.

Gleet. after having used injections some time with advantage, they become less attentive in using them, and neglect them even for a day. This omission is always followed with bad consequences, the discharge returning with double force; and the patient is obliged to continue the injections during some weeks more than would have been necessary, if the use of the remedy had not been interrupted.

In order, therefore, to prevent the danger of a relapse, it is always prudent to advise patients to inject three, four, or even six times a day, if the circumstances demand it, and to continue the same two or three times a-day regularly for at least ten or fifteen days after the discharge has entirely ceased.

For women the canula ought to be larger and longer. A canula of ivory, an inch in diameter, and two or three inches in length, fixed to a bottle of elastic gum, is the most convenient form of a syringe *.

Of Gleet.

It very often happens, that after the specific inflammation of the urethra is removed, from which gonorrhea is supposed to originate, a discharge still continues. This discharge is not attended with pain, nor can it be communicated from one person to another. The matter which escapes is generally of a tenacious consistence, and of a yellow colour, appearing to be composed of globules, mixed with a mucous fluid. When a cure cannot be performed, either by the use of injections, or by bougies, it has sometimes been proposed to inject liquids capable of exciting irritation and inflammation in the affected part of the urethra. It is probably from this principle that some glects have been cured by violent exercise on horseback, or a long journey. There have also been examples of similar cases cured by coition; but this is a cure not to be recommended, as there always may be a risk of communicating the disease to the women. A blisters, applied externally to the part affected, or to the perineum, has also been found useful. The cold bath has often been recommended in obstinate glects, from which good effects often result; but there are other cases in which it seems to increase the discharge.

It is also proper to change the injection; for it is observed that an injection less strong sometimes produces a good effect, after a strong one has been employed without success, and vice versa. In many cases it is useful to combine the use of internal medicines with external means. The chief of these are mercurial preparations, balsamic and resinous substances, and tonics. Swediaur has used, with much success, in glects, pills made of turpentine and oxide of mercury. Among the resinous substances which are employed, the most common is the balsam of copaiba. The best way of taking this remedy is to give the patient thirty or forty drops in a small glass of cold water morning and evening, or from fifty to eighty drops for one dose in the middle of the day, and afterwards to take, in a small glass of water, twenty drops of the elixir of vitriol, which renders the balsam less disagreeable to the stomach. Half a dram of turpentine, of the balsam of Tolu, or of the balsam of Canada, answers the same end. Swediaur mentions the case of a young man, who, having been for a long time distressed with a very obstinate gleet, swallowed at once between two and three ounces of the balsam of copaiba, and was cured.

Sometimes the balsams, combined with tincture of guaiac, or with kino, produce a defecable effect.

Among the corroboration or tonic remedies, the kino, which we have already mentioned, is one of the most useful; the cinchona also in powder or infusion in red wine, or, which is still better, in lime water; tormentilla in powder, or in extract, in the form of pills, joined, according to circumstances, with preparations of iron, Glauber's salts, are useful and efficacious remedies. The tincture of cantharides, given in a dose from twenty to thirty drops, has often been found a most useful remedy. It is one, however, which ought to be given with precaution, as it might do much harm to people of a delicate and irritable temperament.

There are, however, cases, where all our efforts to cure a gleet are fruitless; and we sometimes see, that nature alone can in time succeed, after we have uselessly tried all the resources of art.

There sometimes remains a species of corded or curvature of the penis after all the other symptoms of gonorrhoea have disappeared. Frictions, with mercurial ointment, with camphorated oil, spirituous lotions, or electricity applied to the part, are most appropriate remedies in such cases.

In all cases of obstinate gleet, which are situated far back in the canal of the urethra, the state of the prostate gland should be carefully examined; for they often arise from a disease in that part. When the prostrate is found livelled and hard, Swediaur has seen instances where, after a mercurial treatment, the repeated application of cupping-glasses to the perineum, and the use of large doses of the conium maculatum, has succeeded, other remedies having failed.

The gonorrhoea of the prostate is a morbid discharge of mucus from that gland, mixed sometimes with the liquor of the seminal vesicles; and it takes place principally through the day, without any venereal desire. This disease is soon followed by feebleness and general debility, with emaciation of the whole body, and even with death; particularly if the patient has not employed proper remedies.

The remedies most efficacious are the cold bath, injections of metallic salts, fomentations of hemlock, blisters to the perineum, and internally tonic medicines, with a well-regulated diet.

Sect. II. Of Inflammation of the Mucous Membrane of the Nose.

Inflammation of the mucous membrane of the nose is generally preceded by dryness in the nostrils, with an itching feeling, and with a weight over the forehead. It is also accompanied with sneezing and an increased flow of tears. The secretion of mucus from the nose is at first diminished, and afterwards becomes very abundant. At first it is limpid and irritates the found skin of the upper lip, over which it passes, and becomes afterwards opaque, of a yellowish white colour, and a disagreeable odour. This state is sometimes accompanied by fever, and it continues for a longer or shorter period. Most commonly it ceases at the end of a few days. It sometimes, however, becomes chronic and indetermined, in which case it is often intermittent, and re-appears at regular intervals. regular periods. Coryza, like all other inflammations of the mucous membranes, terminates by resolution. It sometimes passes into the state of chronic catarrh, and it also occasions an ulceration of the mucous membrane of the nose; but this is extremely rare.

Coryza is frequently accompanied with inflammation of the mucous membrane of the eye, it also spreads in many instances along the eustachian tube, producing deafness, and it is very apt also to pass down the trachea and affect the lungs.

The nose is sometimes affected with a discharge of thick viscid mucous, when there is very little apparent redness or pain. Such instances are often connected with the formation of polypi: but we have observed several cases, where no other symptom than the mucous discharge appeared, and where the disease had very much the general character of some discharges from the urethra.

Treatment.—Coryza is commonly an affection so slight, and of such short duration, that it is seldom necessary to employ any means to produce an abatement of its symptoms. Sometimes, however, the symptoms go to a very high degree, and it is then that emollient vapours directed into the nasal cavities are particularly indicated. If much symptomatic fever accompanies the disease, it may be advisable to draw some blood from the arm, and in all cases a brisk purgative will be found to relieve the fullness and uneasiness in the head. When the inflammation spreads along the mucous membrane of the trachea, it becomes the more necessary to use every means to alleviate the inflammatory symptoms, and to prevent the inflammation affecting the mucous membrane of the bronchi.

Patients labouring under this disease, feel remarkable relief from living in a warm atmosphere; and the symptoms of inflammation of the nose and trachea will be much alleviated by the internal exhibition of opium.

When the inflammation and the discharge are of a chronic nature, astringent injections, or a douché dipped in similar solutions, kept in the nose during the night, are in such cases the most useful applications. They gradually diminish the quantity of the discharge, and render it more thick and tenacious; and the sense of smelling, which is commonly destroyed, is gradually restored.

If the discharge be fetid, and occasionally mixed with blood, in all probability it originates from the formation of an abscess or ulcer, connected with a carious bone.

SECT. III. Of the Inflammation of the Mucous Membrane of the Ear (Otitis).

In inflammation of the ear, there is the same characters deduced from analogy of structure, as in other mucous membranes. The principal causes of this disease are sudden changes in the atmosphere; above all, the change from heat to cold, or from dryness to moisture; coldness of the nights, north winds, suppression of any regular discharge, the crisis of acute diseases, metastasis, the presence of an irritating body in the ear, or the imprudent application of oily or spirituous substances.

The inflammation sometimes takes place in the meatus auditorius; and in other cases it is confined to the cavity of the tympanum and eustachian tube. In the first case, Otitis there is more or less pain, and buzzing in the ears, and afterwards a discharge of thin reddish yellow matter. This matter gradually becomes white and opaque, and increases in consistence till the termination of the disease; when it differs in nothing from the wax of the ear, but in its white colour. This affection generally lasts twelve or fifteen days. It sometimes spreads to the external parts of the ear, and often passes into a chronic state.

When the inflammation is confined to the cavity of the tympanum, it produces an obscure tingling sensation, and a feeling of tension, which the patient supports without much inconvenience; but most frequently the inflammation is propagated from the cavity of the tympanum along the eustachian tube. In this case, the pains become more violent and extend along the contiguous mucous surfaces; they pass from the interior of the ear into the throat; there is great difficulty in swallowing, and the food, when passing through the pharynx, gives a sensation as if the skin had been eroded. The motions of the neck also become uneasy, and the smallest attempt to cough, to sneeze, or blow the nose, produces a painful sensation in the ear. The patient also complains of a floppage in the nose, of a frequent dry cough, and of pain in the head, and more or less fever in the evening. The ear also feels hard and diffused, and there is generally deafness, particularly towards the end of the disease. Soon all these symptoms diminish except the hardness in the ear, which augments continually till the fifteenth or twentieth day.

Most commonly after this period, a quantity of fecid matter is suddenly discharged into the external ear, or into the throat, and then all the symptoms disappear. This discharge generally diminishes daily, and in a short time ceases altogether. At other times, particularly in young people, it continues, and becomes chronic.

Treatment.—When the inflammation is confined to the external meatus, the disease is generally so slight that it may be allowed to run though its common periods, and it is merely necessary to keep the patient warm. When the inflammation is very considerable, the mildest injections give pain, and in place of moderating the symptoms, they increase the irritation. We ought therefore to do nothing, except, perhaps, to allow some warm vapour to pass into the ear, and to pursue the antiphlogistic regimen. About the twelfth or fifteenth day, it may be useful to apply tonic medicines, such as aromatic alcohol dipped in a piece of cotton. When the inflammation is in the tympanum, or the eustachian tube, besides emollients, it will be also necessary to give some brisk purgative, or to employ local or general blood-letting. If the membrane of the drum is much diffused, and accompanied with violent pains, it has been even proposed to make an opening through the tympanum*. When the matter has been discharged from the tympanum either spontaneously or artificially, little more is required to be done, unless the disease assumes a chronic form. This is more frequent in children. We often see the purulent discharge continue in them for many months, and some of the small bones of the ear become carious, and are discharged along with the matter. In such cases small doses of calomel, for some time repeated, blisters applied behind the ear, and injections of lime water

* Nefserathe, physiique Fiedel. water combined with muriate of mercury, acetate of lead and the like, should be employed.

SECT. IV. Of Angina.

The parietes of the mouth, trachea, and larynx, are often inflamed in catarrhal affections, and present symptoms which vary according to the intensity of the disease, and particular seat of the affected membrane.

Angina has therefore been distinguished according to its seat in the tonsils, the trachea, the pharynx, and larynx.

When the patient has great difficulty in swallowing his food, and when the pain stretches in chewing, to the ear along the eustachian tube, by a sort of crepitation, and if, on inspection of the throat, the amygdalae and edge of the palate appear much inflamed, along with an abundant excretion of mucus, the angina has its seat principally in the amygdalae.

Angina affects the pharynx when deglutition is difficult or impossible, and the food is returned by the nose, respiration at the same time not being impeded. This inflammation is also visible by examining the bottom of the mouth.

But if the deglutition is difficult; if no redness is to be perceived at the bottom of the throat, and if the patient has great difficulty in respiring, a sharp pain in the motions of the larynx, the voice acute but weak, and the speech short, we may then conclude that the inflammation has attacked the larynx, or upper part of the wind-pipe. An affection of this kind, though a few cases have been known to take place in adults, generally attacks children under twelve years of age. It is known by the name of croup.

When the inflammation affects the amygdalae, inhaling steams of warm water and vinegar will often be found to give great relief. A poultice, too, applied to the outside of the throat, assists in lessening the tension of the inflamed parts. Though in many cases the inflammation seems to be confined to the mucous covering of the glands, yet in others it spreads into the glandular substance, where it generally advances to suppuration and abscess. In such cases, the early discharge of the matter gives great and immediate relief; and though no matter has been formed, puncturing the inflamed part with a sharp instrument often produces an alleviation of all the symptoms. The instrument delineated in Plate DXIV, fig. 14, is well calculated for these purposes. By altering the position of the screw in the handle, the depth of the cutting part of the instrument may be regulated. When it is to be used, the fore finger of the left hand is to be introduced down the mouth, and the perforator concealed in the canula introduced as a director. When the extremity of the canula reaches the inflamed part, the perforator may be then safely pushed into it, of a sufficient depth, which had been previously regulated.

When the inflammation affects the pharynx, relief will also be obtained by inhaling the steam of warm water, and by employing antiphlogistic remedies. In croup, calomel has been found to have a specific effect; and it is astonishing the quantity that has been given to infants for the cure of that disease. See Medicine.

When the effusion which takes place in croup, is chiefly confined to the upper part of the larynx, and produces symptoms of suffocation, it has been proposed of the Cato make an artificial opening into the trachea below, where the matter is effused, in order to save the life of the patient. See Bronchotomy.

SECT. V. Of the Catarrh of the Bladder.

The ureters, the bladder, and the urethra, are all liable to be affected with catarrhal affections from general causes, the same as those affections of the mucous membranes which have been already mentioned; and besides, the surfaces of the mucous membranes of these parts are exposed to the action of particular causes, namely, the ureters and the bladder to calculi, and the urethra to the venereal virus.

The catarrh of the bladder is more frequent among men than among women; and old people are more subject to it, than those at any other period of life. It is often produced by the internal use of cantharides, by acrid diuretics, and by the progress of hemorrhage from the urethra. The sudden exposure to cold, suppressed perspiration, the disappearance of different diseases of the skin, of rheumatism, and of gout, are followed almost suddenly by this catarrh. Other circumstances may also give rise to the chronic catarrh of the bladder. The presence of a calculus or any foreign body, the continual application of bougies, a swelling of the prostate gland; and above all, strictures of the urethra.

This disease is marked by pains of the bladder, and at the point of the urethra, both before, and whilst making water. The injection of the urethra is more or less difficult, according to the action of the bladder, and of the freedom of the passage of the urethra. The hypogastric region is tenue, and the urine presents variety of colours; it is sometimes whitish, or reddish, or of a deep yellow colour; it is muddy, and it exhales an odour of ammonia, which becomes more sensible a short time after it has cooled. It also forms, in most common cases, a mucus, which mixes and comes away with the urine in the form of glairy filaments, and which is afterwards deposited at the bottom of the vessel, in the form of the tenacious glairy substance, resembling somewhat the white of egg.

The chronic inflammation of the mucous membrane of the bladder, may be accompanied with an ulceration of the kidneys or bladder; the mucus discharged then becomes of a greenish yellow colour, sometimes mixed with streaks of blood. It is deposited slowly, is mixed easily among the urine, and in water; it has little viscosity, or fetor, and does not coagulate by ebullition. The other symptoms which accompany this excretion, as fever, pain, wasting of the flesh, sufficiently distinguish this double affection of the bladder. The chronic catarrh is subject to return with intolerant pain in the region of the pubis and perineum, accompanied with restlessness and anxiety. These intermissions are irregular, and may remain some weeks.

Treatment.—The matter which exists in the mucous membrane of the bladder, and that of other membranes of the same name, is sufficient to point out the means which are to be employed in its treatment. The warm bath, and mucilaginous drinks, are particularly indicated at the beginning of the acute catarrh; but the tendency which it has to become chronic, ought to make us cautious tious in not prosecuting debilitating remedies too far. Opium should be employed with great prudence, notwithstanding the intensity of the pain; and as this is often the result of the diffusion of the bladder, from the accumulation of urine, it is sometimes necessary to have recourse to the introduction of the catheter.

The chronic catarrh of the bladder is generally difficult to cure, and the more so, if it occur in old age: if it arises from the pressure of a stone in the bladder, there is no cure but the operation of lithotomy; if it arises from metaltasis, rheumatism, or any other disease, we ought to employ remedies to the skin and intestinal canal, and pour tonic injections into the bladder. The uva ursi has also been found a useful remedy. Exercise, dwelling in dry and elevated places, the use of woollen clothes next the skin, contribute often more to the cure of this disease, than the use of medicines, and they ought always to be combined.

The conjunctiva covering the eye-ball, eye-lids, and lacrimal passages, are also subject to inflammation; but these will be treated of among the diseases of the eye and its appendages.

SECT. V. General Remarks on Strictures.

The term stricture has been usually applied to a contraction of the urethra; generally arising from a thickening of the mucous membrane lining that canal. This change of structure is not, however, confined to the mucous membrane which lines the urethra; the same morbid alteration takes place in the oesophagus, in the eustachian tube and meatus externus, in the maxillary sinus, in the bladder, in the lacrimal passages, and in all canals lined by mucous membranes. Strictures, however, occur much more frequently in the urethra, and are there more pernicious than in any other part. They appear also sometimes in the upper part of the oesophagus. A similar change has been observed in the internal part of the bladder. Bichat found the membrane lining the maxillary sinus several lines in thickness, and also the canals of the tympanum much thickened*; and reasoning from analogy, and from what we may observe by an attentive examination of the symptoms of many cases, of what is usually called fistula lacrymalis, there is little doubt but a contraction and thickening often take place of the mucous membrane lining the lacrimal sac and duct, and produce that disease.

This change in the structure of mucous membranes is always the consequence of inflammation; and when the membrane is thus altered, the discharge, instead of being healthy mucus, is generally a puriform fluid, apparently a mixture of pure mucus and globules of pus.

SECT. VI. Of Strictures in the Urethra.

The treatment of the diseases of the bladder and urethra has always been considered a difficult branch of surgery, as their true nature is often obscure, and as it is by no means easy to direct the proper means of relief.

Of the great variety of caules which disturb the functions of these organs, strictures in the urethra are perhaps the most frequent, and most ferocious. They prevent the free evacuation of the bladder; greatly disturb, if not entirely destroy the function of generation; and often give origin to constitutional symptoms which sometimes increase to an alarming degree, and even prove fatal.

That the urethra should be subject to many morbid changes, we may infer, not only from our knowledge of the functions it performs, but also from its delicate and no less complicated structure.

One part of this structure is intended for the evacuation of the urinary bladder, the other for the transmission of the seminal fluid; and as in the exercise of this last function, the urethra sympathizes, in a greater or less degree, with the whole system, and also with the mind itself, it must have a connection with many of the other organs of the body.

Accordingly, we find that patients who have obstructions in the urinary canal, have at the same time other complaints, which get well when the obstruction is removed. And, on the other hand, diseases of other parts bring on morbid affections of the urethra, which are cured along with the original complaint.

The whole extent of the urinary canal is lined by a delicate membrane, which is constantly covered with a viscid fluid, secreted by numerous glands, whose ducts open on its internal surface by orifices which are called lacunae.

It is highly vascular, and is endowed with so much nervous sensibility, that irritating bodies applied to it often affect, or even derange the whole system.

It has a considerable degree of contractility, is evidently elastic, and perhaps may possess a muscular power, although no muscular coat has yet been demonstrated; but to whatever cause this contractility be owing, it is well known it does not contract upon irritation.

As a proof of this contractile power, a remarkable case is mentioned by Mr Cline in his lectures, where a stone was lying in the membranous part of the urethra one evening, which during sleep had been expelled and was found among the bed clothes the following morning.

The contraction which forms a stricture in the urethra may take place round the whole circumference of the canal; it may arise chiefly at a particular point of the circumference; or, it may extend along a considerable extent of its surface, and thus produce obstructions of different forms.

The stricture once begun, continues no longer than the cause which first produced it continues to operate. But if the parts are kept long in this state of contraction they generally are attended with a degree of inflammation; the membrane of the urethra acquires a morbid degree of thickness; the surrounding parts are altered in structure; and this change of form and appearance remains after the cause which originally produced them has ceased to operate.

That spasmodic strictures do exist appears from the impressions made on bougies which have been passed through them, and from the examination of the parts after death; for although complete obstructions to the bougie were found when alive, yet not the smallest remains can be observed on dissection. This contraction is peculiarly violent, and from what we have seen more frequent, at the fossa navicularis than at any other part of the canal.

A gentleman, after many attempts to make water during the night, was not able to pass a drop, and he applied for relief in the morning. A bougie was introduced, and met with a complete obstruction at the glans, Chap. III.

Strictures, which yielded in a few seconds after the bougie was in close contact with it; on being withdrawn the urine flowed freely, and the complaint has never since returned.

Contractions at this place are sometimes so violent as for a long time to interrupt the entrance of the bougie; and in one case it was so strong as nearly to cut the instrument through, after it was introduced. What is remarkable, this happened repeatedly with the same patient.

When there has been a permanent stricture, the natural structure of the urethra is changed, and the morbid alterations it has undergone may be seen on dissection. There is commonly a contraction at one particular part of the canal; and the appearance of it has been compared to that which would have been given had a pack-thread been tied round it, or in flight cases it is a mere narrowing *.

When a ridge is formed projecting into the cavity of the canal, it is found to be a doubling of the inner membrane, with the cellular substance lying between the fold. The internal membrane itself is diseased; it assumes a whitish colour; becomes much harder, sometimes as hard as cartilage; and in some cases this change is confined to the doubling of the stricture itself, whilst in others it extends into the cavernous bodies. These ridges or folds often form over one another, so that the intermediate portion of urethra becomes preternaturally contracted also; but it never becomes so narrow as at those parts where the original strictures were formed. Instead of a distinct curtain or fold, it happens also in some cases that the urethra has the appearance of a cone gradually converging before the stricture, and diverging in the same manner behind it.

The contraction is generally round the whole of the circumference of the urethra; but it sometimes happens that it is only at one side, and in such cases the urethra does not form a uniform tube, but it becomes serpentine and contorted in various directions.

When one stricture is formed, that portion of the urethra anterior to it is liable to suffer some changes, and these probably arise from its not meeting with the ordinary diffusion, the stream of urine being diminished. It is by no means uncommon, therefore, to find in those cases where the original stricture has been formed near the bladder, another stricture anterior to it, so that when an obstruction is found at the glans or four inches and a half from it, another is generally met with at seven inches, or at the bulb.

From the peculiarity in the form of the urethra, some parts are subject to strictures much more frequently than others.

In the adult, and in the relaxed state, the urinary canal is about nine inches long, and nearly of the same diameter as a common quill; but its size varies at three different points, and there strictures most frequently arise. These contractions are at the glans, the bulb, and the prostate gland (see fig. 5, Plate DXIV.) The narrowest part is just below the bulb, and here strictures most frequently occur.

The natural contraction renders it, in almost every case of stricture, the seat of the disease. This part of the canal seems also to possess an uncommon degree of irritability, as it is here that the contraction takes place in cases of strangury. When strictures continue long, and the violence of the symptoms increase, diseases arise in other parts.

The urethra between the stricture and bladder, from the obstruction the urine has to overcome, enlarges, and is sometimes attacked by inflammation.

As in most cases the stricture is attended with a gleet, the glands situated about the neck of the bladder become diseased. The bladder becomes extremely thickened, and its capacity diminished. From the strong exertions it is necessary to make in order to overcome the obstruction, and as it cannot contain much urine, the ureters also become dilated.

When the disease advances still farther, so that it is impossible to evacuate the bladder, the obstruction being complete, the urine escapes by some new channel; for as in such cases the parts between the bladder and obstruction make less resistance than its coats, both on account of their natural structure, and as these parts are generally inflamed or ulcerated, they give way, and the urine takes a new course. When this change has once taken place, so that no urine passes through the meatus urinarius, the other symptoms will differ according as the aperture has been formed by ulceration of the inner membrane of the urethra, or by a sudden rupture. For when the membranous part of the urethra has been eroded, a suppurring cavity must have formed in the contiguous cellular substance, and as the urine cannot so easily be diffused in the surrounding parts, it makes its way without difficulty through the integuments.

But when a sudden rupture or ulceration of the inner membrane of the urethra takes place, as the urine meets with no obstruction in infusing itself into the cellular membrane, it effuses itself in a short time over the perineum, scrotum, and adjacent parts; extensive abscesses are formed where the urine was diffused; and as these burst in numerous places, fitful openings are formed, which have either a direct or indirect communication with the bladder, and through which the urine continues to pass till the original obstruction is removed.

Symptoms.—Often this complaint does not become of such importance as to give alarm to the patient till many months, or even years, after the original cause has been forgot. At other times, a few months after a gonorrhoea has been cured, the urine, instead of coming away with the accustomed ease, begins to be passed with some difficulty. The stream, in place of being full and even, diminishes and becomes unequal; sometimes it comes in drops after much straining and exertion, has a forked appearance, or scatters in all directions. From the irritable state of the parts, the smallest quantity collected in the bladder, brings on a desire to make water, and a continual uneasiness all along the course of the canal, about the perineum, anus, and lower part of the abdomen. In most cases there is a discharge of matter from the urethra. The gleet is always more severe after any debauch or venereal act. It comes on immediately after such excess, and gradually diminishes or disappears. It is also not unfrequent to find strictures accompanied with that profuse discharge of mucus from the bladder called catarrhus vesicae. The irritation communicated to the bladder in consequence of the disease of the urethra, brings on inflammation, which is followed by a profuse discharge of mucus from the whole of its internal surface, and this mucus comes away with the urine, and Strictures. is deposited, and firmly adheres at the bottom of the pot in the form of a tough tenacious mass.

Nocturnal emissions are sometimes the only symptoms which lead us to suspect the existence of stricture; for in some cases the disease is neither attended with any fixed pain in the urethra, nor is there any discharge of matter.

Fistulas in the perineum, and along the course of the penis, often derive their origin from an obstruction of the urinary canal.

When, either from irritating injections, bougies, or any other cause, inflammation comes on, the urethra is completely shut at the place of the stricture, and the internal membrane giving way, the urine is effused in the cellular membrane, which gives rise to abscesses and fistulous openings, through which the urine continues to pass, till the stricture is removed.

The inflammation in some cases spreads to the surrounding parts; the mucous glands inflame, suppurate, and burst; and hemorrhoidal tumors often form at the extremity of the rectum.

Besides these, the more usual symptoms of stricture, there are others which accompany that complaint, and arise from constitutional causes.

The most frequent of these is a febrile attack, in the form of a complete paroxysm; but it differs from the common intermittent fever, in its short continuance, its irregularity, and in the violence of its termination. It happens most frequently to those who have been in warm climates; but it is by no means confined to them alone.

People of weak constitutions have often sickness at stomach, nausea, and vomiting, and sometimes an uneasy state of irritability about the stomach, which gets better when the stricture is relieved.

Gout, epilepsy, hydrocele, sciatica, erysipelas, swellings in the perineum, occasional suppressions of urine, have all been found connected with stricture; but such cases rarely occur.

There are other diseases of these organs which have so many symptoms in common with stricture, that it is necessary to inquire with much attention into the history and state of all the symptoms, before we can judge of the true nature of the complaint; and when there is any reason to suspect that an obstruction exists, it is ascertained only by the introduction of a bougie; but the mode of doing this will be explained when speaking of that instrument.

There are diseases that ought to be mentioned as being liable to be mistaken for stricture, and always kept in view in forming the diagnosis. An irritable state of the urethra, proceeding from gonorrhoea, is one that is very frequent.

In such a case there is a discharge of matter and a pain in making water. The urine flows in a small stream at the commencement, but before it is all evacuated it is of the natural size. The symptoms come on a few hours after coition, but abate in a short time, and whenever the irritating cause is repeated, they return.

The bladder also, when irritated, brings on diseases of the urethra, as these parts sympathize so strongly with one another; but when the primary affection is in the bladder, there are always symptoms which aid us in discovering the true complaint.

Enlargements of the prostate gland are by far the strictures, most apt to mislead our judgement. Scrophulous and schirrous enlargements of that organ were at one time supposed to be very frequent causes of retention; it is now generally believed that they occur seldom, and are chiefly confined to people advanced in life.

It will be afterwards mentioned how swellings of the valvular process of the prostate are apt to be mistaken for stricture when a bougie or catheter is introduced. The obstruction in such a case is always at a distance, as the canal has increased in length from the enlargement of the parts.

If attention be paid to this remark, and if the gland be at the same time examined from the rectum, little doubt will remain of the nature of the disease.

It is often difficult to draw off the water when the prolate gland has become thus diseased: to do this, much benefit will be found in using a catheter longer than ordinary, as the common curve cannot reach the extremity of the urethra from the increased length of that canal. Pouches or irregularities are also apt to form from the unequal growth of the gland; and as the ducts of the seminal vesicles and mucous glands become enlarged, the instrument ought to be of a large diameter to avoid being entangled by them.

From the idea we have of the manner in which cases of strictures are formed, we infer that many substances of an irritating nature, whether applied immediately to the parts themselves, or to those connected with them, may, under particular circumstances, produce this disease. The stone irritating the bladder, numerous diseases of that organ and prostate gland, irritations in consequence of gonorrhoea, long and repeated erections or other stimulants, and the natural disposition which the urethra has to contract in some constitutions, are the common causes of stricture. In whatever manner this irritation is produced, the symptoms and changes observed in the structure of the urethra, make it probable that there is always a certain degree of inflammation subsequent to or accompanying it. Obstructions in the urethra were supposed by Daran, and others about his time, to originate from causes very different from those now mentioned. They conceived that the discharge from gonorrhoea proceeded from internal ulcers, and that the cicatrices and indurations they left behind were the most common causes of stricture. But since the nature of the discharge from gonorrhoea is found very rarely, if ever, to be purulent, and as ulcers occur very seldom, they cannot be considered as a common cause of the disease in question.

Caruncles were also supposed to be frequent causes of obstruction in the urethra; but these are rarely met with. One preparation of such a case may be seen in the museum of St Thomas's Hospital. Drs Hunter and Baillie have seldom met with them. Indeed, since the internal membrane of the urethra so much resembles that which lines the cavities of the nose, mouth, and oesophagus, and as ulcers in these parts are more disposed to form skin and heal, than to produce fungi, few cases of obstruction can be ascribed to such tumors.

The other causes which prevent the free discharge of the urine, are those which are attended with no morbid change in the structure of the urethra itself.

Such are tumors or indurations of the prostate gland, of the vesicular seminales, or parts composing the body Chap. III.

Strictures of the penis, or of the mucous glands along the course of the canal.

By far the most common of these, is an obstruction into the entrance of the bladder, from a diseased prostate gland.

This proceeds from a new form which the canal has assumed in consequence of an enlargement of its parts. Its cavity becomes deeper from the growth of its sides, and the posterior extremity or valvular process forms a projecting tumour into the cavity of the bladder, which interrupts the passage of the urine, or the entrance of a catheter.

From the frequency of this appearance in diseased prostate glands, it is probable that it is the cause of diseases of that organ being often mistaken and treated as strictures of the urethra, and has in numerous instances not only prevented the introduction of a bougie into the bladder, but has been the cause of the formation of artificial passages through the substance of the gland.

Treatment of Stricture.—From the erroneous ideas that the older surgeons formed of the nature of strictures, it was not to be expected that the means of cure they employed were either founded on just principles, or attended with much success.

They made use of various external and internal remedies; they prescribed long and tedious courses of mercury, and gave many medicines which were supposed to have peculiar virtues in curing diseases of these organs.

They sometimes introduced into the canal mechanical instruments in order to dilate it; and when that was impracticable, a new passage was made by force, or the diseased parts were dissected away, and a new canal formed in the sound parts.

Wifeman, so far back as the beginning of the last century, exploded many of these rude and dangerous practices, and introduced into use the waxed candle or bougie, by means of which he said he "crushed the carunculi to pieces." He met with cases, however, where this could not be done; that is to say, cases where it was impracticable to pass small bougies into the bladder; and this led him to adopt another mode of treatment. He confirmed them by stimulating applications in the following manner. The wax at one end of the candle was scraped away, and the wick dipped in plasters composed of alum, red precipitate, calcined vitriol, ærugo, and other such substances, and then it was applied to the caruncle.

"But (says he), if after doing this you cannot pass the caruncle, you may well conclude it callous; in which case you may pass a canula into the urethra to that caruncle, and whilst you hold that there steady, you may convey a grain of caustic into the canula, and press the caustic to it; and whilst you hold it there, you will perceive its operation by the pressing forward of the caustic. The caruncle thus consumed, cast in a lenient injection daily; and if you take notice of his urine, you may see the separation of the sloughs as rags in it. After which you may with the common medicated candles wear away the remainder, and with the injections cicatrize it."

After Wifeman, Daran introduced into use a kind of bougies, the particular composition of which was kept secret. They were supposed to possess very great medical virtues; and it was from these qualities that their superior efficacy was supposed to proceed. Other surgeons soon began to imitate them, and they found that those they made had the same qualities as those of the original inventor. This led them soon after this to alter their opinion of their mode of action; and, instead of supposing that all the beneficial effects proceeded from the medicines in their composition promoting suppuration, cicatization, &c. they explained their action on the principle of a simple wedge.

But however successful their practice might have been in alleviating, if not in curing strictures, yet many cases occurred where the obstruction was so complete as altogether to prevent the bougie being introduced. They were therefore obliged to continue forcing past the obstruction, till the mode of treatment described by Wifeman was renewed, and held out as an original invention. The practice, indeed, generally followed by modern surgeons is founded entirely on what Wifeman has written; but since these have been better understood, from the progress of pathological investigation, it has been considerably modified and improved.

When we consider the effects of these modes of practice, and try to reconcile them with the ideas we have formed of the causes producing the stricture, it would appear that those very means employed for their removal belong to the same class of bodies as those originally producing the complaint.

As this cannot be denied, yet it will appear neither surprising nor improbable, when we reason from analogy, and observe the effect of similar applications to other diseased parts, and similar phenomena in other organs. It may be here observed, that the action of any part depends not only on the kind of the stimulus applied, but also on its degree of violence. We know that a slight pressure on the skin produces uneasiness or tickling, whilst to a stronger degree it passes unnoticed. A certain degree of light produces distinct vision, but a more intense one destroys it. The upper part of the throat is thrown into violent action by a slight irritation, but a more powerful one has no effect. Similar phenomena take place in disease; or slight irritations sometimes occasion violent morbid action, whilst those that are more powerful not only produce a lesser degree of disease, but are even employed to remove such as are brought on from a lighter cause. We see this opinion strongly confirmed in ulcers, attended with much local or constitutional irritation. The most emollient applications in such cases, if they do not increase the sufferings of the patient, bring no relief; whilst strong stimulating ones, such as a solution of lunar caustic, or diluted nitrous acid, seldom fail to diminish the pain and promote the cure of the disease*.

In toothache, the irritation produced by the external air on the exposed nervous surface excites much pain and even symptomatic fever; but the application of caustic or acid destroys these sensations.

The same we will find to take place when we consider the nature and the mode of treating strictures of the urethra; and if we can prove that strictures have all that variety of character which an ulcer or many other diseases have, we will be better able to judge of the comparative merit of the different modes of treatment, and be able in some degree to account for their mode of action.

* See Home's Observations on Strictures. Of the Bougie.

When surgeons attributed all the beneficial effects of bougies to their mechanical qualities, the principal deferatum was to have them sufficiently pliable to take the curvature of the urethra, firm and elastic to make resistance, and mild so as to produce no irritation. But however simple such instruments might be in their composition, yet it will appear probable that their ultimate effect is not the same as that which a wedge produces on inanimate matter. That bougies cannot act by their mechanical powers in removing spasmoid stricture, appears from those cases where the mere introduction of the instrument into the urethra, and its contact with the obstruction, removes at once all spasm.

The same thing is observed in those cases of permanent stricture which are attended with occasional spasm. In such cases it frequently happens that a bougie finds a complete obstruction on its first introduction, but after being allowed to remain for some time in the canal it passes readily without force. A remarkable case of this kind happened, where there was not only a stricture in the urethra, but fulvous openings in the perineum and scrotum, through which most of the urine was discharged. After much trouble, a very small-sized elastic catheter was passed into the bladder, and as it gave no pain it was allowed constantly to remain. For the first five days the urine flowed through the instrument, but afterwards it began to pass along its sides; and gradually as the urethra dilated, larger instruments were introduced with similar good effect.

The silver files used by Mr Ware seem to act, in removing obstructions of the lacrymal passages in fistula lachrymalis, on the same principle as the catheter appears to have done in the above example. The file when first introduced, fills up completely the lacrymal duct; but in a short time the tears begin to flow along the sides, and pass into the cavity of the nose. In these examples it is difficult to explain the action of bougies on mere mechanical principles; it seems much more probable that they produce their good effects, either by a change of action of the living body, or by some alteration in the structure of the diseased parts. Says Hunter, "Pressure produces action of the animal powers, either to adapt the parts to their new position or to recede by ulceration."

When speaking of the symptoms of stricture, it was observed, that in order to determine with certainty their presence, it was necessary to introduce a bougie. To do this, either with a view of ascertaining the state of the urethra, or in order to remove a stricture, a good deal of caution and nicety is required; for as the urethra is generally tender, painful, and easily thrown into spasmoid action, any awkwardness might entirely prevent the possibility of ascertaining the nature of the complaint, or of affording the means of relief.

When, therefore, the operation is to be performed, in order to discover the kind of obstruction, bougies ought to be provided of different sizes, of a soft consistence, common goose quill, or even larger, generally passes Strictures easily, and is less apt to meet with obstructions before it comes to the stricture, than one of less diameter. Being of a soft consistence, it readily takes an impression of the stricture, and its blunt point prevents its being entangled by any accidental irregularity.

As it ought always to be rubbed over with oil before being used, it generally passes with little more force than its own weight, till it comes to the contracted part, where it stops. After changing with much caution the direction of the point, by elevating or depressing the other extremity of the bougie, and perhaps bringing it a little backwards and then forwards, so as to be satisfied of the situation of the stricture, the instrument may be allowed to remain in close contact with it for a few seconds and receive its impression, so that when it is withdrawn, a precise knowledge is obtained of its situation and form.

Some patients are often so irritable, that any foreign body touching the urethra excites much irritation and pain. In such cases it is the more necessary not to employ the smallest force, and to use an application of opium, or such medicine, to the perineum, to prevent these inconveniences as far as possible.

When the stricture lies near the extremity of the urethra next the bladder, the point of the bougie ought always to be considerably bent previous to its introduction, so that it may readily accommodate itself to the curve of the urethra; for as a large instrument does not bend easily, it is apt to press on one of the side of the canal, and give rise to the suspicion of a stricture.

It is also of considerable importance that the point of the instrument be not conical *. When once we are well * See Plate acquainted with the state of the parts, such formed in fig. 2. instruments may be used with much advantage, as the small point enters the stricture, and by pushing the bougie forward it is dilated by the base of the cone.

It may be also here remarked, that in some instances a catheter can be easily introduced when no bougie can be made to pass; we ought therefore to make use of that instrument before finally deciding on the nature of the obstruction (d).

When a stricture is discovered, and when bougies are to be used with a view of curing it, the first thing we are to attempt is to pass one through it. As the bougie we employ is most frequently of a very small size, we must attend particularly to the irregularities in the canal which may entangle the point of such a small instrument and the occasional bendings it may make, while it is supposed it is passing forwards towards the bladder. As the mouth of the lacunae are chiefly situated on the superior part of the canal, the point of the bougie ought to glide along its inferior surface to avoid them.

The bending of the bougie is only to be prevented by a forbearance in using force, and in directing properly the point; but as the common bougies are apt to do this, it is often extremely useful to have catgut ones for this purpose; and it is necessary to have them very small.

In order to overcome the obstruction when the bougie reaches it, the situation of the point ought to be changed by shifting it backwards and forwards, and from

(d) The silver balls represented in Plate DXIV. fig. 4, have also been found useful in ascertaining the nature of strictures by Mr Charles Bell. Chap. III.

Strictures.

from side to side, and even employing a little preasure, till it passes forwards, provided the surgeon has a clear and distinct idea of the direction of the urethra.

As the introduction of the bougie almost always brings on spasm to a greater or less degree on the first attempt, it is often necessary to persevere some time before it can be made to pass the stricture; and we must continue in our endeavours a long time before we declare it impracticable.

Blisters on the perineum or loins, fomentations of warm water and spirits, turpentine glyffers, dipping the feet or glans in cold water, anodyne applications, and the internal use of camphor, opium, or tincture of iron, all assist in alleviating the spasmodic symptoms when they occur, and may be selected for use according to the judgement of the surgeon.

Attention ought to be paid to the composition of the bougie; for those made of elastic metal, catgut, or elastic gum, often give pain, while those made of soft plater are mild and harmless.

The time which a bougie ought to remain in the urethra, must depend greatly on the peculiarities of the case, for there are no diseases which appear under more various forms than stricture. In most cases bougies can be introduced with little pain, and can remain for some minutes without inconvenience; but there are others where the introduction not only produces general irritation, but the pain is so violent, as hardly to allow them to enter the canal, and sometimes they give rise to constitutional symptoms. In the first case, from the little pain the patient suffers, their use has been abused, and they have been allowed to remain not only when asleep, but they have been worn during the patient's daily employments.

It is found, however, that bougies have a more powerful effect when retained for a short time, and often repeated, than when they are longer continued, but seldom used; so that in no case, however little pain they may produce, ought they to be allowed to remain for a long time. Many indeed think that all their good effects are obtained after they have remained twenty or fifteen minutes, while others allow them to remain for one or more hours.

In cases of stricture accompanied with much irritation, whatever pain the bougie may bring on, it ought not to be thrown aside, but it should be introduced repeatedly whenever there is the least abatement of the symptoms. This practice should be continued for weeks before we despair of success, as afterwards the pain, from daily habit, will be diminished, and the patient will be gradually more and more able to bear it. Whilst we continue the use of the bougie, it ought gradually to be increased in size as the stricture gives way, and be introduced once or perhaps twice a-day till the obstruction is no longer felt, and till the urine flows in a full, even, and natural stream.

When this happens we are not to consider the cure as altogether complete; for it is very generally found, that if the use of the bougie is at this time given up, the parts soon begin to contract again, as they have still a disposition to return to their former situation, and the disease in a short time is completely renewed. It will therefore be proper to continue using them at distant intervals, some time after the cure appears complete, and give them up in a very slow and gradual manner.

It may be here mentioned, that it is not necessary to retain the point of the bougie in the cavity of the bladder, but merely to allow it to pass the stricture.

Of the Caustic.

In speaking of the use of bougies, we have supposed that it has been practicable to pass one through the stricture; but it is well known, that cases do often occur, where, from the tortuous form the canal has assumed, the smallest bougie is prevented from entering the bladder.

In such cases, preasure was employed on the diseased parts, in order to produce ulceration to destroy the obstruction; but as this mode was found in many cases to be followed with violent inflammation, and attended with great pain, it was not often performed.

Laying open the sinules, and dissecting out the diseased parts, was also a painful and no less difficult operation, so that no easy mode was ever adopted till Wifeman employed lunar caustic.

From the delicate structure of the urinary canal, it was not without much caution, and in very urgent cases, that this remedy was first employed; but since its action was found not to be so violent, it has been freely used by many surgeons, and its application not confined to the more advanced stages of the complaint.

From the time of Wifeman to that of Mr J. Hunter, we find little worthy of remark in surgical writers regarding the use of caustic. The latter of these authors, however, again introduced it into practice, and applied it to all those cases where he could either do no good with bougies, or when he could not pass them through the stricture. In his first trials he met with success; and as he soon improved the mode of its application, he was able to employ it with considerable advantage.

Mr Hunter's mode of applying caustic was first adopted by Wifeman; but as the silver canula which he employed, not only gave much pain, but could not be introduced as far down the urethra as a common bougie in many instances, and as the caustic could not be applied directly to the centre of the obstruction, a new mode was invented. A piece of caustic was fixed in the extremity of a common bougie, and covered with the plaster except at the extremity, where a part was exposed, but so small as merely to form the apex of the conical point of the bougie. In this manner it is found possible to apply it to almost all cases, and when in dexterous hands, may be used with considerable safety. When it is to be applied to a stricture, it is necessary that some previous knowledge of the case has been obtained from the introduction of a soft bougie. When this has been done, the armed bougie must be introduced rather quickly, but steadily, till it meets the stricture, which we know both from the feel, and from the situation previously determined. When brought into contact with the stricture, it is perhaps better merely to touch it with the caustic the two or three first applications, and afterwards it may be retained longer. When the bougie is to be withdrawn, it ought to be done cautiously; for as it has become soft, and the caustic not so firmly fixed in it, it may fall out, and be left behind in the urethra. Although this Strictures. this mode has advantages over the silver canula formerly employed, yet there is a way which we think may be attended with considerable superiority, as it not only requires less dexterity on the part of the surgeon, but is less apt to do mischief.

It is evident, that when the armed bougie is passed to a stricture, it will unavoidably touch several parts of the side of the canal in its passage; and as often its introduction brings on a spasm, which lasts some seconds, or even minutes, a considerable portion of caustic may be diffused on the found membrane.

The frequency of the application of the caustic must be determined by the particular circumstances of the case. It should never be repeated till after the effects of the first application have ceased; in general, every second day will be found to be enough, but in some instances it may be applied daily.

After the use of the caustic, the patient ought to be kept quiet; he should not make any exertions to empty the bladder, nor take any violent exercise. In general the pain from the caustic lasts but a few minutes; and the day following, when the flough separates, a rawness is felt on making water.

The application of caustic to the urethra is, however, often followed by a train of very alarming symptoms; instead of a mere burning heat in the parts, the patient is seized with violent pain, followed by retention of urine, swelling of the testicles and perineum, hemorrhagy, and sometimes, a complete febrile paroxysm.

From the sympathy that exists between the urethra and testicles, it is not unfrequent to find diseases of the former produce morbid affections of the latter.

Stone of the bladder and the use of common bougies often bring on swelling on one or both of the testicles; and in one case the irritation of a bougie brought on an inflammation, which terminated in a hydrocele of the vaginal coat. It is a frequent effect of caustic, but soon disappears when its use is given up.

Strangury has often followed the application of caustic after any imprudence on the part of the patient; and it generally happens in those cases where it has been applied near the bladder. This may happen not only from the great susceptibility this part of the canal has to contract; but it may arise from the bougie passing a part of the urethra where caustic had been formerly applied, and which remained still tender. This retention of urine in general does not continue long, and in most cases it is relieved by the introduction of a bougie, or the application of a blister.

When caustic has not only destroyed the stricture, but its action extended to the found parts, blood is often poured out into the canal, or is effused into the cellular texture of the penis. The hemorrhage is sometimes very profuse, and seems to proceed from an erosion of the spongy bodies; but as it has, in every case hitherto published, ceased of itself, no particular means have been found necessary to stop it. Keeping the parts cool, and giving cold acid drinks, quietness, and caution against all causes of irritation, should be attended to. The tumor composed of effused blood generally gives little inconvenience, and like an ecchymosis on any other part, it may be removed by the topical application of stimulants.

By far the most serious and most alarming symptom which arises from the use of caustic is an ague or febrile fit. It begins with a severe cold fit, which continues from fifteen minutes to an hour. This is followed by another fit, which lasts sometimes several hours, and is succeeded by a very profuse perspiration, which is much greater than what happens in common ague. These paroxysms do not return at the same periods, and seldom occur more than two or three times. When repeated, they become more and more severe, and every future application of the caustic brings on one fix or twelve minutes after. Patients attacked in this manner become extremely debilitated; and three instances have come under our immediate knowledge where it proved fatal. When such a symptom occurs, the caustic ought to be immediately laid aside, emollients applied to the urethra, and the patient supported by cordials.

The caustic too has been sometimes known to fall out falling out of the bougie, and diffuse in the urethra. When such an accident happens, if it be not immediately removed, etc. it may produce a flough of almost the whole extent of the canal, and bring on very alarming symptoms.

In place, therefore, of fixing a large piece of caustic in the bougie, take such a quantity as is intended to be applied on the stricture; reduce it into a fine powder, caustic, and stick it on the point of the bougie, by pressing them on one another. When this is done, it may be dipped in warm wax, and receive a thin covering of it.

A bougie prepared in this manner may be introduced down to the stricture without any risk of injuring the found membrane; for as the thin layer of wax which covers the caustic, prevents it being immediately diffused, it is not till it has been kept some time in contact with the stricture that it begins to act. By following this plan we not only avoid injuring the internal membrane, but we diffuse no more of the caustic on the diseased parts than what is wished for, and there is no risk from a portion of caustic being left behind.

There are, however, cases where a soft bougie cannot be so easily introduced as a metallic instrument: in them, a silver catheter, or one made of Smith's elastic metal, may be used with much advantage.

Instead of the holes being made at the sides of the instrument, it ought to be perforated at the extremity, and this hole filled with caustic, and fixed in that situation with adhesive plaster. Or, what answers equally well, the catheter may be introduced down to the obstruction, and an armed bougie puffed through it.

Comparative advantages of the Bougie and Caustic.

Thus far we have mentioned the manner in which the bougie or caustic are to be employed; we now come to consider the peculiar merits of those two modes of practice, and to point out those cases where the one is to be employed in preference to the other.

Notwithstanding the zealous advocates which have lately introduced caustic as a general remedy for strictures, we have no hesitation in declaring it as our opinion, that the simple bougie is the instrument to be preferred in the generality of cases of this disease, and that in all cases where the cure can be accomplished by its means, it should be adopted. Caustic, however, is a remedy by no means less beneficial, though its use ought to be much more circumscribed; for we certainly believe that Chap. III.

Strictures, that by its proper application many of the worst cases of stricture, cases indeed which are quite incurable by the bougie, may be benefited by its application.

In those cases of spasmodic stricture where the common bougie either cannot pass the strictured part, or where it has no effect in relieving the symptoms, cautic may be used with advantage.

It may be also employed whenever the stricture is attended with much pain and irritation or constitutional symptoms; and in cases where the contraction of the urethra is such, as entirely to close up the canal, and the urine to come through fistulous openings in the scrotum and perineum, the use of cautic is attended with the best effects. We have met with cases, where during a succession of years, urine has drilled through fistulous openings in the scrotum, in which fix, eight, or ten applications of the cautic bougie have opened a free passage into the bladder, and allowed all the fistulas to heal up.

From the rapidity of the cures performed by cautic in comparison to those of the bougie, the former a few years ago came into very general use, and was tried by different surgeons all over this island in every possible variety of the disease. In this extensive field of experiment the merits of cautic have been fairly balanced, and its exaggerated good effects have fallen into disrepute, whilst the calumniouss reports of its fatal and dreadful consequences in the hands of experienced men, have been shown to be without foundation. Thus in the midst of medical rancour and dispute, cautious and intelligent men have become acquainted with the good qualities of a most active application; and an unprejudiced mind has laid open before it a vast field of observation on a disease which deeply interests a considerable number of men.

Sect. II. Of Strictures in the Oesophagus.

The mucous membrane lining the oesophagus, like that of the urethra, is liable to become contracted, forming a stricture. These contractions may be formed at any part of the canal; but it is observed that there is one spot more liable than any other to become affected with it. The part alluded to is immediately behind the cricoid cartilages of the larynx, where the fauces may be said to terminate, and the oesophagus begin. The disease appears, on dissection, to consist of a transverse fold of the internal membrane of the oesophagus, filling up in different degrees the aperture of the canal.

This part of the oesophagus is also liable to two other diseases, whose symptoms are nearly alike, and therefore may be mistaken for stricture. One of these is a thickening of the coats of the oesophagus, which extends to the surrounding parts, and in the end most commonly degenerates into cancer. The other is an ulcer of the lining of the oesophagus, which is commonly situated a little below the ordinary place of stricture, and upon the posterior or vertebral portion of the canal. Both of these complaints produce a difficulty in deglutition, and in their early stages are only to be distinguished from stricture, by an examination with a bougie. Stricture appears to be a disease more frequent in the early periods of life; while the two other diseases are more commonly met with at an advanced age.

With a view to ascertain the true nature of the disease, it is always necessary to introduce a bougie. The best mode of doing this, is that recommended by Mr. Everard Home. The patient is desired to push the tongue as far as possible out of the mouth, thus bringing the orifice of the stricture as nearly as possible in a line with the middle of the pharynx. The bougie being oiled or covered with muciage, is then to be thrust down into the oesophagus. When the bougie passes down to the distance of eight inches, measuring from the cutting edge of the front teeth in the upper jaw, the surgeon may be satisfied that it has gone beyond the usual seat of stricture; and if it is brought back without any resistance, he may conclude that the aperture of the oesophagus considerably exceeds the size of the bougie which has been used. But if the bougie flops at fix inches or even lower, he is to retain it there with a uniform steady pressure for half a minute, so as to receive on its point an impression on the surface to which it was opposed. If the end of the bougie retains its natural form, or nearly so, and there is an indentation like the mark of a cord on its side, whether all round or only partially, he may decide that the disease is a stricture. But if, on the other hand, the bougie passes without any difficulty to the distance of seven inches and a half, and when brought back the point has an irregular jagged surface, it is equally clear that the disease is an ulcer on the posterior surface of the oesophagus.

When strictures of the oesophagus have been of long continuance, ulceration takes place on the side of the stricture next the stomach. When such ulceration takes place, the character of the original disease is lost; and when the ulceration extends upwards, the stricture itself is destroyed. A bougie passed under such circumstances, will, in general, have its point entangled in the ulcer; and when so skilfully directed as to go down into the oesophagus, it will meet with a difficulty while it is passing from the found oesophagus to the ulcer, and again when it leaves the ulcer and re-enters the found canal below; and in its return there will also be two parts at which a resistance is felt. This may mislead the most accurate observer, and create a belief that there are two strictures, whereas in fact there is none but an ulcer of some extent, and a power of contraction in the upper and lower extremities of the oesophagus where they terminate in the ulcer.

Treatment.—The treatment of stricture in the oesophagus is to be conducted on the same general principles as stricture in the urethra.

Bougies which are made much longer and of larger dimensions than those for the urethra, may be used with the greatest safety. At first, indeed, they sometimes create a good deal of irritation and a febrile attack; and in such cases they must be employed with the greatest caution. Once in twenty-four or forty-eight hours, according to the nature of the case, will be sufficiently often to introduce them; and they may be discontinued in proportion to the alleviation of the symptoms. The use of cautic in this species of stricture has also been not only proposed, but adopted; a practice which is more a proof of the boldness of its inventor than of his prudence *. It is not to be denied, that some * Home on desperate cases of the disease may occur, where every remedy proves useless, and that in these, the cautic bougie, Strictures, bougie, introduced and applied to the stricture with much dexterity, may be beneficial. But these cases are so rare, and there are so few able to use this active remedy properly, that we cannot help thinking it can never be very generally introduced into practice.

SECT. III. Stricture of the Rectum.

As far as we know, there is no author who has given any accurate account of the various morbid appearances of the extremity of the rectum. Under the general name of hemorrhoids, a variety of tumors very different from one another have been classed; whilst under the name of schirrus, have been considered all cases where the diameter of the lower part of the intestinal canal has been diminished. In a practical point of view, these observations are of the greatest importance, as they lead the surgeon to discriminate between those cases which are likely to be aided by the use of medicines, and those which are beyond the reach of art, or which the same mode of treatment might tend more to aggravate than to alleviate.

In many cases of the true schirrus, or cancerous affection of the intestines, the disease first appears by the formation of one or more grisly tumors on the internal surface of the canal; and these by increasing in number and in size, and by involving the adjacent parts, contract the canal, and at last ulcerate, forming true cancerous fores. But there is another class of cases, in which the diameter of the intestines becomes narrowed by a thickening of its coats, and which, were we to reason from analogy, might be compared to that thickening which forms stricture in the other mucous surfaces, as in the oesophagus and urethra. It is the same cases that we suspect Deffault treated with so much success by the use of bougies*; and from the good effects of this mode of treatment in cases of stricture in other parts of the body, it is reasonable to expect benefit from their use in strictures of the rectum. Deffault, however, wishes it to be understood that the practice is to be employed in the true schirrus; but the two cases which are given in detail by Bichat in his edition of Deffault's works, in illustration of the practice in schirrus, are by no means conclusive. The first is a case of tumors of the internal membrane, which were much alleviated by the compression of a bougie; whilst the second was a case which shows the relief to be obtained by the use of bougies in cases of schirrous contraction in the discharge of the faeces, but by no means in the cure of the disease.

In cases, therefore, of contraction of the rectum which are not of a schirrous nature, besides the strict attention to keep the bowels regular, and render the faeces as liquid as possible by the use of laxatives and emollient injections, bougies made of a proper size may be used with relief; and, as we have mentioned in another place, the practice is also highly serviceable in some cases of tumors which grow from this part of the intestines.

SECT. IV. Of Polypi.

When the mucous membrane of any part of the body becomes elevated above its natural level, so as to form a circumscribed swelling, the disease is called a polypus.

Polypi have been found on all the different mucous surfaces; in the nose, frontal and maxillary sinuses, pharynx, gullet, mouth and gums, meatus externus, conjunctiva, stomach, intestines, rectum, uterus, vagina, bladder, and urethra.

There are four different kinds of polypi, varying from each other in their structure. 1st, The mucous; 2d, the flebby, 3d, the carcinomatous; and 4th, the encysted polypi.

The mucous polypi have a slippery surface, and are constantly covered with a quantity of mucus. They are of a greyish or dull white colour, and have a demi-transparent appearance, resembling, particularly at their extremities, a piece of softened glue. They are easily torn and bleed freely; they are neither painful nor sensible to the touch; they suffer remarkable alterations from changes in the state of the atmosphere, extending prodigiously in cold and moist, and contracting in a dry and warm air. They are of an irregular and angular shape, and often seem to take the particular form of the cavity in which they grow. They are commonly attached by a narrow neck, and are quite moveable.

The flebby or carcinomatous polypi are of a bright red colour, their surface is smooth and regular. They are of a rounded form, and are attached by a narrow neck. They are firmer and are not so easily torn, nor do they bleed so readily as those of the mucous kind.

The carcinomatous polypi are of a darker red or more purple colour than those of the flebby kind, and sometimes they are of a livid hue. They are supplied by a great number of blood-vessels, which makes them bleed profusely even when slightly injured, or gives them a disposition to bleed of themselves. They are of a very hard firm structure; some of them are as hard as cartilage. They are more or less painful, and are very sensible to the touch. Sometimes the pain is of that flinging lancinating kind which carcinomatous tumors have in other parts of the body. Their surface sometimes ulcerates, and the ulcer assumes all the characters of a cancerous sore. They are commonly attached by a firm broad basis.

The encysted polypi occur least frequently. Richter says that they resemble a reticular sac, which contains fluid sometimes resembling mucus; at other times it is of a thick consistence. In one case we found the mucous membrane covering the superior spongy bones extended, but not much thickened; and between its folds there were several round semitransparent vesicles, containing a thick glairy fluid.

SECT. V. Of Polypi of the Nose.

All the four different kinds of polypi have been found growing from the mucous membrane lining the cavity of the nose; we have also seen the superior spongy bone so increased in bulk, as to form a tumor resembling the flebby polypus.

The first symptom of a polypus in the nose is a preternatural degree of redness of its mucous surface. It becomes spongy and callous, and there is an increased secretion of mucus. The patient has some interruption in breathing, and the voice is rendered more or less indistinct; he feels as if stifled, and he tries to get quit Chap. III.

Of Polypi, of something which incommodes him by blowing his nose, for the same reason as a person does who labours under a common catarrh; the sense of smell becomes impaired, and all these symptoms are more troublesome in wet than in dry weather.

The symptoms increase till the extension of the mucous membrane increases to such a degree, as to form a distinct circumscribed tumor; and the progress of the complaint is generally so slow, that its nature is frequently not suspected till it gets this length.

By degrees the breathing through the nose and the sense of smell are entirely destroyed from the mechanical obstruction of the tumor; and the patient himself finds, that by a violent expiration or inspiration, the tumor can be pushed forward or backward in the nose.

The pressure which a polypus sometimes makes on the nasal duct prevents the tears from flowing freely into the nose, and is the cause of a watery eye.

When the tumor is large, the septum of the nose is frequently pressed on, and pushed to the opposite side, and then the respiration is oppressed in both nostrils. Sometimes the tumor descends, and part of it projects through the nostril; when this takes place, the surface of the part exposed to the air becomes like common skin. This indeed happens when any mucous surface is exposed. We have observed it in the vagina when it was inverted, and in the eyelid when the palpebral membrane was turned outwards, from a tumor, or any other cause.

Morgagni takes particular notice that the natural position of the septum is apt to be mistaken for disease, as it very frequently divides the nasal cavity into two unequal portions.

More frequently polypi extend backward into the pharynx, and can be felt by introducing the finger behind the velum pendulum palati. In one rare instance, we have known a polypus so large, as to descend along the esophagus into the stomach, and in another to fill up the whole cavity of the mouth, and produce suffocation.

It happens also that polypi growing from an extensive base, separate, displace, and produce an absorption of the bones which surround them. The bones of the nose are pulled upward; the maxillary bones and the palate bones are disjointed, and carried outward; the arch of the palate depressed; the inferior margins of the orbits are pressed upward, and push the eyes out of their orbits.

Polypi are found to arise from every part of the nasal cavity; but most frequently from the inferior spongy bones. Many surgeons have conceived that polypi arose from general diseases of the constitution, as scrofula, syphilis, &c.; but it will in general be found to be a mere local disease, and probably to arise from whatever tends to produce a continued or repeated attack of inflammation in the part.

Treatment.—If polypi are attached to the upper spongy bones, their removal will be more dangerous, as the inflammation excited by an operation will be readily conveyed to the brain. When they are attached to the inferior spongy bones, they can be removed with perfect safety.

The most celebrated surgeons have never advised any operation when the tumor is small and gives no distress; but whenever it becomes of such a size as to fill up the cavity of the nostril, disturb respiration, and assume a malignant aspect, it ought to be removed.

As long as polypi continue small, or when the mucous membrane acquires that appearance which indicates the commencement of the disease, tonic and astringent remedies are generally recommended, as decoction of oak bark, with alum; strong solutions of white vitriol, saccharum saturni, or muriate of mercury, ardent spirits, and vinegar. Either of these solutions, which may be selected, ought to be thrown up a little warm into the nasal cavity with a syringe, retained there half a minute or more, and repeated four or five times daily; or a piece of charpee wet with them may be put into the nose with a probe, and applied to the diseased surface. Kino, galls, white vitriol, &c. sabine in the form of powder, snuffed up into the nose, as strong as the patient can suffer it, are also useful in stopping the progress of the disease. Mercury has been found rather to make them worse; caustic and other corroding applications have been of use in the softer kind, though they have never produced a cure. Bougies have been recommended by Mr. B. Bell, and are said to have been useful; and when the polypus is small, they may act on the same principle as bougies do on tumors of the rectum, a practice so successful in the hands of Default.

Polypi may be removed either by tying a ligature round their neck, by tearing or twisting them, or by cutting them out with a knife or scissors.

Operation.—Professor Richter of Gottingen, and several eminent practitioners of this country, use, in general, the forceps; and in those cases where the polypus is attached to the inferior spongy bones, or to any of the inferior part of the nasal cavity, this mode of operation is much more easily performed, and has the best chance of success.

From the soft spongy texture of the superior spongy bones, and ethmoid bone, with which they are connected, there is a considerable risk of tearing and injuring more parts than is necessary for the removal of the polypus; and, as any inflammation excited on these may spread to the membranes of the brain, it is more advisable to remove polypi attached to these parts by the ligature.

When polypi are completely within the reach of the knife, adhering towards the external opening of the nostrils, they may be easily cut away.

In performing any operation, or even making an examination of the state of the nose, it is of considerable importance to attend to the position of the forehead, and to employ a proper light.

The head should be bent backwards; and in order to enlarge the external nostril, an afflantant, on whose breast the head of the patient rests, ought, with the fore-finger of his right hand, to press upward the point of the nose; whilst, with a probe in his left, he spreads out the alae.

Of removing Polypi with the Forceps.—Forceps for this purpose ought to be fix inches or fix inches and a half long, and the axis at two-thirds of their length distant from the extremity of the handle; so that the operator may have the advantage of a long lever. See Fig. 1. Plate DXV.

The points of them ought to be blunt, rounded on the outside, perforated, and a concavity, made rough, extending Of Polypi, extending to near the axis. The two blades ought to be separated at their union, when closed, and not to become parallel till they are opened to a considerable distance, in order that the polypus may be held very firmly. The blades should be strong, and pretty broad.

Even this form of forceps is not always sufficient; and it is useful to have a pair of such as has been recom- * See Plate mended by Richter *. They are intended to be em- DNV.fig.2: ployed in those cases, where the polypus is so large as completely to fill the nostril, and so hard, that the upper part of the blades of the common forceps cannot sufficiently dilate to allow their extremity to pass down the nostril, and reach the bottom or neck of the tumor.

It is of great importance to fix the forceps as near the root of the polypus as possible; for, when that is accom- plished, the whole mass may be at once removed: and the hemorrhagy is never so great as if the polypus was torn through the middle.

Often, however, it happens, that the polypus is so large as to defend the nostrils in such a manner, that it is impossible to discover the root till the extremity is removed. We must, in such a case, remove as much as we are able, and even although the bleeding is pro- fuse, persevere in the operation as long as we can pull any away with safety.

When the operation is to be performed, the patient ought, by his own efforts, to push the body as far for- wards as possible; then the surgeon, with a pair of small forceps in his left hand, seizes the point of the polypus, and having kept fast hold of it, he cautiously introduces the polypus forceps on the outside of the others. The more time that is bestowed on this step of the operation, the more the polypus becomes elongated and thinner, the more room is given for the forceps, and therefore the higher up can the polypus be grasped. After it is completely secured between the blades of the forceps, it is to be twisted slowly round, and at the same time pulled outwards. If only a portion of the polypus is removed, what remains is to be extracted in the same manner. The hemorrhagy is generally pro- fuse, but seldom requires the assistance of art to stop it.

Of Removing Polypi by the Ligature.—The liga- tures consist of wire, catgut, silk or cord; and dif- ferent methods have been employed for passing them round the root of the polypus. In order to remove a polypus, the anterior part of which is situated in one of the nostrils, a ligature (a) † is to be introduced through a double canula (b), and one end fixed round the ring (c); whilst the other end (d) being loose, al- lows the noose at a, to be increased or diminished, ac- cording to the size of the polypus. The polypus is to be grasped by a pair of forceps put through the noose, and drawn forwards. The ligature is then to be carried to the root of the polypus, either by means of the forked probe (fig. 4.), or by one of the porte-neuds (fig. 5.), taking care to tighten the wire gradually, the further the instrument is introduced. When the noose reaches the root of the polypus, the ligature is to be firmly drawn, and secured by being twisted round the ring of the canula. If the polypus hangs down behind the ve- lum pendulum palati, the doubled wire is to be slowly inhaled through the nostril into the throat. The finger of the surgeon is to be introduced into the mouth, and by opening its doubling the noose passed over the extremity of the polypus, and conducted to its root, by gradually tightening the ligature, and then it is to be firmly fixed. The ligature should be tightened once or twice a-day, until the tumor entirely separates. As there is generally a considerable degree of swelling and inflammation of the tumor before this takes place, if it be so situated as to disturb respiration, it may even be ne- cessary to perform bronchotomy as a preliminary step. Should any part of the polypus remain, it may be de- stroyed by caustic, or the actual cautery, if practicable.

Besides this, which is the common and most simple mode of applying the ligatures, there are others which are well adapted for particular cases. The apparatus employed by Deffault is extremely ingenious and well- suited for its purpose, but is more particularly useful in polypi of the vagina and uterus.

When this apparatus is to be used, two porte-neuds Deffault's (a a) ought to be procured, and having pulled the apparatus cylinder over the branches of the stalk, fo as to shut the rings (d) completely, a ligature of waxed thread, cat- gut, or silver wire, is to be passed through them (d), and the extremities may be either held along with the canula or secured at e *.

The two canulas, thus armed, are introduced pa- rallel to one another between the tumor and parietes of the cavity in which it lies; and when they reach its base, one is held firm, and the other carried round the base, crossed over the other, forming a noose round it.

The ligature being pulled tight by an assistant, the two ends are to be put through the hole (g) of the other canula, and fixed to the axis at h.

The extremity (g) is then to be sift along the ligature close to the polypus; and the ligature being firmly fixed to the other extremity, the two porte-neuds may be at once removed, by allowing the ring to divide, and the ligature to escape.

This being done, nothing remains to complete the operation. The ligature is kept round the polypus till it drops off, and as the parts begin to give way, it ought to be retained always perfectly tight; and this may be ea- fily accomplished by turning the screw at h.

The apparatus, too, (fig. 6. Plate DXV.) may also be sometimes useful, from the flexibility of the canula, which conveys and directs the ligature.

2. Of the Polypus of the Rectum.

Polypi of the rectum differ considerably from the common hemorrhoidal tumor, in their symptoms and ap- pearances. They resemble the fleshy polypi in other parts of the body, in their colour and external form, and they are also sometimes ulcerated on the surface. On cutting through a large tumor of this kind, we found it composed of a vast number of cells, some of them very large, and all of them filled with blood. Their progress is slow, and we have seen them grow as big as a large walnut. They do not alter their size at different times, as is observed in the hemorrhoidal tu- mor, except that they are apt to swell, when allowed to remain long external to the anus. They are most commonly situated in the rectum, close to the anus; so that when the patient goes to stool they are pushed downwards, Chap. III.

Of Polypi downwards, and appear externally. When very large, they are also apt to come through the anus by the least exertion in walking. They are generally attended with more or less pain or uneasiness on going to stool; and when they become too large as to come through the anus in walking, the disease becomes very distressing. They are often accompanied with a discharge of mucus. Sometimes, too, hemorrhoidal tumors are formed contiguous to the polypus; but the latter is generally pointed out by the patient as the original swelling, and that which gives most pain. These tumors may also be readily distinguished from one another by their difference in colour and general form.

Treatment.—Astringents, with opium, and bougies, may alleviate the symptoms; but as they seldom give permanent relief, the most complete and safest mode of cure is removing them with the knife, if they can be readily reached; if not, the ligature is preferable, although it gives much more pain; for it sometimes happens, that a very profuse bleeding follows after they have been cut away. The hemorrhoidal tumors which accompany the polypus disappear after its removal.

When they are tied with a ligature, this can be done in most cases by simply tying a strong silk thread firmly round the base of the tumor. Often the base is larger than the apex, and then it is necessary to pass through the middle of the tumor a curved needle with two ligatures, one to tie each half of it. To prevent any mistake, and accelerate the operation, surgeons make one of the ligatures of black, and the other of white thread. Whilst the mortified part is separating, great attention is necessary to keep the surrounding parts from excoriating; and this is to be done by frequently washing with warm water, or a turpentine solution, and anointing them with turpentine ointments, or the unguentum refoenum. Fig. 7. Plate DXV. gives an outline of tumors of this kind.

3. Polypi of the Gums

Most frequently are connected with a carious tooth, or of the alveolar processes of the jaw bone; sometimes, however, not. They are generally of a firm fleshy texture, rounded form, polished surface, and are very apt to bleed; and they sometimes grow to a very large size, and become malignant. They are best removed by the knife; and, as they bleed profusely, it is often necessary to use the actual cautery to restrain it. If the bone is found carious, the diseased part should, if possible, be removed, or means used to assist and promote its exfoliation; and when this has taken place the polypus often disappears without any operation.

4. Polypus of the Frontal Sinus.

This is a very rare disease, and it produces the same dreadful consequences as that of the antrum. Art can perhaps venture to do little, as the close connection to the brain would render any attempt to remove it dangerous.

5. Polypus of the Antrum Maxillare.

The surgeon is seldom aware of the presence of this disease until it is far advanced, and has begun to distend the bony cavity in which it is formed. It sometimes acquires a prodigious bulk, separating and rendering various the bones of the face, pulling the eyeball out of the orbit, and filling up the cavity of the mouth. If the nature of the complaint is early suspected, by removing a portion of the external parietes of the antrum with a trephine, the polypus may perhaps be removed from its attachments; but if that is impracticable, strong astringent applications, caustic or the actual cautery, or removing portions by the knife, may arrest the progress of the disease.

6. Polypi of the Urethra.

These are what have been called caruncles, and were supposed to be the most common cause of stricture. It is now, however, well known that they occur seldom. If their growth is not checked by the use of a bougie, and if they are not near the meatus urinaris, it may be necessary in some cases to cut in upon the urethra, in order to get them extirpated; but that must happen rarely.

7. Polypi of the Bladder

Are beyond the reach of the surgeon, but they occur very rarely; and the distressing symptoms which attend this disease, can only be alleviated by those internal medicines which dilute the urine and allay the irritability of the bladder.

8. Polypi of the Ear.

They sometimes grow from the membrana tympani, but they generally arise from the cavity of the tympanum, after the membrana tympani has been destroyed by ulceration. They resemble the common mucous polypi in structure; and they are most frequently accompanied by a discharge of puriform matter and a total loss of hearing. They may be removed with a ligature in most cases very easily; or they may be torn out with forceps; and it is always necessary to touch the part to which they adhered repeatedly with caustic, and to use strong astringent washes, in order to prevent their future growth.

9. Polypus of the Conjunctiva.

We have never observed them on the conjunctiva covering the eyeball; but they are formed on the inner membrane of the eyelids, and most frequently on the upper one. They are soft pendulous masses, which, being loose, float between the eyelid and ball, and sometimes even pass beyond the edge of the lids. They are of the red colour of the inflamed mucous membrane; but those portions which are exposed to the external atmosphere become dry, and often drop off. They are often formed in consequence of the membrane being inflamed by the abscess bursting internally. They are easily removed by the knife; and they are prevented from being regenerated, by slight scarifications or the application of lunar caustic to the base.

10. Of the Polyps of the Uterus.

These polypi are found to grow either from the fundus, the lower edge of the os uteri, or from the inside of the cervix. The first is the most, and the second the least frequent. The shape of the uterine polypus is generally pyriform, having a very narrow neck. They are commonly of the farcomatous kind; though it often happens that polypi are formed in uteri affected with cancer. cancer. Polypi protruding into the vagina are apt to be mistaken for prolapsed uteri; and this mistake is more likely to take place in some cases where the polypus acquires a large bulk in the uterus, and is suddenly protruded into the vagina, and strangulated by the os tinci. Cafes, too, of prolapsed uteri have been mistaken for, and treated as polypi.

The safest mode of removing uterine polypi is with the ligature. When it is situated in the uterus, this operation is impracticable; but when it descends into the vagina, it may be very readily done by the apparatus of Default (Plate DXV, fig. 5.).

SECT. VI. Of Aphthae.

The formation of aphtha, when they are examined with care in their different degrees, may probably extend our views of the intimate structure of the mucous membranes. Boerhaave considered them as small superficial ulcerations, and Stahl regarded them as tubercles or pustules. From the present state of our knowledge it is difficult to determine whether aphtha arise from the chorion of the mucous membrane, in its papillae, or in its mucous follicles.

Aphthae are formed on the lips, the gums, the interior of the mouth, the tongue, the palate, the amygdalae, the oesophagus, and also in the stomach and intestines. They are most frequent in children and old people, and they have been observed in people who inhabit places where the air is tainted, and who live on unwholesome food.

The aphtha of the adult may be considered as a collection, more or less agglomerated or inflated, of white superficial rounded tubercles, each about the size of a millet seed. These tubercles discharge a serous humour; the pellicle which covers the mucous membrane is detached, and is progressively formed in the different parts of the mouth, and even in the rest of the alimentary canal. They are sometimes delineated in solitary pustules over the tongue, the angles of the lips, or the back part of the mouth, with a benign character. At other times they are formed and seemingly propagated from the interior of the oesophagus; pass the back part of the mouth, forming a white, thick, and strongly adhering crust; and these are often dangerous from a complication of typhus fever.

The aphthous tubercles vary in colour. Sometimes they are transparent; at other times they are white, with a certain degree of thickness; they are also sometimes of a deep yellow colour, and sometimes they are livid or blackish, a symptom which always indicates a greater degree of danger.

Aphthae may also be frequently observed in people who have taken many courses of mercury. In these cases, the repeated action of the mercury on the mouth appears to leave on that organ a degree of sensibility or weakness which disposes it to the disease. It happens not unfrequently that these aphthae are considered as venereal sores, in consequence of the venereal disease not having been properly cured; on this supposition a new mercurial course is employed, which only augments the disposition to aphtha, and makes the sores spread more rapidly.

The aphthae of children are preceded by a profound sleep, by agitation of the muscles of the face and lips, difficulty of respiration, prostration of strength, feebleness of the pulse, and vomiting. In the mild form of the disease, white superficial spots appear in different parts of the mouth, which are separated from one another, and the interfaces are neither red nor inflamed. The bottom of the mouth has often been discoloured, and the heat immoderate; there is no difficulty in swallowing, and the child can readily suckle; the sleep is natural, and there is a slight diarrhoea. The spots during the first days preserve their whiteness and transparency; they afterwards become a little yellow, exfoliate in flakes, and go away entirely about the ninth or tenth day, particularly when the child has a nurse.

The confluent or gangrenous aphtha have other characters. The small pustules are contiguous to one another, and spread not only over the lips, the gums, the tongue, and the interior of the cheek; but we also see them at the bottom of the throat. The mouth of the child is burning; the lips are with difficulty applied to the nipple, and sometimes it is excoriated by their contact. Deglutition is very difficult, and the most simple drinks given in small quantities, and with precaution, do not enter into the stomach but with pain. There is a constant purging of greenish matter, which inflames and excoriates the skin round the anus; the child is very feeble and heavy, and the eyes are sunk and shut, and the child screams. The whole interior of the mouth from the lips to the throat becomes at last lined with a white thick crust, resembling coagulated milk. This crust becomes yellow, and forms a flough, which, after it falls off, exposes gangrenous ulcers of a dark brownish yellow colour.

Treatment.—In the benign form of the disease in children, it is of great consequence to get the child a good nurse; and the affected parts may be washed over five or six times a-day with a piece of caddis dipped in a little water gruel, to which has been added a few drops of sulphuric acid. Borax, either in powder or solution, has also been considered by some as a useful application. When the crust has separated, if the remaining ulcer be painful and irritable, its surface may be rubbed over with nitrate of silver, or any other caustic application. Sometimes very malignant looking ulcers remain in the adult, after the separation of the crust. In these cases, cautic may be employed; and we have often seen them heal rapidly by touching their surfaces once a-day with a weak solution of corrosive sublimate or muriatic acid. For the treatment of the confluent aphtha, see Medicine.

SECT. VII. General Remarks on the Hemorrhagy from Mucous Membranes.

All the mucous surfaces are particularly subject to hemorrhagy; and this may arise either from a rupture of the vessels, or the blood may be poured out by the exhalents.

The superficial position of the vessels, and consequently their want of firmness and support, exposes them much to rupture by very slight concussions. We have examples of this in the bronchiae, brought on by coughing; in the nose, by flight blows on the head, or by violent sneezing; and in the rectum, by straining on going to stool. The effects of stones or gravel on the mucous membrane lining the urinary organs are the same; and even even the most cautious introduction of a sound or bougie into the urethra, often causes bleeding; or the slightest friction of polypi of the nose and gums, or the introduction of a probe into the lachrymal passages. When considering the diseases of the skin, we mentioned, that in some diseases, particularly some phthisical fevers, the exhalents of the skin poured out red blood. The same thing happens among the mucous membranes. We often see blood come from the nose, from the bronchiae, stomach, and intestines, urinary bladder and kidneys, where there has been no reason to suppose ulceration previously to have taken place, or any thing to cause a rupture of any of the vessels.

1. Haemorrhagy from the Nose.

Haemorrhagy from the nose arises from a variety of causes. We often observe it after fevers, and then it has been considered as critical. In young people it occurs very frequently, and from very slight causes; and it has been sometimes known to take place at the menstrual period.

Haemorrhagy from the nose is generally preceded by symptoms of an increased quantity of blood to the head, pulsating motion of the temporal arteries, feeling of weight about the head, symptoms which are preceded or accompanied by other changes in more distant parts; such as spontaneous laughter, pains about the belly.

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

2. Hemorrhagy from the Rectum, or Fluxus Hemorrhoidalis.

The discharge of blood from the rectum is a disease chiefly confined to those advanced in life. It is often occasioned by full living, change from an active to a very sedentary life, the abuse of purgatives, particularly aloes; violent passions, or habitual melancholy. The symptoms which precede and accompany this disease, are bearing down pains, and a fenlation of weight in the back and loins, sometimes a numbness in the limbs, and a contracted pulse, thirst, diminution of urine, flatulence, and sometimes a discharge by flood of a white mucus. The discharge returns commonly in a periodical manner once a month, and thus becomes necessary for the preservation of health; for if it be suppressed, or if it flops spontaneously, it occasions a variety of nervous affections, such as spasmic tightnings about the chest, colic and vertigo.

Treatment.—When the haemorrhoidal discharge has become habitual like the menstrual discharge, we not only ought not to attempt curing it, but it it be from any cause suppressed, it ought to be restored. If it be the effect of general plethora, it is to be removed by a vegetable diet and moderate exercise. In order to moderate the discharge, the patient ought to lie in the horizontal posture on a hard bed, avoid all exercise, keep the belly open by cooling laxatives, or even to take acids if the bleeding is excessive, and apply cold to the loins and perineum. As a sudden suppression of the haemorrhoidal discharge is the cause of many diseases, it is of much importance to reproduce it. To effect this, leeches applied to the anus, and warm fomentations, are the most efficacious remedies.

3. Haemorrhagy from the Bladder (Hematuria).

Haemorrhagy from the bladder is a disease most frequent in old people; it is often occasioned by a suppression of the haemorrhoidal discharge, or any other accustomed discharge of blood. It is sometimes the consequence of excess in living and drinking, and of a sedentary life followed by great exercise. It also arises from a plethoric state of the system, violent exercise on horseback, the internal use of cantharides, a contusion in the region of the kidneys, or from stone in the bladder.

Treatment.—The treatment to be employed is the same as in hemorrhagy in general. Every thing ought to be avoided which might tend to irritate the kidneys or the urinary bladder. Laxatives, acid drinks, the application of ice to the lumbar region, hypogaltrium, and perineum, or to the inside of the thighs, is of great importance. Under the articles Medicine and Midwifery, we have considered the haemorrhages from the lungs and uterus. We may here remark the connection and strong sympathy which subsists between these organs, and also between them and the other organs of the body; for a minute acquaintance with these may often lead to a successful mode of treating their diseases. When the menes are suppressed, there is often a hemorrhagy from the mucous membrane of the lungs; and there are also many cases of obstruction in the bowels which bring on hemorrhagy both from the lungs and uterus; a hemorrhagy which never ceases until the primary affection be removed.

SECT. VIII. General Remarks on the Ulceration of Mucous Membranes.

Simple inflammation of a mucous surface seldom, if ever, terminates in ulceration, most ulcers of these parts having a specific character. The venereal inflammation rapidly terminates in ulceration; and aphtha have the same tendency, forming often what are called phagedenic sores.

The mucous membrane of the nose is peculiarly subject to ulceration; ulcers also occur in the different parts of the mouth and gums, in the intestinal canal, and also, though very seldom, in the urethra. It is the first of these only which are to be treated of in this place.

Of Ulcers of the Nose, or Ozæna.

This species of ulcer sometimes appears in the nostrils, and sometimes in the frontal or maxillary sinus. It generally succeeds a violent coryza. It also sometimes arises from blows on the nose, or from the application of very acrid substances. Ozæna is often accompanied with inflammation, hemorrhage, pains, caries of the bones which sometimes destroys the palate bones, cartilages of the nostrils; and by hindering more or less the free passage of the air, it alters the tone of the voice.

Treatment.—In the simple ozæna, much benefit generally arises from the use of astringent washes, such as a decoction of oak-bark and alum, solutions of sulphate or acetate of zinc, or the acetate of lead. The best mode of using these is to inject them a little warmed, with a common syringe, into the affected nostril, three or four times a day; and when the quantity of discharge diminishes and becomes of a better quality, an ointment composed of the flowers of zinc or the like, spread on a piece of lint, should be introduced once or twice a day into the nostril.

When the ozæna is of a more virulent nature, and the bones affected with caries, there is generally great reason to suspect a venereal taint. This can only be determined by the history of the complaint and the constitutional symptoms of the venereal disease being present. In such cases mercury is the only remedy, and along with its internal use the injection of mercurial lotions, and the use of fumigations, will be serviceable. In such ulcers as are obstinate, and which do not partake of any venereal taint, a liniment, with an eighth part of the red precipitate of mercury, or a smaller proportion of the acetate of copper, has been recommended by Mr Bell as a useful application. In some cases, too, where, after the venereal taint is destroyed by a proper mercurial course, there remains an obstinate sore, the above liniment may be useful, and it has also been found in such cases of much advantage, a course of sarsaparilla or cinchona.

CHAP. IV.

Of the Diseases of Serous Membranes.

General Remarks on the Pathology of Serous Membranes.

The phenomena of the diseases of serous membranes are very different from any of those of the other textures which have been mentioned. When they are attacked with inflammation, the serous surfaces often adhere together, or if suppuration takes place, it is never accompanied with ulceration or erosion of their substance. However abundant these purulent collections may be, the membranes always remain found, with only a little additional thickness; the purulent fluid rejected from them, being like the natural fluid formed by exhalation.

The serous cavities are also subject to hemorrhagy, and to preternatural collections of the exhaled fluid.

Under the article MEDICINE we have treated of inflammation of the pleura, membranes of the brain and peritoneum, and also of hemorrhagy from these organs. Of Ascites. In this place we shall consider dropy and hemorrhagy from the vaginal coat of the testes, as the only diseases belonging to surgery.

SECT. I. Dropy of the Peritoneum, or Ascites.

When water collects in a considerable quantity within the cavity of the peritoneum, the skin becomes dry and scurfy, and the superficial veins varicose. In one case they appeared like large tubes half filled with blood, the anterior part of the canal thin and dry, and the posterior portion hard and unyielding. The skin at the umbilicus is sometimes much distended, and the water seen shining through it as in a common blisters. The water varies much in its appearance; most frequently it is yellow or brownish. We have seen it as thick and dark coloured as coffee grounds. In one case it was viscid and tenacious, resembling the white of an egg; and in other instances it resembled milk and water, with the milk partly curdled. Ascites is generally accompanied with a disease of some of the abdominal viscera, and most frequently the liver.

It is not confined to any particular period of life, but has been observed more frequently in men than in women.

The symptoms of ascites are, 1. The swelling and sense of tightness over the belly. 2. Laborious and difficult breathing, especially in the horizontal posture. 3. The distinct feeling of fluctuation, upon applying one hand to one side of the belly, and striking it with the other hand on the opposite side. 4. The urine is in small quantity, and of a dark red colour. There is also thirst, a dry skin, often a feeling of heat, and very frequently oedema of the inferior extremities.

Paracentesis.—When the swelling becomes large, and Operation. internal medicines have no effect in diminishing it, it is advisable to discharge the water by an artificial opening, an operation which seldom cures the disease, but is always attended with temporary relief, and may be repeated as often as the water is found to collect. Smucker has performed it seventy times, and protracted the patient's life for many years. The operation is to be performed by introducing a trocar* at the linea alba, as in a hydrocele, about two or three inches below the umbilicus. Many surgeons now prefer this place, as it prevents all risk of wounding the epigastric artery, or any other important part. It was formerly the common practice to introduce the instrument on the left side of the abdomen, half way between the umbilicus and anterior superior spinous process of the ileum, in order to avoid the liver and epigastric artery. But those who laid down this rule were not aware of the change in the relative situation of parts when diseased; and it has several times happened to Mr Cline and other eminent surgeons, in performing the operation at this place, that they have wounded the epigastric artery, and the patient has died of hemorrhage. The dissection of the abdominal muscles in patients who have died of dropy, shows how much the recti are extended in breadth, and the situation of the epigastric artery changed.

The place for entering the trocar being determined, and marked with ink, the patient should be placed in the horizontal posture, and in such a situation that the water can be run off readily into a vessel proper to receive it. But as patients are very apt to faint if the water is suddenly removed, and no pressure applied to support the belly as it is emptied, it is necessary to make an equal prelure during, and after the operation. From neglecting this in some cases, dangerous symptoms have arisen, and in one instance the patient died three days after the operation from this cause.

A piece of flannel as broad as the belly, and divided into several pieces at each end, and these drawn across each other by affidants, or the bandage*, answers for this purpose. By either of these modes the belly may be gradually compressed as the water is let out, and the compression continued for several days after the operation. Sometimes the water does not come out readily, by a portion of omentum or intestine coming in contact with the end of the canula; but the discharge may be assisted by introducing within the canula a blunt probe, or a less canula within the first, having small perforations at the extremity and edges. After all the water is discharged, a piece of platter should be applied to the wound, and every caution taken to exclude the admission of the external air. The bandage should also be kept applied, and it may be worn for some time.

Sect. II. Water collected in the Cavity of the Vaginal Coat, or Hydrocele.

The effusion of water in the tunica vaginalis frequently accompanies hernia, the scrophulous scirrhus, venereal and other enlargements of the testicle; but in such cases, it is merely to be considered as a symptom accompanying these disorders. Mr Home mentions cases where it was a symptom of stricture. It occurs also during the abatement of inflammation of the testicle; and sometimes more or less of the water remains after the inflammatory symptoms have disappeared. In cases of this kind the tunica vaginalis is generally found thickened, and there is an effusion of lymph over its surface and over the surface of the albuginea. In many cases, the water is collected where there is no apparent alteration in the structure of the parts. The disease in such cases most probably arises either from a diminished absorption or from an increased exhalation. If the disease has been of long duration, the tunica vaginalis is generally thickened, to a great degree sometimes; and particularly in old people it becomes hard or cartilaginous. We have seen several preparations where it was converted into a shell of bone. We have met with two cases where a round substance resembling cartilage was found floating loose in the water of a hydrocele. It is not uncommon to find the vessels also of the spermatic veins become more or less varicose. Collections of water of a very considerable size form sometimes after birth (wind rupture); but in old people they are most frequent. The water is usually collected only in one cavity; but it sometimes happens, that in consequence of adhesions between the tunica vaginalis and testicle, several irregular shaped bags are formed in which it is contained. The water usually collects in one side of the scrotum, sometimes also in both. The water is generally clear and straw-coloured, sometimes it is coloured with blood, sometimes yellow or brown, and sometimes thick, and like coffee grounds. See Morgagni, Ep. xxxviii.

The quantity of water varies. In the A&. Erud. Lipsiensis 1725, p. 492, there is mention made of a case which contained forty pounds of fluid. Doight saw one which contained four pounds. There are sometimes also hydatids found along with the water. Richter has met with four cases of this kind.

Symptoms.—1. The scrotum is commonly of a pyramidal form, and the corrugations of the external skin are destroyed in proportion to the bulk of the swelling. The shape of the tumor, however varies; in some cases, it is very globular, and in others it appears like two swellings joined. It is even altered from the manner in which it is suspended; if a bag trus has been worn it is usually oblong. 2. The swelling generally begins at the lower part of the scrotum, and as its bulk increases, it gradually ascends towards the abdominal ring. 3. It appears pellucid when held between the eye and a candle; but this is not a certain prognostic, as the transparency is destroyed when the tunica vaginalis is thick and hard, or when the water is turbid and dark. 4. It gives the distinct sensation of fluctuation. In some cases, however, the degree of thickening of the tunica vaginalis renders the fluctuation obscure or imperceptible, and also destroys its transparency. 5. The tumor cannot be made to recede or change its situation from pressure or change of posture of the body. 6. The testicle is involved in the swelling, and can be distinguished like a firm unyielding mass at the posterior part of it. In cases where adhesions have been formed, the position varies; but the patient generally knows where it lies, and prelure applied to the part of the swelling where it is situated gives pain. Sometimes the testicle is placed at the under part of the swelling, sometimes in the middle. Mr Bell felt it twice forwards. Sometimes along with the water there are hydatids floating in the cavity of the vaginal coat. Sommering says, that he has often observed this appearance. 7. The spermatic cord can be readily distinguished unaltered. 8. The tumor gives little or no pain, and the patient suffers merely from its bulk. 9. The growth of the swelling is generally very slow, and sometimes years elapse before it becomes a great inconvenience; sometimes, however, it forms rapidly. When it grows very large, the integuments become thick, and the veins varicose; if the swelling extends up to the inguinal ring, the cord cannot be felt, and the penis is sometimes so much involved in the tumor, that it appears like an umbilicus or piece of corrugated skin.

Treatment.—In children, the water generally disappears in a short time, by the application of strong astringent or diuretic applications. In some cases, the disease advances so slowly, that it is sufficient to wear a suspensory bandage. Richter mentions a case where it was twenty years old before it was necessary to remove the water. When the swelling becomes so large as to render it necessary to discharge the water, the operation may be either palliative or radical. The object of the first is merely to remove the water, after which the disease commonly returns; and by the second, an adhesion is intended to be produced between the surface of the vaginal coat and albuginea, and consequently the cavity in which the water was collected entirely obliterated. In making choice of these modes of treatment, it is necessary to attend to the following rules. 1. When the hydrocele is large, it is safer to perform the palliative operation; and afterwards when it has again collected in less bulk, the radical one may be employed. 2. When the state of the testicle is not accurately ascertained, it is better first merely to discharge the water, which allows it to be completely examined. 3. The palliative operation should be employed in all cases where the disease is connected with a morbid state of any contiguous organ. 4. In all other cases, the radical operation is preferable.

Palliative Operation.—The matter may be discharged either by a puncture made with a lancet or by a small trocar.

When the trocar * is to be introduced, the posterior part of the tumor should be firmly grasped in the left hand, so that the fluid is pushed to the anterior and inferior part of it. A puncture is to be made, with a lancet, through the integuments at the most prominent part of the swelling, large enough to admit readily the trocar, taking care to avoid any large superficial vein. The trocar is then to be pushed through the coats of the tumor perpendicularly; but when it has entered the cavity, which is known by the feeling of a sudden want of resistance, the point should be directed upward, and carried forward a sufficient way; so that the surgeon is assured of its being within the cavity so far that there is no risk of its falling out.

After all the matter has been allowed to flow out, and the canula withdrawn, the wound should be covered with a piece of sticking plaster, and the scrotum supported by a suspensory bandage. If the operation is to be done with a lancet, an incision should be first made through the skin, rather larger than what is necessary into the cavity. Then a puncture is to be made through the tunica vaginalis, which will allow the water to flow out; and the discharge may be assisted by the introduction of a probe, director, or hollow tube, into the opening. The trocar should always be employed for this operation, except when the hydrocele is so small that the testicle would be in danger of being wounded by it, or when there is any enlargement of the testicle accompanying the hydrocele, which is not well underflowed, or if the tunica vaginalis is extremely thick and the fluctuation not distinct.

Radical Operation.—An obliteration of the tunica vaginalis may be produced either by an effusion of lymph on the surfaces of the tunica vaginalis and albuginea, or by the process of granulation. The first is effected by injecting into the cavity a stimulating fluid to produce inflammation and adhesion; the second is by laying open the cavity to produce inflammation and suppuration, and to allow it to fill by granulation.

By Injection.—Dr. Monro primus first proposed and adopted this ingenious, yet simple mode of cure; and it is now that which is most generally practised in all cases not attended with any peculiarity or puzzling symptom. The fluid contained in the tunica vaginalis, is to be discharged by a trocar, in the manner recommended in the palliative treatment. The trocar for this purpose should be of a rounded form, which is either altogether cylindrical, or only a small slit at its extremity; for that of André, which is flat and slit up at both sides, is apt to allow the fluid to be effused into the cellular membrane of the scrotum; an accident which we have seen repeatedly happen, and always frustrates the object of the operation.

The fluid is then to be injected through the canula either by a syringe (Plate DXIV.), which has a moveable stop-cock, that it may be filled as frequently as is necessary, or by an elastic bottle, which has a valve in its pipe, so as to allow the fluid to pass forward, but to prevent its exit. It is not necessary to inject as much fluid, as there was water in the hydrocele; it answers well to fill the cavity moderately and by gentle strokes on the scrotum agitate it over the whole surface. The fluid most commonly employed is port wine. Some recommend it to be diluted, but it is better to use it pure, and allow it to remain a longer or shorter time according to the degree of pain it excites, and the general irritability of the patient. In hospitals, other fluids are used, as being less expensive. Mr Cline of St Thomas's hospital employs a solution of the sulphate of zinc 5a. ad lbi. From five minutes to a quarter of an hour is in most cases a sufficient length of time to allow the wine to remain. If it excite severe pain in the testicle or cord, it may be detained more or less time. A considerable degree of uneasiness is always to be wished for in order to secure success in the operation. After the wine is withdrawn, the wound should be covered with a piece of sticking plaster or caddis; the scrotum well supported with either pillows or a trus, and the patient put to bed. The operation excites more or less swelling in a longer or shorter period. The medium effect on the testicle is to cause it to swell about the bulk of a turkey's egg in four or five days; and the surgeon should, by pursuing the antiphlogistic regimen, moderate as far as in his power the inflammatory symptoms to that pitch, and by an opposite treatment bring them up to that degree should they be too mild. Low diet, local or even general blood-letting, purging, the horizontal posture and fomentations, are the most powerful means to arrest inflammation; but if the patient has little pain, he should live on a nourishing diet, and some local stimulant may be applied over the scrotum until a sufficient degree of inflammation comes on. If the inflammatory symptoms abate, the swelling disappears; and it is advisable to wear always afterwards a bag trus to support the whole scrotum. In some cases the water again collects, and then the operation should be repeated; but it requires caution, as the relative situation of parts is sometimes altered from some partial adhesions having formed between the tunics.

We have seen frequently cases where it was thought that the water has been regenerated a few days after the operation, which swelling afterwards disappeared. This probably arises from an effusion in the cellular membrane, but it requires no particular treatment.

By Incision.—After grasping the tumor firmly, an incision is to be made through the skin with a scalpel, from its superior to its inferior part. A puncture is to be made towards the upper part, with a lancet, large enough to admit the point of the fore finger; the fluid is allowed gradually to escape through the opening; and the tunica vaginalis is to be laid open its whole extent with a probe-pointed bistoury in the same direction as the incision through the integuments. Pledgets of lint dipped in oil, oil, or covered with simple ointment, are to be put between the lips of the wound, down to the bottom of the cavity, one on each side of the tefticle; and the edges of the scrotum are to be brought together either by straps or future. A fingle ligature put through the inguinal parts opposite the tefticle, answers best, and prevents the tefticle from being pulled without the edges of the wound in consequence of the degree of swelling the operation occasions. The whole should be covered with a pledget of ointment, and suspended in a tight bandage.

In three or four days after the operation, the external dressings should be removed; and in one or two days more, the pledgets interposed between the tunica vaginalis and tefticle may be taken away and renewed. The ligature should be cut out whenever the swelling of the parts begins to abate, or at any time when it appears to create irritation. During the cure, great care should be taken, first, by the introduction of slips of platter, to prevent the union but from the bottom; secondly, to guard against the collection of matter in any cavity; thirdly, to prevent the lips of the wound separating far, thus exposing the tefticle and protracting the cure; and fourthly, to lay open freely any finuses which may form. The cure goes on much more rapidly by persevering in the horizontal posture, and keeping the scrotum well supported. The bowels should be always kept open and regular, and when suppuration has begun, the patient's strength should be supported by a nourishing diet and bark or port wine, if necessary. The cure takes from three to eight weeks in most cases. This mode of operating, is the most eligible when there is any ambiguity in the case, as it allows the tefticles to be accurately examined, and castration performed if necessary. It ought also to be performed when the tunica vaginalis is much thickened and hardened, and it is sometimes necessary, even to cut away some of the hardest portions. The mode of curing hydrocele by a feton, caustic, &c. are now generally given up.

SECT. III. Drophy of the Thorax, or Hydrothorax.

The fluid is sometimes confined to one, and sometimes affects both sides of the chest. It is commonly of a brown or yellow colour; sometimes it is reddish from a mixture of blood. Its chemical qualities are those of serum. When it is accumulated in a large quantity, the lungs are more or less compressed. Dr Baille has seen a lung not larger than the closed fist. It is also in some instances accompanied with adhesions between the surface of the lungs and pleura.

The existence of water is known by the following symptoms. Respiration is short and difficult; and the patient cannot rest in bed, except the head and trunk be elevated from the horizontal posture. The sleep is often interrupted by alarms and disagreeable dreams, and the patient suddenly starts from it with a sense of suffocation: he is unable to floop much forward, or raise any thing from the ground. There is sometimes a tearing cough, with little expectoration. During the progress of the disease, the pulse is very variable; but it is generally irregular. The countenance is pale, and the lips and cheeks of a purple hue. The urine is diminished in quantity, and of a high colour. The bowels are generally constipated. The feet and legs are commonly anaefarous. The undulation of a fluid may be heard by the patient himself, and moving the body by sudden jerks will sometimes affit in discovering the disease. The affected side has in some cases been observed to be enlarged.

This disease is treated by the exhibition of internal medicines, where the quantity of water is small; but when it collects in such a quantity as to threaten suffocation, it ought to be discharged by an opening made into the cavity of the thorax. The incision ought to be made between the fifth and sixth ribs, half way between the sternum and spine; two inches in length through the skin. The subjacent parts ought to be cautiously divided; and the incision should be directed rather towards the upper part of the fifth rib, to avoid wounding the intercostal artery and nerve, which creep along the inferior edge of the fifth rib. The pleura, which is distinguished by its bluish colour, should be carefully cut with the point of the knife; so that, in case of adhesion, the lung is not wounded: and if the water flows out, a canula should be introduced into the opening. If it does not, in consequence of adhesion, another incision must be made. Great care should be taken to prevent the admission of air, and for that purpose, the opening should be made valvular, by pulling up the skin which is to be cut through. If the quantity is very great, it may be drawn off at two different intervals; or if it is collected in both cavities of the thorax.

SECT. IV. Drophy of the Pericardium.

Water is sometimes found in the pericardium when there is none in any other cavity of the thorax, but it is generally accompanied with a collection of water in some of them. The symptoms of this disease are nearly similar to those of hydrothorax; and we find that Deffault and other very eminent surgeons have not been able to distinguish them. Dr Baille says, "that the feeling of oppression is more accurately confined to the situation of the heart; and the heart is more disturbed in its functions in drophy of the pericardium than in hydrothorax." It is also said, that a firm undulatory motion can be felt at every stroke of the heart.

If the existence of this complaint is ascertained, and if the quantity of water is suspected to be great, it may be perhaps advisable to discharge it, as practised in one case by Deffault, by making an opening between the fifth and seventh ribs of the left side, opposite to the apex of the heart.

SECT. V. Blood effused in the Tunica Vaginalis. (Hematocoele).

The effusion of blood within the cavity of the vaginal coat is characterized by the sudden appearance of the tumor, by its wanting the transparency of a hydrocele, by its greater weight, and by its being most commonly occasioned by some accident. It is usually produced by the trocar used in performing the palliative operation wounding a vessel which pours its blood into the vaginal cavity; it is still more apt to happen when a lancet is used and a varicose vessel punctured. It also takes place from the rupture of a varicose vessel by the sudden depletion of a large hydrocele.

If the swelling is small, it may disappear by the local ule of difcutents and stimulants, such as solutions of saccharum saturni, or that of alum, vinegar, &c. If it does not yield to these, and if it has acquired a considerable bulk, the blood should be discharged by an incision; and any bleeding vessel either secured by a ligature, or by strong stimulants, and the wound afterwards treated as in common hydrocele.

CHAP. V. Diseases of the Sinovial Membranes.

SECT. I. General Observations on the Pathology of Sinovial Membranes.

The diseases of the sinovial membranes are much more limited and less understood than those of the textures which we have examined. They do not appear to be sympathetically affected in the diseases of other parts. In the acute diseases of the important viscera, the skin, the mucous surfaces, the cellular membrane, the nerves, &c. are more or less sympathetically affected, whilst all the sinovial membranes remain undisturbed. In this respect they resemble the bones, cartilages, and fibrous membranes. Neither is the sinovial fluid subject to the different alterations, which we observe of the serous fluid. We never find any preterminal membranes formed on the articulating surfaces; and the preterminal collections of sinovia never contain any of the white flocculent matter so frequent in serous collections.

The sinovial membranes are subject to inflammation, and are probably the seat of many of those pains about the joints which are so frequent. Their fluids are also sometimes increased to a preterminal quantity, and chalky or earthy depositions are also occasionally found in them.

SECT. II. Of Ganglions.

An increase of the sinovial fluid in the bursae, or tendinous sheaths, forms a species of dropy called a ganglion. It is not, however, probable that these tumors are always formed in a natural sinovial capsule: most commonly they are accidental, and are formed in the cellular membrane; for they are frequently found in parts where no natural capsule exists. They are most frequently met with over the tendons upon the back of the wrist, and often likewise about those of the ankle and other parts of the extremities. When pressed, they are found to possess a considerable degree of elasticity, from which, and from their situation, they may generally be distinguished from other encysted tumors. They seldom arrive at any great bulk, are not often attended with pain, and commonly the skin retains its natural appearance. On being laid open, they are found to contain a tough, viscid, transparent fluid, resembling the glaire of egg, which is also sometimes of a reddish colour.

They are generally produced by sprains or contusions of the joints, or by rheumatism. In many instances, they go off infensibly, without any affluence from art; but as this is often not the case, means ought to be used for removing them. For this purpose, friction frequently repeated, or gentle compression applied to them by means of thin plates of lead and bandages, sometimes remove them. In some instances they have been removed by the application of blisters; but the most certain method is, to make a small puncture into the sac, or to draw a cord through it; or, after the puncture is made, to press out the contents, and then inject some gently stimulating fluid, as port wine and water heated blood-warm.

SECT. III. Of Collections within the Capsular Ligaments of the Joints.

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

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

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

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

Of the Dif- should be put upon a strict antiphlogistic regimen, and of the bones in every respect should be managed with caution; for inflammation being very apt to ensue, we cannot too much guard against it.

Sect. IV. Of Moveable Bodies which are found within the Sinovial Capsules.

Moveable bodies have been found in many of the sinovial capsules of the human body. But they are most frequent in the knee joint; and it is there only where they require surgical affluence. These bodies are generally composed of cartilage in the form of lamellae, and there is often an osseous concretion in their centre. The cause of their formation is not known; but it is probable that they are formed by a gradual deposition of the cartilaginous matter on the articulating surface. They have been often met with, attached by narrow necks to the sinovial cavity; so that when this attachment is destroyed, they float loose in the cavity, and undergo perhaps but little future change.

When they occur in the knee joint, and acquire such a bulk as to obstruct or derange the motions of the joint, it then becomes necessary to remove them. This ought to be done by bringing the moveable body to the outer part of the joint, and making a valvular incision of such a size as admit of its extraction. Sometimes much inflammation succeeds this operation, which ought to make us careful in choosing a proper time for performing it, and in using every endeavour to prevent any inflammatory symptoms afterwards.

Sect. V. Of the Spina Bifida.

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

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

CHAP. VI. Of the Diseases of the Bones.

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

The diseases of bones are remarkable for their slow progress, in comparison with what is observed in the other organs. Inflammation proceeds extremely slowly, and callus is remarkable when compared with the cicatization of other parts, for the length of time necessary for its formation; the origin and progress too of an ex-cas of the otositis is very different from a tumor of the soft parts, as we observe in phlegmon. Suppuration too, which requires only a few days in other organs, takes months before the same process is completed in bones. There is also a striking difference between a gangrene of the soft parts and a caries or necrosis of the bones. In the natural state the bones have no sensibility, but when diseased, they are often the seat of acute pain; we observe this in the spina ventosa, in caries, necrosis, &c. Besides the changes to which the bones are subject from inflammation and various accidents, they also suffer alterations in their hardness and softness. Pretermurinal growths also form upon them; and they are liable to abortion.

Sect. II. Of Particular Diseases of the Bones.

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

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

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

Gummi is a soft tumor on the surface of the bone, between it and the periosteum; and its contents resemble gun foitened, from whence it has taken its name.

The confirmed venereal node has the appearance of a Venereal divarication of the osseous fibres. When the periosteum node is thickened, but the bone not affected, a course of mercury will often produce a perfect cure: but when the bone itself is diseased, this method will often fail. But here the division of the extended periosteum has been known to give perfect ease.

The usual method, formerly, was to apply a caustic equal to the extent of the node, which being laid bare, required exfoliation before it could be cicatrized. If the incision is made early, that is, before matter be formed under the inviting membrane, it seldom requires exfoliation; and, as we often find that the bone itself is not affected, but only the periosteum thickened, we may be deceived even after a careful examination: it is therefore proper that the patient should be pretty far advanced in a course of mercurial unction before even the incision is made; for, should the tumor decrease, and the pain abate during the course, chirurgical assistance, with the knife, most likely may become unnecessary. A bone may become carious first in its internal parts; and that from external injury, as well as from a vitiated state of the animal-fluids. Authors seem not to agree as to the technical term for this kind of disease of the bones; some calling it cancer or gangrena effis; others, spina ventosa, from the pointed exuberances usually attendant on this disorder of the bone; and some again, teredo, from the appearance of the carious bone, like wood that is worm-eaten.

It is universally allowed, that this disease takes its rise from matter being formed either in the diploe, or in the marrow: whenever obstruction is begun in the vessels expanded on, or terminating in, the medullary cysts, the consequence will be inflammation, and, if not early removed, matter will form; for this reason this case may be called abscessus in medulla. Whenever, then, a patient complains of dull heavy pain, deeply situated in the bone, consequent to a violent blow received on the part some time before, though the integuments appear perfectly sound, and the bone itself not in the least injured, we have great reason to suspect an abscess in the medulla. Children of a bad habit of body, though they have not suffered any external injury, will often become lame, and complain of the limb being remarkably heavy; and though not attended with acute pain, yet the dull throbbing uneasiness is constant. If rigors happen during the time the patient labours under this indisposition, it generally implies that matter will be formed within the substance of the bone. If the extremities of the diseased bone swell, or if it becomes enlarged throughout its whole extent, it may be known to be an abscess in the medulla, or the true spina ventosa, as it is called: if neither of these symptoms take place, the great infertibility of the bone in some subjects will prevent that acuteness of painfulness in other parts where matter is formed, though the acid matter is eroding the bone during the whole time it is contained within it. This matter at length having made its way through, arrives at the periosteum, where it creates most violent pain. The integuments then become swelled and inflamed, and have a sort of emphysematous feel. On being examined by preasure, the tumor will sometimes be lefened, from part of the matter retiring into the bone: from this appearance to the touch, most likely the name of ventosa was added to the term spina.

When we are assured of matter being under the periosteum, we cannot be too early in letting it out, as it will save a considerable deal of pain to the patient, though probably it may not be of any considerable advantage in respect to the carious bone; for, where the fluids in general are vitiated, no chance of cure can be expected from topical remedies; but where the constitution is mended, nature will sometimes aftenith us in her part, as the carious bone will be thrown off from the epiphyses, or the teredines will be filled up by the osific matter that flows from the parts of the bone where some of the spine have come away.

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

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

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

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

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

Where the affection of the mesenteric glands is evident, Mr Bromfield afferts, that after a dose or two of the pulvis basiliacus to empty the intestines thoroughly, the purified crude quicksilver is by much the most efficacious medicine to remove obstructions in those glands. When the belly begins to soften and subside, the chyle passes without interruption, and the child begins to get flesh; then the cold bath becomes truly serviceable, and the decoction or cold infusion of the Peruvian bark is a Chap. VI.

Of the Dif- proper restorative; but the cold bath used too early, or eases of the bark given before there is a free circulation of chyle through the lacteals, would be very injurious.

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

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

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

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

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

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

Chap. VII.

Of the Diseases of the Arterial System.

Sect. I. General Remarks on the Diseases of the Arterial System.

The diseases of the vascular system form an important class in systems of Nofology. In the diseases of every organ, the action of the arteries and veins is more or less influenced, though the changes of structure to which these vessels are subject are very limited. The only diseases to be considered in a system of surgery, are aneurism and varix.

Sect. II. Of Aneurisms.

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

The true or encysted aneurism, when situated near the surface of the body, produces a tumor at first small and circumfribered; the skin retains its natural appearance: when pressed by the fingers, a pulsation is evidently distinguished; and with very little force the contents of the swelling may be made to disappear; but they immediately return upon removing the preasure. By degrees the swelling increases, and becomes more prominent; the skin turns paler than usual, and in more advanced stages is edematous: the pulsation still continues; but parts of the tumor become firm from the coagulation of the contained blood, and yield little to preasure; at last the swelling increases in a gradual manner, and is attended with a great degree of pain. The skin turns livid, and has a gangrenous appearance. There is an oozing of bloody serum from the integuments; and, if mortification do not take place, the skin cracks in different parts; and the artery being now deprived of the usual reftance, the blood bursts out with such force as to occasion the almost immediate death of the patient.

When affections of this kind happen in the larger arteries, the soft parts not only yield to a great extent, but even the bones frequently undergo a great degree of de-rangement.

The false or diffused aneurism consists in a wound or rupture in an artery, producing, by the blood thrown out of it, a swelling in the contiguous parts. It is most frequently produced by a wound made directly into the artery. A tumor, about the size of a horse bean, generally rises at the orifice in the artery soon after the discharge of the blood has been stopped by compression. At first it is soft, has a strong pulsation, and yields a little to preasure, but cannot be made entirely to disappear; for the blood forming the tumor being at rest, begins to coagulate. If not improperly treated by much preasure, it generally remains nearly of the same size for several weeks. The enlargement however proceeds more rapidly in some cases than in others. Instances have occurred of the blood being diffused over the whole arm in the space of a few hours; while, on the contrary, swellings of this kind have been many months, nay even years, in arriving at any considerable size.

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

When an artery is punctured through a vein, as in blood-letting at the arm, the blood generally rushes into the yielding cellular subfidence, and there spreads so as neerism, to flout the tides of the vein together. But in some instances where the artery happens to be in contact with the vein, the communication opened has been preserved; and the vein not being sufficiently strong for resisting the impulse of the artery, must consequently be dilated. This is a varicose aneurism. Soon after the injury the vein immediately communicating with the artery begins to swell, and enlarge gradually. If there be any considerable communications in the neighbourhood, the veins which form them are also enlarged. The tumor disappears upon preasure, the blood contained in it being chiefly pushed forwards in its course towards the heart; and when the tumor is large, there is a singular tremulous motion, attended with a perpetual hissing noise, as if air was paffing into it through a small aperture.

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

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

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

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

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

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

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

Treatment.—In every case of aneurism, the use of preasure has been indiscriminately recommended, not only in the incipient period of the disease, but even in its more advanced stages. In the diffused or false aneurism, as preasure cannot be applied to the artery alone, without at the same time affecting the reftent veins; and as this, by producing an increased resistance to the arterial pulsations, must force an additional quantity of blood to the orifice in the artery—no advantage is to be expected from it, though it may be productive of mischief.

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

But preasure, even in encysted aneurism, ought never to be carried to any great length; for tight bandages, by producing an immoderate degree of reaction in the containing parts to which they are applied, instead of answering the purpose for which they were intended, have evidently the contrary effect. Indeed the greatest length to which preasure in such cases ought to go, should be to serve as an easy support to the parts affected.

Of late years the subject of aneurism has attracted the notice of several eminent surgeons of this country; and arterial trunks have been successfully tied, which had been often proposed, but never executed. Mr John Bell several years ago, tied the trunk of the gluteal artery. Mr Abernethy of St. Bartholomew's hospital, tied the common femoral. Mr Affley Cooper of Guys, tied the common carotid; and Mr Ramfied of St. Bartholomew's hospital, has lately tied the subclavian artery.

SECT. III. Of the Popliteal Aneurism.

We are indebted to Mr John Hunter for the ingenious operation for popliteal aneurism. The operation consists in exposing the femoral artery about the middle of the thigh, and putting a ligature round the vessel. An incision is to be made through the integuments, two inches and a half in length on the inner edge of the sartorius muscle (see Plate DXV. fig. 1.). An incision is to be made through the sheath containing the artery with its accompanying vein and nerve, and a double ligature is to be introduced underneath it, by means of a blunt needle; care being taken not to include either the femoral vein, or crural nerve. One ligature is to be tied as high up, and the other as low as the artery is separated from the contiguous parts; the distance between the two being rather more than half an inch. The artery should then be divided by a probe-pointed bistoury, (Plate DXIII.) in the interspace between the two ligatures, but nearer to the lower ligature than to the upper one. The ligature should be moderately thick, in order that the noose may be drawn as tightly as possible, without risk of tearing, or cutting the coats of the vessel. The limb may be kept warm after the operation, by artificial heat if necessary; and the wound treated in the usual manner.

SECT. IV. Of the Femoral Aneurism.

The external iliac artery was first tied by Mr Abernethy*; and there are now eight cases on record where the practice has been followed, fix of which were successful. Mr Abernethy's operation consists in making an incision through the integuments of the abdomen, about three inches in length in the direction of the artery, beginning just above Poupart's ligament, (see Plate DXV. fig. 1.), and half an inch on the outside of the abdominal ring, in order to avoid the epigastric artery. The aponeurosis of the external oblique muscle is then to be divided in the direction of the wound. The lower margin of the internal oblique and transverse muscles is to be cut with a crooked bistoury. The finger may then be passed between the peritoneum by the side of the psoas muscle, so as to touch the artery. A double ligature is to be put underneath the vessel, and tied as in the operation for popliteal aneurism.

SECT. V. Of the Carotid Aneurism.

It had been repeatedly proposed to tie the carotid artery; but the operation was first performed by Mr Affley Of Varicose Veins. Aftley Cooper. There are three instances of this artery having been successfully tied, so that there is sufficient encouragement to adopt the practice in future cases, where there is room to tie the artery above the sternum. The operation is to be done by making an incision on the side of the artery next the trachea, laying bare the vessel, and carefully avoiding the par vagum and the recurrent branch in placing the ligature.

SECT. VI. Of the Axillary Aneurism.

Mr Keate of St George's Hospital, tied with success the axillary artery, where it passes over the first rib; and Mr Ramdlen has lately tied the subclavian artery for an axillary aneurism. The patient however died. A similar operation was attempted by Mr Cooper, but he failed in tying the ligature round the artery, from the bulk of the tumor. The great difficulty felt in these operations was the passing of the ligature below the vessel on account of its depth. Some contrivance is therefore necessary in order to facilitate this part of the operation.

CHAP. VIII.

Of the Diseases of the Venous System.

SECT. I. Of Varicose Veins.

When the veins of any organ become prematurely dilated, they are said to be varicose. This state of the veins is most usually met with in those which are superficial, and seems to arise either from some mechanical cause preventing the ready flow of blood through them, or from the veins themselves losing the necessary support of the skin and adjacent parts. The gravid uterus, by pressing on the iliac vessels, frequently renders the veins of the lower extremity varicose. Various tumors produce similar effects. We also see the veins of the integuments of old people become tortuous and swelled from no mechanical pressure.

Varicose veins are a frequent attendant on ulcers of the leg, and it has been observed that the ulcer seldom or ever heals until the varix is cured.

Varicose veins of the extremities may generally be much relieved by the application of a proper bandage from the toes upwards; and in cases where this does not give relief, the venous trunk should be tied with a ligature as directed in aneurism.

SECT. II. Varicose Spermatic Veins (Varicocele).

The veins of the spermatic cord often remain varicose after inflammation of the testicle, and also in early life without any known cause. The disease is generally easily distinguished by the tortuous irregular swelling. It sometimes, however, acquires a large size; but even then its nature may be readily distinguished by placing the patient in a horizontal position, and applying pressure to the tumor. By this the swelling disappears, and if the upper part be grasped so as to allow nothing to pass out of the abdomen, the swelling will nevertheless be again formed.

The disease occurs most frequently in the left side, and this may arise from the vein in that side not terminating directly in the vena cava, but in the emulsion of the Ducts of the Testicle.

Treatment.—The use of astringents, along with a proper sulphuric bandage, will generally afford relief. It has also been proposed to tie a ligature round one or more of the varicose vessels. In one case this was done with complete success.

SECT. III. Of Haemorrhoidal Tumors.

The haemorrhoidal tumor consists in a dilatation of the veins about the anus and extremity of the rectum. They are round smooth tumors of a purple colour, and more or less painful. They vary in their size and number. Sometimes they are accompanied by a regular periodical discharge of blood, (bleeding piles) and in other cases no such discharge takes place, (blind piles) and then they are more subject to inflammatory attacks.

Haemorrhoids occur more frequently in women than in men, and they commonly arise from a long continued pressure on the rectum; as obstinate coliciveness, prolapsus, gestation, calculus or tumors about the bladder, uterus, or vagina.

Treatment.—When they are inflamed, local bleeding, fomentations and poultices give much relief, care being taken at the same time to keep the tumours within the anus, and to keep the bowels very open by mild laxatives and catheters.

In some cases the piles acquire a very considerable bulk, and form a number of large and loose tumors round the anus, which prevent the free discharge of faeces. In such cases the tumors ought to be removed, and this may be best done with the knife; or, as sometimes happens, if they be so situated as to render this dangerous, they may be removed by a ligature.

CHAP. IX.

Of the Diseases of the Glandular System.

SECT. I. General Remarks on the Pathology of the Glands.

We observe a vast variety of diseases of the glandular system, and the greater number of these arise from a morbid state of their secretions. We see striking examples of an increased secretion in diabetes, in the mercurial salivation, and in many bilious disorders: on the other hand the natural secretion is diminished in suppression of urine, in dryness of the mouth, &c.

An alteration in the secretory function is not, however, the only disease of this system; there are a great number of organic alterations of structure with which they are affected, and a variety of tumors are also found to form in them. As, however, most of the principal glands of the body are situated within the larger cavities, few of their diseases come within the province of the surgeon.

SECT. I. Of the Diseases of the Testicle.

1. Of the Schirrus and Cancer of the Testicle, (Sarcocele).

This affection is liable to a considerable variety in its appearances; and as in the description of it which has been given by authors, they have included symptoms of Chap. IX.

Of the Dif- fects of the Testicle.

The most remarkable symptom of schirrous testicle is a gradual enlargement and induration of the body of the gland or epididmis, advancing from one point, without marks of inflammation or pain. Along with its increase in bulk it acquires additional hardness, and its surface, from being smooth, turns by degrees unequal and knotty. The integuments become of a purplish red, at last ulcerate, discharge a fetid ichor, and a cancerous fungus grows from the wound. The spermatic chord also becomes enlarged, knotty, and hard, and the glands of the groin swell, the health of the patient becoming entirely destroyed, and at last carrying him off in the greatest misery.

The progress of this disease is in general slow, and is commonly attended with an aching sensation about the testicle, and severe pain darting from it to the loins, particularly when the testicle is not supported. The disease is most frequent in the advanced stages of life. It commonly arises from an unknown cause. It has at times been known to succeed a venereal affection, but this is by no means common, and it is sometimes preceded by a blow or some accident which excites inflammation.

When the schirrous testicle is examined by dissection, D. Ballie observes that "it is found to be changed into a hard mass of a brownish colour, which is generally more or less intersected by membrane. In this there is no vestige of the natural structure, but cells are frequently observable in it containing a finous fluid, and sometimes there is a mixture of cartilage." Sometimes water is found collected in the cavity of the tunica vaginalis, but more frequently the tunics adhere to each other. When the spermatic cord is affected, that exhibits the same changes of structure as the testicle itself.

Treatment.—When a testicle is known to be affected with the true schirrus, all prospect of a cure by the exhibition of internal or external remedies becomes hopeless, as there is no fact better known and more severely felt in the history of schirrus and cancer in every organ of the body, than its resisting all means of relief, but by the complete removal of the diseased part. In a few rare cases, by a moderate diet, keeping the bowels open, suspending the tumor, avoiding violent exercise, or anything which may prove a source of irritation, the disorder has been said to be not only prevented from increasing, but has in a gradual manner entirely disappeared; but we much suspect that these cases whose termination was so favourable, have not been of a schirrous nature. This is probable from what is known of the termination of schirrus in other organs of the body, and also from the difficulty we have in forming an accurate diagnosis in the diseases of the testicle. There are, we hesitate not to say, many testicles extirpated which might have been saved; for our imperfect knowledge of the various morbid changes of this organ, has made it too much an established practice to extirpate all testicles which are enlarged and hard, and which do not yield to mercury.

When, however, by an attentive examination of the history and symptoms of the disease, no doubt is entertained of its schirrous or cancerous nature, the more speedily the tumor is removed, the better chance there is of a permanent cure. In performing the operation, care should be taken to remove completely every part of the Dif- fects of the Testicle, and no part of the skin should be left with a view of covering the wound more completely which has the least discolouration or mark of disease.

Mode of extirpating the Testicle.

The parts being previously shaved, the patient is to be laid upon a firm table covered with a blanket or matres. His legs should hang over the table, and be supported by affiants. An incision is to be made through the integuments with a common scalpel, extending from a little above the external abdominal ring to the bottom of the scrotum. The cellular membrane around the spermatic chord is to be dissected back, and the chord laid fairly bare; and this part of the operation is much more easily accomplished when the incision through the skin is very free. A ligature of considerable thickness is to be put underneath the chord, and it may be introduced with a blunt pointed needle or instrument (fig. 17. Plate DXIII.). The extent of the disease in the chord should now be examined as accurately as possible, and the ligature should be tied firm with a running knot, as far above the diseased part as possible. If any hardness extends to the external abdominal ring, the chord may be even dissected up along the inguinal canal, and the ligature put on at that place. The chord may be divided one-fourth of an inch below where the ligature has been applied, and then the whole of the testicle and its vaginal coat may be readily dissected away, taking care not to cut into the vaginal cavity of the opposite side of the scrotum. After the testicle is removed, the ligature should be loosened, and the spermatic artery and veins included in separate ligatures. The ligature upon the spermatic chord is to be left loose, so as to act as a tourniquet if a hemorrhage should ensue. Much care should also be taken to secure any arteries of the integuments of the scrotum which are seen bleeding; as we once met with a very troublesome hemorrhage from one of these retracting among the loose cellular texture, and not being seen after the operation. It therefore will be a good general rule to tie these with ligatures immediately after they are divided.

The wound is to be dressed, so as to be healed if possible by adhesion; and this may generally be accomplished, except at the upper part where the ligatures come through. With this view the wound and scrotum are to be carefully washed, and two or three stitches, as may be thought most expedient, are to be put through the edges of the wound; for in a part like the scrotum, where the skin is loose and puckered, it is hardly possible to apply adhesive straps with sufficient accuracy, so as to serve the purpose. Small pieces of adhesive platter, however, should be neatly placed between each of the stitches, along the whole extent of the wound, and a pledget of simple ointment and comprels afterwards to be laid over it, the whole being secured with a T bandage.

After the operation, the patient is to be put to bed, being directed to lie on his back with a pillow between the thighs, so as to support the scrotum.

Opiates should be given to allay pain, and if any inflammatory symptoms supervene, bleeding at the arm should be had recourse to without the least hesitation; Or the Dif- for we have made a general remark, that after almost all surgical operations, there has scarcely ever an in- cates of the Tefticle. flance occurred where the patient died from loss of blood, and on the contrary, that almost all patients who have lost much blood, or who have been previously much emaciated, have recovered more quickly than those in full health. The antiphlogistic regimen in almost every case should be rigidly pursued, until at least all inflammatory appearances of the wound are gone, and a healthy suppuration commenced. About four, five, or fix days, according to circumstances, the dressings should be removed, and if the wound has healed by adhesion, the fitches may be withdrawn, and the edges of the wound kept together by adhesive plasters. The ligature on the spermatic chord may now be safely taken away, and that round the spermatic artery and veins generally comes readily away before the tenth dressing. In this manner the wound should be dressed daily until it is cicatrified. When the wound, instead of healing by adhefion, suppurrates, the fitches may be taken away as soon as it appears that the edges of the wound can be accurately kept together with the adhesive plasters; for if the fitches are allowed to remain long, they generally ulcerate the contiguous skin, and form sinules, which continue to discharge matter after the rest of the wound has healed. The wound should be dressed once or even twice in twenty-four hours if the discharge be profuse, and care should be taken to wash away with a sponge any matter which may be deposited on the found skin of the scrotum or groin. The edges of the wound should be brought accurately together at each dressing, any matter collected in different parts of it should be gently squeezed out, so as to prevent any lodgement from taking place. Should the patient become weak from the continuance of the discharge, he should be ordered a nourishing diet, with a proper proportion of wine; and if the discharge be at any time thin and very profuse, we have found much benefit in such a cafe from the internal ufe of bark (cinchona).

2. Inflammation of the Tefticle (Hernia humoralis).

Inflammation is one of the most frequent diseases of the tefticle. Sometimes the inflammation is confined to the substance of the tefticle, at other times it affects the epididimis, and in some cases it spreads to the albuginea and vaginals. The surface of the inflamed tefticle is uniform and smooth, more or less sensible to the touch, equally firm and tense throughout when pressed upon, and the integuments are generally discoloured, having a bluish redness, and interperforated with varicose veins. When examined by dissection, the tefticle exhibits, according to Dr Bailie, precisely the same appearances as the inflammation of the substance of other parts. The vas deferens sometimes partakes of the inflammation, its coats becoming considerably thickened, and in other instances the veins of the spermatic chord become varicoce. Inflammation of the tefticle most frequently is preceded by gonorrhoea, but it also occurs from a variety of causes. It occurs sometimes from exposure to cold, from violent exercise, and is often excited from blows, riding on horseback, &c.

The inflammation of the tefticle concomitant of gonorrhoea generally begins by spreading along the vas deferens from the prostate gland through the inguinal canal till it comes to the tefticle; it is in most cases at- Of the Dif- tended with excruciating pain from the rapidity of its progres; and as it commonly comes on when the gonor- rhalical discharge diminishes or disappears, and subsides when the discharge returns, many authors have sup- posed that it was a true metafasis of the venereal mat- ter.

If the disease be left to itself, the body of the tefticle becomes more hard and painful, with all the symptoms of local inflammation, and the tumor sometimes acquires an enormous bulk. Sometimes the inflammation is accom- panied with violent fever, with a pulse hard and strong in the plethoric, and lebile and rapid in constitution which are delicate and irritable. The patient also often complains of pains in the loins, and has nausea and vomiting. In general the discharge from the urethra diminishes considerably, and often it ceases altogether before the tefticle becomes affected; but sometimes that does not happen in any remarkable degree till one or two days after the swelling has begun to appear. It never happens that both tefticles are affected at the fame time, but when the swelling of one disappears, often the other one begins to be attacked.

The tefticles sometimes swell and inflame from the absorption of the matter of a chancr, and as the progres of the swelling is in such cases slow, and generally more irregular, it has sometimes been mistaken for a chitrous tefticle; but an investigation into the history of the cafe, and particular attention to the appearance of the skin of the scrotum, and any symptoms of the vene- real disease in other parts of the body will generally lead to a knowledge of the true nature of the cafe. It some- times happens that inflammation is chiefly confined to the spermatic chord, and in many cases it affects the epididimis alone. The extent of the disease is always easily ascertained by a careful examination of the parts. It seldom happens that both tefticles are inflamed at once; we have, however, remarked this to take place. Inflammation such as has now been described, generally abates by the application of proper remedies: in some cases, however, an induration of the tefticle remains. It terminates, though rarely, in suppuration.

Treatment.—When an inflammation has arisen from a blow, from exposure to cold, or from any injury done to the tefticle, it ought to be treated according to the general plan laid down of treating inflammation of other organs. Local bleeding by leeches is a most useful re- medy, and ought to be the first thing employed, if there is the slightest pain, tenderness, or redness of the scro- tum. Fomenting the scrotum with warm water, or a decoction of poppy heads, chamomile flowers, or tobacco leaves, often give much relief, and great attention should be paid in supporting the tefticle with a silk net truss (Plate DXIV.). Some have also used with suc- cess the application of ice or snow to the part. If the symptoms and pain are very violent, bleeding at the arm may be necessary. The bowels should be kept open, and even purged; the patient should be confined to a low diet, and he should keep as much as possible to the horizontal posture, as this is found to be of the greatest importance in promoting the cure.

When the inflammation arises from gonorrhoea, par- ticular attention must be paid not only to the disease in the tefticle, but to that of the urethra. Indeed it is of much importance in the treatment of gonorrhoea to use Chap. IX. SURGERY.

Of the Dif- means to prevent the testicles from becoming inflamed; and as every thing which causes a suppression of the discharge tends to produce a swelling of the testicle, it is natural to suppose, that in order to prevent this trouble- some disorder, every thing should be avoided capable of increasing the irritation and inflammation of the urethra, as exposure to cold, violent exercise, ill chosen injec- tions, and balsamic medicines; but above all, the use of a suspensory is most efficacious, and Swediaur * recom- mends one to be worn in every case of gonorrhoea from the commencement of the disease, to prevent all risk of the testicles becoming inflamed. When the inflamma- tory symptoms are severe, the treatment should be adopted as we have recommended in common inflamma- tion of the testicle. If the discharge from the urethra is stopped, means should be used to relieve it. Whenever the inflammatory fever is rendered more mild, Swediaur recommends, with this view, a dose of opium to be given, and according to circumstances, an injection com- posed of two or three ounces of oil of linseed and decoction of barley, along with fifty or sixty drops of the vi- nous tincture of opium. This may be repeated every ten or twelve hours, taking care always to have the bowels well opened before using it. Swediaur has found the extract of hyoscyamus in many cases answer better than opium. Fomentating the penis and adjacent parts with warm vinegar and water, injecting warm oil, and the use of bougies, may also be advantageous in pro- moting the discharge from the urethra.

* Traité fur les Maladies Veneriennes.

3. Induration of the Testicle.

After the inflammatory symptoms have abated, it generally happens that a degree of swelling and hardnes of the body of the testicle, but still more frequently of the spermatic cord or epididimis, remains, and in many cases continues for months, or even during life. This effect takes place from whatever cause the inflammation may have arisen. In many cases the testicle itself remains quite found, and the epididimis is converted into a very hard unyielding mass, which feels as if it were in- jected with quicksilver. Sometimes the testicle, whilst it remains hard, diminishes in size, and becomes much smaller than natural. When the testicle is examined by dissection, it is found to have lost its natural struc- ture, and is sometimes changed into a hard brown-coloured mass (Voigtel), interlaced more or less by mem- branous bands; sometimes parts having a cartilaginous quality appear it, and sometimes cells are formed which contain matter. The seminal vessels are so changed and hardened, that they cannot be distinguished from each other. In some cases the whole testicle has been found converted into a cartilaginous mass, and in a few instances some parts of it have been converted into bone.

The treatment usually recommended in cases of indura- tion of the testicle preceded by inflammation, are strong stimulating and astringent applications; such as solutions of the muriate of ammonia, acetate of lead, ful- phate of zinc, &c. either applied by moilening with them a piece of linen, which is to be kept constantly wet, or by using them in the form of a poultice. Frictions with mercurial ointment, either singly or combined with camphor, over the scrotum and perineum, sometimes produce a good effect; mercurial fumigations to the genital organs have also been recommended. In some cases the internal use of mercury has been found neces- sary. A mercurial plaster with camphor, or the com- mon soap plattz, is also a good application, and is very useful in defending the testicle.

The internal and external use of the hemlock (co- nium maculatum) has been much recommended by Plenk. Electricity has also been successfully employ- ed. The muriate of lime, and the muriate of barytes, have been used by some authors. Swediaur says that he has known some affections of the testicle produced by gonorrhoea, and also some diseases of the eye from the same cause, cured by the patient getting a fresh infection. In a few cases of induration, and swelling of the testicles, we have employed blistering with good effects. The scrotum should be shaved before this is done; and it is often necessary to repeat the blisters several times before the hardness or swelling begin to abate.

4. Abscess of the Testicle.

It sometimes, though rarely happens, that the testicle Symptoms. suppurrates. The matter which is formed, is commonly a tough, thready, yellow-coloured substance, which ad- heres to the surface of the cavity in which it is contained. Sometimes there is only one abscess; in other cases the matter is contained in several small irregular shaped cavities. Sometimes the matter is formed in the very middle of the body of the testicle; in other cases we have observed small abscesses in different parts of the epididimis, the body of the testicle remaining quite sound. When an abscess is formed in the testicle, the structure of the gland becomes more or less changed; generally instead of being soft, and the tubes of which it is com- posed being easily separated, it degenerates into a hard firm mass.

Abscesses of the testicle should be opened as soon as possible, in order to prevent the substance of the testicle from being destroyed. The presence of matter is learnt by a fluctuation which can be felt externally; but it is often extremely difficult to determine the true situation of the abscess, whether it is formed in the body of the testicle, in the epididimis, or between the albuginea and tunica vaginalis, or in the cellular membrane external to the tunica vaginalis; for when such a degree of in- flammation has taken place as to terminate in the forma- tion of an abscess, the accompanying swelling destroys the natural form of the parts, and involves the whole into a undetermined shapeless mass. Richter remarks, that there are sometimes soft spots in the testicle, in which it is believed there is a fluctuation. When such swellings are opened no matter is discharged, nothing but blood appears, and the inflammatory symptoms are afterwards increased. The more matter which is dis- charged from an abscess of the testicle, the smaller the testicle grows, as the matter is sometimes formed partly of the thready substance of the testicle. Cases have occurred where the whole testicle has been pulled away, the surgeon having mistaken the seminal tubes for flounds. Abscesses of the substance of the testicle seldom heal, and generally a fistulous opening remains, through which there is a constant oozing of the seminal fluid.

5. Fistulous Sinus of the Testicle.

As far as we know no author has taken notice of this appearance. In one case we observed it very remark- able. The epididimis alone was swelled, and there was a thickened portion of scrotum adhering to one part of it, in which there was a small sinus, and through which the seminal fluid constantly oozed. In a similar case the sinus was laid open, but with no good effect; for a small opening remained unhealed, through which the semen continued to be discharged.

6. Scrofulous Testicle.

When the testicle is affected with scrofula, it presents some of those general characters of scrofula in other glandular parts. Its tubular appearance is destroyed; it becomes enlarged; and when cut, it is found to be composed of a dull white substance, of the consistence of curd, which in some parts is mixed with a thin puriform fluid. The scrotum is in almost all cases involved in the disease; it becomes red and inflamed, and the vaginal coat adheres to the albuginea. Abscesses also form in various parts of the cellular membrane of the scrotum, which sometimes communicate with the body of the testicle. This disease generally occurs during the early periods of life, and most commonly only one testicle is affected with it. Sometimes, however, when one recovers, the same disease attacks the other.

In most cases of this kind surgical aid does not avail much, for the progress of the disease cannot be checked by any internal and external remedies. All that can be done is to relieve the inflammatory symptoms, to alleviate pain, and to prevent the formation of sinuses. With a view to alleviate the symptoms of inflammation, nothing is so beneficial as the application of leeches to the scrotum, and the use of fomentations and poulticing, or solutions of the acetate of lead. Opiates and laxatives may be also freely given, unless in cases where from experience these are known to disagree. When matter has once formed, the sooner it is discharged the better, and this should be done by a small incision. After one abscess has healed, others are very apt to form in succession; these should be treated in the same manner, and if at any period of the disease sinuses form, they should be at once laid completely open to the bottom; or if they are very deep and extensive, a feton may be introduced; if this, however, does not produce an adhesion of the cavity, they should be laid open with a bistoury in the manner directed when treating of sinuses.

7. Testicle preternaturally small, and wanting.

After violent attacks of inflammation, or in cases of abscess, the testicle sometimes diminishes greatly in size, is almost entirely absorbed; and in a few instances people have been born with them much smaller than natural (Baillie). Sometimes a testicle has been known to waste away without any known cause, so as to disappear altogether. Sometimes one testicle, and sometimes both remain in the cavity of the abdomen through life; so that a person appears to have only one testicle or to be without them altogether. Mr Hunter suspects that in these cases they are not so perfect as when they descend into the scrotum; and if we were to reason from what is observed in other animals, in the horse particularly, where this by no means unfrequently takes place, it is highly probable that when the testicles do not descend into the scrotum, they are not capable of performing their functions.

These cases, though they cannot be relieved by medical aid, yet they are worthy of the notice of medical men.

8. Fungus of the Testicle.

There sometimes arises from the testicle a species of fungous tumor, which was first accurately described by Mr Lawrence, demonstrator of anatomy at Bartholomew's hospital, in London.

The patient generally affirms the origin of the complaint to some injury. In some cases, it is the consequence of hernia humoralis, and in others it appears spontaneously. The scrotum, after a certain length of time inflames, and adheres to the testicle already swollen; at last the skin ulcerates, and the opening thus formed, instead of discharging matter, is filled up with a fungous tumor, which is of a firm texture, and generally insensible. Whilst the fungus is increasing, the inflammation of the scrotum diminishes; and if the fungus is at this time removed, a cicatrix is formed in the skin, which adheres to the testicle. There is sometimes a copious and very fetid discharge from the whole surface of the fungus. On dissection, the fungus is found to arise from the pulpy substance of the testicle, more or less of which remains according to the duration and extent of the disease.

It may be worth while to remark here, that we have met with one case, where, from an abscess and ulceration of the scrotum, the testicle itself flipt out at the ulcerated orifice, and exhibited very much the appearance of the fungus above described.

This species of tumor may be safely removed by the knife, by ligature, or by elocharotics; the removal by the knife is perhaps the safest, and certainly the most expeditious method.

For an account of Fungus Hæmatodes in the testicle, we refer to Wardrop's Observations on Fungus Hæmatodes.

Sect. II. Of the Diseases of the Mamma.

From the changes which take place in the female breast at the age of puberty, during the menstrual discharges, and before and after the birth of the child, we ought to expect a considerable variety in the diseases of this organ; and, in considering these, we should always keep in view the powerful sympathy between that gland and the uterine system.

The gland of the mamma is subject to inflammation and abscess. Scrofulous tumors also form in it; it is subject to a particular disease, called milk abscess, to cicirrus, and to other species of indurations, the nature of which is not well ascertained.

The nipple and integuments around it are also subject to particular kinds of excoriations and ulcerations; the lymphatic glands which lie close to the mamma, are also frequently diseased, and the contiguous cellular membrane is subject to those diseases which are met with in the cellular membrane of other parts of the body.

At the age of puberty, when the uterine system becomes fully developed, the female breast swells, turns hard, and becomes tender, or even painful. A change also takes place during pregnancy; the breast enlarges, becomes very tender and painful, and a dark-coloured zone is observed round the nipple. In women who are suckling about the ninth or tenth month after parturition, and sometimes sooner, the menses reappear; and if the woman afterwards continues to suckle, at each monthly return a remarkable change takes place in the milk; it loses its sweetness, acquires a bitterish taste, becomes of a reddish colour, and excites a temporary derangement in the system of the child. Obstructions of the menes, their final cessation, and all the diseases of the womb, affect more or less the mamma; and it is at the age of puberty, at the time of menstruation, during pregnancy, in the early months of suckling, and at the time of the cessation of the menes, which are the peculiar periods when blows and other injuries are most apt to produce disease in the mamma.

This consent between the mamma and uterine system ought to be always kept in view when forming our opinion of any disease in these organs; and it is particularly worthy of the notice of surgeons when operations on that organ become necessary.

1. Of Inflammation and Abscess of the Mamma.

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

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

2. Of Scirrhous and Cancer of the Mamma.

Cancer has been met with in the female breast more frequently than in any other part of the body. We have also seen an example of it in that gland of the male; but such instances are extremely rare.

The commencement and progress of a scirrhous tumor in the female breast, is extremely various in different persons; and has been often the cause of scirrhous tumors, and tumors of a more benign nature, being mistaken for one another.

Scirrhous tumors have generally made some progress before they are taken notice of. Sometimes they are first felt like a pea underneath the skin, and lying loose over the gland of the mamma; in other instances, a portion of the central part of the gland is found indurated. Of whatever bulk, and in whatever situation the swelling be discovered, it is remarkable for its unyielding and incompressible hardness, and its rugged unequal feel.

When the tumor is small it seldom gives any pain, and the patient generally discovers its presence by accident. In some cases its existence is discovered by an acute pang darting through the breast leading to its examination; but in many cases it acquires the bulk of a large hazel nut or walnut, particularly when the patient is fat, before any circumstance leads to its discovery.

As the tumor increases in bulk, it advances towards the surface of the body and adheres to the skin. The skin then becomes thickened, inflamed, and ulcerated. If the tumor be situated near the nipple, the disease speedily affects that part, sometimes enlarging and hardening it; and in other cases puckering it and drawing it inwards. When the nipple becomes involved in the disease, the fœnus fluid formed in the tumor often escapes before the skin ulcerates, by the lactiferous tubes.

The pain which accompanies the tumor in its more advanced form, is generally of a lancinating kind; but its frequency and degree is susceptible of great variety. Sometimes sharp stinging pains pass frequently from the tumor as a centre, and extend through the whole breast; in other cases there is more of a burning heat in the part.

The progress of the disease is generally very slow, and in many cases three, four, or more years elapse before it ulcerates. When ulceration has taken place, the appearance of the ulcer is similar to that we have described when treating of cancer of the skin*; and the progress of the ulceration is often so slow, as that many II. lect. v. years elapse before the disease proves fatal.

Scirrhous tumors have been met with in the mamma, from the age of twenty or twenty-five, to a very advanced period of life; but they occur about that period, when the catamenia disappear, much more frequently than at any other.

Treatment.—There is no part of practice about which less has been satisfactorily established, than the treatment of scirrhous in the mamma. The good effects of an early extirpation of cancer in the skin is very generally admitted; but the want of success in removing scirrhous mammas in the hands of many, has not only led some surgeons to desist performing an operation, except in very recent cases, but has even deterred others from attempting their removal in the first stages. There are no doubt many patients who submit to a painful operation from which no relief can be reasonably expected; on the contrary, the irritation and fever occasioned by it seem to hasten the progress of the disease. But there are others where this practice has had a happier effect, and where the patients have lived for many years without a return of the disease. Whenever, therefore, a scirrhous tumor appears in the mamma, which is moveable and distinctly circumscribed, past experience warrants us in removing it. On the other hand, when any of the absorbent glands have become enlarged and hardened, or when the skin has ulcerated, we believe the operation in all such cases should not be resorted to. Some solitary examples of the disease, assuming this form, may have occurred to individuals, where an operation has arrested the progress of the disease; but these, opposed to the vast number of unsuccessful cases, are by no means sufficient to warrant us in propounding the operation.

Method of Extirpating the Mamma.—In extirpating the mamma, which we shall first suppose is to be done where the skin is found, and where the tumor has no uncommon adhesion to the pectoral muscle, the patient ought to be placed horizontally in a bed, or upon a table covered with a mattress. Two incisions are to be made with a common scalpel through the skin and cellular substance along the whole extent of the tumor, including a small portion of skin. When the longest diameter of the tumor is across the body, instead of a longitudinal incision, a transverse one is to be made. The integuments being dissected from the mamma on both sides of the incisions, the patient's arm is to be extended Of the Dif- ed to save the pectoral muscle; and the whole glandular part is to be detached from the muscle, though a small portion only should be difealed, beginning at the upper side, and separating downwards. After the difealed parts are removed, the wound is to be cleaned with a sponge wrung out of warm water, which will generally render the small bleeding vessels more conspicuous. These are to be tied, and the integuments are to be closely applied to the parts underneath, and retained there by adhesive straps. A large pledget of simple ointment is now to be laid over the whole; and this is to be covered with a compres of list, tow, or soft linen; and the dressings to be kept in their place, and moderate pressure made by a circular roller and scapulary bandage.

3. Of Sore Nipples.

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

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

Swellings and hardnesses are found in the breast which are not of a feirrhus nature. Scrofulous indurations are particularly frequent. They often become old and hard, and are then commonly considered as safe of the Dif- ferirus. If the surgeon succeeds in discharging them by means of any kind of remedy, he is apt to think that he has disficulted a feirrhus. These scrofulous swellings sometimes inflame, and the progress of the inflammation is very tedious. The breast is long painful before any softening or fluctuation can be perceived. The surgeon then perhaps considers it as an occult cancer, extirpates it, and thinks that he has successfully cured a cancerous affection. If the surgeon opens such a suppurring knot before all the hardness is diffolved by the suppuration, and if he makes a large opening, then commonly follows a very malignant ulcer, which may be also mistaken for a cancerous sore. Many cases, where ulcerated cancers have been supposed to have been extirpated with success, may have been of this kind.

Venereal indurations are not unfrequent in the breast, and also cause similar mistakes in practice. Encysted tumors are also met with in the breast, and are most commonly of that kind called melierius.

In the breast of young girls, ten or twelve years of age, hardneffes sometimes appear, which disappear as soon as menstruation takes place. Sometimes they do not go away until the first delivery. Sometimes the breast swells to an enormous size, and becomes indeed not hard, but throughout firm, like muscular flesh. In such a case the extirpation has been successfully performed.

Sometimes considerable and often quite hard swellings appear in the breasts, which proceed merely from blood. In such cases blood flows from the nipple at each menstrual period. When the menes disappear with years, the discharge of blood no longer appears from the breast; but then there is a hard not painful swelling arises, which often acquires a considerable size. If it is opened, coagulated and fluid blood is discharged, and a fistula follows, which discharges a purulent fluid, and sometimes pure blood, and often continues several years, without giving great uneasiness. The swelling, which was at first quite hard, sometimes becomes soft, and then the surgeon is commonly induced to open it. Sometimes such swellings are observed in women who have the menstrual discharge; and in such cases the swelling always becomes greater at each period. Sometimes hectic fever and death follow the opening of these tumors. (Monro). The mamma is also subject to fungus haematodes; for an account of which, we refer our readers to Wardrop's Observations on Fungus Haematodes.

SECT. III. Of the Diseases of the Tonfils and Uvula.

1. Of the Enlargement of the Tonfils and Uvula.

The tonfils sometimes grow so large and hard as to become incurable, and even to threaten suffocation. The tumors have been commonly considered to be of a feirrhus nature; but they are neither attended with shooting pain, nor are they apt to degenerate into cancer; neither do swellings return after the tonfils have been extirpated: hence they ought not to be removed till by their size they essentially impede deglutition or respiration; but whenever they do this, they may be removed with safety. The only proper method of re- moving them is by ligature, which is not only void of danger, Chap. IX. SURGERY.

Of the Diseases of the Tonils and Uvula.

danger, but seldom fails to perform a cure. If the base of the tonil be smaller than the top, the ligature is to be used as for polypi in the throat; but however broad the base of it may be, much difficulty will seldom occur in fixing it, for the swelling is always very prominent. In diseases of this kind both tonils are generally affected; but if the removal of one of them forms a sufficient passage for the food, the other may be allowed to remain. When, however, it is necessary to extirpate them both, the inflammatory symptoms produced by the extirpation of the first should be allowed to subside before any attempt be made to remove the other.

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

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

Treatment.

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

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

2. Of Scarifying and Fomenting the Throat.

In inflammatory affections of the throat, the means commonly employed are gargles, fomentations, scarification, or topical bleeding. Gargles are useful for cleaning the fauces from mucus, or in cases of ulceration. In relaxation of the parts, they are employed with advantage when made of astringent materials. Fomentations may be of some use when externally applied; but the steam of water, &c. drawn into the throat, by means of Mudge's inhaler (Plate DXV.), is preferable. Sometimes it is necessary to draw blood from the part affected. Here recourse may be had to scarifying, which may be readily done by the scarificator (Plate DXIV., fig. 14.). After a sufficient number of punctures have been made, the flow of blood may be promoted by the patient's frequently applying warm water to the punctures. When an abscess forms, notwithstanding the use of these remedies, the matter may be discharged with the scarificator already mentioned.

Chap. X.

Of the Diseases of the Eye and its Appendages.

In the account of the diseases of the eye, we shall follow the same principles of arrangement as we have already adopted, and treat of the diseases of each particular texture of which the eye is composed, in the order in which they appear most natural; as the diseases of the conjunctiva, cornea, iris, crystalline lens, &c.

Sect. I. Of Inflammation of the Conjunctiva.

The general phenomena of inflammation of the conjunctiva, are analogous to those which have been already enumerated, when treating of the inflammation of mucous membranes*. Along with the symptoms there *See Chap. III. lar functions of the organ. The eye cannot endure the usual quantity of light, vision becomes obscured, and there is an increased secretion of tears. The inflammation is sometimes confined to the palpebras, sometimes to the conjunctiva covering the white of the eye, in some cases to that portion of it which forms the external layer of the cornea, and in others it spreads over the whole of these surfaces. These differences merely regard the extent of the inflammation: but there are others which arise from a difference in the specific nature of the disease, forming three distinct species; 1. The purulent ophthalmia; 2. The purulent eyes of new-born children; and, 3. The gonorrheal ophthalmia.

1. Of the Purulent Ophthalmia.

The purulent ophthalmia appeared in this country as symptoms of an epidemic after the return of our troops from Egypt in the year 1801. Since that period, it has spread with the greatest violence over most part of Britain. This disease generally begins with a peculiar purple-coloured redness over the whole eyeball and inner membrane of the eyelids. There is a sudden pain produced in the eye, as if sand or some foreign substance was lodged between it and the eyelid. As the redness increases, the conjunctiva becomes swelled, from the effusion of a transparent fluid in the loose cellular membranes, between it and the sclerotic coat. There is at first a profuse discharge of tears from the eye, and the eyelashes are glued together when the patient awakes. There is soon created intense pain in the ball of the eye, and a dull aching pain in the forehead. The cornea sometimes becomes opaque; and if the violence of the inflammation continues, it ulcerates and ruptures, allowing the aqueous humour to be discharged; after which, an abatement of the inflammatory symptoms generally takes place.

Before the disease advances thus far, the eyelids are generally considerably swelled; and, besides the flow of Of the Dif- cases of the Eye.

tears, there is a profuse discharge of a puriform fluid. The inflammation usually attacks both eyes, and it begins in one several days before the other.

Treatment.—In lighter cases of the disease, fomenting the eye with a decoction of poppy heads, and a brisk purge, have been found sufficient to abate the inflammatory symptoms. In other cases, however, it has been necessary to draw blood to a very great extent. When the disease occurs in a strong plethoric person, recourse should be immediately had to the lancet, and the operation repeated on any recurrence of the symptoms. It has been the usual practice of Dr Veitch, and of those who have had extensive opportunities of treating this disease, to draw the blood from the arm. A smaller quantity, however, taken from the temporal artery or external jugular vein, would be found to have an equally good effect.

When the purulent discharge becomes profuse, some have recommended the use of collyria, in the form of injections. The aqua camphorata is recommended by Mr Ware; and a weak solution of corrosive sublimate, with opium, has been found to have equally good effects. In those cases where there is much pain and tension in the eyeball and brow, along with a turbid state of the anterior chamber, and ulceration beginning in the cornea, the discharge of the aqueous humour has been attended with much success*. This operation may be easily, and at all times safely performed, by making a puncture with a common extracting knife, through the found part of the cornea, near its junction with the sclerotic coat.

2. Of the Purulent Ophthalmia in Children.

The symptoms of the purulent eyes of children are very similar to those which have been mentioned. The disease generally appears a few days after birth, by an increased redness of the palpebral membrane, more or less swelling, and a puriform discharge. Sometimes the membrane swells so much as to evert the eyelids, and render it impossible to examine the eye-ball. The cornea becomes obscure, ulcerates, and allows the aqueous humour to be discharged. The disease generally affects both eyes. From what we know of the origin of purulent ophthalmia, and from some ingenious observations of Mr Gibbon of Manchester*, it appears probable, that the origin of this disease is communicated by the lodgement of an acrimonious discharge upon the eyes of the child, from the vagina of the mother. In a great proportion of cases, Mr Gibbon found the mothers of those children, affected with purulent ophthalmia, had leucorrhoea; and it is probable, that this, as well as other scrophulous discharges, which we know to take place from the mucous membranes of these parts, produces the disease.

Treatment.—Solutions of saccharum saturni and opium, injected between the eyelids, or the aqua camphorata of Bezet, ought to be employed in the first stage of the disease; and the eyelids ought to be likewise covered with some mild unctuous application. When ulceration has advanced so as to endanger a rupture of the cornea, that may be prevented by discharging the aqueous humour. In the second stage of the inflammation, clarifying the eyelids, and applying the red precipitate ointment, will generally be found to be useful in allaying the inflammation and swelling of the eyelids, and in restoring the transparency of the cornea.

3. Of the Gonorrhæal Ophthalmia.

The gonorrhæal ophthalmia occurs very rarely; and it has been known to arise from the suppression of a gonorrhœa, or from the accidental application of the gonorrhœal matter to the eyes. In this respect, its origin is very similar to the common purulent or Egyptian ophthalmia, and to the purulent ophthalmia which occurs in children.

The symptoms and progress of the disease are also similar, only that its progress is much more violent, and it generally completely destroys the organ.

Treatment.—When it is suspected that the disease has arisen from a suppressed gonorrhœa, such means ought to be employed as are most likely to restore the discharge from the urethra; such as the introduction of a bougie, the injecting of warm oil, and the application of poultices and fomentations to the perineum. If the inflammatory symptoms run high, powerful evacuants should be employed. Besides purgatives, blood should be taken from the arm or temporal artery.

The local applications should consist of weak injections of corrosive sublimate and opium, or acetate of lead and opium; and the swelling and redness may be also relieved by the application of the red precipitate ointment, or the ointment of Janin.

Sect. II. Of the Pterigium.

The word pterigium denotes all those morbid changes in which that portion of the conjunctiva covering any part of the cornea or sclerotic coat becomes thickened, vacuolar, and opaque. If the disease be confined to a particular part of the conjunctiva, the disease is observed at its commencement like a small globule of fat, or condensed cellular substance, situated most frequently near the junction of the cornea and sclerotic coat; and this spot extending imperceptibly along the surface of the conjunctiva at length passes over the cornea, the conjunctiva on the adjoining part of the sclerotic coat becomes puckered, and as if it were forcibly drawn over the cornea. The portion of it which lies on the sclerotic coat is commonly loose, and can be easily elevated, but that which is on the cornea adheres more firmly. This species of pterigium has generally a triangular form; one of the angles of the triangle advancing towards the cornea, or covering a portion of it, and the base lying on the sclerotic coat. Sometimes the thickening of the conjunctiva is first perceived on the cornea. The conjunctiva covering the sclerotic coat remaining quite found. A pterigium is always considerably elevated above the adjacent cornea; but the degree of its thickness varies from that of a thin membrane to that of a fleshy mass.

Pterigia arise most commonly at the nasal angle of the eyeball. They are formed, also, at the temporal angle; and they sometimes occur at both places in the same eye. In one case there were two pterigia in each eye. They are formed very rarely on the upper and under parts of the eyeball.

Treatment.—The only mode of removing this disease is by excision. This may be done by elevating the diseased portion of the conjunctiva with a pair of forceps; and separating it at its base by cutting it through with a Chap. X.

Of the Difficulties of the cases of the Eye. Of the pair of scissars; and then carefully dissecting it off to its apex. If any portion of it has been allowed to remain, or if the wound shows any tendency to form a fungus, lunar caustic ought to be applied to it, and the application repeated as often as may appear necessary. Any slight inflammation or weakness in the eye which may continue after the operation, may be speedily removed by the application of the vinous tincture of opium.

SECT. III. Of Pustules (Ophthalmia pustulosa).

Pustules are small tumors which are formed both on the cornea and sclerotic coat, but they occur most frequently near the junction of these membranes. A pustule commonly first appears like a dusky yellow or reddish spot, a little elevated above the surface of the cornea or sclerotic coat; and in a short time it becomes a distinct conical tumor. The adjacent part of the cornea is always more or less dim; and a considerable degree of inflammation accompanies it, which is either confined to the white of the eye contiguous to the pustule, or is spread over the whole eyeball. Whilst the pustule is forming, the inflammation is generally confined to that part of the white of the eye which is in its immediate vicinity. The blood vessels are of a pale livid hue; they appear superficial, and can be readily elevated by a pointed instrument; each trunk can be distinguished, for they are never so numerous as to appear confused, or like one red mass. They sometimes run in various directions, anastomose freely with one another, forming net-works upon the white of the eye.

If the inflammation and pustule remain for some time, the pustule generally advances to suppuration. When suppuration takes place, the apex of the pustule ulcerates, and frequently a chalky white spot appears at the centre of the ulceration; and the opacity of the cornea at the same time daily increases around it. In other cases, the opaque matter separates, and leaves behind it a deep ulcerous excavation.

Sometimes the suppuration proceeds more like a common pimple or phlegmon of the skin; a small quantity of a thick matter collects within the pustule, and when it is discharged, a conical tumor remains, which has a depression at the apex. When the pustule contains a watery fluid, the fluid is most frequently absorbed in a gradual manner; but at other times the pustule breaks, and an ulcer is formed.

If, in either of these cases, the contents are artificially discharged, all the accompanying inflammatory symptoms are much increased.

Most frequently there is only one pustule, and only one eye affected; but in some cases there are several both on the cornea and sclerotic coat of each eye.

The disease, at its commencement, is almost invariably accompanied with the sensation of a mote in the eye, and the whole conjunctiva covering the sclerotic coat has often a yellowish and shining glairy colour before the redness appears. There is often, also, a degree of redness and swelling, chiefly of the upper eyelid; and the tarli are found adhering together in the morning, from the exudation of a yellow matter among the cilia. There is frequently an unusual dryness felt in the eye; but if it be exposed to a bright light, or if an attempt be made to use it, the secretion of tears is increased.

This species of inflammation is always accompanied with a much greater degree of general fever, in proportion to the severity of the local symptoms, than any other ophthalmia. The pain is rarely acute till the pustule ulcerates; but, if that takes place, it is commonly very severe.

An eye which has been once affected with pustule, is very subject to repeated attacks of the disease. Pustules of the cornea are met with in people of all ages; but they are more common in young people than in those advanced in life.

Treatment.—Sudorific medicines, cooling diluent drinks, and purgatives, ought to be employed in the first stage of the disease; and given according to the violence of the constitutional symptoms. The eye, and parts around it, should be fomented three or four times a day, with a decoction of poppy heads; to which may be added a small quantity of spirits. When the symptomatic fever abates, and the redness assumes a more purple hue, the vinous tincture of opium may be applied to the eye once or twice a-day; and this will be found equally useful whether the pustule is in a state of suppuration or not; and it ought to be continued as long as there are any remains of the disease.

SECT. IV. Of Matter collected between the Lamellae of the Cornea.

Purulent matter is sometimes collected between the lamellae of the cornea, when the disease is termed unguis or enix; or in the anterior chamber, when it is called hypopion.

When the matter is collected between the lamellae of the cornea, it appears in the form of a yellow spot; and as the quantity increases, the spot becomes larger, but does not alter its situation from the position of the head.

When the matter is collected in the anterior chamber, it generally appears like a small yellow globule between the iris and cornea, occupying the inferior part of the cavity. These abscesses are commonly the effect of violent ophthalmia, occasioned by a blow, or injuries of the eyeball; they are also formed, though rarely, without any accompanying inflammatory symptoms.

Treatment.—Though the purulent matter may be more or less absorbed on the abatement of the accompanying inflammatory symptoms; yet it would be found a good general practice to evacuate the matter whenever it appears, by making an incision through the cornea. The discharge of the aqueous humor along with the matter, never fails to diminish the inflammation; and this perhaps may be the reason why the practice is so useful. Besides this, fomentations, brisk purges, and cupping at the temples, may be necessary if the inflammatory symptoms are severe.

SECT. V. Of Ulcers of the Cornea.

Ulcers of the cornea have been divided by some authors into a number of species, from differences in their size, in their duration, in the degree of the severity of the accompanying symptoms, and from the various causes from which they have been supposed to originate.

The most frequent variety of ulcer, is that which remains after the cornea has suppurrated and burst; either in consequence of a pustule or of an abscess.

When a pustule suppurrates, the central part of it generally Of the Dif-ferently gives way; and as the disease continues, the ulceration extends in all directions from that point. Ulcers of this kind are generally circular, and the edges rounded and smooth; having sometimes the appearance of a small artificial dimple: in other instances they have an irregular shape, and their edges are jagged and acute. The size of ulcers is very various; in some cases they do not appear larger than a depression made by the point of a pin, whilst in others they cover a large surface. Most frequently the part of the cornea contiguous to the ulcer becomes more or less dim; and in some cases red vessels may also be traced in it.

Treatment.—The acute pain which generally attends most ulcers, particularly those which are the consequence of pustules, will generally be much relieved by the application of the vinous tincture of opium, repeated two or three times a day. When this produces no good effect, and the ulcer spreads rapidly, attended with acute pain, much relief will be obtained by touching the surface of it with lunar caustic, or if there is a rift of the ulcer eroding the whole thickness of the cornea, and a prolapsus of the iris to take place, it may be advisable to prevent this by discharging the aqueous humor.

Sect. VI. Of Specks of the Cornea.

There are three forms of the corneal speck; the first and most simple variety, is when a particular part of the cornea loses its natural transparency, and appears clouded; objects being seen by the patient as if looked at through a mist or smoke. Some of these specks are undefined, others distinctly circumscribed, and they have each an equal degree of opacity throughout, or one part is more opaque than the rest. They are most commonly of a circular form; but in some cases their shape is very irregular. This size varies from the smallest spot, to such an extent as occupies the whole cornea.

In the second form of the corneal speck, the opacity is of a darker shade, giving the cornea a bluish, or in some parts a milky appearance. It is seldom equally opaque through its whole extent; being generally more so at the centre, and becoming gradually of a lighter shade towards the margin. In some instances the shade is very unequal in the different parts of the speck.

In the third form of the corneal speck, the cornea becomes of the opaque glittering white colour of common pearl, and the opacity generally extends through the whole of the lamellae of the cornea; so that if even several of those layers which are external be removed, the remaining ones completely interrupt vision. Specks of this description sometimes produce a slight thickening of the cornea, and are accompanied by adhesions between the cornea and iris. They are almost always distinctly circumscribed, though generally not so opaque at the edge. When they are of any considerable size, they are nourished by one or more red vessels.

In the first form of speck, the iris can be seen through the diseased portion of the cornea; but in the second and third form of the disease, the degree of opacity is such, that nothing can accurately be distinguished behind it. If there is an external inflammation accompanying the speck, the red vessels will be seen in a cluster on that part of the sclerotic part nearest to it; and some of the branches can often be traced passing over the edge of the cornea, and terminating in the substance of the speck. As the accompanying inflammation abates, the number of the red vessels on the cornea commonly diminishes; but sometimes one or more trunks remain, and are distributed on the speck. In some cases, there are large specks with numerous blood-vessels supplying them during the continuance of active inflammation; and although the opacity remains extensive after the inflammation abates, yet no red vessels continue to nourish it. The number of blood-vessels is in no case in proportion to the degree or extent of the opacity during any stage of the accompanying inflammation. For we frequently observe a net-work of blood-vessels on a cornea which has very little obscurity, and at other times there is a large opaque spot, with only one, or even without a single red vessel supplying it. Specks appear on every part of the cornea, but most frequently towards its centre.

Specks appear to be formed most frequently on the external lamella of the cornea; but it is difficult to determine accurately their situation. They vary in number. Commonly there is only one; but it frequently happens that there are two, three, or more distinct spots on one cornea, all of which differ in their size, shape, and in degree of opacity.

Specks impede vision in proportion to the degree of their obscurity, and according to their situation. Even a speck of the slightest shade, which is hardly perceptible to a common observer, if it be placed directly opposite the pupil, materially injures the sight; whereas those of the opake kind, if placed beyond its circumference, diminish the sphere, but not the difficulties of vision. In those cases where the speck is of a moderate size, and placed towards the centre of the cornea, the patient feels better in a dull, than in a clear light. For in a clear light the pupil contracts so much, that it becomes covered by the speck, and the rays of light are prevented from entering; but in a dull light it becomes larger, so that the rays of light enter by its edge.

Specks, most commonly, are either preceded or accompanied by inflammation of the cornea. Likewise wounds, if they do not unite without suppuration, and ulcers of the cornea, are followed by a speck.

Specks are formed at every period of life; but they occur most frequently in young people; probably because in them the cornea is much softer, and more spongy; and also as they are more subject to inflammatory complaints of the eye than adults.

Treatment.—Those specks which have been described under the first and second form of the disease, generally disappear either by the use of remedies, or in some cases after the inflammatory symptoms abate.

When the eye is inflamed, and the eyelids turgid with blood, slightly scarifying the eyelids, and immediately after the bleeding ceases, applying a quantity of an ointment composed of the red oxide of mercury (ten grains to a dram of simple ointment), will be found a very active remedy. And the scarifications along with the ointment should be repeated every second or third day as long as any inflammation continues. When there is no inflammation accompanying the speck, the ointment may be applied alone. The unguentum citrinum, and various powders composed of the sulphate of alum, sulphate of zinc, sub-borate of soda, diluted with from a fourth to an eighth Chap. X. SURGERY.

Of the Dif-eighth part of sugar, may also be advantageously employed of the ed. In specks of long duration, it will be found useful to vary the application, and to employ two or three of the above medicines ten days or a fortnight alternately.

Those specks of the third form, seldom become more transparent, even by the use of the most active remedies. In those cases where only a small central portion is of that description, the size of the speck may be diminished by the treatment already mentioned; and in some cases, much benefit has arisen from cutting away an external layer of the most opaque part; and afterwards using the above applications. It often happens, however, that if portions of a very old and opaque speck be cut away, the part is regenerated by an equally opaque matter.

The specks which are formed rapidly, are in general most speedily removed. They go away, too, much more quickly in children than in old people; and in them, also, a much greater degree of obscurity can be made entirely to disappear. When a part of the cornea has become opaque, the opacity begins to disappear at the circumference of the speck, or at that portion of it nearest to the circumference of the cornea. In some cases it may also be observed, that the external laminae of the cornea first regain their transparency.

SECT. VII. Of the Staphyloma.

When the cornea, besides losing its transparency, swells to such a degree, that its internal surface comes in contact with, and adheres to the iris, and when it forms a prominent tumor externally, the disease has generally been called staphyloma. When the whole cornea is affected, it generally assumes a more or less conical form; looses entirely its natural transparency; and vision is completely destroyed. The opacity is generally most remarkable towards the apex of the tumor, and is generally of a pearl white colour diffused through the whole corneal substance. The internal surface of the cornea adheres to the iris, and the pupil is in most cases altogether obliterated.

In many cases the cornea does not project beyond the eyelids; but in others, particularly in children, a large tumor is formed, which projects beyond the eyelids, and is attended with pain and inflammation, which, in some instances, renders the other eye weak and irritable.

Treatment.—When a part of the tumor gives way, and allows the contents of the tumor to be discharged, the patient always experiences a speedy relief, but the tumor is soon formed again; so that in order to prevent its growth, it is necessary not only to discharge its contents, but also to remove a portion of the diseased cornea of such a size as to prevent the humors from again collecting. A common extracting knife may be passed through the tumor, so as to divide a segment nearly equal to half the cornea, and the other half may be readily cut away with scissors. Inflammation and suppuration succeed; and the eyeball finally collapses if there be not a sufficient degree of inflammation excited. A pointed instrument may be introduced through the wound, so as to allow the crystalline lens, or any portion of the vitreous humour which may have remained, to be pressed out.

SECT. VIII. Of Inflammation of the Iris.

Inflammation seldom affects the iris alone, though in some cases it appears to be the principal diseased part of the organ. The disease is accompanied with intense pain on exposure to light; discoloration of the iris from the addition of red blood; dilatation of the pupil to contract; and lymph to be effused on the surface of the iris and pupil.

Treatment.—Copious bleedings from the arm, or temporal artery, are generally necessary; and in order to prevent any permanent contraction of the pupil from taking place, much benefit will be derived from keeping it dilated by the action of an infusion of belladona.

SECT. IX. Of the Mode of making an Artificial Pupil.

The iris, whether from previous inflammation or other cause, has been often found with the pupil so much contracted, and adhesions formed between it and the capsule of the crystalline, to such a degree, as to prevent vision. The pupillar edge of the iris, too, sometimes adheres to the cornea, and is contracted; and sometimes a portion of cornea opposite to the pupil is a cause of blindness. In all such cases it has been repeatedly attempted to make an artificial pupil; but this operation has seldom been successful. Various modes have been proposed to perform it, but that recommended by Scarpa is entitled to most attention. This method consists in introducing a curved couching needle (Plate DXVII. fig. 20.), as in the operation of couching the cataract, passing its point through the iris at the place where it is intended the new opening should be made, and then forcibly tearing down a portion of iris from its connection with the ciliary ligament. After the operation it will be found useful to keep the iris for some time under the influence of belladona. We understand that Mr Gibbon, an ingenious surgeon in Manchester, has operated with great success in a new manner. He makes the punctuation of the cornea at its transparent part with an extracting knife (Plate. DXVII. fig. 1.), and presses the eyeball so as to squeeze the iris through the incision of the cornea; or if any adhesions render that impracticable, he drags it out with a hook (Plate DXVII. fig. 19.), and afterwards cuts away with a scissor the prolapsed portion. Then immediately the perforated iris falls back into its natural situation, leaving a proper opening.

SECT. X. Of the Cataract.

The most common disease of the lens is a loss of its natural transparency; and this arises either from a change in its structure, or from a deposition of new matter. The capsule of the lens is also subject to opacities. These diseases are known by the name of cataract.

There are four species of cataract generally enumerated. In the first, the crystalline lens itself becomes opaque (cataracta crystallina). In the second, the capsule is changed in its structure (cataracta membranacea). In the third, the liquor Morgagni becomes opaque (cataracta interstitialis); and when all these parts are affected at the same time, it has been denominated the mixed cataract, cataracta mixta. When the crystalline lens becomes opaque, the opacity generally begins towards the central part of the lens, and extends towards its circumference; in other cases a general obscurity extends over the whole lens.

The confuseness of the lens varies very much in the different kinds of cataracts. Sometimes it is converted into an aqueous or milky fluid, or like thin jelly; at other times it becomes harder and firmer than natural; and in several cases it has been found converted into bone or into a chalky looking substance. It has been generally remarked, that the fluid or milky cataract is most frequent in children, but we have also met with it in those advanced in life. The solid or concrete cataract, on the other hand, has been generally found in adults. At the same time, we have observed the lens of young people converted into a hard and white substance resembling chalk.

The colour of different cataracts is very various; and they never appear of the same colour in the eye as when removed from it. The most usual colour of them in the eye is a bluish white or gray; sometimes clouded in different parts or fricated, sometimes of a lead colour, sometimes greenish, and sometimes of a yellow or amber colour. When taken out of the body, those which appeared white or gray are generally dark yellow or amber; and those of a yellow tinge in the eye often appear white when extracted.

There is scarcely any diagnostic mark of a soft and hard cataract which can be altogether depended on. The colour proves nothing, those of a milky colour being often quite hard, and sometimes those of a pearl colour are quite soft. Neither is there any thing to be learnt from the degree of the opacity; for it will be found that those who see no more than to be able to distinguish light from darkness have the lens quite soft, whilst those who can distinguish colours and large objects have the lens quite hard. Richter, however, has remarked two symptoms, which he says have seldom deceived him in ascertaining this point. The softer the lens is, the larger and thicker it is in general, and therefore approaches nearer to the plane of the iris or to the edge of the pupil. Hence he always concludes that the cataract is soft when it is near the pupil. In order, however, to judge of the space between the pupil and lens, the surgeon must look into the patient's eye from one side; and in general it requires much experience to judge of this with accuracy.

We are also able, in some cases, to discern points, streaks, or inequalities, in the shade of a cataract. If, after having observed the place, figure, and disposition of them, we find that in some days afterwards, or upon rubbing the eye pretty hard, they have undergone any change in their figure, situation, or shade of colour, we may then conclude with certainty that the cataract is soft; only we must be cautious not to draw an opposite conclusion, viz. that we are not to conceive the cataract to be hard if these changes should not be perceptible.

"A perfectly hard cataract," says Beer, "shows itself very plainly before the operation; the pupil is equally opaque in its whole circumference; there are not to be observed any points, streaks, or spots, of a clearer or darker colour; the lens is evidently separated from the iris, so that a sufficient number of rays of light can enter, and the patient is still capable of distinguishing some objects from the side of the eye; the motions of the pupil are extremely lively, and it never remains considerably enlarged." The opacity behind the pupil at the commencement of the disease is first observed in the middle, and it then extends, but very slowly, towards the circumference. Such patients, if the middle part of the pupil is completely opaque, can for the most part read writing by the assistance of a magnifying glass, and distinguish small objects. "The colour of the hard cataract is gray, palling more or less to a greenish hue; and the smooth level of the lens may be very plainly remarked."

In most patients the cataract is to be considered as a Cataract local disease, though there are also many cases where an opacity of the lens comes on after or along with other local diseases of the eye. It has been observed in gouty and rheumatic constitutions, and in such people there is reason to suspect that it is more or less connected with the general constitutional affection. This observation is of importance; for when an operation is performed in such cases, a total blindness is usually the consequence. Richter operated on a man who had been much troubled with gout, and his sight was restored. In seven months afterwards the pupil gradually contracted, at last closed, and a second blindness followed. In one case of a similar kind on which we operated, an attack of gout succeeded the operation, the eye suppurred, and the inflammation has never altogether disappeared, though two years have elapsed since the operation. Even in such cases the operation is not to be entirely forbidden: the success is less certain, and the patient will require a very careful preparation before it, and much attention after it.

There are some varieties of cataract which are considered to be hereditary. Richter extracted a cataract cataract from a man whose father and grandfather were both blind from that complaint. Maitre Jean and Janin have both met with similar cases. Richter also saw three children, born of the same parents, who had all cataracts at the age of three years. We have known several similar facts, and particularly one of twins, who both were affected with cataract when one year old.

When the cataract is seated in the capsule above, it in general arises from a blow or wound with a pointed instrument. Sometimes the whole anterior portion is opaque and very much thickened, whilst that which is posterior remains transparent; and in some cases the capsule has been extracted in the form of a bag, having become altogether opaque, and containing within it the crystalline. Such cases have been called by Richter the cataracta cylica. He says he has only met with one case of that form of the disease; Beer, however, mentions many; and from meeting with them he has been led to propose the extraction of the capsule along with the crystalline in all cases of the disease.

The cataracta membranacea primitiva of Scarpa is also another form of the disease. In this variety the lens disappears, and leaves the capsule opaque, or at most in its interior a speck not larger than a pin-head. This kind of cataract, Scarpa remarks, occurs most frequently in infants, or in people under twenty years of age. It may be distinguished by its resemblance to a very thin scale, or by a very white point, at the center or at the circumference of the crystalline.

The tremulous cataract (cataracte tremblante of the French), is another variety of the disease which deserves cataract to be noticed. It is generally of a very opaque white colour, Chap X. SURGERY.

Of the Dif- colour, and seldom large. It moves about on every motion of the eye, and the whole iris trembles and fluctuates to and fro. Sometimes they altogether disappear, at times passing behind the iris, but they soon regain their situation. In one example of this disease we observed that the opake lens sometimes fell into the anterior chamber through the pupil. In this form of the disease it generally happens that the functions of the retina are impaired or lost; though this is not always the case.

Cataract is often accompanied with a complete amaurosis. In some cases of this kind there is a great dilatation, and immobility of the pupil, and the opake lens is observed of a very large size behind it. The patient can seldom distinguish right from darkness; and the want of sight generally precedes any obscurity of the lens. In some cases, where there is a combination of cataract and amaurosis, the pupil remains of its natural form, and alters according to the quantity of light. But, as in the former variety of the disease the opacity of the lens most commonly precedes the amaurosis, it generally too comes on suddenly, preceded by sparks of fire appearing before the eyes, or clouds flying before them, or headache, and pains about the brow or temples. We have seen an instance of a simple cataract in one eye, and in the other cataract and amaurosis combined.

Commonly cataract affects both eyes simultaneously; but there are also many examples of the disease affecting only one eye. It also happens, that first one eye is affected, and many years afterwards the second. We have in general observed, that when the cataract takes place only in one eye in young people, or when it succeeds a blow, the other eye is seldom affected. But on this we should not trust much, for it is an undeniable fact, that a great sympathy exists between the two eyes; and that when one of them becomes diseased, the other is very apt to become similarly affected. We have seen a case where a phlyctoma arose in one eye in consequence of a wound, and in a few years afterwards the other eye became phlymophatic. A man who received a blow on one eye, which produced amaurosis, had soon afterwards a cataract formed on the other. Richter mentions an analogous case. St Ives mentions a very remarkable case of a man who was wounded in the right eye with a small shot, and shortly after that eye was affected with a cataract. Some time afterwards the same disease took place in the left eye, but which gradually disappeared after the cataract had been extracted from the right eye. These observations on the connection between the two eyes, have led some surgeons to advise operating for cataract when only one eye is affected, in order to prevent the second eye from becoming diseased. There are a few cases where this practice has been successfully adopted, and there are others where it has failed. We know of one gentleman, now upwards of seventy years of age, who was couched for a cataract in one eye when twenty years old, and the disease has never attacked the other eye. Richter once performed the operation on a woman who had a complete pearl-coloured cataract in the left eye, and an incipient one in the right, which, before the operation took place, was beginning to advance rapidly. After operating on the left eye, the progress of the disease in the right seemed to be checked, and for years after the operation it had not made the smallest progress. On the other hand, we have operated in several cases where the disease was just commencing in one eye, and when the operation did not appear to arrest its progress in the second one. It is therefore a point not yet determined in what cases it would be advisable to operate when only one eye is affected; for in those where the progress of the disease in the second eye cannot be arrested by an operation on the first, no operation should be performed on either eye until vision is nearly altogether destroyed.

The progress of this disease is very various; sometimes it proceeds so slowly as not to destroy vision for the disease many years, at other times a complete obscurity of the lens has been known to take place almost instantaneously. Richter and Eschenbach both relate cases where people labouring under gout, which suddenly retrograded, were entirely deprived of their sight in one night. We have observed analogous cases, though we could not determine the existence of any constitutional affection.

From the found crystalline being chiefly composed of albumen and a small quantity of gelatine, whatever might produce a coagulation of these, would destroy the pellucidity of the lens. Whatever too would produce inflammation of the capsule of the lens might also render it obscure; for when any ferous surface is inflamed, and to that class belongs the capsule of the lens, its transparency is destroyed, and it becomes thickened from an effusion of albuminous matter on its surface. Cataracts arising from wounds are probably produced in this manner.

In old people there is often distinguishable a slight obscurity of the lens, and sometimes it even forms a complete cataract. In such cases the obscurity probably arises from a want of balance in the secreting and absorbtion systems, or the necessary perfection of these functions to preserve the natural state of parts, which we observe to decay in many other organs, as well as the eye, in those far advanced in life.

Besides the symptoms which are to be observed in an eye affected with cataract, there are others remarked by the patient. Objects appear to him as viewed through a mist or cloud; and as the opacity of the lens increases, the cloud appears greater until it finally prevents even the largest objects from being distinguishable.

The patient, at the commencement of the disease, can distinguish objects better in a moderate than in a bright light; and the same thing happens if the light be interrupted by the interposition of the hand or any other shade. The reason of this is obvious; because the pupil is more dilated in a moderate than in a bright light, and thus still admits a certain number of rays of light by means of the pellucid circle of the lens.

When the exterior part of the lens is less obscured than the centre, the patient sees those objects much better which are placed by his side, than those which are opposite to him.

If the obscurity has not affected the middle of the lens, but some part of its edge, any circular body looked at by the patient, appears to have its edge imperfect. It has been also remarked that some patients see everything with perforations in them. The cataract is seldom accompanied with any pain. When it is brought on from internal causes, both eyes are generally affected. Of the Treatment of Cataract.

In the treatment of cataract, recourse has generally been had to a surgical operation. Some have pretended to cure cataract by internal medicines. Small doses of calomel, electricity, extractum hycsyami, aqua laurocerasi, have been extolled; but their use is now very generally given up. In some cases of cataract which have arisen from an injury of the eye, Mr Ware has seen them disappear by an external application of aether, which promoted the absorption of the opaque body*.

There are two operations which have been proposed for the cure of the cataract; the one called extraction, and the other couching. In the first, an incision is made into the cornea, and the lens removed by pulling it through the pupil. In the second, the lens is taken out of its capsule, and lodged in some part of the vitreous humour, where it may be entirely out of the axis of the eye. Each of these methods has been much practised; and though a decided preference seems at present to be given by the most distinguished surgeons to the mode by extraction, yet there are also cases attended with peculiar circumstances, in which the operation of couching may be successfully employed. Both operations ought therefore to be well understood by every surgeon.

It was formerly the custom, before performing either of these operations, to confine the patient for several weeks, or even months, to a strict antiphlogistic regimen; but this precaution, except in very particular cases, may be generally dispensed with. People who have become blind, generally lead a quiet life, and are not exposed to any of those dispositions which are likely to affect the constitution. It will therefore generally be found sufficient precaution, before attempting an operation, to enjoin the patient to live moderately; to avoid spirituous liquors, and take a few doses of any of the common laxative medicines. If he be strong and plethoric, it will be necessary to pursue such a course a little further; to give doses of laxative medicines for a longer period, and even to bleed the patient in the arm. Many surgeons lay it down as a general rule, to take some blood on the morning of the day of the operation, either from the arm, from the temples, or from the neck by cupping; and either of these methods is to be preferred, according to the quantity of blood which is intended to be taken. In old people of a healthy constitution, we have often found it unnecessary to use any of these means, no inflammatory symptom having arisen during the progress of the cure. In many cases, instead of bleeding before the operation, we have preferred doing it after the operation was performed, when the patient was put quiet in bed. Blood taken at this period may be reasonably supposed to have a more powerful effect in giving check to any inflammatory attack which might be apt to succeed the operation, than if an equal quantity had been taken away before it. The bleeding too, immediately after the operation, we have often observed, renders the patient calm, and more disposed to rest, whereas at the same time any of those disagreeable symptoms are avoided during the operation, which are apt to remain for several hours after bleeding, when the patient is in the erect posture. It is also of importance before the operation is performed, the patient being so situated, that he can be easily put to bed. The operation should therefore be performed in the same chamber in which he is to re-eyes of the main, or in one immediately adjoining; and he should be clothed in a bed-gown, or some loose dress, so as to enable him to get into bed without much trouble. The bed should be placed in such a position in the room that the light does not fall directly on the patient's face, so that during the cure, all glaring lights may be easily avoided.

Of the Extraction of the Cataract.

In this operation the object of the surgeon is to make a wound in the cornea, and to extract through it the opaque lens. In performing it there are four steps which require to be particularly considered. The first of them is the means to be employed for securing the eye during the operation. The second is the mode of making the incision through the cornea; the third, the mode of opening the capsule of the crystalline lens; and the fourth is the extraction of the lens. All these shall be considered separately.

Mode of securing the Eye and Eyelids.

One of the great improvements in modern surgery is the simplicity of the mechanical means employed in performing operations. A great variety of contrivances have been proposed, in order to secure the eyeball and eyelids during the extraction of the cataract. Experience, however, shews, that almost all these are completely useless, and most of them extremely hurtful. To dispense, therefore, with these instruments, and to be able to execute with the fingers alone those parts of the operation for which they were employed may be justly considered as a material improvement. The eyeball and eyelids may be completely secured in almost all cases, by the fingers of one hand of the operator, and those of an assistant. The assistant will generally find that, with the forefinger of one or of both hands placed upon the tarbus, one upon the internal, and another towards the external angle of the eye, he will be easily able to raise the upper eyelid, so as to expose the cornea; and by the finger being placed towards the internal angle he will be also able to assist the operator in preventing the eyeball from being turned inwards, when the incision into the cornea is about to be made. The operator is to secure the under eyelid by the fore and middle fingers of his left hand. They are to be placed in such a manner over the edge of the tarbus, that they may come in contact with the eyeball; and the middle finger is to be pressed pretty firmly in the internal angle of the eye, between the eyeball and lachrymal caruncle, so as effectually to prevent the motion of the eye towards the nose. In this position of the fingers of the operator and assistant, those who are accustomed to perform operations on the eye, find that they are completely master of the motions of the eyeball; and by altering the positions of the points of the fingers, and applying more or less pressure, they are able to counteract any untoward motion of the organ. Before attempting to secure the eyeball, the operator should be prepared to advance in every step of the operation; for it will be generally found, that if an attempt has been made to open the eyelids forcibly, a certain degree of irritation and watering of the eye takes place; so that, when a second attempt is made, Chap. X. SURGERY.

Of the Dif-with a view of proceeding to the other flaps of the operation, more difficulty is met with in holding the eye than at first would have been the case. It is a good precaution, however, for the surgeon to take an opportunity, before the day of the operation, to try to fix the eye, and to explain to the patient this step of the operation; for it often happens, that patients flart, and make great reluctance by squeezing the eyelids, when the operation comes to be performed; so that by habituating them to the mode of securing the eye, it is more easily accomplished. The first thing to be attended to, before attempting to fix the eye, is a proper light, the position of the patient's head, and the height of the chair in which he is to sit. The light of the room should come from one window, and the patient fit in such a manner that the light falls obliquely over his nose upon the eye to be operated on. If he be placed so that the rays of light from the window fall in the direct line of the eye, the surgeon will find that he is obliged, either to fit in his own light, or that the reflections upon the cornea tend to embarrass him. As soon as the other eye is covered, so as to prevent it from having any motion, and communicating that motion to the eye on which the operation is to be performed, the affiant is to be placed behind the patient, and the patient's head to be supported firmly on his breast. The height of the chair on which the patient is to be placed, will depend on the height of the patient, and always should be so low, that the affiant is able to look over the head, and completely command the motion of his own fingers. The operator and affiant should open both eyelids at the same time, which will more readily secure the eyeball in a proper position. The eyeball, however, is apt to be turned upwards, so that the cornea is thrown out of view. When this happens, the upper eyelid should be first raised, and the affiant should be always ready with the points of his fingers, to press in such directions, that when the eyeball at any moment places itself in a proper position, he may be ready to secure it. When, on the other hand, the eyeball is thrown downwards, the operator himself must place it in a proper position, and in this manner both the operator and affiant are to co-operate with each other, and the one or the other placing his fingers in such a manner as to counteract most effectually any awkward position of the eyeball. When the eyeball appears steady, the incision of the cornea ought to be immediately performed. But before entering the knife, it will be found a useful precaution to touch the cornea frequently with its back, and see if the patient starts, or if the eyeball remains quite steady. It will often happen, that whenever the point of the instrument touches the eyeball, it is suddenly thrown into motion; and was the incision of the cornea to have been begun at this moment, much difficulty would have arisen. If, however, the eye be repeatedly touched with the knife, the startling motion will sooner or later cease, and then the incision of the cornea may be begun with every possible advantage. When the knife has passed through both sides of the cornea, there is no danger of any motion of the eyeball hindering the operation.

If sometimes happens that the eye is extremely small, and that it is sunk deep in the orbit. In such people the operation becomes much more difficult; and we have met with cases, where, from these circumstance it was almost impossible to secure the eyeball with the fingers; Of the Dil. of the room which the fingers necessarily take preventing the knife from being properly managed, and covering a portion of the cornea. In such cases, the speculum contrived by M. Pellier will be found to be a useful instrument. See Plate DXVII. fig. 8. The speculum consists of a piece of silver wire, bent in the manner represented in the plate; and though in itself extremely simple, it requires a good deal of management and nicety in using it. The curved edge of the wire (a) is to be placed upon the inside of the cilia on the horizontal plate of the tarbus; the skin of the upper eyelid being previously stretched upwards. The affiant is then to move the speculum upwards, imitating, as it were, the natural motion of the eyelids; and, when the eyeball is sufficiently exposed, the speculum, with the handle (b) resting on the brow of the patient, is to be kept firm and steady in the same position. In using the speculum, it is necessary to make a considerable pressure on the eyeball, in order to prevent the eyelid from slipping from underneath the speculum. At the same time as little pressure should be employed, as will prevent this from taking place. Many surgeons, in using the speculum, place it behind the cilia; and whenever any watering of the eye takes place, from the irritation of the instrument, it is very apt to slip from the moisture of the skin. In order to prevent this, we have found very material benefit from simply folding round the speculum a thin fold of crape, which, from its roughness, effectively prevents the risk of the speculum slipping. The operator is to manage the under eyelid in the same manner as if the upper eyelid was covered by the fingers of an affiant; and it more particularly rests with him to prevent the eyeball from rolling inwards, the speculum merely serving to support the upper eyelid.

After the knife has penetrated both sides of the cornea, the affiant is to be aware that no pressure is to be made upon the eyeball. When, therefore, this step of the operation is completed, the affiant, if he be using the speculum, is to be particularly careful in taking off any pressure which it may make, and merely to support the eyelid.

Mode of making the Incision of the Cornea.

The great object to be kept in view in making an incision of the cornea is, that it be of sufficient size to allow the easy extraction of the crystalline lens, and that any cicatrix which may remain may not interrupt the entrance of the rays of light through the pupil. The mode which has been recommended to effect these purposes, is to make a semicircular incision, parallel to the circumference of the cornea, and about half a line distant from the junction of the cornea and sclerotic coat. One of the knives (Plate DXVII. fig. 1, 2, 3.) is to puncture the cornea half a line distant from its circumference, to be carried across the anterior chamber to the opposite side, and brought through the cornea at the same distance from the sclerotic coat to where it was entered; afterwards the incision is to be finished by putting the knife forwards till the incision is completed.

Instead of making the incision in this manner, Mr. burg Ate. James Wardrop has proposed another form of incision, stick and in order to remove several objections to which the other Chirurgical operation was liable*. The disadvantages which Mr War- *See Edin. Journal vol. iv. drop Of the Dif-drop supposes to arise from the usual mode recommended by the Eye.

1. The cornea being of very considerable thickness, a great part of the semicircular incision will be carried through between its laminae, and therefore the length of the incision of the internal lamina will be much less than that of the external one. This he explains by two plans, Plate DXVII. fig. 11. and 12, where besides the external form of the incision (aaa), there is drawn a second line (b), intended to represent the incision of the internal lamina. The dark space, therefore, included between these two lines (b and a) is intended to represent that portion of the incision which is made between the laminae.

2. The external form deceives us in the extent of the internal incision, and much more difficulty is met with in bringing the lens through it, than from its apparent length could have been expected; for, as the line of the internal incision has a very slight curvature, the thickness and tension of the cornea allow the edges of the wound from being separated only a little way from one another.

3. When the cornea is divided nearly at its union with the sclerotic coat, and when the aqueous humour and lens have escaped, the portion of the iris opposite to the centre, and most depending part of the wound, loses its natural support given to it by the cornea, and is pushed forward, so that it comes in contact with the cornea, and even infinuates itself between the edges of the incision. The greater the opening is, the more danger there is of a prolapsus, both of the iris and vitreous humour; for it would seem as if these two parts of the eye were pushed forwards in consequence of the contraction of the coats of the eye, which takes place as soon as the incision is made; and if two thirds of the cornea be cut, there is certainly much less resistance than when the half only has been divided. Thus, the iris and cornea form permanent adhesions in consequence of the inflammation which always follows the operation. The pupil becomes an irregular form, is drawn from the centre of the eyeball; is sometimes very much contracted, and retains but a very limited sphere of contraction and dilatation.

4. The contraction of the muscles of the globe of the eye pressing forward the contents of the posterior chamber, are very apt to push a portion of the vitreous humour through the pupil and wound of the cornea. When this happens, the pupil becomes irregular, and drawn down towards the incision, the form of the eyeball is somewhat altered, and the prolapsed vitreous humour inclosed in its capsule, appears externally in the form of a round transparent tumor.

5. As the external edge of the semicircular flap of the cornea is very thin, and lies loose, the smallest movement of the eyelids, particularly of the upper one, is apt to catch and raise it out of its proper situation, and thus that speedy union is prevented which would take place if the two divided surfaces had been kept in accurate and constant contact.

6. And lastly; As the internal edge of the incision is often unavoidably made, from the smallness of the anterior chamber, and the flatness of the cornea, nearly opposite to the inferior margin of the pupil; and as all the extent of the cut surface a b (Plate DXVII. fig. 12.), sometimes remains opaque after the wound is healed, the opacity of the cicatrix must diminish the sphere of vision.

All these disadvantages in the usual mode of making an incision of the cornea, appeared to Mr Wardrop to arise chiefly from the want of a sufficient portion of the cornea being left at the inferior part of the wound, to support the iris, and to prevent the pressure of the parts contained within the eyeball, and the occasional action of the muscles pulling forward the iris towards the wound of the cornea; he therefore conceived that if the incision could be made in such a manner that a larger portion of the cornea could be left at the inferior part of the wound, being at the same time made of such a form as to allow the easy extraction of the cataract, and the cicatrix not afterwards to interfere with vision, a considerable improvement would be made in the operation. With this view he made the incision in the following manner.

The best knife for the purpose is of the same size and shape with that delineated in Plate DXVII. fig. 1, near knife. The blade is of a simple triangular form, the back being one continued line with the handle, except merely the point. The point, though extremely sharp, should be made firm, and the blade should turn gradually thicker from the point towards the handle. The point of the knife must be sharp on both edges for at least the breadth of a line, in order that it may penetrate the cornea quickly and easily. The back of the knife should not be left angular, but the edges rounded off and made smooth, so that it be convex on both sides. Particular care ought to be taken that the point of the knife be well conditioned; and it is not only necessary that it be sharp, but that the metal of which it is made be neither too hard nor too soft. This may be easily ascertained by pressing the point upon the nail; for if it bend readily, not being so brittle as to break through, and sufficiently elastic to recover the straight line, we may be confident that it will answer the purpose. It is also a good precaution to have the knife sharpened the day before, or the morning of the operation; and in case of any accident happening to the point, the operator himself should carefully examine by trying how it penetrates a thin piece of leather, immediately before using it. From the point of the knife being too brittle, we have known a case where the point of it was broken off, when attempting to penetrate the inner part of the cornea; and from the point being too soft, we in one case, after puncturing the cornea, found it impossible to penetrate with the knife the opposite side, and this we found had arisen from the point of the knife bending round.

Having previously smeared the knife with oil, or smoothed the edge of it upon the palm of the hand, in order to make it cut more keenly, its point is to be thrust through the cornea at its transverse diameter, and at least half a line distant from the sclerotic coat, and in a direction as if it was to wound the iris, or nearly perpendicular to the spherical surface of the cornea (see Plate DXVII. fig. 13. and 15. a). When the point of the knife reaches the plane of the iris, it is to be turned towards the opposite side of the cornea, by moving the blade upon the incision already made, as a fulcrum. It is then to be carried forward, so that the cornea is again punctured at its transverse diameter b, at the same distance from the sclerotic coat at which it had been entered on the Chap. X.

Of the Dif- the opposite side (fig. 13.). By these two incisions the blade of the knife has cut perpendicularly, or very nearly so, to the spherical surface of the cornea, and the gradual thickening of the knife, by filling up the wound as fast as it is made, prevents any of the aqueous humour from making its escape. The eye is now completely secured with the knife, and the assistant who has been supporting the upper eyelid, should receive a signal from the operator, to take away all pressure from the eyeball, and merely to support the eyelid sufficiently to allow the inferior half of the cornea to be seen. When the knife has been pulled forward a little way, as is represented in fig. 15. the incision is to be finished, by turning round the blade on its axis, and thus keeping the edge turned outwards, in such a manner, that the remaining part of the incision is made a straight line, and therefore nearly perpendicular to the lamelle of the cornea (fig. 13. e). Whenever the last step of the operation is begun, the aqueous humour begins to escape, which allows the knife to cut the cornea readily and in any direction.

Supposing, therefore, that the cornea, instead of being spherical, were a plain surface, the incision now described would be represented by the lines a, b, and c, fig. 13.; but as it is a segment of a sphere, the form will more resemble that represented in fig. 14.; at least this is the form of the incision which the operator should have in view when performing the operation. By the inspection of these figures (13 and 14.), it appears,

1. That a large portion or ring of the cornea is left attached to the sclerotic coat, and must form, from its thickness, a complete support to the iris.

2. That as the incision is made throughout nearly perpendicular to the lamelle of the cornea, the length of the incision of the internal lamella will be nearly equal to that of the external one, and will be greater than when it is made in the usual manner, by the fenicular incision; and consequently the cataract will be more easily extracted through it.

3. The upper edge of the internal incision is at a greater distance from, or further below the edge of the pupil.

4. As the flap of the cornea is very small, the external edge thick, and not easily moveable, or apt to be caught by the motion of the eyelids, the edges of the incision are not liable to be displaced, and consequently the wound has a much better chance of uniting by adhesion.

Lastly, the cicatrix which remains is scarcely perceptible, and cannot even be distinguished when the cornea is looked upon in a direction perpendicular to its surface. The incision should be made so that the inferior edge of the wound (fig. 3. e) is half way between the circumference of the cornea and the edge of the pupil, supposing the pupil to be in a moderate state of dilatation. If it be made nearer to the sclerotic coat, then the advantages to be expected from this mode of operating will be lost; and on the other hand, if it be made at too great a distance from the sclerotic coat, and consequently too near the pupil, the edge of the pupil will be apt to pass through between the lips of the wound. In one case in which this accident happened, partly on account of the incision being at too great a distance from the sclerotic coat, and also from the knife having been entered too far above the transverse diameter of the cornea, the wound was long in uniting, and after it was healed, the pupil remained very irregular and contracted.

In making the incision of the cornea in the manner that has been directed, another circumstance also particularly deserves notice, which is, that after having punctured both sides of the cornea, in giving the knife the motion round its axis, some of the aqueous humour escapes, and there is a great risk of the iris turning over the cutting edge of the knife. An operator who meets with this for the first time, is apt to think an wound of the iris is inevitable; but if he cautiously stops the progress of the knife by gliding the point of the forefinger over the cornea, and prelling the iris from its edge, the incision will be completed with perfect safety.

It sometimes happens that after the knife has entered the cornea, the eyeball makes a sudden motion inwards, towards the nose, and a considerable part of the cornea is thus thrown out of view. This accident happens either from a fault in the operator or his assistant, and ought to be particularly guarded against; for when it has taken place, it is irremediable. The operator must not attempt to proceed any further, but immediately withdraw the knife, allow the wound of the cornea to heal, the aqueous humour to be regenerated, and after any slight inflammation which might succeed, has gone off, the operation may be a second time attempted without any additional risk.

It sometimes happens that, on puncturing the cornea on the nasal fide, the point of the knife does not come through at the proper distance from the sclerotic coat. If it passes through too near the centre of the cornea, as is represented in Plate DXVII. fig. 17., considerable disadvantage arises; for besides the incision being too small, so that the lens is extracted with difficulty, the eye is apt to receive considerable injury, and the cicatrix afterwards to interfere with vision. When this accident happens, it will be the most prudent practice to proceed no further in the operation, but to allow the wound to heal by adhesion, so that a second operation might be afterwards attempted with all the advantages of the first. It is astonishing the rapidity with which a wound of the cornea made by a cutting instrument heals, and except it be very large, scarcely can the most acute eye detect any cicatrix. It is therefore much more prudent whenever any fault in the incision arises, that the wound be allowed to reunite, so that afterwards a second operation may be successfully performed, instead of attempting by scissars or other instruments to correct any bungling. If the knife passes through the cornea too close to the sclerotic coat, it is not attended with such bad effects as when it passes near to the pupil; and was it not for the danger in wounding the iris, it would be advisable in all cases to lay it down as a general rule to make the knife come out very close to the sclerotic coat.

Of the Mode of opening the Capsule of the Lens.

After the operator has completed the incision of the cornea, he should make a pause, and allow the patient to compose himself a little, in case of any involuntary motion of the eye-ball injuring any part of its structure. It sometimes happens, indeed, that the moment the incision of the cornea is finished, the lens suddenly follows the knife; but this is a circumstance never to be wished for, as the same cause which throws out the lens may Of the Dif-also push after it some of the vitreous humour. When the incision of the cornea is finiish'd, and nothing has escaped but the aqueous humour, the patient should be directed to turn his eye from the light, and to keep his eyelids shut, taking great care not to squeeze them, so that the pupil may be allowed to dilate. In most surgical operations, particularly those attended with much pain, it is of importance to finish them as quickly as possible. This, however, is not the case in the extraction of the cataract. It will be in general found that the severity of an injury done to any part of the body depends, not only on its extent, but on the sudden manner in which it is inflicted. Thus, a small drop of blood suddenly effused on the surface of the brain, often produces a series of much more distressing symptoms than a large collection of purulent matter in that organ. It is therefore reasonable to expect that if the different steps of the operation for the extraction of the cataract are gone through in a rapid manner, the eye will be much more injured than if the same operation be performed more slowly. There is another advantage too, derived from performing the operation in a cautious manner; by holding the eye firmly for some time, the muscles become fatigued, and during the latter steps of the operation, when there is the greatest danger of injuring the organ, the power of resistance to the operator is much diminished.

The next step of the operation is to make a puncture in the capsule of the crystalline lens, so that the lens is allowed to pass through the pupil. On opening the eyelids, it will generally be found that the pupil has a very irregular appearance, which a beginner may often suppose to be in consequence of a wound of the iris, though no such accident has happened. Some surgeons employ an assistant to support the upper eyelid, whilst others take both eyelids completely under their own management; and when the operator finds that he can easily accomplish this last mode, he should always prefer doing so. When the eyelids are opened in such a manner as to expose the incision of the cornea and pupil, the point of the instrument called the curette*, is to be introduced through the wound of the cornea and pupil, to puncture the capsule of the lens. Richter advises that the capsule should be punctured several times with the point of this instrument, in order that a large opening may be made into it. When the lens is soft and milky, this may be necessary, but when it is of a firmer texture, if one puncture is made it sufficiently tears the capsule so as to allow itself to come away easily. Before introducing the curette, moderate pressure should be made on the eyeball, which has the effect not only of keeping the eye steady, but also of dilating the pupil. The convex part of the instrument (a) is then to be introduced through the wound of the cornea, and conducted to the central part of the pupil. When it reaches the pupil, from the curvature of the instrument, a very small turn of the handle will place the point upon the capsule of the crystalline lens, and by pulling the point inwards, the capsule will be readily punctured. It is not necessary that the point of this instrument be very thin; a rounded point will answer all the purposes of puncturing the capsule; whilst from this form there will be less danger of wounding the iris from any unexpected motion of the eyeball. Very little force is necessary to puncture the capsule, and when the point of the curette passes through it, it gives the sensation as if puncturing a piece of very fine paper with a pin.

This part of the operation we have often found to be one of the most difficult; for in many patients the eye becomes extremely unsteady, and whenever an attempt is made to hold it firm, or introduce the point of the curette, the eyeball is immediately rolled upwards under the roof of the orbit. The eyeball, too, is apt to make some untoward motion, after the point of the curette has been introduced into the anterior chamber; so that if the operator be not on his guard, the iris may be caught and torn by the point of the curette. In one case where, after the point of the curette was introduced through the pupil, the eye turned suddenly upwards, and the hooked part of the instrument catching the edge of the iris, pulled it a good way downwards, though fortunately it did not tear it.

Mode of Extracting the Lens.

Whenever the capsule of the lens is punctured, the lens in many cases begins to move forward, and the pupil to dilate. The operator carefully watching this effect, should keep up an equal and moderate pressure upon the eyeball, which will assist the lens in getting through the pupil. Whilst the lens is making its escape, and appears to press very much on the inferior part of the pupil, the iris should be supported by the back of the spoon, (b Plate DXVII. fig. 19.) which is generally for convenience, fixed upon the opposite end of the handle of the curette. In applying the pressure on the eyeball, it is of great importance that it be kept up uniformly, and it should always be proportioned to the effects which it appears to produce on the dilatation of the pupil. In most cases a very moderate pressure will be found to answer the purpose. We have met with others, however, where it was necessary to compress the eye with a good deal of force, before it was possible to remove the lens.

Any small portion of opaque lens which now remains in the capsule, or on its surface, must be extracted by means of a small scoop. When the fragment lies on the surface of the capsule, or in any part of the anterior chamber, it is in general easily removed; but when the opaque body remains within the capsule, it becomes necessary, that the scoop should enter the capsule through the opening which was made in it. When this opening is large and wide, the scoop will easily get in, and reach the opaque fragment; but on the contrary, when the opening is small, the scoop may be moved about in every direction, in hopes of laying hold of it, for the scoop is on the outside of the capsule, and cannot procure an entrance. It has happened accordingly, that every endeavour to extract the remaining fragment has been fruitless, and in such cases it was supposed by the operator to adhere to the capsule. It was more probable, however, that the capsule had not been sufficiently opened, and that the scoop could not reach the small fragments. In all cases, however, it is an object of importance, completely to remove the opaque body; for though any remaining portions be ultimately absorbed, yet in the mean time the operation is by no means so complete as it would have been, had nothing been allowed to remain. It has been advised by some, (and the practice has certainly been attended Chap. X.

Of the Extraction of the Capsule.

When, after the crystalline lens is removed, the capsule is found to be opaque, it is absolutely necessary that it be at the same time taken away. Opacities of the capsule are generally situated in its anterior parts, which renders the removal of them much more practicable. The forceps for this purpose (Plate DXVII. fig. 9.) are to be cautiously introduced through the wound of the cornea and pupil, and any opaque portion laid hold of, and cautiously removed. It has been observed that though the capsule did not appear opaque during the operation, yet in consequence of inflammation, which occurs more or less afterwards, the capsule has become opaque. This circumstance has led to a proposal, that in all cases the capsule should be extracted along with the opaque lens. From the natural structure of the eye, and the strong adhesion which exists between the posterior part of the capsule of the lens and the anterior portion of the capsule of the vitreous humour, it would appear impracticable to separate them from each other, so as to extract the capsule entire. Many cases, however, are recorded by different authors, where, in performing the common operation, the lens inclosed in its capsule has made its escape. In these cases, however, it is probable, that the natural adhesion between the capsules of the two humours had been destroyed by some morbid alteration of structure. Such cases have probably been the cause of the proposal to extract in all cases the capsule of the lens. Mr Beer, a celebrated oculist in Vienna, has published a work*, in order to recommend and describe the mode in which such an operation should be performed. After some general observations on the bad consequences which arise from portions of the capsule remaining behind after the lens is removed, he describes his mode of operating in the following words.

"Immediately after dividing the cornea, I dilate the pupil as much as possible, by a gentle pressure on the eyeball with the finger. I then introduce the lancet (Plate DXVII. fig. 4.) through the wound of the cornea, and plunge it into the lens; one surface being turned upwards, and the other downwards, so that none of the lancet is visible. It is particularly to be recommended to the instrument-maker, that this lancet have a pretty thick body, by which means, the moment of introducing it, the lens will be somewhat pressed back, and its weak anterior adhesion will be separated. The lancet must now, when in the middle of the lens, be moved upwards and downwards, in order to divide its connections above and below. Lastly, the instrument must be turned suddenly on its axis, and moved to the inner angle of the eye, and then drawn out in a straight direction. The lens often follows with its capsule, immediately after the lancet is withdrawn, or at least it comes out quite easily, along with its capsules, on a continued pressure of the finger. There is not merely a slight hand, which must be carefully observed in the use of the lancet; experience has taught me many precautions which must not be neglected the moment that the lens comes out, otherwise the capsule may be very easily rubbed off from the lens, either in passing the pupil, or in the wound of the cornea.

"In order to avoid this, the opening of the cornea should be made as large as possible, and it is best to divide two-thirds of it; thereby the operator has the following advantages.

"1. The pupil dilates itself after the division of the cornea by the preluding forward of the lens; and this dilatation may be easily increased by the slightest preluding.

"2. The more the pupil is dilated, the better the operator can observe the management of the lancet; he can move his instrument more freely in different directions in the lens, and consequently separate more quickly and more surely, the lens along with the capsule, from all its connections.

"3. The lens with its capsule passes more easily through the pupil, the wider the opening in the cornea, (which indeed requires in most cases much space), and the further and more easily the pupil dilates, the less danger there is of the capsule being separated on coming out. If the wound of the cornea is small, the capsule will be either separated from the lens in the pupil, or in the wound of the cornea, or passed back again either entirely, or at least partly, into the posterior chamber of the eye."

To those who are accustomed to perform operations on the eye, the method which we have detailed will at once appear to be difficult, extremely dangerous, and in many cases totally impracticable. The causes of failure in the operation for the cataract seldom arise from an opacity of the capsule of the lens, and when this does occur, it is always in consequence of a violent or long-continued inflammation of the eyeball. Whenever, therefore, the inflammation which takes place after the operation is checked by proper remedies, a cataract of the capsule will seldom be met with.

Of the Treatment after the Operation.

After the lens has been extracted, and the eyelids allowed to remain shut for a short time, the eye ought to be examined, in order to ascertain that the edges of the wound of the cornea are in their proper place; that no portion of the iris has passed through it, and the pupil is quite regular. When the incision of the cornea is made in the manner and size already described, the edges of the wound, from their firmness and thickness, accurately apply themselves to each other; and if the iris has sustained no injury, it will remain in its natural situation, and the pupil will become perfectly circular. When the pupil is not regular, it has been generally recommended to expose the eye to a bright light, in order to make it contract, and thus detach it from any part to which it might have adhered. When a portion of the iris protrudes through the wound, this generally arises, not from any injury of that part, but in consequence of the incision of the cornea having been made too large. If the incision be more than semicircular, (or two-thirds of the circumference of the cornea as directed by Mr Beer) this accident will almost constantly happen; and when it does take place, can never, as far as we know, be remedied. In such cases the operator should be careful not even to attempt with the spoon, or any such instrument, to replace the prolapsed iris; for it has always Of the Dif- been observed, that attempts of this kind are fruitless, and never fail to increase the inflammation which succeeds the operation.

In applying the necessary compresses and bandages on the eye, the objects to be held in view are, to keep the eyelids in such a position, that they cannot disturb the wound of the cornea by their motion, and that the eye be not exposed to any light. The upper eyelid will be completely secured, by placing over it, and in the hollow of the orbit, a small stripe of wet caddis. The piece of caddis should not be so large as to press much upon the eye, and from its being wet, it will be readily kept in its situation. Above the caddis should be placed a piece of linen covered with simpleointment, large enough to cover both eyes; and this may be secured by one turn of a bandage round the head. In applying the bandage, care should be taken to place it so that the pins are put in at the forehead and temples. The convenience of this will be afterwards found, the bandage being easily removed without moving the patient's head from the pillow. The patient should now be put cautiously to bed, and his head kept extremely low. The room in which he sleeps should be made so dark, that no light may pass through the bandage to the eye. In an hour or half an hour after the operation, after the patient has become composed, he should be bled in the arm, if from the previous state of the patient's health that should be deemed a proper precaution. Rest, quietness, and abstinence, ought to be rigidly adhered to for the first day after the operation; the patient should be allowed no food except that which is liquid, in order that any motions of the jaw may be avoided, and the food should be given through a tea-pot, in order to prevent any motion of the head. Sixteen or twenty hours are sufficient to produce an adhesion of the cornea in favourable cases; and after this period, the compress of wet caddis placed upon the upper eyelid, becomes no longer necessary; for if it be allowed to remain any longer, it becomes hard and dry, and will be apt to irritate. The bandage and platter ought therefore to be loofened, and the piece of caddis removed. The eyelids will now be found to adhere, and the patient will find much relief by cautiously wetting the cilia with cold water, in order to liberate the eyelids. From this period it is adviseable to keep the eyelashes constantly greasy with any unctuous application.

In all cases, the symptoms which we are particularly to guard against after this operation, are those of inflammation; for when these arise, various effects may be produced which might frustrate all our endeavours to restore the patient's sight. If the wound in the cornea, instead of uniting by adhesion, goes through a tedious process of suppuration, the pupil becomes irregular and contracted; or if there is an effusion of lymph in the pupil, or if an opacity of the capsule takes place, these effects, all of which may arise in consequence of inflammation, might either greatly impair, or entirely destroy vision. The patient, therefore, ought to be carefully watched every six or eight hours for several days, and on the evening of the day of the operation, or at any future period, if symptoms arise which indicate the commencement of inflammation, he ought to be freely bled. The symptoms which are to guide us in adopting such means, are pain and uneasiness darting through the eye or head, and a frequent and full pulse.

We have often remarked, after this operation, that even of the Dif- in those cases where no bleeding is necessary, the pulse of the Eye. becomes unusually full. This symptom alone would not, therefore, be sufficient to warrant us in proceeding far in adopting such a practice. We have long believed, that the success of all surgical operations depends much on the adoption of the means to prevent any inflammatory action. It is well known the danger of amputation, and such operations in a vigorous and healthy condition; it is equally well known the speedy recovery of patients from operations, who have been much debilitated from previous disease; and we have repeatedly remarked that patients who have lost much blood from some accident, after an operation, have recovered much more speedily than those to whom no such accident had happened. Aware of these circumstances, we have invariably adopted rigorously the depletive system after the operation for the cataract; and in many of those patients from whom a very considerable quantity of blood has at different periods been taken, we have observed that the success of the operation has been more speedy and more complete. The surgeon will sometimes find cases where, from the mildness of the symptoms, he is led to hesitate on the propriety of bleeding. In such a situation it is the safest plan to have recourse to it; for in general, wherever no symptoms have arisen which may indicate the impropriety of such a practice, if it be not useful, it is at least never followed by any bad consequences.

Venefection at the arm is the easiest and best mode of extracting the blood; but should any circumstances occur which render the operation at this place impracticable, or should it be thought necessary to take away the blood nearer to the inflamed organ, an opening may be made in the temporal artery. For the first two or three nights after the operation, the patient's arms should be watched, or secured in such a manner, that when he is asleep, he shall not be able to raise his hand towards his eye; for the most gentle stroke upon the eye, even several days after this operation, is attended with most excruciating pain, and is generally succeeded by violent inflammation. The patient should be enjoined to lie on his back, or on the sound side of the head; and after the first twelve hours he may be allowed to raise his head to the usual height. Most authors who have laid down rules to be followed after this operation, have directed that the eye should be kept shut up, and in total darkness for many days after the operation. We have, however, found an opposite practice attended with the most beneficial effects, and we have always considered it as a general principle to be followed, that the eye, from the very day after the operation, be gradually restored to its natural state, that the globe of the eye and eyelids be allowed to move, and that day after day the quantity of light to which it is exposed be gradually increased. In regulating the quantity of light, and the motion of the eye and eyelids, we should be entirely guided by the patient's feelings. Whatever be the quantity of light to which the eye is exposed, or its extent of motion, if it does not create uneasiness or pain, it will never be found to prove injurious; but on the contrary, if such a quantity of light be admitted as to create uneasiness, or if any motion of the eyes or eyelids gives pain, these circumstances will all tend to increase the inflammatory symptoms. It has been already mentioned, that on the first day after the operation, the wet caddis should be removed, and the eyelids separated and covered with some unctuous substance, so that the patient may, from time to time, cautiously move the eyelids, provided it gives him no uneasiness. The pledget of ointment covering the eyes will prevent, during this day, any light from entering.

On the second day the pledget of ointment may be removed, and both eyes covered with two or three folds of old linen, the patient being directed to bathe his eye frequently with a little warm water, so as to remove any glutinous or concreted matter from the eyelids. He should also continue frequently to move the eyelids, and by opening them, to expose the eye to the small quantity of light which passes through the linen. On the following days, the light is to be admitted more and more freely into the room, and by degrees the patient will find that he is able to look down upon the bed clothes, or any large object, without uneasiness. People are often apt, from the joy which they feel in having their sight restored, to make too much use of the eye, and to render it weak and painful. Too much care, however, cannot be taken, to avoid any accident of this kind; and though the patient may feel his eye perfectly easy, and has no other complaint, yet it is always prudent to confine him to his bed for the first fix or eight days. After the second or third day he may raise the head or body safely in bed; but we have repeatedly observed that when patients began to sit up early, and particularly when they approached too near a fire, they have been seized with a peculiar headache and inflammation of the eye, which were attended with much distress, and very difficult to remove. In ten or twelve days after the operation, the patient is commonly able to use the eye with considerable freedom, and to look even at minute objects without pain or uneasiness. It sometimes happens that after this period, a slight irritability of the eye remains, but this in general is speedily removed by the use of the vinous tincture of opium, or sometimes by the application of a weak ointment composed of the red oxide of mercury. The application of the vinous tincture of opium will be found peculiarly useful; and we have known many instances of patients who have undergone this operation, who were frequently, for a long time afterwards, attacked with slight pain or inflammation of the eye, which were always speedily and completely removed by the use of this medicine. It is scarcely necessary to observe that during the whole of the after treatment, the antiphlogistic regimen should be rigidly pursued, and that the patient should avoid every kind of food which from experience he knows to be apt to disagree with him; and that above all he should abstain from the use of wine and spirituous liquors of every description.

Of Couching.

By this operation the lens is depressed from its natural situation behind the pupil, by introducing a needle into the posterior chamber.

The operation may be performed by introducing a needle (Plate DXVII. fig. 23.) through the sclerotic coat, about two lines distant from its junction with the cornea. The point of the needle is to be directed immediately over the opaque lens, and the lens to be depressed a little with the convex surface of the end of the needle. The point is to be pushed in a transverse ease of the direction as far as the inner edge of the lens. Then the operator is to incline the handle of the instrument towards himself, by which means its point will be directed through the capsule into the substance of the opaque lens, and by inclining the needle downward and backward, the former will be lacerated and conveyed with the latter deeply into the vitreous humour. The treatment to be employed after couching is similar to that after extraction.

SECT XI. Of the Fistula Lacrymalis.

When the lacrimal sac is distended with a puriform fluid, or when it has ulcerated, and the tears do not pass freely down the nasal duct, the disease is called fistula lacrymalis. In the first stage of the disease, a distinct tumor is formed in the situation of the sac, which, when compressed, a quantity of puriform fluid flows upon the eyeball through the puncture, or some of it passes through the nose. In the second stage of the disease, the integuments covering the sac ulcerate, and the puriform fluid and tears are constantly oozing through the fulvous opening. The eyelids are affected most commonly in the second stage of the disease, and sometimes also in the first, though not always. From the affection of the internal palpebral membrane, Scarpa has supposed that all the puriform fluid contained in the sac was secreted by it, but this does not always happen.

Treatment.—When the disease has originated in the mucous membrane of the eyelids, applications to it alone will be sufficient to remove the accumulation in the sac. A collyrium of the muriate of mercury, and the daily application of the ointment of Janin, or of an ointment composed of the red oxide of mercury, are well suited for this purpose. When the sac has been the original seat of the disease, a solution of corrosive sublimate, acetate of zinc or of lead, will be useful, and these may be used by allowing them to be absorbed by the puncta into the sac, along with the tears, or by injecting them into the puncta by a proper syringe, (see Plate DXVII. fig. 23.).

If there be a complete obstruction in the nasal duct, these remedies generally fail, and it becomes necessary to open the sac, and remove the cause of obstruction in the duct. The sac may be readily opened by boldly plunging a common lancet into it while distended with matter. The sac should then be examined with a probe, and the probe passed down into the nose in the direction of the natural canal. A surgeon well acquainted with the situation and direction of the duct, can never fail in introducing the probe; for we never met with any case where the obstruction could not be overcome. A style, (Plate DXVII. fig. 24.) such as has been recommended by Mr Ware, is to be introduced in place of the probe, and allowed to remain until the canal is quite open. When the parts around the sac appear healthy, the style may be withdrawn, and the opening of the sac then heals. In many cases the disease returns, and in such, after the parts are a second time healthy, a tube (Plate DXVII. fig. 25.) may be introduced and allowed to remain during life. This operation requires that there be a free external opening, and that the head of the tube be pressed completely down Of the Dif- down below the edge of the skin. Generally the ex- cates of the external opening heals in a few days. When the fac has ulcerated, there will generally be found some sinuses in the integuments covering the fac, all which should be freely laid open, and the style introduced as in the former case. After the skin and fac are apparently healthy, the tube may be introduced as in the former case. Besides the use of the style, it is also requisite to apply the eye-waters and ointments recommended in the first stages of the disease.

Sect. XII. Of the Pterophthalmia.

In this disease there are numerous small brown coloured eminences formed at the roots of the ciliae of both eyelids, and generally both eyes are affected. The adjacent skin has a brownish red tinge, and becomes scurfy; the ciliae drop out, and the patient has a difficulty and uneasiness in opening the eyelids, particularly in candle light. The blood-vefels of the internal palpebral membrane are also turgid, and preternaturally numerous. This disease affects often many branches of the same family.

Treatment.—The unguentum citrinum is a specific remedy in this disease. When there is much inflammation of the eyelids, they ought to be scarified, and the ointment applied immediately after. A collyrium composed of a weak solution of corrosive sublimate is also sometimes useful.

Of the Ophthalmia Tarfi.

In many people who use their eyes much, particularly in candle light, and in those who live freely, the internal membrane of the eyelid often becomes gorged with blood; a thick puriform fluid gushes the ciliae together in the morning, and the patient complains of an inability to move the eyelids, or to look at an object in a bright or dazzling light, without much uneasiness being excited. In other instances the eyelids become affected with serous inflammation, the glands of Meibomius swell and suppurate, the ciliae drop out, and the eyelids lose their natural form.

Treatment.—Scarifying the inflamed vefels, and applying immediately afterwards a quantity of the red precipitate ointment, seldom fails in bringing relief, and in many instances alone the ointment will answer. In some cases the disease in the eyelid is much aggravated, and connected with affections of the stomach and bowels, and in such the greatest attention becomes requisite to keep the belly regular, and even to purge.

Of the Entropion.

When the eyelids are inverted, so that the tarbus with its cilia come in contact with the eyeball, the disease is called entropion. This disease, Mr Crampton has shown, arises in some cases from a thickened and diseased state of the internal palpebral membrane. In others the ciliae are turned in upon the eye from repeated and tedious inflammation altering the form of the tarbus, and in some old people where the integuments are very loose, the whole tarbus is inverted by the action of the orbiculari muscle.

Treatment.—In the first case, Mr Crampton has ingeniously recommended that the tarfi be divided at their junction towards the external canthus, and that the eyelids thus liberated be kept in their proper situation by plasters, compresses, and when in the upper eyelid by fixing the speculum of Pellier, until such time as the cates of the wound has healed. In the second case little can be done but pulling out from their roots any of the ciliae which may have taken a wrong direction, and repeating the operation whenever they grow again. In the third case the disease may be cured by removing an oval portion of the skin the whole length, and close to the tarbus, and uniting the wound by one or two stitches and adhesive plasters. This operation may be also advisable along with that of Mr Crampton, when one is not sufficient to cure the complaint.

Chap. XI.

Of the Diseases of the Ear.

The functions and structure of the internal membrane of the external meatus, and also of the eustachian tube and cavity of the tympanum, prove that it belongs to the mucous system, and that it is not a continuation of the periosteum as many anatomists have supposed. The analogy in the diseases of this organ prove the same. In catarrhal affections of the pituitary membrane of the pharynx, the ear is always more or less affected, and often the function of the organ is much impaired. Polypi also grow from the cavity and membrane of the tympanum of a similar structure to those found in other mucous surfaces. See Polypi. It is also subject to haemorrhages, and when it becomes inflamed, instead of suppuration taking place, there is a discharge of a puriform fluid from the surface, the same as what is observed in inflammation of the urethra, nose, &c.*

* See Inflammations of the Mucous Membranes.

The internal membrane of the ear is also subject to the same kind of thickening and contraction of the canal, as what takes place in the urethra and lacrimal fac, &c., in consequence of long continued inflammation†. This we might conclude from analogy, but the fact has been proved in one instance. Bichat dissected the body of a person who had been exposed during his life to a puriform discharge from the ear, in which he found a very remarkable thickening of the membrane of the tympanum, but no mark of erosion could be detected.

The most common disease of the ear, and almost the only one which the surgeon can relieve, is a collection of wax in the meatus externus. Its presence can always be determined by the inspection of the ear; and it can be removed by directing the patient to drop some warm water into the ear for a few successive nights, and afterwards syringing out the softened wax, an operation which may be performed with a syringe, such as is represented in Plate DXVII.), having fitted for it a pipe of considerable length.

Chap. XII.

Of the Diseases of the Nervous System.

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

A great number of diseases have been considered under the class of nervous; and much obscurity has been thrown on this department of medical science, from from our imperfect knowledge of the laws which regulate this part of the natural system, and from mere symptoms having often been considered as primary affections.

Pathological investigations have been also unsuccessful; and in only a few cases has the knife of the most skilful anatomist been able to detect any morbid alteration of structure in nerves, which, during life, had been the seat of agonizing disease. In a few cases, where tumors have been found growing in their substance, it is not unlikely, that the cellular structure, connecting their fibrils, has been the first part affected. Their arteries and veins are subject to the diseases of these systems in other organs; and we have seen an aneurismal tumor as big as a hazel nut formed in the nutrient artery of the popliteal nerve; and Bichat mentions having seen the veins of the tetic nerve varicose in a paralytic limb. Mr E. Home has described in the Philosophical Transactions a particular tumor of one of the axillary nerves, in which it is difficult to ascertain if the medullary portion be affected; and in the Encyclopédie Methodique there is a description of a case of a disease, resembling in some respects the case of Mr Home's. The disease was in the middle of the radial nerve; and as the hand had neither lost its sensibility nor the movement of any of the fingers, this circumstance led to the supposition, that the medullary portion of the nerve was not affected, but merely its neurilema. In the fungus hermatoide, it is by no means improbable that there is a morbid alteration in the medullary matter of the nerves; though this fact can only be determined by an accurate examination of the disease in various organs.

Most diseases belonging to this system have been fully treated of in the article MEDICINE. There is only one which becomes an object of surgical treatment.

SECT. II. Of the Tic Doleureux (Neuralgie).

Affections of this kind are distinguished by the nature of the pain, which is sharp, gnawing, and, particularly at its commencement, accompanied with torpor, and sometimes with pulsations. It is attended with no heat or redness, or any tension or swelling of the part. It comes on in paroxysms, more or less long, and at different intervals. Sometimes the attack is periodical.

The pain is always fixed in the trunk or branch of a nerve; and, during the paroxysm, it darts from the part first affected through all the ramifications of the nerve.

Many nerves of the body have been found affected with this disease. The first pair of the loins (neuralgie ilio-scrotale), the posterior crural (ichias nervosa politica), the crural, but particularly the nerves of the face are subject to it. When the disease affects the face, it is generally situated either in the frontal nerve, in the infra-orbital nerve, or in the submental nerve. Sometimes the pain affects not only all the branches of these nerves, but it extends to their anastomosing branches, and spreads to one or more of the trunks.

This disease appears to be produced from a variety of causes, according to which its symptoms are varied. Sometimes it has been known to succeed a local irritation, such as an injury on the trunk of the nerve; and in other cases, the affection of the particular nerve is Of Herniae. sympathethic of a disease in some distant organ.

In some instances we have observed this disease arise from an affection of the prime vie; so that in all cases it becomes the first object of the surgeon to trace the cause of the disease.

Treatment.—When the stomach or intestinal canal are disordered, along with the particular affection of the nerve, the nervous affection will often cease when they are restored to their natural state. This is to be accomplished in most cases by emetics, and a course of laxative medicines, purged according to the qualities and quantity of the evacuated matter.

In some cases, particularly in the affection of the frontal nerve, we have found great relief from the repeated application of small blisters over the nervous trunk. In some instances, too, the patients have experienced great relief, and have even completely recovered, by a continued attention to a very spare vegetable diet, or to a milk diet. The celebrated Marmontel was a remarkable instance of this kind.

There are, however, cases where these means fail, and where the disease appears to depend on some fixed cause of irritation in the affected nervous trunk. In such cases, it is the usual practice to divide the trunk of the nerve. This operation generally gives instant relief; but its effects have, we believe, in most cases, been but of short duration. It is a fact completely established, that the ramifications of the nervous as well as of the vascular system, though divided, are gradually regenerated. The numerous anastomoses preserve the life of the part on which the divided trunk was distributed, and the divided edges of the trunk gradually coalesce; so that the nerve is again able to perform its natural functions. This reunion of the nerves does not take place so rapidly as we observe it in the arteries, in the skin, cellular membrane, or muscle; and months elapse before it is completed: but, from this reunion, it is probable, that the morbid action in tic doleureux, of the nature of which we are ignorant, the operation, in most cases at least, brings merely temporary relief.

When the operation is to be performed, the necessary steps are extremely simple. Some have contented themselves with introducing a sharp-pointed bistoury through the integuments towards one side of the exit of the nerve, passing the point underneath it, and then dividing it; thus leaving only a final puncture of the skin.

When, however, the operation is done in this manner, the divided extremities, from being separated only a little way, are apt immediately to reunite; a circumstance which should be prevented. We would therefore advise that a free incision be made immediately above the nerve; that the nerve be completely divided, and either a portion cut altogether away, or the divided extremities separated to a distance, and the wound allowed to heal by suppuration.

CHAP. XIII.

Of Herniae.

The word hernia has been used to signify a protrusion of any viscus, from its proper cavity; but we shall only treat in this place of abdominal hernia. The viscera of this cavity are most frequently protruded at the inguinal and crural rings and the umbilicus. They, however, protrude also at the foramen ovale, at the peritoneum, through the ischiatic notch, and diaphragm.

The names that have been given to different kinds of hernia, have been derived both from the contents of the hernia, and from its situation. If they contain omentum only, they are called omental hernia, or epiplocele; if only intestines, intestinal hernia; if both, omentum and intestines, enterop-epiplocele; if the stomach is contained in the tumor, gastropcele; if the liver, hepatoccele; if the bladder, cystocele; if the uterus, hysteroccele.

The peritoneum generally protrudes prior to any of the viscera, forming a bag called the hernial sac, in which the protruded viscera are afterwards contained. The protruded portion of peritoneum is not dragged from its natural situation, but becomes elongated by gradual diffusion; and it is usually not only lengthened, but more or less thickened.

SECT. I. Of the Inguinal Hernia.

In an inguinal hernia, the protruded viscus enters the abdominal ring, passes along the inguinal canal, and comes out either at the inguinal ring, and goes into the scrotum (scrotal hernia), or bursts through the tendon of the external oblique muscle (inguino-abdominal). Or, it passes through the tendon of the transversalis, and internal oblique, and appears at the inguinal ring (abdomino-inguinal).

Inguinal hernia is more frequent in men than women, the round ligament of the uterus being of a smaller size than the spermatic cord. It sometimes appears on both sides, but most frequently on the right side.

When the skin of the scrotum of an inguinal hernia is removed by dissection, a fascia is found lying underneath it, which varies in thickness according to the bulk and duration of the tumor. This fascia comes off from the tendon of the external oblique muscle above the abdominal ring. Below this fascia is the cremaster muscle, which is united both to the fascia and hernial sac, though easily separable from them by dissection. When the fascia and cremaster muscle are removed, the hernial sac is exposed. The epigastric artery is situated on the pubic side of the sac. The spermatic cord lies generally behind the sac; sometimes to one side, and sometimes on its anterior part. Often the vessels of the cord are split, the epididymis passing along one side of the sac, and the artery, veins, and abortents, on the other. Sometimes there are more than one hernial sac on the same side. Mr Cooper found, in one case, two within the inguinal canal. This arises in some cases from wearing a trus.

In the inguino-abdominal hernia, the sac enters the abdominal ring; and, instead of being continued along the inguinal canal, it passes through the tendon of the external oblique muscle. The hernial sac, in this case, is composed of two distinct layers; the one internal and peritoneal, the other external, and produced by an elongation and gradual thickening of the aponeurosis of Petit.

In the abdomino-inguinal hernia, the sac passes through the tendon of the transversalis or the tendons of both the transversalis and oblique muscle, enters the inguinal canal, appears at the inguinal ring, and then passes down into the scrotum. In this case, Mr Cooper observes, that the spermatic cord lies on the upper or outer part of the sac. The epigastric artery lies on the outside of the lac †.

The inguinal hernia is generally pyriform, small towards the ring, and enlarging as it descends. It may be distinguished from other swellings of these parts, by the following symptoms: 1. When the patient is desired to cough, the tumor becomes immediately distended, owing to the pressure of the abdominal muscles forcing into the sac more of the viscera or of their contents. 2. When the patient can remember that the tumor used to disappear when in the horizontal position. 3. When the progress of the tumor has been from the groin to the scrotum. 4. When the tumor contains intestine, it is elastic and uniform; and, when pulled up into the abdomen, it returns with a gurgling noise. When omentum is contained, the tumor is less equal on its surface, receives an impression with the fingers, and does not return with a gurgling noise. Most commonly, however, both intestine and omentum are contained in the sac. 5. The functions of the viscera are somewhat interrupted, producing eructations, sickness, constipation, colicky pains, and diffusion of the abdomen.

The inguinal herniae ought to be carefully distinguished from hydrocele of the vaginal coat, from incysted hydrocele of the spermatic cord, from enlargements of the testicle, from haematocele, and from varicocele. Hydrocele and hernia, too, are often combined, particularly omental hernia.

SECT. II. Of Reducible Inguinal Hernia, and of Trusses.

Herniae are either reducible, irreducible, or strangulated. In the reducible state, the parts may be returned into the cavity of the abdomen. To prevent the escape of the bowels, and the danger of such an accident, a constant preasure should be applied at the part where the hernia opens into the abdomen, to shut the mouth of the sac, and thus oppose an effectual resistance to the protrusion of its contents. To accomplish these purposes, various trusses have been contrived. The trus should be made of steel, and the spring not stronger than what is sufficient to keep up the bowels; for, if the pressure be great, the abdominal muscles, where it is applied, are weakened, and even absorbed. Mr Cooper advises the pad to be made of a conical form, the apex of which should rest on the mouth of the sac. But, as there will be found much variety in the situation and size of the opening through which the hernia passes, it will often be necessary to vary the form and bulk of the pad. The trus ought to be applied so that it makes preasure not on the inguinal ring where the hernia comes out, but upon that part where the spermatic cord, and with it the hernia, first quit the abdomen; and this point may always be determined, by making the patient cough after the hernia has been reduced, and ascertaining the furthest part from the inguinal ring, where the hernial sac is found to protrude. On this point the pad should rest. If the pad be too large, and presses merely on the inguinal ring, it will allow the bowels to pass through the internal or abdominal ring, and enter into the inguinal canal. On the other hand, the pad should Chap. XIII. SURGERY.

Of Inguinal not be too small, so as to press into the mouth of the Hernia. sac and plug it up, for that would prevent all chance of a permanent cure; the bowels may be prevented from entering into the sac; but the pad will act as a dilator or bougie, keep the mouth of the sac constantly open, and even increase its diameter. The pad, therefore, ought always to be made of such a size and shape, as to make a pressure on the abdominal ring, inguinal canal, and inguinal ring.

SECT. III. Of Irreducible Hernia.

Herniae become irreducible when the protruded parts are suffered to remain long in the hernial sac and increase much in bulk, when membranous bands form across the sac and entangle its contents, or when an adhesion takes place between the sac and its contents, or amongst the contents themselves.

Treatment.—In such cases, a bag trusks ought to be worn, so as to keep up a uniform and steady pressure on the scrotum. The application of ice, too, has been known to procure the return of a hernia which appeared irreducible.

SECT. IV. Of Strangulated Hernia.

A hernia is said to be strangulated when not only the intestine and omentum are irreducible, but when the protruded bowels are inflamed, and when the passage of the feces through the strangulated portion is completely interrupted.

The tumor is attended with considerable pain, which sometimes extends through the abdomen, and is often situated at the umbilicus. Hiccup and vomiting succeed; at first the contents of the stomach only are evacuated, but afterwards those of the lower portions of the alimentary canal. The bowels are completely obstructed, except that portion below the seat of strangulation. The pulse is commonly quick and hard; sometimes, however, it is full. If the disease continues, the skin covering the tumor becomes discoloured and slightly oedematous, and the abdomen tender and tense; the pulse becomes small and thready, the countenance has an expression of anxiety; and all these symptoms are subject to exacerbations. They are greatly mitigated for a while, but soon recur with increased violence.

After having suffered great pain during the first stage of the disease, the patient becomes suddenly easy, and the tumor becomes of a purple colour, and has a crackling feel. The abdomen becomes more tense, a cold sweat covers the body, and the pulse is weak and intermittent. At last the patient, deluded with the hopes of a recovery, sinks under the complaint.

On dissection, the hernial sac is generally found to contain a quantity of dark bloody serum. The intestine is of a dark chocolate brown, with black spots interspersed over it, which are easily torn on being touched with the finger. The surface is covered with a layer of coagulated lymph. Even when the intestine is not mortified the colour is extremely dark, but then the black spots do not appear. Within the abdomen the whole intestinal canal sometimes appears quite natural; at other times portions of the intestines appear inflamed, and in some rare cases they are glued together by an effusion of lymph.

VOL. XX. Part I.

On examining the seat of stricture, it will be found to take place either at the abdominal or inguinal ring. In large herniae, Mr Cooper has remarked that the stricture is most frequent at the external opening, and then it may be often seen from the particular shape of the tumor, a constriction being distinguishable at that part. In other cases the stricture is seen at the entrance of the spermatic vessels into the inguinal canal; so that, in operating for hernia, it is not sufficient to dilate the external ring, but it becomes necessary to dilate the upper part of the canal.

Treatment.—In the treatment of strangulated hernia, the leading object which is to be kept in view, is to return the displaced viscera as speedily as possible, and, at the same time, while doing this, to diminish the symptoms of inflammation or prevent their accession. The first thing to be attempted, except when the tumor is much inflamed and painful, is the reduction of the hernia. In doing this, it is necessary to attend to the position of the patient and the mode of applying the pressure. The body of the patient should be placed on an inclined plane, with the head downwards, and the thighs bent towards the trunk of the body. The pressure which is employed on the tumor should always be directed upwards and outwards along the course of the spermatic cord, and it may be persevered in from a quarter to half an hour. Besides these mechanical means, tobacco cysters, and cold, have been useful in accomplishing the reduction. Ice is the easiest and best mode of applying cold to hernial tumors; but, when this cannot be procured, Mr Cooper uses a mixture of equal parts of sal ammoniac and nitre. To one pint of water in a bladder, ten ounces of the mixed salts are added, the bladder tied up, and then laid over the tumor. If, after four hours, the symptoms become mitigated, and the tumor lessens, this remedy may be persevered in for some time longer; but if they continue with equal violence, and the tumor resists every attempt to reduction, no further trial should be made of the application.

The operation which it is now necessary to perform, consists in making an incision through the integuments along the upper part of the tumor, making an opening into the hernial sac, and extending it, so as to allow the contents to be examined, and the fore finger to reach the seat of stricture. The stricture will be readily detected by the point of the finger, and may be easily divided by introducing the bitoury along the finger, till the point of it passes below the stricture.* A very slight prelude of the edge of the instrument will be sufficient to divide the stricture, and allow the bowels to be returned into the abdomen. If merely the stricture is divided, and it is never necessary to extend the incision further, it is of little importance in which direction the incision is made; though surgeons have been at great pains to point out the dangers which might arise were it of too great an extent.

SECT. V. Of Femoral Hernia.

In femoral hernia, the hernial sac lies beneath the crural arch, being pushed through an opening between the edge of the broad insertion of Poupart's ligament, and the pubic side of the femoral vein.† As the tumor enlarges, instead of falling downwards like the inguinal hernia, Of Femoral hernia, it passes forwards, and often turns over the anterior edge of the crural arch. As it proceeds, the swelling increases more laterally than upwards or downwards; so that it assumes an oblong shape. In the crural hernia, the fasc has two coverings besides the integuments; the superficial fascia of the external oblique muscle, and the fascia propria of Mr Cooper, which is formed by the protrusion of the fascia which naturally covers the opening through which the hernia passes, and the fascia of the crural sheath. The taxis and use of trusses are the same in femoral as in inguinal hernia; and the same series of symptoms indicate the necessity of an operation in both when strangulated.

Operation.—Mr Cooper recommends that the incision of the integuments be made in the form of a T, beginning one incision about an inch and a half above the crural arch, in a line with the middle of the tumor, and extending it downwards below the arch, and meeting a second incision nearly at right angles with the other, the whole length of the tumor. The two fascias are next to be divided, and the hernial fasc opened at its lower part, sufficiently large to admit readily the finger. The seat of the stricture is to be ascertained by the introduction of the point of the fore finger under the crural arch, and it may be readily divided in a direction upwards and inwards, of a sufficient extent to liberate the intestines; generally a very slight motion of the edge of the bistoury will be found sufficient for that purpose.

CHAP. XIV.

Of Hare-lip.

The hare-lip is a fissure in the upper lip, very seldom in the under one.* It is attended with want of substance, and has its name from a resemblance to the lip of a hare. In general it is only a simple fissure, though sometimes it is double.

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

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

CHAP. XV.

Of Amputation.

There are two modes generally employed for performing amputation; the common operation by two circular incisions, and the flap operation. We shall describe in detail both these modes of operating in the thigh.

The patient should be placed on a table of a convenient height, in such a manner that the diseased limb may hang over the edge of it, and be secured by an assistant seated on a low chair before him; the other limb and the arms are also to be secured by proper assistants. The tourniquet (see Plate DXVI.) is to be placed on the thigh, three or four inches below Poupart's ligament, where the femoral artery may be most easily and completely compressed. Default preferred to the tourniquet, the finger of a strong and intelligent assistant. A cushion fixed on a handle answers very well for making pressure on the artery when a tourniquet is not to be used; and it is a useful instrument to have in readiness, in case the tourniquet should go wrong; or when it becomes necessary to amputate the thigh so far up, that a tourniquet cannot be safely fixed.

After the operator has determined on the place for the incision of the integuments, an assistant should grasp the limb with both hands a little above the place where the skin is to be divided, and draw it upwards as far as possible. The operator then with the knife (see Plate DXXII. fig. 10.) makes a circular incision through the skin and cellular membrane, down to the muscles; and this may be done, either by one stroke of the knife, or by first making one semicircular incision round the under part of the limb, and afterwards another incision upon the upper part corresponding with the former. When this is made, the integuments retract considerably from their natural elasticity, and they are to be separated from the muscles and dissected with the point of the knife, as far back as to leave a sufficient quantity of skin to cover the stump. The skin being turned back, the operator, operator, by a second incision carried close to its inverted edge, cuts the muscles perpendicularly down to the bone. During this part of the operation, care should be taken to avoid wounding the edge of the skin, by tracing attentively the edge of the knife during the whole course of the incision. After the muscles are divided, a considerable retraction takes place, and any muscular fibres attached to the periosteum should be separated from it by the point of the knife, in order to allow the bone to be fawn through as high as possible, and thus secure to it a firm fleely covering. All the soft parts are next to be drawn upwards as far as their separation from the bone will admit of. They are to be kept in this situation by an instrument called the retractors, until the bone is fawn through. The retractors may be either made of iron plates (see Plate DXXII. fig. 5.), or a piece of linen or leather cut as represented in fig. 6. The assistant who uses either of these instruments, should take care when he applies them, that the soft parts are completely out of the reach of the saw, and that they are held back as far as the place where the bone is to be divided. Any sharp edges which may be left on the end of the bone after it has been fawn through, should be taken away with pliers, Plate DXXII. fig. 8. The arteries are next to be tied, and both the femoral artery and vein may be included in one ligature. The bleeding being stopped, and the wound cleaned, the tourniquet is to be altogether taken away, and the soft parts drawn down, so as to cover the extremity of the bone. In order to keep them in this situation, a bandage of thin flannel or cotton cloth, not exceeding two inches and a half in breadth for an adult, is to make one or two circular turns round the body above the ilium; it is then to be carried obliquely over the groin, and turned round the upper part of the thigh pretty firmly two or three times, forming as it were at this place a point of support to the muscles and skin. It is afterwards to be passed in a spiral manner downwards to near the edge of the wound, taking care to pull the soft parts towards the stump, whilst applying each turn of the bandage. The turns should not be so tight as to cause pain, but sufficient to keep the parts in the situation in which they are placed. The surface of the muscles and the edges of the skin are now to be accurately brought together in such a direction, that the wound forms a straight line, extending from the anterior to the posterior aspect of the limb. Strips of adhesive plaster, about half an inch in breadth, and eight or ten inches in length, should be applied, in order to keep the lips of the wound in this position. Those over the middle part of the wound ought to be put on first; and great attention is necessary in their application, to prevent the edges of the skin from overlapping and puckering. They should be of such a number as completely to cover the surface of the wound, leaving only a small opening for the ligatures of the arteries to be brought out at that part of the wound nearest the place where the artery is situated. The wound is to be afterwards covered with a piece of linen or calico spread with simple ointment, and a compress of fine tow laid over it, the whole being secured by a few turns of the roller.

The bedclothes should be kept from pressing upon, and coming in contact with the stump, by a frame or cradle, as it is called. (See Plate DXXIII. fig. 11.).

When this operation is to be performed, the incision Lithotomy, of the integuments may be made, either with a common scalpel, or with the end of the amputating knife, as represented in Plate DXXII. fig. 10. After the skin is divided, it is of importance to allow it to retract as much as possible, by cutting the fibres of cellular membrane which connect it with the fascia of the thigh, before dividing the muscles. If the limb be much emaciated, the division of the muscles may be also made with the scalpel; if, on the contrary, the limb be bulky, the incision ought to be made by a common amputating knife, in order that the surface of the flaps be plain and uniform. After dividing the muscles obliquely upwards down to the bone, they should be separated from it a sufficient way, to as to leave enough to cover the end of the bone, and they should be allowed to contract as much as possible before the bone is fawn through. After the limb is amputated, and the circular bandage applied, the flaps will be found to meet very accurately together, and to form a round and smooth stump. From the angles of the skin being removed, no puckering or corners are left, and the two surfaces and muscles being applied to each other, and covering the end of the bone, give it a firm and fleely covering, whereas in amputations performed in the common mode, the bone is covered by integuments alone. The adhesive plasters are to be applied in the same manner, and the patient is to be treated afterwards as in the other modes of operating.

The general rules to be attended to in amputation in other parts of the body, are the same as those already mentioned; and in Plate DXXII. and DXXIII. we have delineated the place and direction of the incisions.

CHAP. XVI.

OF LITHOTOMY.

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

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

The operator is now to introduce a grooved staff (Plate DXXI. fig. 5.) of proportionable size, and open to the end, through the urethra into the bladder; and having fully satisfied himself of the existence of a stone, he inclines the staff, if he be right-handed, obliquely over the right groin, so that the convex part of the staff may be felt in the perineum on the left side of the raphe. He then fixes it, and delivers it to his assistant, who is to hold it with his right hand, desiring him to press it gently, in order to make the fulcus of the staff project in the direction in which he received it. With his left hand the same assistant is to raise and support the scrotum.

The thighs of the patient being sufficiently separated by the afflantants, and the surgeon being seated upon a chair of a proper height, and in a convenient light, he makes an incision with a common convex-edged scalpel through the skin and cellular substance, below the symphysis of the osa pubis, which is a little below the scrotum, and on the left side of the raphe, and continues it in a slanting direction downwards and outwards to the space between the anus and tuberosity of the ischium, ending somewhat lower than the basis of that process, by which a cut will be made of three or four inches in length. This incision ought not to be shorter than is here directed, otherwise there will not be room for the rest of the operation. As soon as the integuments are divided, he ought to introduce two of the fingers of the left hand. With one he keeps back the lip of the wound next the raphe, and with the other he presses down the rectum. He ought likewise particularly to guard against cutting the crura of the penis, which he can readily feel, and separate at their under part with one of his fingers. He next makes a second incision almost in the same direction with the first, but rather nearer to the raphe and anus, by which he preserves the trunk of the arteria pudica. By this incision he divides the transversalis penis, and as much of the levator ani and cellular substance within these as will make the prostate gland perceptible to the finger. If any considerable vessel be cut, it is immediately to be secured, though this is seldom necessary. He is now to search for the groove of the staff with the fore finger of his left hand, the point of which he presses along from the bulb of the urethra to the prostate gland, which surrounds the neck of the bladder. He keeps it there; and turning the edge of the knife upwards, he cuts upon the groove of the staff, and freely divides the membranous part of the urethra, till the staff can be felt perfectly Lithotomy, bare, and that there is room to admit the nail of the finger; and as the finger assists in keeping the parts stretched, and effectually prevents the rectum from being hurt, the incision into the urethra may be made with perfect ease and safety.

The next part of the operation, viz. dividing the prostate gland and neck of the bladder, might, by a dexterous operator, be safely performed with a common scalpel, with the edge turned the opposite way. But to guard against accidents, a more convenient instrument, called the cutting gorget, is now in general use. It was originally invented by Mr. Hawkins of London, and since his time has undergone various alterations.* The membranous part of the urethra being now divided, and the fore finger still retained in its place, the point of the gorget, previously fitted to the groove, is to be directed along the nail of the finger, which will serve to conduct it into the groove of the staff; and as this is one of the nicest parts of the operation, the most particular attention is required that the point of the gorget be distinctly felt to rub in the bare groove.

The operator now rises from his seat, takes the staff from the assistant, raises it to near a right angle, and presses the concave part against the symphysis of the osa pubis; satisfies himself again that the point or beak is in the groove, and then pushes on the gorget, following the direction of the groove till the beak slip from the point of the staff into the bladder. The gorget is not to be pushed farther than this, otherwise it may wound the opposite side of the bladder, &c.

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

* See Plate DXXL Fig. 2. † Plate DXXI. Fig. 6. &c. Chap. XVI. SURGERY.

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

EXPLANATION OF THE PLATES.

Plate DXIII.

Fig. 1. and 2. Common scalpels. Fig. 3. A blunted-edged silver knife for dissecting close to important parts. Fig. 4. and 5. A sharp and blunt-pointed bistoury. Fig. 6. Richter's hernia knife. Fig. 7. Dissecting forceps. Fig. 8. A blunt hook. Fig. 9. and 12. Directories. Fig. 10. and 11. Dissecting hooks. Fig. 13. Lancet. Fig. 14. 15. and 16. Seton needles. Fig. 17. and 18. Sharp and blunt-pointed needles. Fig. 19. Outline of a fleatomatous tumor, the dotted line pointing out the direction in which the incision of the integuments ought to be made for its extirpation.

Plate DXIV.

Fig. 1. 2. and 3. shew the different forms of the points of bougies. Fig. 4. 5. and 6. are different sizes of silver balls used by Mr C. Bell for introducing into the urethra in order to determine the form and length of strictures. Fig. 7. An outline taken from a cast of the urethra, to shew the difference of the diameter at different parts of that canal. Fig. 8. and 9. shew the form of strictures in the urethra. Fig. 10. shews a fracture in the oesophagus. Fig. 12. and 13. Male and female syringes. Fig. 14. Scarificator for the throat. Fig. 15. is the apparatus for injecting hydrocele.

Plate DXV.

Fig. 1. and 2. Forceps for removing polypi described in Chap. III. Sect. V. Fig. 3. 5. and 6. Instruments for removing polypi by ligature. Fig. 7. Outline of one large and two small polypi in the rectum. Fig. 8. A breast-glas. Fig. 9. Cheelden's needle. Fig. 10. A speculum oris. Fig. 11. Mudge's inhaler.

Plate DXVI.

Fig. 1. Drawing of a femoral aneurism given by Mr Freer. a is the direction and extent of the incision as made by Mr Abernethy. The artery, however, may be more easily tied by making an incision parallel to Poupart's ligament (b). c is the place and direction where the incision ought to be made in the high operation for popliteal aneurism. Fig. 2. is the instrument used for compressing the artery or aneurismal tumor. Fig. 3. The common tourniquet.

Plate DXVII.

Fig. 1. 2. and 3. Different forms of extracting knives. Fig. 4. Beer's lancet for extracting the capsule of the lens. Fig. 5. Instruments for scarifying the eyelids. Fig. 6. A thin scalpel for paring the cornea. Fig. 7. Instrument for holding down the under eyelid. Fig. 8. Pelier's speculum. Fig. 9. Capsule forceps of Wenzel. Fig. 10. Eye scissors. Fig. 11. 12. 13. 14. and 15. have been referred in No 224. Fig. 16. represents the wound of the cornea where the knife has been entered too near the inner edge of the pupil; Fig. 17. where it has been brought out at too great a distance from the sclerotic coat; Fig. 18. where it has been brought out too close to the sclerotic coat. Fig. 19. A curette and Daniel's spoon. Fig. 20. Scarpa's needle: Fig. 21. shews its point magnified. Fig. 22. Common spear-pointed couching needle. Fig. 23. Fistula lachrymalis syringe. Fig. 24. The style for introducing into the lachrymal duct. Fig. 25. Tube for introducing into the lachrymal duct; and fig. 26. Instrument for introducing the tube.

Plate DXVIII.

Shews the external appearance of herniae. Fig. 1. is a femoral hernia, the tumor being unequal and divided into two portions at a; the iliac portion is formed of favelled glands, and the pubic contains the intestine. Fig. 2. is a specimen of inguinal hernia, and fig. 3. of inguino-abdominal.

Plate DXIX.

Fig. 1. Common inguinal hernia, copied from Mr Cooper's plate. a, The abdominal ring. b, Poupart's ligament. c, The femoral artery. d, The epigastric artery. e, Hernial fac below the ring. f, Hernial fac above the ring. g, Sharp part of the knife introduced between the ring and the fac, with its side placed towards the fac. Its edge should be turned forwards to divide the stricture. Fig. 2. The hernia on the inner side of the epigastric artery. a, The abdominal ring. b, Poupart's ligament. c, The femoral artery. d, The epigastric artery. e, Internal oblique and transverse muscles passing over the fac. f, Tendon of the transverse muscle passing under it. g, Falcia from Poupart's ligament, from which the cord has been withdrawn to shew the place through which it passes. h, i, The hernial fac. k, Knife introduced to shew the manner of dilating the stricture, which Mr Cooper directs always to be done forwards and upwards, opposite to the middle of the mouth of the hernial fac, in all the varieties of inguinal hernia. Fig. 3. Form of the hernial truis; and fig. 4. Mode in which it should be applied.

Plate DXX.

Fig. 1. Crural hernial fac removed to shew the hole by which it defended in the female. a, Seat of the pubes. b, Crural arch extending towards the ilium. c, Abdominal muscles. d, Crural arch. e, Falcia IIO Surgery.

Explanation of the Plates.

lata. f, Semilunar edge of the fascia lata. g, Third insertion of the external oblique. h, Crural artery. i, Crural vein. k, Crural sheath. l, Abdominal ring. m, The orifice by which the crura hernia descends formed on the outer side by the crural sheath; on the inner by the semicircular insertion of the tendon of the external oblique; and above, in part, by the crural, and in part by the semilunar edge of the fascia lata. Fig. 2. A small crural hernia in the female; shewing its passage through the crural sheath, and its distance from the crural arch. a, Seat of the symphysis pubis. b, Spinous process of the ilium. c, Crural arch. d, Abdominal ring. e, Fascia lata. f, Semilunar edge of the fascia lata. g, Portion of the crural sheath. h, Saphena major vein passing into the crural sheath. i, Hernial sac inclosed in its fascia, which is extremely dense, and is proportionably so as the hernia is small. k, The hole in the crural sheath through which the hernia passes. Fig. 3. A small crural hernia dissected. a, Seat of the symphysis pubis. b, Seat of the spinous process of the ilium. c, Tendon of the external oblique muscle. d, Internal oblique and transversalis. e, Fascia of the transversalis. f, Tendon of the transversalis. g, Inner portion of the fascia transversalis, passing to unite itself with the tendon. h, The crural arch. i, Round ligament. k, The round ligament passing into the abdomen. l, Crural artery. m, Crural vein. n, Origin of the epigastric artery. o, Course of the epigastric artery behind the round ligament. p, Crural nerve. q, Superficial fascia. r, Fascia propria of Mr Cooper, the hernial sac having been drawn into the abdomen to shew this fascia distinctly. Fig. 4. shews the form and mode of applying the trus in femoral hernia.

Plate DXXI.

Fig. 1. An umbilical hernia trus. (a), The pad. (b), The spring added to the pad. (c), An elastic band to assist the prehension of the pad; the lower (b) points to the belt which is added to keep this trus in its place in corpulent people. Fig. 2, 3, 4. Different forms of the gorget, as used by Hawkins, Cline, and Cooper. Fig. 5. The staff. Fig. 6. and 7. Different forms of the forceps for the extraction of stones from the bladder.

Plate DXXII.

Fig. 1. A lateral view of the thigh and leg; the dotted lines shewing the direction of the incision in amputation. Fig. 2. An anterior view. Fig. 3. Form of the stump; and, Fig. 4. Mode of applying the circular bandage. Fig. 5, 6, and 7. Retractors. Fig. 8. Pliers for removing any spicule of bone. Fig. 9. Head of a trephine, two-thirds of the cutting teeth being removed. This instrument is intended for removing the ends of bones, particularly those of the metatarus and metacarpus. Fig. 10. and 11. Amputating knives. Fig. 12. Amputating saw.

Plate DXXIII.

Fig. 1. Lateral view of the arm and hand, the dotted lines shewing the direction of the incision, in amputation at the shoulder joint and last joint of the forefinger. Fig. 2. and 3. Saws used in amputations of the hands and feet. Fig. 4, 5, 6, 7, 8. and 9. shew the different parts of an artificial leg. Fig. 11. Cradle used after amputation in order to prevent the bedclothes pressing upon the limb.

Plate DXXIV.

Fig. 1. shews the hare-lip with a fissure of the palate. Fig. 2. The simple hare-lip. Fig. 3. A double hare-lip with two irregular teeth. Fig. 4. shews the part of the lip into which the pins ought to be introduced. Fig. 5. shews the mode in which the ligatures ought to be applied. Fig. 6. The lip after the operation. Fig. 7. and 8. Pins for the lip. Fig. 9. Lip forceps. Fig. 10. Lip forceps, with one blade broader than the other, which is covered with wood in order to make resistance, and not injure the edge of the knife. Fig. 11. Strong scissors for dividing the lip. Fig. 12. Scissors with curved blades to be used when the lip is very thick, and not easily grasped by the common scissors. Fig. 13. Shews the appearance of the club-foot. Fig. 14. Machine invented by Scarpa for the cure of club-feet. Fig. 15. Distorted foot from a relaxed state of the ligaments, a deformity which may, in general, be removed by wearing a boot, fig. 16. to which is fixed a steel-rod, extending from the sole of the foot to the knee.

INDEX.

A. ABSCESSES treated by Celsus, page 26 nature of, 32 opening of, 33 by caustic, 34 by incision, ib. by the leton, 35 Abscessus in medulla, nature of, 76 Aesculapius, a Greek surgeon, 25 Aetius writes on surgery, 27 Albucasis, an Arabian Surgeon, ib. his horrid operations, 106 Amputation,

Angina, symptoms of, treatment of, 55 Aneurism, varieties of, encysted, 78-80 false or diffused, 78 varicose, 79 diagnosis of, 79 prognosis of, 79 treatment of, 79 Anthrax, see Carbuncle. Anthrum maxillare, polypus of, 67 Aphtha, symptoms of, 68 treatment of, 68

page 55 Archagathus, a Greek, practises surgery in Rome, page 26 ib. is banished from the city. ib. Arrangement of surgical diseases, 29 ib. objected to, ib. of Richat, ib. Arsenic employed in cancer by Celsus, 27 ib. Arterial lytlem, diseases of, 77-80 ib. Asplepiades practises medicine in Rome, 26 Afeites, symptoms of, 70 operation for, ib. Atheroma, a kind of tumor, 39 ib. Avicenna revives medicine in the east, 27 Avicenna, Index.

Avicenna, his system of surgery, page 27 Axillary aneurism, 80

B. Barbers practise surgery in Britain, 28 in Holland and Germany, ib. Beer, his method of extracting the cataract, 99 Bell, Benjamin, his system of surgery the completest, 29 Bichat's arrangement of surgical diseases according to textures, ib. Bladder, polypi of, 67 hemorrhage from, 69 nature and treatment of, ib. Boil, nature and treatment of, 45 Bougie, nature and method of using, 60, 61 Brownfield, an English surgeon, 29 Bones, diseases of, 75-77

C. Cancer of the skin, 46 symptoms of, ib. treatment of, ib. Capsular ligaments, collection of fluid in, 74 treatment of, ib. Capsules, sinovial, moveable bodies in, how removed, 75 Carotid aneurism, 79 Carbuncle, nature of, 38 treatment of, ib. Carpus, a writer of 16th century, 28 Cataract, nature of, four species of, 91 confluence of, 92 colour of, 92 diagnosis of, 92 a local disease, sometimes hereditary, of the capsule, trembling, combined with amaurosis, progress of, symptoms of, observed by the patient, treatment of, 94 extracition of, 94-101 treatment of; after extraction, 99 couching, method of performing, 101 Cataracts couched by Celsus, 27 Catarrh of bladder, nature of, and treatment, 55 Caustic applied in opening abscesses, 34 in stricture of urethra, 61 bad effects of, 62 use of, in stricture compared with bougie, ib. method of applying, ib. Cellular membrane, diseases of, enumerated, 31 Celsus, his work on surgery recommended, 26

S U R G E R Y.

Chilblains, nature of, page 45 how treated, 46 Conjunctiva, polypi of, 67 inflammation of, 87 Cornea, diseases of, 89, 90 ulcers of, treatment of, ib. specks of, mode of treating, 90 ib. Corns, nature of, 47 treatment of, 48 Coryza, symptoms of, 53 treatment of, 54 Couching of the cataract, 101 Croup, nature and treatment of, 55 Cupping glasses employed by Celsus, dry, 33 Cyflocele, 104 Cysts, nature of, 39 D. Deafness on wounds of the head, 29 Driftion of surgical diseases, 30 E. Ear, inflammation of mucous membrane of. See Otitis. polypi of, 67 diseases of, 102 Else writes on hydrocele, 29 Empty fema, nature and symptoms of, 43 Encysted tumors, treatment of, 40 by the feton, ib. by an operation, 41 Entropion, nature and treatment of, 102 Epiplocele, or omental hernia, 104 Eryphelias, nature and symptoms of, 44 treatment of, 45 Eyes, diseases of, treated by Celsus, 26 of, 87-102 Exostosis, nature of, 75 F. Fabricius ab Aquapendente, a writer on surgery of 16th century, 28. Femoral aneurism, 79. Fistula lacrimalis, nature and treatment of, 101, 102 Fistulae, nature of, 36 causes of, treatment of, by injection, ib. by compression, ib. by incision, ib. Fluxus hemorrhoidalis, nature and treatment of, 69 Fomentation, method of applying, 32 French writers on surgery, 29 Frontal sinus, polypus of, 67 Furunculus, nature and treatment of, 45 G. Ganglions, nature and treatment of, 74 Grafcelle, 104 German writers on surgery, 29 Glandular system, diseases of, 80-89 Gleet, a form of gonorrhoea, 50 nature and cure of, 53. Gonorrhoea, nature and symptoms of, 49, 50 virus, of, 51 treatment of, ib. in women, 52 treatment of, ib. injections for, how used, ib. Greek surgeons, 25, 26 Giuns, polypi, nature and treatment of, 67 Gummy, a disease of the bones, 75

H. Haemorrhage from mucous membranes, 68, 69 Haemorrhoidal tumors, nature and treatment of, 80 Haematuria, symptoms and treatment of, 69 Hare-lip, 106 Homotocelle, nature and treatment of, 73 Hernia, described by Celsus, 27 Herniae, different kinds of, 103, 105 Hepatocele, 104 Hill writes on cancer, 29 Hippocrates, a Greek physician, 25 method of treating surgical cases, 26 Hydrocele, nature and symptoms of, 71 treatment of, ib. palliative operation for, 72 radical operation for, ib. cured by injection, ib. different solutions for, ib. cured by incision, ib. mode of treatment by incision preferred, 73 Hunter, William and John, eminent surgeons, 29 Hydrothorax, symptoms and treatment of, 73 Hydrocele, 104

I. Inguinal hernia, nature and symptoms of, 104 reducible, ib. irreducible, ib. strangulated, ib. Iris, inflammation of, 91 treatment of, ib.

L. Lens, crystalline, method of extracting, 101 capsule of, method of opening, 97 Lithotomy, operation for, by Celsus, 27 performed by females among the Arabians, 28 modern operation for, 106

M. Mamma, diseases of, page 84-86 inflammation and abscess of, 85 schirrus and cancer of, ib. treatment of, ib. method of extirpating, ib. anomalous swellings of, 86 Maturation Maturation of a tumor, page 33 Meliceris, a kind of tumor, 39 Monro lectures on surgery, 28 his treatise on osteology recommended, Mucous membranes, diseases of, 48 pathology of, 48 extent of, 48 inflammation of, 49 haemorrhage from, 68 ulceration of, 69

N. Nevi materni, description of, 48 how removed, ib. Nervous system, diseases of, 102, 103 Nipples, fore, nature and treatment of, 86 Nodes, venereal, 75 how treated, ib. Nose, inflammation of mucous membrane of. See Coryza. polypi of, 64 treatment of, 65 removed by an operation, ib. with forceps, ib. by ligature, 66 haemorrhage of, 69 ulcers of, 70 how treated, ib.

O. Oedema, symptoms of, 48 treatment of, ib. Oesophagus, strictures in, 63 how treated, ib. Ophthalmia, purulent, symptoms of, 87 treatment of, 88 in children, nature and treatment of, ib. gonorrhoeal, ib. putulosa, symptoms and treatment of, 89 tarifi, nature and treatment of, 102 Otitis, symptoms of, 54 treatment of, ib. Oxana, symptoms, and treatment of, 70

P. Palpy in lower extremities, 77 Pancreatic sarcoma, 42 Paracentesis, operation of, 70 Parey, a French surgeon, 28 Paronychia. See Whitloe. Paulus Egineta treats of surgery, 27 best surgical writer among the ancients, ib. Pericardium, dropy of, 73 Peritoneum, dropy of, 70 Phlegmon, symptoms of, 31 resolution of, 32 terminates in abscess, ib. treatment of, ib.

Pott, an English surgeon, page 28 greatly improves the art, ib. Polypi, different kinds of, 64—67 Popliteal aneurism, 79 Pfrophthalmia, symptoms and treatment of, 102 Pterygium, nature and treatment of, 88 Pus, nature of, 39 Pupil, artificial, method of making, for the eye, 91 Mr Gibbon's method, ib.

R. Rectum, strictures in, 64 treatment of, ib. polypi of, 66 how treated, 67 haemorrhage from, 69 treatment of, ib. Resolution, what, 32 Rhazes revives medicine in the east, 27 Rickets, nature and treatment of, 76 Romans, history of surgery among, 26, 27 Rose. See Erysipelas.

S. Santies, nature of, 30 Sarcoma, nature of, 41 pancreatic, 42 mammary, 42 tuberculated, ib. Sarcomatous tumors, treatment of, 42 by cautile, ib. by incision, ib. Sarcocole. See Testicle. Schirrus of testicle, 80 Serous membranes, diseases of, 70 Sinovial membranes, diseases of, 74, 75 Strictures, remarks on, 56 in urethra, ib. situation of, 57 symptoms of, 58 diagnoses of, 58 causes of, 59 treatment of, 60 by Wifeman, ib. bougies applied to, 60 method of using, 60, 61 Sedative remedies in inflammation, 32 Seton, used in opening abscesses, 35 Skarpe, an English surgeon, 28 Sinus, nature of, 36 method of treating, ib. Skin, diseases of, 43 pathology of, ib. Spina bifida, nature and management of, 75 ventosa, nature of, 76 Steatoma, a kind of tumor, 39 description of, 41 Steatoma, treatment of, 41 Suppuration in the cellular membrane, 30 Staphyloma, nature and treatment of, 91 Surgeon, qualifications of, 25

Surgery, definition of, page 24 different from medicine, ib. departments of, ib. history of, 25 among the Greeks, ib. practised in Britain by barbers, farriers, &c. in 16th century, 23 greatly improved in the 18th century, ib.

T. Testicle, diseases of, 80—84 mode of extirpating, 81 inflammation of, 82 induration of, 83 abscess of, ib. scrophulous, 84 preternaturally small, ib. fungus of, ib. Throat, dropy of, 73 Throat, method of scarifying and foaming, 87 Tic doloureux, nature and treatment of, 103 Tophus, a disease of the bones, 75 Tonsils, diseases of, 86 treatment of, ib. Trusses, nature and application of, to herniae, 104 Tumors, nature of, 38 encysted, ib. symptoms of, 39 mode of formation, ib.

V. Varicose aneurism, 78 veins, 80 spermatic veins, nature and treatment of, ib. Varicocele, nature and treatment of, ib. Venereal disease brought from America, 28 Venous system, diseases of, 80 Urethra, inflammation of. See Gonorrhea. polypi of, 67 Uterus, polypi of, ib. Uvula, diseases of, 87 treatment of, ib.

W. Warner, his writings on surgery, 28 Warts, description of, 47 of two kinds, ib. treatment of, ib. White, his works on surgery, 29 Whitloe, symptoms of, 37 treatment of, 38 finules in, to be avoided, ib. Wounds treated of by Celsus, 26 SURGERY

Fig. 1. Boog

Fig. 2.

Fig. 3.

Fig. 4. Stoddart

Fig. 5.

6 7 8 9 10 11 12 13 14 15 16 17 18 19

E. Mitchell Sculp. SURGERY

Fig. 1. 2 3 4 5 6 Fig. 7.

8 9 10 12 13 14 15 16 17

E. Mitchell sculp't SURGERY

Fig. 1. Fig. 2. Fig. 3. Fig. 4. Fig. 5. Fig. 6. Fig. 7.

Plate DXV. SURGERY

Fig. 1.

Fig. 2.

Fig. 3. SURGERY

Fig. 1.

Plate DXVII.

E. Mitchell sculp. Surgery

Fig. 1. Femoral Hernia

Fig. 2. Inguinal Hernia

Fig. 3. Inguinal Abdominal Hernia

E. Mitchell sculpt. SURGERY

Fig. 1.

Fig. 2.

Fig. 3.

Fig. 4.

Plate DXIX. Fig. 1.

Fig. 2.

Fig. 3.

Fig. 4. SURGERY

Fig. 1.

Fig. 2.

Fig. 3.

Fig. 4.

Fig. 5.

Fig. 6.

Fig. 7.

E. Mitchell sculpt SURGERY

Fig. 1.

Fig. 2.

Plate DXXII.

E. Mitchell sculp! Fig 1 SURGERY Plate DXXIII.

E. Mitchell, sculp. Fig. 1. SURGERY Plate DXXIV.

Steel Spring

E. Mitchell sculp.