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

INTRODUCTION.

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

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

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

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

To become an intelligent and expert operator, several qualifications are necessary; and some of these fall to the lot of few individuals. There are many people, who, though they have acquired an extensive knowledge of diseases, have not that calmness of mind, that collect-

edness of thought, which is necessary for a good operator; and there are some who are even deficient in that mechanical dexterity, which, though not requisite in all, is yet necessary in several of the operations in surgery. These talents, however, are never given in such perfection as not to require cultivation. An early habit of being present, and of assisting at operations, prepares the student to act for himself; and a long and unremitting habit of using the knife, and of performing operations on the dead body, gives a facility in all the mechanical part of them, which even experience on the living body does not procure.

History of Surgery.

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

Concerning the surgery practised among the Egyptians, Jews, and Asiatic nations, we know little. The art descended from the Greeks to us, though they confessedly received it from the eastern nations. The first Greek surgeons on record are Aesculapius and his sons Podalirius and Machaon. Aesculapius flourished about 50 years before the Trojan war; and his two sons distinguished themselves in that war both by their valour and by their skill in curing wounds. This indeed is the whole of the medical skill attributed to them by Homer; for in the plague which broke out in the Grecian camp, he does not mention their being at all consulted. Nay, what is still more strange, though he sometimes mentions his heroes having their bones broke, he never takes notice of their being reduced or cured by any other than supernatural means; as in the case of Aeneas, whose thigh-bone was broken by a stone cast at him by Diomed. The methods which these two famous surgeons used in curing the wounds of their fellow soldiers, seems to have been the extracting or cutting out the darts which inflicted them, and applying emollient fomentations or styptics to them when necessary; and to these they undoubtedly attributed much more virtue than they could possibly possess; as appears from the following lines, where Homer describes Eurypylus as wounded and under the hands of Patroclus, who would certainly practise according to the directions of the surgeons.

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

Till the days of Hippocrates we know very little of what was the practice of the Greek surgeons. From him, however, we learn, that the practice of blood-letting, cupping, and scarification, was known to them; al- History. to the use of warm and emollient fomentations, infuses made with hot irons, pessaries, injections, fumigations, &c. Hippocrates also gives directions with regard to fractures, luxations, ulcers, fistulas. He directs the extension, reduction, bandages, and splints, proper to be used in fractures and luxations of different bones, with several machines to increase the extension when necessary. He directs the laxity and tightness of the bandages; the intervals for unloosing and binding them on again; the position and repose of the fractured member, and the proper regimen; and he mentions the time when a callus is usually formed. He treats also of fractures of the skull, and the method of applying the trepan. In his treatment of ulcers, he speaks of reducing fungous flesh by means of elcharotics, some of which are alum, nitre, verdigrise, quicklime, &c.

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

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

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

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

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

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

In the year 500 flourished Aëtius, in whose works we meet with many observations omitted by Celsus and Galen, particularly on the surgical operations, the diseases of women, the caules of difficult labours, and modes of delivery. He also takes notice of the dracunculus, or Guinea worm. Aëtius, however, is greatly excelled by Paulus Egineta, who flourished in 640; whose treatise on surgery is superior to that of all the other ancients. He directs how to extract darts; to perform the operation sometimes required in dangerous cases of rupture or hernia. He treats also of aneurism. Galen, Paulus, and all the ancients, speak only of one species of aneurism, and define it to be "a tumor arising from arterial blood extravasated from a ruptured artery." The aneurism from a dilatation of the artery is a discovery of the moderns. In violent inflammations of the throat, where immediate danger of suffocation was threatened, Paulus performed the operation of bronchotomy. In obtinate defluxions upon the eyes, he opened the jugular veins. He describes the manner of opening the arteries behind the ears in chronic pains of the head. He wrote also upon midwifery. Fabricius ab Aquapendente, a celebrated surgeon of the 16th century, has followed Celsus and Paulus as text books.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

General Remarks on the Pathology of the Cellular Membrane.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

SECT. I. Of Phlegmon.

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

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

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

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

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

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

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

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

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

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

In flight cases of inflammation, a due perseverance in the mode of treatment which has been mentioned, will be in general sufficient to accomplish the intended purposes; but when there is likewise a full, hard, and quick pulse, with other symptoms of fever, general blood-letting becomes necessary; and the quantity of blood taken away is always to be determined by the extent and violence of the disease, and by the age and strength of the patient. Evacuations, however, should never be carried to a greater height than what is merely necessary for moderating the febrile symptoms; for should suppuration take place after the system is too much reduced, its progress becomes more slow and uncertain; not is the patient able to support the discharge that ensues. The use of gentle laxatives, with a cooling diet, is also attended with very good effects.

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

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

But, on the contrary, if all the different symptoms rather increase, and especially if the tumor turns larger, and somewhat soft, with an increase of throbbing pain, we may with tolerable certainty conclude that suppuration will take place; and we should therefore immediately desist from such applications as were judged proper while a cure was thought practicable by resolution, and endeavour to assist nature as much as possible in the formation of pus, or what is called the maturation of the tumor. To effect this, nothing is more useful than warm fomentations and cataplasms; and should these not have been employed during the former stage, the cold fumurine applications should be given up, and recourse had to the emollient remedies.

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

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

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

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

In addition to the several local symptoms of the presence of pus already enumerated, may be mentioned the frequent shiverings to which patients are liable on its first formation. These, however, seldom occur so as to be easily distinguished, unless the collection is considerable; but it is a symptom constantly observed in all large abscesses; and when it takes place, along with other symptoms of suppuration, it always contributes to point out the true nature of the disease.

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

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

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

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

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

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

Of the different Methods of opening Abscesses.

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

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

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

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

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

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

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

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

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

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

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

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

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

SECT. II. Of Sinuses (Fistula).

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Sect. III. Of the Whitloe (Paronychia).

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

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

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

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

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

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

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

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

SECT. IV. Of the Carbuncle.

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

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

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

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

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

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

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

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

SECT. V. Of Encysted Tumors.

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

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

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

Under the class of encysted tumors (tumours enkystés, loup cystides), are comprehended all those tumors of preternatural formation, the contents of which are surrounded by a bag or cyst.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Of Encysted Tumors.

The formation of the cyst forms as it were the nucleus of a new tumor.

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

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

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

VOL. XX. Part I.

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

Sect. VI. Of the Steatom or Fatty Tumor (B).

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

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

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

Sect. VII. Of the Sarcoma or Fleshly Tumor.

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

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

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

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

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

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

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

These different terms employed to characterize the various kinds of swellings which form in the cellular membrane, are by no means adequate; and tumors will be daily met with which it is impossible to assign to one or other of these species. This subject therefore still remains open for the investigation of future inquiry. And it is probable, that when the subject is better understood, the surgeon will not on all occasions be obliged to have recourse to the knife; and that he will be able to distinguish those which may be allowed to remain, or as harmless treated by external applications, from those whose nature is more malignant, and require an early extirpation.

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

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

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

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

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

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

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

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

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

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

Sect. IX. Of Emphysema.

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

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

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

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

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

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

Chap. II.

Of the Diseases of the Skin.

General Remarks on the Pathology of the Skin.

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

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

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

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

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

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

5. The epidermis is passive in all the diseases of the skin, and is only affected by its continuity. Its sensibili- Diseases of lity is never increased, nor is it susceptible of being in- the skin.

flamed, and consequently it never forms adhesions. Its internal surface, too, raised by a blister or any other means, and applied to the parts below, never reunites. The excrescences which form on it, such as corns, &c. are dry and inert, and without circulation; if they are painful, it arises alone from their pressure on the nerves of the subjacent parts.

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

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

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

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

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

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

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

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

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

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

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

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

Sect. I. Of the Erysipelas, or the Rose.

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

The rose is very apt to spread rapidly to a great ex- tent; and it frequently changes its situation, growing gradually well in one side, and extending itself on the other. Sometimes it disappears entirely at one place, and attacks some other. As the disease gets well, the cuticle peels off from the affected part.

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

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

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

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

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

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

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

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

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

SECT. II. Of the Furunculus or Boil.

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

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

SECT. III. Of the Chilblain.

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

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

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

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

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

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

SECT. IV. Of Cancer of the Skin.

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

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

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

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

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

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

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

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

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

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

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

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

SECT. V. Of Warts.

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

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

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

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

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

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

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

SECT. VI. Of Corns.

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

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

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

Sect. VII. Of Naevi Materni.

Naevi materni are those marks which frequently appear upon the bodies of children at birth, and which are supposed to originate from impressions made on the mind of the mother during pregnancy. They are of various forms; their colour is likewise various, though most frequently resembling that of claret or port-wine. Many of these marks are perfectly flat, and never rise above the level of the skin: these do not require the assistance of surgery; but in some cases they appear in the form of small protuberances, which frequently increase to a great size in the course of a few months. They appear to be soft and fleshy; of a cellular texture, the cells containing liquid blood. They may be removed with little danger when not involving any important organ. They are supplied indeed more plentifully with blood than most other tumors are; and even sometimes they appear to be entirely formed of a congeries of small blood-vessels; but the arteries which supply them may be, for the most part, easily secured by ligature. An operation should never be long delayed; for as the size of the vessels corresponds with that of the tumor, they sometimes are so large as to throw out a good deal of blood before they can be secured. In performing it, the tumor is to be cut out, the arteries taken up, and the remaining skin brought as well together as the nature of the part will allow, and kept so by adhesive plaster or future.

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

Chap. III. On the Diseases of Mucous Membranes.

General Remarks on the Pathology of the Mucous Membranes.

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

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

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

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

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

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

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

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

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

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

SECT. I. Inflammation of Mucous Membranes.

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

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

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

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

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

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

The term gonorrhoea is employed to signify a discharge of puriform matter from the orifice of the urethra or prepuce in men, and from the vagina in women (Ecoulement Mucosae), whether it proceed from a syphilitic or any other irritating cause.

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

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

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

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

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

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

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

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

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

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

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

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

When the urethra of a person who has laboured under gonorrhoea is laid open, no ulcer is almost ever found upon the surface of the internal membrane; and in those who have suffered much in consequence of the disease, there is merely a thickening and contraction of one or more parts. Gonorrhoea, parts of the urethra. Sometimes, though very rarely, excrefences are formed within it. The ducts of the mucous glands are obliterated, and the prostrate gland and bladder changed in their structure.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

It often happens, particularly in young people, that after 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 fix 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 gonorrhoea 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 formed, 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 gleets 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 blister, applied externally to the part affected, or to the perineum, has also been found useful. The cold bath has often been recommended in obstinate gleets, from which good effect 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 gleets, 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 Ceryza.

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

Among the corroborant 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 very beneficial. 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 feel, that nature alone can in time succeed, after we have uselessly tried all the resources of art.

There sometimes remains a species of cordee 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 prostate is found swelled 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. III. Of Inflammation of the Mucous Membrane of Coryza, 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 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 mucus, 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 dossel dip 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 curious bone.

SECT. IV. 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, mental affections, 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, 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 stoppage 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 fetid 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 through 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

* Nofogrphie Philo- sophique par Pinel. water combined with muriate of mercury, acetate of lead and the like, should be employed.

SECT. V. 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 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, affords 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 Ca- to make an artificial opening into the trachea below tarth of the where the matter is effused, in order to save the life of the patient. See BRONCHOTOMY.

SECT. VI. 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 these 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 glary filaments, and which is afterwards deposited at the bottom of the vessel in the form of the tenacious glary 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 coher, 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 cau- Strictures. 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 distention 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 prelure of a stone in the bladder, there is no cure but the operation of lithotomy; if it arises from metastasis, 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 lacrymal passages, are also subject to inflammation; but these will be treated of among the diseases of the eye and its appendages.

SECT. VII. 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 lacrymal 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 thickened, 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 lacrymal 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. VIII. 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 causes which disturb the functions of these organs, strictures in the urethra are perhaps the most frequent, and most serious. 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, which 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 distension, 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 insinuating 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, fulvous 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 vesice. 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. Seropulous 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 prostatic 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 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 caules 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 vesiculae seminales, or parts composing the body 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 prostatic 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 prostatic 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 confounded 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, ergo, 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, call in a lenient injection daily; and if you take notice of his urine, you may see the separation of the floughs 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, cicatrization, &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 flight 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 slighter 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 terebentin 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 fittulous 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 lacrimal 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 lacrimal 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, and of a cylindrical form*. One of the size of a 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 acquainted with the state of the parts, such formed 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 lacune 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

(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. pictures from side to side, and even employing a little pressure, 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 glysters, 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 platter 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, pressure 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 sinuses, 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 platter 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 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 paroxism, 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 slough 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, haemorrhage, and sometimes, a complete febrile paroxysm.

From the sympathy that exists betwixt 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 haemorrhage 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 echinocoeis 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 stage, 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 of the bougie, and diffuse in the urethra. When such an accident happens, if it be not immediately removed, it may produce a slough 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 dissolved on the stricture; reduce it into a fine powder, and tick 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 passed 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 pictures, 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, caustic 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 fitulous openings in the scrotum and perineum, the use of caustic is attended with the best effects. We have met with cases, where during a succession of years, urine has drilled through fitulous openings in the scrotum, in which six, eight, or ten applications of the caustic 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 caustic 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 caustic 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 shewn 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 mucilage, 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 stops 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 skillfully directed as to go down into the oesophagus, it will meet with a difficulty while it is passing from the sound oesophagus to the ulcer, and again when it leaves the ulcer and re-enters the sound 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 caustic 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 caustic 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 haemorrhoids, a variety of tumors very different from one another have been classed; whilst under the name of schirrhus, 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 schirrhus, or cancerous affection of the intestine, the disease first appears by the formation of one or more gritty 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 sores. 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 Delfault 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. Delfault, however, wishes it to be understood that the practice is to be employed in the true schirrhus; but the two cases which are given in detail by Bichat in his edition of Delfault's works, in illustration of the practice in schirrhus, 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 feces, 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 feces 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 intestine.

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 fleshy, 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 fleshy 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 fleshy 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 face, 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 vehicles, 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 fleshy 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 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 circumferenced 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 prelude 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 oesophagus 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 pushed upward; the maxillary bones and the palate bones are disjoined, 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 arise 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, faccharum 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. fabine 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 Delault.

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 forceps.

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 parts 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 afflant, on whose breast the head of the patient rests, ought, with the forefinger 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 recommended by Richter*. They are intended to be employed 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 accomplished, 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 dilate 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 profuse, 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 forwards 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 profuse, but seldom requires the assistance of art to stop it.

Of Removing Polypi by the Ligature.—The ligatures consist of wire, catgut, silk or cord; and different 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, allows the noose at a, to be increased or diminished, according 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-nœuds (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 velum pendulum palati, the doubled wire is to be slowly infinuated 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 necessary to perform bronchotomy as a preliminary step. Should any part of the polypus remain, it may be destroyed by cautery, 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 Desault 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-nœuds Default's (a a) ought to be procured, and having pulled the apparatus cylinder over the branches of the stalk, so as to shut the rings (d) completely, a ligature of waxed thread, catgut, or finer wire, is to be passed through them (k), and the extremities may be either held along with the canula or secured at e*.

The two canulas, thus armed, are introduced parallel 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 (s) of the other canula, and fixed to the axis at h.

The extremity (q) is then to be flit along the ligature close to the polypus; and the ligature being firmly fixed to the other extremity, the two porte-nœuds 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 easily 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 Polypi of the Rectum.

Polypi of the rectum differ considerably from the common hemorrhoidal tumor, in their symptoms and appearances. 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 tumor, 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 so 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 fatumine solution, and anointing them with fatumine ointments, or the unguentum resino- fum. 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, pushing 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 urinarius, 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 Polypus 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 polypi 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. Of 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. Cases, 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 Deffault (Plate DXV. fig. 5.).

SECT. VI. Of Aphtha.

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.

Aphtha 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 infolded, of white superficial rounded tubercles, each about the size of a millet seed. These tubercles discharge a scrous 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 disseminated 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.

Aphtha 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 aphtha 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 aphtha 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 interstices 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 flint, and the child fevers. 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, caustic 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 Haemorrhage from Mucous Membranes.

All the mucous surfaces are particularly subject to haemorrhage; 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 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 pestilential 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 bronchia, 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 compression. Doffils 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 pressing equally on them, has been attended with advantage. When these remedies likewise fail in their effect, a piece of catgut or wire may be introduced through the nose into the throat, and brought out at the mouth; a piece of sponge, or a bolster of lint of a size sufficient to fill the back-part of the nostril, is then to be fixed to it; the sponge is next to be drawn back and properly applied. Another is to be applied to the anterior part of the nostril and secured. The same may be done to the other nostril, if it be necessary; or the sponge may be of such a size as to fill the ends of both nostrils at the same time. By this contrivance the blood not finding an outlet, will soon coagulate, and prevent any farther evacuation.

2. Haemorrhagy 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 sensation 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 stool 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 stops spontaneously, it occasions a variety of nervous affections, such as spasmodic 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 if 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 catharides, 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 haemorrhagy 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, hypogastrium, and perineum, or to the inside of the thighs, is of great importance. Under the articles MEDICINE and MIDWIFERY, we have considered the hemorrhagies 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 haemorrhagy from the mucous membrane of the lungs; and there are also many cases of obstruction in the bowels which bring on haemorrhagy both from the lungs and uterus; a haemorrhagy 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 acid substances. Ozæna is often accompanied with inflammation, haemorrhagy, 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 an 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 farfaparilla 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 haemorrhagy, 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 haemorrhagy from these organs, or Ascites. In this place we shall consider dropsy and haemorrhagy from the vaginal coat of the testes, as the only diseases belonging to surgery.

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

When water collects in a considerable quantity within the cavity of the peritoneum, the skin becomes dry and sourly, 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 blister. 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 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 haemorrhage. The distinction of the abdominal muscles in patients who have died of dropsy, 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 preasure applied to support the belly as it is emptied, it is necessary, to make an equal preasure 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 affittants, 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 scrofulous ichthirus, 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 flapped 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 Act. Erud. Lipsiensis 1725, p. 492, there is mention made of a case of Hydrocele, 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 truis 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 preasure 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 preasure 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. Somering 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 alimenting 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, Of it is necessary to attend to the following rules. 1. When Hydrocele. 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 tefficle 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.

*See Plate DXIV. 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 tefficle would be in danger of being wounded by it, or when there is any enlargement of the tefficle accompanying the hydrocele, which is not well understood, 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 infusion 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 5i. ad libi. 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 tefficle 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 truss, and the patient put to bed. The operation excites more or less swelling in a longer or shorter period. The medium effect on the tefficle 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 truss 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 testicle; and the edges of the serotum are to be brought together either by straps or sutures. A single ligature put through the integuments opposite the testicle, answers best, and prevents the testicle from being pushed 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 testicle 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 plaster, 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 testicle and protracting the cure; and fourthly, to lay open freely any sinuses which may form. The cure goes on much more rapidly by persevering in the horizontal posture, and keeping the serotum 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 testicles 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 modes of curing hydrocele by a seton, caustic, &c. are now generally given up.

SECT. III. Dropsy 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 Baillie 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 flarts from it with a sense of suffocation: he is unable to stoop 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 anaëraeous. The undulation of a fluid may be heard by the patient himself, and moving the body by sudden jerks will sometimes afflit 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 sixth 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. Dropsy 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 Default and other very eminent surgeons have not been able to distinguish them. Dr Baillie 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 dropsy 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 supposed to be great, it may be perhaps advisable to discharge it, as practised in one case by Default, 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. (Haematocele).

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 use of disfectants and stimulants, such as solutions of faccharum faturni, 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 preternatural membranes formed on the articulating surfaces; and the preternatural collections of synovia 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 preternatural 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 dropply 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 glare 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 insensibly, without any assistance from art; but as this is often not the case, means ought to be used for removing them. For this purpose, 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 dropical 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 burse 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 burse, 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 disfectants. Even considerable collections arising from rheumatism may commonly be disguised 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 stocking, or with a roller, has frequently been of service. But whether a rheumatic tumor can be disguised 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 blooded to such an extent as his strength will bear; he Chap. VI.

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

Bones.

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 to 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 repulse 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 serous 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 bursts, 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 unofficed 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 of the Dif- for its formation; the origin and progress too of an ex-ces of the odotisis 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, necroses, &c. Besides the changes to which the bones are subject from inflammation and various accidents, they also suffer alterations in their hardnels and softnels. Preternatural growths also form upon them; and they are liable to absorption.

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

There are risings or tumors observable on the bones Tophus, which are often the consequences of venereal virus, and are termed tophi, gummi, or nodes.—Tophus is a soft tu- mor 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, be- Gummis- tween it and the periosteum; and its contents resemble gum softened, 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 investing membrane, it seldom requires exfoliation; and, as we often find that the bone itself is not affected, but only the periosteum thickened, we may be deceived even after a careful examination: it is therefore proper that the patient should be pretty far advanced in a course of mercurial unction before even the incision is made; for, should the tumor decrease, and the pain abate during the course, chirurgical affluence, 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 ossis; 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 insensibility of the bone in some subjects will prevent that acuteness of pain usual in other parts where matter is formed, though the acid matter is eroding the bone during the whole time it is contained within it. This matter at length having made its way through, arrives at the periosteum, where it creates most violent pain. The integuments then become swelled and inflamed, and have a sort of emphysematous feel. On being examined by pressure, 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 venefica 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 astonish us in her part, as the carious bone will be thrown off from the epiphyses, or the teredines will be filled up by the offic matter that flows from the parts of the bone where some of the spine have come away.

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

Besides those above mentioned, the bones are liable to two opposite diseases; the one termed friabilitas, the other molilitas; 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 salivations, the bones in old people have been rendered extremely brittle; infomuch 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 sourbitter 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 assistance of a skilful mechanic is necessary both to support the parts improperly acted on, and to alter the line of direction of the distorted osseous fibres.

Though the curvature of the extremities, or thickness of the ends of the bones near their articulations, may give the first alarm to those who are constantly with children, yet there are other symptoms that give earlier notice; 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 effect 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 pressure 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 basilicus to empty the intestines thoroughly, the purified crude quicksilver is by much the most efficacious medicine to remove obstructions in those glands. When the belly begins to soften and subside, the chylo passes without interruption, and the child begins to get flesh; then the cold bath becomes truly serviceable, and the decoction or cold infusion of the Peruvian bark is a proper restorative; but the cold bath used too early, or the bark given before there is a free circulation of chyle through the lacteals, would be very injurious.

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 up on 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 feces, &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 disease 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, illues made by incision, and illues 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. Illues 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 echarchs of an oval form, about two-thirds of an inch in diameter on each side of the curve, taking care to leave a sufficient portion of skin between them. In a few days, when the echar 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 illues I keep open until the cure is complete; that is, until the patient recovers perfectly the use of his legs, or even for some time longer: and I should think that it would be more prudent to heal only one of them first, keeping the other open for some time; that is, not only until the patient can walk, but until he can walk firmly, briskly, and without the assistance of a stick: until he can stand quite upright, and has recovered all the height which the habit or rather the necessity of stooping, occasioned by the distemper, had made him lose."

CHAP. 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 circumscribed; 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 pressure. By degrees the swelling increases, and becomes more prominent; the skin turns paler than usual, and in more advanced stages is oedematous: the pulsation still continues; but parts of the tumor become firm from the coagulation of the contained blood, and yield little to pressure; at last the swelling increases in a gradual manner, and is attended with a great degree of pain. The skin turns livid, and has a gangrenous appearance. 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 resistance, 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 derangement.

The false or diffused aneurism consists in a wound or rupture in an artery, producing, by the blood thrown out of it, a swelling in the contiguous parts. It is most frequently produced by a wound made directly into the artery. 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 pressure, 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 pressure, it generally remains nearly of the same size for several weeks. The enlargement however proceeds more rapidly in some cases than in others. Instances have occurred of the blood being diffused over the whole arm in the space of a few hours; while, on the contrary, swellings of this kind have been many months, nay even years, in arriving at any considerable size.

As the tumor becomes larger, it does not, like the true aneurism, grow much more prominent, but rather spreads and diffuses itself into the surrounding parts. By degrees it acquires a firm consistence; and the pulsation, which was at first considerable, gradually diminishes, till it is sometimes scarcely perceptible. If the blood at first thrown out proceed from an artery deeply seated, the skin preserves its natural appearance till the disorder is far advanced: but when the blood gets at first into contact with the skin, the parts become instantly livid, indicating the approach of mortification; and a real phæcetus 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 the blood-letting at the arm, the blood generally rushes into the yielding cellular substance, and there spreads so as to shut the fides 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 pressure, the blood contained in it being chiefly pushed forwards in its course towards the heart; and when the tumor is large, there is a singular tremulous motion, attended with a perpetual hissing noise, as if air was passing 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 pressure, but returns immediately upon the pressure being removed. If, after the swelling is removed by pressure, the finger be placed upon the orifice in the artery, the veins remain perfectly flaccid till the pressure is taken off. If the trunk of the artery be compressed above the orifice, so as effectually to stop the circulation, the tremulous motion and hissing noise immediately cease; and if the veins be now emptied by pressure, they remain so till the compression upon the artery be removed. If the vein be compressed a little above, as well as below the tumor, all the blood may generally, though not always, be pushed through the orifice into the artery; from whence it immediately returns on the pressure being discontinued.

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

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 tu- mors, scrofulous 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 pressure, and their returning on the compression being removed. The want of this circumstance, however, ought not to convince us that it is not of that nature; for it frequently happens, especially in the advanced stages of aneurisms, that their contents become so firm that no effect is produced upon them by pressure. Hence the propriety, in doubtful cases, of proceeding as if the disease was clearly of the aneurismal kind.

In the prognoses, 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 pressure 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 pressure cannot be applied to the artery alone, without at the same time affecting the adjacent 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 pressed entirely out of the sac into the artery, it often happens, by the use of a bandage of soft and somewhat elastic materials, properly fitted to the part, that much may be done in preventing the swelling from receiving any degree of increase; and on some occasions, by the continued support thus given to the weakened artery, complete cures have been at last obtained. In all such cases, therefore, particularly in every instance of the varicose aneurism, much advantage may be expected from moderate pressure.

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

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 Astley Cooper of Guys, tied the common carotid; and Mr Remiden 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 DXVI. fig. 1.). An incision is to be made through the flesh 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 DXVI. 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 palled between the peritoneum by the side of the ploas 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 Astley. Of Varicose Veins. 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 Ramsden 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 preternaturally 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 emunctary of the varicose vessels of the testicle.

Treatment.—The use of astringents, along with a proper sulphury 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 Hemorrhoidal Tumors.

The hemorrhoidal 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 coition, prolapse, 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 tumors within the anus, and to keep the bowels very open by mild laxatives and clysters.

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 feces. 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.

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 The most remarkable symptom of schirrous testicle is a gradual enlargement and induration of the body of the gland or epididimis, 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, Dr Baillie observes that "it is found to be changed into a hard mass of a brownish colour, which is generally more or less interlaced by membrane. In this there is no vestige of the natural structure, but cells are frequently observable in it containing a fannous 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 chord 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 schirrhus, 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 schirrhus 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 schirrhus 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- suspected to be diseased, 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 dif- ease.

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 mat- tress. His legs should hang over the table, and be supported by assistants. 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 hemorrhagy 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 hemorrhagy 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 those 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 plaster, however, should be neatly placed between each of the stitches, along the whole extent of the wound, and a pled- get of simple ointment and compress 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; Of the Dif-for we have made a general remark, that after almost all surgical operations, there has scarcely ever an instance 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 six days, according to circumstances, the dressings should be removed, and if the wound has healed by adhesion, the stitches 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 adhesion, suppurates, the stitches 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 stitches 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 case from the internal use of bark (cinchona).

2. Inflammation of the Testicle (Hernia humoralis).

Inflammation is one of the most frequent diseases of the testicle. Sometimes the inflammation is confined to the substance of the testicle, at other times it affects the epididimis, and in some cases it spreads to the albuginea and vaginalis. The surface of the inflamed testicle 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 blush of redness, and interspersed with varicose veins. When examined by dissection, the testicle exhibits, according to Dr Baillie, 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 varicose. Inflammation of the testicle 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 testicle concomitant of gonorrhoea generally begins by spreading along the vas deferens from the prostate gland through the inguinal canal till it comes to the testicle; it is in most cases at- of the Di- tended with excruciating pain from the rapidity of its progresf; and as it commonly comes on when the gonor- rheal discharge diminishes or disappears, and subsides when the discharge returns, many authors have sup- posed that it was a true metastasis of the venereal mat- ter.

If the disease be left to itself, the body of the testicle 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 feeble 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 testicle 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 testicles are affected at the same time, but when the swelling of one disappears, often the other one begins to be attacked.

The testicles sometimes swell and inflame from the absorption of the matter of a chancr, and as the progresf of the swelling is in such cases slow, and generally more irregular, it has sometimes been mistaken for a schirrhus testicle; but an investigation into the history of the case, and particular attention to the appearance of the skin of the scrotum, and any symptoms of the veneral disease in other parts of the body, will generally lead to a knowledge of the true nature of the case. It sometimes 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 testicles 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 testicle 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 testicle, 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 gives much relief, and great attention should be paid in supporting the testicle with a silk net trus (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 testicle, 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; aces of the Tefticle. and as every thing which caufes a suppression of the difcharge tends to produce a swelling of the tefticle, it is natural to fuppoft, that in order to prevent this troublefome diforder, every thing fhould be avoided capable of increafing the irritation and inflammation of the urethra, as expofure to cold, violent exercife, ill chofen injec- tions, and balsamic medicines; but, above all, the ufe of a fulpenfory is moft efficacious, and Swediaur * recommends one to be worn in every cafe of gonorrhoea from the commencement of the difeafe, to prevent all risk of the tefticles becoming inflamed. When the inflammatory symptoms are levere, the treatment fhould be adopted as we have recommended in common inflamma- tion of the tefticle. If the difcharge from the urethra is flapt, means fhould be ufed to refore 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 compofed of two or three ounces of oil of linseed and deco- cution of barley, along with fifty or fixty 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 hylocyanus in many cafes anfwer better than opium. Fomentating the penis and adjacent parts with warm vinegar and water, injecting warm oil, and the ufe of bougies, may alfo be advantageous in pro- moting the difcharge from the urethra.

3. Induration of the Tefticle.

After the inflammatory symptoms have abated, it ge- nerally happens that a degree of swelling and hardnefs of the body of the tefticle, but still more frequently of the spermatic cord or epididimis, remains, and in many cafes continues for months, or even during life. This effect takes place from whatever caufe the inflammation may have arifen. In many cafes the tefticle itfelf re- mains quite found, and the epididimis is converted into a very hard unyielding mass, which feels as if it were injected with quickfiver. Sometimes the tefticle, while it remains hard, diminishes in fize, and becomes much smaller than natural. When the tefticle is examined by diffection, it is found to have loft its natural structure, and is sometimes changed into a hard brown-co- loured mass (Voigtl); interfefted more or lefs by mem- branous bands; fometimes parts having a cartilaginous quality appear in it, and fometimes cells are formed which contain matter. The feminal vesfels are fo changed and hardened, that they cannot be distinguished from each other. In some cafes the whole tefticle has been found converted into a cartilaginous mass, and in a few instances fome parts of it have been converted into bone.

The treatment usually recommended in cafes of in- duration of the tefticle preceded by inflammation, are strong stimulating and astringent applications; fuch as solutions of the muriate of ammonia, acetate of lead, ful- phate of zinc, &c. either applied by moiftening 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 fingly or combined with camphor, over the frotum and perineum, fometimes produce a good effect; mercurial fumigations to the genital organs have alfo been recommended. In some cafes the internal ufe of mercury has been found necef- fary. A mercurial plaster with camphor, or the com- mon soap platter, is alfo a good application, and is very useful in defending the tefticle.

The internal and external ufe of the hemlock (co- nium maculatum) has been much recommended by Plenk. Electricity has alfo been fuccesfully employed. The muriate of lime, and the muriate of barytes, have been ufed by fome authors. Swediaur fays that he has known fome affections of the tefticle produced by gonorrhoea, and alfo fome difeafes of the eye from the fame caufe, cured by the patient getting a fresh infec- tion. In a few cafes of induration, and fwellings of the tefticles, we have employed blithering with good effects. The frotum fhould be shaved before this is done; and it is often neceffary to repeat the blifter feveral times before the hardnefs or fwellings begin to abate.

4. Abscess of the Tefticle.

It fometimes, though rarely happens, that the tefticle Symptons. suppurrates. The matter which is formed, is commonly a tough, thready, yellow-coloured fubfance, which ad- heres to the furface of the cavity in which it is contained. Sometimes there is only one abfcef; in other cafes the matter is contained in feveral small irregular-shaped cavities. Sometimes the matter is formed in the very middle of the body of the tefticle; in other cafes we have obferved small abfcefles in different parts of the epididimis, the body of the tefticle remaining quite found. When an abfcef is formed in the tefticle, the ftructure of the gland becomes more or lefs changed; generally instead of being soft, and the tubes of which it is compofed being eafily feparated, it degenerates into a hard firm mass.

Abfcefles of the tefticle fhould be opened as soon as Treatment, poſsible, in order to prevent the fubfance of the tefticle 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 fitation of the abfcef, whether it is formed in the body of the tefticle, in the epididimis, or between the albuginea and tunica vaginalis, or in the cellular membrane external to the tunica vaginalis; for when fuch a degree of in- flammation has taken place as to terminate in the for- mation of an abfcef, the accompanying fwellings deftroys the natural form of the parts, and involves the whole into a undetermined shapelefs mass. Richter remarks, that there are fometimes soft spots in the tefticle, in which it is believed there is a fluctuation. When fuch fwellings are opened no matter is discharged, nothing but blood appears, and the inflammatory symptoms are afterwards increased. The more matter which is dif- charged from an abfcef of the tefticle, the smaller the tefticle grows, as the matter is fometimes formed partly of the thready fubfance of the tefticle. Cafes have oc- curred where the whole tefticle has been pulled away, the surgeon having made the feminiferous tubes for floughs. Abfcefles of the fubfance of the tefticle feldom heal, and generally a fittulous opening remains, through which there is a constant oozing of the feminal fluid.

5. Fistulous Sinus of the Tefticle.

As far as we know, no author has taken notice of this appearance. In one cafe we obferved it very remark- able. The epididimis alone was fwellied, and there was Of the Dif- a thickened portion of scrotum adhering to one part of it, in which there was a small sinus, and through which the femoral 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 seton 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, or 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 assigns the origin of the complaint to some injury. In some cases, it is the consequence of hernia humeralis, 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 slided 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 elchorotics; the removal by the knife is perhaps the safest, and certainly the most expeditious method.

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

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 discharge, 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 abscesses. Scrofulous tumors also form in it; it is subject to a particular disease, called milk abscess, to seirrhus, 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 the Dif- 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 menses, 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 menses, 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 people; 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 fœnious 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 flinging 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. feet. iv. 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 scirrhus 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, affuming 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 proposing 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 glandu- laces of the lar part is to be detached from the muscle, though a small portion only should be difaced, beginning at the upper side, and separating downwards. After the dif- eased 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 pledgit of simple ointment is now to be laid over the whole; and this is to be covered with a compres of lint, tow, or soft li- nnen; and the dressings to be kept in their place, and moderate pressure made by a circular roller and scapu- lary 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 affluence 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-glaflers* may answer the same purpose. By applying these to the nipple, and sucking out the air, the child will com- monly 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 appli- cations are most to be depended upon in such complaints; saturnine 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 applica- tions 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 re- mains 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, de- fending 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 scirrhus nature. Scrofulous indura- tions are particularly frequent. They often become old and hard, and are then commonly considered as cases of the D. firrhus. If the surgeon succeeds in diffusing them by means of any kind of remedy, he is apt to think that he has difaced a scirrhus. 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 dissolved by the suppuration, and if he makes a large opening, then commonly fol- lows a very malignant ulcer, which may be also mis- taken for a cancerous sore. Many cases, where ulcer- ated 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 melicercis.

In the breast of young girls, ten or twelve years of age, hardneses 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 mucular flesh. In such a case the extirpation has been successfully per- formed.

Sometimes considerable and often quite hard swell- ings appear in the breasts, which proceed merely from blood. In such cases blood flows from the nipple at each menstrual period. When the menses 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 hematodes; for an account of which, we refer our readers to Wardrop's Observations on Fungus Hematodes.

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 scirrhus nature; but they are neither attended with shooting pain, nor are they apt to degenerate into can- cer; 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-Treatme moving them is by ligature, which is not only void of danger, Surgery.

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

When the form of the tonsils happens to be conical, so that the ligature would be apt to slip over their extremities, Mr Chefelden has recommended a needle (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 so 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.

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 tonsils.

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 (fig. 1.) 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. enumerated, there are others which arise from the peculiar 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 palpebrae, 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 gonorrhoeal ophthalmia.

1. Of the Purulent Ophthalmia.

The purulent ophthalmia appeared in this country as 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 tears, Of the Dif-tears, there is a profuse discharge of a puriform fluid, eases of the 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 are 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 Gibson 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 Gibson found the mothers of those children, affected with purulent ophthalmia, had leucorrhoea; and it is probable, that this, as well as other acrimonious 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 Beater, 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, scarifying 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, vascular, and opaque. If the disease be confined to a particular part of the conjunctiva, the disease is observed at its commencement like a small globe 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 sound. 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 Of the Dif-pair of seiffars; and then carefully dissecting it off to its apex. If any portion of it has been allowed to remain, or if the wound shews 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 tarh are found adhering together in the morning, from the exudation of a yellow matter among the ciliae. 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 of the 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 onix; 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 humour 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 suppurated and burst; either in consequence of a pustule or of an abscess.

When a pustule suppures, the central part of it generally of the Dif- generally gives way; and as the disease continues, the ul- ceration extends in all directions from that point. Ul-cers 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 risk 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 lamellas 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 cluter on that part of the fleshy 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 lightest 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 opaque kind, if placed beyond its circumference, diminish the sphere, but not the distinctness 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 ferifications 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, fab-borate of soda, diluted with from a fourth to an Chap. X.

Of the Dif- eighth part of sugar, may also be advantageously employ- 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, feldom 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; loses 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; disposition 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 pupillary 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 cristallina). 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 opake, 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 confistence of the lens varies very much in the different kinds of cataract. 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 striated, 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 anything 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 opake 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 opake, 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, paling 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 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 from a man whose father and grandfather were both blind from that complaint. Maître 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 opake 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 opake, and containing within it the crystalline. Such cases have been called by Richter the cataracta cystica. He says he has only met with one case of that form of the disease; Becr, 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 opake, 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 centre or at the circumference of the crystalline.

The tremulous cataract (cataracte tremblante of the Trembling French), is another variety of the disease which deserves to be noticed. It is generally of a very opake white colour, 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 opaque 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 opaque lens is observed of a very large size behind it. The patient can seldom distinguish light 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 phthyloma arose in one eye in consequence of a wound, and in a few years afterwards the other eye became phthylomatous. 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 cuffed 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 Eichenbach both relate cases where people labouring under gout, which suddenly retroceded, 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 absorbent 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, extraction hyoscyami, 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 ether, which promoted the abortion 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 pushing 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 dissipations 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 remain, 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, with a view of proceeding to the other steps 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 start, and make great resistance 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 assistant 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 assistant is able to look over the head, and completely command the motion of his own fingers. The operator and assistant 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 assistant 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 assistant 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.

It 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 circumstances, it was almost impossible to secure the eyeball with the fingers; of the difficulty 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 tarsus; the skin of the upper eyelid being previously stretched upwards. The assistant 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, effectually 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 assistant; 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 assistant is to be aware that no pressure is to be made upon the eyeball. When, therefore, this step of the operation is completed, the assistant, 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. figs. 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 pushing the knife forwards till the incision is completed.

Instead of making the incision in this manner, Mr. James Wardrop has proposed another form of incision, in order to remove several objections to which the other operation was liable *. The disadvantages which Mr. Wardrop vol. iv. Of the Dif- drop supposes to arise from the usual mode recommend- ed are, Eye.

1. The cornea being of very considerable thickness, a great part of the femicircular 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 (a a), 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 infinates 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 reluctance 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 of 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 femicircular 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 ab (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, neat 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 Dif. the opposite side (fig. 13.). By these two incisions the edge of 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 pushed 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. c). 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 femicircular 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 edges 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 flops the progress of the knife by gliding the point of the forefinger over the cornea, and pressing 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 side, 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 eyeball 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 Diff.-also puth after it some of the vitreous humour. When the incision of the cornea is finished, 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 upwards, 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 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 preasure 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 sleight of 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 of itself after the division of the cornea by the pressing forward of the lens; and this dilatation may be easily increased by the slightest preasure.

"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 in 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, nor 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 simple ointment, 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 compresses 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 loosened, 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 advisable to keep the eyelashes constantly greasy with an 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 fix 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 in those cases where no bleeding is necessary, the pulse 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 constitution; 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.

Venesection 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 found 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 pledge of ointment covering the eyes will prevent, during this day, any light from entering.

On the second day the pledge 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. 20.) 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 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 lacrymal fac is distended with a puriform fluid, or when it has ulcerated, and the tears do not pass freely down the nafal duct, the disease is called fistula lacrymalis. In the first stage of the disease, a distinct tumor is formed in the situation of the fac, 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 fac ulcerate, and the puriform fluid and tears are constantly oozing through the fistulous 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 fac 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 fac. 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 fac has been the original seat of the disease, a solution of corrosive sublimate, acetite of zinc or of lead, will be useful, and these may be used by allowing them to be absorbed by the puncta into the fac, 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 nafal duct, these remedies generally fail, and it becomes necessary to open the fac, and remove the cause of obstruction in the duct. The fac may be readily opened by boldly plunging a common lancet into it while distended with matter. The fac 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 flyle, (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 fac appear healthy, the flyle may be withdrawn, and the opening of the fac 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 Diff-down below the edge of the skin. Generally the exudates of the external opening heals in a few days. When the sac has ulcerated, there will generally be found some sinuses in the integuments covering the lac, all which should be freely laid open, and the style introduced as in the former case. After the skin and sac 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 Pforophthalmia.

In this disease there are numerous small brown coloured eminences formed at the roots of the cilia of both eyelids, and generally both eyes are affected. The adjacent skin has a brownish red tinge, and becomes scurfy; the cilia drop out, and the patient has a difficulty and uneasiness in opening the eyelids, particularly in candle-light. The blood-vessels 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, glues the cilia 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 scrofulous inflammation, the glands of Meibomius swell and suppurate, the cilia drop out, and the eyelids lose their natural form.

Treatment.—Scarifying the inflamed vessels, 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 cilia 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 tarbus 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 Pellicer, until such time as the wound has healed. In the second case little can be done but pulling out from their roots any of the cilia 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 Polyp. It is also subject to hemorrhages, 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. *

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 draw 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, 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 fibrilla, 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 sciatic 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 Encyclopedic 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 hematoidei, 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 (Nevralgie).

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 pallorations. 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 (neuralgic ilio-frotale), the posterior crural (ischias nervosa postica), 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 Hernia-sympathetic of a disease in some distant organ.

In some instances we have observed this disease arise from an affection of the prime vice; 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 doloreux, 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 small 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 could 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 HERNIA.

The word hernia has been used to signify a protrusion of any viscous, 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 Of Herniae and crural rings and the umbilicus. They, however, protrude also at the foramen ovale, at the perinaeum, through the sciatic 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 intestine, intestinal hernia; if both, omentum and intestine, entero-epiplocele; if the stomach is contained in the tumor, gastrocele; if the liver, hepatocoele; if the bladder, cystocele; if the uterus, hysterocele.

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 distension; 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 (testical 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 chord. 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 absorbents, 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 truss.

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 the external oblique muscle *.

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 sac †.

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 prelude 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 pushed 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 distension of the abdomen.

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

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 prelude 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 prelude 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 prelude 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 rests 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 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 prelude 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 trus ought to be worn, so as to keep up a uniform and steady pressure on the ferotum. 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 intestines and omentum are irreducible, but when the protruded bowels are inflamed, and when the passage of the faeces 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 cracking 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 deflection, the hernial sac is generally found to contain a quantity of dark bloody serum. The intestines 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 intestines 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 inflated 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 prelude. 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 prelude 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 clysters 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 resit 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 bitbury along the finger, till the point of it passes below the stricture*. A very slight pressure 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‡ See Plate DXX, 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 fascia 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 trifles 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 sac 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-teeth 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 sutures. 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 lip, that the edges of the wound may be kept properly in contact. An assistant now keeps the parts together, while the operator applies a firm waxed ligature first to the under pin; and having made three or four turns with it in the form of an eight figure, 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 plasters applied to the cheeks and tied between the pins. During the time of the cure the patient should be fed upon spoon-meat, and prevented from making any exertion with the lips, otherwise the cure might be considerably retarded. At the end of five or 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 attendant, 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 Popart'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. 15.) 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, 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 flethy 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 affiant 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 too 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 cadis 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 DXXXIII. 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, so 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 flethy 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 DXXXIII. 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 sit 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, Lithotomy, 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, deferring 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 assistants, and the surgeon being seated upon a chair of a proper height, and in a convenient light, he makes an incision with a common convex edged scalpel through the skin and cellular substance, below the symphysis of the osa pubis, which is a little below the scrotum, and where the crus penis and bulb of the urethra meet, and on the left side of the raphe, and continues it in a slanting direction downwards and outwards to the space between the anus and tuberosity of the 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 prostatic 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 prostatic 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 bare, and that there is room to admit the nail of the finger; and as the finger affilts 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 prostatic 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 forcible 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 slips from the point of the staff into the bladder. The gorget is not to be pushed farther than this, otherwise it may wound the opposite side of the bladder, &c.

The gorget having now entered the bladder, which is readily known by the discharge of urine from the wound, the staff is to be withdrawn, and the finger introduced along the gorget to search for the stone, which, when felt, will point out the direction to be given to the forceps; at any rate, the introduction of the finger serves to dilate the wound in the bladder; and this being done, a pair of forceps † 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.

After 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. Directors. 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 floatomatous 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 stricture 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. Chefelden'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 scissars. 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 swelled 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, Fascia 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 trus; 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, Fascia lata. 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 crural hernia defends formed on the outer side by the crural sheath; on the inner by the semilunar 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. o, 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. o, 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 affix the prelude 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 forget, 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 lipiculae 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 metatarsus 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 resilience, 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. Surgery.

Chilblains, nature of, page 45 how treated, 46 Conjunctiva, polypi of, 67 inflammation of, 87 Cornea, diseases of, 89, 90 ulcers of, ib. treatment of, ib. specks of, ib. mode of treating, ib. Corpus, 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 Cystocele, 104 Cysts, nature of, 39 Deafness on wounds of the head, 29 Division of surgical diseases, 30

E. Ear, inflammation of mucous membrane of. See Otitis. polypi of, 67 diseases of, 102 Elle writes on hydrocele, 29 Emphysema, 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 Frysipelas, 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 lacrymalis, nature and treatment of, 101, 102 Fistulae, nature of, 36 causes of, ib. 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 Gastrocele, 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, p. 49, 50 virus, of, 51 treatment of, ib. in women, 52 treatment of, ib. injections for, now used, ib. Greek surgeons, 25, 26 Guntr, 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 Hemotocele, nature and treatment of, 73 Hernia, described by Celsus, 27 Hernia, different kinds of, 103, 105 Hepatocele, 104 Hill writes on cancer, 29 Hippocrates, a Greek physician, 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 Hysterocele, 104

I. Inguinal hernia, nature and symptoms of, 104 reducible, ib. irreducible, ib. strangulated, ib. Iritis, 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, 84—86 inflammation and abscesses of, 85 schirrhus and cancer of, ib. treatment of, ib. method of extirpating, ib. anomalous swellings of, 86 Maturation. Maturation of a tumor, page 33 Melicris, a kind of tumor, 39 Monro lectures on surgery, 28 his treatise on otoecology recommended, ib. Mucous membranes, diseases of, 48 pathology of, ib. extent of, ib. 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, sore, nature and treatment of, 86 Nodes, venereal, 75 how treated, ib. Noe, 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. pustulosa, symptoms and treatment of, 89 tarfi, nature and treatment of, 102 Otitis, symptoms of, 54 treatment of, ib. Ozaena, symptoms, and treatment of, 70

P. Palsy 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 Peritonenum, dropy of, 70 Phlegmon, symptoms of, 31 resolution of, 32 terminates in abscess, ib.

Phlegmon, treatment of, page 32 Poti, an English surgeon, 28 greatly improves the art, ib. Polypi, different kinds of, 64—67 Popliteal aneurism, 79 Pterophtalmia, symptoms and treatment of, 102 Pterygium, nature and treatment of, 88 Put, nature of, 30 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 Ricketts, nature and treatment of, 76 Romans, history of surgery among, 26, 27 Rose. See Erysipelas.

S. Saines, nature of, 30 Sarcoma, nature of, 41 pancreatic, 42 mammary, ib. tuberculated, ib. Sarcomatous tumors, treatment of, 42 by cautio, ib. by incision, ib. Sarcocele. 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, ib. diagnosis of, 58 causes of, ib. treatment of, 59 by Wifeman, ib. bougies applied to, 60 method of using, 60, 61 Sedative remedies in inflammation, 32 Seton, used in opening abscesses, 35 Sharpe, an English surgeon, 28 Sinuses, nature of, 36 method of treating, ib. Skin, diseases of, 43 pathology of, ib. Spina bifida, nature and management of, 75 ventoia, nature of, 76 Steatoma, a kind of tumor, 39 description of, 41 treatment of, ib. Suppuration in the cellular membrane, 30

Staphyloma, nature and treatment of, page 91 Surgeon, qualifications of, 27 Surgery, definition of, 24 different from medicine, ib. departments of, ib. history of, 23 among the Greeks, 23 practised in Britain by barbers, farriers, &c. in 16th century, 21 greatly improved in the 18th century, 15

T. Testicle, diseases of, 80—81 mode of extirpating, 81 inflammation of, 81 induration of, 81 abscess of, ib. fierphulous, 81 preternaturally small, 81 fungus of, ib. Thorax, dropy of, 73 Throat, method of scarifying and foaming, 87 Tic doloureux, nature and treatment of, 103 Tophur, a disease of the bones, 73 Tumors, diseases of, 86 treatment of, ib. Trusses, nature and application of, to herniae, 101 Tumors, nature of, 33 eneyfied, 33 symptoms of, 33 mode of formation, 33

V. Varicose aneurism, 78 veins, 83 spermatic veins, nature and treatment of, ib. Varicocele, nature and treatment of, ib. Venereal disease brought from America, 28 Venous system, diseases of, 83 Urethra, inflammation of. See Gonorrhoea. polyi of, 67 Uterus, polypi of, 87 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

PLATE DXIII.

Fig. 1. Boog

Fig. 2.

Fig. 3.

Fig. 4. Stoddart

Fig. 5. 6 7 8

9 10 11 12

13 Boog 14 15 16

17 18

19

E. Mitchell Sculp.

PLATE DXIV.

Fig. 1. 2 3 4 5 6

Fig. 7.

8 9 10

12 13

14

15

16

17

E. Mitchell sculp.

PLATE DXV.

Fig. 1. Fig. 2. Fig. 3. Fig. 4. Fig. 5. Fig. 6. Fig. 7. Fig. 8. Fig. 9. Fig. 10. Fig. 11.

E. Mitchell sculp't

PLATE DXVII.

Fig. 1.

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26

E. Mitchell Sculp't.

PLATE DXVIII.

Fig. 1. Femoral Hernia

Fig. 2. Inguinal Hernia

Fig. 3. Inguinol Abdominal Hernia

E. Mitchell sculp.

PLATE DXXI.

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

E. Mitchell Jnr.

PLATE DXXII.

Fig. 1.

Fig. 2.

6

7

10

11

12

F. Mitchell sculp.

PLATE DXXIII.

Fig 1

2

3

4

5

6

7

8

9

10

11

F. Mitchell Sculp. Fig 1. SURGERY. PLATE DXXIV.

Steel Spring

E. Mitchell sculp't