults in his diet, and his exercise and choice of remedies, and perhaps also the nature of the virus itself, which is more or less acrid, and of which the action will be more or less violent, often renders gonorrhoea a very severe disease. Experience confirms, that the sooner proper remedies are applied, and the sooner the patient is cured, the less he suffers; and the more certainly he avoids the disagreeable accidents which are to often the consequence of that disease. From this consideration, it is evidently of importance, either to prevent the disease entirely, or destroy it in its beginning. Two means have been proposed to accomplish these ends; one is, to remove the virus before it can act on the parts exposed to it; the other destroys and alters its nature, and prevents these effects from the moment that it gives the first signs of its action.

Different practitioners have tried and recommended various prophylactic remedies. Some have applied mercurial ointment upon the surface of the glans and prepuce, immediately after coition, and others different kinds of lotions and injections, as caustic alkali, lime water, alcohol diluted with water: these preparations being injected seven or eight times a-day, for several days after the commencement of the discharge.

By the use of injections the irritation is diminished, and the progress of the inflammation stopped; and when the discharge becomes thicker during their use, they ought to be continued eight or ten days after it has disappeared; for if we were to give up too soon the use of Gonorrhoea, these injections, the inflammation and discharge would increase. In this case it is necessary to make the injection stronger, and to use it more frequently. The advantages to be derived from this practice do not seem, however, to be altogether confirmed; and it is to be wished, that enlightened and prudent practitioners would make some decisive experiments to determine whether injections are useful or hurtful in the commencement of gonorrhoea.

When inflammation has taken place, and when the discharge and other symptoms of gonorrhoea are completely formed, a different mode of treatment ought to be pursued. Repose, abstinence from all kinds of irritating food, spices, wine, &c. will contribute much to allay the irritation.

In order to defend the irritable parts against the acrid matter, and to moderate the symptoms of inflammation, authors have recommended the use of mucilaginous, oily, and sedative applications. That which renders the urethra in man so violently affected by gonorrhoea, and so different from catarrh, is not from the difference of structure in the organ, which has been supposed to be more irritable than the mucous membrane of the nose and other parts of the body. It is the faults of the urine passing along the urethra, which keeps up the irritation produced by the virus. It has been proposed, in order to remedy this source of irritation, to give gum arabic or the infusion of linseed internally; but these, when taken in the necessary quantities, generally injure the stomach. An infusion of hemp has been found by Swediaur to answer all the purposes, and not to be subject to the inconveniences of the others. This remedy may be rendered more agreeable to take, by adding a little sugar to it; and in some cases a weak decoction of farfaparilla may be advantageously added. All these drinks should be taken cold, or at least nearly milk-warm, and in small doses frequently repeated.

The antiphlogistic regimen must also be purged in the treatment of gonorrhoea. The patient ought to avoid all exercise, or high-leaflon food. Lint, wet with a turpentine solution, should be kept constantly applied to the penis; and the patient should keep his bowels open with saline purgatives. When the symptoms of inflammation are considerable, and the pulse hard and frequent, bleeding becomes necessary, either general or topical: the constant application of fomentations and emollient poultices is also useful. Swediaur has advised, that camphor and the nitrate of potash should be given internally, and this should be continued according to its effects. Camphor alone, taken in the form of emulsion with sugar or fresh egg, is an efficacious remedy in allaying the pain and ardor urine. The use of camphor has also been recommended externally, with a view to allay the cordee.

These remedies ought to be continued as long as the pain and symptoms of inflammation in the urethra continue. After they are abated, the patient may be allowed a better diet, in order to prevent the urethra from being affected with a chronic gonorrhoea or gleet. Injections made of the extract of opium with acetate of lead, applied frequently from the commencement of the disease, contribute much to shorten it, and allay the accompanying pain. Sometimes, however, even the most mild injections do harm, from a particular irritable state of the Gonorrhoea urethra. Great advantage has also been obtained by some, in very aggravated cases of the disease, by frictions of mercurial ointment on the perineum, and along the course of the urethra, or by mercurial fumigations applied to the genital organs, and even by the injection of mercurial ointment into the urethra.

On the other hand, when the symptoms of erysipelatous inflammation prevail; when the patient is feeble, and of an irritable temperament; when he feels better after dinner; when the discharge is clear and profuse, accompanied with sharp pain, often lancinating throughout the whole urethra; and if the pulse is feeble and frequent, it is more advisable to give him a less rigid diet; to allow him the moderate use of wine, and in some cases to give him opium and bark internally. We are sometimes surprised at the sudden changes which these remedies in such cases produce. The use of opium also contributes much to prevent cordice; and in all cases this ought to be avoided as much as possible, by fixing the penis downwards, and in making the patient lie on his side upon a mattress, which answers better than lying upon the back, and in a feather bed.

If in consequence of the violence of the inflammation the discharge stops, and the posterior parts of the urethra begin to be affected, we should have recourse to the warm bath, or apply vapours to the part, by placing the patient upon a vessel containing boiling water, and this should be repeated three or four times a-day; the patient should keep his bed, and an emollient cataplasm applied upon the penis, which should be renewed every hour. All kinds of injections in such cases are hurtful. The same treatment is also applicable when the discharge is stopped by the use of acrid and astringent injections, or by injections improperly used, or by the improper use of turpentine and balsams.

When the prostatic glands and the neck of the bladder are affected, and the patient of a plethoric habit, it becomes necessary to bleed profusely, either at the arm, or by applying a number of leeches to the perineum. In all these cases, a sedative clyster repeated every seven or eight hours, and a general or local warm bath used twice a-day, are the best remedies which can be used. Sometimes a blister applied to the perineum is also useful.

The swelling of the lymphatic glands of the groin which sometimes takes place, is purely sympathetic, and disappears along with the inflammatory symptoms of the urethra.

In all cases of gonorrhoea the patient should wear a suspensory bandage whilst the disease continues*. It is also useful to persons who are obliged to take exercise, to wear a convenient bandage round the penis, which may be united to the suspensory in such a manner, that the penis may be enclosed in a kind of case, and thus defended from external injuries, from cold, and from friction; this bandage being kept constantly clean, by often changing the caddis, which is placed in its cavity. For this purpose, a hole should be left in the bag, covered by the caddis, which the patient can take away each time he makes water. Another general precaution which it is useful to make, is never to keep the penis bound up high, but to keep it low, in order that the matter may flow out freely, and may not pass backwards along the urethra.

The gonorrhoea which takes place in the glans and Gonorrhoea prepuce is generally easily cured, by injecting frequently warm milk between the glans and prepuce, and by keeping the penis in an emollient poultice. In those cases where the prepuce is so swelled that it cannot be pulled back, we ought to have recourse to sedative injections.

It is a useful general rule, which ought to be observed in all cases of gonorrhoea, to touch the parts affected as little and as seldom as possible; and every time that it is touched, to wash the hands immediately afterwards, and with the greatest care, fearing that, by carrying them unintentionally upon the eyes, nose, &c. these organs might be inoculated with the disease.

Gonorrhoea in women is seldom followed by so violent symptoms, or by so severe and dangerous consequences as in men. In some cases the symptoms are so slight, that they conceive the discharge, particularly at its commencement, to be nothing but the whites, to which disease a great many are subject, especially in the large towns of Europe.

The gonorrhoea in women has been supposed by many authors to have its seat in the cavities of the urethra. This, however, will not be found to be the case. The disease is seated, either upon the clitoris, or on the orifice of the urethra; upon the nymphae, or in the cavity of the vagina; or even upon the inferior commissure.

With regard to the treatment, we have the same indications to fulfil in gonorrhoea in women as in men, with this difference, that one can see the change of structure in these parts, and thus, from the seat of the disease, employ proper injections and lotions from the beginning.

Precautions in using Injections.—The syringe used in men for this purpose ought to have a short point of a conical form and of a thickness proportioned, that not more than its extremity may pass into the orifice of the urethra*. The body of the syringe should be perfectly cylindrical, and the piston ought to play very accurately; for if the piston does not fit the body of the syringe, the injection, instead of passing into the urethra, regurgitates between the piston and the syringe. From the unsteadiness of the motion of the piston, the point of the syringe is apt to move suddenly on the urethra, and injure its thin and delicate membrane. To prevent any injury of this kind, we have employed with great advantage, particularly if the mouth of the syringe is made of metal, a small strip of caddis wrapped in a spiral manner round the mouth of the syringe, so as nearly to expose its point. If the disease is seated near the point of the urethra, the patient should be attentive to compress with one hand the urethra above the arch of the pubis, where the scrotum commences, whilst with the other hand he holds and guides the syringe. The liquid should be thrown in gently, and so as slightly to distend the urethra; the liquid is to be kept for a minute or two, and the same operation repeated two or three times in succession.

The liquid employed should always be used warm, which may be easily done by filling a cup with the necessary quantity, and placing the cup in a bason of boiling water.

It often happens, particularly in young people, that after: Chap. III.