in Surgery, have been divided into simple, contused or lacerated, and gun-shot.

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

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

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

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

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

5. There are other wounds which prove fatal if neglected and left to nature: such are wounds of the larger external blood-vessels, which might be remedied by ligature. Wounds of such parts generally prove fatal; and though a few instances may have occurred where people have recovered after them, yet they are always to be considered as extremely dangerous. Portions of the brain have been destroyed, and wounds have been made into it, and the patients have lived. It is possible, too, that the thoracic duct might be wounded and the patient live; Mr A. Cooper having shewn, in a very ingenious paper in the Medical Records and Researches, that it may become obstructed, and the chyle conveyed into the system by anastomosing lymphatics.

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

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

If by a wound any considerable artery happens to be divided, the blood flows out with great velocity, and by fits; the patient soon becomes faint with loss of blood; nor does the haemorrhage stop until he faints away altogether; and if as much vis viva still remains as is sufficient to renew the operations of life, he recovers after some time, and the wound heals up as usual. The part of the artery which is below the wound in the mean time becomes useless, so that all the inferior part of the limb would be deprived of blood, were it not that the small branches sent off from the artery above the wounded place become enlarged, and capable of carrying on the circulation. Nature allo, after a wonderful manner, often produces new vessels from the superior extremity of the divided artery, by which the circulation is carried on as formerly. The consequences of such a profuse haemorrhage may be, however, very dangerous to the patient, by inducing extreme debility, or an universal dropsy. This great hemorrhagy happens especially where the artery is partially divided; because then the vessel cannot contract in such a manner as to close the orifice: however, if the wound is but small, the blood gets into the cellular substance, swelling up the member to an extreme degree, forming what is called a diffused aneurism. Thus the hemorrhagy soon flops externally, but great mischief is apt to flow from the confinement of the extravasated blood, from bringing on exterior suppuration among the muscles and bones; and thus not only the use of the limb is entirely lost, but the patient is brought into great danger of his life.

Wounds of the ligaments, nerves, and tendons, are likewise attended with bad consequences. When a nerve is entirely divided, the pain is but trifling, though the consequences are often dangerous. If the nerve is large, all the parts to which it is distributed below the wound immediately lose the power of motion and sensation. This, however, takes place only when all or the greatest part of the nerves belonging to a particular part are divided. If the spinal marrow, for instance, be divided near the head, the parts below soon lose their sensation irrecoverably; or if the bundle of nerves passing out of the axilla be divided or tied, sensation in the greatest part of the arm below will be lost. But though a nerve should be divided, and a temporary palsy be produced, it may reunite, and perform its former functions. If a nerve be wounded only, instead of being divided, the worst symptoms frequently ensue.

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

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

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

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

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

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

For the cure of wounds, it has been already observed, that the ancients imagined balms, the juice of herbs, &c. to be specifics. In after-ages, and in countries where balms are not easily to be procured, salves were substituted in their place; and even at this day there are many who reckon a salve or ointment essentially necessary for healing the lightest cut. It is certain, however, that the cure of wounds cannot be effected, nay, not even forwarded in the least, by ointments, unless in particular cases. That power which the human frame has of repairing the injuries done to itself, which by physicians is called vis medicatrix nature, is the sole agent in curing external injuries; and without this the most celebrated balms would prove ineffectual. When a wound has been made with a sharp instrument, and is not extensive, if it be immediately cleaned and all the extravasated blood sucked (A) out or washed away, it will almost always heal by adhesion. When a wound does not heal by this process, there are three stages to be observed in its cure; the first, called suppuration, which takes place when the ends of the wounded veils contract themselves, and pour out the liquor which is converted into pus. As soon as this appears, the second, or granulating stage, in which the flesh begins to grow up, takes place; and as this proceeds, the edges of the wound acquire a fine bluish or pearl colour, which is that of the new skin beginning to cover the wound as far as the granulations have filled it up. This process continues, and the skin advances from all sides towards the centre, which is called the cicatrizing of the wound. For the promoting of each of these processes, several ointments were formerly much in vogue. But it is now found, that no ointment whatever is capable of promoting them; and that it is only necessary to keep the wound clean, and to prevent the air from having access to it. This, indeed, nature takes care to do, by covering the wound with a cake of coagulated blood; but if a wound of any considerable magnitude should be left entirely to nature, the pus would form below the crust of coagulated blood in such quantity, that it would most probably corrupt, and the wound degenerate into a corroding ulcer. It is necessary, therefore, to cleanse the wound frequently; for this purpose it will be proper to apply a little ointment spread on soft scraped lint. And, in a healthy body, the wound will heal without farther trouble. As to the ointment employed, it is almost indifferent what it be, provided it has no acrid or stimulating ingredient in its composition; hogs lard or the simple ointment of the Pharmacopœia will answer perfectly.

But though, in general, wounds thus easily admit of a cure, there are several circumstances which require a different treatment, even in simple divisions of the fleshy parts, when neither the membranous nor tendinous parts are injured. These are, 1. Where the wound is large, and gapes very much, so that, if allowed to heal in the natural way, the patient might be greatly disfigured by the scar. It is proper to bring the lips of the wound near to each other, and to join them either by adhesive plaster or by future, according as the wound is superficial, or deep. 2. When foreign bodies are lodged in the wound, as when a cut is given by glaís, &c. it is necessary to extract them, before the wound is dressed: for it will never heal until they are discharged. When these bodies are situated in such a manner as not to be capable of being extracted without lacerating the adjacent parts, which would occasion violent pain and other bad symptoms, it is necessary to enlarge the wound, so that these offending bodies may be easily removed. This treatment, however, is chiefly necessary in gunshot wounds, of which we shall afterwards speak. 3. When the wound is made in such a manner that it runs for some length below the skin, and the bottom is much lower than the orifice, the matter collected from all parts of the wound will be lodged in the bottom of it, where, corrupting by the heat, it will degenerate into a fistulous ulcer. To prevent this, we must

(A) See an account of the method of sucking wounds, in Mr John Bell's Discourses on Wounds, Part I. discourse v. p. 215. must use compresses, applied so that the bottom of the wound may suffer a more considerable pressure than the upper part of it. Thus the matter formed at the bottom will be gradually forced upwards, and that formed at the upper part will be incapable of descending by its weight; the divided parts, in the mean time, easily uniting when brought close together. Indeed, the power which nature has of uniting different parts of the human body is very surprising; for, according to authors of credit, even if a piece of flesh be totally cut out, and applied in a short time afterwards to the place from whence it was cut, it will unite. That a part cut out of a living body does not entirely lose its vital power for some time, is evident from the modern practice of transplanting teeth; and from an experiment of Mr John Hunter's, where he put the testicle of a cock into the belly of a living hen, and the testicle adhered to the liver, and became connected to it by means of blood-vessels*. We have therefore the greatest reason to hope, that the divided parts of the human body, when closely applied to each other, will cohere without leaving any sinus or cavity between them. However, if this method should fail, and matter be collected in the depending part of the wound, it will be necessary to make an opening in that part in order to let it out; after which the wound may be cured in the common way. 4. During the course of the cure, it sometimes happens that the wound, instead of filling up with granulations of a florid colour, shoots up into a glairy-like substance which rises above the level of the surrounding skin, while, at the same time, instead of laudable pus, a thin ill-coloured and fetid ichor is discharged. In this case the lips of the wound lose their beautiful pear colour, and become callous and white, nor does the cicatrizing of the wound at all advance. When this happens in a healthy patient, it generally proceeds from some improper management, especially the making use of too many emollient and relaxing medicines, an immoderate use of balms and ointments. Frequently nothing more is requisite for taking down this fungus than dressing with dry lint; at other times desiccative powders, such as calamine, tutty, calcined alum, &c. will be necessary; and sometimes red precipitate mercury must be used. This last, however, is apt to give great pain, if sprinkled in its dry state upon the wound; it is therefore most proper to grind it with some yellow balsam ointment, which makes a much more gentle, though at the same time an efficacious excharotic. Touching the overgrown parts with blue vitriol is also found very effectual.

Hitherto we have considered the wounded patient as otherwise in a state of perfect health; but it must be observed, that a large wound is capable of disordering the system to a great degree. If the patient is strong and vigorous, and the pain and inflammation of the wound great, considerable degree of fever may arise, which it will be necessary to check by bleeding, low diet, and other parts of the antiphlogistic regimen, at the same time the inflamed lips of the wound and parts adjacent are to be treated with emollient fomentations or cataplasms till the pain and swelling abate. On the other hand, it may happen, when the patient is of a weak and lax habit, that the vis vitae may not be sufficient to excite such an inflammation in the wound as is absolutely necessary for its cure. In this case, the edges of the wound look pale and soft; the wound itself ichorous and bloody, without any signs of granulations; or if any granulations shoot up, they are of the fungous glairy kind above mentioned. To such wounds all external applications are vain; it is necessary to strengthen the patient by proper internal remedies, among which the bark has a principal place, until the wound begins to alter its appearance. In such persons, too, there is some danger of a hectic fever by the absorption of matter; and this will take place during the course of the cure, even when the appearances have been at first as favourable as could be wished. This happens generally when the wound is large, and a great quantity of matter formed; for by this discharge the patient is weakened; so that the pus is no sooner formed, than it is reconveyed into the body by the absorbent vessels, and immediately affects the patient with feverish heat. When this takes place, the best remedy is to exhibit the bark copiously, at the same time to support the patient by proper cordials and nourishing diet. Indeed, in general, it will be found, that, in the case of wounds of any considerable magnitude, a more full and nourishing regimen is required than the patient, even in health, has been accustomed to; for the discharge of pus alone, where the quantity is considerable, proves very debilitating. And it is constantly found, that the cure of such sores goes on much more easily when the patient is kept in his usual habit of body, than when his system is much emaciated by a very low allowance; and, for the same reason, purgatives, taken more freely than what is necessary to keep the bowels open, and whatever else tends to weaken the constitution, are improper in the cure of wounds.

Haemorrhages very frequently happen in wounds, either from a division of a large artery, or of a number of small ones. In this case, the first step to be taken by the surgeon is to effect a temporary stoppage of the blood by means of compression, and he is then to tie up all the larger vessels according to the methods usually directed.

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

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

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

By the same means the patient, from being in a febrile heat and much confused, soon becomes very tranquil: the violent pulsation of the heart and larger arteries abates, and the blood not being propelled with such impetuosity into the smaller vessels of the part, they are left at more liberty to retract.

The patient ought to be kept exceedingly cool; wine and other cordials should be rigidly avoided; cold water, acidulated either with the mineral or vegetable acids, ought to be the only drink; motion of every kind, particularly of the part affected, should be guarded against; and the lip of the wound being drawn together by adhesive plaster, and gently covered with soft charpie, it ought to be tied up with a bandage so applied as to produce a moderate degree of pressure on the extremities of the divided parts.

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

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

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

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

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

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

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

In finishing the dressings of such wounds, after the adhesive plaster and compresses have been applied, a bandage properly adapted to the part ought to be employed, and in such a manner as to produce as equal a degree of pressure over the surface of the wound as possible. But it now and then happens that no bandage can be applied so as to produce the desired effect; and in such cases the hand of an assistant is the only resource; which being firmly pressed over the dressings, will commonly succeed when no other means is found to have much influence. Wounds of the nerves, tendons, and ligaments, are attended with much more violent symptoms than those where even considerable arteries are divided, and they frequently result every method of cure proposed by the most skilful practitioners. In the simple process of blood-letting, it frequently happens that the tendinous expansion called the aponeurosis of the biceps muscle is wounded, or even the tendon of that muscle itself is punctured, by the point of the lancet; or sometimes a nerve which happens to lie in the neighbourhood is partially divided. Any one of these wounds, though they are the smallest we can well suppose to be given, are frequently very dangerous and difficult of cure. It sometimes immediately happens on the introduction of the lancet, that the patient complains of a most exquisite degree of pain; and when this occurs, we may rest assured that either a tendon or a nerve has been wounded. On some occasions, by proper management, such as evacuating a considerable quantity of blood at the orifice newly made, by keeping the part at perfect rest, and preferring the patient in as cool a state as possible, the pain at first complained of will gradually abate, and at last go off entirely without any bad consequence. At other times, however, this pain which occurs instantaneously on the introduction of the lancet, instead of abating, begins soon to increase; a fullness, or small degree of swelling, takes place in the parts contiguous to the wound; the lips of the sore become somewhat hard and inflamed; and, in the course of about 24 hours from the operation, a thin watery serum begins to be discharged at the orifice.

If, by the means employed, relief is not soon obtained, these symptoms generally continue in nearly the same state for two or perhaps three days longer. At this time the violent pain which at first took place becomes still more distressing; but instead of being sharp and acute as before, it is now attended with the sensation of a burning heat, which goes on to increase, and proves, during the whole course of the ailment, a source of constant distress to the patient. The fullness and hardness in the lips of the wound begin to increase, and the swelling in the neighbouring parts gradually extends over the whole members. The parts at last become exceedingly tense and hard; an erysipelatous inflammatory colour frequently appears over the whole member; the pulse by this time is generally very hard and quick; the pain is now intense, the patient exceedingly restless; twitchings of the tendons occur to a greater or less degree; on some occasions, a locked jaw and other convulsive affections supervene; and all these symptoms continuing to increase, it most frequently happens that the torture under which the patient has been groaning is at last terminated by death.

Different opinions have prevailed respecting the cause of these symptoms. By some they have been imputed to wounds of the tendons. By others the tendons are supposed to be so entirely destitute of sensibility, as to be quite incapable of producing so much distress; so that wounds of the nerves they consider, on all such occasions, as the true cause of the various symptoms we have mentioned.

One or other of these ideas continued to be the only source for explaining the various phenomena found to occur in this malady, till a different opinion was suggested by the late ingenious Mr John Hunter of London. Mr Hunter supposed, that all the dreadful symptoms found now and then to be induced by the operation of blood-letting, might be more readily accounted for from an inflamed state of the internal surface of the vein, than from any other cause. Such a state of the vein he has often traced in horses that have died of such symptoms from venefication, and the same appearances have sometimes occurred also in the human body. And on other occasions, inflammation having in this manner been once excited, has been known to terminate in suppuration; and the matter thus produced being in the course of circulation carried to the heart, Mr Hunter supposes that in such cases death may have been induced by that cause alone.

There can be no reason to doubt the fact held forth by Mr Hunter, that in such instances the vein in which the orifice has been made, has frequently after death been found greatly inflamed: but however ingenious his arguments may be for concluding that the state of the vein is the original cause of all the bad symptoms enumerated, and although we must allow that such an inflammatory affection of a vein must have a considerable influence in aggravating the various symptoms previously induced by other causes; yet we may very fairly conclude, that it could not probably in any one instance be able to account with satisfaction for their first production.

In many cases the patient, at the very instant of the operation, feels a very unusual degree of pain. In some cases, the violence of the pain is almost unpardonable. Now this we can never suppose to have been produced by the mere puncture of a vein; for although the coats of veins are not perhaps entirely destitute of feeling, yet we know well that they are not endowed with such a degree of sensibility as to render it probable that such intense pain could ever be induced by their being punctured in any way whatever. This inflamed not just state of the veins therefore, as detected by Mr Hunter after death, must be considered rather as being produced by, than as being productive of, such affections; and that such ailments should frequently produce an inflammation of the contiguous veins, is a very probable conjecture. In the course of 48 hours from the operation, when the febrile symptoms are just commencing, such a degree of hardness and evident inflammation is induced over all the parts contiguous to the orifice, that it would be surprising indeed if the vein, which is thus perhaps entirely surrounded with parts highly inflamed, should escape altogether. We shall therefore proceed upon the supposition of this inflamed state of the veins to the being a consequence rather than the cause of such ailments; and of course we now revert to one or other of the opinions long ago adopted on this subject, that all the train of bad symptoms found on some occasions to succeed venefication, proceeds either from the wound of a nerve or of a tendon.

That a partial wound of a nerve will now and then produce very distressing symptoms, no practitioner will deny: but it has been attempted to be shewn, that tendons are almost totally destitute of sensibility; and it has therefore been supposed, that their being wounded can never account for the various symptoms known to occur in such cases. There is great reason however to think, that in different instances the same train of symptoms have been induced by different causes; that in one Wounds. instance a wounded nerve, and in others pricks of the tendons, have given rise to them, as we have already supposed.

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

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

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

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

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

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

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

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

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

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

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

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

Wounds of the abdomen must be closed as soon as possible, and then treated as simple wounds; only they ought to be dressed as seldom and expeditiously as possible. Copious bleeding and a spare diet, with other parts of the antiphlogistic regimen, are here absolutely necessary.

It sometimes happens, that, through a large wound of the abdominal integuments, the intestines come out without being injured. The most certain method, in all such cases, is to return the protruded part as soon as possible; for although writers in general formerly recommended warm fomentations, &c. to be previously applied, the latest authors upon this subject consider the most natural and proper fomentation to be that which is produced by the heat and moisture of the patient's belly, and that therefore the intestines, if no mortification has taken place, are to be cleared from extraneous matter, and immediately returned.

When the wound of the abdomen is large, the intestines easily prolapse, and they are as easily returned. But when part of an intestine has been forced through a narrow wound, it is much more dangerous. For the prolapsed intestine being distended by flatus, or the ingested aliment driven thither by the peristaltic motion, it will become inflamed, tumefied, and incapable of being returned through the stricture of the wound; whence gangrene will soon follow. In this case the utmost care is to be taken to reduce the intestine to its natural size. When this cannot be accomplished by other means, some practitioners of great eminence have even advised the puncturing of the intestine in different places in order to discharge the flatus. This practice has also been recommended in an incarcerated hernia, but is exceedingly disapproved of by Mr Pott and later writers; and it seems to be very dubious whether any good can possibly arise from it. To puncture any part that is already inflamed, must undoubtedly add to the inflammation; and it is very improbable that the discharge of flatus procured by the punctures would be at all a recompense for the bad consequences produced by the increased inflammation. The method of Celsus is much more eligible: It is to dilate the wound so as to reduce the intestine with ease.

Sometimes part of the intestine is lost either by suppuration or gangrene. In this case, all that can be done is to put a single stitch through the wounded bowel, and to fix it to the external wound by passing theuture also through the sides of the wound. The ends of the intestine may perhaps adhere; or at any rate the wound will continue to perform the office of an anus, out of which the feces will continue to be discharged during life. The directions given by some surgeons about inserting the upper end of the gut into the lower, and stitching them together, are perfectly impracticable; and even if they were practicable, would certainly produce new mortification, which could not but be fatal.

When the omentum appears prolapsed, the same general treatment is to be observed; only that, when it is mortified, the dead part may be safely extirpated.—We shall conclude the article of abdominal wounds with a case from the memoirs of the academy of sciences for the year 1795, which shows that we ought not to despair, even though the most desperate symptoms should take place. A madman wounded himself in 18 different places of the abdomen. Eight of these penetrated the cavity, and injured the contained viscera; he had a diarrhoea, nausea, and vomiting, tension of the abdomen, with difficult respiration and violent fever, so that his life was despaired of. During the first four days he was bled seven times; and during the greatest part of the cure his diet consisted almost entirely of flesh-broths, with the addition of some mild vegetables. By these means he was not only cured of his wounds, but restored to his right senses. Seventeen months after, he went mad again, and threw himself over a precipice, by which he was instantly killed. On opening the body, the wounds were found to have penetrated the middle lobe of the liver, the intestinum jejunum, and the colon.

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

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

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

Of contused and lacerated Wounds.—When the small vessels are ruptured by a blow with any hard instrument without penetrating the skin, at the same time that the solid fibres of the part are crushed, the injury is termed a contusion: and when at the same time the skin is broken, it is termed a contused and lacerated wound.

Every contusion therefore, whether the skin is broken or not, may be properly reckoned a wound; where the injury is so slight that none of the contents of the small vessels are extravasated, it scarcely deserves to be mentioned. The immediate consequence of a contusion, therefore, is a swelling, by reason of the extravasation just mentioned; and the skin becomes discoloured by the blood stagnating under it; but as this fluid, even though covered by the skin, cannot long remain in the natural state, it thence happens, that the contused part soon loses its florid red colour, and becomes blue or black; the thinner parts being in the mean time gradually taken up by the absorbent vessels. This at last happens to the blood itself; the blue disappears, and is succeeded by a yellowish colour, showing that the blood is now dissolved; after which, the part recovers its former appearance, and the ruptured vessels appear to have united as if no injury had happened.

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

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

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

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

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

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

Where the wounded person has not suffered any great loss of blood, and this is generally the case, it will be advisable to open a vein immediately, and take from the arm a large quantity; and to repeat bleeding as circumstances may require, the second, and even the third day.

Repeated bleedings in the beginning are followed by many advantages. They prevent pain and a good deal of inflammation, lessen any feverish assaults, and seldom fail to obviate impothumations, and a long train of complicated symptoms which are wont otherwise to interrupt the cure, miserably harass the poor patient, and too often endanger his life. Even where the feverish symptoms run high, and there is almost a certainty that matter is forming, bleeding, in such a state, is very frequently of great advantage.

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

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

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

Although no considerable hemorrhage may happen on first receiving a gun-shot wound; yet after the sloughs commonly produced upon such occasions have come off, some considerable arteries may be exposed, and then a dangerous hemorrhage may ensue. The hemorrhage is often preceded by a great heat in the injured parts, and with a throbbing pulsatory pain. At this period it may frequently be prevented by plentiful blood-letting, particularly local. But if the hemorrhage has fairly taken place, and from arteries of considerable size, nothing will restrain it but the proper application of ligatures. As the discharge in these cases would often prove dangerous before the surgeon could be procured, the attendants should be furnished with a tourniquet, with directions to apply it, upon the first appearance of blood.

Till of late years the scarifying of gun-shot wounds was a practice which prevailed very universally among surgeons; and it was expected by this, that the sloughs with which wounds are sometimes covered would sooner separate, and that the cure would thereby be more readily performed. It is now, however, known, that this practice, instead of being useful, very generally does harm by increasing the inflammation. It should therefore be laid entirely aside.

When a gun-shot wound cannot easily or safely be laid open from one end to the other, perhaps it may be proper to introduce a cord through the sinus. This, however, should not be attempted till the first or inflammatory state of the wound is over: but when a cord cannot be properly introduced, on account of the situation or direction of the wound, compression may prove equally useful here as in cases of punctured wounds.

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

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

Some of the milder of these symptoms, as vertigo, flupelaction, and a temporary loss of sensibility, are frequently induced by flight blows upon the head, but commonly soon disappear, either by rest alone, or by the means to be afterwards pointed out. But when any other symptoms ensue, such as dilatation of the pupils, and especially when much blood is discharged from the eyes, nose, and ears, and that there is an involuntary discharge of faeces and urine, it may be reasonably concluded that compression of the brain is induced.

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

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

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

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

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

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

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

When blood-vessels of any considerable size are divided, either before or in time of the examination, they ought to be allowed to bleed freely, as in no case whatever is the loss of blood attended with more advantage than the present. When, however, it appears that the patient has lost a sufficient quantity, the vessels ought to be secured.

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

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

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

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

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

The patient ought to be laid on a table, with a mattress under him, while his head is placed upon a pillow, and secured by an assistant. When the extent of the fracture has been determined, and the bleeding from the incision stopped, the depressed bone is now to be elevated; but previous to this it is necessary to search for detached pieces. Should any be found, they ought to be removed by a pair of forceps adapted to this purpose. By the same instrument any splinters of bone which may have been beaten in may be removed; but when a part of the bone is beaten in beyond the level of the rest of the cranium, as much of the pericranium is then to be removed by a raphatory, as will allow the trephine to be applied; or, if the operator incline, for the sake of dispatch, he may use the trepan; or the operation may be begun and finished with the trephine, while the trepan may perform the middle and principal part of the work. This part of the work is begun by making a hole with the perforator, deep enough to fix the central pin of the trephine, in order to prevent the saw from slipping out of its central course, till it has formed a groove sufficiently deep to be worked steadily in; and then the pin is to be removed. If the bone be thick, the teeth of the saw must be cleaned now and then by the brush during the perforation, and dipped in oil as often as it is cleaned, which will considerably facilitate the motion, and render it more expeditious; making it at the same time much less disagreeable to the patient, if he possess his senses. That no time may be lost, the operator ought to be provided with two instruments of the same size, or at least to have two heads which can be readily fitted to the same handle.

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

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

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

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

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

After the elevation of the depressed pieces, or the removal of those which are quite loose, the extraction of the extraneous bodies, and the evacuation of extravasated fluids, &c. the sure is to be dressed in the lightest and easiest manner; all that is necessary being to apply a pledget of fine scraped lint, covered with simple ointment, to that part of the dura mater which is laid bare by

(b) A trepanning instrument has been invented by Mr Rodman, surgeon, Paisley, which has no central pin, and it is so contrived that any given thickness of bone may be cut, so that the danger from other instruments is by the use of this entirely avoided. See a more detailed account of this instrument under ABAPTISTON. Wounds. by the trepan, or otherwise; after which the edges of the scalp are to be brought together or nearly so, and another pletget laid along the whole course of the wound; a piece of fine soft linen is to be laid over all, and the dressings may be retained in their place by a common night-cap applied close to the head, and properly fixed.

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

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

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

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

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

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

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

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

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

in Farriery. See Farriery Index.