NATIONAL LIBRARY OF MEDICINE Washington Founded 1836 U. S. Department of Health, Education, and Welfare Public Health Service i DICTIONARY OF ilracrfiral &ur&tr%t COMPREHENDING KLL THE MOST INTERESTING IMPROVEMENTS, FROM THE EARLIEST TIMES DOWN TO THE PRESENT PERIOD; AN ACCOUNT OF THE INSTRUMENTS, REMEDIES, AND APPLICATIONS EMPLOYED IN SURGERY; THE ETYMOLOGY AND SIGNIFICATION OF THE PRINCIPAL TERMS: Numerous Reference-? to Ancient and Modern Works, forming together a " Catalogm Raisonnee" of Surgical Literature : WITH A VARIETY OF ORIGINAL FACTS AND OBSERVATIONS BY SAMUEL COOPER* (ir.Ml.r.r.V SURGEON TO THE* FORCES; MEMBER OF THE'ROYAL COLLEGE OF SURGEONS r\V THE MEDICAL'AND CHIRUROICAL SOCIETY OF LONDON; AT 01' THT, MEDICAL SOCIETJT OF MA*nSEIM.Vc WITH NOTES AND AN APPENDIX. BY WILLIAM ANDERSON, iK THE COLLEGE OF SURGEONS OF EDINBURGH J PROFESSOR OF ANATOMY ANT PHYSIOLOGY TO THE VERMONT ACADEMY OF MEDICINE J AND LECTURER ON SURGICAL ANATOMY IN SEW- IN TWO VOLUMES. VOL. II. MtOM THE FOURTH LONDON EDITION- NEW-YORK : I'lBLI-HF.D BY COLLINS & HANNAY, 230 PEARL-STKEKT. J. It J. Harper, Printers. wo c ns-U y. 3u southern District ol New-York, s&. BE IT REMEMBERED, That on the second day ot December, in tue lori>-seveiiti. year of the Independence of the United States of America, Collins &. Hahnay, of tli< said District, have deposited in this office the title of a book, the right whereof they claim as proprietors, in the words following, to wit: ' A Dictionary of Practical Sprgerj comprehending all the most Interesting Improve " ments, from the earliest times down to the present period ; an Account of the Instru- " ments, Remedies, and Applications employed in Surgery ; the Etymology and Signi- " fixation of the Principal Terms ; and Numerous References to Ancient and Modern ■'' Works, forming together a " Catalogue Raisonnee" of Surgical Literature ; with a 'Variety of Original Facts and Observations, by Samuel Cooper, formerly Surgeon to ,! the Forces; Member of the Royal College of Surgeons ; of the Medical and Chirur- •' gical Society of London ; and of the Medical Society of Marseilles. With Notes and 'an Appendix, by William Anderson, of the College of Surgeons of Edinburgh. ''Professor of Anatomy and Physiology to the Vermont Academy of Medicine ' "and Lecturer on Surgical Anatomy in New-York." In conformity to the Act of the Congress of the United States, entitled " An Act l'oi the encouragement of Learning, by securing the copies of Maps, Charts, and Books, to The authors and proprietors of such copies, during the times therein mentioned." And also to an Act, entitled " An Act supplementary to an Act, entitled An Act for the en- couragement of Learning, by securing the copies of Maps, Charts, and Books, to the authors and proprietors of such copies during the times therein mentioned, and extending ♦he benefits thereof to the arts of designing, engraving, and etching historical and other JAMES DILL, Clerk fif fb>- Smith rm. District of Xnn-Ynrl •ttin«"iii Dr. JOHN MILLER LANCASTER DICTIONARY OF PRACTICAL SURGERY. This mark (*) will signify, that the Word which it precedes is further spoken of in the Appendix. HER XIE'RNIA. (From cgvcr, a branch, from its protruding forward.) Surgeons under- stand by the term hernia, a tumour, formed by the protrusion of some of the viscera of the abdomen, out of that cavity, info a kind of sac, composed of the portion of perito- neum, which is pushed before them. How- ever, there are certainly cases which will not be comprehended in this definition ; either because the parts are not protruded at all, or have no hernial sac, as the reader will learn in the course of this article. " The brilliant progress which surgery has made in modern times (says Scarpa) is, properly speaking, only the result of patho- logical anatomy, that is to say, of exact comparisons of the natural slate of our or- gans with their different diseases, which may depend upon an alteration' of texture, a de- rangement of fund ions, a solution of con- tinuity, or a change of situation. It is from i morbid anntomy, that the most rational curative methods, with which modern sur- , gery is enriched, are deduced as so many corollaries; methods, to which we are also indebted for the perfection of operations. " There are indeed a certain number of surgical operations, for the prompt and safe execution of which, more anatomical know- ledge will suffice; but in many others, the surgeon cannot promise himself success, even 'though he be well acquainted with ana- tomy, unless he has particularly studied the numerous changes of position, and altera- tions of texture, of which the parts, upon which he is ubout to operate, are susceptible. If he has not the requisite information upon all these points, fake appearances may de- cei\e his judgment, and make him commit mistakes, sometimes of a very serious and irreparable kind. " In order to have a convincing proof of this truth, it will be sufficient to take a view of (he different species of hernia:, und their numerous complications. Assuredly, no anatomist would believe, that the intestine ccecuin, naturally fixed in the right ileum, and the urinary bladder, situiited at thejbot- tom of the pelvis, could undergo, without being torn, so considerable a displacement us to protrude through the abdominal ring, HER and descend even into the scrotum ; flint the same intestine, the coecum, could pass from the right iliac region to the umbilicus, pro- trude at this opening, and foirn an umbili- cal hernia; that the right colon could have been found protruded from the abdomen at the left abdominal ring, and the left colon through the right one ; that the liver, spleen, and ovary could sometimes form the con- tents of umbilical, inguinal, and femoral hernia?; that the coecum could engage itself within the colon, and even protrude at the anus; that the stomach could be forced through the diaphragm, and form a hernia within the chest : that the omentum, or in- testine, or both these parts together, could sometimes escape from the belly through the foramen ovale, or sacro-ischiatic notch of the pelvis; that a noose of small intestine, after being engaged in the abdominal i-inr^ or under the femoral arch, could suffer the most violent strangulation, without the course of the intestinal matter being inter- cepted ; lastly, that in certain circum- stances, the intestine and omentum could be in immediate contact with the testicle,, within the tunica, vaginalis, without the least laceration of this latter membrane. These and several other analogous l'ac'.-0 says Scarpa, are so surprising, that they would yet be regarded as incredible, had they not been proved by numerous obser- vntions on individuals affected with hernia: their possibility (repeats this experienced professor) would not even have been sus- pected, either by the anatomist or physiolo- gist." (See Searph, TraM des Hemits, Prcf.) The pa>ts of the body, where hernia; most frequently make their appearance, are the groin, the navel, the labia pudendi, and the upper and forepart of the thiiih ; they do also occur at every point of the anterior part of the abdomen ; and there are several less common instances, in which hernial tu- mours present themselves' at the foramen ov:de ; in the perinamin; in the vagina; at the ischiatic notch, Lc. The parts, which, by being thrust forth from the cavity, in which they ought natu- rally to remain, mostly produce hornise, are either a portion of (he omentum, or a part A HERNIA of the intestinal eanal, or loth together, part of the panetes of (be J . n, pro- Bit the stomach, the liver, spleun, uterus, motes the occurrence of hernia, »«•'«, ovaries, bladder, be. have b,•en known to persons who have had the^ pel rtoiiemn farm the contents of some hernial tumours, wounded, are very liable to the present d.s- From these two circumstanccsof situation ease ; (RicheraiidJVosogr. Lhtr. ':-/P- ^17, nd contents, are derived all the different Schmucker, I'trmischU Chir. bchnften B. 1, ..pellntions, by which hernia: ore distin-^. 197,) and men are much more liable than a portion of intestine alone women, to inguinal hernia, owing evidently ntentsof the tumour, the rase to the larger size of the abdominal ring; while in women, as there is a larger space £Ui>hcd. If forms the co Is called tnlerocele ; if a piece of omentum enly, e, i/locele; and if both intestine and bi;ieutuui contribute to the formation of the tumour, it is called an entero-epiplocele. VViicn the contents of a hernia protrude at the abdomiual ring, but only pass as low as (lie groin, or labium pudendi, the case re- ceives the name of bubonocele, or inguinal hernia; but if the parts descend into the sciotum, it is called an oscheocele, or scrotal lamia. The crural, or femoral hemic, is the name giveu to that which takes place below Poupart's ligament. When the bowels protrude at tbe navel, the case is named an esomphalos, or umbilical hernia ; and ventral is the epithet -iven to the swelling, when it occurs at any other promiscuous part of the front of the abdomen. The congenital rupture is a very particular rase, in which the protruded viscera are not covered with a common hernial sac of peritoneum, but are lodged in the cavity of the tunica vagi- nalis, in contact with the testicle, and, as must be obvious, it is not named like hernia: in general, from its situation, or contents, but from the circumstance of its existing from the time of birth. H hen the protruded bowels lie quietly in the sac, and admit of being readily put back into (he abdomen, the c ;.se is termed a re- ducible hernia; and when they sutler no constriction, yet cannot be put hack, owing to adhesions, or their large size in relation lo the aperture, through which they have to pass, the hernia is termed irreducible. An incarcerated, or strangulated hernia sig- nifies one, which notfomly cunnot be re- must" be considered, as being under th duced, but suffers constriction ; so that if a influence of some predisposing cause. A gentleman, who has gained great honour by for the protrusion of the viscera, below Pou- part's ligament, they are more exposed than men to femoral hernias, o With regard to the exciting causes, our knowledge is involved in less doubt. The grand cause of this kind, is the powerful action of the abdominal muscles^and dia- phragm on the viscera. In feats*of agility, such as jumping, he. the pressure which the contents of the abdomen must often en- counter, sufficiently accounts for their pro- truding at any part, where the abdominal parietes do not make adequate resistance. The same consideration explains, why her- nia: very often lake place in lifting and car- rying heavy weights, running, vomiting, straining at stool, parturition, &o. and in people who inhabit mountainous countries. This diminution of the capacity of the abdomen, by the action of the abdominal muscles and diaphragm, in many occasional exertions, must take place in every body by reason of the common habits and necessi- ties of life. But as only a certain number of persons meet with the disease, it is fair to infer, that either the exciting causes must operate with greater force in them, than in the generality of people, or else that their abdominal parietes have not been ca- pable of the ordinary degree of resistance. Many patients, who meet with hernia;, in making violent efforts and exertions, may be in the former circumstance ; while others . whose viscera protrude from such trivial J* things as coughing, sneezing, ciying, &tc. ** -piece of intestine be protruded, the pressure to which it is subjected, stops the passage of its contents towards the anus, excites inflam- mation of the bowel, and brings on a train «f alarming, and often fatal consequences. The causes of hernia: are either prtdispo- iing, or exciting. Among the former, wri- ters mention a preternaturally large size of the openings, at which the bowels are liable to protrude; a weakness and relaxation of the margins of these aperture?; a preterna- tural laxity of the peritoneum ; an unusually long mesentery, or omentum, &c. With regard to the abdominal ring, the transverse tendinous fibres, which naturally cross and strengthen its upper and outer part, are much weaker in some subjects than olhers. JNo idea seems more prevalent in books, Chan that taking a good deal of oil with our food, is conducive to the formation of her- n al diseases. Some of the alleged predis- posing causes, may justly excite scepticism ; but several cireuu,stances tend to prove, that anatuxal deficiency of resistance, in any a most valuable treatise on hernia, remarks, that " hernia:, which originate in predispo- sition, generally come on gradually, and almost imperceptibly ; while iMose which are produced by bodily exertions, are form- ed suddenly, and by the immediate action of the exciting cause. The occurrence of the complaint is often indicated, in the first instance, by a fulness, combined with a sense of weakness, about the abdominal ring. The swelling is increased by any ac- tion of the respiratory muscles, and disap- pears on pressure, and in the recumbent po- sition of the body. It gradually finds its way through the tendon of the external ob- lique muscle, into the groin, and afterward into the scrotum. When a hernia takes place suddenly, it is generally attended with a sensation of something giving way at the part, and with pain." (Lawrence on Hun- tures,p.29, Edit. 3.) • Upon the subject of the immediate cause of hernia?, it 1s observed by Scarpa, that se i HERNIA, S veral distinguished modern surgeons, as, for instance, Warton, (Adenograph. cap. 11.) Benevoli, (Dissertazioni Chirurgische, 1.) Rossius, (Acta Nat. cur. T. 2, Obs, 178.) Brendel, (rfc herniarvm nalalibus,) and Mor gagni, (de sed. et cam. morb. epist. 43, art. 13,) consider a relaxation and elongation of the mesentery as the principal cause of hernia: in general, and of the bubonocele in parti- cular. Hence, say they, the whole mass of intestines, or only a portion of an intestine, descends against the inner orifice of the inguinal ring, presses against this opening, and gradually makes its way out of the abdomen. In examining this pathological Eoint without prejudice, it is incontesta- le, says Scarpa, that an intestine cannot be moved beyond its natural limits, unless that part of the mesentery, which retains and fixes the bowel in its proper place, be at the same time elongated. But it does not follow from this, that a relaxation of the mesentery must precede the displacement of the intestine. It appears to Scarpa much more probable, that these two events are limultaneous, and depend upon one and the same cause. " In the healthy state the abdomen, con- sidered altogether, is submitted to two oppo- site forces, which reciprocally balance each other. One is the pressure of the viscera against the abdominal parietes; the other is the reaction of the same parietes upon the viscera which they contain. If these two forces were in perfect equilibrium in all in- dividuals, and under all the circumstances of life, we should not be in the least subject to hernia:. If, when the equilibrium has been broken, every point of the parietes of the belly were to yield equally to the im- fiulse of the viscera, an increase of the vo- ume of the whole abdomen would be the consequence ; but a true hernia would never happen. The cavity of the abdomen is al- ways completely full. The containing and contained parts react upon, and reciprocally compress one another. It is by the effect of this moderate, but equal and unremitting ^ pressure, that all the viscera mutually sup- port each other. Without it, the ligaments ■f'S^f the liver, those of the spleen, and the w various membranous bands of the intestines in general, would only be feeble means for fixing such parts in their respective situa- tions. But there are certain points of the abdominal parietes which naturally present much less resistance than others, and which react with much less power against the pres- sure made from within outwards by the ah dominal viscera. Such is particularly the part which extends from the pubes to the anterior superior spinous process of the ili- um. This relative weakness of some points of the abdominal parietes is very marked in certain individuals, iu consequence of a defect of organization. It may also be in- creased by internal or external causes, which are as various as they are numerous. When in one of these cases the pressure made by the viscera is unusually increased, as hap- pens in a violent effort, a defect in the equi- librium between the two forces above men- tioned is occasioned ; that is 1 o say, the re- action of the abdominal parietes is no longer proportioned, at least at cr-rtain points, to the force of the impulse of the viscera. The conjoined powers of the abdominal muscles, diaphragm, and levator ani, are then directed and concentrated against the most feeble point of the abdomen, towards which they propel the nearest viscus, or that, which from its moveableness, is the most liable to displacement. If such viscus should happen to be the noose of an intestine, it is evident that the power which tends to make it protrude from the belly, must at the same lime act upon the corresponding portion of the mesentery ; and the intestine, in passing through the parietes of the abdomen, drags the mesentery after it, and makes this mem- brane yield and become elongated. When the displaced viscera meet with little resis- tance on the part of the parietes of the ab- domen, the hernia is quickly formed, and the elongation of the mesentery occurs with equal celerity. We have an example of this in the inguinal congenital hernia : in this ease the intestine ~Ts, in some measure, precipitated into a sac previously prepared for its reception. .On the contrary, in the ordinary inguinal hernia, a totally different disposition of the parts renders the progress of the disease much slower. In most in- stances, the hernia is not formed immediate- ly the equilibrium between the impulse of the viscera and the reaction of the abdomi- nal parietes is broken. But in the groin, a slight elevation is first observed,'in the di- rection from the anterior superior spinous process of the ilium towards the inguinal ring. Some time afterward, when the intes- tine has made its appearance onOie outside of the ring, the enlargement of the hernia, and the elongation of the mesentery, make much more rapid, though always simulta- neous progress. "Numerous practical observations, (says Scarpa) concur in proving, that we must not search for the immediate cause of hernia: in "the relaxation of the mesentery, but rather in a want of equilibrium between the pres- sure of the viscera and the resistance of one or several points of the abdominal parietes. Indeed hernia: are seen occurring from the slightest causes in infants, in whom the neck of the tunica vaginalis is not speedily oblite- rated, and in individuals, w ho from being fat, have all on a sudden become extremely thin. Such women as have had children, are more subject to the diseas% than others. Persons also of both seues, who carry considerable burdens, or who play upon wind instru- ments, or who have suffered a forcible con- tusion of the abdomen, are particularly ex- posed to the* disorder, even though there is not the least reason for suspecting in them a relaxation of the mesentery. " Vaginal her- nia*, which arise after difficult labours, af- ford another proof of the same truth : their cause is owing to a laxity and weakness of the parietes of the vagina, which, not being capable of making any further resistance to HBRMA. the pressure ot the viscera, ituated in the cavity of the pelvis, at length suffer these parts 'o protrude. • With respect to the second proposition, that during the formation of a hernia, the combined "force of all the abdominal mus- cles is. as it were, directed and concentra- ted against the most feeble point of the pa- rietes, we see a proof of it in a fact that occurs to our observation every day. In order to convince ourselves of this, we need only noticr what happens in indivi- duals afflicted w ilh hernia-: if they cough, or sneeze or make the .slightest effort, they i:>i >ntly find tl* size of the swelling in- creased, and hasten to support the part with their hand. During the slightest ef- fort*, which render the hernia: larger it is also indisputable, that the mesentery is elon- gated in the same proportion as the intes- tine protrudes. All the viscera have such a tendency to be displaced aud carried to- wards the w< .Vest point of the "parietes of the abdomen, that even those, which are naturally the nin«t di-innt from it, and are the moM firmly fixed by the folds of the me- sentery, may in their turn descend into the hernia*. Anatomical knowledge alone would never have led us to havejl suspicion of the possibility of these occurrences. Sandifort and Paletta h:ive tunnel, irfan umbilical her- nia, the reecum, with » portion of the ileum and colon, (ttbs. Palhol. cap. 4,'fy A'ora Gu- bernaciili t'stit Descriplio i Muuchart, Cam- per, and Bose, have met with the coecum in an ingriinal hernia of the left side. (I)e Hern.Inrnrc. i.i Halleri Disput. Chirurg. Tom '■>. Demonstrat. anat.palholog. lib 2, p. 18, fy Animadrers. dc hem. ingiiin. p. 5.) Lassus has seen the left colon protrude at the right in- guinal ring. (M&deciite Optrnt-.ire, T. I, p. 173.) If it be proved by all these facts, that such viscera,as are the most closely united to the great sac of the peritoneum and neigh- bouring parts, are nevertheless liable lo form hernia? ; ami if such displacements cannot happen w'itnout a considerable elongation of the membranous bands fixing these bowels, in their natural situation, how can we refuse to admit, that a noose of intestine, pushed by degrees'through the inguinal ring, drags along with it the corresponding portion of the mesentery ? In order to explain this event, there is no necessity for supposing a partial relaxation of the mesentery." (Trnitt Pratique ties Hemies, Par A. Scarpa, trad, de Pflatten, p. 37—43.) The general symptoms of a hernia, which is reducible, and free from strangulation, are an indolent tumour in some point of the abdomen, most frequently des> ending out of the abdominal ring, or from just beiow Pou- part's ligament, or else out of the navel; but occasionally,'from various other situations, as will be presently explained. The swelling often originates suddenly, except in the cir- cumstances above related, and it is subject to a change of size, being smaller when the patient lies down on his back, and larger when he stands up, or holds his breath. It frequently diminishes when pressed, and grows large again when the pressure is remo- ved. Its sine and tension often increase af- ter a meal, or when the patient is flatulent. In consequence of the unnatural situation of the bowels, many patients with hernia are occasionally troubled with colic, consti- pation, and vomiting. -Sometimes, however, the functions of the viscera seem to suffer little or no interruption. If the rase be an interoeele, and the por- tion of intestine be small, the tumour is small in proportion ; but, thou ,b small, yet, if the giit be distended with wind, inflamed, or have any degree of stricture made on it, it will be tense, resist the impression of the finger, and give pain upon being handled. On the contrary, if there be no stricture, and the intestine sutler no degree of ii.flam- tnatfthi, let the prolapsed piece be of what length it may, and the tumour of w hat- e\er size, yet the tension will be little, and no pain will attend the handling it; upon the patient's coughing, it will feel as if it were blown into: and, in general, it will be found very easily returnable. (Pott.) A gugg'ing noise is often made when the bowel is ascending If the hernia be an epiplocelt, or one of the omental kind, the tumour has a more flabby and a more unequal feel ; it is in ge- neral perfectly indolent, is more compressi- ble, and (if in the scrotum) is more oblong. ' nnd less round, than the swelling occasion- ed in the s;,nif situation by an intestinal hernia; and, if the quantity be large, and the patient adult, it is in some measure dis- tinguishable by its greater weight. (Pott ) If the case be an enlir -ipiploctle, that is, one consisting of*botji intestine and omen- tum, the characteristic marks will be less clear, than in either of the simple cases : but** the disease may easily be distinguished from every other one, by ai y body in ihe habit of making the examination. (Pott, P. 28.) As the smooth slippery surface of the in- testine generally makes its reduction easier than that of the omentum, we may infer with Mr. Lawrence, " that, if a portion of the contents sfcp up quickly and with noNe, leavingbebitid something which is less easily reduced, the c:i*" is probably an entero-epip- locele. (Sec Treatise on Rupluris, Eoit.Z."' p. 32.) On the subject of prognosis, Mr. Pott re- marks, that the age and constitution of the subject, the date of the disease, its being free, or not free from stricture, or inflamma- tion, the symptoms which attend it, and the probability or improbability of its being re- turnable, necessarily produce much variety. If the subject be an infant, the case is not often attended with mucbdiflkuliy or hazard, the reduction being easy as weil as the de- scent ; and though from neglect, or inatten- tion, the bowel may fall down again, yet it is as easily replaced, and mischief seldom produced: Mr. Pott says seldom, because he has seen an infant, one year old, die of a strangulated hernia, w hich had not been down two days, with all the symptoms of mortified iule-tine. (For nthe/example* of '4 * IU£ft.VfA. •ilcaugulated hernia iu very young infants, refer to Gooch's Chir. Works, Vol. 2,p3S; luiwrenee on Ruptures, p. 65, Edit. 3 ; Edinb. •1/cd. and Surgical Journal, Vol. 3, p. 470, *r.) " If the patient be adult, and in the vigour of life, the consequences of neglect, or of maltreatment, are more to be feared than at any other time, for reasons too obvious to need relating. The great and principal mis- chief to be apprehended, in an intestinal hernia, is an inflammation of the gut, and an obstruction to the passage of the aliment and feces through it; which inflammation and obstruction are generally produced by a stricture made on the intestine. In very old people, the symptoms do not usually make such rapid progress, both on account of the laxity of their frame, and their more languid circulation ; and also that their rup- tures are most frequently of ancient date, and the passage a good deal dilated ; but then, on the other hand, it should also be remembered, that they are by no means ex- empt from inflammatory symptoms; and that if such should come on, the infirmity of old age is no favourable circumstance in the *' treatment, which may become necessary. (Pott.) If the disease be recent, and the patient young, immediate reduction, and constant care to prevent another protrusion, are the only means whereby it is possible to obtain a perfect cure. " If the disease be of long standing, has been neglected or suffered to be frequently down, and has given little or no trouble, the aperture in the abdominal muscle, and the neck of the hernial sac, may both be pre- sumed to be large ; which circumstances in general render immediate reduction less necessary and less difficult, and also frus- trate all rational expectation of a perfect cure. On the contrary, if the rupture be recent, or, though old, has generally been kept up, its immediate reduction is more ab- i solutely necessary, as the risk of stricture is greater from the supposed smallness of the |i j> aperture, and narrowness of the. sac. If the I . rupture be very large and ancient, the pa- :''' tient far advanced in life, the intestine not bound by any degree of stricture, but does its office in the scrotum regularly, and no other inconvenience be found to attend il, but what proceeds from its weight, it will Tn general be better not to attempt reduc- ^ tion, as it will, in these circumstances, most • probably prove fruitless, and the handling the parts in the attempt, may so bruise and injure them as to do mischief." With respect to the correctness of the ad- vice here delivered, some doubt may be entertained, because, though it would cer- tainly not be right to protract the attempts at reduction, so as to do mischief, it must be equally wrong to make no trial, whether the hernia is reducible or not; and, if re- ducible, I should say, that it ought to be reduced without delay, and a truss applied. This opinion, however, seems to agree w ith the injunctions delivered by Pott in another place, as will he seen in tte next section of this article. With regard to the contents of a herniaj, Mr. Pott observes, that " if it be a portion of omentum only, and has been gradually formed, it seldom occasions any bad symp- toms, though its weight w ill sometimes render it very troublesome. But, if it be produced suddenly by effort or violence, that is, if a considerable piece of the caul by accident slip down at once, it will sometimes prove painful and cause very* disagreeable com- plaints; the connexion between the omen- tum, stomach, duodenum, &.c. being such as to render the sudden) descent of a large piece of the first sometimes productive of nausea, vomiting,colic,and all the disagreea- ble symptoms arising from the derangement of these viscera. When the piece of caul is engaged in such a degree of stricture as to prevent the circulation of blood through it, it will sometimes, by becoming gangrenous, be the occasion of rery bad symptoms and even of death, as I have more than once seen : and thus, as a mere omental hernia, it may sometimes be subject to great hazard. But even though it should never be liable to the just-mentioned evil, that is, though the portion of the.caul should remain, uninjured in the scrotum, yet it renders the patient constantly liable to hazard from another quarter; it makes it every moment possible for a niece of intestine to slip into the same sac, and thereby add to the case all the trouble and all the danger arising from an intestinal rupture. It is by no means an un- common thing for a piece of gut to be added to a rupture, which had for many years been merely omental, and for that piece to be strangulated, and require imme- diate help " An old omental hernia is often rendered not reducible, more by an alteration made in the state of the prolapsed piece of caul, than by its quantity. Il is very common for that part of the omentum, which passes through the neck of the sac, to be compress- ed into a hard, smooth body, and lose all appearance of caul, while what is below in the scrotum is loose and expanded, and en- joys its natural texture ; iu this case, reduc- tion is often impossible, from the mere figure of the part; and I have so often seen this, both in the living and the dead, that I am satisfied, that for one omental rupture, rendered irreducible by adhesions, many more become so from th*; cause above-men- tioned. "In the sac1 of old omental ruptures that have been lorigfrdown, and only suspended by a bag truss, it is no veiry uncommon thing to have a pretty considerable quantity of fluid collected : this, in different states and circumstances of the disease, is of different colour and consistence, and seldom so much in quantity as to occasion any particular at- tention to it ; Jtiut, on the other hand, it sometimes ia-so^uch in cjuantity as to be- come an additional diseaie to the original one. I have more than once been obliged to let it out, in order to remove the incon- 8 11ER.MA. veniencr arisi'jjr i>oji its weight, and the distention of the scrotum, which I hnve also seen become gangrenous by the neglect of this operation. . , . . , •• If the hernia be of the intestinal kind merrly, and the portion of gut be small, the risk is great, r, strangulation being more likely to happen in this case, and more productive of mi ichief, when it has hap- pened : for the smaller the portion of gut is which is engaged, the tighter the tendon binds, and the more hazardous is the con- sequence. I have seen a futal gangrene, in a bubonocele, whifh had not been formed forty-eight hours, and in which the piece of intestine was little more than half an inch. Another observation made by Pott is, that "ifthe hernia be caused by a portion of the intestine ileum only, it is in general more easily reducible, than if a part of the colon has descended with it, which will also require more address and more patience in the attempt. The reduction of a mere in- testinal hernia too (tetteris paribus) will al- ways remain more practicable, than that of a mere omental one, after it has attained to a certain size and state, 83 the part con- tained within the former is liable to less al- teration of form thnn that within the latter ; which alteration has ulready been mention- ed as no unfrequeut hindcrance of the re- turn of an old caul rupture. " Not that the parts within a mere intes- tinal hernia arc absolutely exempt from -uch an alteration as may render fheir re- turn into the belly impracticable, even where then: is no stricture ; for, says Pott, I have seen that part of the mesentery, which has lain long in the neck of the sac of an old rupture,so considerably hardened and thick- ened, as to prove an insuperable obstacle to its reduction." Upon the whole, this author infers, that an intestinal rupture is subject to worse symptoms, and a greater degree of hazard, than au omental one, though the latter is, by no means, so void of either as it was formerly supposed to be; that bad symp- toms are more likely to attend a recent rupture, than one of ancient date ; that the descent of a very nnall piece of intestine is more hazardous than that of a larger ; and that the hernia, which consists of gut only, is in general attended with worse circumstan- ces, than that which is made up of both gut and caul. Mr. Hey coincides with Pott, in thinking the prognosis more unfavourable when the tumour is smsll. I think it is not a bad general rule, that the smaller the hernia, the less hope then> is of reducing it by the taxis Long-conti nued efforts to reduce a prolapsed intestine;, are most likely to suc- ceed in old and large hernias, when no ad- hesions ha^a tak en place." (Pract. Observ. in Surgtry, p. 21'B) "The openijg (says' Mr. Lawrence) through which t!»e parts protude, is narrow- er in some situ itions than in others; the progress of the case will therefore be more rapid, and the danger of the patieut more urgent. The aperture is generally very small in femoral hernia ; this kind of rup- ture in men, and the bubonocele in women, have a particularly narrow entrance. -On the same grounds, femoral, inguinal, and umbilical ruptures are more dangerous than the ventral, perineal, or vaginal kinds. (Treatise on Ruptures,p. 63, Ed. 3.) mF.ATMr.ST or a iikkSia cap ah lb of Easit AMD IMMEDIATE RKDUCTIO.N, AND NOT ATTENDED WITH ASY TROUBLESOME OK BAD SYMrTOMS. " This case," says Mr. Pott, " is very fre- quently met with in infants and sometimes in adults, and is too often neglected in both. In the former, as the descent seldom hap- pens but when the infant strains to cry, and the gut is either easily put up, or returns sui rponle, as soon as the child becomes quiet, it often is either totally unattended to, or an attempt made to restrain it only by a ban- dage made of cloth, or dimity, and which being ineffectual for such purpose, lays the foundation for future trouble and mischief. "This is, iu great measure, owing to a ' common opinion, that a young infant can- not wear a steel truss; a generally prevail- ing error, and which ought to be corrected. There is no age at which such truss may not be worn, or ought not be applied ; it is, when well made, and properly put on, not only perfectly safe and easy, but the only kind of bandage that can be depended upon ; and as a radical cure depends greatly on the thinness of the hernial sac, and its being capable of being so compressed as possibly, to unite, and thereby entirely close the pas- sage from the belly, it must therefore appear to every one who will give himself the trouble of thinking on the subject, that the fewer times fhe parts have made a descent, and the smaller and finer the elongation of the peritoneum is, the greater the probabili- ty of such cure must be. " The same method of acting must, for the same reasons, be good in every age in which a radical cure may reasonably be expected ; that is, the prolapsed parts cannot be too soon returned, nor too carefully prevented from falling down again, every new descent rendering a cure both more distant and more uncertain. " As soon as the part3 are returned, the truss should be immediately put on, and worn without remission, care being taken, especially if the patient be un infant, to keep the parts on which it presses constantly washed, to prevent galling. " It can hardly be necessary to say, that the surgeon should be careful to see that the truss fits, as his success and reputation de- pend on such care. A truss which does not press enough, is worse than none at all, as it occasions los3 of time and deceives the patient, or his friends ; and one which press- es too much, or on an improper part, gives pain and trouble, by producing an inllani- HKRMA. 0 mation and swelling of the spermatic chord, and sometimes ofthe testicle. "In adults, whose ruptures are of long standing, and accustomed to frequent de- seen'., the hernial sac is generally firm and thick, and the aperture in the tendon of the abdominal muscle large ; the freedom and ease with which the parts return into the belly when the patient is in a supine posture, and the little pain which attends a rupture of this kind, often render the persons who iabour under it careless : but all such should be informed that they are in constant dan- ger of such alteration in their complaint, as may put them into great hazard, and perhaps destroy them. The passage from the belly being open, the quantity of intestine in the hernial sao is always liable to be increased. and when down, to be bound by a stricture An inflammation of that portion ofthe gut which is down, or such obstruction in it as may distend and enlarge it, may at all times produce such complaints as may put the life of the patient into imminent danger; and therefore, notwithstanding this kiud of hernia may have been borne for a great iength of time, without having proved either troublesome or hazardous, yet as it is always possible to become so, and that very sud- denly, it can never be prudent or safe to neglect it. " Even though the rupture should be of the omental kind, (which considered ab- stractedly is not subject to that degree or kind of danger to which the intestinal is liable) yet it may be secondarily, or by accident, the cause of all the same mischief ; for while it keeps the mouth of the hernial sac open, it renders the descent of a piece of in- testine always possible, and consequently always likely to produce the mischief which may proceed from thence. " They who labour under a hernia thus circumstanced, that is, whose ruptures have been generally down while they have been in un erect posture, and which have either gone up of themselves, or have been easily put up in a supine one, should be particularly careful to have their truss well made, and properly fitted ; for the mouth of the sac, and the opening in the tendon being both large and lax, and the parts having been used to descend through them, if the pad of the truss lie not placed right, an) then' be not a due degree of elasticity in the spring, a piece of intestine will, in some posture, slip dowrn behind if, and render the truss productive of lhat very kind of mischief which it ought to prevent." (>ee Truss.) Mr. Pott (hen comments upon the im- portance of having the parts co upletely re- duced before the truss is applied, and upon the dinger that may be incurred by laying such bandage aside after it has been worn some time; since the partial closure of the ring, whereby the descent of the ;;iit is ren- dered less easy, will also make the reduction more difficult, if a piece should happen to slip down ; and hence he insists, th it a truss " should be long, and unremittingly worn by nil those, whose time of life makes the es- v..i.. II 2 prctntions of a perfect cure reasonable, many of the ruptures of adults being owing to the negligent manner in allien, children at school are uffered to wear their trusses." Besides the danger of strangulation, anc' the loss of all chances of a radical cure, when a reducible hernia is neglected, and al- lowed to remain down, there are other mo- tives for keeping up the tumour with a truss, and preventing its increase of size. "The vasl size, to which neglected hernia? some- times increase, not only prohibits all active exertion, but by involving, in the male, the integuments of the penis, incapacitates the subject from the act of copulation, and gives rise to excoriation from the discharge of the urine over the swelling. Probably too, the testis may be affected by the pressure of a very large scrotal hernia. (Mwgagni de. Caus. et Sed. Ep. 3.'>, Art. \-2 ; Sckmwker Vermischte Chir. Schriften, D. 3, p. Wo.) Disorders of the intestinal functions invari- ably attend these large ruptures, and in- crease in frequency and violence in propor- tion to the size of the swelling, and age of the patient. All the moveable viscera of fhe abdomen gradually find their way into the hernial sac, if a rupture be entirely neglect- ed. (Lawrence on Ruptures, p. G7, Edit. '5, 1816.) TREATMENT OF IRREDUCIBLE HEUN1.E, FREE FROM INFLAMMATION, AND UKATTEiNDED WITH TROUBLESOME OR DANGEROUS SYMP- TOMS. Mr. Po't, and all the best writers on rup- tures, ascribe (he incapacity of reduction, iu most cases, either to the largeness of the quan- tity of the contents, an alteration made in their form and texture, or to adhesions, which they have contracted with each other, or (heir containing bag. Mr. Poll was also a v. are, that ruptures are sometimes rendered difficult to be. reduced, by the ccecum being contained in the hernial sac. Of which fact, he was as much con- vinced as the nature of such kind of things would permit ; that is, by observations made both on the iiving and the dend. This state- ment, which was made by Mr. Pott very many years back, deserves particular notice, because its truth is confirmed by the modem observations of Scarpa, whose very import- ant explanations of the cause of the diffi- culty of reduction, may be seen in the second vol. of (he Firs! Lines of Surgery. Mr. Pott has adverted to the kind of im- pediment to reduction, produced by the thickening of the neck of the sac, when the hernia is long neglected, and suffered to re- main iu the scrotum, without any bandage to support its weight. Ttie same author reckons an alteration produced by time, and constant, though gentle pressure in the form and consistence, Or texture of the omentum, as no infrequent cause, why neglected omental ruptures he- roine irreducible. When a portion of omentum " has been suffered to remain for a greul length of time let lll.R.MV in the «rrolum, without having ever been re- turned into the belly, it often happen*, that, although lhat part of it, which is in the lower part of the hernial sac, preserves its natural soft, adipose, expansile sntc, yet all that part which passes through what is culled the neck of the sac, is, by constant pressure, formed into a hard, firm, incompressible, carnous kind of body, incapable of being expanded, and taking the form of the pass- age in which it is confined, exactly filling thai passage, and rendering it impossible to push up the loose part which fills the scro- tum. '• The same reason for incapacity of reduc- tion is also sometimes met with in ruptures of the intestinal kind, from an alteration produced on th.it part of the mesentery which has been suffered to lie quiet for a great length of time in the neck of an old hernial sac. " The other impediment, which I mention- ed to the return of old ruptures, is the con- nexion and adhesion of the parts, either with each other, or with the bag containing them. This is common to both the intestinal and omental hernia, and is produced by slight in- flammations of the puis which have been permitted to lie Ion!: in contact with each other, or perhaps iu many cases from the mere contact only. Tne.e adhesions are more or less firm in different cases, but even the slightest will almost always be found mi invincible objection to the reduction of the adherent parts, by the hand only. " Many, or perhaps most of these irreduci- ble ruptures become so by mere time and neglect, and might at first have been return- ed ; but when they are got into this state, • hey are capable of no rilief from surgery, but the application of a suspensory hag, to take off or lessen (he inconvenience arising from the weight of the scrotum. "People in this situation should be parli- cularly careful not to make any attempts he- yondtheir strength, nor aim at feats of agilily; they should take care to suspend (he loaded scrotum, and (o keep it out of the way of all barm from pressure, bruise, fcc. When the tu- roouris very large, a softquilted bolster should be worn at the bottom of the suspensory, to prevent excoriation, and the scrotum should be frequently washed for the same reason ; a loss of skin in this part, and in such cir- cumstances, being sometimes of the utmost importance. They ought also to be particu- larly attentive to the office of the intestinal canal, to see that they do not by any irregu- larity of diet disorderit, and keep themselves from being costive." Mr. Pott observes, however, that the quiet, inoffensive state of this kind of hernia is by no means to be de- pended upon ; many things may happen to it, by which it may be so altered, as to be- come hazardous, and even fatal: an inflam- mation of that part of the gut which is down, any obstruction to the passage of the aliment or feces through it, a stricture nude by the abdnminil tendon, eitli»r o»t what has been long down, or on a iipw portion which may *t any time be added to i'. are always capa- ble of so altering the stale of (he esse, as to put the life of the patient Into danger. " Indeed the hazard arising from a stric- ture m nle on a piece of intestine contained in the sac of an old irreducible hernia, is in one respect greater 'ban (hat attending on« thai has been found at times reducible; since trout the nature of the case it >yill hrudly admit of any attempt toward relief, but the operation, which in these circum- stances must necessarily be accompanied with additional diffii ulty. '■ Among the ruptures, which have been thought not reducible, and treated as snch, there have been some which, upon more ju- dicious and more patient attempts, have been found capable of reduction. "When this is suspected to be'the ease, the proper method is by absolute rest, in a supine posture, for a considerable length of lime, by great abstinence, and the use of ev-Acuiints, so as to lessen the size of (he pads in (he hernial sac, and render them ca- pable of passing back again into the belly." (Pott on Ruptures.) Fabricuis Mild.mus gives nn account of a man who was radically cured of a rupture, of twenty years dale, by six months confine- ment to bed. (Cent. 6, Obs. 51.) Le Dran and Am,old relate instances of moii«trous bubonoceles, which disnppenfed entirely after (be patients had been long confin-d to bed, and rendered much emaci- ated by tedious illnesses. Some of tint mo- dems have imitated this operation of nature, and by frequent bleedings, and repeated pur- ge*, have sometimes so far reduced the size of the hernia, that it has been returned into the abdomen. Mr. Hey has several limes succeeded in this way. (P. 219.) But the practice cannot prove successful, when the viscera adheres to the sac, or to the perito- neum, just within the abdomen The greal- est objection (o (his* method of cure, is the want of an abs »lute criterion for distinguish- ing when the parts do, or do not adhere to (he hernial sac, and in advanced years, though one were sure that the viscera were free from the sac, the possibility of burling the body by the necessary evacuation*, is also another objection. (Sharp'f Critical Inquiry, p. 15.) Were the plan to be thought worthy of trial, keeping up a constant pressure on the tumour, by means of a suspensory bandage, made (o lace in front, would be proper for promoting the absorption of (he thickened parts in (he hernial sac. Mr. A. Cooper has reduced such hernia:, after applying ire to (hem, (be good effects of which he imputes to its producing a cc>fitrac(io;i of the scro- tum, and thus a strong and permanent com- pression of (he tumour. Mr. Earle lately in- formed me of a method of keeping up a ge- neral pressure on the swelling, by means of a bladder containing quicksilver, the quanti- fy of which can be regulated according to circumstances. Whenever any attempts of this kind sue- ce -d, a tru*s should be immediately put on, anH worn constantly without remission lifcHMA. 11 However, (here are instances on record, wlie--- the • i i -e'.iv of (he ahno'ii"'- had be come so *ap t > (he diminished u ut'tyof the visc«*ra i •! \vhen the cont'-ms .if iiie hernia were reduced, serious complaints aro,« from their introduction into the belly Scli.nucker met with several ^uch case-, in which he was obliged to take off the truss again. Petit has known (tie reduction of a hernm of this kind prove fatal, the parts not descending again when the truss was remo- ved, the n*u-,ea and vomiting continuing, and peritonitis 'aking place. (Chirurgische Wahrnehmungen, Vol. 2, p. 243. Traiti des Maladies Chir. T. 2, p. 392.) Mr. Pott remarks, that " an omental rup- ture, which bus been so long in the scrotum as to have become irreducible, is very seldom attended with any bad symptoms, considered abstractedly ; but it is constantly capable of being (he occasion of an intestinal hernia, and all its C"ns"cpi(-nces', neither is that all, for the omentum, either so altered iu foim and texture, or so connected as to be incapa- ble of reduction, may by accident inflame, and either become gangrenous, or suppurate, and the occasion of a great deal of trouble." In a few instances, epiploceles produce very bad symptoms indeed, cases of which are to be found iu G.irengeot, Dionis. ha. Sometimes, in old cases of entero-epiplo- cele. the interline is reducible, bul the omen- tum is no!, in wuich case some writers advise keeping up ihe piece of bowel with a truss, the pad of .vtiie.h must be so contrived as not to presb on the omentum. Mr. Polt, how- ever, considers this method not often practi- cable, and should such a truss be used, he re- commends great caution in its construction and application, lest a small piece of gut slip down, and being pressed on by the truss, produce fatal mischief. " Irreducible herniae must of course be ex- posed to all the consequences of external injury and violence; hence, various cases are recorded, in which the bowels have hewn burst by blo.vs. falls, 8tc." (Lawrence on Ruptures, p. 110 Edit. 3.) For examples of sm h accidents, Mr. Law- rence refer-, to A. Cooper on Hernia, Part 2, Pref p. 2, and to Travers's Inq. into the Pro- cess of Nature, &fC. p. 37. -V case is also quoted from Scarpa, p. 310, where a violent exertion caused a sudden return of a hernhi, which bed been long regarded as cured. The viscera lay in the tunica vaginalis, which was burs! to the extent of an inch. SYMPTOMS AND TREATMENT OF A STRANGU- LATED, OR AS INCARCERATED HERNIA.— MEANS TO BE TRIED, BEFORE AN OPERA- TION. •"' Difficulty of reduction (say3 Pott) may be owing to several causes. The size of the pice? of omeutum, or the inflamed state of it; the qua itity of intestine and mesentery, an inflammation of the "ut, or its distention by feces, or wind : or the smallness of the ape i line of tne tendon, through which the hernia passes. B;;t to whatever cm use it be owing, if the prolapsed body cannot be im- mediately replaced, and the patient suffers pain, or is prevented thereby from going to stool, if is called an incarcerated hernia, a strangulated hernia,or a hernia with stricture. 'The symptoms are a swelling.in the groin, or scrotum, resisting the impression of the fingers: if the hernia be ofthe intestinal kind, it is generally' painful to the touch, and the pain is increased by coughing, sneezing, or standing upright. These are the very first symptoms, and if they are not relieved, are soon followed by others, viz. a sickness at the stomach, a frequent retching, or incli- nation to vomit, a stoppage of all discharge per anum, attended with a frequent, hard pulse, and some degree of fever." A patient, thus circumstanced, is in some danger, and demands immediate assistance. A stricture made on the prolapsed pari of the gut, by the aperture through which it passes, is the immediate cause of all the bad symptoms, and of course, the removal of such stricture is the only thing which can bring relief. This object can only be accom- plished by returning the bowel back into the abdomen, or dividing the parts which form the stricture. The former plan is always the most desirable, when practicable. We next proceed to notice the various measures to be adopted for the relief of a strangulated hernia, so as to obtain the best chance of doing away the necessity of an operation. After treating of the merits of each plan, a few remarks will be offered on the order iu which the means should be put in practice. Taxis—This is the term applied to the operation of reducing a hernia with the hand. It is much promoted by the position of the body ; which Winslow thought should be placed on an inclined plane, and the thighs bent towards the trunk. Mr. A, Cooper advises the same practice, observ- ing, that this posture, by relaxing the fascia of (he thigh, relaxes also the aperture, through which the hernia passes. Every degree of tension, and relaxation of the fe- moral fascia, must undoubtedly be attended with a corresponding change in the abdo- minal ring. But flexion ofthe (high, besides relaxing this fascia, also relaxes the abdo- minal, internal iliac, and psoas muscles. In cases of inguinal hernia, the pressure made on the tumour by (he hands of the surgeon, should always be directed upwards and out- wards, along the course of the spermatic cord, and Mr. A. Cooper advises it to be continued from a quarter to half an hour. (On inguinal and Congenital Hernia.) As the femoral hernia passes downwards, and then forwards, Ihe pressure must be di- rected first backwards, and then upward?. No violence should ever be used ; for, be- sides being unavailing, it greatly aggravates the inflamed state of the contents of the her- nial sac, and has been known, even to burst the intestine. (See Cooper on Inguinal Her- nia. Ac. p. 23) Besides bending the thigh, care should also be taken to rotate it inwards, which will 12 HERNIA have i.reat effect in relaxing the femoral fascia, and tendon of the external oblique muscle* Suspension ofthe patient over the shoulders of an assistant has been thought to facilitate reduction : " I have tried it of- ten, (says Mr. Hey;) but have not found it to be of such superior efficacy, as some au- thors have represented." (P. 144.) The return of a piece of intestine is gene- rally- preceded by a peculiar noise, caused by the passage of air through the stricture It recedes at first gradually, and then slips up suddenly. The omentum goes up slow- ly to the very last portion, which must be actually pushed through the opening. If the taxis should not succeed at first, it w ill often do so after the warm bath, bleeding, or cold applications. Small hernia.*, being attended with the closest stricture, are r.ie most diffi- cult to reduce, and for the «ame reason, cru- ral ruptuies clo not so often yield to the taxis, as iogninaj hernia* in the male subject. The taxis becomes less likely to succeed, tie longer the inflamed viscera have been down, because adhesions are liable to form. Mr. Lawrence observes, (p. Chi.) " When the rupture becomes painful, we are no longer justified in persevering in attempts at reduction by the hand. A sufficient pressure cannot now be endured ; and the force which is employed only tends to increase the inflammation, and accelerate the ap- proach of gangrene. At this period the ope- ration is required, and should be performed u i'.hovt delay." Desaiilt even proscribed the taxis altogether in the inflammatory strangu- lation, until the previous use of other means had produced a change in the state of the swelling. That trie taxis K frequently nbused, and (be cause of serious mischief; is a truth which ran.iot be doubted. '■ Strangulated hernia?, i'-ays Scarpa) very frequently mortify from the negligence ofthe patients, and their re- pugnance to submit to an operation, and perhaps, slill more frequently from the effect of the taxis, unskilfully exercised by unin- formed surgeons, who are determined, at •itiy price whatsoever, to accomplish the speedy reduction of the viscera. The ma- jority of them make no distinction between the acute and the chron c strangulation. In both case, no sooner are the symptoms of strangulation evinced, than they begin to handle the swelling rough y, and to push the viscera with all their force, in order to make them return into the abdomen ; whilst, when Ihe strangulation is acute, and the patient young and strong, the taxis ought never to be practiced, before all the means proper for diminishing the strength, calming spasm, and relaxing the parts which are to be re- duced, have been employed for a certain time. These means we know, are bleed- ings, fomentations, emollient clysters, and especially the warm bath, which, next to bieeding, holds the first rank. At this school of surgery, I have frequently had opportuni- ties of observing the salutary effect of this treatment. My pupils have, more than nice, se°:; hernia which had been p-dnfully handled without any good, reduced, as it were, spontaneously, after a bleeding, or whilst the patient was in the bath. If what I have said upon the subject of the acute strangulation, and the treatment that il re- quires, were generally known by surgeons, I think that operation's for strangulated her- nia* would be less frequent. Thing? are dif- ferent with regard to the chronic strangula- tion of old large hernia*, in feeble, or aged persons for iu these cases, it is of great im- portance to support (he patient's strength. Bleeding, the warm bath, and other weak- ening means, should also be avoided, which, in producing a general atony, might bring on gangrene of the intestine, either during the strangulation, or after the reduction of the viscera It is ascertained that these kinds of strangulation are almost always oc- casioned by an accumulation of fecal mat- ter, or an extraordinary quantity of air in the hernia. Nothing is more efficacious than cold applications, for promoting (he action of the bowel on the matter which distends it, or for lessening (he volume of the air. They produce a corrugation of all the scro- tum, and contractions of the cremaster, which alone sometimes suffice for reducing the viscera, in a much better manner than could be done by the hands ofthe most ex- perienced surgeon." (Scarpa, Trailds des Hernies, p. 244—247.) Bleeding.—The inflammation which at- tacks the protruded viscera, and spreads thence over the whole abdomen, and the temporary weakness and often fainting, which the sudden loss of blood induces, and which is a peculiarly favourable opportunity for reducing the hernia by the hand, are the reasons in favour of bleeding. Sharp, Pott, B. Bell, Sabaticr, Richtcr, Callisen, and Scarpa, names which can never be sur- passed in respectability, are all subscribed in favour of bleedinr. Wilmer, Alanson, and A. Cooper, have published against the prac- tice. Mr. Hey has related two cases, which strongly evince the manner in which bleed- ing facilitates the return of a hernia : the protruded viscera, in one instance, went up spontaneously, on blood being taken away ; in the other, the taxis succeeded immedi- ately afterward, though the previous attempt had been made in vain. (P. 125,126.) Mr. Hey's experience, however, leads him to concur so far with Wilmer and Alanson, as to deel .re, that bleeding has generally fail- ed to procure a reduction of the strangula- ted intestine, though he is persuaded, that in many cases it may he used with advan- tage. But he cannot agree with Wilmer, that it generally renders the subsequent operation more dangerous. (P. 126) The majority of candid practitioners 1 believe will allow, that bleeding is always proper when the hernia is small and recent; the abdomen tense and painful; and the patient young, strong, nnd plethoric. PurgativeM-.dicities.—My experience, (says Mr. Hey) leads me to condemn almost uni- versally the use of purgatives while an in- testine remains firmly strangulated. In the HERNIA. 13 entero-epiplocele, when the intestine has retired, and the omentum remains strangu- lated : or in a simple strangulation of *'ic omentum, where the intestine has not been prolapsed, purgatives are of great utility. So likewise in very large and old hernias, where there is reason to doubt, whether the disease is not to be considered as a morbid affection of the intestinal canal, rather than Hie effect of strangulation, purgatives may be as useful as in the simple ileus without hernia. While the intestine remains firmly strangulated, they usually increase the vo- miting, and add to the distress of the patient. If they are to be tried at any time with hope of success, the trial would appear to have the greatest advantage when the vomiting has been removed by means of an opiate ; yet I have repeatedly given them in vain during such an interval of relief. (Practi- cal Observations in Surgery, p. 128.) Purgatives are supposed to operate by ex- citing the peristaltic action of the intestine, and thereby extricating it from the stricture. Besides the above eminent surgeon, Pott and Richter have joined in their general condemnation, and to all appearances, with very great reason. Purgative clysters cer- tainly have not the objection of increasing the irritation ; but their efficacy is not de- serving of much confidence. Mr. Hey says, that he has never seen one case, in which either purgative, or emollient clysters, pro duced a return of a strangulated hernia. Such injections will empty the large intes- tines ; but they do no more. It is common also for a natural evacuation to be the im- mediate consequence of strangulation. (P. 131.) WarmBalh.—" .Many instances (says Hey) are upon record of the good effect of warm bathing in procuring the reduction of a stran- gulated hernia. I have often seen it use- ful ; but I have also often seen it fail When- ever it is used in this disease, the patient should be placed, if possible, in a horizontal position. Gentle efforts with the hand to reduce the prolapsed part are perhaps at- tended with less danger, and with greater prospect of success, while the patient lies in the bath, than in any other pos'tion. The free use of opiates coincides with that of warm bathing, and under some circumstan- ces, these means deserve to be tried in con- junction " (P. 132.) Cold Bath, and Cold Applications.—The cold bath, and dashing of cold water on the patients, are little to be depended upon, (hough success has sometimes bi en obtain- ed iu this manner. (Petit,Trait6 des Chir. T. 2, p. 325; Hey, p. 136.) Wilmer strongly recommended the appli- cation of cold to the tumour itself, and this plan has acquired the approbation of the most celebrated modern surgeons. It is ge nerally tried in conjunction with the effect of tobacco clysters, which will be presently noticed. Cold applications, in the form of ice, were indeed paiticularly recommended by B. Bell. The best way is to pound the ice, tie it up in a bladder, and place it on the rupture. When ice cannot be procured, Mr. A. Cooper employs a mixture of equal parts of nitre and muriate of airmen it* To one pint of wattr, in a bladder, ten ounces of the mixed salts are to be added. " If, aft«*r four hours, (sn. s this distinguished surgeon) tn,: symptoms become mitigated, and the tumour lessens, this remedy may be persevered in for some time longer; but, if they continue with unabated violence, and the tumour resist every attempt at reduction, no farther trial should be made ofthe appli- cation." (On Inguinal and Congenital Her- nia.) When ice is not at hand, aether some- times proves a good substitute, when allow- ed to evaporate from the surface of the swelling. Care must be taken, that the cold be not so applied as to freeze the scrotum, and bring on sloughing. (A. Cooper, p. 15.) Opiates.—Mr. Hey met with several cases in which opiates, giyen freely, (in athletic persons after bleeding) procured a reduc- tion of strangulated hernia. He cannot say, however, that this remedy is generally successful; but it has the advan- tage of removing, for a time, the pain and vomiting usually attendant on strangulation, even though it prove ultimately inefficacious. Opiates should be given in large doses, when it is wished to try their effect in procuring reduction ; and whenever the symptoms of strangulation return, after having been re- moved by opiates, the operation should be performed without delay. (P. 134, 135.) Tobacco Clysters.—For this purpose, some surgeons prefer a decoction of tobacco, made by infusing, or boiling, one dram of the plant for ten minutes in a pint of water ; others employ the smoke, which is prepared and introduced into the rectum by means of an apparatus, sold at almost every surgical instrument maker's. Perhaps both methods are equally efficacious ; but, as one re",'res an apparatus, while the other does not. uid is equally proper, the decoction may be entitled to most recommendation. The ma- chine for the smoke is also frequently out of order. Next to the operation, tobacco clysters are the most certain means of brino-- ing about the reduction ofthe strangulated parts. Besides exciting the action of the iifestines, they exert a peculiar depress- ing influence on the whoie system, reduciri" the pulse, and causing nausea and sickness" cold sweats and fainting, under which cir- cumstances the parts often recede sponta- neously, or may be easily reduced. Mr. A. Cooper prudently advises injecting half the above quantity at .first; for he has seen two drams, and even one, when used as an in- fusion, and introduced at once, prove fatal. (P. 24.) The rest should be injected pre- sently, when it appears that tiie tobacco do s not operate with the extraordinary vio- lence with w hich it does in a few particular constitutions. A case recently published by Mr. C. Bell looks to me very much like an example of the occfional poisonous effects of the to- bacco clyster, though not reported as «uch 14 HERNIA. bv the author. At least, no particulars of anv fatal mischief, either in (he tumour or abdomen, are detailed, and it is remarked of the patient: •' His strength held up until the tobacco clyster was administered lo him, after which he verv suddenlv f.'ll low, and sunk." (S'.rv-V"' O'.-s Part 2,p. 189.) The smoke prove' fatal iu an bistauce witnessed bv Uesault, V'K tvrts de Chir. T 2, p. 344.) and an infusion of 3M- to 3v»j- °f wafer, seemed to produce sudden mortal effects in another example on record. (Edinb. Med. and Surgical Journ. Vol. 9, p. 159.) Poultices and fomentations have not the confidence of any experienced or intelligent surgeon. Whoever, in these urgent cases, wastes time in trying the effects of such applications,merits censure for his credulity, ignorance, and unfitness to undertake the treatment of a rapid disease, in which, as Pott remarks, if we do not get forward, we generally go backward ; and whatever does no good, if it be at all depended upon, cer- tainly does harm, by occasioning an irre- trievable loss of time. OF THE ORDER IN WHICH THE PRECEDINO METHODS \ND REMEDIES SHOULD BE TRIED, AND OF THE TIME WHEN THE OPERATION SHOULD NOT BE DELAYED. In the treatment of a strangulated hernia, a surgeon cannot be too deeply impressed with the danger of spending lime in the triai of methods of inferior efficacy, or of such as are evinced to be ineffectual in the cases before (hem. The rapidity with w hich gangrenous mis- chief sometimes arises, and (he patient loses his life, has been proved in a multitude of unfortunate examples, and should operate as a warning to all practitioners against the danger of deferring the operation too long. In the course of my reading, tiowever, I have not met with so remarkable an instance of the sudden mortification, and rapidly fatal termination of a hernia, as the follow- ing case recorded by Baron Larrey, in speaking of the fatiguing and forced marches performed by the French soldiers in Egypt. These marches, he says, brought on in one case, • a hernia a hich formed suddenly, and became at the same time strangulated. The man was immediately brought to my ambu- lance ; but a spontaneous gangrene, which had all on a sudden attacked the intestine, and extended to the other abdominal vis- cera, caused the patient'* death in the space of two hours, and made it impossible for me to do the operation for him. This is the second example that I have been acquainted with, in which the effects of the accident were thus rapid." (Larrey, in Mem. de Chi- rurgie Milituire, T I, p. 196.) The taxis is generally among the first things to be tried, and Mr. V Cooper thinks the attempts should be continued for a quarter or half an hour. When these have been ineffectual, the patient, if the circumstances do not forbid, .-'lould be im- mediately .bled, and have a large opening made in the vein, so that the suddenness of the evacuation may be most likely to bring on fainting. The taxis should then be tried again. When the strangulation is very acute, and the patient voung and strong, perhaps it may be most adviseable to follow (he advice delivered by Scarpa and Desault, which is to bleed the patient and put him in the warm bath, before the taxis is attempted at all. If bleeding alone has been practised, and the manual efforts at reduction should not now succeed, the warm bath may be em- ployed, provided it can be got ready in a very short time, but none should ever be lost in waiting for it to be prepared. When the bath is used, the taxis may be attempted as the patient lies in the wafer; a situation in which I have succeeded in reducing several hernia;. Certainly not more than one hour should ever bp allotted for putting in practice the first attempts at reduction, bleeding, and the warm bath. The plan should be, while the trial of one thing is going on, another should be pre- paring. So when the preceding measures have been tried in vain, the application of a bladder filled with ice, or the solution of nitre and muriate of ammonia, and the in- jection of tobacco, in the form of smoke or decoction, should never be delayed for wnnt of due previous preparation of all the requi- sites. Both these measures should be prac- tised at the same time, immediately after the failure of the taxis, bleeding, and the warm bath. Mr. A Cooper computes, that four hours are enough for the trial of the tobacco clyster, together with cold appli- cations. In omental herniae, the necessity for ope- rating may frequently be obviated by the good effects of bleeding, purgative medi- cines, and clysters, and leeches applied to the tumour. Mr. Lawrence has justly ob- served, that " when, as it very frequently happens, the aid of the surgeon is not requi- red until the complaint has lasted for some time, a trial of the tobacco, together with the topical use of cold, should be immedi- ately resorted to, a3 circumstances will not admit of delay in the previous me of less powerful remedies. (P. 148, Edit. 3.) Every man who has seen much of herniae will immediately recognize the propriety of the following sentiments ofthe experienced Mr. Hey: \ " I can scarcely press in too strong terms the necessity of an early recourse to the operation, as the most effectual method of preserving life in this dangerous disease. If Mr. Pott's opinion be true, that the opera- tion, when performed in a proper manner, and in due time, does not prove the cause of death oftener than perhaps once in fifty times; it would undoubtedly preserve the lives of many, to perform itaonost as soon as the disease commenced, without increasing the danger by spending much time iu the HERNIA. 15 use of means which cannot be depended upon for a cure. " I have twice seen this disease prove fatal in about twenty-four hours. In such cases, it is evident there is little time for delay. A surgeon who is competent to per- form the operation, is not perhaps consulted till the intestine is on the point of being mortified, or is actually in a state of mortifi- cation. The dilemma into which he islhen cast is painful indeed. But, when the fullest opportunity is afforded him of using the best mode of treatment, I am satisfied that his success will be the greatest when the opera- tion is not long delayed. This, at least, has been my own experience. When 1 first en- tered upon the profession of surgery, in the year 1759, the operation for the strangulated hernia had not been performed by any of the surgeons in Leeds. My seniors in the profession were very kind in affording me their assistance, or calling me into consulta- tion when such cases occurred ; but we con- sidered the operation as the last resource, and as improper until the danger appeared imminent. By this dilatory mode of prac- tice, I lost three patients in five, upon whom the operation was performed. Having more experience of the urgency of the disease, I made it my custom, when called to a patient who had laboured two or three days under (he disease, to wrait only about (wo hours, that I might try the effect of bleeding (if this evacuation was not forbidden by some peculiar circumstances of the case) and the tobacco clyster. In this mode of practice, I lost about two patients in nine, upon whom I operated. This comparison is drawn from cases nearly similar, leaving out of the ac- count those cases in which a gangrene of the intestine had taken place. " I have now, at the time of writing this, performed the operation thirty-five times; and have often had occasion to lament that I had performed it too late, but never that I had performed it too soon. There are some cases so urgent, that it is not advisea- ble to lose any time in the (rial of means to produce a reduction. The delay of a few hours may cut off all hope of success, when a speedy operation might have saved the life ofthe patient." (P. 141,<^c.) To determine tiie exact moment, when to give up the trial of the preceding measures, and to have immediate recourse to the ope- ration, is certainly difficult; but no one can doubt, that it is generally better to operate too early than too late. All directions must be general ones, liable to many exceptions: in rapid cases, little or no time should be allotted to the trial of any plan, and the operation should be done without the least delay. In other instances, we have full time to try the effects of every thing at all likely to succeed. The symp- toms, which ought to guide us, in having recourse to the operation, arise from an attack of inflammation in that part of the intestine contained in the hernial sac, and from its spreading into the abdominal cavity. ft is in proportion to Their violence, (hat we ought to urge the performance of the ope- ration. Mr. A. Cooper considers pain on pressingthe belly, and tension, a- (he symp- toms which point out its immediate neces- sity. He adds, " Indeed, flier* is scarcely any period of the symptoms, which should forbid the operaton ; for, evu if mortifica- tion has actually begun, th- operation may be the means of saving i'fe, by promoting the ready separation i»i gangrenous parts." (On Inguinal f. Congenital Hernia, p. 27.) Whenever the surgeon has succeeded in reducing the parts, without having recourse to the knife, if the symptoms of pain,iiiflam- mation, &.c. ran high before surh reduction, they will not always cease immediately afterward. As they probably depend on the reduced bowel having been inflamed by the stricture, the body should be kept open, and the diet and regimen should be low and sparing, whilst the least degree of pain and tension remain ; in short, till all complaint is absolutely removed from the abdomen, and the intestines do their office freely, and without trouble. (Pott) PROGRESS OF THE SYMPTOMS OF A STRAN- GULATED HERNIA. The earliest symptoms have been already related, viz. " tumour in the groin, or scro- tum, attended with pain, not only in the part, but all over the belly, and creating a sickness and inclination to vomit, suppres- sion of stools, and some degree of fever. These are the first symptoms, and, if they are not appeased by the return of the intes- tine, that is, if the attempts made for this purpose do not succeed ; the sickness be- comes more troublesome, the vomiting more frequent, the pain more intense, the tension ofthe belly greater, the fever higher, and a general restlessness comes on, which is very terrible to bear. When this is the state of the patient, no time is to be lost; a very lit- tle delay is now of the utmost consequence, and if the one single remedy, which the disease is now capable of, be not adminis- tered immediately, it will generally baffle every other attempt. This remedy is the operation whereby the parts engaged in the stricture may be set free. If this be not now performed, the vomiting is soon ex- changed for a convulsive hiccough, and a frequent gulping up of bilious matter; the tension ot the belly, the restlessness and fever having been considerably increased for a few hours, the patient suddenly be- comes perfectly easy, the belly subsides, the pulse, from having been hard, full, and frequent, becomes low, languid, and gene- rally interrupted; and the skin, especially that ofthe limbs, cold and moist; the eyes have now a languor and u glassiness, a lack- lustre not easy to be described ; the tumour of the part disappears, and the skin covering it sometimes changes its natural colour for a livid hue; but whether it keeps or loses its colour, it has an emphysematous feel, a crepitus to the touch, which will easily be conceived bv all who have attended to it, 1(3 but words tor HERNIA. is not so easy to convey an idea of by opening of the '"«»' W,J; "fM ds : this crepitus is the too sure indica- surface, distinctly ^'f*>h«\* ,™MnJ of gangrenous mischief within. In this delicate fleshy and tenduunn »bres o« "« stale, the gut either goes up spontaneously, internal obliqu . . .ihmche or is returned with the smallest degree of sprung, 4>c. der Leisten-und-Schenkelbrnche muscle; (Ueber den Ur- iche, pressure; a discharge is made'by si"ool,~a,i~d p. 4~f and that behind them is the weakest (he patient is generally much pleased at the pui! of what he names the ttUernal tngui.iai ease he finds ; but this pleasure is of short ligament, iu the rear of which is (he perito- duration, for the hiccough and the cold neum, with (he intervention of a very loose sweats continuing and increasing, with the cellular substance. (Op. cit. p. -6.) Ihe addition of spasmodic rigours and subsul- internal inguinal ligament of Hesselbach, is tus tendinum, the tragedy soon finishes." therefore clearly (he same thing as the above (Pott.) fascia pointed out by Mr. A. Cooper. This poim of the abdomen is one of the three weak places on the inside of (he inguinal region, where herniae are liable to occur; This subject must necessarily precede the yet, weak as it appears to be, it is not the account of the operation, •• hich would other- most common situation of such tumours. A wise be unintelligible. It is chiefly in the computation has been made, that in an nun- anatomical information, relative to berniae, dred c.ises of inguinal hernia, not ten occur ANATOMY OF INGUINAL HEBN1A. and in the mode of operating, that modern surgeons have a decided superiority over their predecessors; for before Gimbernal, Camper, Hey, Lawrence, Cooper, Scarpa, and Hesselbach, published their several works on heniee, (he anat >my ofthe disease was only imperfectly understood. Th«* tendinon« fibres of (he aponeurosis of the external oblique muscle, as they run downwards and forwards towards the pubes, separate from each other, so as to leave a triangular opening, called the abdominal ring, which is usually more capacious in the male than the female subject. The upper and inner pillar (as it is termed) of this aper- lure is inserted into the symphysis of the pubes, and is the weakest of the two ; the lower and outer one, which is (he Wrongest, is chiefly a continuation of Poupart's liga- ment, (Hesselbach uber den Vrsprung, tyc. der Leisten-und-Schenkelbrache, p. 4,) and n fixed into the angle; and crista of 'he same bone. Some tendinous fibres cross the uppc r and outer angle of the ring, so as to diuiini h the triangular appearance of the whole apei- (ure : these are said to be very strong in obi hernia?. The anterior and thicker layer of (he aponeurosis of the internal oblique mus- cle joins the tendon of (he external oblique ; Ihe posterior and thinner one joins (hat of the transversalis; but the lower poilion of (his tendon, together with ihi corresponding part of the transvers ilis, goes wholly in front of ihe rectus muscle. Thus Ihe inferior bor- der of (he obliquus inlernjs and transversa- lis, which originates from the upper part of Poupart's ligament, lies behind the outer pil ;! the point here specified. (H. J. lirnnmng- hausen, Unterricht uber die Bruche, fyc IVurzb. 1S11.) The spermatic vessels, joined by the vas def-rens, run in front of the epigastric artery, very near the place of its origin. They then pass (liBOugh the above fascia, go under the edge of the internal oblique and transverse mu-cles, and ntil obliquely downwards and loiwards, between the above fascia, and aponeurosis of the external oblique muscle (o ti e opening of the ring. When orrived on the smooth urface, immediately behind (he ring, they describe an obtuse angle, aid pass forwards and downwards into the s olum. (Hesselbach, op. cit. p. 5.) I nus we see, (hat the spermatic cord, be- lore it actual emerges at what :s named the abdominal ring, runs through a kind of canal. to which the epithet inguinal is often appli.d This oblique passage of Ihe cord through the abdominal parietes, was well known lo, and elegantly delineated by Albinus; Gimbernat makes distinct mention of it in his Account of a new Method of Operating for Femoral Hernia, p. 19,32 hut Mr. A. Cooper has the merit of having given.the earliest correct ac- count of the inguinal canal, iu reference to hemia ; a subject rendered complete by the nine iLient elucidations of Hesselbach and Scarpa. The abdominal ring is then only the outer opening of the canal, or passage, through which the spermatic cord passes before it emerges. The inner one, at which (he vis- cera first protrude in the most common cases lar oi (he abdominal ring. Mr. A. Cooper Of inguinal hernia, is situated about an inch first noticed, ihat a thin fascia proceeds from and a half from the abdominal ring, in the the inner edge of Poupart's ligamejt, and direction tdVvards the anterior superior spi- spreads over Ihe posterior surface of the nous process of (he ilium ; or, according (o transversalis. 1 his fascia forms the only par- liesselbaeii, the inguinal canal is almost an tition between the peritoneum and the outer inch and a haif in length, the average dis- opening of the abdominal ring, and were it tanee of the outer pillar of Ihe abdominal not for its existence, inguinal herniae would ring, from the inner pillar of what he terms probably be much more frequent. The par- the posterior ring, being about sixteen lines. tition in question, however, is said by Scarpa (Op. cit. p. 14 ) This inner opening is rather to be formed by the aponeuroses of ihe in- in arerthe pubes than the ilium, and its upper ternal oblique and transverse musclef, while border is formed by the lower edge of (he Hesselbach, who has named the small smooth internal oblique, and transverse muscles, point, situated directly behind (he outer which can be plainly felt with the finger, iu- HERNIA. 17 hoduced upward and outward into the abdo- minal ring. " The precise point at which the hernia most commonly begins, (says Scarpa,) is that which corresponds, in the foetus, to Ihe commu- nication of (he tunica vaginalis with the pe- ritoneum, and, in the adult, to the passage of the spermatic cord under the transversa muscle. In the sound state, (he peritoneum presents at this part a small funnel-like de- pression, the depth of which increases in pro- portion as the spermatic cord is pulled from above downwards. It is this small pouch, (his sort of digital appendage, whose pro- gressive augmentation constitutes the hernial sac. Resting upon the anterior surface of the spermatic cord, it first makes its appear- ance under the inferior edge of the trans- verse muscle ; thence it extends itself in (he separation of the inferior fleshy fibres, of the internal oblique muscle, always following the spermatic cord, in front of which it is situa- ted ; and afler having in this manner passed through the whole of the canal, which ex- tends from the iliac region to the pubes, it lastly protrudes at its external orifice, which is the inguinal (or abdominal) ring, properly so culled. In all (his track, the hernial sac, ns well as tho spermatic cord, is situated above the femoral arch, the direction of which it follows. The canal, which it tra- verses, is of a conical shape, the apex of which is towards the flank, and the base at fhe external orifice of the ring." (Scarpa, Traiti des Hernies, p. 44, 45.) The epigastric artery runs behind the spermatic cord, along the inner margin of the internal opening of the above canal, then upwards and inwards, so as to pass at the distance of half an inch oraa inch from Ihe upper extremity of the outer opening, or abdominal ring. In common cases of inguinal hernia, the viscera, protruded at the inner opening of (he inguinal canal, lie over the spermatic cord, and form a tumour on the outside of the abdominal ring. When the viscera have entered the above described digital pouch of the peritoneum, but do not protrude through the abdominal ring, the case is sometimes termed an incom- plete inguinal hernia; and complete when they pass out of that opening. The viscera may continue for a long while quite within Ihe inguinal canal, and even become stran- gulated there: sometimes, also, they are prevented from passing further towards the ring by some kind of impediment; and, iu this circumstance, if (he hernial sac have any addhion made (o its contents, it may ex- pand between the external and internal ob- lique muscles, as Hesselbach had an opportu- nity of seeing in the body of a female. (Ueber den Ursprung, <§-c. der Leisten-nnd- Schenkelbriiche, p. 2c-*.) The stricture may take place eilher at (he internal or external opening of (he inguinal c.inal. In recent and small hernia, according lo Mr. A. Cooper, the strangulation is most frequently situated at the inner opening; in large old ruptures, at the abdominal ring. Even when fhe parts \V)r.. II. 3 are completely profruded out of the laffer opening, the strangulation may exist at the inner one; but there may occasionally be two strictures, viz. one at each opening. (See Lawrence on Ruptures, p. 183, Edit. 3.) The hernial sac descends through the ab- dominal ring over the spermatic cord, and is covered by a fascia, senl off from (he (endon of the external oblique muscle. Beneath this fascia, the cremaster muscle is also situ- ated over the sac, which, after it has de- scended a certain way, lies on the tunica vaginalis, as well as the spermatic cord. As the epigastric artery naturally runs first behind the spermatic cord, and (hen along Ihe inner margin of the internal opening of Ihe ring, and as (he viscera are protruded over the cord, (hey must be situated on the outer side of the artery, which runs first be- hind the neck of the sac, and (hen on its inner side. Hence, the inner margin of the sac, when inspected on the side towards the abdomen, seems to be formed, as it were, by the track of fhe vessel. (See Lawrence, p. 179) That this is the ordinary situation of the epigastric artery, in relation to the ingui- nal hernia, is confirmed by the concurrent testimonies of Camper, Chopart, Desault, Sabatier, A. Cooper, Hesselbach, Scarpa, Sic. and by preparations to be seen in almost every museum, In recent inguinal hernias, the internal and external openings of the ring are at some distance from each other, the first being situ- ated obliquely upwards and outwards in rela- tion to the former; but (he pressure of the protruded viscera, gradually forces (he inter- nal opening more (owards the pubes, and nearer to the abdominal ring, so as to render Ihe posterior side of the neck of the hernial sac, and of the inguinal canal, very short. (Hesselbach, p. 29.) Thus, in large berniae of long standing, the opening into the abdo- men is almost direct, and the epigastric artery becomes situated nearer (he pubes, than iu (he natural state. Though such is the ordinary direction, in which a bubonocele protrudes, there are oc- casional varieties. In one of these, tiie vis- cera, instead of descending through the canal of the ring, are at once thrust through the abdominal ring itself, and Ihe opening into the belly is then direct: the hernial sac, instead of passing on the external side of (he spermatic vessels, as is usual, now lies on their inner,or pubic side ; and the epigas- tric artery, which is commonly situated be- hind, now pursues its course, in front of the sac, at its usual distance from the upper and outer angle of the abdominal ring. *- The following is Scarpa's description of the displacement of the epigastric artery in the greater number of cases of inguinal her- nia. " This artery, which in the natural state, runs about ten lines from the abdomi- nal ring, has its situation and direction so changed, in subjects affected with hernia, tiiat it crosses the posterior part of the neck of (he hernial sac, and is pushed from the outer (o the inner side of the abdominal ring. In order fo comprehend the reason of this u HEflNI \. displacemenf. it i- necessary to recollect what I hue elsewhere said of the formation of inguinal hernia, and of the manner, in which the .spermatic cord crones the epi- gasJric artery . The hernia begins to form at the very place, where the spermatic cord passes under Ihe inferior margin of (be transverse muscle ; and this place is rather nearer the flank, than that where the epigas- tric artery passes towards the rectus muscle. In-its progressive extension, the hernial sac constantly follows the same (rack as the spermatic cord, since it is situated upon its anterior surface. As has been already ex- plained,this cord crosses the epigastric artery; consequently, the hernial sac must necessa- rily pass with the cord above this artery, before protruding from the canal of the abdominal ring. \t the same time, the inter- nal orifice of the hernia becoming larger, and the inguinal canal shortened by the approximation of its twe orifices to each other, it follows, that at the period when the hernia begins to make its appearance in the groin, the epigastric artery is unavoidably situated behind the neck of the hernial sac, and is pushed from the outer to the inner side of the ring. Let us suppose a piece of string to be pas *d from the inside of the abdomen into the scrotum, all through the inguinal canal, and the middle of the hernia ; and that Ibis string is pulled so as to bring the internal orifice of the hernia, which is situated beyond the point where the sperma- tic cord crosses the epigastric artery ; this artery will immediately be found to be car- ried from the outer to the inner side of the neck of the hernial sac. The same thing happens from the effect of the enlargement of the hernia. The removal of the epigastric ar- tery from one side ofthe ring to the other, (saysScarpa)isa phenomenon,which may be regarded as almost constant in the inguinal hernia. I have examined (he bodies of a great number of subjects, affected with this 3peciesof hernia ; and it has been only in a very few, that I met with the epigasfiic artery retaining its natural situation on the outer side of the abdominal rim-. In investigating the reason of (his exception, I have obser- ved, in all the individuals who presented it, a very remarkable weakness and flaccidity of that part of the abdominal parietes, which extends from the flank to the pubes. In all the displaced viscera had passed through the aponeuroses of the transverse and internal ob- lique muscles, not in the vicinity ofthe ilium, as is commonly (he case, but, at a little dis- tance from the pubes, giving to the upper pil- lar of the ring a curvature that is extraordi- nary, and disproportioned to the srnalluess ofthe hernia. I observed, also, thatthe neck of the hernial sac did not pass in an oblique dnection, from the flank to the pubes, but that it protruded from the abdomen almost in a direct line from behind forwards In snort, in these individuals, the small cul-de- sac of the peritoneum, which constitutes the origin of the hernial sac, had not begun to be formed under the edge of tin transverse mii-rle, at the point where the spermatic cord runs outward; but, U had passed throng the aponeuroses of tin internal obhoue and transverse muscles, at a little distance from the pubes, and within the point at irhich the sper. malic cord crosses the epigastric artery, the small hernial sac, having at this part come into contact with and united to the sperma- tic cord, protrudes at the external orifice of (he inguinal canal, without displacing the epigastric artery from its natural situation, j This species of hernia, properly speaking, is a mixture of the ventral and inguinal. It resembles the former, inasmuch as the her- nial sac pierces (he aponeuroses of the trans- verse and internal oblique muscles ; the lat- ter, inasmuch as it passes out at the abdomi- nal ring, conjointly with the spermatic cord." (Scarpa,Traite des IIernies,p. r>8, fyc.) Hesselbach particularly adverts to a tri- angular space to be seen on the inside of the inguinal region : the upper bound- ary of it is formed by the outer edge of the rectus muscle ; the lower by the horizontal branch of the os pubis ; and the external shortest boundary by the crural vein and epigastric artery. JVow, says ha, when it is considered, that this artery ascends obliquely inwards, between the inner opening of the -ring, and the above triangular space, one cannot fail to know on which side of the neck of the sac the artery must lie in the two species of in- guinal, as well as the crural, hernia ; for, iu those hernia"-, which originate in the above triangular space, this artery lies at the outer side of the neck ofthe hernial sac; while, iu every hernia that takes place through the in- ner opening of the inguinal canal, the same vessel is situated at the inner sideof the neck ofthe sac. To one species of bubonocele, Hesselbach applies the epithet external; and to the other, internal; according to the si- tuation of the point at which they first protrude. The external inguinal hernia is much more frequent than the internal, and is said to happen oftener on the right, than the left side of the body: a circumstance, coinciding wilh another observation, viz. that iu children, the tunica vaginalis remains longer open on the right lhan the left side. The circumstance of there being two forms of inguinal hernia formerly caused considerable perplexity: surgeons knew, that the epigastric artery lay sometimes at the inner, sometimesat the outer side of the neck of the hernial sac, but knew not how to account for this variation. Hence arose the very different opinions about the proper method of dividing the ring when the her- nia was strangulated ; some authors direct- ing the incision to be made obliquely in- wards and upwards ; and others, upwards and outwards. But, as a modern writer has judiciously remarked, had they paid greater attention to the direction of the swelling, formed by the neck and body of the hernial sac in the groin, and to the position of the spermatic cord, which is as inconstant as that of the epigastric arlerv ; and had they dissected the parts in the diseased, as well as healthy, state, thev could not fail «oon to HERNIA. iy have suspected, that every inguinal hernia does not originate exactly at one and the same point. For the first establishment of this very important distinction, the world is indebted to Mr. A. Cooper ; and the tract, in which Hesselbach pointed out the fact in a very particular manner, I believe, is the next publication in which the subject is ex- plained. (Anal. Chir. Abhandlung uber den Ursprung der Leistenbruche, IVurzb. 1806 ; and .Xeusle Anal. Pathol. Unlersuchungen fiber den Ursprung, fyc. der Leisten-und- Schenkelbrtiche, 4to. Wursb. 1814, p. 18, 26, 28, fy-c.) According to the latter author, since each form of inguinal hernia also pre- sents characteristic appearances externally, the surgeon can have no difficulty in deter- mining the species of hernia; which dis- crimination must be highly important in the taxis, the application of atruss, and especially the operation. The sac of the external scrotal hernia can only pass down within the expansion of the cremaster as far as this part is separate from the cord and tunica vaginalis. Hence, the testis, covered by its tunica vaginalis, lies under the lowest part of the hernial sac, while the vessels of the spermatic cord, in a more or less separated form, are situated behind the posterior part ofthe sac ; viz. the spermatic veins exter- nally, and the vas deferens internally, and the arfery in (he middle. Should the hernia cjescend still further, the testis being inclu- ded as well as the sac within the tendinous expansion of the cremaster, it cannot glide out of the way, but must be pressed still fur- ther downwards by the sac, so as to con- tinue invariably under its fundus, but some- times inclined a Utile behind it. (Hesselbach, p. 34.) And, as the same author justly ob- serves, the position ofthe spermatic cord and testis, and the oblique direction ofthe swell- ing iu the external species, are the two strongest characteis by which every case of inguinal hernia may be discriminated. Although the spermatic cord commonly lies behind, or under, the hernial sac,- there are cases in which the vas deferens is found on the outer side of it, while the rest of the spermatic cord lies, as it usually does, on the inner side, or rather under it. (Cooper.) Le Dran, Schmucker, and Blizard, found the whole cord situated in front of the sac. Sometimes the vas deferens runs on the front and inner part, and the rest of the cord on the back and external part of the swelling. (Camper, Hey.) The cord has been known to be before, and the vas deferens behind, the sac. (Camper, A. Cooper.) Upon this part of the subject, the reader may deem the following passage interesting. " While the hernia is of moderate size, (says Scarpa) the surrounding cellular substance is not very greatly compressed, mid no change is observed in the situation of the spermatic vessels. The artery and veins of this name always form, with the vas defer- ens, one single cord, which is intimately ad- herent to the posterior surface ofthe hernial sac. But, iu proportion as the tumour in- creases in £ize: the ce!Uilarsubsta£ce, v. hich immediately surrounds it, and unites it to the spermatic cord, is more and more distended and compressed. At length, at a certain pe- riod, the distention is carried to such a pitch, that the spermatic vessels are separated from one another, and change their position with respect to the hernial sac. This kind of gradual unravelling of the spermatic coid is quite similar to that, which would be pro- duced by pulling the surrounding cellular substance in two o|>posite directions. Such is the reason, why in scrotal hernia of large size, the spermatic artery, the vas deferens. and the spermatic veins are found separated upon the posterior surface of the sac. All these vessels, instead of being conjoined in one cord, are divided by interspaces, which are sometimes very considerable. Ordina- rily, the vas deferens is less separated from the spermatic artery, than from the vein of this name. In some subjects, Camper has seen it situated on one side of the s-ac, and the artery and veins on the other, (hones Hcrniarum, Tab. 5, L. 0. Tab. 8. 1,2.) The displacement and splitting of the spermatic cord take place equally in adults and in chil- dren affected with large scrotal herniae. (Camper, loco cit.) In general, towards the up per part and neck of the hernia, the vessels are not much separated ; but as they proceed downwards, they diverge more and more. Sometimes, when the hernia is very old and bulky, they are no longer found at the pos- terior part, but rather at the sides, and even on the front surface of the sac ; they show themselves through the cremaster muscle, which covers them, and form a sort of vas- cular train, which arrests the band of the operator at the moment when he is about to open the hernial sac. Le Dran relates, that in operating upon a large scrotal hernia, he found the spermatic cord on the anterior surface of the hernial sac. (Operations de Chir. p. 127.) This fact has been the cause of numerous conjectures, and has appeared altogether inconceivable to such surgeons as have not been acquainted with the changes, to which the spermatic cord is exJ posed, in cnses of large scrotal hernia*. (Lassus could not (Med. Operat. T. 1, p. 152.) conceive the. possibility of the occur- rence.) The observation of Le Dran is not the less true and exact; it exemplifies a very important fact, of which it is easy to give a true explanation when the state of the sper- matic cord in ordinary inguinal hernia*, and in those which have obtained a considerable size, has been comparatively examined. In the first, the spermatic cord quite entire is always found situated on the posterior surface of the hernial sac ; but, in the second, the spermatic vessels are so separated from one another, that they sometimes extend over the sides and even the forepart of the hernial sac." (Scarpa, Traitt des Hernies, p. 61, fyc) The hernial sic is commonly described as an elongation of peritonaeum. When more minutely examined, however, it is fonnd, in cases of inguinal hernia, to consist of the purlion of peritoiuvuiu, pushed out uith tbu! IIKKMA. xiscera ; of a layer <>l cellular substance on the outside of (his, which becomes more or less thickened by the pressure of the rupture in different cases; of a fascia, sent off from the tendon of the external oblique muscle ; and of the cremaster muscle, which latter parts form the exterior cover- ing, which consisting of several layers, oftpn leads the operator to fancy that he has open- ed the cavity of the sac, when, in reality, he hns not. It is observed by Professor Scarpa, that " the cremaster muscle, in cases of old large scrotal hernia?, acquires a thickness, which is really surprising. Its fibres, wrhich are naturally very thin, become from four to six times more considerable. Being spread over the neck and body of the hernial sac, they sometimes present a remarkable con- sistence, and a yellow i=h colour. Such al- teration, however, does not prevent the muscular texture from being discovered, and Haller was not mistaken about it. ^Opusc. Patholog. p. 317.) Pathology fur- nishes us with several examples of similar changes of organization. In certain cases, the muscular coat of the bladder, that of the stomach and intestines, and even the ex- ceedingly delicate fleshy fibres of the liga- ments of the colon, are found to have be- come yellow, and much thickened. " In old scrotal hernia? (says Scarpa) it is not unusual to find an intimate adhesion of the fibres of the cremaster muscle to the edges ofthe abdominal ring. This may de- pend on the pressure, which the contents of the I ernia makes on those edges, and per- bpps it may also depend on the union of the cremaster muscle with the prolongation of the aponeurosis of the fascia lata, whic1, is continued from the margins ofthe ring to the groin and scrotum. Howsoever it may be, certain it is, that in old large scrotal hernia?, there is much difficulty iu introdu- cing a probe between the fleshy fibres of the cremaster and the margin ofthe abdomi- nal ring; and that, on the contrary, in recent hernia?, a probe passes as easily between the edges of the ring and the cremaster, as be- tween this muscle and the hernial sac. " Few authors (according to Scarpa) have spoken of the sheath, formed by the cre- master muscle, in which are enclosed the hernial sac, the spermatic cord, and the tu- nica vaginalis of the testicle. Sharp (in Critical Inquiry) and Monro, the father, (Anat. and Chirurg. Works, p. 553.) were the first to dwell upon this important patho- logical point. Monro had seen the cremas- ter muscle covering the hernial sac ; but he did not believe, that the same thing occur- red in all individuals affected with inguinal hernia. In this respect he was mistaken ; for this disposition of the cremaster muscle is one ofthe essential characters of the dis- ease. Petit has not omitted to describe the relations which exist between the cremas- ter and the hernial sac. (CEuvres Pos hum. T. 1, p. 288 j On this subject, he even re- lates an interesting fact, from which it re- sults, that in certain cases, this muscle may by its contractions alone cause a reduction ofthe hernia. Guntz explains, with tolera- ble perspicuity, how the cremaster and its aponeurosis form one of the coverings of the inguinal and scrotal hernia. (Lxbellusde Hemits, p. 50.) Morgagni once saw its fleshy fibres extended over the hernial sac ; (De se.d. et cans. morb. epist. 34, art. 9; cpi.it. 31, urt. 15.) and Neubaver positively assures us, that he made the same remark upon the dead body of a man affected with an entero-epiplocele. (Dissert, de Epiplo- oscheocele.) After these facts, so positively and accurately observed, I cannot compre- hend (says Scarpa) how in our time Pott, Richter, and several other authors, should have passed over in silence, or only men- tioned vaguely, this point, so important iu the history of the inguinal and scrotal her- nia." (Scarpa, Traiti des Hernies, p. 48, 50.) When surgeons speak of a hernial sac be- ing usually thicker and slronger, in propor- tion to the magnitude and duration of the hernia, their language is not at all correct; for in fact, the peritoneal investment of the hernia is seldom, or never, thus alter- ed. I can declare (says Scarpa) after nu- merous observations, that in the majority of cases, the hernial sac, strictly so called, is not perceptibly thickened, and that in gene- ral it does not differ from other parts of the peritonaeum, however large and old the scrotal hernia may be. ( Traiti des Hernies, p. 53.) In a very enormous hernia, the pressure of the contents is so great, that instead of •h'ckeningthe sac, it renders it thinner, and even makes it ulcerate. The protruded vis- cera have been met with immediately be- neath the integuments, when the sac has been burst by a blow. (Cooper; J. L. Petit.) The outer surface of the peritona?al part of the hernial sac, is always most closely ad- herent to the other more external covering by means of cellular substance. This con- nexion is formed so soon, after the first occurrence of a hernia, that any hopes of returning a hernial sac into the abdomen are now generally considered as chimerical. There must, however, be a certain space of time, before adhesions form, though it is, no doubt, exceedingly short. Upon this point, Scarpa does not adopt the opinion commonly received. There is no doubt, he observes, that in re- cent and small inguinal hernia?, the intes- tine, strangulated by the neck of the hernial sac, has been known, in more instances than one, to have been reduced by the taxis, and carried with it the whole of the sac into the abdomen. Observations, not less authentic, inform us, that after the operation for hernia, when the viscera could not be reduced on account of their adhesions to the sac, they have been seen, notwithstanding such ad hesions to get nearer to the ring daily, and at length, spontaneously to return into the belly together with the hernial sac. Louis he thinks was wrong in denying the possi- b.l, y of these facts. (Acad. Royale dtChir. i. 11, p. 466.) HERNIA. 21 Scarpa argues, that ''under certain cir- cumstances, the cellular substance will bear, without laceration, a considerable elonga- tion, and afterward shrink again. Thus we often see a viscus, which has suffered a con- siderable displacement, return spontaneous- ly into its natural situation. In the ingui- nal hernia, the spermatic cord is elongated, and descends farlher, than in the natural state No laceration of the cellular sub- stance, however is then occasioned; for,if the hernia be kept reduced, the spermatic cord becomes shorter, daily retracts, and at last has only the same length, which it had previously to the disease. When a sarco- cele becomes large and heavy, the portion of the spermatic cord naturally situated wilhin the belly, is by degrees drawn out into the scrotum; but, after the tumour is extirpated, this portion ascends again, and of itself returns into its original situation. " The same thing happens after the ope- ration for the strangulated inguinal hernia. All practitioners have noticed, that the hernial sac retracts and reascends progres- sively towards the ring. This alone would prove, that the cellular substance, which surrounds the spermatic cord, and unites it to the hernial sac, is highly endued with the property of yielding, and afterward re- turning to its original state. Can the same property be refused to the cellular sub- stance, which unites the sac to the cremas- ter muscle and other surrounding parts ? " While the inguinal hernia is recent, and not of much size, the cellular substance in question, possesses all its elasticity, and hence, the hernial sac and the spermatic cord, may easily ascend towards the abdo- minal ring. I have had occasion (says Scarpa) to make this observation upon the dead body of a man, who had an incipent inguinal hernia. The small hernial sac was capable of being pushed back into the ring with the utmost facility ; and in carefully examining the parts, both within and with- out the belly, it appeared to me, that the cellular substance, which united the sac to the spermatic cord and cremaster muscle, was disposed to yield equally from without inwards, and in the direction precisely op- posite ; that is to say, it made an equal re- sistance to the protrusion and the reduction of the hernial sac. Monte.--. !-t has seen a case exactly similar: althoi.;''., recording to his own expressions, (Inslituz. Chirurg. T. 3, sez. 2, p. 249,) the hernial sac was not very small, it adhered very loosely to the eurrounding parts, and it admitted of being entirely reduced into the abdomen with great facility." la large old scrotal hernia?, Scarpa allows, that such reduction is quite impracticable : •"In these, the cellular substance, which unites the sac to fhe spermatic cordf and cremaster muscle, has acquired such a den- sity, that it does not oppose less resistance to the further enlargement of the hernia, than to the efforts of the surgeon, who en- deavours to effect its reduction." (Scarpa, Traili dts Hernies. p. 57, i-c.) Though Scarpa thus reasons about the elasticity of the cellular substance, as forming the con- nexion between the sac and surrounding parts, many surgeons would refer the con- nexion to the adhesive inflammation, and explain the diminution and shrinking of parts, after the distention and weight are removed, not by the elasticity of the cellu- lar substance in particular, but by the same property inherent generally in the elonga- ted parts, which elasticity, and the action of the absorbents together, produce the al- teration in question. We shall conclude this anatomical account of the inguinal hernia, with the following explanation of the parts as they appear on dissection : " the removal of the integu- ments exposes the exterior investment°of the hernial tumour, continuous with the margins of the ring, and formed of tendi- nous fibres from the aponeurosis, the cre- master muscle, &c. This is connected by cellular substance with the proper hernial sac, formed of the peritonaeum. This pro- duction of the peritonaeum passes within the ring of the external oblique, and then goes upwards and outwards. Behind and above the ring, the inferior margin of the obliquus internns and transversalis crosses the neck of the sac. When these muscles are reflected towards the linea alba, the fascia, ascending from Poupart's ligament, and forming the upper opening of the ring, is exposed, and the epigastric artery is dis- covered emerging from the inner side of the neck of the hernial sac, (Camperi Icones Tab. X. F. M.) which, at this precise point| becomes continuous with the peritonaeum, lining the abdomen. The removal of the hernial sac will disclose the course of the spermatic cord in its descent towards the testicle ; and when this is also elevated, the first part of the course of the epigastric ar- tery, and its origin from the iliac trunk, are exposed." (Lawrence on Hernia, p. 18° Edit. 3.) r "' In females, the round ligament of the ute- rus bears the same relation to the tumour, as the spermatic cord in males. In the formersubjects, bubonoceles are uncommon. Mr. Lawrence had a very rare instance pointed out to him, in which a bubonocele in a female was situated on the inner side of the epigastric artery. A still rarer case was examined by Hesselbach : it was not only an example of internal bubonocele in a woman, but of one in which the epigastric artery arose from the obturatrix artery an inch from the origin of this latter vessel from the inner side of the external iliac: the obturatrix first passed an inch obliquely downwards and inwards over the crural vein, and immediately afterward, on the ho- rizontal ramus ofthe pubes, made a sudden turn backward and downward to the obtu- rator foramen; and at this bend arose the epigastric artery, which ran transversely in- ward along the horizontal ramus of the pubes, behind the neck of the hernial sac, at the inner si«> of which it ascended to the rectus muscle, accompanied by the liga- 22 HERNIA. mentous remains of the umbilical arteries, which were do e behind it. (Ueber den Ursprung, S,-e. der I.eiuid not have* csraped injurv. Mr. A. Cooper's rule of always 'tilting in one eiircction, viz. upward, which J Delieve was first advised by Autenrielh. /■*;«- serf, .'f'ineni circa Herniotom. prcrcipue circa rvilandam art.epigaslr. l.Tsioncm. Tub. 179$>) is perhaps a very good one, because it is at least easy for the memory, and will answer very well even when it is not in the power ofthe surgeon (o pronounce positively whe- ther the case is a shorl-necked external bu- bonocele, or an internal one with an oblong oval fissure, cases having a great external • resemblance, especially in women, in whom there is not fhe spermatic cord as a crite- rion ; for, after all, this part, when present, is the surest guide, and that on which De- sault founded his perfectly safe advice, viz. when the cord is at the posterior or inner side o( the neck of the hernial sack, to divide the ring upwards and outwards, but inwards and upwards when it lay at the outer or on the forepart of the sac. (QZuvres Chir. de Bichat, T. 2.) At least, this advice is sub- ject but to one exception, which is the very rare one of the epigastric running round the inner side of the neck of the sac in an inter- nal bubonocele; a possibility which has been already explained, and which leads Hesselbach particularly to recommend the division of the ring in every internal ingui- nal hernia, to be made straight upwards. (P. 47.) Indeed, the long-necked external bubonocele is the only case in which he thinks the latter plan should give way to that of cutting upwards and outwards. The safety and propriety of the method of always cutting upward, are strikingly illus- trated by what Scarpa observes: he states, that the right direction ofthe incision ofthe ring is directly upwards, parallel to the linca alba. " I have (says he) operated in the way which I recommend upon several dead subjects, who had either external or internal inguinal hernia?, directing my inci- sion in the course of a line drawn from the upper part of the ring parallel to the linea alba; in all, I constantly left the epigastric artery untouched, even when I extended the cut about an inch above the inguinal ring." (Scarpa, Traitt Pratique des Hernies,p. 111.) Only one objection, as far as I know, has been made to this plan, and it is founded on the alleged impossibility of introducing the knife, so as to cut straight upwards, when the neck ofthe hernial sac is long, because then the posterior side ofthe inguinal canal is in the way. (Hesselbach, p. 40.) No more ofthe parts forming the stricture, should be cut than is just sufficient for allowing the Srotruded viscera to be reduced without ruising or otherwise hurting them ; and I consider the middle of the upper margin of the ring the safest place for making tiie ne- cessary incision. Mr. A.Cooper, in his valuable work on the Inguinal Hernia, advises a mode of di- viding the stricture, considerably different from (be usual method. He directs the fin- ger of the operator lo be introduced into the »ac. (which, in his plan, we know is left un- divided for the space of one inch beiow ;oe ring.) When the stricture is felt, a probe- pointed bistoury is to be conveyed over the . front of the sac into the ring (between the two parts,) and the latter only is then lo be divided, in the direction upward, opposite the middle of the neck of the sack, and to an extent just sufficient to allow the protru- ded parts to be returned into the abdomen without their being hurt. The two chief advantages which Mr. A. ( ooper imputes to this method, are, that the danger of perito- neal inflammation will be less, and that the epigastric artery, if wounded, would not bleed into the abdomen. I am of opinion, flint Mr. Lawrence's remarks, concerning this proposal, are judicious : " An accurate comparative trial of both methods would be necessary, in order to determine the weight of the first reason. The second circum- stance cannot be a matter of any importance, if we cut in such a direction as to avoid the risk of wounding the artery. Many circum- stances present themselves as objections to this proposal. The manmuvre itself, although perhaps easy to the experienced band of such an able anatomist as Mr. C, would, I am convinced, be found highly difficult, if not impracticable, by the generality of sur- geons. This difficulty arises from the firm manner in which the sac and surrounding parts are connected, we might almost say consolidated, together. The experience of of Richter (Traile des Hernies, p. 118) shows, that this objection is founded in reality. He once tried to divide the ring, without cut- ting the sac, but he found it impracticable. If the stricture is so tight as to prevent tho introduction of the finger, there must be great danger of wounding the protruded parts. The practice would still be not adviseable, even if it could be rendered as easy as the common method of operating. Mr. C. leaves an inch of the sac, below the ring, undivided ; thus a bag remains ready to receive any future protrusion, and the chance of a radical cure is diminished. It would be better to follow the advice of Richter, and scarify the neck of the sac, in order to promote an adhesion of its sides. He has found this practice so successful in accomplishing a radical cure, that he ad- vises (p. 191.) its employment in every operation lor strangulated hernia." (Sec Lawrence on Ruptures, p. 321, Edit 3 ) If the stricture should be at the inner opening of the canal for the spermatic cord, Mr. A Cooper advises the operator to intro- duce his finger into the sac, as far as the stricture, and then to insinuate a probe- pointed bistoury, with the fiat part of its blade turned towards the Anger, between the front of the sac and the abdominal ring, ill it arrives under the stricture, formed by the lower edge of the transversalis and obli- 2iUeUnV!it?IT\ The" tbeedSe ofthe instru- nient is to be turned forward, and the stric- ture cut in the direction upward. This nlan to "n\hUUi^ l,l? neck of f,he «".'iSX to all the objections stated by Mi* T iw rencc i„ regard to the case jn which "lie HERNIA. ■Mrangudation takes place at the abdominal ring. Mr. A. Cooper's bistoury is a very proper one for dividing the stricture, as it only has a cutting edge to a certain distance from the point. Perhaps, on the whole, we may infer, that il is both most easy and ad- vantageous to divide the neck of the sac, together with the stricture, whether this be situated at the ring, or more inward. The method of cutting the stricture from without inAvards I consider objectionable, on the ground of the risk of wounding the bowels in this mode, being greater, than that of any accident wounding the epigastric arte- iy, when it art.-es in an unusual manner, and deviates from its regular course ; a re- flection, which has made Dr. Hesselbach, junior, an advocate for the practice. (See Xicherste Art dts Bruchschniltes, Alo. Bam- berg. 1819.) Room being made for the reduction of ihe protruded parts into the abdomen, by the division ofthe stricture, they are imme- diately to be returned, if sound, and free from adhesions. This object is considerably facilitated by bending the thigh. The intes- tines are to be reduced before the omentum, but when a portion of mesentery is protru- ded, it is lo be returned before either ofthe preceding parts. The intestine should al- ways be reduced, unless it be found in a state of actual mortification. Il often ap- pears so altered in colour, that an uninform- ed person would deem it improper to re- turn it into the abdomen. However, if such alteration should not amount to a real mor- tification, experience justifies the reduction ■ >f the part. Mr. A. Cooper has judiciously cautioned the operator not to mistake the dark chocolate brown discolorations, for a slate of gangrene. With these the protruded part is frequently found affected; and as they generally produce no permanent mischief, they ought to lie carefully discriminated from the black-purple,or lead-coloured spots which usually precede mortification. To determine whether a discoloured portion of intestine be positively mortified, some re- commend pressing forward the blood con- tained in the veins, and if they fill again, it is looked upon as a proof that the bowel is sfill possessed of life. In reluming a piece of intestine into the abdomen, the surgeon should first introduce the part nearest the ring into this aperture, and hold it there until another portion has succeeded it. This method is lo be continu- ed till the whole ofthe protruded bowel is reduced. Writers on surgery cannot too severely reprobate the employment of any force, or violence, in the endeavours to return the contents of a hernia in the operation • a method the more pernicious, because such parts are more or less in a state of inflam- mation. It is always better to enlarge the stricture, than pinch and bruise the bowel in trying to get it through an opening, which is too small. Distention of the intestine -'■metimes prevents "*' ^act. Ob, p. m2el?"lj "»i?g,on which the establish- ment 0f the cont.nuous state of the intesti- nal canal depends, in all these cases sthe adhesion which the living portion of bowel, adjoining the mortified part cm. rac.switb the peritoneum all roUl d , this manner, the escape of the contents r! HERNIA, 29 Ihe bowels into the cavity of the peritonae- um becomes in general completely prevent- ed. The two ends of the sound portion of intestine, after the mortified part has separa- ted, open into a membranous cavity, which previously constituted a portion of the peri- tonaea! sac, and now unites the extremities of (he gu(. The gradual contraction of Ihe wound closes the membranous cavify exter- nally, and thus the continuity of the canal is restored. The two ends, however, are not joined so as to form a continued cylindrical tube, like that of the natural gut; hut they are united at an angle more or less acute, and the matter, which goes from one (o (he other describes a half circle in a newly form- ed membranous cavify that completes the canal ; a subject which has been more fully explained in another part of this w ork. (See Anus, Artificial.) It is an observation of Mr. A. Coopers, that Ihe degree of danger, attending an arti- ficial anus, depends on the vicinity of the sphacelated part of the intestinal canal to the stomach. Thus, if the opening be in the jejunum, there is such a small extent of sur- face fur absorption, between it and the sto- mach, that the patient dies of inanition. Let us now suppose, that the mortified state of fhe intestine has only been discover- ed, after laying open the hernial sac in the operation. The mischief may only consist of one or more spots ; or of (he whole dia- meter of the protruded bowel. In the first case, the proper practice is to divide the stricture, and return the intestine into the ab- domen, with the mortified spots towards the wound. Mild purgatives and clysters are then to be exhibited. The most favourable mode, in which a case of (his kind ends, is when (he intestinal matter gradually resumes its natural course, after being either partly or entirely discharged from the wound. But sometimes the patient sinks under the dis- ease, or an artificial anus continues for life. The repeatud observations of modern sur- geons huve now decided, that no ligature, passed through (he mesentery, to keep the gangrenous part of the bowel near the wound, is at all necessary. The parts, in the neighbourhood of the ring, have all become adherent together, in consequence of inflam- mation, at the same time (bat the parts in the hernial sac mortify; and of course, the partially gangrenous bowel, when reduced, is mechanically hindered, by these adhesions, from slipping far fjporfi the wound. Desaiilt and De la Faye, both confirm the fact, that (he intestine never recedes far from (he ring; and even were it to do so, the adhesions, which it soon contracts to the adjacent sur- face.', would, as Petit has explained, com- pletely circumscribe any matter which might be effused, and hinder il from being exten- sively extravasated among ihe convolutions of the viscera. (Man. de I'Acad. de Chir. T. 1. 2.) Where the chief pnrf, or the whole of the diameter of the protruded bowel is mortified, the first and most urgent indication is to re- lieve the bad symptoms arising fr-.'tn the dis- tention of Ihe intestinal canal above the stricture. •' Let a free incision (says Mr. Lawrence) be made through the mortified part of the gut, in order to procure that eva- cuation of Ihe loaded canal, which nature a(temp(s by the process of gangrene." If the intestine has already given way, a free divi- sion of the integuments and sac allows the exit of the accumulated matter; and the opening in the gut may be enlarged, if ne- cessary. (Lawrence on Ruptures, p. 283.) Here the division of the stricture is nnne- cessary, since all the mischief, which the bowel can receive from it, is done. This subject is well explained by Mr. Travers. (See Inq. into the Process of Nature in Re- pairing Injuries of the Intestines, fa. p. 300, fy-c.) Mild purgatives and clysters will be proper to unload the bowels, and determine the course of the feces towards the anus. Should, however, the stricture appear after the mortification, to impede the free escape of the intestinal contents, a moderate dilata- tion of it must undoubtedly be proper. Mr. Lawrence, in his valuable Treatise on Ruptures, has clearly exposed the improprie- ty of sewing the ends of the intestinal canal together, introducing one within the other, supported by a cylinder of isinglass, fcc. put in their cavity, in those case?, in which the whole circle of the intestine has mortified, and been cut away, as wras advised by for- mer writers. By drawing the intestine out of (he cavity, in order to remove the dead part, the adhesion behind the ring, on which Ihe prospect of a cure chiefly depends, must be entirely destroyed ; and new irritation and inflammation must be unavoidably pro- duced, by handling and sewing an inflamed part. fSee Laurence on Ruptures, p. 298, Instead of such practice, this gentleman judiciously recommends dilating the stric- ture, and leaving ihe subsequent progress of the cure entirely to nature. Tlie sloughs will be cast off, aud the ends of the gut are retained by the adhesive process in a stale of apposition to each other, the most favour- able for their union. Thus, there is a chance of (he continuity of (he iulestinai canal be- coming established again. Whatever experiments it may be allow- able to make in wounds with protrusion and division of the bowels, nothing, I think, is now more completely established, than the absurdity and danger of attempting to stitch the bowels in cases of hernia. OPERATION FOR VERY LARGE INGUINAI HERN I.E. When the tumour is of long standing, ex- ceedingly large, perhaps extending half way down to the knees, and its contents have never admitted of being completely reduced, the indication is (o divide the stricture, pro- vided a sliangulation tatfes place ; but with- out laying open the hernial sac, or attempting to reduce the parts. ihe rer.sons against the common plan of operating, under such circumstances, are. :*o HERNIA the difficulty of separating all the old adhe- sions ; the hazardous inflammation, which would be excited by laying open so vast a tumour, and the probability thai parts so long protruded, might even bring on serious com- plaints, if reduced. J. L Petit, and after- ward Dr M'>nro, advised (be sac not to be opened. (See Mai. Chir. T. 2, p. 372 De- scription of Bursa Mucosce, l"i$8.) • PERATION WHEN THE HERNIA IS SO SMALL THAT IT DOES NOT PROTRUDE EITEKNAL- IV THBOLGH THE RING. In this kind of case, there is little appear- ance of external tumour; consequently, the disease is very apt (o be overlooked by the patient and surgeon, and some other cause assigned for the scries of symplons. The manner of operadng, in (his form of Ihe disease, differs from that in the common scrotal hernia; (he incision is (o be made pa- rallel (o the direction of the spermatic cord, and the stricture will be found at the inter- nal ring. (A. Cooper on Inguinal Hernia.) TREATMENT AFTER THE OPERATION. Evacuations from Ihe bowels should be imn c-diately promoted by means of clysters, oleum rtcini, or small doses of any of (he common salts, dissolved in peppermint water. For some time, the patient must only be al- lowed a low diet. W hen symptoms of in- flammation of the bowels and peritonaeum threaten the patient,general bleeding, leeches applied to the abdomen, fomentations, (he warm bath, blisters, doses of the oleum ricini, and clysters, are the means deserving of most dependence, and should be resorted to without the least delay. When all danger of peritonaeal inflammation is past, and the pa- tient is very low and weak, bark,wine, cordials, and b generous diet, must be directed. The effervescing saline draught, with opium, is the best medicine for quieting sickness, after the operation. Opium and cordials are the most eligible for checking diarrhoea. As the operation does not usually prevent the parts from becoming protruded again, a truss must be applied before the patient leaves bis bed, and afterward constantly worn. PROPOSALS FOR THE RADICAL Ct"RE OF THE BCBONOCELE, Of castrating the patient, applying caustic, or of the operation of the punctum aureuiu, wi(h this view, I need only say, (hal they are barbarous, and not at nil adapted for the at- tainment of the desired end. A description of these methods may be found in Pare, Wiseman, kc. The old operation, termed (he royal stitch, was one of the most promising plan*, it consisted in putting a ligature under the neck of the hernial sac, close to (he abdomi- nal ring, and then tying that pail of the sac, so as to render it impervious, by the adhesive inflammation thus excited. The royal stitch, performed in (hi« m nr.er. has been actually attended with »uf"*£ (Heister, Vol. 2.) The umbilical rupture was cured by Saviard, on si ..ular principles, and Desault radically cured nine cases of the exomphnlos in children, by tying the hernial " Schmucker cured two irreducible ruptures, free from strangulation, by culling away the body of the sac, after tying Us neck (Unr. lVahrnehmungcn,B.2) In one case, Mr. A. Cooper found cutting away the sac, alone insufficient. Dissecting away the whole hernial sac, or even laying it open, must be a formidable operation, compared with merely making a small incision down to the neck of the sac, and applying one ligature. If the hernia were reducible, and (he upper part of the sac could be rendered impervious by the li- gature, all other more severe plans would he superfluous. However, Petit, Sharp, Acrel, &.c. record cases, which lend lo prove the danger and inefficacy of the royal stitch; though it is true, that none of these surgeons operated exactly in Ihe simple manner above suggested. Richter recommends scarifying the neck of the sae, with (he view of producing an ad- hesion of its sides to each other ; a plait, which, he says, he found very successful. From the account, however, which has been given of the anatomy cf the bubono- cele, it is obvious, thnt none of these me- thods could do more than obliterate the sac as high as the ring, and never that portion of it, which is within the inguinal canal. Hence, the neck of Ihe sac must si ill remain open for the descent of the viscera. This consi- deration, and that of the chances of bad and fa(al symptoms from any operation un- dertaken solely for this purpose, and not urgently required for (he relief of slrangula- (ion, are the grounds on which these experi- ments are now disapproved. CRURAL, OR FEMORAL HERSIi. Verheyen, who wrote in 1710, first de- monstrated the distinct formation of crural henna, which until then bad been generally confounded with bubonocele. The parts, composing this kind of hernia, always protrude under Poupart's ligament, and the swe ling is situated towards the inner part of (he bend of the thigTi. The rupture descends on the inside of (he femoral artery and vein, between these* x;esSe|s ancJ (h„ 07s pulm, through the crural ring, or canal for (he transmission of the same vessels. And, -s Hesselbach ..as remarked, the inner open- Muiof,f,hI,"?0rCanfl " tbe Predisposing ove i, hit ",S^Se',,,l)e 'ier'"°^"'n spread over ,t, being gradually propelled into it bv various occasional causes, so as (o compete he tendency to hernia. The nctuaTnro. rus.on of the bowels may be formed ei5 e suddenly, or by degrees. As soon asTe bowels have once palsed Ihe outer "nert, „. "what Cloquet terms more propel t5 ower opening of the crural canal, the ?,, ° has more room for extending i(c..*, for„.a"Vs HERNIA 31 and to each side, and the integuments now become elevated into an oval swelling, the long diameter of which is nearly transverse. (Hesselbach, p. 47.) Gimbernat nair.es the passage through which the femoral hernia pro- trude? from (he abdomen, the cr>al; Hey the femoral ring; and Cloquet, the crural ca nal. Females are particularly subject to this kind of rupture. If has been t omputed. t is a foramen almost round, proceeding HE KM A. 33 from the i.tternal margin of the crural arch (Poupart's lignmcnl,) near i(s insertion into the branch of the os pubis, between this bone and the iliac, vein ; so tha(, in this her- nia, the branch of (he os pubis is sifuated more internally than the intestine, and a little be- hind; the vein,externally,and behind; andthe internal border of the arch,before. Now it is this border which always forms the strangu- lation." (See A new Method of Operating for the Femoral Hernia, by Don Antonio de Gimbernat, p. 6, Trans, by Beddoes.) The utility of knowing, (hat it is not Pou- part's ligament which produces the strangu- lation, in cases of femoral hernia, is import- ant ; for we then know, that cutting the lower and outer border of the external ob- lique muscle, is quite erroneous. This pro- ceeding is the more to be reprobated, because (he lower pillar of (he abdominal ring, in both sexes, will be divided by directing the incision upward, or upward and inward; and (bus the abdominal and crural rings will be made into one common aperture, large enough to make Ihe future occurrence of hernia very likely to happen. In the male, there is also considerable danger of the spermatic cord being cut. Cutting Pou- part's ligament obliquely outwards, is attend- ed with still more danger; for the epigastric artery will infallibly be divided at its origin ; and with all these hazards, the incision uiusl be quite useless, unless carried on»lo the in- ternal edge of the crural arch. (Gimbernat, p. 16.) The inclination, however, of several mo- dern writers to refer the strangulation en- tirely toGimbernat's ligament,is no( sanction- ed by the most careful observers, like Hes- selbach and Langenbeck. (A'eue Bibl.B. 2. p. 132.) The former justly remarks, llia( a complete femoral hernia may be strangula- ted in two places, either at the outer or in- ner opening of the passage, through which the protrusion happens. Nay, says he, that the strangulation is sometimes caused by the outer opening, was known (o former sur- geons, for they remarked, (hat (he constric- tion was removed by dividing (he fascia. (P. 53.) And, in addition (o (hese two modes of strangulation, is to be enumerated a third, in which (he viscera are constricted by protruding through some weaker point, or accidental opening, in the anterior parie- tes of the crural canal (Hesselbach, p. 4S ; also Langenbeck, Op. cit. p. 132,) or even through an aperture in the inner side of this passage, ns we find depicted in the twentieth plato of Laugenbeck's treatise, " De Struc- lura Peritonrei." I know of no surgical writer, who has given a clearer accouiK of the anatomy of the femoral hernia, than Langenbeck (Neue Bibl. B.2,p. 112, 4-r.) He observes, that when the dissection is begun at the inside of the inguinal region, the following circum- stances are noticed : after the removal of the peritonaeum from the abdominal muscles, and from the psoas, iliacus interims, and the great vessels, the inner surface of the trans^ vorsalis still has au investment, which Clo- Vol. H, 5 epiet terms fhe fuscia transversalis, and which is always a white glistening aponeurosis. From the place, where the femoral artery lies under Poupart's ligament, lo the anterior superior spine of the ilium, the preceding fascia is extended in a strong fibrous form behind the inner surface of Poupart's liga- ment, and a thin continuation of it is ex- tended over the iliacus internus and psoas muscles, where it is named by Mr. A. Coop er and Cloquet the fascia iliaca. The fascia ofthe transverse muscle closes the belly be- hind Poupart's ligament, as completely as the peritonaeum does, so that between the femoral artery and the anterior superior spine of the ilium none of the bowels can protrude, which occurrence is still further prevented by the fascia lata, which below Poupart's ligament is closely attached to the muscles of the thigh. By the pelvis being thus shut up, the origin of a crural her- nia on the outside of the femoral vessels is rendered quite impossible. (Langenbeck, op. cit.) This part ofthe explanation very nearly resembles that delivered by Mr. A. Cooper, except that the latter describes the iliac fas- cia, and not what Cloquet calls the trans- verse fascia, as closing the pelvis from the spine of the ilium to the crural vessels. But, this difference is easily accounted for by the circumstance of Mr. A. Cooper extending the name fascia iliaca beyond the limits given it by Cloquet and Langenbeck. Near the anterior superior spinous process of the ilium, Langenbeck remarks that the fascia of the transverse muscle has some strong fibres, which proceed inwards under the internal opening of the inguinal canal, of which they form, as it were, the bottom, nnd are named by Hesselbach the internal inguinal ligament. They go over the femo- ral artery and vein, are connected above with the fascia of the transverse muscle, and below are continued into the fascia of the psoas and iliac muscles. Where these fibres pass over fhe femoral vessels, they expand into a firm aponeurosis, which passing down- wards, is intimately attached at the inner side of the femoral vein to the horizontal branch of the os pubis, close to the symphy- sis, and then joins the aponeurosis of the recti muscles. The expanded portion of the foregoing tendinous fibres, thus continu- ed along the crista of the os pubis to the sheath of the rectus, forms the inner surface of Gimbernat's, or the femoral or crural liga- ment. The inner edge of this ligament is falciform, and concave, the concavity being lurned towards the femoral vein. Now where the fascia of the transverse muscle extends downwards, on the outer side of the crural artery, to the fascia of the psoas and iliac muscles so as to close the pelvis between that vessel, and the anterior supe- rior spinous process of the ilium, it also forms, like Gimbcrnat's ligament, a falciform edge, the concavity of which lies close over (he external convexity of the crural artery. Thus, partly by the concave edge of Gimber- nat's ligament, directed towards the crural vein,and partly by the concave edge of the S4 extension ofthe i-seia of the transverse mus- cle to the liiM hi iliaca, which edge is turned towaids the crural artery, an aperture is pro duced, through winch (he femoral vc ssds pass ou( <■■( (he pelvis. This opening is named by Cloquet the upper opening of the crural canal, or as many Knjisli surgeons would ~ay, of the crura' or femoral'ring By Hesselbach, it is called t.ic internal opening for the femoral vessels. Hnncvcr, as lin-c vessels do not lie loosely and uncouiiecteuly in tnis aperture, the opening itself is shut up, as it were, a.id cannot be s -en without dis- section. Ou the above described f i-ria3, there is a considerable quantity of ceiliiiar substance, which covers the vessels in the pelvis, forms a sort of sheath for the crural artery and vein, and accompanies these v <-.-m Is through the inner opening of the crural canal, or rim:, which is it-*-11 accurately shut up by it. When this cellularsubstancc is removed, the while glistening fascia are plainly seen pass- ing through the suue opening, and coming nearer together in a funnel-like manner. Where the fa-cia ofthe trans\ erst: muscle forms the outer falciform edge of this aper- ture, and is passing over ihe arteria circum- flexa ilii to the psoas and iliac muscles, it sends off through the opening a process, which becomes connected w -ill (lie outer side of the crural canal, or ring: while from the internal inguinal ligament, which lies above this opening, and constitutes the upper edge of the inner aperture of the crural canal,a production is sent, which is connect- ed with the anterior side of this canal. As for the posterior and inner sides, they have a connexion with the fasciae of Ihe psoas and levator ani. When the groin is externally dissected, in •rder to have a view of the crural ring or canal, on the outside of the pelvis, fhe fol- lowing appearances present thems Ives: after the removal of the common integu- ments, one finds below Poupart's ligament, a quantity of fat, glands, lymphatics, veins, and arteries, which vessels come out through small openings in the fascia lata. As soon us the outer surface of the external oblique muscle is cleared, its aponeurosis is found to become stronger at the anterior superior spinous process of the ilium, and its fibres to collect together, and assume the form of a band, which is Poupart's ligament, called fey Hesselbach the external inguinal liga- menl, and by Gimbernat, Cloquet, and others, the crural arch. This ligament, as is well known passes obliquely inwards and down- wards towards the os pubis, and after form- ing the external pillar of the abdominal ring, is first closely inserted into the angle or tu- bercle of the os pubis, and then being con- tinued inwards, or backwards, in the form of a firm fascia, is attached to (he horizon HbltMA. ternal inguinal lament is a sl.engthe^ part of tie fascia o, the;— J the outer inguinaMigumen, or, as i eoniinouK called, Ponpait s l.g» ' > » P'* duic-J by'the strengthened fibre ofthe low , :• portion of the Aponeurosis-of the external oi.1 que muscle, ihe fibres „i it making he exlc- n«.l pillar of the ring, being continued further towards the syn.phy=:s of ihe pubes, in the form of the outer surface of G.rn- bernuts ligament. (Langenbeck, Acne Bill. B.-2, p. 12ti, 121.) Lnglish surgeons make the formation of t'iuibernal's, or the fe- moral ligament more simple : thus Mr. Laurence states, that when Poupart's liga- ment approaches the pubes, " it becomes suddenh broader; that it is fixed by this broad portion, along the whole length of the angle and crista of the: pubes ; that it has a rounded and strong anterior edge, a thin and sharp posterior margin ; and that the former of these is nearer to the surface, while the latter is comparatively deeply seat- eel. The breadth of ibis part varies, in dif- ferent subjects : it is generally from three quarters of an inch to an inch Sometimes, as (jiimbeinat has stated, it measures more than an inch. Dr. Monro has observed, that il is broader in the male than in the female subject; and from this structure, he ex- plains in part the more rare occurrence of this rupture in the male." (P. 308, Ed. 3.) . The fascia lata, which is spread over the muscles of the thigh, is only a continuation of the aponeurosis of the external oblique muscle, and, as il proceeds downwards from Poupart's ligament, is very closely altached to the muscles of the thigh, all the way from the anterior superior spinous process of the ilium, to the femoral artery, drawing as it were Poupart's ligament downwards and in- wards, or backwards, towards the cavity of the pelvis, so as to give to its external edge aconvex appearance, and shut up the out- side of the pelvis, from the anterior superior spine of the ilium as far as the crural nerve and artery, so firmly, that the formation of a femoral hernia at this part is impossible. And, if small apertures, filled with fat, he discernible iti this portion of the fascia lata, still no hernia can here take place, because, as Langenbeck has already explained, here the interior of the pelvis is again shut up by fasciae already described. Lnder the fascia lata are situated the an- terior crural nerve, the vein and artery. The vena saphena magna lies on the outside of it, ami passes through an opening in it into the femoral vein. This aperture in the fas- cia lata is at the inner side of the groin, op- posite the internal opening of the crural ring, or canal It is named by Hesselbach the external aperture for the femoral vessels, ta, ramus of that bone, making the anterior ^Tmtl^Z^ °^^Z or outer surface of Gimbernat's, or the femoral, tice of its external semilunar edge and two ligament, whkh ,s consequently produced horns, which are directed inward* '£narts fay the junction of Poupart's with Hessel- first particularly described by Mr' " T,™ Whs internal inguinal ligament along the of Glasgow, under the name of the „S spine of the os r„bi->. 'lh„s,.*uSt as the In- nar, or falciform process af the fa^TfcU HERNIA. The lower born beuds rather inwards and upwards, and terminates iu the production of the fascia lata spread ovi'r fhe pectinalis muscie. The upper horn, which is less cur- ved, buries itself under the external pillar of the- abdominal ring. Over the lower born of the opening, jtist now described, the vena saphena magna ascends into the femoral vein. Thro.tgli the s.mie aperture also pass nearly all the superficial lymphatics of the lower extremity. According to Cloquet, tlie fascia lata consi-ts of two layers, of which the anterior superficial one is closely attach cd to the crural arch, extends over the femo- ral vessels, and forms Hie anterior side of the < rural canal. The other layer, near the pubes, quits the former, and, covering the pectinalis 'iiuscle, constitutes (he hinder side of that eanal. The anterior layer of the fascia then forms an oval aperture, through wnich lb? vena saphena passes, and which i> considered by CI..quel as Me lower opening of Ihe crnralcanal. This openi.ig. called by Hesselbach the external foramen for Ihr femo- ral vessels, is well delineated both in his cx- celleut work, and in the twenty-third plate of Langenbeck'* book (!)<■ Slruriura Pe.rito- nmi, lesticulorumluniris,S,"C.8vo. G'Ai. 1817.) According to tin: investigations of the last anatomist, as soon as the integuments are removed, this opening in the fascia lata, with its external semilunar edge, and two horns, are regularly seen. The front side of the crura! canal is formed by the fascia lata. Where this fas-, la proceeds in the form of Hes- selbach'supper horn under and bellind the; ex- ternal pillar of the abdominal rin.;, and makes the outer layer of Ghnbf-riMl's ligament, it is contiiur-d as a thin aponeurosis over (he vena saphena. so'hat it makes not merely Ihe upper horn, but reaches further downwards, and forms the outer-side of the crural canal. The outer side then of the crural camel, or ring, according to La.i.;cnbeck, extends from the outer semilunar edge of the external open- ing for the femoral ves-e's. or. as English surgeons would say, from the edge of Hie falciform process of the fascia lata. The !ar- er tlie preceding thin contiuua'i jm of la.,.-ia i», the smaller is lilt: external opening for the: lemoral vessels, the more is the upper horn bent downwards, and the more determinate i.- the form of the canal. (Langenbeck, .Yeuc liibl. B.-l.p. 124. 125.) According to Mr. Lawrence, '• the fascia lata, or fascia ot the thigh, has two distinct ins••rlious at the upper and anterior part of the limb. II is aitachcd !o th- front edge ofthe pubes, over the origin of the pecti- rieus, the fibres of which it closely covers, and it is also fixed to the front of the. crural arch. The former of these is continuous, behind the femoral vessels, with theiliac fascia : the latter is not inserted along the. whole length of the tendon, its attachment ceasing on the inner side of the vessels, which il covers anteriorly. Here, therefore, the femoral artery mid vein are interposed between the two divisions.'- (On Ruptures, Edit.'3,p. 37\.) Where the insertion of the fascia lata into Pouparl'-i ligament ends, it forms what Mr. Bums of Glasgow calls the falciform process, the upper part of which is attached! to the above i/ament, while the lower pro- ceeds further downlhethigh. The concavi- ty of the falciform process is directed to- wards the pubes. This anatomical connex- ion is one chief cau.-e, why extending the thigh, and rotating it outward, render the crural arch tense. The hernia, being situated in front ofthe pectinens, must of course be exterior to the fascia lata. In my opinion, surgeons arc very much indebted to Mr. Lawrence for his able explanation of this fact. As for myself, f am candid enough to own that, until f read his clear and concise account ofthe anatomy ofthe crural hernia, I could never reap any accurate notions, concern- ing the relative situations of the hernial sac and fa-eia of the (high, from other move prolix works, with ihe exception of those of Hesselbach and Langenbeck, by whom the anatomy is made perfectly intelligible. Mr. Lawrence lemiuds us, however, thai the pnrlieeilar crural henna, contained in Ihe sheath of the femoral vessels, lies under the fascia ; p. 3S2, Edit. 3. And he men- tions, that '•* the falciform process of the fa-cia lata, passes along the upper and ottler part of the tumour. The iliac vein is placed on the outer side* of the neck of the sac ; the pubes is directly behind it; and the upper and inner pans are bounded by the thin posterior edge* of Poupart's ligament. The inner side of the crural ring or ca- nal: as already explained is connected with tiie fascia of the transverse muscle. And, according to I -in gen beck, below the part ofthe fascia lata, which forms (he external foi'ainen for the femoral vessels, the front side of the crural canal is sometimes form- ed by a continuation of fhe fascia of the transverse muscle, as he found was the case in both fioiiis of one female subject. In such a case, there is a good deal of fat be- tween the fascia lata, and the aponeurosis of the transverse muscle, and the two parts are easily separable. Langenbeck admits, however, that the same appearance may arise from a splitting of the layers of the fascia lata. Frequently the front side of crural ring is so short, that the opening cannot rightly he-termed a canal, and it is always shorter than the posterior side. When the outer side exits, it is extended across the inner over the space between the iu o horns, and is then connected with the aponeurosis of the pectinalis derived from the fascia of the psoas ana levator ani muscles. In the anterior and inner sides of (he crural canal, there are some small open- ings. Doubtless, this stricture is referred to bv Hesselbach, when he says, that, in the male subject the outer opening for the fe- moral vessels is further closed by a net-like web of tendinous fasciculi. The posterior side of the crural canal, or ring, is entirely formed by the part of the fascia of the psoas, which enters its inner Opening, and joins the aponeurosis of the pectinalis mu-- 36 HERNIA. cle. The outer side of the canal lies under the fascia lata, and joins the anterior and posterior sidc«, where the aponeuroses of (he transverse and iliac muscles proceed to (he outside of the femoral artery. Langen- beck thinks the opening, by which the vena saphena passes over the lower horn of the falciform process of the fascia lata, might be named the lower aperture of the crural canal, i^ee Langenbeck's Ncue Bibl. filr die Chirargie, B. 2, p 126, 127 Sio. Ha- uorer 1811'.) vecordingto ilciSelbach, in femoral hcr- ,ua, the two openings ot the passage now termed the crural or femoral ring, are one half larger (ban natural. The outer portion of the inner of these apertures is pro, elled more outward, and with it the epigastric ar- tery. The femoral vein no longer lies at the' external end of this opening, but rather at the back of the canal or passage. The external semilunar edge (the falciform process) of the outer opening, is carried more outward and upward, and is tightly ap- plied over the distended hernial sac. In this state of the parts, the outer opening forms an oval firm tendinous ring, the di- rection of which, like that of the inner opening for the passage of the femoral ves- sels, istransverse. The neck of the hernial sac is that portion of it, which lies within the canal between the two openings. The posterior side of this canal, or passage, now frequently named the crural, or femoral ring, is longer than the anterior. Iu one large hernia, Hesselbach found it an inch and a halt in length, but the anterior side of the passage more than one-third shorter. The greatest diameter of the inner opening was one inch five lines, while that of the outer one was only one inch four lines. Most ofthe posterior part of the neck of the hernial sac, with the binder side of the ca- nal, lies upon the pectineus muscle, and towards theouterside upon the femoral vein. The neck of the hernial sac adheres more firmly to the anterior, than to the posterior side of the passage. At the outer opening of the passage, the neck terminates at almost a right angle forwards in the body of the sac, the upper portion of which lies upon Poupart's ligament, but the largest part of it is situated on the deep-seated layer of the femoral fascia, by which the outer side of the body of the sac, as high as the neck, is separated from the crural vessels and nerves. In the male subject, when the tendinous fibres, mixed with the cellular substance covering the outer opening of the passage, make great resistance at par- ticular points, the hernial sac of a femoral hernia may be double, or even divided into several pouches, a preparation exhibiting which occurrence is in the anatomical museum at Wurzburgh. (Htsstlb-uh, p. 13.) Except in a few cases, in which the ■ •rigbi and course of the epigastric artery are unusual, this vessel runs very close to the external side of the neck of the hernial sac, much nearer than it does in an internal bubonocele. The sac of the femoral hernia is >xce«d« J IIC SrtU Ul U1C III..."— ,.(..., Jf, inglv narrow at its neck; and, * here its body begins, it becomes expaudeidI it. a globular for,,', ; the sac of the hnbonocele is generally of an oblong pyramidal shape. The body of the sac of the femora hernia, makes a right angle with the neck, by being thrown forward and upward, a circumstance very necessary to be known in trying to reduce (he parts by the taxis. Though the tumour, formed by the body of the sac, is oval and nearly transverse, it is found, when attentively examined, to take the direction of the groin, which extends obliquely downwards and inwards, the outer, rather smaller end of the swelling being somewhat higher than the inner. (Hesselbach, p. 50.) The sac of the femoral hernia is said by Mr- A. Cooper to be immediately covered by a kind of membranous expansion, con- sisting of condensed cellular substance, and named by him, the fascia propria. Accord- ing to the same gentleman, a weak aponeu- rosis derived from the superficial fascia of the bend of the thigh, also covers the swell- ing, and is described as lying immediately beneath the skin and adipose substance. Under this fascia is the condensed cellular substance, or fascia propria, (hen some adi- " pose substance, and lastly the true perito- incal sac itself. It is of infinite use to re- member these circumstances in operating, lest one should think the hernial sac divided when it is not so. All late writers on hernia, have remarked how very small the aperture is, through which the viscera protrude in the femoral rupture ; how much greater the constriction generally is, than in the bubonocele ; con- sequently, how much more rapid the symp- toms are ; how much less frequently the taxis succeeds ; and how much more danger- ous delay proves. (See A. Cooper, Hey. Lawrence, tyc.) Though the crural ring is almost always small, yet in a few instances, in which the ' tumour is large, and of longstanding, it be- comes very capacious, just as the opening oiteni becomes, through which the inguinal hernia protrudes. Dr. Thomson, of Edin- burgh Mr. Hey, and Mr. Lawrence, have related examples of this kind. The remarks already made, concerning the treatment of hernia, before having re- course to the knife, are all applicable to the present case, and need not be repeated. In attempting to reduce the femoral hernia by „"'?' j1"* surgeon should recollect, how- Z rV™ 1r?"!n6.1'»upart's ligament, and aue,o^°rHfaSC,a'liS0f t»'e highest conse- quence Hence, the thigh should b and rolled inwards. The be bent, aisntn .„ K......"- , i,lc pressure ought a.U„°!° b.e nrsVnade downwards and back- wards PounaJl1 l°rd6r l° *,Ush lhe swe"'">§ off ^P [ S, ,,lSament ; and afterward the parts should be propelled upwards so that they may return through the crural ring. OPERATION FOR Mr. A. Cooper says, "the incision of THE FEMORAL, OR CRURAl HERNIA. the HERNIA. 37 integuments is to be begun an inch and a half above the crural arch, in a line with the middle of the tumour, and extended downwards to the centre of the tumour be- lowthcarch. A second incision, nearly at right angles with the other, is next made, beginning from the middle of the inner side of the tumour, and extending it across to the outer side, so that the form of this double incision will be that of the letter T rever- sed." The angular flaps are, of course, to be next dissected oft', and reflected. The making of two incisions, however, is not deemed necessary by the majority of surgeons ; and, in all the numerous opera- tions which I saw performed in St. Bartholo- mew's Hospital, during a space of nearly fifteen years, a transverse wound was not found necessary. The division of the skin should begin about an inch above the crural ring, and be continued obliquely downwards and outwards. In this manner, we cut exactly over the place, where the incision of the stricture should be made. " The first incision (says Mr A. Cooper) exposes the superficial fascia, which is given off by the external oblique muscle, and which covers the anterior part ofthe hernial sac ; but, if the patient is thin, and the her- nia has not been long formed, this fascia escapes observation, as it is then slight and delicate, and adheres closely to the inner side of the skin. When this fascia is divi- ded, the tumour is so far exposed, that the circumscribed form of the hernia may be distinctly seen ; and a person not well ac- quainted with the anatomy of the parts, would readily suppose that the sac itself was now laid bare. This, however, is not the case, for it is still enveloped by a membrane, which is the fascia, that the hernial sac pushes before it, as it passes through the in- ner side of the crural sheath. This mem- brane, the fascia propria, is to be next divi- ded longitudinally from the neck to the fun- dus of the sae ; and if the subject is fat, an adipose membrane lies between it and the sac, from which it may be distinguished, by seeing the cellular membrane passing from its inner side to the surface ofthe sac. " This is, in my opinion, the most diffi- cult part of the operation ; for (he fascia propria is very liable to be mistaken for the sac itseli; so that when it is divided, it is supposed that the sac is exposed, and the in- testine is laid bare; following upon this idea, the stricture is divided in the outer part ofthe sac, and the intestine, still stran- gulated, is pushed, with the unopened sac, into the cavity ofthe abdomen. " The hernial sac being exposed, is to be next opened ; and, to divide it with safety, it is best to pinch up a small part of il be- tween the finger and thumb ; to move the thumb upon the finger, by which the intes- tine is distinctly felt, and may be separated from the inner side of the sac ; and then to cut into the sac, by placing the blade of the knife horizontally. Into this opening, a di- rector should be passed, and the sac opened from its fundus to the crural sheuth. (On Crural and Umbilical Hernia.) Sometimes the contents of the hernia, thus exposed, admit of being returned, with- out the further use ofthe knife. When (his object, however, cannot be readily done, the protruded parts should never suffer in- jury from repeated manual attempts ; and it is safest to divide the stricture at once. '1 he merit of having first proposed the safest plan of cutting Poupart's ligament, even before surgeons were aware of the parts which really form the strangulation, is assigned by Gimbernat to Mr. B. Bell, who introduced his finger below Poupart's liga- ment, between the ligament and the. intes- tine, (an evideut proof, says Gimbernat, that there was no strangulation there ;) he then made a very superficial incision from above downwards, into the thickest part of the ligament to its lower edge ; and, with- out cutting quite through it, he continued his incision about an inch. He rested the back of the scalpel upon his finger, which served as a guide to the instrument, and, at the same time, as a defence to the intestine. The incision, however, having been con- tinued for an inch, would, as Gimbernat re- marks, inevitably cut the internal edge of the crural arch. Now, cutting this, only for a few lines, gives sufficient room for the easy reduction of the parts, and there is no necessity to touch the ligament, as it never occasions the strangulation.—(Gimbernat, p. 27.) Gimbernat's method of dividing the stric- ture, in cases of femoral hernia?, is now fre- quently regarded as the safest and most ef- fectual. "Introduce, alongthe internal side of the intestine, a cannulated or grooved sound, with a blunt end, and a channel of sufficient depth. This is to be directed obliquely in wards, till it enter the crural ring, which will be known by the increased resistance ; as also when its point rests upon the branch of the os pubis. Then suspend the intro- duction ; and keeping the sound (with your left hand, if you are operating on the right side, and v. v.) firmly resting upon the branch of the os pubis, so that its back shall be turned towards the intestine, and its canal to the symphysis pubis, introduce gent- ly with your other hand, into the groove of the sound, a bistoury, with a narrow blade and blunlend, till it enter the ring. Its en- try will be known, as before, by a little in- crease of resistance. Cautiously press the bistoury to the end of the canal: and em- ploying your twro hands at once, carry both instruments close along the branch to the body of the pubis, drawing them out at (he same time. By this easy operation, you will divide the internal edge of the crural arch at its extremity, and within four or five lines of its duplicative ; the remainder continuing firmly uttached, by the inferior band, or pil- lar, of which it is the continuation. This simple incision being thus made, without the smallest danger, the internal border of the arch, which forms the strangulation, will be considerably relaxed, and the parts will be irattMA. reduced with the greatest case." (Gimber- nat, p. 4o, 4ei ) Mr. A. Cooper recommends the stricture to be divided " obliquely inwards and up- wards, at right angles to the crural arch." After advising us to open the -ac of a fe- moral hernia, with particular care, on ac- e introduced at the proper place, a director with a deep groove must be used instead of the finger ; but I prefer the latter. Tne finger, or director, should not be introduced Ve-iv near the great ves-cis; but on tiiat side of (he intestine or omentum ivhn.ii is near- est to the symphysis of tne ossa pubis. The iiiri.-.ioii may Una be marie difeclly upwards. The surgeon must lake especial care lo in- troduce his finger or director v. ithiu that part where hefands tht stricture lo be the greatest, which, in this speeie:s of hernia, is the mosl interior part ol the wound." (P. lor,.) Ginibernats mode is preferable to Mr. Hey's. because, were the operation done on a male, cutting directly upward would en- danger the spermatic cord. Mr. Lawrence lias noticed, that " an inci- sion of tne most interior part ofthe stricture is tree Irom all danger, in the ordinary course of tiie vessels. But that variety, iu which the obturulrix arieiy, arising ficuu the r, igasi.K., runs ido.ij; tiie inner mat-Lin of the sac, seems to preclude us from cutting even iu this direction, llesseiiiac.ii met with a remarkable instance of such irregularity in the origin and course of the obturatrix ur- ic rv in (tic body ot a female, in whom there were two small crural hernia?. On the right side, the epigastric and obturatrix arteries arose, by a en.union trunk, from the crural artery below Poupart's ligament. They soon separated from one auotuer ; the epigastric taking its ordinary ce:,rse upwards at th« outer side of the neck ot the hernial sac while Ihe obturatrix made a consicieiaiile turn, and ran transversely inwards over the strong fibres ot tne tcmoral li^ument, aim encircled tiie anterior and inner side ot the neck of the hernia, wi;e:u:e it afterward proceeded obliquely downwards and out- wards, bthind the Horizontal branch of tiie os pubis, towards the obturator foramen. (Ile-silbuch, p. o2.) A mo.-.t* of opeioling has beeu lately prop; :,., witu a view of avoiding this Hunger. We are directed to make an incision inrough the aponeurosis of the e Menial oblique muscle, just above the crural arch, and in a direction parallel to fhat part; to introduce a director under tne culling iijc sun.""' •- ..... c imputes tnat ,be obturator ariery may arise Itoiii (he cpig„siric-, once in twenty-five or tlnrty subjects, but, ubowing thai it oti-i- •ty SUbjteio. uui, ».........n -- - o- n.ites more trequenlly, it lucn does not always deviate from Us usual course a,ong the outside ol tne sac. Mr. A. Cooper says: •• in all cases, w iiicli 1 have myself dissected, wnere tins variety existed witu crural her- nia, tue obturator has passed into the pels is, on the outer aide ot the neck ot the sac, en- Incly out oi the reach of any danger ol tiie kuile." (On Lrorul Hernia, p. 21.) Mr, Lawrence concludes, that the comparative number of instances, in winch il is found on fhe opposite side, cannot be more than one in twenty, and c msequenlly it we admit, that the obturatrix artery arises from the epigastric once in five times, it .vould only Le liable to be wounded once in a hundred operations. (P. 412, Edit. 3.) W i.en the origin and course ofthe epigas- tric artery cfitf i Irom what is common, this vessel, as ilesselbach remarks, sometimes passes inwards along the horizontal branch oi the os pubis, ere il ascends towards tiie rectus muscle; and when this variation exists in a case ot femoral henna, the ariery does not pass over the outer side of the neck of the sac, but first under it, and then rou.,d its inner side. Iicss-, Ibacii has seen only one instance of this irregularity of the epigastric artery in a female, and never iu a male subject. (Leberden Ursprung, ^c. der Leisten-unU Schenkelbriiche, p. v'iu.) The industnoiis Cloquet examined 2o0 bouies, for the purpose of estimating the average number of cls.:,, in which the origin and c .urse of the obturatrix artery are different from wh.it is mosl c jmuioh. lie found, that when lids uiter, a:,d the epigas- tric arts-, by one common trunk, thev some- times separate from each other above, and rarely below the upper opening of the crural canal. In the first wise, the longer their common trunk is, the closer do they lie to l.imbernafs l«ba„;ent, and to the inner edge •>t the uppe, opening of the above canal. in tue second case, the common trunk of iesc arteries arises within this ,;a,,al, and the two ve.se,s then return into the abuo- »«eii. In Km l.odies, ot* which b? up(.e i-'-ile, and ;3 female, the obturatrix artery aose on both sides from the hypogastric, and only in on. of which •/!•, , . J <\ t,.. i i ■ ■ ".ll,t'1 xl >Vt'e male, and ■i> female, dm it or.g-mile on both sides foui the epigastric, lo ^, o{ u cl '"^ were male, and 1., u-maie, llle o|)(ui arose on one side irom the hypo •<». "£.'J \iz. _ u.de, and 4 female, it oiig,i,ut,.,i ♦ ,.,.,„ tieriiii-il i<.. „ li i , ■■ "'"-Ccj Irom ineciuiji. <.->ei; hechcrchtsAnal ~.,u-i,.ii nits,4lo. Paris.) Iu"°* It is observed by Professor Scarpa, ,|iat HERNIA. 33 " the round ligament of the uterus, in pass- ing through the abdominal muscles, follows precisely the same track as the spermatic cord. It is equally situated behind Poupart's ligament, with the ditterence, that it does not become so distinct from the internal extremity of this ligament, as the spermatic cord does, because it has not so far to run, in order lo get from that ligament to the in- guinal ring, the latter opening being situated lower in the female, than the male sjbject. The round ligament, like the spermatic cord, also crosses the epigastric artery, before reaching the inguinal ring. And as the crural hernia always begins at (he internal and inferior angle of the arch of this name, as well in the male as the female, it follows, that, in the two sexes, the epigastric artery remains in its natural situation, and invaria- bly corresponds to the external side of the neck of the crural hernia; whilst the sper- matic i-old, iu men, and the round ligament, in women, pass over the extremity of the front of the neck of the hernial sac. In the operation for the crural hernia, in females, the incision of the neck of the hernial sac, and crural arch, when directed upward to- wards the tinea alba, cannot wound the epigastric artery, which it is of the most consequence to avoid ; but it always divides, either totally or partially, the round liga- ment of the uterus, which cannot lead to any dangerous hemorrhage; to;, except in the period of pregnancy, the arteries of the round ligament are very small; they are almost obliterated in women advanced in years ; and in general, they are quite capil- lary in the extremity of ihe ligament ad- joining the ring. Hence, it cannot be surpri- sing, that so many crural hernia? have been successfully operated upon in women, by cutting the hernial sac and cruwal arch directly upward, while not a single instance can be cited of such an incision being made in man without mischief, although, iu both sexes, the epigastric artery may have been avoided in operating by this process." (Scarpa, TraM des Hernies, p. 2-10.) Iu operating for the crural hernia in males, Scarpa recommends us to follow a method, which he calls new, but which, in fact, is the same as that advised by Gimbernat. I have found (says Scarpa) that, in man, the neck ofthe hernial sac maybe divided with- out danger, by giving to the incision a di- rection exactly contrary to that which is practised in the female subject. After having opened the hernial sac, it is to be drawn outward by one of its sides suffi- ciently to allow the introduction of a small director between its neck and the strangula- ted intestine, the groove of the instrument being turned downwards towards the internal and inferior angle of the crural arch. A probe-pointed bistoury, the eage of which is also to be directed downwards towards the point of insertion of Poupart's ligament lo the pubes, is to be pushed along the groove. By this means, the neck of the hernial sac will be divided its whole length, at its internal and in- ferior side, and Povparl's ligament will be cut close to Us attachment to the top of the os pubis. The epigastric artery will certainly be avoided, because it lies upon the oppo- site side of the hernial sac. As for the sper- matic cord, I have demonstrated, that it is situated on the forepart of fhe neck of the hernial sac ; consequently, it cannot be touched by an incision made from above downwards, whilst it is constantly cut in the ordinary method, since the knife is carried from beiow upwards. In the first case, this part may be the more easily avoided, as it lies at some: distance from the internal and inferior angle of the crural arch. In fact, it is at this place that it epiits, as we have seen, the edge of Poupart's ligament, in order to ascend towards the inguinal ring. The incision that I propose (says Scarpa) not only has the advantage of slitting open the neck of the hernial sac its whole length, it also divides a part of the insertion of Pou- part's ligament into the upper part of the os pubis, a thing that gently contributes to re- lax the crural arch, and facilitate the re- duction of the viscera; of those, at least, which are not adherent to the sac." (Scarpa, Op.c.t. p. 2 o.) ' Although this accurate anatomist and sur- geon appears to be quite unacquainted with many of the late valuable publications on hernia, which have made their appearance in this country, it is curious to find, both in his account of the inguinal and crural her- nia, how strongly his doctrines and observa- tions tend to confirm every thing that has recently been insisted upon in modern works, respecting the place where the bubo- nocele first protrudes, its passing through a sort of canal before it conies out of the ab- dominal ring, the advantage of cutting in the crural hernia the internal and inferior angle of Poupart's ligament, or, in other terms, that part of the ligament which was first particularly pointed out by Gimbernat., as causing the principal part ofthe strangu- lation, and about which so much has been said by Mr. A. Cooper, Mr. Hey, Sic. Hesselbach considers an incision through the outer side of the crural ring safer than one through Gimbernat's ligament, and aider in women than men. I women, lie recom mends the cut to be made through the mid- dle of the forepart ofthe ring, nearly straight upwards, or a little inclined inwards, in which mode the epi :astric artery cannot be hurt, whether it lie at the outer, or inner side of the neck ofthe sac. In men, this in- cision, directed obliquely upwards and in- wards, he says, cannot be made, on account of the nearness of the spermatic cord: therefore, in the male subject, he advises cutting the inner side of the opening, that is to say, Gimbernat's, or the femoral liga- ment directly inwards (.wards the symphy- sis of the o, pubis. (Leber den Ursprung, eye. dec Leislen-und-Schcnkelbr'uche, p. 54.) W hen the epigastric, or obturator, artery de- viates from its usual course, ami surrouuds the inner side of the neck of the hernia (which variety enn never be ascertained a 4fl 1IERMA. priori,) a wound of the vessel Hesselbach regards a« unavoidable. From the* views taken of femoral hernia in (his article, I consider the unrestricted iliirrlion always (o cut Gimbernid •• liga- ment in the operation perfectly erroneous. 1'or, as Langenbeck has stated, the seat of strangulation may either be in the external ap< iture of Ihe crural canal, or in an open- ing of the front or inner side of this passage, or in its inner opening, where then Gimber- nat's ligament is truly concerned. When the strangulation is of the two first descrip- tions, only the fascia lata need be cut . but, in the third, most frequent ense, (he inner semilunar edge of the internal opening of (he ring must, of course, be divided In all cases, says Laneenbeck, whether (he stran- gulation he caused by the inner or external opening of the crural canal, or by an aper- ture in the front parietes of this passage, the stricture must be cut inwa.-ds, as directing the cut iu the least outwards would injure the epigastric arteiy. When it is perceived in the operation, (bat the neck ofthe hernial sac is strangulated, close below and be- hind the external pillar of the abdominal ring, then the inner opening of the crural canal must be divided inwards, with the knife directed along the horizontal ramus of the os pubis, under the externa! pillar of the ring, towards the symphysis of the pubes. If, in such a case, the knife were carried in- wards and upwards, that part of Poupart's ligament forming the upper side of the cru- ral canal might be cut, and the spermatic artery injured. (Neue Bibl. 2 B.p. 133.) Dr. Trustedt has published some remarks in favour of employing dilatation instead of an incision, in the operation for the strangu- lated crural hernia. He observes, that even when the common trunk of Ihe obturatrix and epigastric arteries is short, (he bowels may protrude under the first of these arte- ries, which will lie upon (he upper and inner side ofthe hernia. In an operation perform- ed upon a woman, in la Charite, at Berlin, for a strangulated femoral hernia, the crural ligament was divided in Gimbernat's way by an incision exaclly parallel (o the hori- zontal ramus of (be os pubis, and (lie obtu- ra(rix artery was wounded. The patient died eight days r-.i'ter the operation, bavin" been previously attacked by trismus and opisthotonos. On dissection, about six ounces of putrid blood were found in the lesser cavity of (he pelvis, and (he above ariery cut. The vessel arose from (he epi- gastric, ran over the upperjedge of ibe inner opening of the crural canal, or ring, and then descended along its inner edge, towards the obturator foramen. This occasional course of the obturatrix artery leads Dr. Trustedt to suggest (he following rules: if, afler the her- nial sac is opened, the bowels cannot be re- lumed, the outer opening of the crural canal should be cut directly inwards, in order lo produce a considerable relaxation. But, if the reduction should yet be impracticable, (the strangulation being at the inner opening of the canal) (hen an attempt is to be made to insinuite the end of the finger through lie constriction, a plan said to have •"*"£""*■ very often in the practice of ^f"'^; ral Rust. Should the resistance be to great, however, for (his method to smK ^ tndt advises (he crural ligament o be forci- bly drawn inwards and upwards, towards the navel, with Arnaud's tenaculum, assisted by the introduction of (he finger, or with two hooks. When this plan fails, he recommends Scl.rege.-'s practice of dividing (he anterior edge of Poupart's ligament with a pair of blunt-pointed scissors, and (hen the use of Arnaud's tenaculum again. (See Rust's Ma- gazin far die gesammte Heilkunde, B. 3, II. 2.) The consideration, however, which will ever prevent the common adoption of Dr. Trtlstedl's suggestion, is, that fifty limes more lives would be lost by (he mischief done (o the protruded bowels by the forcible introduction of the lingers and hooks, than by hemorrhage from the obturan-ix, or epi- gastric artery, when the course of the vessel is irregular. CONGENITAL HERNIA. Before the beginning of fhe sixth month of tbe fcetal state, the testicle is situated near the kidney, where it receives a covering from the peritonaeum, just like the other ab- dominal viscera. Between the beginning of the sixth month and end ofthe seventh, the testicle has either descended as low as just above the abdominal ring, or else is passing through it, or arrived a little below it. (Wrisberg. Comm. Reg. Societ. Gotling. 1785.) b b When the testicle passes through the abdo- minal ring into the scrotum, it is received in a production of the peritonaeum, which afterward constitutes the tunica vaginalis; w hile (hat peri(ona?al investment, which was given to the testicle in the loins, is closely adherent (o this body, and forms what is named the tunica albuginea. After the descent of (he testicle inlo (lie scrotum, (he communication between the avity ofthe tunica vaginalis and that ofthe abdomen commonly becomes obliterated, which latter event is usually effected before both, sometimes not till afterward, and, in a tew subjects, even as late as the adult slate. in the congenital hernia, the protruded viscera are situated in the tunica vaginalis, in contact with ibe testicle: having descend- ed into (his position before the closure of Ihe rom.rTflV0n. Wilh ,he "Women. Of S?a «; lh« tun,ca vaginalis itaelf is the her- unders^7terRat!.r,JOf t,,is cas* "as not "er h, !?«' ^i0? U Was elucidated by H..1- H64 7,s6'a,'d ',e!W° liu",. n {-i3'e,Hunler,s Med. Comment • Hal- ;. **•' , ?lany Particulars, relating to (be ori- gin and formation of (bis hernia, hayi,^ bee . described in tbe 2d vol. of tbe Fi stTine- o Surgery, I .hall not here repeat hem R fore he periods now named surgc*™^" ted the circumstance of theco.S^ l»c,naa,,d testicle being in comic £ e HERMA. 41 bowels having made (heir way,by laceration, through the tunica v«^inalis, from the ordi- nary hernial s;ic of a bubonocele. The old surgeons, indeed, frequently cite this in- stance in proof of their doctrine, that some herniae were attended with a laceration of the p ri'onaeum (See Sharp's Inquiry.) From the term congenital, we might sup- pose that tins -•ernia always existed at the time of birth. Tl-e protrusion, however, seldom occurs till after this period, on the operation ofthe usual exciting causes of her- nia-* in general. It does not commonly hap- pen till some months after birth; and, in cer- tain instances, not till a late period. Mr. Hey relates a case in which a hernia conge- nita was first formed in a young man, aged sixteen, whose right testis had, a little '.vhile before the altack of the disease, descended into the scrotum. In (he generality of cases which actually take place when (he testicle descends into the scrotam before birth, (he event may be referred to (he testicle having contracted an adhesion to a piece of intes- tine, or omentum, in its passage to the ring. In an infant, which died a few hours after birth, Wrisberg found one testicle which had not passed the ring, adhering, by means of a few slender filaments, to the omentum, just above this aperture. The appearance of a hernia in very early infancy, Air. Pott observes, will always make it probable that it is of this kind ; but he was not . orrect in asserting, that in an adult, mere is no reason foi supposing his rupture to be of this soi t, but his having been afflicted with it from bis infancy ; and that there is no external mark, or character, whereby it can be certainly distinguished from one contained in a common hernial sac. i his statement is erroneous, inasmuch as the hernia congenita is attended with an impossibility of feeliug (he (estis, which pait in the common scrotal hernia is always dis- tinguishable under the fundus of the hernial sac. Th* hernia congenita, when returnable, ''ought, like all other kinds of ruptures, to be reduced, and constantly kepi up by a pro- per bandage ; and when attended with symptoms of stricture, it requires the same chirurgic assistance as the common her- nia." Mr. Pott notices, " (hat in very young children, a piece of iniestine, or omentum, may get pre.iy low down in the sac, while tbe testicle is still in the groin, or even within (he abdomen. In this case, (he appli- cation of n truss would be highly improper; for, in the latter, it might prevent the de- scent of the testicle from the belly into the scrotnm , in the former, it must necessarily bruise and injure it, give a great deal of un- necessary pain, and can prove of no real use. SiKh bandog-, therefore, ought never (o be a;-plied on n rupture in an infant un- less the 'estielc can be fairly felt in the scro- tum, afiei the gut or caul is replaced ; and when it can be so felt, a truss can never be pui ot. too soon." Many additional observations on fhe fore- going topic are contained in the "d vol. of Vol. I! 6 the First Lines of Surgery, for which reason I do not here expatiate upon it. Mr. Pott explains, (hat an old rupture, originally con- genital, is subject to a stricture made by the sac itself, ns well as lo (hat produced by (he abdominal ring, or, as might have been add- ed, to that caused by the inner opening of tbe inguinal canal. The fact he noticed several times, bofh in the dead and in the living. "I have seen (says he) such --tricture made by the sac of one of these hernia;, as produced all those bad symptoms which render the operation necessary : and I have met with two differ- ent strictures, at near an inch distance from each other, in the body of a dead boy, about fourteen, one of which begirt ihe iniestine so tight that I could not disengage it without dividing the sac. " In this kind of hernia I have also more frequently found connexions and adhesions ofthe pans to each other than in the ccmii- mon one ; but there is one kind of connexion sometimes met with in the congenital hernia which can never be found in that which is a common hernial sac, and which may re- quire all the dexterity of an operator to set free ; I mean thai of the intestine with the testicle. " When a common hernial sac has been laid open, and the intestine and omentum have been replaced, there can be nothing left in il which can require particular regard from the surgeon; but by the division of the sac of a congenital hernia, the testicle is laid bare, and after the parts ceunposing the her- nia have been reduced, will require great regard and tenderness in all the future dress- ings, as it is a part very irritable, and very susceptible of pain, inflammation, Sic. " If a large quantify of fluid should be col- lected in the sac of a congenital hernia, and by adhesions and connexions of (he parts within, the entrance info it from the ab- domen should be totally closed, (a case which I have twice seen) (he tightness of (he tumour, ihe difficulty of distinguishing the (esticle, and (he fluctuation of the fluid, may occasion it to be mistaken for a common hydrocele; and if, without attending to other circumstances, but (rusting merely to the feel and look of the scrotum, a puncture be hastily made, it may create a great deal of trouble, nud pos&;*-.ly do fulal mi .-chief. '■'By what has fallen within my observa- tion, I an inclined to believe (hat the sac of a congenital hernia is very seldom, if ever, distended (o the degree which a common hernial sac often is: it also, from being less dilated, and ra: her more confined by the up- per pHrt of the spermatic process, generally preserves a pyriform kind of figure, and for ihe «-ime reason, is also generally thinner, and will Ibertfore require more attention and dexterity in an operator when he is to open it. To which, I believe, I may add, that common ruptures, or those in a common sac, are generally gradually formed, that if, they are first inguinal and by degrees be- come scrotal; but the'congenilal me seldom, if ever, remembered by tbe patient to have been in Ihe groin only." (Pott on Ruptures, Vol. 2.) The sac of a congenital hernia, especially when the case i< strangulated, is every where equally ten e, (Htsselbach, p. 3d) and below it the lesti* cannot be l» I'. The reader must not conclude, however, from (lie above account, (hut every rupn.ie in children is congenital. Mr La.\ rente has related a case of strangulated bubono- cele, which took place in an infant ou'y fourteen months old. (P. 65, Edit. 3 ) The common inguinal hernia, which first protrudesal the inneropeningof the inguinal canal and which has the epigastric artery on the inner side of its neck, has been named by Hesselbach external, while the less com- mon instance, in which the viscera burst directly through the aponeuroses of the transverse and internal oblique muscles, and pass directly out of the abdominal ring, leaving the epigastric artery on the outer side of the neck ofthe sac, is distinguished by the epithet internal. (Anat. Chir. Ab- fiandlung fiber den Ursprung der Lehtenbruch, Wursb 1S06.) " The inguinal congenital hernia (says Scarpa) cannot be divided into external and internal : it is evident, that it must always be external, since the neck of the tunica vaginalis invariably corresponds to the point, at which the spermatic cord passes under the margin of the transverse muscle. As for other circumstances, the tunica vaginalis lies in its whole course in the same manner as the sac of a common inguinal hernia: like this, it passes com- pletely through the inguinal canal from one eijd to the other, resting upon the anterior surface of the spermatic cord. Consequent- ly, it passes between the separation of the inferior fibres of the obliquus internus, and the principal origin of the cremaster muscle. (See Wrisberg. syllog. comment anal. p. 23.) After coming out of the ring, as it is always united to the spermatic cord, it is enclosed in the muscular and aponeurotic sheath of the cremaster muscle, which accompanies it to the bottom of the scrotum. Since the tunica vaginalis, including the displaced viseera, enters the inguinal canal on the outside of the point, at which the spermatic cord crosses the epigastric artery, it is manifest, that, as it follows exactly the direction of this cord, it must also cross the artery, and remove it from the outer to the inner side ofthe ring, according to the mechanism already explain- ed in speaking of the common inguinal hernia. Hence, the displacement of tbe epigastric artery constantly happens in the inguinal congenital, just as it does in the ordinary external inguinal hernia. " But, if these two species of inguinal berniae have some analogy to each other, in regard to the parts which constitute them, yet, they present some remarkable differ- ences. 1. The common inguinal hernia whether internal or external, when it ex- tends into the scrotum, cannot descend beyond the point al which the spermatic vessels enter the testicle. There the cellular substance of the spermatic cord terminates. UEUMA. There the hernial sac must unavoidably termTnate On the contrary, in the conge,,,- 2 "J"!., the viscera may descend lower than the testicle, with wfc.ch *ey *re m immediate contact ; and, at '*>fth> "»«J even occupy the situation of this otgan, which is then pushed upward and backward. "in the case of a congenital hernia the descent of the viscera from the groin to the scrotum commonly takes place in a very short time, and in some measure precipitate. ly it is much slower and more gradual in the ordinary inguinal hernia. The reason of this difference is very plain. In the first case, the descent of the testicle, and the formation of the tunica vaginalis, have opened and prepared the way. which the viscera must follow in forming a protrusion; while, iu the second, the hernial sac e;annot descend into the scrotum, but by gradually elongating tbe layers of the cellular sub- stance, which join's it to the surrounding parts. This fact is so generalh known, that experienced practitioners consider the promptitude, with which the viscera bare descended from the f.ioin to the bottom of the scrotum, as a characteristic ngn of a scrotal congenital hernia,'' (Scarpa. Traiti des Hernies, p. 73, tyc. ; Hesselbach, p. 35 j Pott fyc.) If circumstances will admit of a truss being applied and worn in cases of con- genital hernia, in young subjects, there will be a considerable chance of a radical cure being effected, in consequence ofthe natural propensity of fhe opening between the abdomen and tunica vaginalis to become closed. The only material difference in the operation, from that for a bubonocele, is, that the surgeon has t ; lay open tbe tunica vaginalis, instead of a common hernial sac. The stricture is to be divided on the same principle as that of an inguinal hernia, and much in the same mam er As, in a case of congenital hernia, the pans are always pro- truded on the outside ot the epigastric artery, 'he stricture may be safely < ivided toward*! the ilium, as well as directly upwards. (Law- rence on Ruptures, p. 481 kdit.3.) The parts having been reduced, the edges of the wound are to be immediately brought to- gether, nrid retained so by means of one or two sutures, and sticking plaster, which is much preferable to the plan of applying dressings to the testicle and inside of the tunica vaginalis, so as to heal the part by the granulating process. A new species of hernia congenita waS described by the late Mr. Hey, in w hich a common peritonaea! hernial sac, containing the viscera, is included in the tunica vagina- lis. It arises from the parts being protruded after the communication, between the abdo- men and tunica vaginalis, is closed, so that the peritonieum is carried down along with the intestine, and forms a hernial sac. within the tunica vaginalis. It is evident also, that such a hernia can only be produced, while the original tunica vaginalis remains, in tbe torm of a bag, as high as the abdominal ring HERNIA. 43 Operators should be aware ofthe possibility of having a sac to divide after laying open the lunica vaginalis. (See the accounts of this hernia iu Hey's Practical Observations, p. 221, 4-c. and A Cooper's Work on Inguinal Hernia, p. 59.) UMBILICAL HERNIA, OR BXOMPHAl.OS. " The exomphalos, or umbilical rupture, (says-Pott) is so called from its situation, and has (like other hernia;) for its general con- teut**, a portion of interne, or omentum, or both. In old umbilical ruptures, the quantity of omentum is sometimes very great. Mr. Ranby says, that he found two ells and a half of intestine in one of these, with about a third part of the stomach, all adhering together. Mr. Gay and Mr. \ourse found the liver in the sac of an umbilical hernia ; and Bohnius says, that he did also. But whatever are the contents, they are origi- nally contained in the sac, formed by the protrusion of the peritonaeum. In recent and small ruptures, this sac is very visible; but in old, and large ones, it is broken through at the knot of the navel, by the pressure and weight of the contents, and is not always to be distinguished ; which is the reason why it has by some been doubted whether this kind of rupture has a hernial sac or not. " Infants are very subject to this disease in a small degree, from the separation of the funiculus; but in general they either get rid of it as they gather strength, or are easily cured by wearing a proper bandage. It is of sfill more consequence fo get this disorder cured in females, even than in males, that its return, when they are become adult, and pregnant, may be prevented as much as possible ; for at this time it often happens, from the too great distention ofthe belly, or from unguarded motion when the parts are upon the stretch. During gestation, it is often very troublesome, but, after delivery, if the contents have contracted no adhesion, they will often return, and may be kept in their place by a proper bandage. - " If such bandage was always put on in time, and worn constantly, the disease might in general be kept wilhin moderate bounds, and some of the very terrible con- sequences wh:■:'... often attend it might be prevented. Tiie woman who has the small- est degree of it, and who, from her age and situation, has reason to expect children after its appearance, should be particularly care- ful to keep it restrained. " In some the entrance of the sac is large, and the parts easily reducible . in others they are diflicult, and in some absolutely irreducible. Of the last kind many have been suspended for years in a proper bag, and have given little or no trouble. They who are afflicted with this disorder, who are advanced iu life, and in whom it is large, are generally subject to colics, diarrhoeas, and, if the intestinal canal be at all obstructed, to very troublesome vomitings. (Hence, pa- tients are often supposed to labour nnder a stricture, when they really do not.) It therefore behooves such to take great cure to keep that tube as clean and free as possible, and neither to eat nor drink any thing likely to make any disturbance in that part." (Pott on Ruptures, Vol. 2.) Authors, y.'ho have published since the time of this celebrated surgeon, have not added much to the stock of information which he has left, relative to theexomphalo?. The writings of Mr. A. Cooper, Scarpa, (TraM des Hernies,p. 327) and of all the most accurate moderns, confirm the fact described by Pott, that, in the umbilical rupture, there U a hernial sac, just as in other instances of hernia; Every one, ac quainted with anatomy, knows, that behind the opening in the linea alba at the umbili- cus, the peritonaeum is complete; and conse- quently must protrude along with the viscera, in cases of exomphalos. In the only two cases which Mr. A. Cooper has seen of a deficiency of the sac, the membrane had been partially absorbed, or lacerated, so as to allow the protrusion of its contents,, and threat-n, from this cause, a double stricture. Similar appearances, less closely inspected, probably gave rise to the opinion so firmly maintained by Dionis, De la Faye, Uaren- geot, and J. L. Petit, that, in the umbilical hernia, the peritoneum was always lacera- ted, and there was no hernial sac. Accord- ing to Bichat, early infancy is most subject to the umbilical hernia, strictly so called, in which the parts protrude through the navel; while the other periods of life are more liable to false umbilical hernia?, or such as arise in the vicinity of the umbilicus. (OZuvres Chir.de Desault, T. 2. p. 315.) Besides a true hernial sac, the exomphalos is also covered by a more superficial expan- sion, consisting of condensed cellular sub- stance. In operating, however, a surgeon should always cut with great caution ; for, the integuments and hernial sac in front of the tumour, are inseparably adherent; and sometimes, in large cas-*s. when an absorp- tion of part of the sac has been caused by the pressure of the bowels, they are even found adherent to the integuments. Pregnant women, and dropsical and corpulent subjects, are peculiarly liable to the exomphalos. In adults, when there is intestine in the sac, there is almost always omentum. The transverse arch ofthe colon is i.bservedtobe particularly often contained in umbilical hernia;, but the small intestines are not untrequently protruded : and even ' the coecum has been found in a rupture at the navel. (See Lawrence on Ruptures, p. 427, Edit. 3 ) In the true umbilical hernia, the stricture is made by the tendinous opening in the linea alba. Let us next consider the umbili- cal hernia in the three particular forms, in which it has been noticed by the latest writers. CONGENITAL UMBILICAL IU'RSIA. Dr. Hamilton has met with about two cases of this kind annually, for the space of 14 HERNIA seventeen years; and they strictly deserve the epithet congenital, n's they appear at birth. The funis ends in a sort of bag, containing some of the viscera, which pass out of the abdomen through an aperture in the situation of the navel. The swelling is not covered with skin, so that the con- tents of the hernia can be seen through the thin distended covering of the cord. The disease is ow ing to a preternatural deficiency in the abdominal muscles, and the hope of cure must be regulated by the size of the malformation, and quantity of viscera pro- truded. The plans of cure proposed, consist of the employment of a ligature, or of a bandage. The latter seems preferable, and was prac- tised by Mr. Hey, as follows: having redu- ced the iniestine, he desired an assistant to hold the funis compressed sufficiently near the abdomen, to keep the bowel from re- turning into the hernial sac. " I procured (says he) some plaster spread upon leather, cut into circular pieces, and laid upon one another in a conical form. This compress I placed upon the navel, after I had brought the skin on each side of the aperture into contact, and had laid one of the lips a little over the other. I then put round the child's abdomen a linen belt ; and pluccd upon the navel, a thick, circular quilted pad, formed about two inches from one extremity of the belt. " This bandage kept the intestine securely within the abdomen, and was renewed occasionally. The funis was separated about a week afterbirth ; and at the expiration of a fortnight from that time, the aperture at the navel was so far enfracted, that the crying of the child, when the bandage was removed, did not cause the least protrusion. I thought it proper, however, to continue the use of the bandage a little while longer. A small substance, like fungous flesh, pro- jected, after the funi3 had dropped off. about half an inch from the bottom of that de- {iression which the navel forms. A dossil of hit spread with cerat. e lapide calaminari, and assisted by the pressure of the bandage, brought on a complete cicatrization." (P 22*7.) ' v This gentleman has related another exam- ple, in which the intestines were quite un- covered and inflamed, the sac having burst in delivery. The parts were reduced ; but thechild died. (See also G. A Fried de reetu intestims plane nudis extra abdomen propen< dentibus nalo. Argent. 1760.) UMBILICAL HERNIA IN CHILDREN. The umbilical hernia, which is sometimes formed in the foetus, from causes difficult of explanation, takes place, in other instances, at the moment of delivery; and then, as Sabatier remarks, should it be tied by mis- take, *witb the funi.-., death would be tiie con- sequence. Most frequently, however, it is not till the second, third, or fourth month after birth, tMat the disease occurs ; and tbe numerous cases collei ted by Dc sault prove that, of ten infants attacked with this hernia, nine become afflicted at the periods jus* , mentioned. , The umbilicus, still open, now begins to contract, so as to close the cicatrix, which soon forms an obstacle capable of prevent' . r .i J *____.... t^sAmttfima» soon lorms an oosiaiit *...,...-.- -- ,■--■--- ng a protrusion of I he* viscera Sometimes, nowever, the repeated crying ol the child" mopels the viscera t'irough the opening, and ihus the closure ot the cicatrix of the navel is prevented. By decrees, the umbilical ring' becomes moie. and more dilated, the quanti- ty of protruded bowel increases, and thus a tumour arises, w hich, from being of trivial size at first, at length attains the size of an egg, or large walnut, and pr--sents itself with all the characteristic marks of a hernia The presence of a piece of intestine and omentum in the tumour, keeps the umbilicus open, and opposes the continual tendency which it has to close. Such tendency, how- ever, being sometimes superior to the resist- ance of the protruded parts, forces them back into the abdomen, obliterates the open- ing through which they passed, and thus the spontaneous cure of the umbilical hernia in children is accomplished. Two cases illus- trative of this fact, are related by Bichat. (QZuvres Chir. de Desault, T. 2, p. 318 ) Nature, however, does no' effect many such cures, and when the case is left to her alone, she not only fails in bringing about a radical cure, but gradually renders it impos- sible. In short, the propensity of the open- ing to rlose diminishes, and is lost, as the sub- ject grows older. Thus, the umbilical hernia of children teems to be essentially different from that of adults, in tbe tendency of the aperture to contract. Hence the case of affecting a radical cure in children, and the almost utter impossibility of doing so in adults. In the former, it is enough to keep the intestines from protruding, and the opening becomes of itself obliterated ; in the latter, the open- ing always remains, whether the bowels con- tinue in it or not. This indisposition of the aperture to contract in the adult, also fre- quently depends upon the protrusion not be- ing through the umbilical ring itself, but through a fissure in the vicinity of it, not endued with the same natural tendency to close, which the umbilicus possesses in young subjects. In fact, it would appear from tbe observations of Scarpa, detailed in the 2d vol. of the First Lines of Surgery, that, unless a grewn-up person has the pro- trusion from infancy, it never occurs exact- ly through the umbilical ring itself The means of curing the umbilical hernia of children, are of three kinds ; external ap- plications ; compression ; and the ligature. The first are totally useless; and as they occasion a waste of time. are improper Compassion, and the ligature, are the only rational plans. The former is the moS modern; the latter the most ancient treat- ment, as it is mentioned bv Celsns Des-o,lt flfs us, that the design both ,,f the (iXe and compression is the same, viz. to prevent he lodgment ofthe protruded viiera n the opening of the umbilicus, and thus fact HERNIA 45 litate the approximation of its sides. To which were immediately operated on with- accomplish this end, the ligature retrenches out any preparation, carried home, and the hernial sac, and skin pushed before it : brought the next, and every following and, by the union of the cut parts, a cicatrix day, to be dressed, till the cure was com- is produced, which hinders the protrusion of plete. the viscera. At the same time, the sides of The children of the poor may be cured the opening, obeying their natural tendency, in an hospital, with the ligature, in the space compression closes the deficiency, or open- of a few days. But, when compression is ing, in the parietes of the abdomen, hinders adopted, the parents are frequently put to the protrusion of the bowels, and keeps these repeated expense, a« the bandage wears out; parts from resisting the contraction of the and to additional loss from the time con- sac. Desault remarks, that though compres- sumed in paying the necessary attention. sion occasions no pain, it is irksome, during The ancients had different modes of ap- the great length of time its employment is plying the ligature. One consisted in redu necessary. The liga'.ure (he says) produces ing the parts, and afterward tying the in- momentary pain ; but it is not at all irksome teguments and sac, without opening the lat- and it effects in a few days, what compres- ter at all. In the other, an incision was sion, when successful, accomplishes in seve- made in the sac, either before or after tying ral months. In one plan, long continual at- it, for the purpose of being sure, that no tention is requisite, and if its employment piece of intestine was, and could become, be only for a short time neglect<'d, the pre- strangulated in the ligature. Celsus adopted vious effect becomes almost destroyed. The the first plan ; Paulus jEgineta preferred the other method always accomplishes its object second ; and he was imitated by Avicenna, with certainty, independently of the crying Albucasis, and (5uy de Chauliac. of the child, and the care of its attendants, The first of these methods is less painful, When compression is adopted, it is executed and equally sab*; for, we soon become either by means of a flal compress applied habituated to esce-rtaining, whether (hce is to the opening, and which does not enter still any intes'ine in fhe sac, by rubbing the it, or else by means of some round or oval opposite sides of this bag against each other. body, such as a ball of wax, a nutmeg, he. The other, vhich is unnecessarily cruet, in- adapted to the shape ofthe aperture, and, creases tbe pain, without making the method as Platner and Richter, (in his Treatise on at all more successful. Some of (he* old Hernia) advise, continually kept within the practitioners simply tied fhe base of the tu- opening. In the first case, Bichat argues, mo.,r ; others passed through it one, or two that if the bandage be exactly applied, the needles, armed with ligatures for the pur- skin and sac will form a fold in the aperture pose of fixing such ligatures in a better man- of the navel, hinder its closure, and operate ner, and, for this purpose, they even some- in the same manner, from without, inward, times made a circular incision. Desault's as the protruded intestines did from within method, which much resembled that of outward. In the second case, he observes, Saviard, was simple, and is described by the foreign body, being depressed into and Bichat as attended with little pain. maintained in tbe opening, will occasion, The child must be placed on its back, with notwithstanding what Kichter says, the same its thighs a little be.it, and its bead inclined inconveniences, and, in a more striking man- towards the, chest. The surgeon is to re- ner, similar consequences. But, on the con- duce tbe protruded parts, and to hold them trary, when the ligature is employed, the so with his finger, at the same time that he sac and skin of the tumour are removed, raises the hernial sac, and rubs its sides be- while the opening remains free, and nothing tween his fingers, so as to be sure that there prevents its obliteration. In this method, is nothing contained in it. Being certain, the omentum can never protrude outward ; that the parts which he lifts up, are only the but, in the other, if the compression should skin and sac, he is to direct an assistant to ever be inexact, the parts slip out again, surround their base several times with a above or below, and the disorder prevails on waxed ligature, of middling size, each turn one side ofthe useless application. The being tied with a double knot in such a man- ligature is also commended as producing an ner as only to occasion little pain. The tu- adhesion of the sides of the opening, either mour, thus tied, is to be covered with lint, to each other, or the adjacent#parts. This which is to be supported with one or two adhesive process arises from tiie inflamma- compresses, and a circular bandage, secu- tion excited, and occasions a degree of firm- red with ascapulary. By the following day ness, not producible by any other mode of a slight swelling has commonly taken place cure. in the constricted parts. With respect to compression, Bichat as- On the second, or third day, the parts serts that children, on whom it is employed, shrink, and then the ligature becomes loose, are miserably annoyed with it for years, ^q,'that a fresh one must now be applied in while the ready sue cess of the treatment vthe same manner as tbe fi<"t, taking care to with the ligature, is attested by i-series of 58raw it a little more figHiy. The »e-.sibili(y wcll-authe..ticated cures, which iu Desanit's*'of the parts, increased by the inflammation, practice, amounted to the number of fifty which iii<- constriction of the filature has In the latter years of his practice, says Bi- already produced, usually rendersfhis second chat, many persons were also seen bringing ligature more painful Viler the operation to his public consultations theh children, the same dressings, as at first, are to be ap! 4o UERMA. plied. The tumour soon becomes discolour- ed, livid, and smaller. \ third ligature, put on in the same way as the preceding ones, entirely obstructs the circulation in it. The part turns black and flaccid, and commonly falls off on the eighth or tenth day. A small qlcer is left, which, being properly dr *scd, very soon heals, and leaves a ciculrix suffi- ciently strong to resist the impulse occasion- ed by coughing, or other efforts of the abdo minal muscles. For two or three months, however, after the operation the child should wear a circular bandage, in order to prevent, with still greater certainty, the viscera from being propelled against the cicatrix, so as to interrupt the process of nature, which is now producing a gradual closure of the umbilical opening. Numerous cases might here be adduced, in confirmation of (he above prac- tice ; but, several (nine) are already publish- ed in the Parisian Chirurgical Journal. But one may doubt, (says Sabatier) quo- ting the article in the journal, where D**sault treats of the present disease, whether the infants got rid of the hernia, as it might have returned some time afterward. To this ob- servation, Bichat replies, that numerous facts remove the doubt; for, several of the sub- jects were brought to Desault's public con- sultation, for other diseases, a long while after they had been operated upon, and the great number of students, who examined them, all acknowledged, that the ring was completely obliterated, and there was no impulse of the viscera in coughing, sneezing, 8z.c. Other children, in the know ledge of the surgeons of ihe H6tel-Dieu, remained perfectly cured, and Bichat was acquainted with two young subjects on whom tbe ope- ration had been performed four years, and they had had no relapse. In young infants the operation almost con- stantly answered ; but, in proportion as their age increased, it was found to be less certain. Bichat relates three eases, whic.h tend to prove, that success may be completely ob- tained at tbe ace of a year Riid a half ; that the cure is difficult, when the child is four years old ; and impossible, when it is nine. (See CEuvres Chir.de Desuult, par Bichat, T. 2,p.3l5,&fc.) Mr. Pott notices the plan of curing the exomphalos with the ligature, and expresses himself strongly against the practice iu gene- ral. To adults the plan is not applicable, paifioularly when the tumour is large. Mr. Pott was decidedly in favour of compression, and he observes, that, in young subjects, and small hernia;, a bandage, worn a proper time, generally proves a perfect cure. (Vol. 2.) Anxious that this work should be stri impartial, I next proceed to relate what been more rec»-n,ly urged ngninst ihe e-JJ „pi„io„, .hM"lt.i.,-,^;,,:»f11»rlS5: sault to revive (In* '.peratmn i r c^ilui,. along while sine, , and for h I together abandoned. lis described the particu- ■■•od reasons, H;;Sof!;a,(Ll7,C>.14,)l.eS.H.r,tha, e nonrissonie.imes.obe.niply.ied, nd lh»S in other ins.....ces, us ba.e ,, to have i. needle and dnuUe ligature introduced through if, in order that it may be embraced almosl in the -,me way as a stapbybmia ,s lied Bui among the causes which contra- indicate il is operation, he mentions so many circiim-tancs in relation to age, constitution,' diseasesoflhesk...,&c.!batheseemstoconsi. der the ca-es in which it may be practisod with success, as very few. 1 be same reflections, were made bv several other ancient surgical writers, especially by Fabric-ius ab Aquapen- dente Desault himself has put some restric- tions to the employment of the ligature, since he observes, with his usual candour, that this method does not radically cure (he umbilical hernia of children, arrived at the age ot four years; (hal i( is indispensable, as Celsus inculcates, to employ a needle and double ligature, when the base of (he tumour is v. r> large; and lastly, that even iu the youngest children, a radical cure cannot be effected h\ the ligature, unless a methodical compression of (he navel, by means of a bandage, he kept up immediately afler Ihe operation and for two or three months It i- perhaps to (he omission of (his last mean?, (hat a tela;-e is to be ascribed in seveial of the n ilfb-eis operated upon by Desnult. •■ De- sault avoit remis en risrueur la ligature torn- b&e en disuitude. II s'abusoit sur sa valeur; et il nest pas difficile d'en conrndtre la cause. Tons les en fans qu'il opiroil d V Hotel- Dieu sorloie.nl guiris el n'y revenoient plus: on r>-gardoit aloes comme radicale une gnirison momentanee." (Rirherand, Nosogra, hie Chir. T. 2,p. -!5o.) 1 have carefully watched (-ays Scarpa) the immediate effects, and the more or less remote consequences of lying (be uu.bilical hernia, either simply or by means of a needle and double ligature ; and, after a considerable number of ueh c-a-es, I be- lieve I e-an assert, th it this operation, how- soever performed, is not always exempt from grave ard sometimes dangerous accidents. I can al.-o add, that it never procures a truly radical cure unless the cicatrix, occasioned by it in the umbilical region, be submitted for some months to a methodical and uninterrupted compression. Il is not so uncommon, as *ome surgeons pretend, to see arise after the applica- tion of the ligature, a fever attended with symptoms of mosl violent irritation, and acute sufferings, which cause incessant crying, and sometimes convulsions. Tin ulcer, which is _ ... .._, —■*-£*▼ -»»«;'»«« i-uuiuisious. Jn> uieer, uluch u ployment of tbe ligature for the cure ol rW*produced by the detachment of the swellms « umbilical hernia in children. » always very large and difficult to heal Every Ihe incessant careiihat a bandage requires, »r<"v and then it becomes painful, and emits either to keep it clean or make it always fungous granulations, even thou£h dressed keep up the proper degree of pressure, r.n- with dry applications. ders its employment difficult in the children « Latterly, it has been explained by a rele of the poorer classes. Scarpa expresses his brated sur0-_on, (Paletta Memor del' Imti turc, Tom. 2, Pnrt 1.) that the umbilical vein and the suspensory lig-onent of (he liver, tir- ing incbi'b-d in the ligature ol the um'i.iutal hernia, the inflammation which crijin;nes in these parts may. peibapi, m certain case--, be coiiirniinir it d lo the liver, so as (o put the child's life iu great dauber. When, in conseejue-nce of the ligature, symptoms of violent irritation come on, they are ordina- rily attributed to certain individual cucum- stances, such as extreme sensibility, or a par- ticular disposition to spasm Hence, it is believed, (hat they should be consideied as exceptions, which do not exclude the gene- ral rule, and prove nothing against the utility of the operation. But how (says Scarpa) can the surgeon ascertain the exislence or nonexistence of these individual dispositions in the children upon which he is (o operate ? As- . rdly (hose subjects, iu which I have had uics'onto notic. the above accidents, en- joyed, before the operation, perfect health in i very respect " Whatever process be adopted for tying the umbilical hernia, it is evident that the tumour can only be constricted as far as a little way on this side of the aponeurotic ring of the umbilicus, whence it follows that the integuments musi always remain promi- nent and relaxed for a certain extent, at the front and circumference of this opening. Also, after the separation of ihe strangulated portion, (hehe navel and tbe integuments, a -inall cavny, forme,) by the neck of the hernial s. ; a cavity into which ihe viscera begin to insi- nuate themselves after the operation, so as to hinder the complete contraction of (he um- bilical ring. The demonstration of wnat I have advanced is, in some measure, to be found in ihe old method of operating for the inguinal hernia, not in a strangulated state, by ll ruptures. \V -en reduci- ble-, i* pB - s'i uld be si pt u,i with a band- age or tin s-, which plan, h-wveve", ingiown- up person" iffords n« hope ,t a radical curt. Mr. Hey lias describe • son, vesry good trusses for the exomphalos, which are appli- cable 'o children, when compression is pre- ferred, as well as tonduli subjects Ore was invented by (he laic Mr. Marrison.an ingeni- ous mechanic a( Leeds. " It consists of (wo pieces of thin elastic steel, which surround tbe sides of tbe abdo- men, and .iearly meet behind. At their an- terior e&tremily they form conjointly an oral ring, to one side of which is fastened a spring of steel ot the form iepresented. A( the end of this spring is placed the pad or bols'er that presses upon the hernia. By the elasticity ol this spring the hernia is repressed in every position of the body, and is thereby retained constantly within the abdomen. A piece of calico or jean is fastened to each side of the oval ring, having a continued loop ri its edie., through which a piece ot tape is put, that may be tied behind the body. This contrivance helps to paise-ve the in- strument steady initsproper situation. (Prac- tical Obs. in Surgery, p. 231.) And, in tbe second edition of the preceding work, ano- ther truss for th' exomphalos is described, the invention of Mr. Eagland, of Leeds, but as some account is given of this instrument, with an engraving, m the 2d. vol. of the Firs: Lines of Surgery, 1 shall not here repeat the description. When Ihe exomphalos is irreducible, and large, '.he tumour must be supported with bandages. **• It is jbserved by Scarpa, that the umbi- lical hernia, am! those of the linea alba, are less subject to be -traugula'.-d ih.oi the ingui- nal and te'.i.irid hernia ; but thai, when they are unfortunately affected *i:h strangulation, the symptoms are. more intense, and gan- grene come; on more rapidlv, than in every other specir-s of rupture. If (he operation bt performeJ, the ••vent isfiequ- ,-itly unfavour- able, because it is generally done too late. This pra tical fact is proved by the experi- ence ofthe mos! i eleh*-H,e.: surs;eoiisof eve ry age. " II est certain (says Dio.ns) que dc cette opiralion il en p6rit plus qu'il n'en ri- chappe." (Cours d Operations, p. 98, Ed. 1777, avec les notes de la Fuye.) '1 • iImi adds, ihat '.hev Who hav. he ini-t .r!i n to be afflxled with an exomphalos bouid ra- ther disp-nse with llieir ahirt than t bandage. He. ter ?vs nearly Ihe same Hiing. (Insti- tut. Chirurg. T. 2, Cap. 94.) Vi ben 'he omentum aloi «. is strangular-d in th* exomphalos, or ie.uia of ihe linea alba, observation prove.., that (he syruploms are r.ot less intense, th?n when iue intestine is also incarcerated. There is this difference, however, that vviien b•■• imei.tum alorit is strangulated, on'y nausea o curs, and, if vo- miting should b'-u-wise lake place, it is less frequent and violent than when the bowel itself is strangulated. In the first JJ^jjj| stools are bar lly ever "'^V'nTdo^ The proximity J the ^^^0^2 the reason why the sir-n«■ casi omentum, m ih•* •'"'*• '^i ympathelic ir- f.,r more intense s;. uipt«>ms ol > ■ I tation than the sirangulat.on... «he same vis- cus in the inguinal or crural Iher,..a Here the operation is not only always ne. cessarv, but urgently required. It is not mate,.ally different from that which is prM; tised for fhe strangulated inguinal and crural hernia;; but. in general, it demands greater circ iiiispection, on account of the connexion or intimate adhesions, which fr. quealy ej.st between the integuments and hernial sac, and also the adhesions whicb often prevail hetween the latter [ h-t and tbe omentim which it contains. The. situation of the in- testine, which is frequently covered by and enveloped in the omentum, is another cir- cumstance deserving earnest attention (Scarpa, TraM des Hernies, p. 361, 362.) Mi. Pott ^ not such an advocate as Scar- pa for the early performance of the opera- tion in cases of exomphalos : " The umbili- cal, like tht inguinal hernia, becomes the subject of chirurgic operation, when the parts are reducible by the hand only, and are so bound as to produce bad symptoms. But though I have in the inguinal and scro- tal hernia advised the early use of the knife, I cannot press it so much in this ; the suc- cess of it i» very rare, and 1 should make il tbe last remedy Indeed, I am much incli- ned to believe, that the bad symptoms which attend these cases are most frequently owing to disorders in (he intestinal canal, and not so often to a stricture made on it at the navel, as is supposed. I do not say that the latter does not sometimes happen; it certainly does ; but it is often believed to be the case when it is not. " When the operation becomes necessa- ry, it consists in dividing the skin and her- nial sac, in aiich manner as sh;,ll set the in- testine free from stricture, and enable the surgeon to return it into the abdomen. (Pott on Ruptures.) The rest ot the conduct of the surgeon is to be regulated by the usual principles. The division of the stricture is properly recommended to be made directly upward, in the course of the linea alba. In consequence of the great fatality of the usual operation for the exomphalos, I think the plan suggested, and successfully practised by air. A. Cooper in two instan- ces, should always be ado, tod, whenever ti.e i imonr is large, and free from gangrene; apla.. that has also received the high sanc- tion of tnat.listingui'hed anatomist and sur- geon, Professor Scar; a. (TraM des Her- that, when the parts admit of being reduced, w.tuout Uy.ng „pe„ the sac, this method should always be pre I erred. It consists in making an incision ju i sufficient to divide the stricture, without op-ning the sac at all, "able. eVCntS' D° m°rC °f *' than 5s toevl' HERMA. 40 In umbilical hernia;, of not a large size, Mr. C. recommends the following plan of operating: " As the opening into th< abdo- men is placed towards the upper part of the tumour, I began the incision a little below it, that is, at the middle of the swelling, and ex- tended it to its lowest part. I then made a second incision at the upper part ofthe first, and at right angles with it, so t;u«t the double incision was iu the form of the letter T, the top of which crossed the middle of the tumour. Ihe integuments being thus divided, the angles of the incision were turned down, which exposed a considerable portion of the herniid sac. This being then carefully opened, the finger was passed be- low the intestines to the orifice of the sac at the umbilicus, and the probe-pointed bis- toury being introduced upon it, I directed it into the opening at the navel, and divided the linea alba downwards, lo the requisite degree, instead of upwards, as in the former operation. When tiie omentum and intes- tine are returned, tbe portion of integument and sac, which i, left, falls over Ihe opening at the umbilicus, covers it, and unites to its edge, and thus lessens lue risk of tbe peri- tonaea! inflammation, by more readily clo- sing the wound." (On Crmaland Umbili- cal Hernia.) LESS FREO.CKNT KINDS OP HI'RNIA. The ventral hernia, described by Celsus, is not common ; it may appear at almost any point of the anterior part of the belly, but is most frequently found between fhe recti muscles. The portion of intestine, &i.c. is always contained in a sac, made by the pro- trusion of the periiona*um. Mr A. Cooper imputes the disease to the dilatation of tue natural foramina for the transmissioii of vessels, to congenital defi.-isucies. lacera- tions, and wounds of the abdominal mus- cles, or their tendons. In small ventral her- nia;, a second fascia is found beneath the superficial one ; but, in large cases, the lat- ter is the only one covering the sac. Hernia; iu the course of the linen alba somc.imes occur so near the umbilicus, that they are liable to be mistaken for true um- bilical ruptures. They may fake place either above, or below the navel, i he first case, however, is more frequent than the second, and the following is the reason of this circumstance according to the opinion of Scarpa. "The upper half of the linea alba, that which extends from the eusiform cartilage to the umbilicus, is naturally broader and weaker, than the low er half, the recti muscles ciming nearer aud nearer together, as ibey descend from the navel to the pubes. (Scarpa, TraM des Hernies, p. 333.) The hernial sac of ruptures at the upper part ofthe linea alba may contain a noose of intestine, and a piece of Ihe omentum, though in most cases, a portion of the latter membrane alone forms the contents. In sprue subjects, the linea alba is so disposed ro give way,that several hernia: are obser- Voi If______________ ___J ved to be formed successively in the inter- space between tbe ensiforin cartilage and the umbilicus. " With respect to the small hernia (says Scarpa,) w hich N considered as formed by the stomach, and concerning which Hoiii and Garengeot have written so much (with- out either of them having related, at least to my knowledge, a single example proved by dissection,) it is at bast unproved, that it was exclusively formed by this viscus. I do not see, why the other viscera, particu- larly the omentum and traiiswrsc colon, might not also contribute to it. In my judgment, il only differs from other hernia; of tne linea alb-i, in being situated on tbe left side of the ensiforin cartilage, a situa- tion that must materially influence the symptoms of the case. In fact, whatever may be the viscera, which form it, a sympa- thetic irritation of the stomach is occasion- ed, that is much more intense, than that which ordinarily accompanies umbilical hernia;, those of the lower part of the linea alba, or, in short, all other hernirv, which are more remote froiii the stomach." (Op. cit. p. ;>;i4 ) I he following are said to be the circum- stances, by which the umbilical hernia, and that which occurs iu the linea alba near the uavef may be discriminated. The first, whether in the infant or the adult, has a roundish neck or pedicle, at the circumference of which tbe aponeurotic edge of the umbilical ring can be felt. Whatever may be its size, its body always retains nearly a spherical shape. Neither at its apex, or its sides, is any wrinkling of t:;e skin, or any thing like the cicatrix of the navel, distinguishable. In some points of the surface of the tumour, the skin is merely somewhat paler and thinner, than elsewher.':. O.i tiie contrary, the hernia of the linea alba has a neck, or pedicle, of an oval form, like the fissure through which it is protru- ded. The body of the tumour is also con- stantly oval. If the finger be pressed deep- ly round its neck, the edges of the opening in fhe linea alba ca. be felt ; and, if tbe hernia be situated very near the umbilical riur, the cicatrix of the navel may be ob- served upon one side of it, which cicatrix retains its rugosity, and all its natural ap- pearance ; a certain indication, that the vis- cera are not protruded through the umbili- cal ring. (Scarpa, TraM des Hernies, p. 336.) The distinction which Scarpa has estab- lished between the umbilical hernia;,proper- ly so called, and those of the lit.ei, alba, is not useless in regard i«> practice. Indeed, when the latter are left to themselves, they make much slower progress, than the form- er. On account of (heir smallness, they frequently escape notice, particularly in fat p-r-ous, and, w hen situated at the side of the ensiforin cartilage. They occasion, however, complaints of the stomach, habitu- al colics, especially after meals; and, un- fortunately for the patient, he may be tor- mented a very Ions time by these indispo- .->© HLftNJA. sitions, before the true felise oT them is dis- covered. The umbilical hernia may be known, from the earliest period of its formation, by the alteration which it produces in the cicatrix ofthe navel, and the rapidity of its increase. In other respects, these two kinds of her- nia; deniu.41 the same means of cure; but tiiose of the linea alba, ra-leris paribus, are more difficult to cure, than ruptures at the umbilicus. This is probably owing to the natural tendency, which the umbilicial ring has to close, when the hernia is kept well reduced, whilst accidental openings in the linea alba have not the same advantage. (Scarpa, p. 340.) When a common ventral hernia is redu- ced, it should be kept in its place by means of abandu-e or truss. When strangulated, it admits, more frequently than most other cases, of being relieved by mcc'ical treat- ment. If attended with stricture, which cannot otherwise be relieved, that stricture must be carefully divided. Mr. A. Cooper recommends the valvular incision, and the dilatation to be made, either upward or dow nwuiel, according to the relative situa- tion of the tumour and epigastric artery, which crosses the lower part of the linea semilunaris. Pudendal Hernia.—This is the name as- signed by Mr A. Cooper, to the hernia which descends between the vagina and ra- mus iscliii, and forms an oblong tumour in the labium, tracealde w ithin the pelvis, as far as the os uteri, lie thinks, that this case has sometimes been mistaken for a hernia of the foramen ovale. When reducible, a ttommou female bandage, or (he truss used for a prolapsus ani, should be worn. A pes- sary, unless very large, could not well keep the parts from descending, as the protru- sion happens so far from the vagina. Mr. A. Cooper is of opinion, that, when strangu- lated, this hernia, in consequence of the yielding nature of the parts, may generally be reduced, by pressing them with gentle and regular force, against the inner side of the branch of the ischium. If not, the warm bath, bleeding, and tobacco clysters are ad- vised. Were an operation indispensable, the incision should be made in the labium, the lower part of the sac carefully opened, and, with a concealed bistoury, directed by the finger, in the vagina, the stricture should be cut directly inward, towards the vagina. The bladder should be emptied, both before the manual attempts at reduction and the operation. (On Crural Hernia, fyc. p. 64.) Vaginal Hernia.—A tumour occurs within the os externum. It iselastic, but not pain- tul. When compressed, it readily recedes, but is reproduced by coughing, or even without it when the pressure is removtd. The inconveniences produced are an ina- bility to undergo much exercise or exertion ; lor, every effort of this sort brings on a sense of bearing down. The vaginal hernia pro- trudes in the space, left between the uterus and rectum. This space is bounded below by the peritonaeum, which membrane is forced dowinvards towards the [J""-'^ but, being unable ,o pro.ru u,«h«r m tttf direction, is pushed toward. ■ i „fu..T.jri».. m ";;«* "U^uVX always intestinal. . Some hernia; protrude at the antenoi part of the vagina. (.1. Cooper on Crural lltr- nia, Sf-c. p. 65, 66 ) Perinatal llernia.—\n men, the parts pro- trude between the bladder and rectum ; in women, between the rectum and vagina. The hernia does not project, so as to form an external tumour- and, in men, its exist- ence can only be distinguished by examin- ing in the rectum. In women, it may be detected both from this part, and the va- gina. In case of strangulator, perhaps, this hernia might be reduced by pressure from within the rectum. An interesting case of perineal hernia, which took place from the peritonaeum being wounded with the gor- get in lithotomy, is related by Mr. Brom- field ; Chirurgical Obs. p. 264. The reducible perinaeal hernia in women may be kept from descending, by means of a large pessary. Bolh this kind of rupture and the vaginal may prove very dangerou3 in cases of pregnancy. (See Smellie's Mid- wifery, Case 5.) Thyroideal Hernia, or Hernia Foraminis Ovale. In the anterior and upper part of the obturator ligament, there is an opening, through which the obturator artery, vein, and nerve proceed, and through which, oc- casionally, a piece of omentum, or intestine is protruded, covered with a part of the peritonaeum, which constitutes the hernial sac. In the case which Mr. A. Cooper met with, the hert.ia descended above the obtu- ratorts muscles. The os pubis was in front of the neck of the sac ; three-fourths of it were surrounded by the obturatorligament; and the fundus of the sac lay beneath the pectineus and adductor brevis muscles. The obturator nerve and artery were situa- ted behind the neck of the sac, a little to- wards its inner side. This species of hernia can only foim an outward tumour, when very large. Garengeot, however, met with an instance, iu which the re was not only a swelling, but, one attended with symptoms of strangulation : he reduced the hernia, which went up with a guggling noise ; the symptoms were stopped, and stools soon followed. The hernia of the foramen ovale, when reducible, must be kept up with a suitable truss; and it it were strangulated, and not capable of relief from the usual means an operation would be requisite, though at- tended with atfficrlties. The division ofthe obturator ligament and mouth of the sac should be made inwards, to avoid the obtu ralor artery. If this vessel, however, were to arise in common with the epigastric ar- tery, it would be exposed *■<> injury bv f.-t" HER MA. lowing this plan. (See Garengeol in M.m. de I'Acad. de Chir. T. 1; A. Cooper on Cru- ral Hi-mia.fyc p. 70; and First Lines of Sur- gery, Vol. 2, p. 80, Vc* ) < yslocele.— \s Mr. Pott observes, " The Urinary bladder is also liable to be thrust forth from its proper situation, either through the opening iu the oblique muscle, like the inguinal hernia, or umier Poupart's liga- ment, iu the same manner as the femoral. " This is not a very frequent species of hernia, but does happen, and has as plain and determined a character, as any other. " It has been mentioned b\ Bartholin, T. Dom. "-iala, Platerus, Bonetus, Ruysch, Petit, Mery, Verdier, (slc. In one ofthe histories given lis the latter, the urachus, and imper- vious umbilical artery on the left side, were drawn through the tendon into tbe scrotum, wilh ihe bladder; in another he found four calculi. " Ruysch gives an account of one com- plicated with a mortified bubonocele. Petit says, he felt several calculi in one, which were afterward discliai_,ed through the ure- thra, itfee also J G. F. Juhn de iusold" Calculi In'^entis per Scrotum txclasione. Wit- tenberg, 1750.) " Bartholin speaks of T. Dom. Salaasthc first discoverer of the disease, and quotes a case from him, in which the patient had all the symptoms of a stone in his bladder ; the stone could never be felt by the sound, but was found in the bladder v which had passed into the groin) alter death. '• As the bladder is only covered in part by the peritonaeum, and must insinuate itself between that membrane and the oblique nitisi-.le, in order to pass the opening in the tendon, it is plain that the hernia cystica can have no sac, and that when complica- ted with a bubonocele, that portion of the bladder which forms tiie cystic hernia must lie between the intestinal hernia and the spermatic cord, that is, the intestinal hernia must be anterior lo ihe cystic. " A cystic hernia may, indeed, be. the cause of an intestinal one ; for when so much of the bladder has passed the ring, as to drag iu the upper and hinder part of it, the peritonaeum which covers that part must foilow, and by that means a sac be formed for the reception of a portion of gut or caul. Hence the different situation of the two hernhe in ihe same subject " While recent, this kind of hernia is easily reducible, and may, like tue others, be kept within by a proper b.inda/e ; but when it is of any date, or has arrived to any consider- able size, the urine cannot be discharged, ■without lifting up, and compressing the .scritutii ; the outer surface ofthe bladder is now become adherent to the cellular mem- brane, and tin* patient must be contented w ith a suspensory bag. " In case of complication with a bubono- cele, if the opeiatiou becomes necessary, great care must be taken not to open the bladder instead of the sac, lo which it will always be found to be po.terior; And it uiav al'O sometimes by the inattentive be mistaken for a hydrocele, and by being treated a* such, may be the occasion of great or even fatal mischief.'' ( Vol. 2.) The cystoccle is always easily distinguish- able by "the regular diminution of fhe swell- ing, whenever the patient-makes water. Verdier and Sharp have accurately de- scribed the cystoele. Pott has offered two cases, which fell under his observation; Vol. 3. Pipelet le Jmiiic mentions a cystic hernia in perinueo, and several cases of its occurrence in the female ; Acad, de Chir. T. 4. Pott cut into one cystocele, by mis- take. Mention is made (t.dinb. Surg. Jour. Vol. 4. p. 512.) of a cystic hernia, which pro*.; ided between the origins of the leva- tor a.ti, and obturalor i.tternus muscles : the tumour made its appearance in the: pu- dendum of an old woman. Much additional information respecting the cyslocele, and its various forms, is contained in the second volume of the First Lines of Surgery, p. 49, i,c, accompanied with references to all the most interesting writers on the -.(inject. An instance of protrusion ofthe bladder through a wound, caused byr a bullock's horn, is rc:- corded by Larrey. (MLm. de Chir. Mil. T. 4, p. 289.) hchialic Hernia.—This disease is very rare. A case, however, which was strangu- lated, and undiscovered till after death, is related iu Mr. A. Cooper's second part of his work on hernia. It was communicated by Dr Jones, so celebrated for his book on hemorrhage. Tbe disease hapi e ed in a your.i'. man, aged 27. On opening the abdo- men, the ileum was found to have descend- ed on the right side ofthe rectum into the pelv.'s, and a fold of it was protruded into a small sac, which passed out of the pelvis at the ischiatie notch. The intestine was ad- herent to the sac at two points : the stran- gulrted part, and about three inches on each side, were very black. The intestines to- wards the stomach were very much distend- ed with air, and here and there, had a livid spot on them. A dark spot was even found on the stomach itself just above the pyhiti- The colon was exceedingly contracted as far us its sigmoid fiexure. A small orifice was found in the side of the pelvis, in front of, but a little above (he se iatic nerve, and on tiie forepart of the pyriformis muscle. The sac lay under the. ghna.-us mnximus muscle, and ils orifi e. was before* the infer- nal iliac ariery, below (he obturator artery, but above the vein. Mr. A Cooper remarks, that a reducible e ase migiii be kept up with a spring truss,'and that if an operation were requisite, the orifice of the s;.c should be dilated directly forwards. (On Crural Her- nia. A, c. p. 73.) For a further account of tlie ischiatie hernia, and references to the most interesting works on the subject, see First I ines of Surgery, Vol. 2, p. 84, 8,-c. Phrenic Hernia.—The abdominal viscer*. are occasionally protruded through the dia- phragm, cither through some ol the natural apertures in this mtscb-, or deficiencies, or wounds, and lacerations in il. Tlie second-• kind of case is the most frequent: .Mcrgugiii HL.RMA furnishes an in>tnner of the first. Two cases, related by Dr. Macnuiey in Med. Obs. and Inq. Vol.'l. two mme detailed in the Medi- cal Records and iusearc'ies, and two others published by Mr. A. Cooper, are instances of the second sort : and another case has been lately recorded by tbe latter gentle- man, affording an example of the third kind. A lacerat.ou of tlie diaphragm by fractured ribs, has produced a hernia A case of this kind was dissected by Mr. Travers, at Guy's Hospital. 'Meu. Chir. Tians I ol. r», p. 37>.) Iu this last volume, may also be found the particulars of an interesting example, in which a considerable part of the lar: e cur- vature of tlie >tons.ich w us protruded through a fissure of the diaphragm. The accident wa> unattended with any fraciure of the ribs, and was caused by the upsetting of a stage couch, on which t.'ie patient was ;.n outsij-e passenger. L.-foie death, he vomit- ed up a lai it quantity of blood, and a small semicircular aperture was discovered on dissection in the lower part ofthe strangu- lated portion ofthe st.imach. (P. *)7b, 379.) See also B. Stehelin, Tenlamen Med. quod rentriculum, qui in ihoracem migraverut,fyc. dtscribit, 17-1 ; (in Hallerii Uisp. Anat. 6, 675.) Hildanus, Pare, Petit, Schenck, iu;. also mention cas- s of phrenic hernia. The disease is quite out ofthe reach of art. Mesenteric Hern a.—If one of the layers of the mesentery be torn by a blow, while the other remains in its natural state, the in- testines may insinuate themselves into the aperture, and form a kind of hernia. The same consequence may result from a natu- ral deficiency in one of these layers. Mr. A. Cooper records a case, iu which all tbe small intestines, except the duodenum, were thus circumstanced. The symptoms during life were unknown. (On Crural Hernia,&-c. ■p. 82) Mesocolic Hernia.—So named bv Mr. A. Cooper, when the bowels -lide between the layers of the mesocolon. A specimen of this disease is preserved at St. Thomas's Hospital. Lvery surgeon should be aware, that the intestines may be strangulated within tbe abdomen from the following causes: 1 Apertures in the omentum, mesentery, or mesocolon, through which the intestine protrudes. 2. Adhesions, leaving an aper- ture, in which a piece of intestine becomes confined 8. Membranous bands at the mouths of hernial sacs, which becoming elongated, by tbe frequent protrusion and return ofthe viscera, surround the intestine, so as to strangulate them within the d'ulo- nien, when returned from the sac. (bee A. Cooper on Crural Hernia, £,c p. 85.) Pott remarks, tnat " Ruysch gives an ac- count of an impregnated uterus being f.vuiid on the outside of the abdominal opening; and so do Hildanus and Sennertus. Ruvsch also gives an account of an entire sp'leen having passed the tendon of the oblique muscle. And 1 have myself seen the ovaria removed by incision, after they bad been some months in the groin." (Vol. 2.) More particulars re-pecting all Hie 1«" »re«1««t kinds of hernia are Kiven in the second vo- lume of the First Lines of Surgery. Irauco, TraM des Hernies, eye. Sro., Lyon, 1561; End. von Hammen. De Ilemm, Umo., Lugd. 1581. Malach-C.tiger, kelegraphia, sive De- scriptio Htrniarum, cum enrundem curatto- nibus. tarn Mediris, quam Chirurgicis, \2mo., Munachii, 1631 ; Ant. Le Quia, Le C/urur* gicn Herniaire, 12ml*., Paris, 1697. Litlre, Obsei ration sur une Noufr-elle Esjicce de Hn- nie. Mim. de I'Acad. des Sciences; 1700. Mcry, in the sanii work; l'ol Litlre, sur une Hemic Rare; same work ; 1714. Mau- chart de Hernia incarcerate nova encheiresi extricata, Tubing. 1722. Heister, Instil. Chi. rurg. et De Hernia Incurcera'n Suppu- rata non semper lethali. Voxel, Abhandlung' alter Arlen der Bruche ; Leips. 1788. Fey. ronie, Observations, fyc. sur la Cure des Her- nias aver Gangrene; Mim de I'Acad de Chir. T. 1. Gu?iz, Observationum Anatomico- Chirurgicarum de Herniis Melius; Lips. 1744; et P.olusio Invdaloria in qua dt Ente.ro-1.piplocele agebat, Lips. 1746. P. kirkschbaum, De Hernia Venlriculi, Argent. 1749. P. S. Kok, De Her mi,; Roterod. i/82. Arnaud on Hernias, 1748 ; also his Mum. de Chir. Hallerde Herniis ( ongenitis, 1749. Ga- revgeot, sur plusieurs Hernies singulie)res; Mem. de I'Acad. de Chir torn. 2. Moreau sur les suites d'une Hernie opirie; Mim. dt I'Acad. de\ Chir. t. 3. Levevoli, una Ernia assai parliculare; Firenso, 1750. G. //. Trosclut, De Morbis ex .,'iieno Situ Partium Abdominis, Francof. 1754: (Haller, Disp. ad Morb. 4, M3.) Haller Hermanm adnota- tiones; extant in opuscul.pathol. 1755. Blanc Nouvelle Millmde d'opirer les Hernies ; avec un Essai sn/ les Hernies, par M. Hoin ; Or- leans, I767,8t'0. Louis Reflexions sur I'Opi- ra'.ondela Hernie; Mem. de I'Acad. de Chir.- Ton. 4. Hoin, Essai sur les Iin< iesrares el peu connues; 1767. Medical Observations and Inquiries. Potts W-.rks, Vols. 2 and 3. Goursaud sur la Difference des Causes de l'6'ranglement des Hernies; Mim. ele I'Acad. de Chir. Tom. 4. Le Dran, TraM des Ope- rahonsde Chir. el Observations de Chir obs. 57 /'. Hildanus, cent. 5. obs. 5-1. J. L. Petit TraM des Mai. Chir. Jam. 2. Sho.p on the Operations, and his Critical Inquiry. Ber- Irandi, Traili des Opiralions ; el Exemple d'une Hernie formie du cdle droit par Tin- test m ileum settlement, donl une portion i'iioil echappie par une des ichancn.res ischiutiques, en se glissant sur les ligaments sacro-sciatiqnes; Mem. deClnr Tom. 2. Saltzmann, Disp de Vesica Untune Hernia; 1712. Mery sur fateKtntt'dela Vess,e, Acad, aes Sconces, V,i/ , L:.Peldsurle' Hernies dt la Vessie; trla I •""/"/ 'I17" V^'^r. Recherches sur la ,,'ernie de la Vesne ; Mem. de I'Acad deUar Tom. 2. Divou.r, Disp. dt „£+ Vesicv-lrinnria:, Argent. 1732. Lev,tl Obs sur la Hernia de la Cessie, Mim. de ' W de Chir. Tom. 2. P. PeUI (le j.-une) sur ,7s Hernies de la Vessie, et de I'Eslomac. Xarf dt Chir. Tom. 4. Voter,ie Lienis Prolan*,I „' H46. .;/. G. Pfannius, De EnTereZZ' cete antiqiia, rcstitutione sacci herniosi fetid"! IlEKNTA. 03 ptracta, absque uracherio et seelione curata. Erlangee, 1748. Peyronie sur un ilrangte- menl de I'inteitin, causi intirieuremenl par f adherence de I'epiploon au-dessus de Van- neau, Mem.de I'Acad. dc (fur. T. 1. Tenon in Acad, des Sciences, 1764." A. G. Zimmer, Herniarum communia Altributa et Partilio, '4to., Gotf. 1764. Call.-sen, System Chirursr. hodieriuz, pars posterior. Rich'e-r Von den Bru-.hen, in 2 vols 1778, 1779.- or the French ; irunsl. by Rougcmon1, 4lo., B'inn, 1788. Also Richter's Bibiiothek.. and hifavg. der Wun- darsn. B. Ph II aefelaerti, De Herniis ea- rumque dicisio.ie, causis, notis, ac med ndi ' ruiione Bruxell. 1765. A. G. Richter, De Hernia incarcerata, una mm sacco sio repoui per annulum a'.dominalem poss* monet, 4lo ; Golt. 17 77. C. F. Suailicanus, De Itemed us pro a puis ad Hernias incarcerata., 4to. Gott. 1774. Wilmer's Prac'. Obs. on Hernia-, 8vo. Lond.1788. Schmucker'sf. 1801. Dr. Hunter's Med. Comment. 1762, 1764. Monro m Ldinb. Med. Essays; and the edition of his works by his son. Gimbernat's Account of a ^ew Mr- i thod of operating for Femoral Htrnia,transl. from the Spanish by Beddoes, 8ro. 1795. Also the German trans, with '.dditionsby Schreger, 12mo. Numb, lt-,17. A. O-oper on Inguinal . and > on genital Hernia, fol. Loud. 1804; and ! on Crural and Umbilical Hernia fol. Lond. 1807. A. Monr> on Crural Hernia, 1803; and the Morbid Anatomy of the Human Gul- let, Stotti'ich, and Inte-tines, 8vo. Ldinb. 1811. Sabutier,Midccine Opiratoire, T. 1. Chopurt et Desault, TraM des Mai. Chir. Desault, Parisian Surgical Journal. Wrisberg, in Comment. Reg. Sociel.Gottiiig.1778. Schmuck- er s Vi-rmis.iite Chir Schriften. Halter's Optra Minora ; and Dispututiones ihir. F. X. Iludl.orffer, Abhanitlung uber die einfachsle und sichersle Operalions-melhode Eingesperr- ter Leislen-und-Schenke'ijruche, 2 Bande, Sro, Wien, 1808. Sull'emie .Memorie anatomico- chirurgiche di Jntoito xarpa, Ediz. nuova) 1S»9 ; or the French Transl. by Cuyol, 1812, or the English, by Wishart. C. Bell's Sur. gical Observations, pi. 2. p. 177 fyc. London, 1816. Lassus, Palhulogie Chirurgicale, T. 1, ;>. I, <^c. Ed. 1809. Pelletan. Cliniqus Chirurgicale, T. 3. Tracers on Injuries of the Intestines, <£-c. 1812. A dse of hernia tentriculi through a laceration of the dia- phiogm, by T Wheelwright, in Med. >hir. Tra.is. Vol. 6, p. 374. F. C. Hesselbach, Disquisiliunes Anatomico-Pathologicce dc orlu et progrrssu Hernial um luguinaiium et (ru- ralium cum tab. 17. aneis, -do. Hiireburg, 1816 : the original edition in German wusjirsi published in 18O6. Also Bcschreioung und Abbildung eines neuen instrumentes zur si- chern Enldeckung und Sldlung einer beidem Bruchschdtte enstandenen gef In lichen Llu- fnmt.4to. Wiirsb. 1816. Soemmcrrina, ilber die Ursache, fyc. der llrudte um lluuchen und Becken, ausser der Nabel und L'islengegend. 8vo. Frankof. 1811. B. G. Schreger, Versuche Chirurgisrhe, T. I, p. 149, tyc. Versuche zur Vcrvultkuinmvng der Herniolomie, Sro Nurn- bcrg, 1811. Also B.2, Leber einige Hernien ausser der Nabel und Leintengegend. p. 155, Sro. Nv-mberg, 1818. F. L. Trustedt, Dc Esiensionis in Sulven-.is Herniis Crnralibus incurceratis prat incisione prastaidia, 4lo. Hcrol. t'-lb* A. C.die stibacb. Die Sicherste Art des Crvchsehimles in der Leiste, 4to. Bamb. et H'urzb. Iftly. B. (,. Seller, Ob- serv alio-.es nonnatUe. tesficulorum ex abdomine in Scrotum Uescensu, et Parlium Genitalium Anomalis, 4to. Lips. it>l7. J. Cloquet Re- cherches .inat. sur les Hernies 4to. Paris, l8li. C. J. M. Langenbeck. ( ommenlarius de Struc ura Peritonai, Testicutorum Tvnieis, eorumque • x Abdomine in Scrotum Desccnsu ad itlustrandam Herniarum iudoLm, bco. G'U'. 1^17. For some valuable remarks on the two preceding works, and on, the Anatomy of Hernia, see Quarterly Journal of Foreign Me- dicine, Vol. I, p. lA'i, SfC L.i.genbeck, Bibl. far die Chir. B. 4, St. 3, and Neue Bibl. B. 2,p. 112,-$»c. G>tt. 1819. Wallher de H.-r- nia t rurali 4to. Lips \.-2u. Co.. above alt, the work, vdiilh I feel infinite pleasure in recomiueulin.., frou- a conviction «,/ its su- perior merit, is a Treatise on Hernia by IV. Lawrence, 8vo.; ./<• first edition of which was published in 1807, and two more have appear- ed since that period, under the title of " A Treatise on R ipturci." HLRMA CLREBRI (Fungus Cerebri. Encephuiocele.) There are two principal kinds of hernia cerebri: one presents it- self in young infants, before the ossification of t.:c skuil is completed; the oilier takes place .ul.-r the destruction of a part of the skull i.y the operation of the trephine, acci- dental violence, or disease. Ihe coii0..ii'.*.. 103, T. 13, Edit. I2nw.) The experience of Callisen also confirms, that hernia cerebri, when of moderate size, may be cured by the foregoing method, the aperture becoming gradually closed. But he adds, that large tumours of this description, especially when situated about the occiput, scarcely admit of any means of relief, ex- cept the employment of some contrivance to protect them from external injury. (Cal- lisen. Si/slcm. Chir. Hodiernal, Vol. 2, p. 513, 514 Ed 1800) When the ossification of the sutures in children is late, the cerebellum, as well as the cerebrum, is liable to protrusion. In lf-l.'f. two such case- occurred at Paris. In one, Professor Lallement mistook the disease for a common tumour, and commenced an operation for its removal, wh"n, after making some of the necessary incisions, his proceedings were stopped by his seeing the white silvery colour of the dun mater, and that theswellin.r came out of an aperture in the occipital bone. The day alter the. ope- ration tlie child was seized with violent pain in the head, had a hard pulse, pros'ration of strength, vomiting, isic. and died in the course of a week. On dissection, a part of the tentorium, and an elongation of the two lobes of the cerebellum, about as large as a nut, were found in (he protruded sac of the dura mater. Several abscesses were also dis- covered iu the substance of the cerf helium. The olher example fell under the observa- tion of M. Baffos, principal surgeon to the I cts should teach the surgeon to be particularly cautious in ascerta niug the na- ture of tumours about ihe back part of the head, before he ventures to attempt their re- moval. The second kind of congenita! encepha- locelc is that, in which not only large por- tions ot the cranium, but also more or less of the integuments of tbe head, are deficient. Il is rather to be regarded as a malformation than a disease, and, indeed, iu most in- stances, the infants are still-born. The case sometimes consists of the protr.si m of most of the brain through the inferior and poste- rior fontanel!:*', so that the child is born with a largish bag, on the back of its head, hanging down over the po-lei-ior part ofthe reck Several specimens of these mall* r . • oc**r"' . » j.-ionts horn in the II* mations, taken from iniains „,..._j ,n ,, nice de la M demife, are preyed in tli, pice ue ia ii i ... de Mi'decme « Museum of the t-acuiie u Paris. (Richerand, Nosogr.■ \'"r- '■ -. P- 316 Edit 4.)- I„ the year 18l»», a remarka- ble case ol this last description of conge* lal hernia cerebri was published by Dr. Bur- rows " The whole of the forehead, sum. mi:, and a great part of the occiput, were deficient, and in lieu of them, a substance projected of a li-ht mulberry colour, and of (ho mushroom form, except that it was pro- portionably broader. From the deficiency of bone, the eyes appeared to project inucl more than us.'al.—The child lived six days without either taking sustenance, or haviuj any evacuation." On dissection, the scalp, (he os frontis, the parietal, and a great part of the occipital bones, were wauling Through the parts, at which these bonei were deficient, the cerebrum projected,er hibiting its usual convolutions. It was co- vered with tbe pia mater; was of a mul- berry colour ; appeared to be more vasculii than the pia mater usually is; and the edge of (he scalp adhered lo the neck of the tu- mour. The cerebellum was not more tlirni one-fourth of its usual size ; for, the poste- rior part of the os occipitis was much nearer to the sella turcica than natural. The child was destitute of the power of voluntary mo- tion, and all the secret ions appeared lo be stopped. (See Med. Chir. Trans- Vol. 2, p. 52.) The most interesting spe- ies of hern'u cerebri to the practitioner, is that which sometimes arises after the removal of a por- tion of tbe skull by the trephine, ort e des- truction of part of it by disease. VuritMB examples of this disease are recorded in ttie Memoi'-s of the French Academy of Sur- gery, and I have myself seen many instanca of it Although the case has attracted con- siderable notice, modern surgeons are fat from entertaining settled opinions concern- ing the exact nature of the tumour. In one example, recorded by Mr. Aberne- Ihy, the hernia cerebri arose on (he tenth day after trephining, and was as large as a pigeon's egg. The pia mater, covering ii was inflamed; and a turbid serum was d¥ charged at the sides of the swelling from beneath the dura mater. On the elevenll day, the tumour was as large as a hen's eg?, smooth and ready to burst The man died the ne\t day. Qri examination, the swelliaj was found st.11 lar,e r, and of a dark colour, with an irregular granulated surface. This appearance was owing to coagulated blood, which adhered to its surface, as the part had bled so much, that the pat'e .,*3 cap wa* rendered quite still* with bloo,J. The p'u m .ter was in general much inllamed, am!,» well as the <*ura mater, was deficient at ll» place of the tumour. The deeper part fll the swelling seemed to consist of tibmi' coagulated blood, a:... it was found to ori.'i- nate about an inch below the surface ofthe brain. Mr. Abernethy explains the formation o: HERNIA. the disease, as follows: " In consequence of the brain being injured to some depth be- neath the surface, disease of the vessels, and consequent effusion of the blood, had ensued ; the effusion was for a time re- • strained by the suptrincumbent brain and its membranes ; but, these gradually yield- 1 ing to the expansive force exerted from within, and at last giving way altogether, the fluid blood oozed out anu congealed upon the surface of the tumour." An organized fungus can hardly be produced so rapidly as these tumours are formed. (On Injuries of . tht Head, in Surgical Works, Vol. 2 p. 53.) On the contrary, .Mr. C. Bell declares, that the swellingis vascular and organized, (t ,-pe- rutive Surgery, Vol. 1.) Dr. John Thomson also entertains a dif- \ ferent opinion from that of Mr. A'>ernethy, i respecting the mode in which these herniae cerebri are formed ; but I question whether he may not have confounded with the dis- i ease now under consideration, fungous tu- mours of the dura mater. At least, some of the cases to which he alludes, as a reason for his sentiment concerning their mode of formation, must have been the disease so well described by M. Louis. (See Dura Mater.) The reader, however, must judge for himself from the following passage : '■ In a considerable numbe of those who had the cranium severely contused, or fractured by musket-balls, (says Dr. Thomson) fungous growths took place through the openings, which had been made at first by the ball or afterward by the trepan. These growths, I am inclined to believe, are the consequence of a contusion of the substance of the brain and of the membranes that cover it, which gives rise to tiie formation of a new organi- zed substance, different in its texture from brain, and are not, as some late w iters would endeavour to persuade us, simply protrusions of the brain, resulting from fhe removal of the natural resistance, which is made to them by the dura mater and cranium. / have known instances of substances, similar lo these growths, Jbrming on the surface of the brain, immediately under the place, where the cranium hud received a contusion, in cases in which ihe trepan had not been applied, or any poiaon ofthe cranium removed. " Fungus ot the brain, in (he greater num- ber of instances, in which we had an oppor- tunity of observing it, was accompanied either with stupor or paralysis, and olher symptoms of compressed brain. In a frac- ture of the vertex of the cranium, produced by a musket-ball, and followed by a fungus of the brain, the paralysis took place in the lower extremities. In a case of wound, made by a musket-ball on the right side of the forehead, and iu which spicuiae of bone had been driven iu upon the brain, a large fungus protruded. The formation of this fungus was followed by slow pulse, stupor, dilated pupils; slight strabismus, and distor- tion of the mouth. In tlie progress of this case, escharotics were applied to tie fungus, portions of it were torn off by the patient, and all of it that was exterior to the cranium, was twice pared off by the knife, with an apparent aliviation, rather than aggravation, of the synq i. i,u, On the death of this pa- tient, nearly he whole of the right hemis- phere of tbe brain was found converted into a soft pulpy mass. The left hemisphere was nol changed in structure, though much vas- cular turgescei.ee appeared on its surface." (See Di.J. Thomson's Report of Observat.uns miule in the Military Hospitals in Belgium, p. 57, 58.) From the investigations of Mr. Stanley, the fact is place > beyond all doubt, that a part of the brain occasionally constitutes the substance of herniae cerebri; and he thus coufirn.sthe opmioi. formerly entertain- ed upon this point by Quesnay and Lou ?. Thus, in the first case which Mr. Hartley has recorded, " the whole tumour was sliced off with a scalpel. During the operation, the boy gave no manifestation of positive pain, although not unconscious of what we we.e doing. Considerable hemorrhage took ph i e from the surface ot the brain, exposet- by the removal of the tumour, the bloo ' being thrown with great force, and to a consider- able distance from numerm1.- vessels, which were attempted to be secured, but ineffect- ually, by ligatures. After a short time, how- ever, the bleeding ceased On examination of the part, which had been cut off, its exte- rior w as found to consist merely of a layer of the coagulated blood ; the rest of the mass was brain, possessing a natural appear- ance, the distinction between the cortical and medullary matter being readily seen, with the convolutions and pia mater dipping down between them." In the dissection, after death, " all that part ofthe dura mater, adjacent to the ulcerated aperture, through which the brain had protruded, v as black, sb ijiy, and much tuickened. The exposed sunace of vhe brain, from which the portion had been cut off, exhibited a softened and broken down texture , a state of disorgani- zation, which extended o ep into its sub- stance. About an ounce of fetid and dark- coloured fluid was found between the dura mater and arachnoid membrane. Several small effusions of blood were met with, both between the membranes audio the substance of the brain. Tlie arachnoid membrane was thickened and opaque over each hemis- phere. The vessels on the surface, arid in the substance ofthe brain, were remarkably free from blood. The lateral ventricles were large, and filled with transparent fluid, and there was some found between the mem- branes at the basis, so (hat, altosrethei the quantity from these two sources was very considerable." (See Med. Chir. Trims. Vol.. 8,p. 15—17.) In another dissection, a con- siderable quantity of pus was found on the arachnoid membrane, on each side of the falx. (P. 27.) In most of-the cases of her- nia cerebri, which I have seen, the pa'ient was at first more or less sensible, but labour- ing under considerable nervous agitation. The stupor, paralysis, and other symptoms of compressed b:ain, noticed by Dr. .1. Thom- son, did not take place, till the latter stage 56 HERNIA of the disease, and then convulsive twitches of the muscles and strabismus occasionally came on. (See Med. Chir. Trans, p. 26.) The disease is usually attended with great frequency of die pulse. Willi regard to the cause of the protru- sion, it is a subject v.. ry difficult of ex plana!ion, because, if the origin of the tu- mour depended simply on tlie re;l: ival of a portion ot the skull, or on any changes of the dimensions of the brain in expiration, the eilccl would always follow such causes, and prevail in all pa'.ieats. From the par- ticulars of t:,e dissections, performed by Mr. Abernethy and Air. Stanley, and those re- ferred lo by Or. Thoin-.on, il is clear, that the uernra cerebri is a disease; connected with deep-seated changes throughout a great pail of the biabi. (see also Larrey, Mem. de Ch.r Mai. T. 4, p 2,;6.) The substance of this organ is found more or less pulpy and disurgan.zed ; and, after death, large effusions of serum, and even sometimes of blood, and purulent matter, are observed. These appearances leave no doubt of the uiaease being associated with inflammatory action within the head. It is highly proba- ble, therefore, that a hernia cerebiiis only produced wuen these deep-seated chan- ges are conjoined with the removal of bone. The changes alluded to, may be sup- posed to cause an increase in the general contents of the skull, and thus a disposition to profusion, as rapid as tn: e-um and other fluids are effused. Ihis statement, however, can only be received as un ,i\ potliesis, be- cause we find, that in one of the dissections, described by Mr. Stanley. " there existed a considerable space between the upper sur- face of the right hemisphere, all around the situation of the protrusion and the internal surface of the dura mater, while in every other part, tin- br.oii and dura mater were in close contact." (See Med. Chir. Trans. Vol S. p. 27.) Now. the idea of an empty space within the cranium is rather inconsistent with the supposition, that the brain is thrust out, in consequence of changes, which aug- ment the quantity ofthe general contents of the skull, unless such space were filled with air, that had no external communication. When the bad symptoms disappear, on the tumour being no longer confined by the dura mater, some practitioners deem it best to interfere as little as possible, and lei the tumour drop off in pieces. (*->e Edinb. Med. Comment. Vol. l,p.9S. Med. Museum, Vol.4, p. 463.) The mildest dressings are to be em- ployed ; butwhethertheprotrusionshouhlbe resisted by pressure, or not, seems unsettled. When the tumour acquires a very great size it may be pared off w ith a knife, as was done by Mr. Hill, in several instances with s-uccess. (Casesin Surgcry,8vo. Edinb 1772.) In one of U e cases, p .biished by Mr. Stanley, the patient, a boy about eleven years of age, recovered afier (he upper part of the tumour had been pared off, and some ot the removed substance found lo con-ist decidedly both of cortical and medullary cub5taiice. In this instance, the reproduction of the tumour was checked by firm pie«U„ will, graduated compresses, and a b'<"--% The protruded brain gradually loM •!» "nturf colour; il acquired a light yellow appear- ance, was pl.t into several portions, and, very fetid odour exhaled from it. lis suh- stance daily became solter, ultimately acquit*- ing almost a semi-fluid state, and in tins con- diiion the whole m-i?s gradually « asted away, Fresh granulations arose to Jill up the vacancy, and they were manifestly produced from tkt exposed substance of the brain. Compression bem- continued, t lie part now t|uickly healed uii. (See. Med. Chir. Trans, p. 20 21.) Ins third case, the part of the tuunc r , a\ 0fit consisted entirely of cortical and medullary subslacee, quite healthy in its appearance (p. 24 ;) and subsequently granulations were formed from the exposed surface of (he brain. Ihe case, however, bad a fatal termination, By tbe removal of the swelling, and tbe u>ts of compression, one cure was effected by j|r, Pring. (See Edinb. Med. and Surgical Jo urn. Vol. 9.) Richerand affirms, indeed, generally, (hat when the bruin is exposed, in consequence of an injury of the bead, (be encephaloceh should be cut down with a knife, and re- pressed hv gentle compression. (See Nosogr. Chir T. 2, p. 318, Ed. 4.) The cases published by Mr. Stanley are rather favourable to the employment of pres- sure, inasmuch as il appeared evidently to check the protrusion, and was mostly borne without inconvenience. The idea, however, that when the brain protrudes through the dura maler, pressure can effect its return, is, as Mr. Stanley judi- ciously observes, quite untenable. (Mid. Chir. Trans. Vol. 8, p. 36.) Quesnay mentions an instance, in which R patient tore off (he protruded mass liitosrll, and the cavity healed up. (Mim. dc I'Acad. de Chir. T. 1.) Van Swielen relates a casein •»hich the swelling was repeatedly rcmi>ved with a ligature, and a cure ensued. (Comment T. 1. ;;. 440.) The danger of applying styp- tics, and irritating applications, is shown by Hildanus, Obs. 14, and Mr. Hill,/*. 198. Baron Larrey considers the treatment ty excision, pressure, and spirituous applict- tions, Imrliul and dangerous: his advice i> merely to apply to the swelling a pledget of slightly camphorated oil of camomile; to have recourse to cooling aperient beverages; lo remove all kinds of h.Station ; lo exclude the air; and apply t|,e dressings with en-tt gentleness. By these means, The only case which Larrey ever saw recover, was saved, /'I- ,n •'.'••e lumour was small. (Mim. dt Chir. Mil. T. 4. p. 206.) One would suppose, that cases of (his kind must generally Ifcquire the employment uf every (long at all likely (o keep off, and di- Disputed. Chir. Vol. 2 m Halltr'i noire mr pEnce- phaloceleparM. Ferrand, in Mim.dtV!Z de Chir T. 13, p. 96, Edit. Un>0. /.™pt MA. 57 tkohgie Chirurgicale, T.2,p. 140, Edit. 1809. Aberncthy's Essay on Injuries of the Head. Hill's Cases in Surgery. Burrows in Med. Chir. Trans. Vol.2. Callisen, Systema Chi- rurgim Hodierme, Vol. 2, p. 512, Ed. 1800. C. Bell's Operative Surgery, Vol. 1. Richter's Ansfangsgrande der Winidanneykunst, B. 2, p. 197, Ed. 1802. Richerand, Nosographic Chir. T. 2, p. 316, Edit. 4, Paris, 1815. Dr. J. Thomson's Report of Observations made in the Military Hospitals in Belgium, p. 57, Edinb. 1816. Delpcch, Pricis Elimcntaire des Maladies Chirurgicales, T. 2, p. 447, ct seq. Paris, 1816. Crell and Sand, in Holler's Disput. Chir. T.\. E. Stanley, in Med. Chir. Trans. Vol. 8; a paper, containing many valuable observations. Larrey, in Mim. de Chir. Mil. T. 4, p. 203, ^c. Hennen's Milita- ry Silrgery, p. 311, fyc. Ed. 2. A. Solomons, De Cerebri Tumoribus, Edinb. 1810. J. L. Schoenlein, Von der Jdirnmelamorphose, Svo. Wurzb. 1816. HKRNIA HUMORALIS. (Swelledor in- flamed Testicle.) A very common symptom, attending a gonorrhoea, is a swelling of the testicle, which is only sympathetic, mid not venereal, because the same symptoms follow every kind of irritation of the urethra, whe- ther produced by strictures, injections, or bougies. Such symptoms are not similar to the actions arising from the application of venereal matter; for suppuration seldom occurs, and when it does, the matter is vene- real. The swelling and inflammation appear suddenly, and as suddenly disappear, or go from one testicle to the other. The epidi- dymis remains swelled, however, even for a considerable time afterward. The first appearance of swelling is general- ly a soft pulpy fulness of Ihe body of the testicle, which is tender to (he louch ; (his increases to a hard swelling, accompanied Willi considerable pain. The epididymis, towards the lower end of the testicle, is ge- nerally the hardest part. The hardness and swelling, however, often pervade the whole of the epididymis. The spermatic cord, and especially the vas deferens, are often thick- ened and sore lo the touch. The spermatic veins sometimes become varicose. A pain in the loins, and sense of weakness there, and in the pelvis, are other casual symptoms. Colicky pains; uneasiness iu the stomach and bowels; flatulence; sickness; and even vomiting; are not unfrequent. The whole testicle is swelled, and not merely the epidi- dymis, as has been asserted. The inflammation of the part most proba- bly arises from its sympathizing with (he urethra. The swelling of the testicle coming on, either removes tlie pain in making water, and suspends the discharge, which do not return, till such swelling begins to subside; or else the irritation in the urethra, first ceas- ing, produces a swelling of the testicle, which continues till the pain and discharge return ; thus rendering it doubtful, which is the cause, and which the effect. Occasion- ally, however, (he discharge has become more violent, though the testicle has swelled ; and such swelling has even been known to Vol.. H. 8 occur after the discharge has ceased; yet, tlie laKer has returned wilb violence, and re- mained as long as (he hernia humoralis. (/. Hunter.) Irritation at (he mouth of the vasa defe- rentia, has been mentioned as a cause ; but were this true, both testicles would usually be affected at the same time, and (he com- plaint would occur more frequently, when the irritation of the urelhra extends far to- wards the bladder, (ban when it only reaches about an inch and a half, or two inches from the. orifice of the passage. Hernia humoralis, with s(oppage of the discharge, is apt lo be attended with strangu- ry. It is singular, (hat the inflammation should more frequently come on when the irritalion in (be urelbra is going off, than when it is at its height. The enlargements of the testicle, from cancer and scrofula, are generally slow in their progress ; (hat of a hernia humoralis very quick. (J. Hunter.) Rest is the best remedy, and (he horizon- tal position of (he body is easiest. At all evenls, the testicle must be •w'ell suspended; to which expedient fhe patient will readily have recourse as soon as he knows the ease which it affords. The case is treated as in- flammation in general, by bleeding and purg- ing, and applying fomentations and poultices. In (he hernia humoralis from gonorrhoea, however, cold applications are sometimes preferred. (James on Inflammation, p. 164.) Leeches have often proved serviceable. The swelling not being venereal, mercury is only useful in removing the induration, after the inflammation has subsided. Vomits have been recommended, and found beneficial. They have even been known to cure tbe complaint in a surprisingly sudden manner. Opiates are useful. When suppuration oc- curs, no mercury is requisite, only common treatment. As the hernia humoralis often appears fo depend on the cessation of the discharge, some (Bromfield) have advised irritating the urethra with bougies (o bring on the gonnor- rhcea again ; but the practice is not followed by the expected good. The introduction of venereal matter into the urethra has also been most absurdly suggested. A hernia humoralis is at first very quick in subsiding ; but some of the swelling remains a long while, and the hardness of the epidi- dymis may even continue for years, nay, for life. However, no inconvenience attends the mere induration. In such instances, the vas deferens may occasionally be rendered im- pervious, though the occurrence must be by no means frequent. Frictions wilh camphorated mercurial ointment; fumigations with aromatic herbs ; and electricity ; are the best means for dis- persing the induration in question. (J. Hun- ter.) The signs distinguishing a hernia humora- lis from a scrotal rupture, are explained in the article Hernia. I once had under my care a patient with hernia humoralis, whose symptoms were se- HERPES. scabs: but in some cases, a copions ^*r& of il (akes place, and ledious ulceration^s eiv sue. The disorder is not contagious w, anj of its forms." (See lis, accompanied with all the symptoms of Synopsis of Cutaneous „..!.., .... r....... ,._,.-, .,* T)li9 au,hor notices si* species ot ▼ere in an extraordinary degree, and strongly resembled (hose of a strangulated hernia, being attended wilh much sickness, and ob- stinate constipation. A swelling of the tes ny Balcmans Practical Disease,, p. 221, 222, Edit. 3) This author n.... the complaint: viz. herpes phlyctaenodes; herpes zoster; herpes circmalus; herpes labialis; herpes prieputialis; and herpes As most of these cases more properly be- long (o the physician, than surgeon, 1 shall briefly describe three of them. According to Dr. Bate man, the Hcrpti Zoster, or shingles, is mostly preceded for two or three days, by languor, and loss of appetite, rigours, beadacl,,jsickness, andja fre- quent pulse, together with a scalding heat, and tingling in tbe skin, and shooting pains through the chest and epigastrium. Some- times, however, the precursory febrile symp- toms are very slight. Upon some pari of the trunk, several red patches occur, of an irregular form, at a little distance from each other, upon each of which, numerous small elevations appear clustered together. These, if examined minutely, are found to be dis- tinctly vesicular, and in fhe course of twenty- four hours, they enlarge to the size of small pearls, and are perfectly transparent, being filled with a limpid fluid. For three or four strangulated hernia, is recorded by Guin- court. (See Journ. de M-'-d. par Corvisari, T. 16.) Although I had never seen hernia humora- lis attended with symptoms so much resem- bling those of strangulated rupture, as in the case which fell under my own notice, nnd fhe patient would not own thai he had had any gonorrhoea, yet I remarked some circum- stances, which made me avoid an erroneous judgment. In the first place, I could dis- cover no protrusion from tbe abdominal ring. Secondly; I observed that there was no ten- sion, nor swelling of ihe belly, as in common cases of strangulated ruptures. Thirdly, I remarked, that the inflammation of the scrotum did not increase as tbe symptoms advanced, as it usually docs in the latter dis- ease. Fourthly; 1 took notice that tbe pain in the belly was most severe under the false ribs on the right side, though at periods it was certainly very diffused; but it was never augmented by pressure, as always happens in strangulated hernia, peritonitis, enteritis, &C. from all which disorders too, the ab- sence of tension seemed to distinguish it. Sometimes likewise, the pain was entirely in days, fresh clusters continue to arise, ahvayi Ihe tumour; sometimes altogether in the nb- extending themselves nearly in a line with domen. HERPES, (from ijira, to creep.) Nothing could be more confused, and un- defined, than the idea conveyed by the term herpes, as generally employed by medical men before the last few years. In fact, nu- merous cutaneous diseases, of the most op- posite kinds, but which had a tendency to creep, or spread slowly, were designated, as specimens of herpes. Thus, when I first entered the profession, it was common for 6ome of the most eminent surgeons in Lon- don frequently to coll noli me tangere, or lupus, herpes of the nose ; and to apply the same term to tinea capitis, or the porrigo favosa. Happily, (his vague mode of regarding dis- eases of the skin is beginning to give way to the judicious distinctions proposed by the late Dr. Willan, and so ably perfected by Dr. Bateman. The appellation, herpes, is limited by these physicians " to a vesicular disease, which, in most of its forms, passes through a regular course of increase, maturation, and decline, and terminates iu about ten, twelve or fourteen days. The vesicles arise in dis- tinct, but irregular clusters, which commonly appear in quick succession, and they are set near together, upon an inflamed base, which the first, towards Ihe spine at one end, and towards the linea alba at the other. While the new clusters are appearing, the vi9icles of the first lose their trasparency, and, on the fourth day, acquire a milky, or yellowish hue, which is soon followed by a bluish, or livid colour, of the bases of the vesicles, and of the contained fluid. They now become somewhat confluent, and flatten, or subside. About this time, (hey frequently break, and discharge for three or four days, a serous fluid, which, at length, concretes into thin dark scabs. These fall off about the twelfth or fourteenth day, leaving the surface of the subjacent skin in a red and tender state; and when the ulceration and discharge have been considerable, numerous^cicatrices, or pits, are left. All the clusters go through a simi- lar series of changes. Youny persons, from fhe age of twelve fo fwenty-five, are most frequently affected; although aged persons are not allogelher ex- empt from the complaint, a„d suffer severely Z^hl Pam °-f ir\ Summer a"d »«turan K!*MT»'" which il is ™* common. bomet.mes ,t supervenes to bowel com- F ratu(e"„/he Chr°"i-C Pai"3 remaining a"f. mem Dp P",mor,ary diseases. In the treat- extends a little way beyond the margin'of each and dianL, r" -H"nks Senl,e laxatives, cluster. The eruption is preceded, when it when X/«etlcs> w,th occasional anodynes, ..... . »*/ucii ine severe Hpr>n-cc«cn,i__• J is extensive, by considerable constitutional disorder, and is accompanied wilh a sensa- tion of heat and tingling, sometimes with severe deep-seated pain in the parts affected. The lymph of (he vesicles, which is at first sre deep-seated pains occur all l » necessary. No .J**,, \$£<™ r^^^-^^is <=* clearand colourless, becomes gradually milky \ liabl little the clothes, which are then e to adhere to the parts : i„ this case a simple ointment mayjbe in,erpo!ed ...cai anu eoinuness, oecomes gradually milky For a fiill*,, *..... V.....JA c '"terposed. and opaque, and ultimately concretes into Synopsis, p"2J"kc? *** """""''P™!. HER Herpes circinalus, or ringworm, makes its appearance in small circular patches, in which the vesicles arise only round the cir- cumference : (hese are small, with moderate- ly red bases, and contain a transparent fluid, which is discharged in three or four days, when little prominent dark scabs form over them. The central area, in each vesicular ring, is at first free from any eruption ; but the surface becomes somewhat rough, and of a dull red colour, and throws off an exfo- liation, as the vesicular eruption declines, which terminates in about a week, with a falling off of the scabs. A succession of these vesicular circles usually arise on the face and neck, or arms and shoulders, thus protracting the case for two or three weeks. The itching and tingling, which are (he only inconveniences of tbe affection, may be relieved by the application of the popular remedy ink, solutions of the sails of iron, copper, zinc, borax, alum, &.c. Some addi- tional interesting observations on other forms of the herpes circinatus, may be found in Dr. Bateman's Synopsis, from which I have ex- tracted the few preceding particulars. Herpes Prceputialis. This focal variety of herpes was not noticed by Dr. Willan, and we are indebted to Dr. Bateman for a de- scription of it. The complaint begins with extreme itching, and wilh some "sense of heat in the prepuce, on which one or two red patches occur, about the size of a silver penny. Upon these are clustered five or six minute transparent vesicles. In twenty-four or thirty hours, the vesicles enlarge, become of a milky hue, and lose their transparency ; and on the third day, they are coherent, and have almost a pustular appearance. If (he eruption is sealed on that surface of the pre- puce, which is next the glans, so that tbe vesicles are kept moist, they commonly break about tlie fourth or fifth day, and form a small ulceration upon each patch. This discharges a little turbid serum, and has a white base, with a slight elevation at the edges; and by an inaccurate, or inexperien- ced observer, it may be readily mistaken for chancre, more especially, if any escharotic has been applied, which produces irritation, and a deep-seated hardness, like that of a true chancre. If not irritated, the slight ul- ceration begins to heal about the ninth or tenth day. When the patches occur on tlie outside of ihe prepuce, the duration of the eruption is shorter, and ulceration does not actually take place. In the treatment, Dr. Bateman recommends theavoidance of all stimulating,and moist,or unctuous applications; and if the complaint be within the prepuce, he advises ihe inter- position of a little bit of dry lint between the sore and the glans. As this gentleman has truly remarked, this case is particularly deserving of notice, be- cause it has often been considered and treat- ed as a chancre. For a great deal more valuable informa- tion respecting Herpes, I beg leave to refer Ihe reader (o the publications of lbs. Willan and Bateman, and also to the article Hzrpes, HOR 5£> written by (his last able physician for Dr. Rees's Cyclopa'dia. HORDEOLUM, (dim of hordeum, bar- ley.) A little tumour on the eyelid, resem- bling a barley corn. A Stye. As Scarpa remarks, the stye is strictly only a little boil which projects from ihe edge of the eyelids, particularly often near (he great angle of the eye. This little tumour, like the furunculus, is of a dark-red colour, much inflamed, and a great deal more painful than might be ex- pected, considering its small size. The latter circumstance is partly owing to the vehe- mence of the inflammation producing the stye, and partly to the exquisite sensibility and tension of (he skin which covers the edge of (he eyelids. On (his account, the hordeolum very o.'fen excites fever and rest- lessness in delicate, irritable constitutions; it suppurates slowly and imperfectly; and, when suppurated, has no tendency to burst. The stye, like other furunculous inflamma- tions, forms an exceptiou to the general rule, that the best mode, in which inflammatory swellings can end, is resolution. For, when- ever a furunculous inflammation extends so deeply as to destroy any ofthe cellular sub- stance, the little tumour can never be resol- ved, or only imperfectly so. This event, indeed, would rather be hurtful, since there would still remain behind a greater or smaller portion of dead cellular membrane; which, sooner or later, might bring on a renewal of the stye in the same place .as before, or else become converted into a hard indolent body, deforming the edge of the eyelid. The resolution of the incipient hordeolum may be effected in tbat stage of if, in which the inflammation only interests the skin, and not the cellular substance underneath, as is the case on the first appearance of the dis- ease. Now repellent, cold applications are u-eful, particularly ice. But when the hor- deolum has affected and destroyed any of the cellular membrane underneath, every topical repellent application is absolutely useless, and even hurtful ; and the patient shouid have recourse to emollient anodyne remedies. The hordeolum and eyelids should be covered with a warm soft bread and milk poultice, which ought to be renewed very often. When a white point makes its ap- pearance on the apex of the little tumour, Scarpa says, the surgeon should not be in a hurry to let out the small quantity of seroUs matter which exists between the skin and dead portion of cellular membrane. It is better (hat he should wait till (he skin within this while point has become still somewhat thinner, so as to burst of itself, and give a ready vent, not merely to the little serous matter, but to all the dead cellu- lar membrane which constitutes the chief part of the disease. When the contents of the little tumour are slow in making their way outward, through (he opening, the surgeon, gently compressing the base of the stye, ought (o force them out. After this, all the symptoms of tlie disease will disappear, and Ihe cavity, left by the dead cellular mem- brane, in the centre ofthe littla tumour, will Co HOSPITAL GANGRENE. be found quite filled up and healed in Ihe course of twenly-four hours. Sometimes, though seldom, this process of nature, destined to detach the dead from tbe living cellular membrane, only takes place incompletely, and a small fragment of yellow dead cellular substance still continues fixed in (he cavity, and hinders the cure. In this circumstance, ihe further employment of emollient poultices is of little or no service The surgeon should dip the point of a camel- hair pencil in sulphuric acid, and (ouch the inside of the stye with it, one or more times, until the sloughy cellular membrane comes away. After this, the small cavity remain- ing will soon close. Should the eyelid con- tinue afterward a little swollen and oedema- tous, this affection may be removed by apply- ing the lotio plumbi. acet., containing a little spirit of wine. Some persons are very often annoyed with this disease. Scarpa imputes this most frequently to a disordered state of the primal vice, often met with in persons who live on acrid irritating food, and drink too much spirits.* (Scarpa^ sulle Malattie degli Occhi, cap. 2.) HOSPITAL UWGRK.NE. (Phagedena Gangrenosa; Putrid, or Malignant Ulcer; Hospital Sore ; Gangrrena Contagiosa.) A severe and peculiar species of humid gan- grene, or rather a combination of this affec- tion, with phagedenic ulceration. It is par- ticularly characterized by its contagious or infectious nature ; its disposition (o attack wounds or ulcers, in crowded hospitals, or other situations, where many of these cases are brought together ; and its tendency to convert the soft parts affected into a pu- trid glutinous, or pulpy substance, in which no tiace of their original, texture is discerni- ble. (Delpech, Pricis Elim. des Mai. Chir. T. I,p. 123.) It is generally believed to be communicated from one sore or wound to another, by its contagious nature ; but whe- ther the infection can be transferred only by actual contact, or both in this way and through Ihe medium ofthe almosphere, is a question on which the best authors differ. The first origin of ihe disease, however, is a mysterious subject, which cannot invariably be explained on any certain principles, as will be hereafter noticed. From the researches of Mr. Blackadder, it appears probable, that several of the ancient writers, in their descriptions of foul, gangre- nous bleeding ulcers, must have alluded to the same kind of disease, which is now usu- ally denominated hospital gangrene. Besides the use of the actual cautery, which, accord- ing to the modern French writers, is the surest means of arresting this distemper, seve- ral of the ancients appear also to have em- I have very often found an alum aird, applied over night in ihe form <,f , ci.iiire, of greal ... neht in this elis.-H.-e. *W tit-n u.nele n>c of jusl after sic; uratioo nas commenced, Ihe tumour eliecharges in ;i lew hours, and in.- patient is treed Irom a very iroulilekomc and paintui companion. U is prepared liv pulling a piece* o alum, aUtm the site of a pea, into"a lable spoonful •>l new milk.. Tl,is,j,v the flame of a candle, -s *oon coaguiaied. and rendered of a eoiiMM.-i.ee lit to be made Uie u a5 a catapta-.ni.—[Am. /:<.'.] ployed for Ihe cure arsen.ca apPJ^""" > a., for inslance, K,'u;;,Faul!,s\^b, whP' Avicenna, Guido, fcc. l/.e only doubt whe- ther these audiors actually referred to hospp al gangrene, depends upon their not having. generally described its contagious nature But, on this point, I would particular y wish (be reader to consult Mr. Blackadder s valu- able (realise. (P. 76, fyc.) Although La Mot(c made cursory mention of hospital gangrene in 1722, under the name of pourriture, and slated, (hat it had occurred in the HOtel-Dieu at 1'aris, yet the first dis- tinct modern account of this disease is con- tained in the 3d vol. of the posthumous works of Pouteau, published in 1783. In the year 1788, Dusassoy, who succeeded Pouteau as chief surgeon of the Hotel-Dieu at Lyons, also published a short treatise on the disorder. The first very accurate des- cription of hospital gangrene, in the Eng- lish language, appeared in the 6th vol. of the London Medical Journal, printed in 1785. The account is entitled " Observa- tions on the Putrid Ulcer, by Mr. Gillespie, surgeon of the Royal Navy." In the edition of Dr. Rollo's work on Diabetes, published 1797, there is a section on this subject, enti- tled, " A short account of a morbid poison, acting on sores, and of the method of de- stroying it." In 1799, Sir Gilbert Blane, in the 3d edit, of his book on the diseasesof Seamen, gave an account of hospital gan- grene, under the name of malignant ulcer; and Dr. Trotter, in the 2d vol. of his Medi- cina Nautica, published in the same year, described that affection by the same appella- tion. In the 3d vol. of the same work, Dr. Trotter has added to his first account seve- ral valuable communications, relating to this disease, received from surgeons of the Royal Navy. Mr. John Bell has also made hospital gangrene the subject of particular remark, in tiie 1st vol. of his Principles of Surgery, published in 1801. According to Dr. Thomson, two excellent theses have likewise been published on the subject in the University of Edinburgh ; the first enti- tled " De Gangnena Contagiosa," by Dr. Leslie in 1804; the second by Dr. Charles Johnson, in 1805, under the title of " De Gangraena Contagiosa Nosocomiale." (See Lectures on Inflammation, p. 45(3—458.) Professor Thomson's account of the sub- ject, published in 1813,contained the fullest history of the disease at that time collected. Boyer afterward gave a very fair account of the distemper. (See TraM des Mai. Chir. T. 1, p. 320, 8vo. Puris, 1814.) These descriptions were followed by the valuable essay .of Delpech, entitled "Me- moire sur la Complication des Plaies et des L/lecres counue sous le nom de Pourriture d Hopital;" 1815 ; some interesting obser- vations by Dr. Hennen, in the London Me- dica Repository for March, \815; a paper by irole,sor Brugman, of Ley-Jen, "in the Annalesde LilteratureMed." vol to 101=. wh!clrly','h-e,reatiSe °/Jt,r- "'ladder', whRli contains some of tbe best remarks ever made concerning this affection, andis HOSPITAL GANGRENE. 61 entitled " Observations on Phagedena Gan- grenosa, 8vo. Edinb. 1818." According to Mr. Blackadder, who is a believer in the doctrine of the complaint be- ing only communicable by the direct appli- cation of the infectious matter, when the morbific matter, which produces the disease, has been applied to some part of the surface of the body, from which the cuticle has been removed, as by a blister, one or more small vesicles first appear, which are filled with a watery fluid, or bloody serum of a livid or reddish brown colour. The situa- tion of the vesicle is generally at the edge of the sore. Its size is not unfrequently that of a split garden pea, and is easily rup- tured, the pellicle which covers it being very thin. When the vesicle is filled with a watery fluid, and has not been ruptured, it assumes the appearance of a grayish-white or ash-coloured slough ; but, when it con- tains a dark-coloured fluid, or has been rup- tured, it puts on the appearance of a thin coagulum of blood, of a dirty, brownish, black colour. During the formation of the vesicle, there is generally a change in the sensation of the sore, accompanied with a painful feel, like that of the sting of a gnat. After a slough is formed, it spreads with more or less rapidity, until it occupies the whole surface of the original sore; and, when left to itself, (which seldom happens) there is little or no discharge, but the slough acquires daily greater thickness. "When the formation of the slough has been interrupted, the stinging sensation be- comes more frequent and acute; phagede- nic ulceration quickly commences; and such is frequently the rapidity of its pro- gress,that even iu the course of a few hours, a very considerable excavation will be formed, while the parts in the vicinity re- tain their usual healthy appearance." The cavity, the edges of which are well defined, is filled with a thick glutinous matter, which adheres strongly to the subjacent parts. When this matter is removed, the surface underneath presents itself of a fine granular texture, which, in almost all instances, is possessed pf extreme sensibility, and is very apt to bleed when the operation of cleaning is not performed with great delicacy. At each dressing, the circumference ofthe cavity is found enlarged, and if there are more than one, they generally run into each other. The progress of the disease is much quicker in some inividuals than others, but it never ceases, until the w.hole surface of the original sore is occupied. The stinging pain gradually becomes of a darting or lancinating kind ; and either about the fourth or sixth day from ihe time when the morbific matter had access to the sore, or afterward, at ihe period of what may be termed secondary inflammation, the lymphatic vessel* and glands are apt to become affected. The discharge becomes more co- pious, its colour varying from a dirty yel- lowish white to a mixture of yellow, black, and brown, depending upon the quantity of blood mixed with it. " The soft parts, iu the immediate vicinity of the sore, daily become more painful, tumefied, and indurated ; and, in a great number of cases, particularly in those of plethoric and irritable habits, an attack of acute inflammation speedily supervenes, and is acccompanicd by a great increase of pain, the sensation being described to be such as if the sore were burning. The period at which this inflammation begins to subside, is by no means regular. Sometimes it sub- sides in the course of two days, and some- times it continues upwards of five ; depend- ing very much on the constitution and pre- vious habits of the patient, as well as the treatment that has been adopted. During its progress, the tliick, puti id looking, and frequently spongy slough which is formed on the sore, becomes more and more moist, and of a pulpy consistence. (Hence this form of disease is actually named by Ger- son pulpy gangrene.) In the course of a few days, a, very offensive matter begins to be discharged at its edges. The slough then begins to separate ; by and by it is thrown off, but only to prepare the way for an ex- tension of the disease by a continued pro- cess of ulceration, and by a recurrence of the last-mentioned symptoms. (Blackad- der, on Phagedeena Gangrenosa, p. 28—30.) The first symptoms, which indicate hospi- tal gangrene in a wound, or ulcer, are, a more or less acute •pain, and a viscid whi- tish exudation on the surface of the granu- lations, which lose their vermilion colour, and present at several points spots of a gray- ish or dirty-white hue, resembling venereal ulcers, or aphtha?. These ulcerated points, thus engrafted (as it were) upon the original ulcer, soon spread, and join together, so as to give to the whole surface of the solution of continuity a gray ash-colour. The surface also becomes more or less indurated, and sometimes bleeds. A red, purplish oedema tous circle, of a greater, or lesser extent, is next formed in the surrounding skin. Some times, when the patient is of a good habit, the causes of infection less active, and the constitution sufficiently strong, the disorder now stops. According to Boyer, it may not even extend to the whole surface of the ul- cer. But, most frequently, its progress is ex- tremely rapid, and occasionally quite terri- fying. The edges of the wound, or ulcer, become hardened and everted, the granula- tions are large and tumid, being swelled up, as Boyer asserts, with a considerable quan- tity of gas. They are afterward detached in the form of soft reddish sloughs, which very much resemble the substance of the fcefal brain, in a putrid state. From day to day, until either nature alone, or aided by art, puts limits to the disorder, it invades new parts both in breadth and depth, so that its ravages extend to aponeuroses, muscles, blood-vessels, nerves, tendons, the perios- teum, and even the bones themselves. Among a number of severe cases, which fell under the notice of Mr. Blackadder, there was one,in which the half of the cra- nium was denuded, the bones having be- come black as charcoal, and the integuments e-2 HOSPITAL GANGRENE. detached posteriorly to the second cervical vertebra, and anteriorly to the middle of the zygomatic process of the temporal bone; and this was originally a superficial wound of the scalp. In another case, the muscles, large arteries, and nerves of both thighs were exposed and dissected, the integu- ments and cellular substance being entirely removed, with the exception of only a nar- row strip of the former, which remained on the outer side of the thighs. This was also originally a simple flesh wound. In other instances, the cavities of the knee, ankle, elbow, and wrist, joints,were laid extensive- ly open, and, in one unfortunate case, the in- teguments and cellular substance, on the anterior parts of the neck, were destroyed, exhibiting a horrid spectacle, the trachea being also wroundcd." (On Phagedena Gan- grenenosa, p. 3.) According to the last experienced author, when the di-ease attacks an old sore, where a considerable depth of new flesh has been formed, the first thing generally observed is asmall dark-coloured spot, usually situated at fhe edge of the sore. But, he states, that in ■'■veral cases of ulcers, the disease, when carefully watched, was found to begin in the form of a vesicle, filled with a livid, or brownish-black fluid, which afterward burst and assumed the appearance ofthe dark-co- loured spot, which is commonly first noticed. Mr. Blackadder always found, that, when there had been a considerable bed of new sumes o livid or purple »°to"'.f^M as if covered with a fine, pelhcle, such a,-| formed on a coagulum ol Wood. (Or, Phagedena Gangrenosa, p. **•'*. . At Bilboa, the disease in cases of wound, „ said generally to have co^dj i sudden attack of severe pain in the head and eyes, tightness about the forehead, want of sleep, loss of appetite, a quick pulse, and other febrile symptoms ; while the wound, which had been healthy and granulating,at once became tumid, dry, arid painful, losing its florid colour, and assuming a dry and glossy coat. (Hennen on Military Surguj, p. 214, Ed. 2.) When left to itself, the above-described pellicle gradually increasei in thickness, forming what has been termed a slough. But, Mr. Blackadder observes, that ai this period, the progress of the disease ii hardly in any two instances precisely alike. Generally, in the course of from five to ten, or fifteen days, a thick spongy, and putrid- looking slough is formed over the whole surface of the sore, and which is more or lea of an ash, or blackish-brown colour. When the pellicle is destroyed, as frequently hap- pens in the process of cleaning, it is not in every case reproduced ; but, an offensive matter begins to be discharged, which be- comes daily more copious, is of a dirty yel- low colour, and ropy consistence, and il very adherent to the sore. The substance, which formed the apparent bottom of tbe wound, is raised up, and pushing the edgci, flesh formed, the phagedenic ulceration makes the sore appear considerably enlarge*!. made comparatively a very slow progress, and put on rather the appearance of mercu- rial phagedena, until the morbific matter had found access to the natural texture of the part, when the progress of the disease became suddenly accelerated ; acute inflam- mation supervened; and a large slough was formed. (Op. cit. p. 31.) He notices, that when tbe morbific matter is inserted in The edges, which are usually jagged, 9 pectinated, become extremely irritable, of I deep red colour, and dotted on their inner surface, with numerous small elevated, and angry-looking points, which may be consider- ed as one of the characteristics marks of tht disease. The surrounding integuments be- come indurated and inflamed, assuming, not unfrequently, an ansarine appearance ; a puncture, or scratch, the first progress of the patient complains of a constant burning, trio fllCO'lCO liOaCC •* |i-3- J« same gentleman found the l-^'^J cases, and the pericardium in a^j"™^™ he often observed the same appearances on lh Hospital g^ngSe must be regarded, „ one ofthe most serious and dangerous con,. plications, to which wounds and ulcers are liable. When the solution of continuity is large, or of long standing, the disorder com- mits great ravages, renews its attacks repeat- edly, and the relapses prove exceedingly obstinate. The same thing is said to happen, when it affects persons labouring under scorbutic or venereal complaints. Hospital gangrene proves particularly dangerous, and mostly fatal, when it complicates large con- tused wounds, attended with badly fractured bones. All the soft parts of the injured limb are then frequently observed to be progressively destroyed, and the unfortnnate patient falls a victim, either to typhoid symptoms, frequent hemorrhages, or hectic complaints. From what has been stated, however, the disease varies considerably in its severity in different cases, being some- times of small extent, and even capable al- most of a spontaneous cure. Patients have been known to continue afflicted more than a month, and when the duration of the dis- ease was thus lengthened, the cases almost always had a fatal termination. In a few cases, the wound puts on a favourable appearance again between the sixth and ninth days ; and, in slight examples, the amendment is manifested between the third and fifth. Whatever may be the period of the complaint, its wished-for termination is always announced by a diminution of pain; the pus acquiring a white colour, and more consistence, and losing its fetid nauseous smell. The edges of the ulcer subside, while its surface becomes less irregular, and puts on more ofthe vermilion colour. The red, purplish, cedematous circle, which sur- rounds the disease, assumes a true inflam- matory nature, and the solution of conti- nuity, restored to a simple state, heals up with tolerable quickness, even when tbe destruction of soft parts is somewhat con- siderable, unless any fresh untoward circum- stances occur to interrupt cicatrization. But, sometimes, when the patient is on the point of being completely well again, his condition is suddenly altered for the worse ; ulcerated spots make their appearance on the cicatril, and these spreading in different directions occasion a relapse, which may happen several times. " From numerous cases of this disease, seen by Mr. Blackadder at Passage in Spain, this gentleman made the following conclusions: 1. That the morbid action could almost always be detected in the wound, or sore, previous to the occurrence of any constitutional ajpection. 2. That in several instances, the constitu- tion did not become affected, until some HOSPITAL considerable time after the disease had mani- fested itself in the sore. 3. That when the disease was situated on the inferior extremities, the lymphatic vessels, and glands in the groin, were ob- served to be in a state of irritation, giving pain on pressure, and were sometimes en- larged, before the constitution showed evi- dent marks of derangement. 4. That the constitutional affection,though sometimes irregular, was in many cases contemporary with the second, or inflamma- tory stage. 5. That all parts of the body were equally liable to become affected w ith this disease. 6. That, when a patient had more than one wound, or sore, it frequently happened, that the disease was confined to one of the sores, while the other remained perfectly healthy, and that even when they were at no great distance from each other. (On Phagedama Gangrenosa, p. 19.) Thus Mr. Blaekadderespousesthe opinion, that hospital gangrene is at first a local, and not a constitutional disease, that is to say, not necessarily preceded, or originally accom- fanied by any diseased action in the system. t is highly important to weigh this distinc- tion well, not only because it is yet the chief point of difference among the best writers on the subject, but because it involves very directly every theory respecting the causes of the disease, and the great question, whether its ravages are to be resisted princi- eby local or constitutional means, or imedies of both descriptions together. 'in the hospital gangrene, observed by Dr. Rollo in the artillery hospital at Woolwich, " The action of the poison seemed to be limited and confined to specific effects. The first were local, producing only a general affec- tion, by a more extensive operation on the sore. Five or six days from the appearance of the small ulcer orulceration, when it b :d ex- tended over one-third of the former sore, with pain and redness in the course of fhe lymphatics, and the glands, through which they led, with enlargement of them, general indispositon of the body became evident." Delpech, in his interesting memoir, particu- larly notices, that the constitutional symp- toms always occurred ihe last in order of succession. Mr. Blackadder distinctly declares, that, in no instance, which he had an opportunity of observing, did the constitutional symp- toms of gangrenous phagedama precede the local, unless the case be held an exception, iu which a stump became affected, after amputation had been performed, on account of the previous effects of the disease. '1 he period at which the constitution'begins to exhibit svmptoms of irritation (he says) is extremely irregular.—sometimes as early as the third, or fourth day, and sometimes even as late as the twentieth. The countenance assumes an anxious, or feverish aspect; the appetite is impaired ; the desire for liquids increases; and tbe tongue is covered with a white mucus. The bowels are generally rather constipated: and the pulse, what Vol.. N » GANGRENE. 65 may be termed, rather irritated, than accele- rated. But, the general symptoms may assume an inflammatory, or typhoid charac- ter, according as the causes of one of these modifications may predominate. According to Mr. Blackadder, when an inflammatory diathesis prevails, the system becomes gradu- ally more irritated, until an attack of acute inflammation seizes upon the sore, and which frequently happens about the end of- the second week. M this period, the pulse is frequent and sharp, and it is not uncommon for the patient to be seized wilh one, or more shivering fits, succeeded by a great increase of heat, but seldom, or never termi- nating in a profuse per-piration. The cold fit is sometimes followed by a bilious dis- charge from the intestines, and mitigation of the febrile disorder. If the local mischief be not arrested, the strength becomes daily- more and more exhausted ; the fever loses its inflammatory character ; and, unless the patient be cut off by hemorrhage, he fulls a victim to extreme debility. When the dis- ease has a typhoid character, the pulse is small and frequent ; the appetite and strength gradually fail ; and the patient at last sinks, retaining his mental faculties lo the last. Not unfrequently diarrhoea has- tens the event. (Blackadder on Phagedena Gangrenosa, p. 39, 4(».) On the other hand, the generality of wri- ters, nay, even some of those who represent the disease as always proceeding from a species of infection applied to the wound, take into the account the operation of con- stitutional causes, as predisposing to, and of course preceding (he local symptoms. Dr. J. Thomson believes, that the constitutional symptoms mostly precede the local. (On Inflammation, p. 459.) The same sentiment is professed throughout Dr. Hennen's re- marks, who placed reliance chiefly upon internal remedies, and regarded external applications, as merely a secondary object. (On Military Surgery, p. 222, Ed. 2.) To this part of the subject, I shall return, after adverting to the causes of hospital gangrene. The hospital gangrene, which occurred in the Artillery Hospital at Woolwich, and Was described by Dr. Rollo, did not atiack speci- fic sores : venereal, scrofulous, and vario- lous ulcers were not attacked, although the patients lay in the wards, where the disease prevailed. Professor Thomson admits, that specific sores are less liable to altacks of hospital gangrene, than common wounds and ulcers ■ but, he declares, that he has frequently seen it attack cancerous and venereal ulcers. (On Inflammation, p. 460.) Dr. Hennen mentions a remarkable in- stance, which also proves the possibility of a specific sore becoming affected, and fatal from this cause, in forty-eight hours after (he potient had first been exposed to the infec- tion. Dr. Hennen relates the- fact to prove that the contagion may be received, without a long residence (iu a tainted air. The patient, "who haef just landed from Eng- land, and was under the influence of m't-reu- 60 HOSPITAL GAM,R|;.YE ry, employed lor a venereal complaint, died within forty-eight hours after his admission, tbe gangrene having seized on an open bubo in his groin, eroding the great vessels in the neighbourhood, antl absolutely destroying the abdominal parietes to a large extent." (Principles of Military Surgery, p. 218, Ed 2.) The effects of hospital gangrene should be carefully discriminated from those of the scurvy. I leers, attacked with hospital gan- grene, are not affected in any degree, like scorbutic ulcers, by the use of vegetable diet and lemon-juice, and they occur among men, who are fed upon fresh meat and vegetables, as readily as they do among those who have been fed altogether upon salt provisions. (Thomson's Lectures on Inflammation,p. 482.) Hospital gangrene is almost always accom- panied with severe febrile symptoms : but, " as to fevers, (says Dr. Lind',) it may indeed be doubted whether there be any such as are purely and truly scorbutic. The disease is altogether of a chronic nature ; and fevers may be justly reckoned among its adven- titious symptoms." (Treatise on the Scurvy, p. 106.) In cases of hospital gangrene, the general symptoms of scurvy are also absent, such as soreness and bleeding of the gums, livid blotches and wheals on the fleshy part ofthe legs, (edematous ankles, &.c. Hospital gangrene (says Boyer) is a spe- cies of humid gangrene, which attacks in some degree epidemically the wounds and ulcers of patients, who happen to be crowd- ed together in an unhealthy place. Its occasional causes are ; the situation of an hospital upon a low marshy ground; the vicinity of some source of infection ; the uncleanliness of the individuals, or of the articles for their use ; the crowded state cf tbe wards, especially when they are small and badly ventilated ; lastly, every thing that tends to corrupt the air which the pa- tients brea'he. An infected atmosphere may produce in the most simple wounds unfavourable changes, partly, as Boyer con- ceives, by its immediate action on the sur- face of the wound, but no doubt princi-1 pally by its hurtful influence upon the whole animal economy. The foregoiti" causes have also sometimes produced alarm- ing and obstinate gangrenes of an epidemic kind, or at least, a state of the constitution, under the influence of which all wounds and ulcers constantly took on a bad aspect, and were often complicated with the most gangrenous mischief. Vigaroux saw such an epidemic disease prevail for twenty months in the two hospitals of Montpellier, and he states, that the most powerful anti- septics were of little avail against the dis- order, which often invaded the slightest scratches. In general, this epidemic species of gan- grene is not observed in new-built hospi- tals, nor in those which are erected out of the central parts of cities, upon high ground. Hospital gangrene may occur in any sea- son ; but,it is most common after the sultry heat of summer. A bilious constitution, mental trouble, un- wholesome or insufficient food, a scorbutic diathesis, great debility, and ^ve", j" . ■ dangerous type, are also reckoned b> he French surgeons as so many predisposing causes of hospital gangrene. The observations of Pouteau, and those of some other practitioners, convincingly prove, that hospital gangrene may be com- municated to the most simple wound, or ulcer, in a subject of tbe best constitution, and breathing the purest air, by merely putting into contact with such wound or ulcer, sponges, lint, or charpie, impregnated with the infection of this peculiar disorder. But, this inoculation is conceived to be the more alarming, and to take effect the more quickly, in proportion as patients have been more exposed to the influence of such cau- ses as are themselves capable of producing the disease, and also in proportion as the kind of constitution predisposes to it. Although the contagious nature of hospi- tal gangrene has been generally admitted by all the best informed writers on the sub- ject, the doctrine was not considered by Dr. Trotter as having a good foundation. Mo- dern authors, however, have not joined thH latter gentleman, and Dr. J. Thomson, Dr. Hennen, and Mr. Blackadder, all believe, that the disorder is infectious. " The con- tagious nature of hospital gangrene (says Professor Thomson) appears to me to be sufficiently proved, 1st, By the fact, that it may be communicated by sponges, charpie, bandages, and clothing, to persons at a dis- tance from those infected with it. 2dly, By its having been observed to attack the slight wounds of surgeons, or their mates, who were employed in dressing infected per- sous ; and that, even in circumstances, where the medical men so employed, did not live in the same apartment with the in- fected. 3dly, By our being able often to trace its progress distinctly from a single in- dividual through a succession of patients. 4thly, By its attacking recent wounds, as well as old sores, and that in a short time after they are brought near to a patient af- fected with the disease. 5thly, By our be- ing able to prevent the progress of the dis- ease in particular situations, by removing the infected person, before the contagion, which h13 sores emit, has had time to ope- rate. 6thly, By its continuing long in one particular ward of an hospital, or in one particular ship, without appearing in other wards, or ships, if pains be taken to prevent intercourse between the infected and unin- 4S4> o SL?c}urel> on Inflammation, p. nfTi' Sat' althou8h thei-e can be no.doubt e ou,e.,a,SeaSe-!preadinSI,ar,,y by "s conta- t»?„ Vi VT' " appears to me equally cer- nc"elaittetn,Uraber-0f Cases i8a1^ often inc. eased by the continued operation ofthe rtanc^w!ii-ch rducedthe "'""t hosphalL d,so«l«*in ™y Particular It is alleged, that when once a pafienf has taken the infection, he cannot aS tlie consequences, whatever precautions b* may adopt. Thus, Boyer inform* trs, that HOSPITAL GAJN'GRENE. c: i'ehas seen hospital gangrene take place in wounded patients, who, in the hope of es- caping this epidemic affection, had quitted the infected hospital, and retired to elevated situations, where they breathed the most salubrious air. (See TraM de Mai. Chir, T. 1,p.322.) The bad state of the air of a crowded hos- pital, as Mr. Blackadder observes, is a ready means of accounting for the origin of pha- gedena gangrenosa ; but, there are various reasons for considering such explanation not altogethersatisfactory ; and he mentions a case, in which the wound of a soldier was found affected with the disease on his first arrival at an hospital, after having been ac- cidentally detained, with two other wound- ed comrades, for five or six days, partly in an open building, and partly in a boat, quite exposed to stormy weather. (P. 43.) Dr. Hennen likewise gives an account of about thirty fresh wounded men, in whom hospi- tal gangrene first appeared in their journey from Vittoria to the hospital near Bilboa. (Principles of Military Surgery, p. 214, Ed. 2.) Dr. Rollo also remarked, that some men in quarters were affected with this dis- ease. And, according to Mr. J. Bell, "there is no hospital, however small, airy, or well regulated, where this epidemic ulcer is not to be found at limes." (Principles of Sur- gery, Vol. 1, p. 112.) For a refutation of the opinion, that the disease ever strictly merits the epithets endemial, and epidemic, I must refer the reader to the observations of Mr. Blackadder. (P. 143, 53.) Delpech remarks, that the causes of the disease do not appear to have depended upon the state of the atmosphere, (P. 25;) and in almost every instance, he traced Ihe propagation of the disorder to the direct application of the morbific matter lo the sores. However, he joins Pouteau in the belief, that it may be communicated through the medium of the atmosphere ; an occurrence, which Mr. Blackadder doubts, or, rather considers as very rare, and only possible where the ef- fluvia are allowed to accumulate in a most negligent manner, so as to resemble a va- pour bath, which mode he would also regard as equivalent to inoculation. (On Phagede- na Gangrenosa, p. 156.) On the whole, I am disposed to think the views, which Mr. Blackadder has taken of the manner in "which the disease is communicated, the most correct, hitherto published, and that, while particular stales ofthe air and consti- tution certainly modify the disorder, they cannot generally have any share in giving origin to fhe disease ; I say generally, be- cause as various facts oblige us to admit, that hospital gangrene sometimes arises, without having been communicated from any patient previously affected, it is impos- sible to assert, that the earliest example of it, under such circumstances, may not arise from the operation of some unknown and inexplicable circumstances on the constitu- tion, or in other words, from the state of the system itself. Nor can a doubt be en- trrtainrd. that, at all events, the disorder is most apt to break out in crowded, badly- ventilated hospitals, and in them appear more extensively and malignantly, than in others, which are well-regulated, properly ventilated, and healthily situated. But, the idea, entertained by Delpech, that hospital gangrene may originate from the same con- tagion as typhus, or other diseases, is a mere unsupported, irrational conjecture, quite as destitute ofthe truth, as the suppositions about the endemial and epidemic character ofthe complaint, independent of its infec- tious nature. The question, how the first example of tbe disorder originates, is at pre- sent a perfect mystery; but, as it cannot be referred to contagion, or inoculation, we should recollect, (hat whatever produces it in one individual, may produce it in ano- ther, similarly circumstanced, and, on this principle, the disorder may sometimes be formed independently, and at (he same time, in a greater or lesser number of patients in the same hospital, as well as spread from these to others by infection. With the view of preventing the disor- der, the wards, in which the wounded are placed, should not be crowded ; they ought to be freely ventilated, and, if possible, not communicate. The utmost attention to cleanliness should be paid ; and all illth and stagnant water removed. It has been asserted, but with what accuracy I cannot determine, that the predisposition of the wounded to this species of gangrene may be lessened by a well-chosen diet,by drinksaci- dulated wilh vegetable acids, or with the sul- phuric acid,and by the moderate use of wine. The state ofthe stomach and bowels should be particularly attended to, and, if out of order, emetics and purgatives ought to be immediately employed, and repeated ac- cording to circumstances. The dressings should be applied with extreme attention to cleanliness, and too much care cannot be taken to prevent the infectious matter of one wound from coming into contact with another through fhe medium of sponges, in- struments, &c. " Whatever may be the source of this disease (says a late writer) it is at least sufficiently ascertained, that, when it occurs, its propagation is only to be pre- vented by the most rigid attention to clean- liness, and by insulating the person, or per- sons affected, so as lo prevent all direct in- tercourse between them and the other pa- tients ; for, so far as I have had an oppor- tunity of observing, ninety-nine cases in the hundred were evidently produced by a di- rect application of the morbific matter to (he wounds, dressings, write", seem all to agree about the utility of purgative amj laxative medicines. When there is debiihv good generous wine should be allowed, either by itself, or mixed with lemonade accordin" HOSPITAL GANGRENE. 69 to circumstances. Bark, whose antiseptic qualities have been so highly praised, is in general more hurtful, than useful; and Dr. Hennen assures us, that he has seen great harm done by large and injudicious doses of this drug, before full evacuations had taken place, and the sloughs begun to separate. Buyer allows, however, that it may be bene- ficially given, when the feveri-h heat has abated, and the debility is very great. In all stages of ibis disease, unattended with diarrhoea, acids are proper. The sul- phuric acid is that which is given'with most success: but the aciduloustarlrite of potassa is also an excellent medicine. From two drams to half an ounce may be given every day, and the best plan is to make an acid drink with it, which should be sweetened and strained. In severe cases, attended witli a quick and feeble pulse, depression, restlessness, and anxiety, an opiate becomes necessary. " So long as we wish to excite a degree of moisture on the skin, (says Professor Thom- son) Dover's powder, or laudanum with anti- monial wine, form in general the best opi- ates." This gentleman, however, is not an advocate for ihe employment of opium, in the early stage of hospital gangrene, while the heat and olher febrile symptoms are at their heigh) (See Lectures on Inflammation, p 494,495.) For ihese cases, camphor, in large and frequent doses, was highly praised by Pouteau. From what has been said concerning in- ternal remedies, it is evident, that none of them can be regarded as means, which can be at all depended upon for arresting th<- ra- vages of hospital gangrene, however advan- tageous (hey may prove in palliating general symptoms, removing particular complica- tions, enabling the system to support the ef- fect of (he local disorder for a greater length of time, or, in a few ruses, even planing na- ture in a condition to throw off the diseased parts herself, and communicate to the subja- cent living flesh a healty action. If credit can be given to several of the authors, who have had the most extensive opportunities of attending to the nature of hospital gangrene, the local treatment is far more effectual than internal medicines. " 1 was told by several of the French sur geons (says a late visiter to Paris,) that they did not rely at all on internal means for stopping the progress of hospital gangrene, and that their experience had proved them to be insuffici-nt, if not wholly inefficacious. Diipuylren, in reply to the account I gave him of the practice and opinions of English surgeons on this subject, assured me, that he had no confidence but in local applications, and (hat internal remedies alone, as far as he had found, did almost nothing. The same remark has been made in a very recent pub- lication on hospital gangrene, (Delpech, Mini, sur la Complication des Plaies, fyc. 1815.) although it seems to be rather at vari- ance wilh its being a constitutional and con- tagious disease, which the author has admit- ted." (See Sketches of the Medical Schools of Paris, by J. Cross, p. 83.) Perhaps, there is not a single antiseptic ap- plication, which has not been tried as a dress- ing for wounds, or ulcers, affected with hos- pital gangrene. All watery applications, and common poultices, and fomentations, are ge- nerally condemned as inefficacious, and even hurtful. Dussassoy was convinced by the observa- tion of numerous cases, that the best applica- tion is powder of bark. He recommends the wound to be covered with several layers of this powder, which are then to be moist- ened wilh turpentine. When this composi- tion dries, he asserts, that it forms a fragile sort of coat, at the sides of which, and through which, the discharge escape-. After twenty-four hours, (he first coat is to be re- moved, and a fresh one applied. In general, according to (his writer, four or five such dressings are sufficient in simple cases, where (he disorder is confined to the skin and cel- lular substance- Healthy inflammation then occurs, the sloughs come away, and (he wound puts on a healing appearance. In bad cases, Dissassoy sometimes added one-fifth of powdered muriate of ammonia to the bark Wh.m (his treatment faild, the actual cautery was n-e.d- On the subject of bark, as a looal applica- tion to hospital gangrene, I need only re- mark, that il is now entirely relinquished, either as possessing no efficacy, (Delpech) or even aggravating the symptoms. (Blackad- der.) The milder forms of the disease appear sometimes (o have yielded to the application of the vegetable and diluted mineral acids ; lime juice ; lemon juice : vinegar; and the diluted nitric, and muriatic acids. And tiie same observation may be m ide, with res- pect to solutions of the nitrates of silver and mercury. The (wo latter substances, and the oxygenated muriatic acid, >nd ga«, were found by D-. Rollo to be capable of effecting a cure. Delpech, in particular, speaks of the benefit derived from ih-* application of strong vinegar, after all the pulpy viscid matter has been carefully wiped away from the surface of the living flesh. The vinegar is (hen poured on the ulcer, which is to be covered with charpie wet with the same liquid. When the case is too far advanced for Ibis (reatment to answer, Delpech tries caustics, especially the nitrate of silver; and if these fail, he his recourse to the actual cautery, and, when the sloughs are very thick, so as to hinder the cautery from act- ing to a sufficient depth, he prefers thrusting into the sloughs down to the livi ig flesh an- gular pieces of caustic potash at small dis- tances from each other! (Pricis. Elem. des Mai. Chir. T. 1, p. 151.) Sun*ly, this must be far more torturing, and less certain of success, than removing the sloughs, aud ap- plying the cautery. Though the actual cautery is generally ad- mitted to be one of the most powerful means of stopping the progress of hospital gangrene, the surgeons of this country entertain a ■10 HOSPITAL GANGRENE. ptrong aversion to the practice ; and I con- fess, (bal my own dislike to it is such as would always lead me to prefer any other treatment, from whLb equal efficacy would result. At the same time, it must be grant- ed, that if tbe actual cautery will more cer- tainly arrest some forms of hospital gangrene, than any other known applications, tbe sur- geon's duty is to put out of (he question his own prejudices against it, and consider only his patient's welfare. 1 am far from thinking, however, that, while (here are such power- ful caustics as "Mie undiluted mineral acids, and a dressing so effectual as a solution of arsenic, it can often he absolutely necessary to employ red hot irons. The meril of having pointed out in mo- dern times the great efficacy of Fowler's solution of arsenic, or (he liquor arsenicalis of the London Pharmacopoeia, es an appli- cation to phagedena gangramosa, belongs to Mr. Blackadder. In answer to the objection, that the external use of arsenic is not unat- tended with danger, he assures us, that he has heard but of one instance of hospital gangrene, in which any deleterious effects were supposed lo arise from the absorption of the arsenic, and (he patient uj question was very soon cured of his uneasy, and pos- sibly merely nervous symptoms " (P. 50.) " Tne fir->t thing to be attended to in every rase of disease (says Mr. Blackadder) is cleanliness, which, if always of great im- portance, is, in this instance, indispensable. The surface of the body ought to be made, and kept perfectly clean, by means of the tepid bath, or olherwise by a plentiful use of -soap; and the linen, and bed-clothes, should be frequently changed, particularly when soiled with matter from the sore." In order to make the sore perfectly clean, and free it from (he viscous discharge, without produ- cing considerable bleeding, and pain, Mr. Blackadder recommends two large (in hos- pital teapots to be filled with a weak solu- tion of the subcarbonate of potass. One of these solutions is to be cold ; the other tepid ; because sometimes one. and sometimes the other, is found most agreeable to the patient's feelings, though the warm is the most effec- tual in cleansing the sore. The liquid is to be poured over the sore, and received into a basin, which ought to be immediately empti- ed into another vessel placed at a distance from the patient. During this ablution, the glutinous matter, which adheres to tbe sore, may be gently detached, by means of small dossils of fine tow, or lint, but these (says Mr. Blackadder) should never be used for two different patients, rigid eromomy, on occasions such as this, being a very mistaken principle. In (hese cases, the use of sponges, (he justly observes) ought to be entirely laid aside, as they can seldom be used more than once with safely. When the sore has been tbos cleaned, a fine piece of dry lintis to be spread over its surface, and gently press- ed into all its depressions with Ihe points of the fimers. When the lint is removed, a quantity of the discharge will be found at» henng to it: and this operation must be re- peated with fresh pieces of lint, not il fa surface of the sore is made perfectly clean ■"ISrfing to Mr. Blackadderthe^solution of arsenic will generally be found strong enough, when diluted with an equal part of watef;'but, in slight cases, .t answered when weakened with twice its quantity of water ; and, in a few examples, it w^as em; ployed without being at all d.luted. Several pieces of lint of the same shape as the sore, but a little larger, are to be prepared : one of these, soaked in the solution, is now to be applied to the cleaned surface of the sore, and renewed every fifteen or thirty minutes, according to tbe time in which it becomes dry. When the heat and inflammation are considerable, great relief will be derived from the frequent application of linen cloths moistened with cold water, which must be kept from weakening the arsenical solution by means of a small piece of oilskin laid over the pieces of lint. When the disease extends into the track of a gunshot wound, Mr. Blackadder uses a syringe for cleaning the sore, and introducing the solution. "A slip of fine lint, well soaked in the solution; may also be inserted by means of a probe, into the bottom of the wound ; and when the openings are at no great distance from each other, and not in the immediate vici- nity of the large nerves and blood-vessels, the lint may be drawn through the wound in the form of a seton. (P. 63.) When (lie pain, caused by the application, is very se- vere, and the constitution is irritable, and debilitated, Mr. Blackadder prescribes an opiate, though he remarks, lhatthis practice will seldom be absolutely necessary. The morbid action in the sore is destroyed by the arsenical solution sooner, or later, in different cases : the best plan is to continue the application, until an' insensible, dark- coloured, dry slough occupies the whole surf act of the sore; and until the patient is com- pletely relieved from the burning and lancina- ting pain. After the slough is formed, Mr. Blackadder employs an ointment, composed of equal parts of the oil of turpentine, and the yellow resinous ointment, or of two parts of Venice turpentine to one of the resinous ointment. " These being melted and mixed together, are to be poured over tbe sore, as hot as the patient can possibly bear." A pledget of dry lint, or low, and a bandage, are then applied; and this dressing may be renewed two or three times a day, (he sore being each time carefully washed with the solution of i^""' a LS°Z? as an-v Part of the slough is loosened, Mr. Blackadder removes it with a e»n*HVCUry.ed SCissors- With lb" view of SmTm"8 ,epara,i0n °f ,he Sl»"gb, he t°hichh 1Timpi0y-aa lins«-d-meal P°«' "'* to be too ^ -eS'red elTcCt' but W" to1-""1 ^f S^der^'V^^ ai After the detachmen( of thP s\n„„u -.», Blackadder dresses the sore w'th theg«,',0^ HYDROCELL. «'4 mentioned ointment cold, or with the addi- tion of a small proportion of the subacetale of copper. The pledget of this ointment is covered with a piece of oilskin, lightly rub- bed over with soap; and a firm bandage is applied to the whole limb. (See Obs. on Phagedena Gangrenosa, p. 49, fyc. 8vo. Edinb. 1818.) The author declares, that, after the introduction of the above treatment, (with the exception of stumps attacked with hospital gangrene) he never saw an instance in which the remedy failed, when applied in time and in a proper manner; that is, before the disease had made such progress as lo preclude all rational hope of success from that or any other mode of treatment. (P. 23.) In Dr. Rollo's treatise on Diabetes, publish- ed in 1797, the opinion is plainly stated, that the progress of hospital gangrene might be slopped by very active topical applications, and, in the same work, Mr. Cruickshank says, that " if an actual caustic were to be em- ployed, we should have recourse to the strong nitrous acid." According to Mr. Blackadder, the oxygenated muriate of mer- cury and the nitrous acid were muck recom- mended, and employed by surgeons in the 16lh and 17th centuries, as escharotics, in cases of gangrene and foul ulcers. (P. 113.) Several army surgeons have informed me, that the undiluted nitrous acid was success- fully used as an application to hospital gan- grene in the military hospitals at Antwerp in the year 1815; but that other strong acids had an equally good effect. Dr. J. Thom- son also notices, that "the application of caustic substances, such as the strong mine- ral acids, the solutions of polass, corrosive sublimate, and arsenic, seemed at Antwerp to arrest the progress of this sore, without exciting inflammation." (Report of Obser- vations made in the Military Hospitals in Bel- gium.) Delpech was informed by some British surgeons, belonging to the Anglo-Portugueze army in the Peninsula, that the muriatic acid was in common use in the hospitals of that army as a local application for checking the ravages of hospital gangrene, being em- ployed in a diluted state for slight cases, and in a concentrated caustic form for others. In S(. Bartholomew's hospital, the undilu- ted nitric acid has been used with great suc- cess as a local application lo phagedenic gan- grpnous ulcers, as may be seen by an inte- resting paper recently published by Mr. Wel- bank. (Med. Chir. Tram. Vol. 10.) Pouteau, Dussassoy, Boyer, and Delpech, all bear testimony to the efficacy of the ac- tual cautery, and they repeat the application of it, until the whole surface of the ulcer is converted into a firm bard eschar. Even the edges ofthe solution of continuity sboulcfnot be spared—" ils doivent etre torrefiis et rdlis pour ainsi dire." (Boyer, Traiti des Mala- dies Chir. T. l,p. 332.) The latter surgeon then covers the eschar with a thick stratum of bark moistened with turpentine. This application H to be removed in twenty-foti'*, thirty-six, or forly-eight hours, and the sur- geon is then to judge from the appearance ofthe flesh, and the quality ofthe discbarge, whether a further repetition of the cautery will be necessary, Pouteau, Glucres Posthumes, T. 3, publish- ed 1783. Dussassoy Dissertation et Observa- tions sur la Gangrine des Hopitaux, e^c. 8vo. Genive, 1788. Moreau et Burdin, Essai sur la Gangrene Hurnide des Hdpitaux, 179G. Observations on the Putrid Ulcer, by L. Gilles- pie, in London Medical Journal, Vol. 6,1785. Rollo on Diabetes, 1797. Sir Gilbert Blanc on the Diseases of Seamen, Ed 3 1797. Trot- ter's Medicina Nautica, Vols. 2and 3,publish- ed 1799. John Bell's Principles of Surgery, Vol. 1, 1801. Wolf Ploucquet, De Gangre- na sic dicta Nosocomiorum, Tub. 1802. Leslie, De Gangrend Contagiosa. Edinb. 1804. Johnston De Gangrend Conlagioia Nosocomi- al, Edinb. 1805. J. Thomson's Lectures on Inflammation, p. 456, et seq. Edinb. 1813, and Report of Observations, made in the Mili- tary Hospitals of Belgium, 8io. Edinb. 1816. J. Hennen, Principles of Military Surgery, p. 210, fyc. 8vo. Edinb. 1820. C. J M. Lan- genbeck, Neue Bibl. 2 B. p. 611, fyc. Hano- ver, 1820. Mimoire sur la Complication des Plaies et des Ulc&res, connne sous le nom de Pourriture d'hdpital,par J. Delpech,8vo. Pa- ris, 1815. Also Pricis Elimenlaire des Ma- ladies Chir. T. 1, p. 123, <^c. Paris. 1816. Brugmans und Delpech uber den Hospital- brand, ubersest mil Anmerkungen und Anhang von Kieser, Jennal, 1815. Boyer, Traiti des Maladies Chir. T. 1, p. 320, Paris, 1814. Sketches of the Medical Schools of Paris by J. Cross, p. 82, London, 1815. H. Home Blackadder, Observations on Phagedena Gan grenosa,8vo. Edinb. 1818, which is nnques tionably the best treatise on the subject, whether his sentiment about the disease being alwaysr or nearly always, communicated by the direct applicahonof the infectious matter to the parts, and not through the contagion in the air, be correct or not; or ichelher his opinion about the local nature ofthe disease in the beginning, and its invariable commencement wilh the local mischief, and not with constitutional, symp- toms, be liable to exceptions or not. The rest of the subject of Gangrene is treated of iu the article Mortification. HYDRARGYRIA. A peculiar eruption occasioned by the use of mercury, and na- med in Dr. Bateman's synopsis eczema ru- brum (See Mercury.) HYDUOCELE. (Irom CSctp, wafer, and iuimi, a tumour.) The term hydrocele, if used in a literal sense, means any tumour containing water; but surgeons have always confined it either to a collection of fluid in the cellular membrane of the scrotum; in a cyst, or the common cellular texture, of the spermatic cord ; or in the tunica vaginalis of the testicle. The celebrated Dr. Alexander Monro of Edinburgh, and Mr. S. Sharp, were almost the only writers, before Mr. Pott, who sensi- bly and rationally explained the (rue nature of these diseases. 72 HYDROCELE ana'arcous tomoi; n of the scrotum: wilh thfe point of a lancet; t})ie.Ja,t" w,,1'" the same ins(rumeiit,or with a knife- Ac.-ord- The hydrocele by infiltration of French ing to the same author, and indeea every writers; hydrocele eedematodes; is mosl fre- man of experience, wounds in anasarcous, quentlv only a symptom of a dropsical habit, or dropsical habits, are apt to inflame, very and very often accompanies both anasarca difficultly brought to suppuration, and otlen and the particular collection within the ah- prove gangrenous, in »piteof all endeavours domen, called ascites. Mr. Pott describes to the contrary. But the larger and deeper it as " an equal,soft tumour, possessing every the wounds are, the more probable are these part ofthe cellular membrane, in which both bad consequences. Simple punctures with tbe testicles are enveloped, and consequently the point of a lancet, are much less liable to it is generally as large on one side as on the be attended by them than any other kind of other ; it leavestbeskin of its natural colour ; wound ; they generally leave the skin easy, or, to speak more properly, it does not red- soft, cool, and uninflamed, and in a state to den or inflame it; if the quantity of water admit a repetition of the same operation if be not large, nor Ihe distention great, the necessary. Incisions create a painful, crude, skin preserves some degree of rugosity ; the hazardous sore, requiring constant care. tumour has a doughy kind of feel; easily Punctures «eldom produce any uneasiness at receives, and for a while retains, the im- all; and stand in need of only a superficial pres-ion of (he fingers; the raphe, or seam, pledget for dressing. of the scrotum divides the swelling nearly It is further explained by tbe same author, equally; the spermatic process is perfectly that as the cavities of the cellular membrane free, and of its natural size ; and (he testicles of the scrotum all communicate together, a seem to be in (he middle ofthe loaded mem- small puncture serves, as well as a large in- brane. This is the appearance when thedis- cision, for the discharge of the fluid con- easels in a moderate decree. But if the tained in them, and consequently upon this quantity of extravasated serum be large, or ground no reason exists for making any ex- the disease farther advanced, (he skin, in- tensive, painful, and hazardous wound. slead of being wrinkled, is smooth, tense, and With respect to the practice of making plainly shows the limpid state of the fluid un- punctures, in cases of anasarcous hydrocele, derneath: it is cold (o the touch, does not I think that it should always be avoided as so long retain Ihe impression of (he finger, much as possible, because it sometimes hap- and is always accompanied with a similar pens, that the slightest pricks of the lancet distention of (he ^kin of the penis; the pre- occasion sloughing. The methpd should only pulium of which is sometimes so enlarged, be adopted, when the distention ofthe skin and so twisted and distorted, as to make a of fhe scrotum is such, as absolutely to re- very disagreeable appearance. These are quire the fluid to be discharged. Care the local symptoms: to which il may be add- should also be taken not to multiply the •d, that a yellow countenance, a loss of appe- punctures unnecessarily nor to let them be tite, a deficiency of urinary secretion, swell- made too near together. (See Diet, des Sci- ed legs, a hard belly, and mucous stools, are ences Med T 23 p 195 ) its very frequent companions." When the (Edematous state of the scrotum As the cellular membrane on one side of is not the effect of a general constitutional (he scrotum w a ""'""""n of the which disease, but proceeds entirely from a local ,s situated on the other and both freely com- cause, such as friction, or the irritation of maturate; the accounts delivered by certain the urine, the mode of treatment consists in authors ofthe possibility of this spec.es of the removal of the cause the use"of astrin hydrocele being con ned ,0 one side of the gent lotions, and thTexbibitiorof a dose of scrotum is not credited by some modem salts. In elderlv «„h;«,«V li! • e surgeons. (See Diet, des Sciences Med. T. bag- rusii*™Z Ja ts, the wearing of a 22, V 193.) At all even^suchacase is o^e 5mpTai7mendedf°rthepreVe,,t,M extremely rare, and, when it happens, is HYDROCELE OF THE SPERMATIC CORD probably induced by tbe irritation of the nrine in infants, or of the frictiou of the c'othes in old persons, only acting upon a part of (he scrotum ; for occasionally, though not often, the disease is acknowledged (o proceed from these local causes. (Vol. et loco cit.) ■•XThe cure of the original disease, when it arises from constilulional causes, comes with Is of two kinds; the first is described as £ S?nfa K°US a|Te?tion' «te»*ng to more sirmatl ^^ substanc« around the enZTffjYT^5,'™? som*imes named the s0ittcrhof-thecord; the—H in the provinceof the physician, and requires is collected In 1 !f.'!• ** ,n lvhich the fl,,id a course of internal medicine: but sometimes which hw nn -«™ • . cavi*y, or cyst. the loaded scrotum and penis are so trouble- ties of the enm™™"",',0?1'0" wilh the cavi" some 10 the patient, and in such danger of cord ThisrTeT?"J?ellu,a.rsubs*ance of tbe mortification, that a reduction of their size : ly, tlle ™C.^■ /* ?eno,m,n"*fd according- becomes absolutely necessary: and at other the ^^^^T^f0^ COrd' That times, a discharge of the redundant extrava- distended whh T ° th/ .COrd is °^n .nted serum is ordered as an assistant .0 (he scrotum is ™L »q»eou. flujd, when the interna, regimen. As Mr Pot, observes, the c^^S'S^ 'J^U dropsi- ine»ns of making (his discharge are two, viz. freqHent attendant in the case T™* ,'S * puncture and incision the former is made " . ------„.. ,„., case, vvhifl, been described as the bvdrocrk -OPdematod has 11-iDKOCELE. 13 t But as I have never seen an instance, in f which such disease was restricted to the cel- ' lular texture of the cord, I am led to sup- t pose that it is a very uncommon case. The } following is said by Mr. Pott tabe the stale j ofthe disease, while of moderate size. The se;rotal bag is free from all appearance of disease ; except that when the skin is not j corrugated, it seems rather fuller, and hangs I rather lower on that side than on the other, ^ and if suspended lightly on the palm of the ( hand, feels heavier: the testicle, wilh its Eepididymus, is to be felt perfectly distinct below this fulness, neither enlarged, nor in any manner altered from its natural state : the spermatic process is considerably larger than it ought to be, and feels like a varix, or like an omental hernia, according to the . different size of the tumour : it has a kind of pyramidal form, broader at the bottom than at the top : by gentle and continued pressure it seems gradually to recede or go up, but drops down again immediately upon reino- ' ving the pressure ; and that as freely in a ! supine, as in an erect, posture : it is attend- ' ed with a very small degree of pain or un- 1 easiness ; which uneasiness is not felt in the scrotum, where the tumefaction is, but in the loins. " If the extravasation be confined to what is called the spermatic process, theappening '- in the tendon ofthe abdominal muscle is not 1 at all dilated, and the process passing 1 through it may be very distinctly felt ; but ' if the cellular membrane, which invests the ' spermatic vessels within tbe abd >men, be 1 affected, the tendinous aperture is enlarged ; 1 and the increased size ofthe distended mem- brane passing through it, produces to the ! touch a sensation not very unlike tiial of an omental rupture." While it is small, it is hardly an object of surgery, and may be kept from being trou- blesome by means of a suspensory ; but when it is large, il is very inconvenient both from size and weight, and according to Pott, the only method of cure which it admits, is fur from being void of hazard. The plan is to make a free incision into the swelling. It must be confessed, with a modern writer, that these observations on th% diffused hy- drocele of the cord by Mr. Pott, are far from being satisfactory, and tlie symptoms, by which he made up his mind lo lay open the disease, were but of an equivocal de- scription, and might have arisen from cases of another nature. (See Diet, des Sciences Mtd. T 22, p. 215.) TUE ENCVSTED HYDROCELE OF TIIE SPERMA- TIC CUK11 Is a complaint by no means infrequent, especially iu children. It was very well known to many of the ancients, and has been accurately described by Albucasis, Cel- sus, Paulus /Lginctn, &C. When Mr. Pott says, that the disease is not infrequent, it ought to be understood, that its frequency, though much greater, than that ol the dif- fused hydrocele of the cord, considered as Vor.'lf. 10 a distinct disease independent of general anasarca, is not at all equal to that of the hydrocele of the tunica vaginalis. Riche- rand has calculated, that the average pro- portion of encysted hydroceles of the cord to those of the latter description, is not more than as 1 to 200. (Nosogr. Chir T. 4, p. 262, Ed. 4.) According to Mr. Pott, the swelling is mostly situated at the middle part of the cord, between tie testicle and groin, and is generally of an oblong figure ; whence it has by so nit- people been compared to an egg, by others to a fish's bladder. Whe- ther it be large or small, it is generally pretty tense, and consequently tiie fluctuation of the water within it, not always immediate- ly or easily perceptible. It gives no pain, nor (unless it be very large indeed) does it hinder any n,*cess-iry action. It is perfectly circumscribed; and has no communication, either with the cavity ofthe belly above, or that ofthe va.-inal coat of the testicle below it. The testis and its epididymis, are per- fectly and distinctly (o be felt below tbe tumour, and are absolutely independent of it. The upper part ofthe spermatic process in the groin is most frequently very distin- guishable. The swelling does not retain the impression ofthe fingers ; and when lightly struck upon, sounds as if it contained wind only. It undergoes no alteration front change of the patient's posture ; it is not affected by his cou^hi!'!', sneezing, &.c. and it has no effect on tbe disi har-e per anum. The two diseases with which this kind of hydrocele is mo-t likely to be combined, are, an hydrocele ofthe tunica vaginalis tes- tis, and a true hernia. " One mark, or characteristic of an hydro- cele of the tunica vaginalis testis is, that it pos- sesses and d iste nds the inferior part of the scro- tum; and that thetesticle beingnearly(tlioUjdi not absolutely) surrounded by the water, it very seldom happens that the former can be clearly and plainly distinguished by the fin- gers of an examiner; whereas, in the en- cysted collection, in the membranes of the cord, the tumour is always above the tes- ticle, which is obvious and plain to be felt below it. " Another circumstance worth attending to is, that although the fluid in a hydrocele' ofthe vaginal coat does mi nearly surround the testis as to render it oft. n not very easy to be distinguished, yet the different parts of the tumour have always a very different feel: for instance, in all those points where the vaginal tunic is loose, and unconnected with the tunica albugiitea, the tumour is soft and compressible, and gives u clear idea of the contained fluid; but where these two coats are continuous, or make one and the same membrane, and have no cavity between them (which is the case on the middle and posterior part) there will always be found a hardness a::(l firmness very unlike to w hat is to be found iu all those places where the distance between tbe (wo tunics leaves room for tlie collection of a fluid ; now the hydro , cele of (he cord being formed iu the mere cellular membrane of it, r Vie- same to the 74 touch in all the parts of the tumour, and feds like a distended bladder through every point ol it. " l he free state of the upper part of the spermatic process, while the tumour i» form- i.;^ below; the gradual accumulation ofthe fluid, and consequently the gradual growth of the swelling ; the indolent and unaltering state of it; its being incapable ot reduction, or return into the belly from the first; its being always unaffected In the patients cougliingor sneezing; and the uninterrupted freedom of the fecal discharge per anion, will always distinguish it from an intestinal hernia . and he who mistakes it for an omen- tal one, must be very ignorant, or very heedless.'' Mr. Pott met w ith an encysted hydrocele situated so high toward the groin, as to ren- der the perception ofthe spermatic vessels very obscure, or even impracticable; but then, the state and appearance of the testi- cle, and the absence of every symptom pro- ceeding from confinement of Ihe intestinal canal, were sufficient marks of the true na- ture of the complaint. Several writers de- s ribe this kind of hydrocele, as in fact a common encysted tumour, formed in the eellular substance, between the vas deferens and spermatic vessels. (Delpech, Pricis Elem. des Mai. Chir. 1.3, p. 464) i et, since or- dinary encysted swellings are very difficult to disperse, there- is probably some differ- ence between the two affections, at least, if the observation of Mr. Pott be correct, that in young children, the encysted hyclro- IIYDROCELE. OYUROCELE OF TBE TCmCA VAClSAU*. JJ] e quantity of limpid fluid, which na- a.O,„ineatand,;ne1insideofthetu n tnequanucy o...-- tfap tUD. tUn,,1yn,°'9inhe tide of the tunica vagi- nal.< be secreted in an undue quantity, or "fe,.dar absorption of it be by any mean, preve ted, it will gradually accumulate, and Sbtendlhe cavity of tbe latter membrane, so as to form the present spec.es of hydro- cele. The case in which the. fluid ■* sup- posed to descend, cither partly or entirely from the cavity of the abdomen, in come. quince of tbe communication not being shut up in the usual time, between tbe ca- vity of the peritoneum and that ofthe tunica vaginalis, is well known to surgeons under the appellation of a congenital hydrocele; a disease, of which particular notice has been taken in the 2d Vol. of the last edition ofthe First Lines ofSwgery, bvo. Land. lSii', and to which I shall therefore very briefly advert in thb article. Hydrocele of the vaginal coat is a disease from which no lime of life is exempt; not only adults are subject to it, but young children are fre- quently afflicted wilh it: and infants some- times born with it. (Potl.) And it is re- marked to be common in old men, and per- sons who ride a good deal on horseback. (Delpcc'jpPricis Elem. des Mai. Chir. 1.8, p. 177.) The causes of hydrocele of the tunica vaginalis can scarcely be said tb be at all understood ; und when Mr. Pott observes, that whatever tends to increase the secre- cele of the cord frequently dissipates in a f"on of fluid into the cavity of that mem- short time, especially if assisted by warm fo- b.ra«e» beyond the due and necessary quan- mentation, and an open belly If it be not absorbed, " the point of a lan- cet will give discharge to the water ; and in young children, will most frequently pro- duce a cure : but in adults, the cyst, formed by the pressure of the fluid, does sometimes become so thick, as to require division through its whole length , which operation may in general be performed with great case, and perfect safety." mt. Pott says, in general, because it is most frequently so tity, or to prevent its being taken up, car led off by tbe absorbent vessels must contribute to the production of the disease, nearly as much is stated, as can be advanced with safety in the present state of our know- ledge. Ruysch had a suspicion, that this hydrocele might arise from a varicose state of the spermatic veins ; but though Mr. Poll acknowledges that these vessels are very frequently found varicose in patients afflict- ed with this disorder, he was unable to pro though he has even seen this, slight as it may Z^Z ?hat™1 foundation might exist ---- '. 5 ■ y. lor the foregoing conjecture, or whether •seem, prove troublesome- hazardous, and fatal, (see Pott on Hydrocele.) The late Sir J. Earle proposed treatin-*- this case in the same way as the hydrocele ofthe tunica vaginalis, viz. by an injection of red wine and water; which method is often successful. (On Hydrocele, p. 154, edit. 2.) However, the c'ire of an eiic-vmed the varicose state of the spermatic veins were a cause, or an effect of the hydrocele; In most instMic-.es, the accumulation of fluid takes place without any* evident cause; though, in a few cases, it has appeared to be the effect of a contusion, or of rough long- continued friction ofthe scrotum. Tbedii- M. ease is observed to affect persons of the best rocele of the spermatic cord, by means health, and mosl robust constitutor a> -l^T*™' - generally regarded by y*elln.^ntBaditBe^ce^\Tq^ unconnected with dropsy, or debility. In en- ob- dud, that ived to re- arrived to some size. Not but" that it some". For additional observations on this times is produced very suddenlyand in a species of hydrocele, (see the first Lines of very short space of time attains consideiiflT the Practice of Surgery, Vol. 2, p. 121.) magnitude. «-°nsiae*^ modern surgeons, as less certain and advan- a* mam. HYDROCELE. In general, at its first beginning, the tu- mour is rather round ; but as it increases, it '' frequently assumes a pyriform kind of figure, "vith its larger extremity downward ; some- times it is hard, and almost incompressible ; ' so much so, that, in some few instances, it : has been mistaken for an induration of the testicle: at other times, it is so soft and lax, ! that both the testicle, and the fluid surround- ing it. are easily discoverable. It is perfectly indolent in itself; though its weight some- times produces some small degree of un- easiness in the back. According to Mr. Pott,ihe transparency of the tumour is the most fallible and uncertain sign belonging to it: it is a circumstance, says he, which does not depend upon the quantity, colour, ' or consistence of the fluid constituting the disease, so much as on the uncertain thick- ness, or thinness of the containing bag, and of the common membranes of the scro- tum. If they are thin, the fluid limpid, and the accumulation made so quick as not to give the tunica vaginalis time to thicken much, the rays of light may sometimes be seen to pass through the tumour: but this is accident- i al, and by no means to be depended upon. The fluid is most frequently of a pale yellow , or straw-colour ; sometimes it is inclined to a greenish cast; sometimes it is dark, tur- bid, and bloody ; and sometimes it is per- fectly thin and limpid. With respect to Mr. Pott's remarks on the transparency of the swelling, as a symptom of hydrocele, they are correct, inasmuch as the absence of this sign is no proof, that the disease is not of this nature ; since thickness of the tunica vaginalis, and, as ought also to have been admitted, the opaque quality of the fluid, sometimes prevent the rays of a candle from passing through the swelling. But, on the other hand, it should have been explained by Mr Pott, that when the transpa- rency is present, il is one of the surest marks of this species of hydrocele. It is next noticed by Mr. Pott, that in the beginning of the disease, if the water has ac- cumulated slowly, and the tunica vaginalis is thin and lax, the testicle may easily be perceived ; but if the said tunic be firm, or the water accumulated in any considerable •quantity, the tetis cannot be felt at all. In most cases, the spermatic vessels may be distinctly felt at their exit from the abdomi- nal muscle, or in the groin ; which will al- ways distinguish this complaint from an in- testinal hernia. But, in a few examples, the vaginal coat isdistended so huh, and is so full that it is extremely difficult, nay, almost im- possible, to feel the spermatic cord: and the same kind of obscurity is sometimes occa- sioned by the addition of an encysted hydro- cele of the cord ; or by the case being com- bined with a true onterocele. In a hydrocele of the tunica vaginalis, the swelling is first noticed at the lower part of the scrotum, whence it ascends in front of the testicle and spermatic cord. The pro- gress of the disease is generally so slow, that six or even eighteen months elapse, be- fore the tumour approaches the abdominal ring. And, among other characters of the case, are to be noticed the disappearance of the corrugations of the scrotum by the effect of the distention ; inclination of the raphe to the opposite side ; and the possibility of feeling a fluctuation, when the fingers of one hand are applied to one side of tiie lumour, and Ihe surgeon slightly taps with the lingers of his other hand upon an opposite point of the swelling. In the hydroceles of children, the testis- occupies a lower situation, than the the same organ in the hydroceles of adult persons, and the swelling passes further up towards the abdominal ring. It is well explained by Mr. Pott, that the tu- nica vaginalis and tunica albuginea, are so inseparably united at the posterior and supe- rior, or rather the posterior and middle part of the tumour, that no fluid can collect between them ; and therefore, the fingers of an intelligent examiner must immediately discover here the firmness and hardness arising from the union of these parts ; while in all others, the two membranes being un- connected, and affording a void space for the collection of water, the fluctuation of it will always be distinguishable. " This (says Polt) must for ever discrimi- nate the simple hydrocele of the tunica va- ginalis from the anasarcous swelling of the scrotum; from the encysted hydrocele of the cord ; and from the intestinal hernia. The first is every where equal, tumid, and soft; and every where equally receives and retains the impression of tbe fingers , the second, though circumscribed, not very compressi- ble, and affording the sensation of fluctuation, yet does not pit, and is alike to the touch in all parts of it; and in the third, if the testicle be distinguishable at all, it is found at the inferior part of tbe whole tumour." A collection of fluid in the tunica vagina- lis, complicated with a scirrhous or* chronic induration and enlargement of the testicle, is well known under the name of iiydro-ca-- cocele; a case, which should be xarefully discriminated from a simple hydrocele, " one of tiie marks of the latter being the natural, soft, healthy state ofthe testicle: and the characteristic of the. former being its disea- sed and indurated enlargement." Mr. Pott docs uot mean that, in a true simple hydrocele, the testicle is never altered from its natural state. He admits (he con- trary, and that it is often enlarged iu size, and relayed in structure, and that the spei- matic vessels are frequently varicose. But, the testicle is never indurated. These two diseases are extremely unlike each other, and require very different treatment. That which would cure a simple hydrocele, would dangerously aggravate the hydro-sarcocele. Mr. Pott observes, that " it may, and does sometimes become necessary to let out the water from the vaginal coat of a testicle, in some degree diseased ; but this should al- ways be done with caution, and under a guarded prognostic ; Icsl the patient be not only disappointed, by not having that per- 76 UilKOCELl' nianrnt relief, which, for want of better in- formation, he may be induced to expect ; but be also (possibly) subjected to other un- expected inconveniences from the attempt. " When the disease is a perfect, true, sim- ple hydrocele, the testicle, though frequently somewhat enlarged, and perhaps loosened iu its vascular texture, is nevertheless sound, healthv, and capable of executing its pmper office ;" neither is tlie spermatic cord any lo contain four pints of fluid. (g'tfW, Handbuch der Pract. Anat. B. 3,P- ***) METHODS OK CI-RIM THE HVDKOCEEE OF THg VAGINAL COAT. A hydrocele is by no means a dangerous complaint, though its weight and size area disagreeable incumbrance, and tbe patient is always obliged lo wear a bag truss, in -»"r"'"""'T'*"■""ri-x'id' °£^'£Tsi"^:: Ks vessels are generally somewhat dilated , spermatic, coiu. neither of which circuinstaiices are objec- tions either to the palliative or radical cure of the disease. But in those disorders, which in some degree resemble this, the case is different ; either I he testicle, or sper- matic cord, or both, bearing evident marks of a distased slate." According to Richerand, a hydrocele may be known from a sarcocele by the following circumstances : iu a sarcocele, the tumour mostly retains the shape of the testicle, being oval and a little flattened at the sides, and its size becomes considerable in a short time, al a rfect c without leaving a possibi- without ascending so near the abdominal ,;, ',-re, se. The e,*d of the former is ring, as a hydrocele does, when of the same __-l____i:„i.„,j i_________i„ „___:.._»■___. magnitude. A large hydrocele leaves no interspace between (hat opening and the tumour, so that it is difficult fo take hold of, and lifl up the spermatic cord ; but, iu a sar- cocele, there i-^ always a space between the tumour and the ring, where the cord can be distinctly felt. Lastly, in a sarcocele, the tumour is always opaque, and its weight, in reference to its size, much more consider- able, than that of a hydrocele. (Nosogr. Chir. T. 4, p. 267, Ed. 4.) The hardness is not a symptom which can be trusted alone. as a criterion of a diseased testicle ; for, when a hydrocele is extremely distended, it often feels so indurated as to deceive prac- titioners of great experience, and a thick- ened, hardened state of the tunica vaginalis may facilitate the mistake. In some instan- ces of hydro-sarcocele, the nature of the dis- ease sometimes remains questionable, until the evacuation of the fluid gives the surgeon a fair opportunity of ascertaining the disea- sed state of the testicle. are also frequently caused by the friction of the tumour against the inside ol the thigh; and when the swelling is very large, it drawn over itself the integuments of the peniSi which appears buried, as it were, in the lu- mour, and its functions are seriously inter- rupled. Hence, the greater number>jf patients are very anxious for relief. " Tlie methods of cure (says Pott) tbougli various, are reducible (o two, (viz.) the pallia- tive, or that which pretends only to relieve the disease in present, by di .-.charging (bit fluid ; and the radical, or that which aims The complication of an hydrocele of the lunica vaginalis with an encysted one of the spermatic cord, may generally be known by the swellings having begun at two differ- ent points, and by a kind of constriction he- accomplished by merely opening the con- taining bag in such manner as to let out the water : that of the latter cannot be ob- tained, unless the cavity of that bag be abo- lished, and no receptacle for a future accumu- lation left; (a proposition, on which the ob- servations of Mr. Ramsden and Mr. Wadd, published since Mr. Pott's time, have thrown a degree of doubt.) One may be practised at all times of (he patient's life, and in almoi any state of health and habit: the other liei under some restraints and prohibitions; ari- sing from the circumstances of age, constitu- tion, sfate of the parts, be. " The operation, by which the fluid is let out, is a very simple one. The only circura stances requiring our attention in it, arc, tbe instrument wherewith we would perform it; and the place or part of the tumour, into which such instrument should be passed. " The two instruments in use, are the com- mon bleeding-lancet, and the trocar. " The former having the finer point, may possibly pass in rather the easier, (thougb the difference is hardly perceptible) but is liable to inconveniences, to which the latter is not. The trocar, by means of its cannula, secures the exit of the whole fluid without tweenthem. The latter symptom, however, »£ &,.f P.peven.t'°n > the lancet can- is not infallible, because the tunica vaginalis when th; VieJ'efore " .frequently happens of a common hydrocele is sometimes more nm" thi, instrument is used, either that or less contracted at the middle ofthe tu- Z ?! the T™ '?,. 'eft behind> or tbat mour, which is thus made to appear as if reno^f6-. han,d!,ng a"d squeezing is there were two distinct pouches. ffi?r V CiCuls,on > or> that the in" The size of a hydrocele, and the thick- such^ nessof the tunica vaginalis, are generally ^t^^^^^^fT**0' '* iaaratiototbetime,whicdrthe|diseasehascon some habits L ,1, to™er °[ *hese may in tinned. Sometimes the latter membrane fh Hatter J*i Pr°duC 'vf of "^animation: acquires nearly a cartilaginous hardness ; be a short nZ^ a W°.U-,d otherwise and portions & it have been found in an Z^°££^£ ^L^W" <** *r ossified state; the only circumstance, in «tion^H™^ wipi'V^T ^ which any free excision of it is now account- mav K„ „^^„,i .!'_* :r .... °' . 1o which » , fy-c.) This author, of course, speaks of the plan as having fully answered his expectations ; but, 1 much doubt whether it has any parti- cular superiority over several of the former methods of employing the tent; methods, which the wisdom, arising from experience, has long since rejected. Selon Was first mentioned by Guido di Cauliaco, in 1498, as a means of curing the hydrocele. In modern times, Pott preferred it to every other method, if we except injection, of which, according to Sir J. Earle, he express- ed his approbation before his decease. Mr. Pott found, that the best mode of making the seton was as follows. He employed three instruments: the first was a trocar, the cannula of which was about one-fourth of an inch broad. The second was what he called the seton-cannula, which was made of silver, was just small enough to pass with ease through the cannula of the trocar, and live inches long. The third instrument was a probe six inches and a half long, having at one end a fine steel trocarpoint, and, at the other, an eye, which carried the seton. The 3eton consisted of so much whitesewingsilk, as would just pass easily through the cannu- la, and yet fill it. The thickness of the seton, however, was not so great in the lat- ter part of his practice. Having pierced the inferior and anterior part of the^ tumour with the trocar, withdrawn the perforator, and discharged tbe water, Mr. Pott used to pass (he seton-cannula through that of the trocar, to the upper pari of the tunica vagi- nalis, so as to be felt there. The probe, armed with the seton, was next conveyed through the latter cannula, and its point pushed through the upper part of the tunica vaginalis, and scrotum. The silk was then drawn through the cannula, until asufficient quantity was brought out of the upper orifice. The two cannula being withdrawn, the ope- ration was finished. Injection. Dr. Monro attributes the first use of infec- tious for the radical cure of hydroceles to an army-surgeon of his own name, who em- ployed spirits of wine. This produced a cure, but the inflammation was so violent that he afterward tried a milder inject,on' which consisted of wine. However, Lam- bert, in his LEweres Chir. published at Mar- seilles early in the seventeenth century, ad- vised injecting a solution of sublimate in lime water, and he has related cases of suc- cess. Mr. *->. Sharp also made trial of spirit of wine, which cured the hydrocele, but not: without causing dangerous symptoms, and . two subsequent abscesses in the scrotum. (Operations of Surgery.) Douglas, Le Dranj and Pott, all disapprove of injections in their works ; though Sir James Earle informs u?, that the latter lived to alter his opinion on the subject. The violence of the inflammatory symp- toms, consequent to the first employment of injections for the radical cure of hydroceles arose from the fluids used being'too irrita- ting. Sir James Earle. at last, preferred wine for several reasons. He found, that it had been used with success in France ■ its strength is never so great as to render it- unsafe ; and it may be readily weakened. This injection, in short, produces less pain than any other mode of cure, does nothin"- more than is intended, and is as certain as any plan. I have commonly used fsavs Sir Jamo8 Poll on the Hydrocele ; Else on tin on the Hydrocele, 8vo. Lond 1776; and Iht HYDROPHOBIA. drocele, Sarcocele, tyc 810. Edinb. 1794. Sir James Earle, Treatise on the Hydrocele, 2d Ed. 8vo. Lond. 1803. Schreger Chirurgisches Versuche, B. 1, 8vo. Numberg, 1811 ; a cure effected by the injection of air, p. 306. Ber- trandi, in Mim. de I'Acad. de Chir. T. 3; and in Traltato delle Operazioni di Chirurgia, Nizza, 1763 Desault, Remarques, fyc. sur diverses espices d'Hydrocele. (Euvres. Chir. T. 2. S. Sharp's Treatise on the Operations, and his Critical Inquiry. J. Howard, Obs. on the Method of Curing the Hydrocele by Means of a Selon, 8vo. Lond. 1783. Sabatier, Midecine Opiratoire, T. 1, Ed. 2. Scarpa, Traiti des Hernies, p. 64, fyc. Ldrrey, Mi- moires de Chir. Militaire, T. 3, p. 409, fyc. T. Ramsden, Practicdl Observations on the Sclerocele, fyc. 8vo. Lond. 1811. W Wadd, Cases of Diseased. Bladder and Testicle, 4to. Lond. 1815. Kinder Wood, some Observations on the Cure of the Hydrocele of the Tunica Vaginalif, without procuring an Obliteration ofthe Sac,in Med. Chir. Trans. Vol.9.p.38, 8vo. Lond. 1818. •HYDROPHOBIA, (from iva?, water,and tM&c, fear. A dread of water.) This being, for the most part, a striking symptom of the fatal indisposition which results from the bite of a mad dog, and some other animals af- fected in the same way, the disease itself has been named Hydrophobia. Some have used the more general term, hygrophobia, from uygpv, liquid. But strong objection has been made to both these terms, because de- rived from a symptom, which does not ex- clusively belong to the disease, nor constant- ly exist in it. The old writers, as we learn from Cadius Aurelianus, used the terms aerophobia, or a dread of air, and pantephobia, or a fear of all things. Since tbe impression of coid air sometimes excites terror, and the disor- der is marked by a singular degree of gene- ral timidity and distrust. Others called it phobodipson (eft-fa?, signifying thirst,) because the patient i3 thirsty, yet fears to drink. Se- veral modern authors, however, objecting to any appellation expressive only of one symp- tom, denominate the disease rabies, and rabies canina, or canine madness. The French call it la rage. With respect to hydrophobia, orthe dread- ful indisposition produced by the bite of a dog, or other animal, affected with rabies, or by the application of some ofthe secretions of such animal fo a part of the body, the first allusion to it to be found in authors, is that made by Aristotle, (Hist. Animal, lib. 7, cap. 22;) but he could have had but very erroneous notions upon the subject, since he sets down man as incapable of receiving the distemper from the bite of a rabid dog. With respect to a name for the disorder^ as the patient does not commonly betray any fendency to fury, while the dread of water is really a customary attendant on the com- plaint, the terms rabies and la rage seem r-trictly even more exceptionable than the word hydrophobia. At the same time, in order not to imbibe confused notions, what- ever name be thought fittest for the illness Vol. if IT arising in the huniau subject lroui the bite of a mad dog, and some other animals simi- larly affected, it is necessary to understand well, that hydrophobia, in the sense of a horror of water, or other liquids, is an Occa- sional symptom of many diseases, and nei- ther exclusively confined to the indisposi- tion caused by the bite of a rabid dog, or certain other animals, nor even constantly attendant upon it. And, with the same \ view of avoiding perplexity, all hydrophobic complaints may be arranged in two general divisions: 1. The first, comprising all eases not ascribable to the bite of a rabid animal, or the application of some of its secretions to a part of the body. 2. The second, comprehending the ex- amples preceded by one of those occurren- ces. The cases included in the first of these divisions are subdivided into the symptomatic and idiopathic, or spontaneous. By symptom atic hydrophobia is understood an aversion or dread of liquids, presenting itself as an occasional symptom of various diseases, a? of certain inflammatory, febrile, affd nervous disorders, hysteria, epilepsy, injuries of the brain, (Trecourt, in Recueil Piriodique, §*c. T. 6; Ada Nature Curios. Vbl. 2, Obs. 205,) the operation of particular poisons; (Viller- may, Traiti des Mai. Nerreuses, T. 1, p. 90 ; Harles uber die Hundiswulli, Frankf. 1809;, Schmkdel, Diss, de Hydrophobia ex usu firuc- luum J'agi, Erlang. 1762, be.) gastritis, pneumonia, hepatitis, angina, be. be. In many of the instances of symptomatic hydrophobia, the aversion, or dread of fluids, occurs on the same day as the cause upon which it depends, or a few days afterward ; and, for tlie most part, may be cured with the disease which has given rise to it, or even independently of it. On the contrary, the hydrophobia from the bite, or infection of a rabid animal, does not come on till a loug time after the occurrence of the cause, and, when once formed, has hitherto proved incurable, or very nearly so. Whatever analogy, therefore, may be imagined to exist between symptomatic hydrophobia and ra- bies, they differ essentially in their causes, progress, degree of curability, and also in the treatment required. (See Diet, des Sciences Med. T. 4, p. 3S.JI Spontaneous, or idiopathic hydrophobia, denotes the questionable form of the com- plaint, sometimes supposed to be induced by violent mental commotion, anger, fright, be. unpreceded by any other primary dis- ease, to which it can be referred as a symp- tom. Numerous facts upon record leave no doubt concerning the reality of symptomatic hydrophobia; but, perhaps, none of the cases adduced by Raymond (Mim de la Soc. Royale de Mid. T. 2, p. 457,) Roupe (Nova Acta Physico-Mid. T. 4,) or Pouteau (Essai sur la Rage, Lyons, 1763,) in proof of the possibility of a spontaneous idiopathic form of the disease in the human subject, arc sufficiently unennivocal to remove all suspi HYDROPHOBIA. cion, that the complaint cither had been preceded by another primary disease (Did. des Scienccs'.Mid. T. 22, p. 333,) or had been the result of an unobserved, or forgotten occasion, on which (he infection was re- ceived from handling a dog, or cat, never suspected at the time to be affected with rabies. Here a wrong conclusion is the more apt to be drawn, in consequence of the disease being communicable without any bite to fix the patient's attention, and not commencing sometimes for months after the unnoticed receipt of the infection. Thus, Francis Stannier died, in Nov 1787, with symptoms of hydrophobia, though it was not known that he had ever been bitten by a mad dog, (Lond. Med. Journ. Vol. 9, p. 256;) yet, what safe inference can be drawn from this case, when the above-mentioned circumstances are recollected, and it is known (hat the man was often drunk, and iu the streets at night? These and other considerations even throw a doubt upon a part of the cases, recorded as instances of symptomatic tetanus, and they lead the generality of the modern writers to incline to the sentiment of Dr. .1. Hunter, that a disease, similar in its nature to what is pro- duced by the bite of a mad dog, never arises spontaneously iu the human subject. (See Trans, of a Soc.for the improvement of Med. and Chir. Knowledge, Vol. \,p. 299—303.) Many of the symptomatic cases, however, or those in which more or less aversion, or dread of liquids, is evinced as an effect of another disease, are too well authenticated to admit of doubt. In the Did. des Sciences Mid. T. 22, art. Hydrophobic, may be found a great deal of information likely to interest such readers as wish to follow up the subject of the symptomatic forms of the disease. However, in looking over some ofthe cases there detailed, a suspicion will sometimes arise in an intelligent mind, that the disorder was mistaken ; for it will be noticed, that sometimes pain shooting up the limbs prece- ded the general indisposition, while the rapidity of the disease, and the appearances found on dissection, corresponded precisely to what is usually remarked in hydrophobia. In particular, one patient is described as a man habituated to drinking, and, as a sports- man, lo dogs also; he died on the third day, and, on dissection, the stomach and intes- tines were found inflamed, and even gan- grenous in several places, the oesophagus and lungs also participating in the inflam- mation. (Commerc. Litter. Noremb. 1743 Hebd. 5.) ' Animals of the dog kind, including Ihe wolf and the fox, are most frequently the subject of rabies; and certain writers have maintained, that, although it may be recei- ved and propagated by other animals, yet it always originates in some of the canine race (Hillary on Diseases of Barbadoes, p. 246.) However, it is asserted, that the disease sometimes originates spontaneously in cats, that is to say, without their having been previously bitten by another rabid animal ; but tbe modern*? do not incline to the belief that it ever has been known /o commence in this manner in other animals, thoughsich an assertion is made by Ccel.us Aurel anus, Porphvrius, Avi enna, Valenola, Stalpa* vande'r Wiel, be. not only with respect to man, but horses, asses, camels, hogs, brj. locks, bears, monkey . anil even poultry. (See Diet, des Sciences Med. T. 47, p. 45.) It is interesting to inquire, what ammali are capable of communicating rabies, and what animals of receiv ing it ? As far as our knowledge yet extends, it appears that ani- mals of the canine species, with perhaps those of the feline race, are the only ones in which this disorder ever arises spontane- ously, and they may transmit it to animals of their own kind, to other quadrupeds, and to man. The experiments made by Dr. Zincke, tend to prove also that birds, at least the common fowl, may have the dis- ease communicated to them. (Neue An- sichlen der Hundswulh, fyc. 8vo, Jend, 1804.) But, though it be well known, that animals ofthe dog and cat kinds can propagate the disorder, it is not settled whether it can be communicated by other animals. In a me- moir read to the French Institute, M Ha- zard explained that herbivorous quadrupeds, affected with rabies, are incapable of trans- mitting the disease ; a position subsequently confirmed by additional experiments and observations made in the veterinary school at Alfort. Professor Dupuy could never communicate the distemper to cows and sheep, by rubbing their wounds with a sponge, which animals of the same class, already labouring under the disease, had had in their mouths; though the'same ex- periment, made with a sponge, which had been bitten by a rabid dog, propagated ra- bies by a kind of inoculation. Dupuy has likewise seen, among several flocks, sheep affected with rabies, yet the distemper was never communicated by them to other sheep, notwithstanding the latter were bit in parts stripped of wool. Dr. Gillman inoculated two rabbits with the saliva of a rabid pig) but the disease was not communicated to them. (On the Bite of -.> Rabid Animal,f. 38.) On the other hand, Ivir. King, of Clifton, is stated to have communicated rabies to a fowl, by inoculating it with the saliva of an ox, which had just fallen a victim to the disease. (J. Ashbumer, Diss, de Hydrophobia, P- 29.) The author of the article Rage (Did. des Sciences Mid.) observes, respecting this singular case, that, as it is accompanied with no details, doubts must remain, whether the fowl actually died of rabies. As for some extraordinary cases, in which the disease is alleged to have been com- municated to the human subject by the bites of birds, or injuries done with tbe claws ot animals, they are generally dismissed by modern writers with the inference, that hvH^T**'"1 thus transmi«ed was not true hydrophob.a or rabies. This conclusion is £n»*-,T ' r^PC.-t lVhe .?ases of ^is kind, Sthen t*9 Aurfanu* and Bader Bar,-h,. n?tonou? examf» e mentioned by A Hac ms of a gardener, who died of the bite HYDROPHOBIA. .83 of a cock, which, according to some, was rabid, according to others, merely enraged. Hildanus also details an instance, in which a young man was scratched on the great (oebyacat: and, some months afterward, was attacked with hydrophobia (Obs Chir. Cent. 1, Obs. 16;) but, as a modern writer observes, if the patient were really affected with rabies, it is conceivable that the cat's claw, with which the scratch was made, might have been wet with the animal's saliva. (Diet, des Sciences Mid. T. 47, p. 47.) Another question of considerable import- ance is, whether hydrophobia, that is to say rabies, can be communicated from one hu- man being to another ?—or whether, in man, the disease is infectious or contagious ? Many attempts have been made, in vain, to communicate the distemper to several kinds of animals, by inoculating them with the saliva of patients who had perished of the disease. These experiments were made in this country by Gauthier, Vaughan, Babing- ton, fiic; but no infection was the conse- quence. In France, Giraud inoculated several dogs with the saliva of a man in the convulsed stage of hydrophobia, but none of them afterward took the distemper. (Bosquillon, Mim. sur les Causes de I' Hydro- phobie, in Mim. de la Soc. d'Emulation, bme annie.) M. Girard, of Lyons, collected some of the frothy saliva the instant it was dis- charged from a patient's mouth, and he in- serted some of it into eight punctures, made on the inside of a dog's four legs ; yet, six months after this inoculation, the animal had not suffered the slightest inconvenience. (Essai sur le Tetanos Rabiens, p. 29.) A similar experiment was made on three dogs by M. Paroisse, who kept the animals be- tween three and four months afterward, during all which time they continued quite unaffected. (Bibl. Mid. T. 43.) Dr. Bezard published the following ex- periments :—Pieces of the flesh of a person who had died of hydrophobia, were smeared with his saliva, and given to a dog ; another dog was suffered to eat the salivary glands ; and a third, the sides of a wound. In three other dogs, incisions were made, the cut parts were then inoculated, and sewed up. Not oue of these six animals became affected with rabies. (See Mim. it Obs. lus c\ la Soc. Mid. Philanthropique, premiere annie, 1807, p. 17.) The preceding experiments only furnish negative results ;. but one, to which we shall now advert, tends to establish a contrary opinion. On the 19th June, 1813, in the Hotel-Dieu, at Paris, Magendie and Brescht t took some of the saliva of a man, who died a few minutes afterward of hydropho bia, and, by means of a bit of rag, they conveyed this saliva to the short distance of twenty paces from the patient's bed, and in- oculated with it two healthy dogs. One of tbe dogs became rabbi o;; the 27th of July, at. f '.nt (wo others, one of which wa.> attack- ed with complete rabies on the 26th of Aiumst. (C. Burnout; see Collect, des Theses, in 4to. de la Facnlte de Paris, 181-1.1 It is remarked, iu the work, from which I have collected these particulars, that the foregoing is one of the best authenticated experiments on the subject; for, in addition to the con- sideration of the talents and characters of the experimenters themselves, the facts were witnessed by numerous medical stu- dents. And, notwithstanding the objections which have been urged against the account, (see Journ. Gen. de Mid. T. 52, p. 13) the main points are declared to be entitled to credit. (See Did. des Sciences Med. T. 47, p. 4*. With these relations, it is proper to notice certain cases, too credulously promulgated as proofs of the possibility ofthe disease be- ing communicated from one human being to another. Neither the instance of the maid-servant, who died merely from seeing her mistress vomit, while labouring under hydrophobia (Mich. Ellmuller, Op. Med. T. 2 ;) the case of the peasant's children, which all died on the seventh day, as is alleged from embracing their dying father; the example of a woman contracting hydrophobia from her husband, as detailed by Mangor (Acta Soc. Reg. Hafniens. V. 2, Obs. 32, p. 408 ;) nor other cases of a similar tenor; are now regarded as proving any thing more than that the patients, supposed to have caught the disease by contagion, fell victims either to violent affections ofthe mind and nervous system, or illnesses accidentally taking place soon after the death of a near relation or mistress. It is clear enough also, that some of the cases were, at most, only instances of symptomatic hydrophobia. With regard to another opinion, that the bite of a man, or other animal, when merely- enraged, may bring on hydrophobia, it is now entirely discarded as erroneous. The cases in support of it, recorded by CI. Pou- teau, Mangetus, Malpighi, Zuinger, Le Cat, be. when critically examined, only prove that the patients were affected with tetanus, or symptomatic hydrophobia, not arising from any infection; for neither the mode of attack, nor the progress of the symptoms, in any of the examples which are related with sufficient minuteness, lead to the infe- rence, that the patients actually died of rabies. (See Did. des Sciences, Mid. T. 47, p. 49.) Wrong notions of a very dangerous ten- dency, have been generally entertained, iu regard to the disease, as it appears in the canine race. The writer of the article Dog, in Dr. Rees's Cyclopaedia, appears to have had extensive opportunities of observing the disorder in dogs, having paid attention to more than two hundred cases. From his remarks, I have collected the following in- formation. The peculiar symptom which character- izes the complaint in the human subject, has been applied to the disease in the dog, and has occasioned it to be called by the same name, hydrophobia. This is a palpable mis- nomer ; for, in no instance, does there ever exist any dread of water; on the contrary, dogs are in general very greedy after it. 64 HYDRUPHOBIA Such untouuelru supposition has often con- duced to a very futal error: for, it being the received opinion, that no dog is mad who can lap water, many persons have been lulled into a dangerous security. Another equally false and fatal idea has prevailed, that every mad dog must be wild and furi- ous ; but this is so far from being true, that, in the greater number of instances, there is very little of that wild savage fury that is expected by the generality of persons. " Hence," says this author, "as it is evi- dent that the (erm hydrophobia, characteri- zing tbe affection in the dog, is a misnomer, so it is evident that the term madness is equally so. In no instance have I ever ob- served u total alienation of the mind ; in very few have the mental faculties been disturbed. The disposition to do mischief is rather an increased irritability than ab- sence of sense ; for, in most instances, even those that arc furious, they acknow ledge the master's voice, and are obedient." The Symptom, which is most frequently first ob- servable in a rabid dog, is a certain peculia- rity in his manner; some strange departure from his usual habits. In a very great num- ber of instances, (he peculiarity consists in a disposition to pick up straws, bits of paper, rags, threads, or tbe smallest objects, which may happen to be on the floor. This is said to be particularly common in small dogs. " Others again show an early peculiarity by licking the parts of another dog. In one instance, the approach of the disease was foretold by our observing a very uncommon attachment in a pug-puppy towards a kitten, which he was constantly licking; and like- wise the cold nose of a healthy pug that was with him. An attachment to the sensafion of cold appears in many cases, it being very common to observe them (the dogs) licking the cold iron, cold stones, be. Some dogs, early in the disease, will eat their own ex- crement, and lap their own urine. An early antipathy to strange dogs and cats is very commonly observed, but particularly to cats. As the disease advances, the affected dogs bite those with which they are domesticated, and, lastly, the persons around ; but, except • n a moment of irritability, they seldom attack the human subject. The irritability that induces them to bite is very strong, but is devoid of wildness. It is more like pee- vishness than fury. A stick held up at them always excites their anger in a violent de- gree, and throughout the disease there is generally a wonderful impatience of control, and the animals are with ^reat difficulty frightened. (See art. Dog, in Rees's Cyclope- dia.) To this passage the followingremarks may be added:—Dr. John Hunter calculated, that out of every dozen of rabid dogs, about one evinces no particular tendency to bite. That these animals, and wolves also, have no particular dread of fluid, is proved by facts. Thus, a rabid wolf, at Frejus, swam across several rivers. (Darluc, Recucil Pi- nod■ d'Obs. Vol. 4.) Duboueix has seen mad do-s drink without difficulty, and plen- tifully. (Hist, dc la Soc. de Mid. an. 1783.1 Rabbi animals will sometimes eat as well as drink. Thus the wolf which bit so many persons at Meyne, in 1718, was found in the morning devouring a shepherd's dog. And Dr. Oilman speaks of a dog, which vyas not deemed rabid, because it eat and drank well; but, as it seemed indisposed, it was killed, though not before it had bit a man, who fell a victim to hydrophobia. (On Ihe Bite of a Babid Animal, p. lo.) When a dog bites a person, it should not be immediately killed, but merely chained up, because, by destroying it at once, the possibility of ascertaining whether it was rabid is prevented, and great alarm is thus kept up in the mind of the wounded person and his friends. If the animal be affected with rabies, it w ill perish in a few days. At the veterinary school at Alfort, when a dog has been bit, it is usual to chain the animal up, for at least fifty days, before it is resto- red to its master, about six weeks being considered the period when a dog generally becomes rabid after being bitten. For additional details, relating to the dis- ease as it appears in the dog, I must refer to the above-mentioned paper. Enough, I hope, has been said to make the reader aware, that mad dogs are not particularly characterized by an inability to lap water, or any degree of fury. These animals, when actually affected with rabies, from their quiet manner, have even not been suspected of having ihe disorder, and have been allow- ed to run about, been fondled, and even slept with. (See Mem of Swedish Acad. 1777.) The causes of this peculiar distemper in dogs are at present unknown, and little more than conjecture prevails upon the sub- ject. It is not positively known whether rabies sometimes originate spontaneously in these animals, though I believe this opinion is at present gaining ground; or whether, like small-pox in the human species, it is propagated only by contagion. That the disease is frequently imparted in conse- quence of one dog biting another, every body well knows. Yet there are many in- stances in which this mode of propagation cannot be suspected. Several facts render it probable, that, among dogs, the disease is often communicated by contagion. It is observed, that, in insular situations, dogs are seldom affected, and this'circumstance is ascribed to such animals being in a kind of quarantine. The celebrated sportsman, Mr. Meynell, secured his dogs from the ma- lady by making every new bound perform a quarantine before he was suffered to join ■ the pack. (See Trans, for the Improvement of Med. and Chir. Knowledge, Vol. I, art. 17.) Great heat was very commonly supposed to be an exciting cause of the disease in dogs; but without much foundation. " A very hot climate, or one exposed to the extremes of beat and cold ; a very hot and dry season; feeding upon putrid, stinking, and magotty nesh; want ot water; worms in the kid- neys, intestines, brain, or cavities of the HYDROPHOBIA 85 nose," are set down by Boerhaave as causes of the disease. (Aphorism, 1134.) We learn from Dr. J. Hunter, that, in the hot island of Jamaica, where dogs are exceed- ingly numerous, not one was known to go mad during forty years. ( Trans, for the Im- provement of Med. Knowledge, toe. cit.) Cold weather has also been set down as condu- cive to rabies among the canine race, as is suggested, because the ponds being frozen, these animals cannot quench their thirst. (Le Roux ) That neither of these senti- ments about heat and cold being the cause ofthe origin of the disease in dogs is cor- rect, will be manifest enough to any body who has patience to look over the volume of the Mim. de la Soc. Roy ale de Mid. devo- ted entirely to the consideration of rabies; and, from the investigations of M. Andry, (Rechtrches sur la Rage, 8vo. Paris, 1780,) it appears that January, the coldest month in the year, and August, the hottest, are those which furnish the fewest instances of hydro- phobia. On the contrary, the greatest num- ber of rabid wolves is in March and April; and that of dogs, affected with spontaneous rabies, in May and September. According to Savary, dogs never go mad in the Island of Cyprus, nor in that part of Syria which is near the sea; and Volney assures us that these animals enjoy the same fortunate exemption both in the latter country and in Egypt. (Voyage in Syrie, T. 1.) The traveller Brown also declares, that, in Egypt, they are never, or very rarely, attacked with rabies. " Although (says Baron Larrey) hydro- phobia is more frequent in warm than tem- perate climates, it is not observed in Egypt, and the natives assured us, that they knew of no instance in which this disease had manifested itself, either in man or animals. No doubt this is owing to the species and character of the dogs of this country, and their manner of living. •' It is remarked, that tbe Egyptian dogs are almost continually in a state of inaction; during the day, they lie down in the shade, near vessels full of fresh water prepared by the natives. They only run about in the nighttime ; they evince the signs and effects of their love but once a year, and only for a few instants. They are seldom seen cou- pled. On our arrival, there was a vast num- ber of these animals in Egypt, because they were held, like many others, in great vene- ration, and were never put to death. They do not go into the houses; in the day time they remain at tbe sides ot the streets, and they only wander into the country at night, in orderto find any dead animals which hap- pen to be unburied. Their disposition is meek and peaceable, and they rarely fight with each other. Possibly all these causes may exempt them from rabies." (Larrey in Mim. de Chir. Militaire, T. 2,p. 226.) This observation, about the exemption of the Egyptian dogs from rabies, i-, a very ancient one, having been made by Prosper Alpiuus, (Rer., Egyptiarum, lib. 4, cap. 8.) according to Barrow, the dogs in the vici- nity of the Cape of Good Hope, and in Caf- fraria, very rarely go mad. (Travels into the Interior of Africa.) Several authors assert, that rabies never occurs in South America. (Bibl. Raisonnie, 1750. Van Swieten Com- ment in Aphor. 1129, Portal fyc.) L.Va- lentin declares, that it is exceedingly rare in the warm regions of America, but common in the northern part of that continent. (Journ. Gin. de Mid. T. 20.) Dr. Tbomas, who resided a good while in the West Indies, never saw nor heard of a case of rabies there, (Practice of Physic;) and Dr. B.'Moseley states that the disorder was not known in those islands, down to 1783. On the other hand, the disease sometimes hap- pens in the East Indies, though not with such frequency as at all to justify the doc- trine about heat beim? the cause of its pro- duction. The silence of Hippocrates proves, that in his days hydrophobia must have been very rare in Greece ; and, as the disorder is not mentioned in the Scriptures, an inference may be made, that it could not be so com- mon in the hot tracts of the globe, inhabit- ed by the Hebrews, as in the temperate cli- mates of Europe and America. Neither can the sentiment be received as correct, that rabies is more frequent in the north than in the temperate partsof Europe; for De la Fontaine particularly notices how extremely rare it is in Poland. (Chir. Med. Abhandl. Breslau, 1792.) The disease is reported to be very common in Prussian Lithuania; but mad dogs are seldom ov never heard of at Archangel, Tobolsk, or in the country north of St. Petersburg. In Mr. MeynelPs account, which was communicated to him by a physician, it is asserted, that the complaint never arises from hot weather, nor putrid provisions, nor from any cause except the bite ; for, however doss have been confined, however fed, or whatever may have been the heat of the season, the disorder never commenced, without a. possibility of tracing it to the preeeding cause, nor was it ever introduced into the kennel, except by the bite of a mad dog. (See art Dog, in Rees's Cyclopedia.) Dr. Gillman endeavours to prove, that the disease in dogs is probably excited inde- pendently of particular climates, of putrid aliment, of deficiency of water, of want of perspiration, or, of the worm under the tongue, to which causes it has been at different times ascribed, and he expresses his belief, that it originates somewhat like typhus in the human subject, and is not always produced by inoculation, or by means of a bite. He thinks that it maybe occasionally brought on by tbe confinement of dogs, without exercise, in close and filthy kennels ; and that the success of Mr. Treval- yan, as related by Dr. Bardsley, in clearing his kennel ofthe disease, by changing even the pavement, after other means of purifica- tion bad faded, affords presumptive evidence ii- favour of the opinion; and, consequently, this author t'a ks, that the method of qua- rantine, adopted by Mr. Meynell, and recom- mended by Dr. Bardsley, on the supposition, 86 HYDROPHOBIA that tbe disease originates exclusively from contagion, will not be a sufficient prevvnt- ive alone ; and he infers, from some facts, reported by Mr. Daniel, that the poison sometimes lies dormant in dogs four, five, and six mon'hs ; and, consequently, that the period of two months is not a sufficient quarantine. (See Gillman's Diss, on the Bite of a Rabid Animal.) In opposition, however, to some of the sentiments contained in the foregoing pas- sage, it sh-mld be known, that Dupuytren, Magendie, and Breschet, have purposely kept many dogs for a long time in the* most disgusting state of uncleanliness, let them even die in this condition for want of food and water, or even devour each other, yet without exciting rabies (Did. des Sciences Med. T. 47, p. 53 ) Yet Professor Rossi, of Turin, is said to have produced this, or some similar disease in cats, by keeping them shut up in a room. (Mim. de I'Acad. Imp. de Turin, 1805, d 1808, p. 93, de la Notice des Travaux.) On the whole, I consider it well proved, that neither long thirst, hun- ger, eating putrid flesh, nor filth, will occa- sion the disease in the canine race. At Aleppo, where these animals perish in great numbers from want of food and water, and the heat of the climate, the distemper is said to be unknown. Nor is rabies found to attack dogs and cats, with particular fre- quency during the copulating season, and therefore, the oestrus veneris cannot be ad- mitted to have any share in its production, as some writers have been disposed lo be- lieve. (See Did. des Sciences Mid. T. 47, p. 65.) Although most writers believe in the reali- ty of a poison, or specific infectious princi- ple, in cases of rabies, the fact has been questioned, or absolutely rejected by others. Bosquillon considered the disease always as the effect of fear, or an impression upon the imagination. This view of the matter is far from being new, and has been ably refined by many authors, and especially by M. De sault, of Bordeaux, who remarks, that horses, asses, and mules, quibus non est in- tellects, had died rabid the very year in which he wrote ; and, it is observed by Dr. J. Vaughan, that an infant in the cradle is sometimes attacked, while many timorous children escape. Another notion has partially prevailed, that rabies does not depend upon any virus, but upon the continuance of an irritation in the bitten parts, affecting the whole ner- vous svstem. (Percival; J.Mease; Girard; fyc.) iiut, this doctrine confounds rabies and tetanus together, and can only apply to the symptomatic non-infectious hydro- phobia from an ordinary wound, or lacera- tion. The tacts, in proof ofthe reality of a pe- culiar infectio •= principle in cases of rabies, are too numerous to leave any doubt upon the subject. I'vventy-threeindividuals were bit on.- morning by a female wolf, of whom tt.irtec .i died in the course of a few months, besides several cows, which had been inju- red by the same animal. How could all these unfortunate persons have had simfc. symptoms, and especially a horror of flaJd,, had they not been all under the influen, of some cause, besides the bites ? The p,. tients who died, were bit on the naked skin ; while in the others, who escaped ia. fection, the bites happened through their clothes, which no doubt intercepted the * liva, the vehicle of the virus. In the Kssaj by Le Roux, mention is made of three par. sons, bit by a rabid wolf near Autun, ia July, 1781, and, notwithstanding mercurial frit. tions, they all died of hydrophobia. Of tea other individuals bit by a wolf, nine died rabid. (Rey, Mim. de la Soc. Royale dt Mii p. 147.) Twenty-four persons were injured in the same manner near Rochelle, .and eighteen of them perished. (Andry,'j{t cherches sur la Rage, Ed. 3, p. 196.) QJijflK 27th January, 1780, fifteen individualsitveri bit by a mad dog, and attended at Senas bj the commissioners of the French Royal So ciety of Physic ; ten had received the bitei on the naked flesh, and five through theit clothes. Of the first ten, only five losttheit lives, three of them dying of decided rabiei between the 27th of February, and the 3d of April; and the other two between the 29th of February, and the 18th of March Unless the opinion be adopted, that the dis- ease is caused by an infectious principle,! sort of inoculation, it would be impossible rationally to explain the cause of so raanr deaths from the bites of rabid animals, il the idea, that rabies originates from fear or nervous irritation were true, how could we account for there being such a differ- ence between the usual consequences ol the bite of a healthy dog, and those of tbe bite of one affected with rabies? Healthy dogs are incessantly quarrelling, and bitinj each other in the streets, yet their u-oundi are not followed by rabies ; and as a mo- dern author remarks, if hydrophobia wen referrible to nervous irritation derived from the wounded part, how does it happen, flat among the thousands of wounded after I great battle, hydrophobia is not seen in- stead of tetanus (Diet, des Sciences Med. T. 47, p. 61.) But, if it were yet possible to entertain a doubt of an infectious princi- ple in hydrophobia, this possibility wouldbi removed by the reflection, that the disease may be communicated to healthy animals by inoculating them with the saliva of cer- tain other rabid animals. In fact, as I haw stated, the bites of such animals are in every point of view only an inoculation ; and the same remark may be extended to the nu- merous instances on record, in which tbe disease arose in the human subject, as a consequence of a rabid dog, or cat, (not suspected to be in this state at the time) hi- ving been played with, fondled, or s-.-Tere] to -ck the naked skin, in which there was at fh- moment some slight scratch, entirely overlooked. ^ Many of tbe ancient writers no. only be- jeved in tne hydrophobic virus, or infec- tious principle, but even i„ its diftusion HYDROPHOBIA. 87 through the blood, flesh, and secretions in general ; and this hypothesis was professed by Boerhaave, Van Swieten, Sanvages, F. Hoffman, &,c. but, in proportion as the hu- moral pathology lost ground, the foregoing idea was abandoned, and the opinio; adopt- ed, that the infection is confined to the sa- liva, and wounded part, in which it has been inserted. , The tales of some old authors would lead jOne to think, that hydrophobia may be . communicated by eating the flesh of a rabid animal. (Ferne'lius, De Obs. Rer. Caus. et Morb. Epidem. lib. 2, cap. 14; Schenckius; ", Mangetus, fyc.) But, respecting these ac- counts, it is remarked, that they are not en- titled to much confidence ; for, it is certain, ,that rabies never begins as is stated, with regard to some of the cases in question, a {few hours after the application of its cause, ■ and its early stage is never characterized by any fury, or disposition to bite. And, be- ' sides, how can such relations be reconciled with the practice ofthe ancients, who, ac- cording to Pliny, employed the liver of the mad dog or wolf, as a remedy ? Palraarius also fed his patients for three days with the dried blood of the rabid animal. (Mim. de la Soc.de Mid. p. 136, et le No. 178.) The flesh of a bullock, which had been bit by a mad dog, and afterward died rabid, was sold to the inhabitants of Medola near Man- tua, yet none of them were attacked with ' hydrophobia. (Andry, R6ch:rches sur la ' Rage, fyc. p. 30.) Dr. Lc Camus informed 1 Lorry, that he had eaten the flesh of animals ' which died rabid, but be suffered no incon- venience from the experiment. And, it is stated in the letter of Di. L. Valentin, that the negroes in the United States of Ameri- : ca had no illness from eating the flesh of pigs, which had died of rabies. (Journ Gin. de Mid. T 3, p. 417.) As for the ques- tion, whether the blood is infected ? It is generally considered to be settled in the negative, notwithstanding the account given by Lemery of a dog, which was attacked with rabies, as is said, from lapping the blood of a hydrophobic patient, who had been bled. (Hist, de I'Acad. Royale des Sciences, 1707,/?. 25.) Dupuytren, Brescbet, and Magendie, were never able to commu- nicate rabies by rubbing wounds with blood taken from mad dogs ; and they even seve- ral times injected such blood into the veins of other healthy dogs, yet none of these latter inimals were attacked with rabies, though they were kept for a sufficient length of time to leave no doubt upon the subject. (See Diet, des Sciences Med. T. 47, p. 63.) A point of greater practical interest than the former, is, whether the drinking of the milk of an animal, labouring under rabies, is attended with any risk of communicating the disease ? It is asserted by Timreus, that a peasant, his wife, children, and several other persons, were seized with hydropho- bia, in consequence of drinking the milk of a rabid cow ; and that the husband and el- dest child were saved by medical treat- ment : but, that the wife and four of the children died. It is further stated, that three or four months afterward, the maid and ;> neighbour, who had partaken of the mi'!: ofthe same cow, also died of hy- drophobia. (Cons. 7, Obs. 33.) In opposi- tion to this account, however, several facts, reported by o'btr writers of greater credit, tend to prove, that hydrophobia cannot be communicated by the milk of a rabid ani- mal. (Nova Act a Nat. Cur. Vol 1, Obs. 55 ; Baudot, in Mim. de la Soc. Royale de Mid. an 1782 et 83, T. 2, p. 91.) The cases reported by F. Hoffman and Chabert, with the view of proving the pos- sibility of infection, through the medium of the semen, are of no weight, because, on a critical examination of them, it will be found, that the infection of the women is stated to have taken place very soon after their husbands had been bit, which is quite at variance with the established character of the disease, as it never commences, and of course can not be propagated in any man- ner, soon after tbe receipt of the bite. Be- sides, these histories are refuted by others of greater accuracy. (See Baudot in Mem. de la Soc. Royale de Med. an 1782, fyc, p. 92; Rivallier, Vol. cit. p. 136; p. 211 ; Bouleille, p. 237 ; Boissiire, in Journ. Gin. de Mid. T. 17, p. 296.) Neither can hydrophobia be imparted by the breath, notwithstanding the statements of Caelius, Auroiianus, and some other old writers. A nurse, mentioned by Dr. J. Vaughan, repeatedly kissed a hydrophobic infant, which she had suckled, and exposed herself incessantly to ifs breath, but with- out the least ill effects. The fear which has also been entertained of tbe disorder being receivable from the application of the pa- tient's perspiration to the skin, is not found- ed upon any authentic facts. Does the infectious principle of rabies re- side in the salivary secretion, or in the mu- cus of the trachea and brorchiae ? The common belief is, that in hydrophobia, the salivary glands are considerably affected. But, it has been remarked by a modern wri- ter, that if these glands exhibit no morbid alteration during the whole course of the disorder; if they are found healthy after death ; if th" air-passages are the seat of inflammation ; if the saliva does not con- stitute the frothy slaver about the lips; and if such slaver, wherewith the disease may be communicated by inoculation, is derived from the inflamed windpipe and bronchia?, and consists of mucus converted into a kind of foam by the convulsive manner in which the patient breathes, there is some reason for questioning, whether the saliva, strictly so called, undergoes the alteration generally supposed ? (See Did. des Sciences Mid T. 47, p. 66.) However, this writer is not exactly correct, when he describes the frothy secretion about the mouth, as be- ing altogether composed of mucus from the trachea, since a great part of it is unques- tionably true saliva and mucus secreted in the fauces and mouth. In the stomachs of dogs, which died rabid. Dr. Gillman con 8s stantly observed traces of inflammation, and he once tried to communicate the disease to two rabbits, by inoculating them wilh matter taken from pustule*, found in the siomae.h of a rabid dos:; but no infection took place. (On the Bite of a Rabid Animal, p. 32.) According to Profe*ssor Rossi, of Turin, the nerves, " before they grew cold, participated with the saliva i.< (he property of communi- cating rabies." He asserts, that he once im- parted the disease by inserting in a wound a bit of the sciatic nerve, immediately after it had been taken from a living rabid cat. (See Mim. de I'Acad. Imp. de Turin, Sciences, Phys. et Mathtm. de 1805 a 1808, part. 93. de la Notice des Travaux.) After all which has been stated, concerning HYDROPHOBIA. For the hydrophobic virus to take effect, therefore it is generally, if not always ■*. cessay t'hat thf infectious saliva be eithe, applied loan abraded- wounded, or ulcer* led surface. In the case of a bite, -he teeth are (he envenomed weapons, which at once cause the solution of continuity, and deposit the infection in the part. Bui the mere abra. sion of the cuticle, and the application of (J., infectious saliva to (be denuded cutis, will-tf. ten suffice for the future production ofthe disease. As the mode of communication, therefore, is a true inoculation, it follows, that the danger must depend very much upon the quantity of infectious matter con- veyed into, or applied to the part, theeffet- tunl mannpr, in which the saliva is lodged in the hypothesis of the infectious principle of the flesh, tbe extent and number of Um hydrophobia being more or less diffused through tbe solids and fluids of a rabid ani- mal, und not being restricted to the saliva, perhaps, the safest conclusion to he made is, not to reject the opinion altogether, but to consider it as at present requiring further proof. And from observations of what hap- pens in the human subject, the same infer- ences should not always be drawn, as from experiments on animals, which are liable to be attacked with spontaneous rabies of a de- cidedly infectious character. (See Did. des Sciences Mid. T. 47, p. 67.) Although many cases arc to be met with in the records of medicine and surgery, tending to convey an idea, that the mere ap- plication of the saliva of a rabid animal to the sound entire skin of tbe human subject, may give rise to bydrophobia, (he assertion is contrary to general experience, and liable to n reflection which roust overturn (he hypo- thesis ; viz. the slightest prick, scratch, abra- sion, or broken pimple on Ihe surface of the body, such as would not be likely iu many instances to excite notice, may render (he application of the saliva to the part a posi- tive inoculation. wounds, and particularly the circumstance of the teeth of tbe rabid animal having passed through no clothes, by which the saliva might possibly be effectually prevented from entering the wound at all. Hence, bites on tbe hands and face are well known to be of the most dangerous description, especially those on the face, the hands being sometimes protected with gloves. From what has been observed, howewr, it is not to be concluded, that the disease al- ways follows, even when the animal, which inflicts the bite, is decidedly rabid, and somi of its saliva is actually applied to the wound- ed or abraded parts. On the contrary, ex- perience fully proves, that out of the great number of ind.viduals often bit by the same mad dog, and to whom no effectual proptsy- la :tic measure is extended, only a greater*! lesser number are afterward attacked with hydrophobia. When this difference in the fate of the individuals cannot be explained by the intervention of their clothes, Ibe thick- ness of 1he cuticle at the injured part, the small size and superficial nature of the bite, the ablution of the part, or some other mode in which any actual inoculation , , . ........-•- -■-/ ......... .iiui.inauuii may nave Instances are also reported, the tenor of been rende.ed ineffectual, it can only be ft Which is to prove, that the hydrophobic virus ferred to some unknown peculiarities, ordil may take eflect through a sound mucous ferences iu the constitutions of the several pLw'X if/^"^*^6"00".^-'" indivi<*«a|s- The lat.er conjecture set* 5*d I "W p ?T'f\}*} ' **/''"««» "ore probable, when (he fact is recollected, Shft.hisclo^To'h P:u10J **•> ,hat some ani,nals are mor* susceptible of B,:t,thft..lhlS.doe.s. not ^PPen '".the human rabies than others, and some appear to resist the infection altogether. Dogs are more susceptible of the infection than the human species. Four men and twelve dogs were bit by the same mad dog, and every one of (he dogs died of the dis- ease, while all the four men escaped, though they used no other means of prevention but such as we see every day fail. There is also an instance of twenty persons being bit by the same mad dog, of whom only one had the disease. subject is tolerably well proved by the con- sideration, that formerly a class of men made it their business to suck the wounds, caused by the bites of rabid animals; yet none of them contracted hydrophobia from this bold employment. (Bosquillon, Mim. di la Soc d'Emulation, T. b,p. 1.) The example of the nurse, who repeatedly kissed a child without the least ill effect, while il was dying of ra- bies, as recorded by Dr. J. Vaughan, has been already noticed. However," if bydro- phobia were apparently to arise in any rare instance from the application of the slaver of a rabid animal to the inside of the lips, no positive inference could be drawn from the fact, unless the means were also possessed of ascertaining, that there were no slight abra- r-ion about the gums, or within-the niomu, previously to stichapnlication. Dr. Heysham has defined hydrophobia to be an aversion and horror at liquids, exciting a painful convulsion of the pharynx, and oc- curring at an indeterminate period after the canine virus has been received into the .. affection of the axillary glands ; and in ano- ther case, (See Medical Communications, Vol. 2,) the pain, occasioned by a bile in the le<*-, was referred to Ihe hip and loins, without any affection of the ing-iiu; their influ- ence became more general, ut this period (he effect was rather proportionate to the ideas thev excited in her mind, than to their vio- lence. Bells, and other strong noises, did not agitate her, but (he clatter of earthen- ware, (he noise of a distant pump, or any thing connected with liquids, produced the paroxysms in all their violence." She could swallow fresh currants with less resistance than any thing else, taking care that they were perfectly dry Her mind had, tiy now, been quite calm and composed, and her con- versation and behaviour pro|ier, during the intervals of the convulsive attacks. But Dr. Powell was obliged to discontinue the pills of argentuin 'uitratutn, iu consequence of (he sufferings which the attempt >o swallow them regularly brought on. Fifteen grains of this siihsiauce had been given without any sensible eff.-ct. The fits, and the irritability to external objects, increased. The pain shot from the back of tlie neck, round tlie angles of the jaws, the chin, and throat. At length the |m'oxys:ns became more frequent, and, indeed, might be said to come on spontane- ously : seven occurred in one hour. She looked pale and exhausted, and a tremor and blueness of her lips and fingers were obser- vable ; her pulse became weaker and more rapid, and her scalp so tender, that touching it brought on convulsions. She had, latterly, eructations of wind, and spit up some (hick viscid saliva. Her urine now came away in- voluntarily, and she was more and more irri- table and uncontrollable. Indeed,she passed iwo hours in almost constant convulsions ; became e&tremi.'ly irritable and impatient of every thing about her, complained of failure of her sight; wished to be bled to death ; her words were fewer and interrupted; she struck, and threatened to bite, her attend- ants ; had copious eructations of air ; dis- charged an increased quantity of viscid saliva with much convulsive effort ; said (he affec- tion of her throat and stomach had quite left her; and continued in a genera! pcrr-piration, with a weak pulse from 140 to 150. She af- terward bit so nit; of the attendants, and was therefore confined with a waistcoat. From this period, she had lost all control over her mind, and continued for almost four hours in a paroxy-m of furious insanity. She now swallowed, with an effort, near half a pint of water: but (his was, iu a fevv seconds, vomit- ed up with some mucus, and a greenish fluid. In this violent laving stale, she continued till within (wo hours of her death, which took place forty-seven hours after the first marked occurrence of hydrophobia. In the course of the case'she swallowed, once or twice, a little porter ; and also some cinnamon-water, with tinct. opii ; but they were always vomit- ed up. (Dr. Powell's Case of Hydrophobia.) It is by no means uncommon lor a period (o occur, when ihe horror of liquids undergoes a considerable diminution, or even entirely ceases; the patient quenching his thirst, and this sometimes as well as if he were in perfect health, and so as to raise doubts of the exist- ence of rabies. But after a few hours, the dread of fluids comes on again, and with it (he convulsive paroxysm*,which now become ge- neral, violent, and incessant. Dr. Cayol at- tended a girl, labouring under rabies, who HYDROPHOBIA. and often expre-ive o sentiments. iW'V- du Sciences P was never affecled witli any very great dread of liquids, nor an ab-olule inability to swal- low them, though she certainly di.slikc-d (hem, and swallowed d. Chir. e «vent is said ,o be directly caused by asphyxia; or e cessation of respiration. Of ten per£„5, who were bitten by the same animal, nin WrS'rtoPllOBlA. & 'jiied on the second and third day, from the •ommenrement of the horror of fluids, and ■-mlyoneonthe fifth day. There is an account 1(if a child at Senlis, who lived nine days, ,,'iut the description ofthe case, and the cir- cumstance of fourteen worms being found ,'ri the intestines, may raise doubts about the mture of the disease. (See Hist, de la Soc. fay. de Med. p- -1W, 15 ».) , Whatever may be the resemblance found 'between rabies and hydrophobia, with re mrd to the rabidity of their course tneir •auses, and s;ime of their symptoms, (he '"ollowing considerations as a modern wri- er observes, will always serve for tne dis- crimination of one disorder from the other: ^.etanus attacks the muscles of the jaw, which "emains motionless, while iu rabies, the jaw is not only moveable, but incessantly mo- ving, in consequence ofthe efforts unremit- tingly made by the patient to free his mouth from the thick saliva with which it is ob- structed. In this last disorder, the muscles are alternately contracted and relaxed ; but in tetanus, they always continue rigid. Te- tanus is rarely attended with any aversion to liquids, and the patient may be kept for a long time in a bath without inconvenience ; and the paroxysms are neither excited, nor increased by a vivid light, a noise, the pa- 'tient's being touched, or the sight of water, or shining surfaces. In addition to these differenc-s. It is to be rcni'-mhered, that tetanus is most frequent in warm climates, and that it mostly comes on a few days after •(the receipt of a local injury, and may occur as a complication of any kind of wound, even that which is made in a surgical o^e- t ration. (See Din. des Sciences Med. T. 47, p. 8(5.) On the subject of prognosis, with respect to the bite inflicted by a rabid animal, and its effects, as evinced iu the decided form , of rabies, there are several things worthy of attention. According to-o;ne writers, small wounds are not less dangerous than others, and an attempt rs made to account for the . fact, by the more copious hemorrhage from larger wounds, and the frequent neglect of lesser injuries. Perhaps another reason is, , that the virus is more likely to be confined in a wound with a small orifice, than in one I which is ample, and admits of being more effectually washed. The more numerous the wounds are, the greater is the risk. If it be inquired, what is the average number of persons attacked wilh rabies out of a given number who have received bites? The question can only be answered by re- ferring to the extremes. Thus, Dr. J. Vaugh- an speaks of between twenty and thirty individuals, bit by a mad dog, of whom only one was afterward attacked with rabies; and Dr. J. Hunter tells us of an instance, in which out of twenty-one persons bit, only one became affected. (See also Fothergill in Med. Obs. and Inq. Vol. b, p. 195.) On the other hand, out of fifteen persons bit by a mad dog and taken care of at Senlis, three at least were seized with the disorder, (Hist. dc la Soc. Roy. dc Mid.p. 130 :) of seventeen others bit by a wolf, ten were allocked; (ib. p. 130;) and of twenty-three, bit by a she-wolf, thirteen died of rabies. (L. F. Trolliet, Nouveau Traiti de la Rage, §-c. Obs. Chirurgique, fyc. No. 25.) iwo important facts should always be recollected; viz. the disease may often be prevented ; it can hardly ever be cured. Experience In s fully proved that when hy- drophobia once begins, i; generally pursues its dreadful course to a fatal termination, the records of medicine furaishing very few unequivocal and well-authenticated cases to ihe contrary. Hence, the imperious ne- cessity of using every possible means for the prevention of the disorder. Probably, however, many things which possess the character of being preventive ot bydrophobia, have no real claim to such reputation. I would extend this observation lo all internal medicines, m.-rcurial fric- tions, and piungiug the patient for a consi derable time under water. Tne instances, in which a prevention i; inferred to have taken place by differeu writers, in consequence of such means, ma*j all be very rationally ascribed to-other cir cumstances. Facts already cited suliicieutlj prove, that out of the great number of per sons frequently bitten by the same dog, onl; a limited proportion is commonly affected The hydropbob-c poison is known to residi in the saliva of the animal ; consequently the chance of being effected must great! depend upon the quantity of this fluid w hie, is insinuated into tbe wound ; and if tii teeth of the animal mould have previous! pierced a thick boot, or other clothing, bl fore entering the skin, the danger must I: obviously much diminished. Many patietf wash and suck the wound, immediately afr- its occurrence, and thus, no doubt, very oftil get rid ofthe poison. Even when it is lotj- ed in the wound, it may not be directly i- sorbed, but be thrown off with the discl>ai". \\\ pru lent patients submit to excisioiol the bitten part. Mow under each of e above circumstances, escapes have frequct- ly occurred, while internal medicines, l!f drowning or salivating the patients, had go not been neglected, so that all the efficacof preventives has too often been most unjujy ascribed to means, which probably neur yet had, and never will have, any benetilal effect whatever. What confirms thelrutjof Ihe preceding statement is these facts -. |at persons bitten by the same animal lye sometimes been treated exactly on the sme plan ; some of them escaped the dUde ; others had it, and of course perished on other occasions, some of the patients,>it- tenJby the same animal, have been tried in a particular way, and have escapejiy- drophobia; while others bitten at the hue time by the animal, also never had anyton- - stitutioual effects, although they toq no medicines, nor followed any other pajcu- lar plan. If to these reflections be acleled theon- sideration, that it is frequently dot|f:il whether the bite has actually been inftted 94 HYDROPHOBIA. bv a truly rabid animal, and that the men- tal alarm will sometimes bring on a symp- tomatic hydrophobia, it is easily conceiva- ble, how mistaken a person may be, who believes that he has prevented the disorder, this secretion, and not the real saliva, which co tains the hydrophobic poison: (-\aor-, Traiti de la Rait, «V<\) '" 8"" §,d" ■* count of a dissection, laure also long «p re, arked, that the frothy «»««« wju onh and how unmerited is the reputation of the met will, in the air-passages, that the sal and how unmeruea is me reputation oi nie met wnu m "<■- ■•■• r -■ , , ., means, which he has employed for the pur- vary organs were unaU tea, anama pose saliva itself did not contribute to the form. Ihe bite of a naturally ferocious beast ation of the thick slaver, \yAm 11 appeal has often been thought to be attended with to have issued from tne^hesi. <"«*-« h appeared more risk than that of an animal naturally Soc. Roy. de Med ann. 1/bcJ, p. *J.) t-roa tame; and hence the bite of a wolf is said fhe preceding observations, mid those rf lo be more frequently follow ed by rabies, Mignot de Genetv (l,d. cit.p. 54,) Morgiiii than that of a dog. this proposition is ad- (De Sedib et Cans. Morb Epist 8 art.\ milted to be true ; but the explanation is *>. 30,) Darlue {Journ. dt Med. de Under- erroneous. The true reason of the differ- mondt T 4 p. 270 :) B. Rush ; and Dupsej ence is, (hat a wolf usually seizes the face, (Obs. !mdiles,No. 138) it would appear: and inflicts a deeper bite; while a dog only miaps as he runs along, and mostly bites through the clothes. (See Dirt, des Sciences, Med. T. 47, p. 88.) The bite of a rabid ani- mal may be. rendered much more d ngerous by being situated near a part, or an organ, vhich increases the difficulty, or risk, of I. That the mouth, strictly so called, and the salivary glands, are without any al- teration. 2. The mucous membrane of the air -pas- sages is affected with inflammation, which in its liighe-t degree extends from the divi- sion of the bronchia* to the pharynx. Whei idopting an effectual mode' of removing the inflammation is of less extent, the pha he whole of the flesh, in which tht* virus rynx appears sound ; and when yet more nay be lodged. Thus, bites near the large irterie s, (he eyes, the joints, ice. are of a riore serious description than others. Dr. Hunter rated the hazard in some degree y (he vascularity ofthe biden parls. The limited, it is usually not to be traced in the larynx. The point where it seems to coro menceand is most strongly marked, is at the lower part of the trachea, or in the bran- chiae. Lastly, when none of these partsare rognosis will always be more unfavourable, found inflamed, the lungs themselves present, 'hen no proper nK-a-'ires have been applied vestiges of inflammation. ) Ihe bite soon after its infliction, nnd per aps the risk may be increased by certain mses not having been duly avoided, which, ; already stated, are though I to have a ten- ancy lo accelerate the attack of rabies. The tact lime after a bile, when (he prevention « rabies is no long' r practicable, is quite an With respect to the theory of Trolliet, wherein the hydrophobic poison is said to be contained in the mucous secretion void- ed from the- lungs, and to be the product el inflammation of the membrane of tbe bronchia;, and not derived from the sali- vary glands; the question requires the idetermined point ; but even fact known confirmation of experiment; for, though uon (he subject, evinces in an urgent man- the salivary glands are not the seat of pain, ir (he necessity of adopting preservative swelling, ivc. it by no means follows, that nasures without the least delay. their secreting process may not have been n almost all the dissections of patienls, subject to some peculiar modification, on wo have died of rabies, eerlain indications which the production of the hydrophobic ol inflammation have been perceptible; virus depended. Thus, severe and obstinate me frequently, in some part of the space ptyalism< often occur, and yet there is do bevvee.i the pharynx and the cardiac orifice manifest change in the state of the salivarv olhe stomach, in the stomach itself, in the glands. According to Van Swieten and i'?' !Ue ?',oro'd Plf:x,JS ?nd membrane-, of Mead, there are also sometimes no morbid n£m,r ( f Rtl'onlory VoL 3- P- 51 •) appearances either in the head, fauces, chest, Mrrolhet opened with the greatest care six or stomach. (Comment, in Boerh. T. 3,f baes of persons destroyed by thi- disease. 502) Tl mouth and fauces in each subject were h, three cases, out of six, the lungs were Unexamined, and found of a pale grayish found emphysematous, that is to say, their cour scaively |U ,r,,at.-d with mucus, and interlobular'substance was distended with qui free from all frothy matter. All ,be air, and the pleura pulmonis raised into*. Vv £ the ."a SvnrTreehPCffeC,Hy , ^^ ^f namh*r °f ^sparent vesicles on the U In the larynx, trachea, and bronchia; surface of the lungs. In a fourth instance, we opened, they appeared to havebeen.be the emphysema was not observed in the sea,f.nflammat.on the (races of which lu,,g.theV.elves,bu^ weithe mosl marked low down, where the between thP iut« in,,„ l,'eceuuiar suosidiu- mums membrane was of the colour of and undcMl mS " / .e med'?st,n.a.mr' winlees. In four of the todies, frothy „,„- Sni a,so noticS ti ,°f ^ -"^'.i M° ' cus.sp.rceived^in.hebronchi^^ynx, fTof^^ T^^\Zt^ .YDR0PH0B1A 95 ,!i foreign body is lodged iu the larynx. (See " Cases by Louis and Lcscure in Mim, de I'Acad. Me Chir. T. 4,p. 538 ; T 5, p. 527 ) J; The lungs were of a deep-red colour in .ill the six subjects dissected by Trolliet, and they were observed to be gorged with blood in cases reported bv numerous writers : as Bonet (See Van Swieten, T 3, § lHo ;) Bo- u'erhaave (Op. Omn. p. 215 ;) Morgagni (Dc ^Sedibus et Caus. Morb. Ep. 8, art. 23, g, and bad hydrophobia prove useful in the present disorder. (See in a mild form, from which he recovered Did. des Sciences Mid. T. 47. p. 132.) By under the use of mercury, blisters to the Dr. Rossi, of Turin, the trial of galvanism head, and cathartic injections, without any was suggested. (Aliberl, Nouveaux Elemens recourse to bleeding ut all. This lust case is dc Thirapeutique, T. 2, p. 436, Ed. 4 ;) yet, even more contrary than thf former, to what the only fact brought forward, as an en- general experience teaches; because mer- couragement to persevere with the last cury, blisters, and injections, have been tried means, appears lo a modern author, from its a thousand times unavailingly ; while, per- symptoms and progress, not to have been a haps, blood-letting, iu the manner practised case of rabies. (Diet. cit. T.47,p. 126.) Tiie by Mr. Tymon, is a new treatment. Dr. vapid'and powerful effects of the bite of a Schoolbrcd, of Calcutta, published! a second viper on tbe whole system, and perhaps the case of hydrophobia cured by bleeding ad idea, that the operation of this animals deliquium animi. and afterward exhibiting venom might counteract that of the hydro calomel and opium. The patient, being phobic virus, led some experimenters to try threatened with a relapse, was largely bled what would be the result of subjecting pa- again. The whole of the success is imputed tients, affected with rabies, to tbe bite of that by Dr. Schoolbred to the venesection. But "kind of snake. The project, however^ was this gentleman is not jo sanguine as to b,-- attended with no success. Three cases of lieve, thai bleeding w'.il cure every case of this description were communicated to the hydrophobia. Il is probable, that there: is a Royal Society of Medicine, (lliz-l. p. 201 ;) period, beyond which its curative effect two additional ones were recorded by Dr. cannot extend, and, therefore, il is upon lb« Gilibert,pliysicinntothe Hotel-Dieu at Lyon**, ii reappearance of unequivocal symptoms of (Advers. Mid. Prad. p. 257;) and Viricel, the disease, that he thinks copious bleeding surgeon of the same hospital, repeated the afford;; a prospect of success, while fhe experiment on a child, which yet fell a vie- delay of only a few hours may prove fatal. ti.n to hydrophobia. Oilier (rials are also He observes, that the: medical profession, said to have been made in France and tier- (aught by numerous disappointments, admit Vor. II. 13 9$ HYDROPHOBIA. very cautiously the claims of any new prac- tice to general adoption. If several patients in hydrophobia, therefore, should happen to be bled in an advanced -tage of the disease, and die, (as they inevitably would do, v> he- ther they had been bled or not,) such cases would be quoted against he new practice, as failures But Dr. Schoolbred rightly con- tends, that numerous failures in an advanced sta:e of the disease can form no just ground for the rejection of a remedy, which has in- conte*tably effected a cure in an earlier stage of the disorder. He insists upon the necessity of making a large -orifice in the vein, so as to evac iate the blood quickly, which must be allowed to How, Without re- gard to q.iautity, ad dehquann niiimi. Dr. Sc hoolbred was well aware,that bleed- ing in eases of hydrop ni'iia had often been tried. Bnt, says he, owin ; probably to the evacuation not having been pushed far enough, when used in the early stage of the disease ; or to the period for its beneficial employment having elapsed ; the cases, in wbicb it was tried, afforded little or no en- couragement to the continuance of the prac- tice. Since the preceding cases, the effect of bleeding has had the fairt >t trials made of it, and some of (he reports are in favour of its occasional uti'ily ;>ee Particulars of the successful Treatment of a ease of Hydropho- bia, by R. Wynne, bvo. Shrewsbury, 1813; Also Edmonstone in Lond. Med. Repository, Vol. 3, p. y3.) In almost every instance, however, it fdls in hindering the usual melancholy event. (See Kirrison's Case and Obs. in Med. R-posilory, Vol. 2, p. 197.) This unpleasant truth, I think receives confirma- tion from tbe fact, that the practice is far from being new. Dr. Mead, who was very confident that he ba;1 found an infallible preventive of the dis- ease in a Utile liverwort and olack pepper, aided by bleeding and cold bathing before the commencement of the course of medi- cine, says, 'as to all other ways of curing the hydrophobia, I own I have not been so happy as to find any success from the many I have tried. Bathing at this lime is ineffec tual. / have taken many large quantities of blood; have given opiates, volatile salts, (Me. All has been in vain, because too late." Not- withstanding his disappointment, he con- cludes, " if any relief could be expected iu this desperate state, I think it would he from btee ling, even ad animi deliquium," &,-c. The doctrines of B ierha ive also led him and his pupils to recommend and practis. bleeding in hydrophobia. " The distemper (says he) ;s tobe treatedasone highly inflam- matory, upon the first appearance of the signs which denote its invasion, by blood- letting from a large orifice, continued till the patient faints away; and soon after by enemata of warm water and vinegar, be. and he adds. " that this practice is supported by some small number of trials." But the particulars of this successful practice, are not given. Dr. Schoolbred finds, that a trial of it was made at Edinburgh, more than sixty yeaB a<-o, by Dr. Kutlierlord who took away criduaHv sixty ounces of blood from a pt. S,t wL S already been bled the same morning. As the patient lived forty-el* Sours after the large bleeding, the method ...... .,mt.nhlv tried somewhat early in the practice. The trials, which »«'"y=™ »«'ors<> del Cane Rabbioso, 8vo. Bolog- na, 1806 Dr. Berry's Obs. and Mr. Tymon's Case cured, by large blood-letting, as detailed in the Madras Gazette of November 23, 1818 ; and Dr. Schoolbred's Case suces.sfully treated by copious bleeding, as related in one of the Asiatic Mirrors fur May, 1812. O'Donnel's Cases of Hydrophobia, 1813. T.Arnold, Case of Hydrophobia succtssfully treated, 8io. Lend. 1793. R. Wynne, Particulars of the success ful Treatment of a Case of Hydrophobia, 8vu. Shrews, 1803 B"i/er, Traiti des Mai Chir. T 1, p. 435, fyc. Paris, 1814 C. II. Parry, Cases of Tetanus and Rabies Contagiosa, or Canine Hydrophobia, bvo. Lond, 1814 A Marshall, The Morbid Anatomy of the Brain in Mania and Hydrophobia, with the Pathology >if these two Diseases, e'w. Sro. Lond. 1515. R. chid on the Nature and Treatment of Te- tanus and Hydrophobia. 8ro. Dublin, 1817. Autenrieth, Diss, de h iclenus pre'er visa nervo- rum ludralione in sectionibus hydrophobornm, 4/o. Tub. 18t»2 Gottfr. Zinke.NeueAusichten der llunsdwut'i 8ro. Jena, 1804. Did. des Sciences Mid. T. 11. art. Hydrophobic, et T. 47, art. Rage. G. Lip-combe Cautions and Refltxions on Cani e Madness, 8ro. Lond. 1807. ('. Gnber. Pracl Abhandl. neber die I'orbeugung, §r der tlundswulh, 8co Win. 181S ; This author has co fid nice in the pow- der of meloe mainlis. C. F. Har'es, neber die Behandlung der Hundsiculh, 4to. Frankf. 18<>9 Stramonium recommended. HYDROPH IHALMIA. (from ifa>g, water, and oqbtK/uoc, the eye.) Dropsy of the Eye. tlydrophthalmiis ; Hydrophlhalmos. Aba Bupfhalnins, or 0\-eye. As in other organs, dropsy of the eye arises from a dispropor- tion taking place between the action of the secerning arteries, by which the flu'd is de- posited in the part, and the action of the absorbent vessels, by which it is taken up and returned to the circulation ; and, ac- cording to this principle, the disease may be supposed to depend, either upon secre- tion being made too rapidly, or absorption being slower than is proportionate lo the natural activity of the vessels by which the secretion of the humours of the eye is effected. According to Beer, dropsy of the eye is seldom entirely a local disease, but at least is generally combined with an unhealthy constitution, or is a mere symptomatic ' effect of some other dropsical affection, anasarca, hydrocephalus, be Sometimes it appears as a symptom of chlorosis. Beer add-, that the disease may originate either from a preternatural accumulation of ;he aqueous humour; from (hat of the vitreous humour ; or from an immoderate accumula- tion of both these humours together. (Lchre von den Augi-nkr. B. 2 p. 616, Wlen. 1 17.) When the vitreous humour collects in this manner, it usually loses its natural consist- ence, and becomes thinner and more wa- tery. (Richlcr Anfungsgr. B. 3, p. 392.) * Professor Beer states, that in the case proceeding from a morbid quantity of the aqueous humour, the first indication of the disease is an increase in the dimensions of the cornea, attended w ith a manifest enlarge- ment of the anterior chamber. The cornea may become in this manner two, three, or even four times wider than natural, without bursting or losing its transparency; for, though a turbi 1 appearance is discernible, (his depends rather upon the state >>f tne aqueous humour itself. The iris, which, in the very commencement of the disease, begins to lose its mobility, soon becomes completely motionless, and acquires a duller colour; the pupil always remaining in the mid-state between contraction and dilata- tion. In the eyeball, an annoying sense of pressure, tension, and heaviness is felt, rather than actual pain. In the beginning of the disease, there is a considerable degree of farsightedness, or praesbyopia, which ito UYDROPI.TFIALMIA. ■soon changes inlo a tree amaurotic weak- ness of sight, but never te-ruiiii-u*..'- i., perfect amaurosis. The free motions of the eyeball are more and more interrupted, i,i propor- tion as the organ grows larger, and it has iuvarii'.bly a nurd feel, while (he sclerotica, to the distance of two lines f-e.ni the mar- gin of the* cornea, is as bluish as it is in the newborn infant. Respecting the precise cause of tiie rccu- mulation of the aqueous humour, beer offers no observation worthv of repetition, excepting perhaps that in which be re-: linds us, that a similar collection happens appa- rently as an effect of the conical star 1> lo- in a of ihe whole cornea. (Sec also h'a--- drop's l.ssn.n on the Morbid Anatomy of the Eye, Vol. 2. p. 19.) Indeed, as far as our knowledge yet vtends, it is impossible to say whether the changes of ihe cornea are, in the present disease, to be regarded us the cause or the effect ofthe increa-^d quantity of the aqueous humour, or whether, as seems to me met probable, both phenomena are only effects of one and the same cause. The examples, somewhat repugnant to this idea, are th -i rel -red lo l.y Beer, tis symp- tomatic of other dropsical affections. On the other hand. Mr. Wurdrop has nev*r seen a preternatural collection of the aqueous ho.nn'i , without its being accompanied with disease ofthe co-its ofthe eve. (Vol. cit. p. 30.) In hydropbthalmia, the prognosis is gene rally unfavourable, and, when the sight is nea -ly or quite lost, scarcely any hope can be entertained, either of restoring vision or preserving the shape of the eye- Yet, ac- cording to Bee;, things are not always quite so unpromising in the preceding form ofthe disease, especially when the surgeon is con- sulted in tim- . and the patient's constitution is not exceed.ugly impaired. The same experienced auhor has never seen ar.v in- stance in which the eye spontaneously burst; on the contrary, when the habit was deci- dedly bad, and the treatment ineffectual, the disease became gradually co-jjined with the second species of dropsy of the eye, and terminated in a frightful disfigure- ment of the whole organ, and death On direction, the innermost textures of the part were found spoiled and disorganized, and sometime^ even the orbit itself carious! (Vol. cit. p. 619.) With respect to the treat- ment, Beer thinks, that this mus! depend very much upon the nature of tin primary disease, to which tbe dropsical affection is ascribable as an effect. He has known great benefit sometimes produced by the submuriate of mercury, combined with di- gitalis, and a drink containing supertirtrate of potassa, and borax. When the disease has been preceded by the sudden cure of any cutaneous disease, he has faith in the method of attempting to restore the affection ofthe skin by inoculation, or, if that be im- practicable, by stimulating its surface with antimonial ointment, or making an issue. This plan is to be aided with internal altera- tive medicines, such as camphor, the sul- phur auratum antimonii, and flowers of suf. phur. The local applications, which he prefers in the eaily stage, are warn. dr, Iipos filled with aromatic herbs, and rubbag the parts about the eyebrow, sonetones with me rciirial ointm-nt. sometimes with a inn- ture of Rther and liquor ammonia*. But, when the disease has made considerable pro revs, and vision is either w eak or nearly lost, while the sclerotica, near the corneaii not inudi discoloured, and there are no appearances of a vi./icose affection of the bloo'l-vr.-sc-ls ofthe organ, Bn-i lccommendi making a juncture with a sin; II lancet in Ihe lowest part o< the cornea, half a line from the sclerotica, so as to discharge the aqueous humour. The anterior c,amber ii then to be kept emply tor several days or weeks, if possible, by reopening the small wound every da_, wiii, the point cf the lan- cet. (See also Richter's Anj'angsgr. B. 3,jt. 4(>3.) After ;he operation, tne eye is lo be dressed in tbe same way as after the extrac- tion of a cataract. (See Cataract.) Previ- ously to (he paracertesis, Beer has often seen every general and iocal means perfectly useless, but highly beneficial, as soon as that operation had been practised. Even when the paracentesis fails in bringing about a peri-'inncnt cure, it may siill be resorted to as a palliative with great advantage, and be often beneficially repeated, if care be taken not to make the puncture too large. How- ever, when t!.c blood-vessels are generally varicose, and the constitution very bad, suca operation is apt to excite violent inflamma- tion, suppuration, and even sloughing of the organ, attended with imminent danger to the patient's life. (Beer, vol. cit. p. 620, 622.) With regard to the second species of hy- dropbthalmia. or that depending upon afpre- ternaturoj accumulation ofthe vitreous hu- u,e,;ir, Beer states, that, iu this case, it h chiefly the posterior part ofthe eyeball which is enlarged, so that the whole organ ac- quires a conical shape, in which the cornea very much participates. The latter mem- brane remains unaltered in regard to its diameter ; but it is more convex than natu- ral, and its transparency is perfect. It is observed by Mr. Wardrop, (on Morbid An* tomyof the Eye, Vol. 2. p. 126,) that an in- crease in the quantity of the vitreous hu- mour happens not unfrequently in staphy- loma, iu which disease, he says, the enlarge- ment of the eyeball will generally be found to arise rn re from an increase in the quan- tity of the .itreous than of the aqueous hu- mour, and he then expresses his belief, that the case, adduced by Scarpa to illustrate the pathology of hydropbthalmia, and cited in the ensuing part of this article, was an example of staphyloma. Be this as it may, one character constant in staphyloma, is often absent in hydrophihalmia; I mean opacity of the cornea. In the case, whieh consists in an immoderate collection of the aqueous humour, the anterior chamber is always enlarged: on the contrary, in the present form of the disea^, thatTarily h HTUROPHTHALMU. 191 ■manifestly lessened, for the motionless iris ■ is gradually forced so much towards the cornea, that at length the chamber in ques- . tion almost completely disappears. Howe- ver, the colour of the iris undergoes no change, and the pupal is always rather dimi- nutive. Around the cornea, the sclerotica is rendered bluish by distention, with a somewhat smutty tinge. In the early stage, the patient is affected with shortsightedness, myopia; but his power of vision is always seriously dimitished, and, at last, is so totally destroyed, that ,tot a ray of light can be per- ceived. The motions of the globe of the eye and eyelids are lessened or impeded at r a still earlier period than in the first species of hydrophthdmia, and to the touch the ' organ seems like an egg-shaped stone. Tbe very commencement of the disease is attend- ed with pain, which daily becomes more 1 and more severe, and, at length, is not con- fined to the eye ana its vicinity, but affects all the side of the head, the teeth, and neck, being sometimes so violent as alm-'st to bereave the patient of his senses .vho urgently begs tbe surgeon to puncture the eye, or even is driven by desperation to do it himself,as Beer once knew happen. Even while the pain is less afflicting, the patient is deprived of his sleep and appetite. (Beer, vol. cit.'p. 623.^ Though an increase in the quantity of the vitreous or aqueous humour has generally been treated of as a distinct disease, and denominated hydropbthalmia, Mr. Wardrop has never seen a dropsy of ' the eye without an accompanying disease of the sclerotic coat, or cornea. (On the Mor- bid Anatomy of the Eye, Vol. 2, p. 126.) Beer offers no valuable remark on the causes ofthe precedinglform of hydropbthalmia, his account of the connexion with scrofula and syphilis being mere conjecture, though deli- vered as a positive matter of fact Howe- ver, another position offered in the para- graph, concerning the prognosis, seems more correct: viz. that as the disease is almost always conjoined with an unhealthy constitution, there can be scarcely any hope of a radical cure. Beer's opinion also is, that, w hen the disease has made such pro- gress that not a ray can be discerned, and the pain in the eye and head is so violent, by r'ay and night that the sleep, appetite, and even the senses are lost; it is fortunate if only the most perilous symptoms can be obviated by palliative treatment; for the preservation of a good-shaped eye is then quite out of the question. And even in the most favourable cases, the utmost which can be expr< -t?d, is to stop the further advance ofthe disease, a perfect cure being extreni'dy rare. According to Beer, fhe first indication is to improve the state of tae he«!'b by medi- cines and regimen *. for, mile- u..s object be effected, no expectation of curing the dropsical affection of Ihe eye can be enter- tained. For this purpose a Ion;' time will be requisite, and as for local treatment in this case, little or nothing can be accom- plished by il. Hence, the disease often con- tinues to grow worse and worse, and, when the pain becomes violent, the best thing which the surgeon can do, both with tho view- to the functions of the organ and its form, is to let out the aqueotr Hmour. But Beer reprobates, in the stronger: terms, the plan sometimes recommended of plunging a trocar through the sclerotica into the vitre- ous humour, and keeping the tube introdu- ced until a certain quantity of that humour is discharged. According to Beer's experi- ence, the usual result of such practice is a carcinomatous disease of the eye, termina- ting in death, which the removal of the part will not prevent. The method preferred by Beer is that which is mentioned by Richter, (Anfangsgr. B. 3, p. 4di.»,) and consistsSin opening the cornea and -apsule of the lens, as in the extraction of tlie cataract, dischar- ging the lens and vitreous humour, and let- ting the coats of the eye collapse; but, in order to prevent any reaccumulation of fluid, he afterward cuts away a little bit of the flap of the cornea. The eye is then to be dressed in the same manner, as after the extraction of the cataract. (See Cata- ract.) Tbe third species of hydropbthalmia, or that produced by an accumulation both of the aqueous and vitreous humours toge- ther, is excelLiitly described by Scarpa. He observes, that in every case on which he has performed the ope ration, and in other examinations of the different stages of (he disease, made on the dead subject, he has constantly found the. vitreous humour more or less altered in its organization, liquefied, and converted into water, according as the disease was ancient or tecent. In some instances he could not distinguish whether the increased quantity of the vitreous, or aqueous humour, had most share iu the formation of the disease. Scarpa also dissected a dropsical eye, taken from the body of a child three years and a half old, who died of marasmus. The vitreous humour was not only wanting in this eye, and the cavity destined for its reception filled with water, but the vitreous tunic was converted into a subtance, partly of a spongy, partly of a fatty nature. This dropsical eye was one-third larger than na- tural. The sclerotica was not thinner than that of the other eye ; but, in consequence of being yielding, flaccid, and separated from the choroides, it had lost its plumpness, and globular shape. The cornea formed a disk, one-third larger than that of this mem- brane in a sound state; it did not retain its uf-.tur.-d pulpy structure, and was obviously thinner than the cori.tc. of the healthy eye. There was a considerable quantity of an aqueous, reddish Puid, between the ; oruea and vis. The crystalline lens, with its opaque capsule, had bee, pushed forwar■•! a lit- tle way into the anterior chamber, but could not advance further on account of a firm adhesion which the capsule had con- (rae tt.d with (.he iris around tlie edge of ths pupil. As soon as (he capsule- was opened, the lens issued from it halt nissolved, the rest exceedingly soft. It iva- Impossible to ifcj PTDROPH detach the whole of the posterior layer of the capsule from a hard substance, which seem- ed to be tbe altered membrane ofthe vitre- ou- humour. Scarpa, therefore, slit open the choroides, from the ciliary ligament to the bottom ofthe eye, when a considerable quantity of a reddisii aqueous fluid gushed out, without, however, one particle of the vitreous humour. In lieu of the latter body, there was found a small cylinder of a sub- stance, partly of a fungous, partly of a fatty nature, surrounded wilh a good deal ol wa ter, which whs effused in the longitudinal axis of the eye, from the entrance of the op.ic nerve, as far as the ciliary ligament, or that hard sub-tance to which ihe posterior layer of the capsule firm>y adhered. This little cylinder was covered for the exten( of two lines and a half forward- from the en- trance of the optic nerve, by a stratum of whitish matter, reflected on itself, like the epiploon, when raised towards the fundus of the stomach. Scarpa conceived tht this stratum of whitish matter was the relics of tbe unorganized ret na ; for, on pouring rectified spirits of wine on the whole inner surface of the choroides, and the little- cy- lindrical body, he found no vestiges of the retina on this membrane, and that the whi- tish substance, which was reflected on itself, became very firm, just as the retina does when immersed in spirits of wine. Both tbe cylinder and the indurated substance, occupying the place of the ciliary body, were manifestly only the membrane ol (he vitreous humour, destitute of water, and converted, as was described, into a sub- stance partly ol a spongy, partly of an adi- pose nature. It is not easy to determine whether this altered state of the vitreous tunic had preceded, or was a consequence ofthe dropsy ofthe eye. However, it may be this fact, in conjunction wilh several other similar ones, that Scarpa has met w ith, in which he found no vitreous humour in the posterior cavity of the eye, b t only water, or a bloody lymph, lends very much to establish tbe fact, that this disease princi- pally consists of a morbific secretion of the vitreous humour, and occasionally, also, of a strange degeneration of the alveolary membrane, by which this humour is formed. Scarpa refers to a similar case. (See Med. Obs. and Inquiries, Vol. 3, art. 14.) The augmentation in the secretion of the aqueous fluid, both in the cells of the vitre- ous humour and out of them, after they have been ruptured from excessive distention, together with a debilitated action of the absorbent system ofthe eyeaffected ; Scarpa regards as ihe probable cause ofthe morbi fie accumulation of humours in the e\e From such a lodgment, and successive in- crease of the vitreous and aqueous humours, the eyeball at first necessarily assumes an oval shape, ending at the point of the cor- nea ; the organ enlarges in all dimensions ; and in the end, it projects from the orbit in such a mamer that it cannot be covered by the eyelids, disfiguring the patient's face as THALMIV much as if an ox's eye were placed in U, °' This disease (says Scarpa) is sometknt pre, eded by blows on the eye, or adjoinfi temple ; sometimes by an obstinate mtemj ophthalmy. Iu other instances it is pre-* ded by no inconvenience, except an uneasy sensation of tumefaction and distention ia (he orbit, a difficulty of moving the eyeball, and a «onsiderable impairment of sight. Lastly, it is sometimes preceded by noneof these c uses, or no other obvious one «hi|. ever, e-speciully when the complaint occur, in children of very tender age, from whoi no information can be obtained. As sooi a- the eye has assumed an oval form, and the anterior chamber has become preterm- turallv capacious, the iris seems situated further backward than usual, and tremulates in a verv singular way on the slightest mo- tion of the eyeball. Ihe pupil reroainadj. lated in every degree 'of light, while tbe crystalline is sometimes brownish from tbe very beginning of the disease; and some- times it does not become cloudy till (be affection has arrived at its highest pilch. The complaint then becomes stationary; and as the crystalline is ii"t deeply opaque, the path tit can distinguish light from dark- ness, and, in some degree, the contsuref objects, and brilliant colours. But whet the eye has acquiied a larger volume, and the whole crystalline has become opaque, the retina at last remains in a state of com- plete paralysis. In the last stage of the disease, to which the term bupthalmos, or ox-eye, is properly applicable, when the dropsical 'eye project! from the orbit, so as not to admit of bein*; covered by the eyelids with the inconveni- ences already enumerated, says Scarpa, olhers associate themselves, arising from the friction of the cilia?, the secretion of gun, the flux of tears, the ulceration of the lower eyelid, on which the eye rests, and the ex- coriation ofthe eye itself. Hence the drop- sical eye is gradually attacked with violent ophthalmies, attended with intolerable pains in the part affected, and the whole head. The ulceration, also, does not always con- fine itself within certain limits; but conti- nues to spread, first depriving the corneaof its transparency, next consuming thesdero- tica, and lastly, destroying progressively the other component parts of the eyeball. At the first appearance of dropsy ofthe eye, many surgeons reco-.imeiid mercurialji the extract of cicuta, and of pulsatilla nigri- cans ; and astringent and corroborant coily- ria, a seton in the nape of the neck, and compression ofthe projecting eye. Howe- ver, Scarpa has never yet met with a single well-detailed history of a dropsy ofthe eye, cured by means of (he above-mentioned internal medicines. With regard to exter- nals he has learnt, from his own experience, that when the disorder is manifest, astr* gent and corroborant collyria, as well » compression of the protuberant eye, at* highly prejudicial. In such circumstance?! HTRROPHTHALMIA. 1G3 (Baking a seton in the nape of the neck, -frequently bathing the eye in a lotion of 'mallows, and applying to it a poultice com- posed of the same plant, have enabled him ;to calm, for a time, that disagreeable sense of distention in the'orbit, and over the fore- head and temple of the same side, of which patients in this state make so much com- "plaint, especially when they are affected with a recurrence of ophthalmy. But as soon as the eyeba'l begins to protrude from 'the orbit, and project beyond the eyelids, ■'he thinks there is no means of opposing the very grievous dangers which the dropsy of the eye threatens, except an operation which consists in evacuating, by an incision, the superabundant humours, then exciting gen- '■*tle inflammation of the membranes, and suppuration within this organ, so as to make 'it contract, and shrink into the bottom ofthe :orbit. To defer the operation any longer, would be abandoning the patient to the con- stant inconvenience of an habitual ophthal- : my, the danger of an ulceration of the eyre- vball and subjacent eyelid, and what is worse, .of carcinoma of the whole eye, with great peril to the patient. Beer's prognosis in the third species of hydropbthalmia is at least as discouraging as • that made by Scarpa ; for the rapidity of the disease is said to be such as leaves scarcely a possibility of benefit being effect- ed by any mode of treatment, and the case usually terminates in a carcinomatous ex- ophthalmia, and death. These melancholy events are said, by Beer, to be accelerated . by paracentesis ofthe eye, however execu- ted ; and he thinks that the sole chance of stopping the progress of the disease depends upon an endeavour being made in its very commencement to improve the general health, though he owns that success is to be regarded as a very rare and fortunate occur- rence. The same author has no faith in any local treatment, and, when the disease is advanced, he considers the extirpation of the eye the only rational expedient, though very precarious in its result. (Lehre von den Augenkr. B. 2, p. 628, 629.) The main point, on which Scarpa differs from Beer, is that respecting the effects of discharging the humours of the eye ; a prac- tice, which the fnrmpr represents as useful, ' even iu cases w here the hydrophlhalmia com- bines an accumulation both of the aqueous and vitreous humours. In former times, says Scarpa, paracentesis of (he eye-bull w>,s greatly e\lolled. Nuck one of (he promoters of (hi-* operation, punctured the eye with a trocar, exactly in the e-enlie of (he cornea. (De Duct. Ocul.Aquos,p. 120.) II has since been though! belie' to puncture the scb rotira about two lines from the junction of 'his membrane wilh (he cornea, that such a small qunntity ofthe vitreous humour may be more easily discharged at ibe same time with (he aqueous, as may be deemed adequate to ef feci a diminution in the morbific enlargement ofthe eye-ball. According to Scarpa, paracentesis of the eye, done so as merely to discharge the hu- mours, enn never be a means of curing drop- sy of the eve, unless the puncture, made wilh (he trocar, excite inflammation and suppura- tion, and afterward a concretion of the membrmes composing the eyeball. Indeed Nuck relates, that in a young man «( Breda, he wrs obliged to puncture the eve five seve- ral times; thai, on the fifth time >f doing this, il wn« necessary fo suck through (he can- nnl.ir of (he* trocar, in order to evarualr the greatest possible quantity of the vitreous humour; and la«tly, (hat it s<*emed proper to intriidue-p a plate of lead between the eyelids and eve-ball, for the purpose of making con- tinual pressure on the eve, in its empty shri- velled state. In a woman at the Hagu-*, he twice omietured the eye in vain ; and she suh-nittol two or three times afterward, to the sv*me operation, but with what degree of success is iiit >necifi"il **■» o-pa has no diffi- culty in believing, that a radical cure of the dropsy has sometimes been accomplished by nr-ansof tbp puncture, after (he (rocar, and other similar hard substances, have been re- peatpdly introduced into (he eye, through the cannula of that instrument; bill (his suecess can never be attributed to the mere evacua- tion of (he supprabundancp of the vitreous and aqueous humour; (hough it may be re- ferred to (hut ci-eu nstanc--, conjoined with the irritation prod-iced by 'be cannul-t. or the tents with which Miuchart kept open the wound. Scarpa condemns Ibe plan of making a circular in<-ision through the sclerotica, s disadvantageous, and evpn dangerous. In fact, this circular reriiion, is constantly fol- lowed by (he most aggravated symptoms, particularly frequent hemorrh-iges, an accu- mulation of grumotisbloo.l a((he bottom ofthe eve-hall, vehement inflammation of the eye, eyelids, and head, obstb ate vomitings, con- vulsions, delirium, and the most imminent danger to tbe pOient's life. Such modern surgeons, as hnve faithfully published Ihe results of thpir nraciice on this point, among whom, after M Louis, (Mim. de I'Acad. de Chir. T. 13 p. 289, 290 ) M .-eln.u, (Journal de Mid.de Paris, Janvier, 1770-. Sur deux Exonhthalmies., ou groaseurs contre nature dn Globe del'(Eil;) an I Terra*. (Ibidem, Mars, 1776; Sur VHydrophlhalmie,) having in-.-enu- ou«ly declared that, after performing thp cir- cu'ar recUion of dropsical eyes in the scle- rotica, they had tbe greatest motives for re- penting of « hat (Iipv had done. Scarpa pre- fers making a circularsection,about three lines in breadth, at the summit or centre of the cornea of the dropsical eye, as directed by ('e'^us, in cases of staphyloma. Whether the cornea be transparent or not, as eight is irrevocably lost, the sun-eon must introduce a small bistoury across the nppx or middle of the cornea, at one line and a half from its central point ; and then by pushing the instrument from one towards the other ranthus of the eye. he will cut the lower part of (he cornea in a semicircular manner. The segment of the cornea being next elevated wilh (lie forceps, the operator is fo turn (be edge of the knife upward, and complete the lw-i HYU work by a circular removal of as much of tbe centre of the cornea as is equal (o (hree lines in diameter, through this circular opening, made in the centre of the cornea, the surgeon m iv, by mean- of gentle pressure, discharge as much of the superabundant humours in the eve, ■ s is requisite to make the eye-ball dimi.iish, and return into the orbit, so as to be covered by the eyelid;. A- for the r->t of the humour lodged in the eye, it will gradu- ally escape of itself, through the circular opening in (!.,: cornea, without any more pressure being made. I'ntil the .-.ppe&rance ot the inflamintition, that is, uaiti- the third or fifth day after the operation, the dressings ,ue to consist ot ihe application of a compres- of dry lint, sup ported by a bandage. As soo;: as the inflam- mation and tumefaction invade- the eye ope- rated on, and the eyelids, the surgeon is to employ such internal remedies as are calcu- lated lo moderate the progress of inflamma- tion ; and he is to over the eyelids with a bread and milk poultice, which must be re- newed at least once every two hours. Il is a very frequent result, bolh in the stapby-oma and dropsy of Ihe eye, that, on the first ap- pearance of inflammation, the eye-ball, on which the operation has bee n dene, augments and protrudes again from tbe eyelids, in the same way a; before the operation. In this circumstance, Scarpa directs the projecting part of the eye-lmll to be covered -.vMi apiece of fine linen, smeared with a liniment of oi! and wax, or tbe yelk of an egg and oleum hyperici; (he application of the bread and milk poultice being continued over this other dressing. Scarpa next states, that wheu the interior of the eye begins to suppurate, the swelling of the eye-lid.- decreases, and the eye-ball diminishes in size, ind returns gra- dually into the orbit. This stale of suppura- tion may be knoo n by oii^erving, that the dres;ing« are smeared with a viscid lymph, blended with a portion of die humours of the eye, which incessantly issue from the centre of the cornea ; and by noticing the appear- ance of the margin of the rcci-.ion. wiiich is changed into a circle of a whitish substance, itsemblir.g the rind of bacon, which is after- ward detached, like a slough, so as to leave a small ulcer, of a very healthy colour. This ulcer, as well as the whole eye-ball, con- tracts, and becomes entirely cicatrized, lea- ving every opportunity for the placing of an artificial eye between the eyelids und the slump of '.he eyeball. If a mild inflammation and suppuration in the interior of the eye should not take place on the tifh day, Scarpa exposes t'.e eye to the air, or remov s a circular portion of the cor- nea, half a line in breadth, or little more, by me.ens of the forceps and curved scissors. The foregoing practice is certainly prefera- ble to that advi-.ed by Ricn'er, who, when tbe eyesight is lost, and the otject is merely to discharge the humours, and let the eye col- lapse, sometimes makes a crucial division of the cornea, and removes the four flaps or an- gles, Or even cuts away the whole of (he anterior part of the eye-ball through the UYP I sclerotica. (AnOvwgr. B. 3, f- ^-Mll orderT*lessen i •"■ »>k of (he eve, thU .1 VI- (\>-d in on.- instance, passed a sele,I ,'h-rougb the fro-.' o! .'lie organ wilhapparw, success C^r Med. (ommumcationa, Vol.]) Consult M.-'uilnvt, De Paracentesi Oculi, U 1744 Conradi, Hand bach der Pathol. An* v 523. Fielh.i. ICfi imd's Jiurn. 4 B.,. 208 Ft-inni, Col! -one d'lhfi nazwm, T.l, Obs. 43." Geiulroo Mai. des Yeux, T. » Louis, in Mim.de ." ■"'"'• de Chir. T. 5,4/,. Marchan in Jouru. de Med. T. 32, p. ft Tirras, op. cit. Vol. 45 p. 239. Scarpa, Sulk p.iucipali Malltttie ucah Orcbi. Can.lZ. f. P.Beger. Ot Hydro,-fiihuL ,;a, Haller Ify Ch,r. i 57b. A. :->r<-ey, De Parauihi Oculi in Hydrophlhalmia el Amblyopia ft. nutn ; Halter, Disp. Chir. 1. 5S7. Tub. 1741 Benedict, de Morbis Humoris Vitrei, bib. Diss, de Ilydropethalmia, Jen. 1S<>3. Rut- ter, Anfangsgr. B. 3, p. 392, &<*. Gut. \',%, BeerLehrevin den Augenkr. B.2, Wien. 1817 J. Wurdrop, Essays on the Morbid Anatuf of the Human Eye, Chap. 18 and 40, Vol.1 See*. Lond. 1818. B. Travers, -Umopsi.; of I/, Diseases of theEyc, p. 195, p.*-~M, hydrops articuli, refer to Joints, diseostsof;i hydrops oculi, see the foregoing artn.'?. Wit regard to hydrops pectoris, hydrothoraxfr' dropsy of the chest, as it is altogether * met! cal case, an accouut of ifs symptom! m treatment will hardly be required in tku Dictionary. The only concern, which a sur- geon has with the disease, is being occasion- ally required (o make an opening for the discharge of the water. (See Paracenlm Thoracis.) HYDROSAROOCELE. (from tVug, water ; elids, the lancinating pabis in the eye abate, the heat considerably .ILnini-hes, the fever subsides, quietude and sleep arc resto- red, the motion of the eye becomes free, and, lastly, the collection of viscid matter forming the hypopium, becomes stationary. It is not unfreqiient to see, especially among t!:e lower orders of the people, persons affected with tlie second stage of severe acute ophthalmy, bearing this collection of <-o i 'dating lymph, in the chambers of the V,.|. n. 1* aqueous humour, with the greatest indiffer- ence, and without complaining of any of those symptoms which characterize the acute stage of ophthalmy. It is only at this crisis, or a' the termination of the acute stage of viol ct inflammation of the eye, that the enlargement of the hypopium ceases, and the coagulating lymph begins to he absorbed, provided this salutary opera- tion of nature be not impeded, nor retarded, by any injudicious regimen. However, if Scarpa had also been aware of the great efficacy «>f mercury, it* arresting tbe effusion of lymph, I can* hardly doubt, that he would have modified some of the preceding obser- vations, as well as his practice ; a subject to which I shall presently advert again Scarpa states, that persot.*, little versed in the treatment of diseases of the eyes, would fancy that the most expeditious and efficacious mode of curing an hypopium, after it has become stationary in the second stage of severe acute ophthalmy, would be that of opening the cornea at its most de- pending part, in order to procure a speedy exit for the matter collected in the chambers of the aqueous humour ; especially as this was once tbe common doctrine. But ex- perience shows, that dividing the cornea, in such circumstances, is seldom successful, and most frequently gives rise to evils, worse than Ihe hypop-um itself, notwithstanding the modification suggested by Richter, (Obs. Chir. Fnsc. 1, Chap. 12.) not to evacuate the whole ofthe matter at evce, nor to promote its discharge by repeated p-essure and in- jections, but to allow it to flow sIoaIv out of itself. The wound made at the lower part of the cornea, for evacuating the matter of the hypopium, small as t.e incision may be, most commonly reproduce^severe acute ophthalmy, and a greater effusion of coagu- lating lymph intothp chambers of the aque- ous humour. Besides, after opening the cornea, if the matter of the. hypopium were allowed to escape gradually t/ itself, it would Ik* several days in being completely discharged, on account of its viscidity. During this time, the glutinous lymph would keep the edges of the wound of the c, HVPOPHM. ment. In the two first mrthods, the subse- quent sfmptoms are constantly milder (ban in the last. Besides, even in the instance in which a spontaneous discharge of the hy- popium takes place through Hie cornea, an escape of the aqueous humour, and a pro- lapsus of the iris, not unfrequently ensues; consequently, the spontaneous evacuation of tiie hypopium cannot justly form a rule for the treatment of the disease. There is only one case, in woicli dividing the cornea, in order to discharge an hypopium, is not of judging whether the matter was actuary situated between the lamina! of that^ mem- brane, or in the anterior chamber. Hence, 1 was asked, whether it might not be evacn- ated by an incision, particularly as the patient complained of great pain in the eye, and eyebrow. She was in the hospital; and in the presence of Dr. Lulb, and several students in surgery, I said that the pain of which the patient complained, was not occ«- sioned by the p'is itself, but the cause which produced it. This cause was inflammation, only useful, bi7iTidi°pe^i,a'ble ;'this'is, when wlrch probably would be increased bj (here is such an imm-nse quantity of coagu- making a larger opening for the external being lymph extravasated in the eve, that air, than what it has to the internal parts, the excessive distention, which it produces while the external ones remain entire. By of all the coats of this organ, occasions fomenting the eye and forehead with warm symptoms so vehement, as not only threaten water, the inflammation subsided, and the the entire destruction of the eye, but even pus disappeared. We have so often wituess- eudanger the life of the patient. But this ed the fact subsequently, that we can alia particular case cannot sarve (says Scarpa) extol the simplicity of the treatment.1 as a model for the treatment oi' ordinary Such, in short, is the successful terminatioi eases. of an hypopium, whenever the disease a The dispersion of the hypopium, by means properly treated at its commencement, aad of absorption, forms the primary indication, the acute stage of severe ophthalmy a at which the stugaon should ai.n. In order promptly checked by internal antiphlogistk to stop its progress, the most efficacious means, and emollient applications. But, in method is to subdue fhe first violence of tlie consequence of the inflammatory period of inflammation, and lo shorten its acute stage, the severe ophthalmy having resisted, in ai by the free employment of antiphlogistic uncommon manner, the best means, or treatment, and the use of mild emollient, because such means have been employed topical remedies. AnJ, in conjunction with too late, it sometimes happens, that (he these means, there can now be no doubt, coagulating lymph, collected in the anterior that the practice of BrUel, published iu l*-.t»!», chamber, is so abundant, even after the as will be mentioned at the close of this acute stage of ophthalmy, that it continue! article, ought to be followed : I mean, the for a long time to cloud the eye, and inter- quick exliibition of the subniuiiate of mercury, which has been also found at the London Eye Infirm ry the most powerful means of checking tlie effusion of lymph in the eye. (See Saunders's Work on the Ey>, Ed. 2, and a Synopsis of the Disease of the Eye, by B. Tracers, p. 135.) If this treatment answer, the incipient collection of coagulating lymph, ai the cept vision. Scarpa has often seen patient*, especially paupers, who from indolence, negligence, or ill treatment, remained i long time after the cessation of the inflam- matory stage of ophthalmy, with the anterior chamber almost entirely filled with tbe glutinous matter of hypopium. When the inflammation had ceased, these unhappy persons wandered about the streets almott bottom of (he anterior chamber of the quite indifferent, and without complainiaj aqueous humour, not only ceasestoauginent, of pain, or any other inconvenience, than but, also, in proportion as the severe the difficulty of seeing with the eve affected. ophthalmy disappears, the absorbent system In this second stage of the ophthalmy, the takes up the heterogeneous fluid extravasa- resolution of hypopium obviously cannot be ted in the eye and the white, or yellow accomplished by the same means, nor with speck, shaped like a crescent, situated at the equal celerity, as in the first. At this cms, bottom of the anterior chamber, gradually the great quantity and density of the gluli- diminishes, and is at last entirely dispersed, nous matter extravasated, and the atony oi Janin consideredI an infusion of the flowers the vascular system of the eye. main > of mallows, applied to the eye that is infla- med and affected with this disease, as a specific resolvent in thee circu usUnces, (Mem. et Obs. sur TLEU, p. 405,) but it is now known, that every topical emollient applica- tion,, provided it be conjoined with such internal antiphlogistic treatment, as is the most proper for repelling the acute -tage of vascular system pfYh'e'eye* the severe oohtha mu m-^u^c „..:,„ ..„ »u„ . . / .. v ... e c>e> the severe ophthalmy, produces quite as the lymphatic good an effect as this infusion. Simple time/accordin warm water produces the same benefit eye. necessary to give nature sufficient time to dissipate the thick, tenacious matter, and,* length, to dispose it to be insensibly absorbed with the aqueous humour which is continu- ally undergoing a renovation. Hence it i« right, -ays Scarpa) to adopt those means, which are best calculated to invigorate tte more especially This requires more or le*-' g as the patient is advanced it* ^ar_S:°f a relaxed fibre and weak; or" the phthrfmy surge-* the removal a *- very thing, which may irritate the eye, or , be likely to renew the inflammation ; and he should only employ such means, as are 'conducive to the resolution of the second -.inflammatory stage, depending on relaxation , of the conjunctiva and its vessels, and such .remedies as tend, at the same time, to invigo- rate the action of the absorbents. There- t:fore, in this -tate. he ought first to examine "carefully the degree of irritability in the eye "affected with the hypopium, by introducing, between (he eye and eyelids, a few drops of vitriolic coilyrium, containing the mucilage of quince seeds. Should (be eye seem too strongly stimulated by this application, it must not be u«ed, and little b,is of warm ' mallows with a fe>v grains of camphor are !to be substituted lor it. In the intervals, the -l vapours of the liquor amnion, comp may "be applied, and recourse had again to a "- blister on (he nape of the neck. When the extreme sensibility of the eye is overcome, the zinc coilyrium must be used again, after- '■ ward strengthened with a few drops of camphorated spirit. Under such treatment, proceeds Scarpa, the surgeon may observe, -. that, in proportion as the chronic ophthalmy disappears, and the action ofthe absorbents >■ is re-excited, the" tenacious matter of the _ hypopium divides first into several small t masses ; then dissolves still further ; and, afterward, decreases in quantity : descend- ing towards the inferior segment of the cornea ; and, finally, vanishing altogether. But Scarpa accurately observes, that the surgeon cannot always expect to be equally successful, whether the disease occur during the first, or second stage of violent acute . ophthalmy, if the tenacious lymph, suddenly extravasated in the interior of the eve, 'prevail in such quantity, as not only to till, but strongly distend, the two chambers of the aqueous humour, and the cornea iu particular. In tins state, notwithstanding the most skilful treatment, the unpleasant complication is often followed by another inconvenience, still worse than the hypopi- um itself; viz. ulceration, opacity, and burst- ing of(he cornea. The ulceration of the cornea ordinarily takes place with such celerity, that the sur- geon seldom has time to prevent it. As soon as an aperture has formed, the exces- sive abundance of coagulating lymph, con- tained in the eye, (sometimes named em- pyema oculi) begins lo escape through if, and a degree of relief is experienced. But, this melioration is not of long continuance ; for scarcely is the glutinous fluid evacuated, that distended the whole eye, and especially the cornea, wheu it is followed by a portion of the iris, which glides through the ulcera- ted aperture, protrudes externally, and con- stitutes the disease termed prolapsus of the; iris. (See Iris, Prolapsus of.) But, if in such an emergency, the cornea already ulcerated, opaque, and greatly deranged in its organization, should not immediately burst, the surgeon is then constrained by the violence ofthe symptoms, depending on the prodigious distention of the eyeball, to OPIUM. 107 make an opening in this membrane, in order to relieve the immense constriction, and even the danger in which life is placed. Were (here the least chance of restoring, in any degree, (he liansparency of the cor- nea, and the functions ofthe organs of vision, after opening the cornea, Scarpa acknowled- ges that it would certainly be more prudent to make the opening at the lower part of this membrane. But in the case of empye- ma of tne eye, now considered, in which the cornea is universally menaced with ulcera- tion an J op-city, and seems ready (o slough, (here can be no hope of its resuming its transparency at any point, and be theicforc deems it the best and most expeditious me- thod of relief |o divide its centre with a siii.iii bisiouty to the extent of a lint* and a half; and (hen to raise with a pair of for- ceps the li lie flap, and cut it away all round wild one -.troke of the scissors, so as to let tiie humours escape without any pressure. The <*yt* is to be covered with a bread and mi'k poultice, which is to'be renewed every (wo hours, the u-e of sue h general remedies, i-s are calculated lo check the progress of acute, inflammation, an I to quiet ihe nervous system, not being omitted. Iu proportion as the interior of the eye suppm sites, Ihe eye- ball gi-rtduafly diminishes, shrinks into the i.rbit, and n( length cicatrizes, leaving things in a favourable state for the application of an artificial eye. When Scarpa delivers his opinion, that in the above aggravated form of hypopium, thine can be no < hunce of the cornea resu- ming its transparency at any point. I think Irs assertion rather imp: ndent. Nor admitting ils general truth, does it follow as a matter of course, (hat it is neces-ary and right to cut away a piece ot Ihe centre of the cornea, and absolutely destroy w hrttcvur little chance may yet be left of saving the eye. In sup- port of this remark, let me contrast what Mr. Travers has said w itb the advise of Scar- pa. " When the hypopium is mi large as to ihe- towards the pupil, and the ulceration of ihe cornea is extending, I think its discharge by section near ils margin adviseable. If not loo long delayed, the ulcerative process is. checked by it, which would otherwise run into sloughing, and the cornea recover uilh only partial op'.city nod disfigurement." (Sy- nopsis if the Diseases of the Lye, p 280.) Manchart de Hypopyo. Tubinge, 1742. C. P. Leporin, de Hypovyo Ito. Goell. 1778. Gocldlin, Diss, dc Hypopyo. Erlang. 1H10. Wollhir Merkitiirdigc Hellung eines Eiler- auges, fyc. Sro. Lands/nil, lyl9. / observe, that in lfofc'.:ivd and Hurley's Journal for Oclob. 1 ,-*!'.>. p. i>:{, there is an account of the treatment of an hypopium, or case of effused lymph in the chambers of the eye, by exhibit- ing from \2 to IS groins of the submitriale of mercury, in the space of 12 hours, and then girinir b irk, while as an external application the tinct. opii crocat. was employed. Thus we see that the efficacy of mercury in checking Ihe effusion of lymph in the eye, and promoting an absorption, has been known many years ia 108 INF IISF Germany. A. Scarpa Saggio di Osservationi Anatomy of the Human Eye, Chap, « e d'Esperienze. suite Principati Mulaltie Eilmb. I«U8. rf«/« See/,.; Vine,ia, iso-j/ WcAfer .*,,- HYSTEKOTOUU. (from «^£, th, fahgst:riinde der Wundarzneykunst, B. 3 womb, and \ the purls them- selves within (lie hernial s-i- , in such a de- gree, that the course of th- intestinal matter lothe .n.is is obstructed, an-.i n usea, -ickuess, pain, and tension ot the swelling and abdo- men, *cc. are occasioned, the rupture is said to be in a slate of incarceration or strangula- tion. Accordingto Professor Scarpa, however, an incarcerated and aslrangulatedhvrni.i, di> not imply exactly the sii ne tiling. Iu Hie thbt e a-e, says be, thecouiseol th.- intestinal matter is interrupted, without any considerable impair m<*nt ol the 0-x ure, or vitality of the bowel. On the contraiy, in ihe strangulated hernia, besides (he obstruction lo ;n- course of tiie fecal matter, there is organic inju y of the coats of the intestine, with lo3s of ils vitality. The bowel th t is merely incarcerated, re- sumes its functions immediately it is replaced in Ihe abdomen , while that which is (ruly strangulated never returns to its natural state. (Trails des Hernies, p. '251.) This distinction, however, is by no means generally adopted. INCONTINENCE OF URINE. (See Urine, Incontinence of.) LNFUMM VTION. (from inflammo, lo burn.) By Ihe term, inflammation- is gene- rally understood the state ol apart in which it is painful, hotter, redder, and somewhat more lurgid than it naturally is ; which topical symptoms, when piesenl in any considerable degree, or when they affect very sensible parts, are attended with fever, ur'a general disturbance of the system. (Burns.) The susceptibility of the body for in- flammatim is ot Uvo kinds; the one ortgi- nal, constituting a part of Ihe animal econu my, and beyond the reach of human investi- gation ; the other acquired from the influence of climate, habits <>| nte, and -late of the mind over the constitution. (Hunter.) The first kind of susceptibility being innate, can- not be diminished by art ; the »ec .ftd uny be lessened by the mere avoidance oi ihe par- ticular causes upon which it depend-. Inflammation may, with green propriety.be divided nio healthy and unhealthy. Ot the first, mere can miiy be one kunl, though di- visible into different stages ; ot the second, there must be ilioii, the laKer turm implying, thai tiie affection ha-some strongly marked par- ticularity about it, rendeii g it in some de- gree independent of such circumstances ai would control and regulate the progress ol common inflammation. Such are venerthL variolous, vaccine, erysipelatous, gouty, and rheumatic inflammation-, be- Inflammation may also be divided into the acute and chro- nic This division of Ihe subject is one of the most ancient, and seems to have obtain- ed the sanction of all (he best surgical wri- ters. Healthy inflammation is invariably quick in ils progress, for which reason, il must always rank as an acute species of Ibe affection. How ever, there are numerous in- (lamination*, controlled by a diseased princi- ple, w hich ar- quick in their progress, aod are, therefore, to be considered as acute, Chronic inflammation, which will be treated of when I come to the subject of tumom, is always accompanied with diseased actioo. My friend, Mr James of Exefer, ju-tly impressed with the utility which would re- sult from a good no-ological arrangement of inflammation, has lately attempted to supply what must generally be allowed to be a great desideratum. To Ihe division of inflamma- tion inlo (he acute, subacute, oi chronic, he o jec-(s, (bat in many instances, the-seare merely different stages of ihe same disease*. Tiie arrangement into the adhesive, sup-pun- hve, ulcerative, or gangrenous i flainmalion, he does not altogether approve, because it is merely founded on (he modes in which either different, or in some instances, the same kinds ol inflammation terminate. Un- der th. heads ot phlegmonous, erysipelatofc and gangrenous inflammation, he argues, Aal diseases ..( ,|lt mog, 0„I)0sj,e natlire fan been indiscriminately brought together. The disposition to terminate in gangrene, he ad- mit?, will afford a basis for subdivision, but not for primary separation. Mr. James makes some ju.iie-ious observations on th* arrangement ot the kinds of inflammation, according to tbe elementary tissue in wiiitb they occur, as proposed by Dr. Carm.cbael Smith, Pmel, and Bich.u. The tissues in question are five, and .he doctrine suppo^, that the inflammation of each is essentially different. Ihe first is phlegmonous inflamma- tion, which affecs the cellular membmi.e, including the parenchyma ol ihe several vis- cera ihe second is iniiammaiioii of seroui membranes. The third, of mucous mem- branes. The fourth, which „ naiIled er¥5i. pehtous, ,s of the skin- And (he fitth, t-Jfl- INFLAMMATION. 109 •ed rheumatic, belongs to fibrous structure. Tint inflammations differ materially from the circumstance of their affecting one of these elementary tissues, rather than another, Mr. James freely admits: but the following objections appear to him fatal to (his system, if they are true 1. Different kinds o' in- flammation are liable to occur i . tht- -ame tissue. 2. The same kind of inflammation is often met «ilh in different tissue.. 3. The same inflammation may be transferred from one toanoth r; a i argu'n-*nt, howevei, on which he lays i,s st -e*s, as bein . difficult of direct pro,»f. (S e Obs. on the different Species of Inflammation, p. 3t—7 8ro. Lond. 1821.) Aim,ugh difference of -Inn ture un- questionably accounts for some of the varie- ties in th-* appearance and character of in- flammation, it will not -ulfic.it utly explain the principal divers ties of (his affection to be laken s the foundation of a nosological arrangement, not only iorthe reasons p inted out by Mr. James, but because the common distinctions of inflammation at prese.it in vogue, and some of which at least are ob- vious and striking, cannot be at all « K -d by any reference merely to texture.. N >r did this theory satisfy Mr. Hunter, who observed, thai if it were true, '• we should s ion be made acquainted with all the different in- flammations in Ihe same person at the same time, and even in the same wound. For in- stance, in an ampuiation of a leg, where we cut through the skin, cellular membrane, muscle, tendon, periosteum, bone, and mar- row, the skin -dionld und consti- tution , and an- accompanied with disorgani- zition-, whicti do not exist in other cases, Mr. James considers them as materially dif- ferent. This author | urpoely excludes from his classification nil mutations of the organs of sense, and of Hie bones, the peculiarities in their structure aud functions rendering them fit subjects lot separate description. 'V ith respect lo -Mr. James's nosological ta- ble of infl mmation, I consider it very inge- nious, and well deserving of the attention of tne profession : I may say this without at all involving myself in the hypothesis, that tbe limitation, or spreading of (he generality of inflammations, is a circumstance entirely de- pendent upon their disposition or indisposi- tion to effuse organizable lymph. Mi. Hun- ter wis well acquainted wilh tbe frequent usefulness of the adhesive inflammation ill setting limits to disea-e, yel be did not ven- ture lo refer the circumscription of every in- flammation to this cause, e>r the spreading of the disorder entirelv (o its absence. Nor, i-ideej, does t( sc-in essential ;o Mr. Ja ne-'s classification, that any canse should be as- signed for the disposition of one class of inflammations to be limited, and of another to spread ; the two facts themselves being sufficient for the basis of the division. There is much foundation for believing that healthy inflammation is invariably an horn >;eueous process obedient to ordained principles, and, in similar structures, similar situations, and iu constitutions of equal strength, uniformly assuming the same fea- tures. If experience reveals to us, thai/'ere it is commonly productive of certain effects, and there it ordinarily pr duces different ones, the same unbounded source of wis- dom communicates to the mind a know- ledge, thai there is some difference in the tone ofthe constitution, or in the structure or situation of the parts affected, assignable as the cause of this variety. A modern author (D . Smith, in Med. Gommumcaltons, Vol. 2.) makes tne nature of the exciting cause one principal ground of the specific distinctions in inflammation, and with good reason, « ien he takes into the account the action of morbid poisons, and the qualities of disease in general. The doctrine ,.lso recr'ves confirmation from w!iat is observed in cases of burns, and chilblains, where the inflammation is un- questionably attended with great peculiari- ty, requiring different treatment from tht.t of common inflammation in general. But, wheu the exciting cause is strictly mechani- cal, its violence and extent may cause dif ferences in the degree and quantity of in ' INFLAMMATION. and resist disease bet er than other parts, of similar structure, more remote from the heart. The lower extremities are rain:'- prone to inflammation ami disease in iiieral, than parts about the chest ; when inflamed, they are longer in getting we circumstance f their i ring de- whicb retards the return of and th pending pirts, blood throui"'i the veins, must also increase the backwardness of s eh parts in any salu- tary process. (Hunter) Healthy inflam- mation is of a pale red when less healthy, it is of a darker colour ; but, in every con- stitution, the inflamed parts will partake more of the healthy red, the nearer they are to the source of the circulation. (Hun- ter.) Inflammation when situated in highly or- ganized and very vascular parts, is generally more disposed to take a prosperous course, mid is more governable by art, than in parts of an opp isite texture. Tlie nearer also such vascular parts are to the heart, the greater will be their triilenev to do well in infl immatioii. (Hunter.) Hence, inflatn mation ofthe skin, cellular substance, mus- cles, &.c more frequently ends favourably, than the same affection of bones, tendons, fascia*, ligaments, &c. It is also more ma- nageable by suagery ; for those parts ofthe body, which are not what anatomists term vascular, seem to enjoy only inferior pow- ers of life, and, consequently, when exciled in a preternatural degree, frequently mor- tify. But, inflammation of vital parts, though they may be exceedingly vascular, cannot go on so favourably, as in other parts of re- sembling structure," but, of different func- tions ; because, the natural operations of universal health depend so much upon the sound condition of such organs. (Ha tir.) The truth of (his observation is illustrated in cases of gastritis, peripneumony. be. All new-formed parts, not originally en- tering into the fabric of the body, such as tumours, both ofthe encysted and sarcoma- tous kinds, excrescences, be. cannot en- dure the disturbance of inflammation long. Hor in a great degree. I he vital powers of adventi antivetiereal quality. Topical stimulents vould fulfil Ihe same object, not only with greater expedition, bul with no injury to the general health. Iiiflam nation, ceteris paribus, always pro- ceeds nue favourably in strong, than ii weak e-onstitutio is; for. when there j- much "trength, there is little irritability |D weak constitutions, the op-rations of in. (lamination are\ backward, note ithstaiielinj the part in which it is seated may, compa- ratively speaking, possess considerable or- ganization, and powers of life. (Hunter.) lie dtliy inflammation, c hire.' r situated, is always most violent er thi.t Mfle of tbe point ot inflammation, which is next to the external surface of the bo !y. Vi hen in- flammation attacks the socket of a tooth, it does not take, place on the inside of the al- veolary process, but towards the cheek. When inflammation attacks the cellular sub- stance, surrounding the recfum, near Ibe anus, the uffec.tion usually extends itself ta fhe skin of the buttock, leaving the intes- tine perfectly sound, though iu contact with the inflamed part. (Hunter.) We may observe the influence of this law in the diseases of the lachrymal sac and duct, in those of the frontal sinus and antrum, and particularly ingunshnt wounds. Suppose a ball were to pass into (he thigh, to within an inch of the opposite side of ihe limb, we should not find, that inflammation would be excited along the track of the ball, but, on the side next the skin which had not been hurt. If a ball were to pass quite through a limb, and carry into the wountla piece of cloth, which lodged in the middle, equidistant from the two orifices, the. skin, immediately over the extraneous body, would inflame, if the passage of the hall were superficial.—(Hunter ) Mr. Hunter compared this law wilh the principle, by which vegetables approach the surface of the earth ; but, the solution of it was too arduous even for his strong genius and pene- tration. We sec three very remarkable effecll follow the prevalence of inflammation; rises'* - r"ev-"*^* viadb^n'-^Tof,,; s^rs J e presence of inflammation, these adven- other; the formation of pi- or sumiura- ous substances are sometimes removed lion ; and ulceration a pc^s inKh Soui T'h! 1;1e'nSa'.kb,,t 7V0,r0r,,-V 'I?6 "V-nphatic, are more' cone-'rued than sough tin- .e nark applies also to sub- the blood-vesM Is Hence Mr Hunter gO-rS^of'thVf Tll f°- ''r °ri- tf™-d ,he dltt«™1 «"ie"of inflam X, HIST and tllur^'rh^nowK ^.f^^ curative, and the ulaf INFLAMMATION. Ill In the cellular membrane, and in the cir- cumscribed cavities, the adhesive stage takes place more readily than tbe others ; suppuration may be said to follow next in order of frequency ; and lastly ulceration. In internal canals, on the inner surfaces ofthe eyelids, nose, mouth, and trachea, in the air-cells of the lungs, in the oesbphagus stomach, intestines, pelvis of the kidney, ureters, bladder, urethra, and in all the ducts and outlets of the organs of secretion, being what are termed mucous membranes, the sup- purative inflammation comes on more rea- dily, than either the adhesive, or the ulcer- ative stage. Adhesions, which originate from the slightest degree of inflammation in other situations and structures, can only be produced by a violent kind in the above- mentioned parts Ulceration is more fre- quently met with upon mucous surfaces, than adhesions. (Hunter.) The cellular membrane appears to be much more sus- ceptible of the adhesive inflammation, than the adipose, and much more readily passes into the suppurative. (Hunter.) Thus we see the cellular substance, connecting the muscles together, and the adipose mem- brane to the muscles, inflaming, suppurating and the matter separating the muscles, from their lateral connexions, and even the fat from the muscles, while the latter substance and the skin are only highly inflamed. (Hunter.) But, it must be allowed, that in situations where fat abounds, we very fre- quently meet with abscesses. This is so much the case, that fat has been accounted a more frequent nidus for collections of matter, than the cellular substance. (Brom- field.) Abscesses are particularly liable to form in the neighbourhood of the anus, mamma, be. With respect to the fat being highly inflamed, however, the expression is not strictly true. Fat has no vessels, princi- ple of life nor action of its own ; conse- quently, we cannot suppose that it can itself either inflame, or suppurate. We know, that it is itself a secretion, and when an ab- scess forms in it, we understand, that the mode of action iu the vessels, naturally des- tined to deposit fat, has been altered to that adapted to tbe formation of pus. When therefore the fat is said to be inflamed, it is only meant, that the membranous cells, in which it is contained, and by which it is se- creted, are thus affected. The deeply-situated parts of the body, more especially the vital ones, very readily admit ofthe adhesive stage of inflammation. The circumstance of deeply-sealed parts not so readily taking on the suppurative stage of inflammation, as the superficial ones do, is strikingly illustrated in cases of extraneous bodies, which, if deeply- lodged, only produce the adhesive inflammation. By this process, a cyst is formed, in which they lie without much inconvenience, and they may even gradually change their situa- tion, without disturbing the parts, through which they pass. Bui, no sooner do these same bodies approach the skin, than absces- ses immediately arise. (Hunter.) All inflammations, attended wilh disease, partake of some specific quality, from which simple inflammation is entirely free. When the constitution allows the true adhesive and suppurative stages to occur, it is to be regarded as the most healthy. Were it in an opposite state, we should see tbe very same irritation excite some other kind of inflammation, such as the erysipelatous, scrofulous, be. (Hunter.) In specific inflammations, the position, structure, and distance of the part affected from the source of the circulation, as well as from the surface of the body, seem also to have as much influence as in cases of common inflammation. Upon this point, 1 feel conscious of being a lit le at variance with what Mr. Hunter has stated ; but, the undecided manner in which he expresses himself, not less than the followurg reflec- tions, encourages me not to deserrt my own ideas. We see, that venereal eruptions sooner make their appearance upon the 'chest and face, than upon the extremities. No organized part can be deemed exempt from the attack of common inflammation ; many appear to be totally insusceptible of the venereal. We know, that scrofulous dis- eases ofthe superior extremities take a more favourable course, require amputation less frequently, and get well oftener than when situated iu the inferior limbs. (Ford.) The venereal disease makes more rapid advan- ces in the skin and throat, than in the bones and tendons ; we often see it producing a specific inflammation, aud an enlargement of the superficial parts of the tibia, ulna, clavido, cranium, be. while other bones, covered by a considerable quantity of flesh, are very rarely affected. Gouty inflamma- tion is prone to invade the small joints; rheumatic, the large. SYMPTOMS, SATURE, AND CAUSES OF IKFL.lM- MAflO.V. Redness, swelling, heat, and pain, the four principal symptoms of phlegmonous inflam- mation, have been accurately noticed by Celsus : Note, vera inflammationis sunt qua- tuor, rubor et tumor, eum colore el dolore lib. 3, cap. 10. If we refer to any writer on this interesting part of surgery, we shall find the above symptoms enumerated as characteri- zing phlegmon. In short, this term is usu- ally applied to a circumscribed tumour, at- tended with heat, redness, tension, and a throbbing pain. These are the first appear- ances observed in every case of phlegmon • and when they are slight, and the part af- fected is of no great extent, they have com- monly very little, and sometimes no appa- rent, influence on the general system. But wheu they are more considerable, and the inflammation becomes extensive, a full quick, and generally a hard pulse takes place, and the patient, at the same time complains of universal heat, thirst, and other symptoms of fever. While the inflamed part becomes red, painful, and swelled, its func- tions are also impaired The same degre-e Ill INFLAMMATION. of inflammation is said to produce more swelling iu soft parts, and less in those of a harder structure. (Burns.) Though tbe redness, suelling. throbbing, tension, and other s> .upturns of phlegmo- nous inflammation, an less manifest, when of your study, than |fc irocluce is more deserving effects which are produced in tne nutm,, bodv bv the operation of cold applied to it! surface'; but the subject is. at the same tun, exceedingly extensive, complicated, anddit- ficult Tlif-c effects differ according to the the affeclion is deeply situated, vet their ex degree in which the cold is HPP'H-d. the • state of the system, the part ofthe body*, which it is applied, and tbe mode of its t> istence is undoubted. \\ hen p rsons die of peripneumony.or inflammation ofthe lungs, plcation. So diversified, indeed, are these effects, that it requires no mean confidence in theoretical reasoning to believe, that the operation of cold in producing them 'set- the air-cells of these organs are found crowded with a larger number of turgid blood-vessels than in the healthy rtate, and of course the parts must appear pieternatu- rally red. Coagulating lymph, and even plicable upon any single general principle." blood, are extravasated in the substance of (.See Thomson on Inflammation, p. 58.) And these viscera, which become heavier, and in tbe preceding page, he observes: "The feel more solid. (Baillie.) operation of cold upon the human body ai- The extravasation of coagulating lymph, fords the best example which I can suggest which is one of the chief causes of the swell- P> you. of the production of inflammatina in<*, is also one of the most characteristic from the operation of a power acting upon signs of phlegmonous inflammation. a part at a distance from that in which tip some writers (Smith, in Med. Commun. inflammation takes place. The instance*) Vol. 2.) have confined the seat of phlegmon formerly mentioned of inflammation of tie to the cellular membrane ; but this idea is throat, chest, or belly, from the applicatioi erroneous. Had such authors duly discrimi- of cold to the feet, are daily occurrences it nated the nature of common inflammation, these climates, of which it is impossiblefor they would have allowed that this affection us, in the present state of o ir knowledge of existed, wherever the capillaries appeared the animal economy, to give any thing like to be more numerous and enlarged ihau in a satisfactory explanation. the natural state, accompanied wilh an effu- <■' In some instances, cold, or b diminution sion of coagulating lymph, whether upon of temperature, seems to act more directif the surface of a membrane, or a bone, or upon the parts, with which it comes into in^o the int.'stiies of the cellular substance, contact. We have examples of this in the and attended vvith acute pain, and a throb- inflammation of the mucous membranes of bing pulsation in tbe part. the nose, fauces, trachea, and bronchia;, As Dr. Thomson has observed, the epithet from the inhalation of cold air; and in the remote, as applied to the causes of inflamma- production of rheumatic inflammation from lion, does not appear to be happily cbc,,en ; the accidental exposure 6f some part or for under this term are comprehended all other of the body to cold. The application those agents, events, and states, which con- of cold, in the instances I have mentioned, tribute immediately, as well as remotely, seems to have somewhat of a directly eui- directly as well as indirectly, to the produc- ting effect ; and perhaps the same remark is tion of the affection. (Lectures on Inflam- still more a Hicable to the local effects of malum, p. •»).) co\a, ;n thP production of the inflammation The remote causes ot inflammation are accompanying the state, which is usually denominated frost-bite. Touching a solid body, as a piece of metal, the temperature of which has been greatly reduced, produce! a sensation like that of btir-iing, and mayle followed, like the application of fire, with a blister." (Op. cit.) Numerous opinions have been entertain- ed respecting ;he proximate cause of Inflam- nitrous, sulphureous, muriatic, oxygenated mnlion\ but almost every theory has been muriatic gases tec. alcohol, a>.her, and all built u^n the supposition of there beioi acrid vegetable essentia o. s, a.iima noi- *„m~ \!\. a e i i i ""V . , „ T ii 11 r . 7 ' ™■"",a, poi- some kind of. obstruction in the inflamed sons.and the whole of that clas- of substances part. uie iniiauicu known bv the name eif rubefacients (Thorn v\\;i«. .i,„ • , .• r- ., , , • w a ,- -- ■, .„, yinom- v.tnle the circulation of the blood was son on Inflammation, p. bo) The second cla-s .,„i,..„..,, i ,'"""" ul .lue ''**-"*-■ " of causef are those wMiicb act mecW.Hy le ^ such as bruises, wounds, pressure, friction' ' l,Vf:l'' '" nre,,ar,n2 a"d infinite in number, but very easy of com- prehension, because on'y divisible into two general classes. The first includes all such agents as esperate by their stimulant or chymical qualities ; for instance, canthari- des, heat, the action ot concentrated acids, alkalies, metallic oxides, and metallic salts acrid vapours, such as anuuoniacal gas, the be. Fevers often seem to become the remote causes of local inflammation. n e,:h«r in- stances, inflam .ration appears to arise spon- taneously, or, as I should rather say, without any perceptible exciting cause. The principle on which (he application of cold to a part becomes the remote cause of inflammation, is i-„t decidedly known preparing sending forth this fluid, continue i to prevail, physicians were so fully persuaded of the existence and influence of dliferent humours and spirit., and s,. little did they k,.oW it the regular and constant motion of the blood, .hat they believed in the possibility of depositions and congestions ofthe bloud, the bile, or lymph ; and acknowledged these as the cause of inflammation. I heir anaio- " No subj.....(savsadistinguidied .Wesson*. "I"** ta"*llt ^'T, aml.their professors el , . »^ii t.eu protessor) physic supported the opinion, that the liver INFLAMMATION. 11» fvas the centre of the vascular system, from which the blood went forth by day to the extremities, and returned again by night. If then any peccant matter irritated the liver, the blood was sent out more forcibly ; and if, at the same time, any part of the body were vv- >'<-,ied, or otherwise disposed to receive a gr-ater quantity ot tfiiid tban the rest, ti en a swelling was produced by the flow of h niiorir3 to this place. Fluxions, or flows of humour to a place, might happen either from weakness of the part which al- lowed the humours to enter more abun- dantly, or from the place attracting the hu- mours, in consequence ofthe application of heat or other agents. The peculiar nature ofthe swelling was supposed to depend upon the kind of humour. Blood produced the true phlegmon ; bile, erysipelas : be. An iden was also entertained, that Ihe blood and humours might slowly stagnate in a part, from a want of expulsive power, and this affection was termed a congestion, while the expression fluxion or defluxion was used to denote any swelling arising from the sud- den flow of humours from a distant part. (J. Burns, Dissertations on Inflammation.) From the theories <>f fluxion and conges- tion, which were quite incompatible with the laws of the circulation of the blood, we turn our attention to the doctrine of ob- str action. Boerhaave ihculu-ated, (Aph. 375 et seq.) that inflammation was caused by an obstruc- tion to the free circulation of the blood in tbe minute vessels, and this obstruction, he supposed, might be caused by heat, diar- rhoea, too copious flow7 of urine, and sweat, or whatever could dissipate the thinner parts of the blood, and produce a thickness or viscidity of that fluid. When the lentor did not exist before the production of inflamma- tion, he imagined that the larger globules ofthe blood passed into the small vessels, and (hus plugged them up. This circum- stance was termed an error loci. The ob- struction, whether caused by viscidity or an error loci, wps imagined to occasion a resist- ance to the circulation in the part affected ; and hence, an increase of the flow of the blood in the olher vessels, an irritation of the heart, and augmentation of the force, or attraction of the blood in that part of the vessel which was behind tbe obstruction. This caused heal and pain, while the accu- mulation of blood produces redness. Bo- erhaave also brought into the account an acrimonious state of the fluids, which render- ed resolution out of the question, and gan- grene likely to follow. (Aph. 388.) Tbe viscidity ofthe blood cannot be ad- mitted as the proximate cause of inflamma- tion ; becau-e we have no proof that this state ever exists ; or, granting that it did, it would not explain the phenomena. Were a viscidity to occur it would exist in the whole mass of blood, would affect every part of the body alike, and could not be sup- posed to produce only a local disorder. How also could such a lentor be produced by causes which bring on inflammation sud- Vnt.-II. 15 denly, without there being time for changes of the fluids to take place ? With regard to the doctrine of error loci, or of red globules going into vessels which did not formerly transmit them, the fact must be admitted, at the same time, that the conclusion is denied. When the eye be- comes inflamed, the tunica conjunctiva is seen with its vessels full of red blood, which in health is not the case; but this redness never appears until the inflammation has commenced, and must therefore be consi- dered as an effect, not a cause. Nor can this error loci occasion any obstruction in these vessels ; for if they be divided, the blood flows freely, which shows that they are large enough to allow an easy circula- tion. (J. Burns.) Boerhaave's theory of obstruction was too circumscribed, and too mechanical; it re- duced all inflammations to one species: the only distinctions which could have arisen, must have proceeded from the nature ofthe obstruction itself; and it was a doctrine that never could account for tbe action of many specific diseases and morbid poisons. (Hun- ter.) As for the supposition ofthe co-operation of an acrimony of the fluids, the proportion of the saline matter of the blood has never been proved to be greater in this, than iu any other state of the body. (Burns.) Even were a general disorder of this kind to be admitted, no rational explanation of the proximate cause of local inflammation could be deduced from it. The decided impossibility of giving a ra*^ tional explanation of the immediate cause of inflammation by any supposed state of Ihe blood alone, led pathologists to investi- gate howr far a change in the blood-vessels themselves might account for the process. It belongs more properly to a physiological than a surgical work, to explain the various facts and experiments in support of the opi- nion, that the arterial tubes, and especially the capillaries, possess a high degree of vital contractility, whereby the motion of the fluids in them, the process of secretion, and other local phenomena may be importantly affected, in a manner not at all explicable, by reference only to the action and power ofthe heart. For such information, I would particularly advise the reader to consult the publications of Dr. Wilson Philip, and Dr. Hastings. According to the latter gentle- man, the actual agency of the capillary ves- sels, **■• is not only supported by such ex- periments as those related, it is also coun- tenanced by an extensive series of pheno- mena presented during disease in the hu- man subject. Of these may be mentioned, irregular determinationsof blood,.the growth of tumours, increased pulsation of arteries leading to inflamed parts, of which the fol- lowing is a well-marked example, the accu- racy of which may be entirely relied upon. The carotids, when the person alluded to is in health, beat equally as to strength and frequency; but when he is attacked with inflammation in the right tonsil, to which 1H INFLAMMATION. be is particularly subject, and which pro- ceeds sometimes so far as nearly to prevent deglutition, each pulsation of the artery gives a throbbing sensation on (he right side ofthe head. On the application of the hand at (his time to each carotid, the right is found to beat much stronger and fuller than the left. This diversity of action in these two arteries cannot arise from any impulse given by the blood to the heart: it . must be derived from some modification of the contractile power of the artery." And Dr. Hastings expresses his belief in this ex- planation, notwithstanding Dr. C H. Parry wishes to attribute to the remote influence of the heart some of the phenomena of local congestion and motion, and to show, that the different states of vascular dilatation are still more conspicuously connected with the different degrees of action of the heart, and the consequent momentum of the blood, than with local circumstances; and that the proueness to local dilatation, or, as it is called, action, is a consequence of slowly succeeding, but continued impulse Tbe blood-vessels, through every part of the system, possess a considerable share of irritability, by which they contract, and pro- pel forward their contents. Hence, the blood, by the action of the vessels, receives a new impulse iu the most minu'e tubes, and a well-regulated momentum is preser- ved in every part of its course. But of all parts ofthe sanguiferous system, the capil- laries seem most eminently endowed with this faculty, and are least indebted to the presiding influence of the heart. Yet even in these vessels, the action ofthe heart is of high importance in sustaining the healthy circulation, inasmuch as it gives the first impulse to the blood, and preserves the har- mony ofthe sanguiferous system. The vessels are endowed with this vital property, in order that each organ in the body may receive such a supply of blood as will enable it duly to exercise its func- tions. Hence, a healthy stale of this pro- perty is absolutely necessary for the preser- vation of the animal functions; for, if the vital contraction of the blood-vessels be either increased or diminished, irregular distribution of the blood inevitably follows, and from this source numerous diseases arise, and none more frequently than in- flammation. However, though these senti- ments, delivered by Dr. Hastings, may be generally correct, I am not prepared lo join in the opinion, that inflammation is ever produced simply by an inequality in the distribution of the blood; a statement which this gentleman probably does not mean to make himself, as he confesses that tahili; Zimmermann de irritabilitatt, p. 24 ■ Hunter on the Blood, fyc) . Dr Cullen attributed tbe proximate must of inflammation to a " spasm of the extreme arteries supporting an increased action h (he course of them." This theory only dif- fers from that of Boerhaave in the cause which is nsshned for the obstruction. Dr, Cullen conceived, however, that some causes of inequality in the distribution oi Ihe blood might throw an unusual quantity of it into particular vessels, to which it must necessarily prove a stimulus ; and that, it- order to relieve the congestion, the vis dm- dicatrix natura* increases still more the action of tbe vessels ; which, as iu all other febrile diseases, it affects by the formalioi of a spasm on their extremities." "A spasm of the extreme arteries, supporting an in- creased action in tbe course of them, may, therefore be considered as the proximate cause of inflammation ; at least, in all casci not arisirig from direct stimuli applied ; and even in this case the stimuli may be suppo- sed to produce a spasm of the extrema vessels" (Cullen.) The inconsistencies in Cullen's theory are very glaring. The congestion or accumula- tion of blood, which is only an effect orco* seepjence of inflammation, is set down u fhe cause of the spasm of the vessels to which spasmodic constriction Cullc strangely enough, assigns the name of pi mate cause. The spasmodic contractioi the extremities of the vessels, instead propelling the accumulated quantity ol blood, would render the passage 01 the blood from the arterial into the venous sys- tem still more difficult. (Burns.) We shall now notice the celebrated and very original opinions promulgated on thi subject by John Hunter. According to him, inflammation is to be considered only as a disturbed state of parts, which requires a new but salutary mode of action to restore them to that state wherein a natural mode of action alone is necessary. From such a view ofthe subject, therefore, inflammatioi in itself is not to be considered as a disetW, but as a salutary operation, consequent either to some violence or some disease. Elsewhere the author remarks, the act of in- flammation is to be considered as an inert* sed action ofthe vessels, which, at first, consiit simply in an increase or distention beyod their natural size. This increase seems to it- pend upon a diminution of the mutad* power of the vessels, at the same time tliat the elastic power of the artery must he di * the same proportion 77iii K lated some Of the phenomena of this disease de- action in the parts to nroducVai pend upon sympathy between the sanguife- of size for particular pulses nnd this Mr. therefore, something more than simply a com- mon relaxation .- we must suppose it an increaH rous and nervous systems. (See Hastings on Inflammation of the Mucous Membrane of the Lungs. H-c. p 32,-84, 6.3 8ro. Ij)nd. 18-20; and C. II. Parry, Additional Experiments on tue Arteries, i,-c.p. 112, 114 ; Also Whytt on the Motion ofthe Fluids in the small Vessels; t erschuir de Arteriarum et Venarum vi irri- purposes • Hunter would call an act ofdilu! whole is to be considered operation of nature. uaii-n. Til' necessary Owinp to this dilata- tion, there is a greater quantity of blood cir- culating in the part, which is according to the common rules of the animal economy tor, whenever a part has more to do than INFLAMMATION. 115 •simply to support itself, the blood is there collected in larger quantity. The swelling Is produced by an extravasation of coagula- ble lymph, with some serum : but this lymph differs from the common lymph, in consequence of passing through inflamed vessels. It is this lymph which becomes the uniting medium of inflamed parts; ves- sels shoot into it; and it has even the power of becoming vascular itself. 1 he pain pro- ceeds from spasm. The redness is produ- ced either by the arteries being more di a- ted than the veins, or because the blood is not changed in the veins. " As the vessels become larger, and the part becomes more of the colour of blood, it is to be supposed there is more blood in the part; and as the true inflammatory colour is scarlet, or that colour which the blood has when in the arteries, one would from hence conclude either that the arteries were principally di- lated, or, at least, if the veins are equally distended, that the blood undergoes no change in such inflammation in its passage from the arteries into the veins, which I think (says Mr. Hunter) most probably the case; and this may arise from the quickness of ils passage through those vessels. When a part cannot be restored to health, after injury, by inflammation alotie, or by adhe- sion, then suppuration, as a preparatory step to the formation of granulations, and the consequent restoration of the part, takes place. The vessels are nearly in the same state as in inflammation ; but they are more quiescent, and have acquired a new mode of action. (Hunter.) Wilh respect to Mr. Hunter's theory, which has deservedly had vast influence in regulating the judgment of professional men in this country, on the nature of the process called inflammation, it cannot be received in the present state of knowledge without some limitation. The hypothesis, that the blood-vessels possess an active power of dilatation, independently of their elasticity, as Dr. Hastings observes, must as yet be regarded as devoid of proof, and therefore, should not be assumed as a basis on which any theory of inflammation is founded. (On Inflammation of the Mucous Membrane of the Lungs, fyc p. 70.) And, as another intelligent writer remarks, how dif- ferent would have been Mr. Hunter's infer- ences, if, instead of trusting to t!,c unassisted eye, he had viewed the inflamed vessels through the microscope. He would then have seen the blood moving, and found, that, " instead of ils passage being quickened in the inflamed vessels, it is uniformly render- ed sower in proportion to the degree of in- flammation, and, in the most inflamed parts, stands still altogether." (On the Vital Func- tions, p. 288, Ed. 2.) And. in another part of his writings, Dr. Philip has endeavoured to prove, from several facts respecting the colour of the blood, that within certain limits, the accumulation of this fluid in the debilitated vessels of the inflamed part neces- sarily causes the blood to retain the florid colour. (On Fevers, Part 2. Introd.) In modern times, the vagin-, but conve- nient expression, increased action of Uie ves- sels has been very generally used as an adequate explanation of the proximatecause of inflammation The doctrine, it is said, derives support from a review of the several exciting causes of the affectioj, which, be- ing in general of an irritating nature, must, when applied to any living or sensible parts, occasion such increased action of the ves- sels ; while the method of cure also tends to confirm the opinion. But, before one can judge whether this doctrine i:- correct, and supported by facts and observation, it is necessary to understand precisely what is implied by increased action of vessels; for it is not every affection of the vessels, capa- ble of being thus denominated, which will of itself constitute inflammation. In gesta- tion, the arteries of the womb are enlarged, and a greater quantity of blood is sent into them ; yet this organ is not inflamed. The carotids are in a similar state during the growth of the stag's horn ; but no inflam- mation exists. If then the proximate cause of inflammation is to be called an increased action of the vessels, we must first be in- formed not only what is meant by the term, but what particular vessels are spoken of, whether the arterial trunks, biv.nches, or capillaries ? Because, if tiie phrase is intend- ed lo signify inc.eased alternate expansions and contractions of all the arteries of the inflamed part, it is an hypothesis entirely destitute of foundation. If it be meant to denote an increased velocity of the mo- tion of the blood in the part affected, the doctrine is rather contradicted than con- firmed by the latest and mo.it carefully insti- tuted microscopical experiments. But if the expression only refers to the dilated sfate of the capillaries, the throbbing ofthe arte- ries leading to the seat of inflammation, the effusion of lymph, be. less fault can be found with the language, though yet requiring much further explanation ere it can com- municate any very precise information. " There are (says a learned professor) two hypotheses, which at present divide the opinions of pathologists respecting the state of the capillary vessels affected with in- flammation. According to the 'irst of these hypotheses, the inflamed vessels are in a state of increased action ; according lo the second, they act with less force than the (ranks from which tbey are derived." (See Thomson on Inflammation, p. 64.) The first of these opinions, according to Dr. Thomson, was suggested by the views which Stahl took of the animal economy7, and his ideas respecting the tonic or vital action of the capillary vessels. The doc- trine, however, was more particularly insist- ed upon by his disciples and followers, especially Dr. Goiter, who in one place expressly states, " that the proximate cause of inflammation consists in an increased vital action of some particular artery or arteries, by which the blood is propelled with greater force than usual into the com municating lymphatic and colourless ves- Ho INFLAMMATION. udimu Me !i ine a.id sels." (See his Cmnp Chirurgia Repurgata ) The doctrine which supposes the action ofthe inflamed vessels to be diminished or to be proportionably less than that of die trunk or trunks from which they are deri- ved, was, as far as Dr. 1 ioi.-i-ii can learn, first stated by Vacca, an Italia.i pliy-u-iun, in a small treatise on inflammation, publish- ed at Florence in 1765. entitled ' LH>cr de Inflammationis Morbose. que in humano ror- porefil naturd, causis. effedibus, et curatione." For an account of the arguments with which Vacca supports his hypothesis, my limits oblige me to refer to the work of Dr. Thomson. (P. 68, SfC.) As this gentleman has observed1, there are certain points in which the two doctrines agree, as well as in which they differ. "The advocates for each hypothesis agree iu admitting, 1st, that inflammation has ts seat in the capillary vessels ; and 2dly, that the redness in inflammation is owing to an unusual quantity of blood in the vessels of the inflamed part, and consequently that the capillary arteries are much dilated du- ring the state of inflammation The con- tractions of these vessels, indeed, it has been said, are increased also in a ratio pro- portional to the dilatations; but, this is an assertion which has not yet been proved, either in the way of experiment or of ob- servation. " The sense of throbbing, which the advo- cates for the hypothesis of increased capilla- ry action regard as the strongest proof of that action, Mr. Allen is disposed to attribute to the difficulty, which tht* blood meets with in passing from the trunk into the capillary branches. This sensation of throbbing, and appearance of increased action, may be produced in an instant, by applying a liga- ture to au uninflamed finger, so as to ob- struct the motion of the blood through its point. Besides, this throbbing,«or pulsatory motion, can afford us no criterion, by which to judge ofthe force, with which the artery contracts, for, it is produced in the dilatation ofthe artery, and by a power foreign to the artery itself." (Thomson on Inflammation, p. 73.) Dr. Wilson Philip, many years ago, en- deavoured to ascertain, by means of the microscope, the state of the vessels in the various stages of inflammation, both in the warm and cold blooded animal. I have put tbe epithet warm in Italics, because it has been very recently observed by my friend Mr. James, that " analogies between the higher and lower orders of animals, the chief subjects of these experiments, cannot be deemed conclusive." (On some of the General Principles of Inflammation, p. 29, Bvo. Lond. 1821) as if it had escaped atten tion, that many of the experiments were really made on the more perfect animals. From the valnable observations, to which plained bv Hip PYnpri-rTonVa- pt?2TteJ^PhiHp0n^e ^^c ^£*ti£*£*™uh ancjfedat STsLni },t tPP-earS' *afltthe,state of acting through this system, are felt by th t£t>l?Si«LVTeI, lR an.,»flamfl Parti, vessels, and that independenflv „f -iefnier- rt*t* prematura! d,^„*>n and Ability, rention of any effect JroduCeion th! bZ k ■ fn,- H,e larger vessels, whose e'ate may be ^ra.er-«'>-'ttl,'-r,d °f ^ 77 scooe, "bey do not undergo a similar d*. £,. and the increased pu sation of fe arteries sufficiently evinces (heir mcrea* notion In i .damnatory affections of fr jaw and the head for example, a greatly » creased action ofthe max.llar, and temporal arteries is readily perceived by the finger. It is to be observed, however, (hat, although inflammation, as was evident from the fore- going experiments, begins in the capillaries if it continues, the circulation in the smallest vessels becoming very languid, those imme- diately preceding them in the course of ihe circulation begin to be distended, and conse- quently debilitated." Dr. Philip adds, tk such distention and debility of the vesseli, which immediately precede the capillar*!, cannot go far, because when the former lose their power, the circulation in tbe latter ia not supported, and gangrene soon ensues. " In short, (says Dr. Philip) inflamn seems to consid in the debility ofthe capilh followed by av appears inflamed. If the stimulus be removed, the vessels do not soon regain their original state ; time is necessary to allow them to recover their contractile power, so as to prevent the impetus, with which the blood is propelled by the hear' and larger arteries from keeping up the dilated state of the ca- pillaries. Here then we are. obliged to ad- mit, with Boerhaave, that there is an error loci ; for, a denser and redder blood passes into small vessels, which before carried much more fluid contents ; but the error loci does not cause the inflammation, but results from •he previously weakened state of the capilla- ries. In this manner, the blood may occa- sionally be extravasated in' inflammation, without any actual rupture of a vessel, for the exhalants may be so weakened, a-.d d lated. as to allow globules to pass through them. " If the stimulus, which produces, the in- flammation, be of a very acrid nature, de- bility of the vessels i« frequently induced without any previous excitement The blood iu all the smaller vessels becomes very red, circulates very slowly, and in some vessels stagnates. . " The application of a stimulus, different from (hat which produced inflammation, will sometimes bring on resolution. When this occurs, the dilated vessels contract; they no longer contain a red, dense homo- geneous fluid, but again receive blood con- sisting of small, nearly colourless globules, which float in a colourless fluid ; and the motion of (hese globules at length becomes as epiick as before the inflammation took place. If, however, the inflammation pro- ceed, the blood becomes nearly stagnant ; it continues Very red, and the vessels are much dilated. '■ When this high decree of inflammation is not relieved sphacelus ensues. The part then feels softer to the finger, and gives way with less force. The vessels are much dila- ted, the blood does not move, it loses its red colour, and becomes of a yellowish brown hue. The separation of the dead from the living part takes place soon after this change in the colour of the blood. " While the ulceration, produced by this separation of the dead from the living part of the web is healing, the capillary vessels, distributed on the ulcerated surface, and the contiguous parts, are much distended with arterial red blood, which is moved very slowly. When the ulceration is healed, the vessels become contracted, and circulate the fluid, with the same degree of velocity as before the inflammation was excited. *' With respect to the seat of inflammation, it may be observed, that the capiljaries are first affected; but even (he small arteries of t'io web are also occasionally "distended." (Hastings on Inflammation of the Mucous Membrane of the Lungs, <§/■'-. p. 90—92.) With respect to the doctrine, espoused by some pathologists, that the smaller branches of veins are the exclusive seat of inflamma- tion, the same author observes, that the microscope shows u-. that the most minute arterial branches, though far less numerous, are equally affected with weakness and distention. Iu the course of Dr Hastings's inquiry, it is proved, that the healthy circulation of the blood essentially depends upon a due degree of action in the vessels throughout the sys- tem ; that the application of stimuli, while it increases the action ofthe vessels, produ- ces none of the symptoms of inflammation. When, however, the excessive action of these stimuli has impaired the excitability of the small vessels, the phenomena of inflam- mation are fully manifested ; and when their INFLAMMATION. that the theory, whicb represents thia cess as'consisting in an increased momentijj of the blood in the part affected, is not f 118 excitability is restored, the inflammation subsides. It may be logically inferred, there- fore, says this writer, that inflammation con- sists in a weakened action of the capillaries, by which the equilibrium between the larger and smaller vessels is destroyed, and the latter be- come distended- And, with respect to the conclusion, drawn by Dr. Thomson from his experiments, that inflammation, in moderate degrees, consists in an increased action of the vessels, Dr. Hastings argues, that the writer's belief in the excitement of the capillaries, in some cases of inflammation, ,. arises from his having denominated that a up for loss of velocity state of inflammation, which ought not to be so called. " Tbe application of the salt, (says Dr. Thomsoi ■ produced an increased velocity in the dilated larger and smaller arteries and ca'pillary vessels, to which it was more immediately applied. In nine experi- ments, the phenomena of which 1 have minutely recorded, the application of the salt was not only follow ed'by a bright red colour, visible to the naked eye, and a sensi- ble enlargement of the arterial and venous branches, but with an increased rapidity of circulation in the capillary vessels; the glo- bules becoming less distinct, than before the application of the salt, and obviously less distinct, from the rapidity of their motion, than the globules in the capillary vessels in the uninflamed part of the web in the same animal. The repealed application, however, of Ihe salt to the same vessels, was always sooner or later followed by retarded capillary circulation, or even by complete stagnation." (See Thomson's Lectures,p. 68.) The results of other experiments, made by this gentle- man, and which coincide with the sentiments of Dr. W. Philips and Dr. Hastings, need not bere be cited. Now, with regard to those experiments, Which seemed to Dr. Thomson to justify the inference, that moderate degrees of inflai% mation may be attended with an increased velocity of the blood in the inflamed vessels, Dr. Hastings, as I have already said, objects, that the appearances seen, while such velo- city of the circulation presented itself in the vessels affected, ought not to have been denominated inflammation ; because " it constantly happened in hisownexperiments, that when inflammation commenced, no globules could be seen even in the blood of the affected vessels It was universally con- verted into a bright red homogeneous fluid. So that globules could never be seen in the capillaries of a really inflamed part, much less moving with great velocity. He argues, that the state, alluded to by Dr. Thomson, is only that temporary excitement of the capillaries, generally preceding their debility, which is inseparable from inflammation. (See Hast- ings on Inflammat on. fy-c p. 98, lol.) Of course, such writers as believe, that the blood in tbe capillaries is not propelled by these vessels themselves, but by the impulse received from the heart, cannot assent to the foregoing view, in which the proximate cause of the inflammation is ascribed to de- bility of those vessels. Dr. Parry argue. lidated, were u even ""'-"' ", -""»«■ the opinion of Dr. Philip, that the velol of the blood in the vessels of an mflav, part is diminished, unless it be also prov^ that the velocity is diminished in a greet, proportion, than the quantity is increased, (Ehmenlsof Pathology, Vol I, p. 84.) Jj far, however, as 1 can judge, the argument- are in favour of Dr. Philip's view of tbeioJ> ject: for, with respect to quantity makiaj 'up for loss of velocity, if the suppoiition were to be adopted, surely it could not t* retained after the inflammation has arrived at that state, in which the fluid in thecapi*. laries is seen with the microscope to be nearly or quite stagnant. It must be coe- fessed, at tne same time, that the questioi about the proximate cause of inflammation is still a topic of endless controversy, into which I consider it perfectly absurd to ester any further than can be avoided, withoaj having leisure at present to prosecute tie in- quiry by experiments. In One sense, boti Dr. Philip and Dr. Hastings admit, that u increased action of the vessels may exists inflammation ; but then this exciteraentor increased action is not in the capillaries, ha* the larger arteries; and Dr. Philip even ntf gests, that the presence, or absence of suck excitement may make the difference be- tween acute and chronic inflammation. The considerations in support of the side of toe question, to which 1 do not myself incline, may be found in the writings of Dr. Parry, Dr. C. H. Parry and Mr. James of Exeter. From this remark, I would not have it infer- red, that I am quite convinced of the propriety of referring the proximate caused inflammation to debility of the capillaries, though the retarded circulation in them, like their dilatation, is now a fact placed out of all doubt. The points, however, on which I should not assent to Dr. Philip's doctrine, will be best understood, when the treatmeat is considered. In the work of Mr. Jamei may be perused a very good summary of Bichat? doctrine, which I would willingly annex, if the subject were intelligible, with- out an explanation of some physiological opinions, tor which I have not room in this edition. (See J. H. James, Obs. on some •/ the general Principles, fyc. of Inflammation, f. 38, 8vo. Lond. 1821.) Redness— This is manifestly owing to th« increased quantity of blood in the inflamed part. More blood must necessarily be con- tained there, because the vessels, which pre- viously conveyed this fluid, are preternatu- rally distended, and the small vessels, which naturally contained only lymph, are now* enlarged as to be capable of receiving red f *,-!'■l froze (sa>s Mr- H""ter) the ear ot a rabbit, and thawed it again ; this occa- sioned a considerable inflammation, an in- creased heat, and thickening of Hie part- u Sura bit was kil,ed whe" the ear was in the height of inflammation, and the bed being injected, the two ears were -emovea INFLAMMATION 119 Wd dried. The uninflamed ear dried clear, and transparent, the vessels were distinctly seen ramifying through its substance ; but, the inflamed ear dried thicker and more ' opaque, and its arteries were considerably larger." Many have supposed, that the redness of 'common inflammation is partly occasioned by the generation of new vessels. This doctrine, however, seems very questionable. ■When coagulated lymph is extravasated upon the surface of a wound, or an inflamed membrane, unquestionably it often becomes ^vascular, in other words, furnished with new vessels. But, in tbe extravasated lymph of a phlegmonous tumour, we have no evidence, that there is any formation of new vessels. /•Were the lymph to be rendered organized : and vascular, the swelling and redness would ^probably be more permanent, and at least inot admit so easily of resolution. When -adhesions form between two inflamed sur- faces, tbe organized substance forming the connexion, lives after the subsidence of the inflammation, and is a permanent effect. In . the experiments detailed by Dr. Hastings, when the inflammation began and termina- ted, without any lesion of the part affected, new vessels were never formed. (On In- flammation, fyc.p. 93.) At the same time, it must be confessed, that great obscurity pre- vails in this very difficult part of the subject; >for when suppuration happens in a phleg- monous tumour, the cavity is lined by a kind of cyst, or membranous layer of lymph, which is unquestionably furnished both with secreting vessels and absorbents ; for, other- wise, how could the continued secretion of pus, or its occasional sudden disappearance, be at all explicable. It was probably the enlargement of the small vessels, and the circumstance of their being filled with red blood, that led to the theory of new vessels being usually formed in inflammation. It has, however, been justly observed, that the supposition easily admits of refutation ; for heat, and many other causes of inflamma- tion, operate so quickly, that there can be no time for the formation of any new vessels; and, yet the redness is as great, and the in- flammation as perfect in a minute as in an hour or a day after the application of the exciting cause. (Burns) Mr. Hunter, it is well known, believed, that a coagulum or a layer of lymph might produce vessels within it- self.—(On the Blood, p. 92, fyc.) Others, however, distrust this hypothesis, and incline to the opinion, which refers the derivation of vessels for the organization of deposits to parent branches. (Tracers, Synopsis of Diseases of the Eye, p 113) The latter sen- timent is corroborated by the appearances noticed by Dr. Hastings, in his experiments, who describes the small vessels first seen in the lymph, upon the surface of a wound, as even then communicating with the inflamed capillaries. (On Inflammation, p. 94.) An- other reason assigned for the redness of in- flammation, is that the blood after it has be- come venous, retains, more or less, its bright scarlet colour. (Hunttr.) And, ia some, late very carefully conducted eiperiments, it was remarked, that the weakened action of the smaller vessels was always accompanied with an alteration in the appearance of the blood. In the natural state of this fluid, globules can be distinctly seen ; but, after inflammation has commenced, the globular structure disappears, the blood becomes redder, and the most minute capillaries are distended with it. (Hastings on Inflamma- tion, fyc.p. 95.) Swelling.—This effect arises from several causes: 1. The increased quantity of blood in the vessels. 2. The effusion of coagu- lating lymph, and serum, and deposition of new matter. 3. The interruption of ab- sorption, particularly noticed by Soemmer- ing. De Morb. Vas. Absorb. Pain —This is observed to be the greatest during the diastole of the arteries. The af- fection is probably owing to the unnatural state of the nerves, and not to mere disten- tion, as many have asserted. Were th© latter cause a real one, the pain would always be proportioned to it. " Parts, which in the sound state have little, or no sensibility (as Dr. Thomson re- marks) become exquisitely sensible in the inflamed. That this is the case with tendon, ligament, cartilage, bone, and membrane, seems to be fully established by Dr. Whytt in the very instructive controversy carried on between him and Haller, respecting the sensibility and irritability of the different parts of man and other animals.—(Lectures on Inflammation, p. 45.) '■ Heat.—The heat or real increase of tem- perature in an inflamed part, when judged of i by me thermometer, is generally much less, ! than might be supposed from the patient's sensations. It is said never to exceed the i heat of the blood at the heart. This in health is usually about 100°. Fahrenheit's thermo- meter ; but sometimes in diseases it arises to 106°, or even 107°. Mr. Hunter artificially excited inflammation in the chest of a dog, and in the abdomen, rectum, and vagina of an ass, without being able to discover any obvious rise of temperature, in these parts. In a patient, however, on whom he opera- ted for hydrocele, the thermometer, introdu- ced into the tunica vaginalis, and kept for some time close to the side of the testicle, was only 9ic ; but rose the following day, when inflammation had come on to 98° 3-4. 'i As Dr Hastings observes, the advocates for excited action of the vessels in an inflamed part have thought, that the increase of tem- perature favours their hypothesis, and have called to their aid the ingenious calculations of Dr. Crawford. They have even gone so far as to say, what state of the arteries enables the blood to give out most caloric. They tell us, that, in consequence of excite- ment of the vessels, more blood is transmit- ted into the minute arltries ; fhe capacity of a greater quantity of this fluid for he at is of course diminished, and more caloric is I evolved in the inflamed part. (Hastings, on I Inflammation, p. 110.) let, this theory, be- I sides involving the contradicted hypothesis 1 120 INFLAMMATION. version into carbonic acid. A living rabbij lot m0 cubic inches of carhop*, acid in un hour. A decapitated animal, fa whom artifirial iespir»,''0ii was kept op, emitted 4ti—48 inches in the same t.me. The thermometer in the rectum ofthe latter hat! fallen irom 97 to 90, while, in mother rab. bit left to itself, but similarly treated in all .,thcr rejects, it had fallen only to S»l. h abbit.^oisoned with woorara, orthees- of an increased and accelerated flow of blood through the vessels ol the n flamed part, cannot be reconciled to various other considerations. " Daily experience con- vince s us, (says the above wri er,) that the temperature is not alw ays proportional to the Telocity of t.-e circulation. In fevers ibe author has several times ascertained, with the ihern-oun-ter. that the heat uas lul.c, when the pulse beat ot-lv 45 time* in a mi- nute. In hydrocephalus', wilh a pulse from senlial oil of bitter almonds, not decapitated, •501.- 7o, ibe heat is often above tbe degree and, in which -rtifical breathing was kef! it reaches in health. In these cases, accord- up, 51 cubit inches of carbonic acid were ing to the theory of Dr. Crawford, the heat emitted in an hour. The thermometer ii shotibl rather be" under, than above, the na- the rectum had sunk to 91 in 30 minutes; tural standard." (Op. cit. p 112.) And, as while it stood at 92 in another animal, treat. another judicious writer has noticed, al- ed e.\actly in the same way, with the oroij. th- u^h the former mode of explaining the sion ofthe artificial breathing. From then production of animal heat has been held experiments, Mr. Brodie infers " that^inu adequate to account for ihe phenomena by animal in which the brain has ceased toei- such philosophers as Black, Crawford, La- ercise its functions, although respirationc** voisitr, and Place, the evidence on which it tinuesto be performed, and the circulate rests, is not so clear as to have commanded of the blood is kept up to the natural stand- universal assent, or entirely set aside objec- ard, although the usual changes in the see- tions. It has indeed been teiien-llv allowed, sible qualities ofthe blood take place in Ihe that respiration and the changes it produces two capillary systems, and the samequeii- in the air and animal fluids, are essential con- tit y ol carbonic acid is formed asunder ditions of the evolution of caloric in ani- ordinary circumstances; no beat is genera. mals; but, it has been thought, that there are ted, and (in consequence of the cold air other circumstances, hilherto, perhaps, not thrown into the lungs ) the animal cooh well understood, which influence the pbeno- more rapidly, than one which is actually mena. In external appearance, the blood is dead." (See Phil. Trans, for 1811, p. 36; the same in all the vessels of the fo*tus: is and for 1812, p. 378.) It appears uertain, this any proof, that its temperature is ov ing therefore, that ihe generation of animal heat, to the conversion of oxygen gas mto carbo- either in an inflamed, or an uninflamedpvt, nic acid ? is the uniformity ol temperature can never be satisfactorily explainedbyanj in the higher animals, under varying states reference merely to chymical principles, of respiration and circulation, and the con- and that the process is essentially connected sumption ot various quantities of oxygen, with and influenced by the state of the whether in the'same, or different individuals, functions of the brain and nervous system, consistent with the theory ? And can ]-. cal and no doubt also by the principle of life variations ol temperature be explained by itself At the same time, I think, thatanj it? (Rees's < yclopediu art. Respiration ) hypothesis, suggested without due reference Doubts mudt also spring from the recollection to the connexion', which respiratic* hi! of the discordance of the experiments, re- with this curious and interesting process, lated by Dr. (raw ford, Dr. John Davy, De la w ill never be established. Neither wooUl Roche, and Bernard In fact, the deteimi- venture so far as Dr. Philip, who believes, nations of the specific heats of oxygen gas that animal heat is evolved by the same and carbonic ac.d by the two lalter expert- means, by which the formation of tbe se- mentors are conceived to be very much creled fluids is effected, viz. the action of against the probability of Dr Crawford's nervous influence on the blood, and fbattk theory. Otner stronger grounds for scepti- production of such heat is to be regarded « cisin in this subject are the results of Mr. a secrelion. (0„ the Vital Functions, P-^) TetoZ;T?ZT\ "if™2 Pithed-' -0, H°Wever' ** nfluenceof Z^ervoW decapitated animals, he kept up artificial tern over (his process must be allowed lobe respiration, and thus maintained their i ircu lation. The blood continued to be changed very trre at, and may afford a more probaUl and healthy animals. Y.-t, the temperature of an animal, tln.s heated, sunk faster, than that of another aiimal sin ply killed and left to itself ; anu the former was supposed to be more quickly cooled bv the air con- veyed into its chest. Other experin ents, detailed by Mr. Brodie, tend to prove, that We oyx^en of the air employed in arti- fcial respiration, underwent its usual con- Buff i,i coal.—The blood, when taken out ofthe living vessels, spontaneously separtttl into two distinct parts, the serum and lW crassameiiium. The last is a compound substance consisting chiefly of coagulate lymph, and red globules, the most heuvyfo- gredients in the blood. Blood, taken a'waj jrom persons affected with inflammation,'« longer in coagulating, and coagulates mor« firmly, than in other instances. Hence, tb« INFLAMMATION. 121 red globules, not being so soon entangled in the lymph, descend by their gravity, more deeply from its surface, which being more or less divested of the red colouring matter, is from its appearance termed the buffy coal or inflammatory crust. The firmer and more compact coagulation ofthe lymph compresses out an unusual quantity of serum from it, and the surface of the sizy blood is often formed into a hollow, the edges being drawn inward. (Hunter.) In some cases, these changes in the blood are deemed more in- fallible proof of the existence of inflamma- tion, than the state of Ihe pulse itself. They are however, only a criterion of some un- usual operation going on in the system ; for, the blood taken from pregnant women is al- ways found to present the same phenomena. In peritoneal inflammation, the patient sometimes seems to be in the most feeble state, and the pulse, abstractedly considered, would rather induce (he practitioner to em- ploy tonics, and stimulants, than evacua- tions ■ but, should the continuance or exas- peration of the disorder, or any other reason, lead him to use the lancet, then the buffy coal, and the concave surface of the blood, materially obviate any doubt of tbe exist- ence of inflammation. Surgeons should never forget, however, that in a few anoma- lous constitutions, the blood, when drawn, always exhibits the above peculiarities. Terminations.—Inflammation is said to have thiee different terminations; or, in more correct language, we may say, that, after this process has continued a certain time, it either subsides entirely, induces a disposition in the \ essels to form pus, orcoin- pletely destroys the vitality of the part. When the inflammation is to end in the first manner, which is the most favourable, the pain becomes less, the swelling subsides. the fever, and every other symptom gradually abate till at last the part is wholly restored to its natural size and colour. There is no forma- tion of pus, nor any permanent injury of structure; and if Dr. Philip'stheory of inflam- mation be corre. t, the debilitated capillaries are excited to due action by the increased ac- tion of the larger arteries. (On the Vital Func- tions, p. 29S.) This termination of inflamma- tion is termed by surgeons resolution. Il is for- tunately the most common, as well as the most desirable manner, in which the affec- tion ends. If, however, notwithstanding the applica- tion of the usual remedies. Ihe several symp- toms of heat, pain, and redness, instead of diminishing, rather increase; if the febrile symptoms are likewise augmented, and the tumour gradually acquires a larger size, turns soft, somewhat prominent in the mid- dle, or towards its most depending part; if it should next acquire a clear shining appear- ance, and become less painful, the different symptoms of fever being at the same time diminished, and a fluctuation perceptible iu the tumour; the inflammation has ended in suppuration. The worst, but happily, the least frequent consequence of common inflammation, is t'oi. II 16 the death, or mortification, of the part affect- ed. In the microscopical experiment ol Ur. Hastings, it was observed, that, on tlie ap- proach of gangrene, the blood entirely loses its red colour, and acquires a yellowish brown tinge (On I flammation,p. 97.) ine part, which was of a bright red, becomes. ot a livid hue; small vesicles, filled with a thin fetid serum, arise on its surface, and air is plainly felt within the cellular membrane. The pain is indeed diminished; but the pulse sinks, while the tumour is gradually changed into a black, fibrous mass. These are the three common terminations of inflammation In books,scirrhus is some- times enumerated as one of the terminations of inflammation. The best modern surgeons, however, do not regard scirrbus as one ot the usual effects of ordinary inflammation ; " the term scirrhus, as used by the older medical writers, is extremely indefinite, having been sometimes used to express every kind of induration, which remained after an attack of inflammation, as well as the morbid incipient state of parts about to become affected with cancer. Surgeons now usually limit the use of the term to the last of these significations." (Thomson on Inflammation, p. 126.) Common inflammation, particularly when it affects glandular parts, is often followed by induration, which afterward continues for a greater or lesser time. Thus, when the testis has been inflamed, a hardness of the epididymis frequently remains during life. Such induration, however, is not at all malignant, and, consequently, very different from what is implied by a real scirrhus. TRTIATMKNT OF INFLAMMATION, One principal difficulty in believing the fact of tbe retardation of the circulation in the capillaries of an inflamed part, andagamst the supposition of their being in a state ot debility, is, that the most effectual treatment of common inflammation consists of means, which are generally of a debilitating nature, as bleeding, purging, be. And surgeons are still further attached to the theory of in- crea-ed velocity of the blood's motion, in the part affected, by the recollection of the local augmentation of temperature, the throbbing, and the instantaneous return of the red co- lour, after the discontinuance of any pres- sure, by which the redness has been mo- mentarily removed at some point of the in- flamed surface. These too are all so many- facts, which, as far as I can judge, are ad- mitted by the generality of reasoners, what- ever may be their particular theory. At the same time, it appears equally well proved bv careful microscopical experiments, that in the capillaries ot the part, which is direct- ly the seat of inflammation, there is a retar- dation, and sometimes even a stagnation, of the circulation. But, this is not all, it is fur- ther manifested, lhat the capillaries are con- siderably dilated, the blood in them materi- ally altered, and that there phenomena are followed by an increased action oi tne lar 122 ~cr arteries leading to the part affected Now, I think, if we remain contented with these obvious circumstances, and dismiss the hypothesis of debility of the capillaries, not only the necessity for ventinesonie conjec- tures may be avoided, but a more rational account delivered of the principles of the efficacy of the usual mode of treatment. Thus, I would not presume to offer any sup- position, why (he capillaries are dilated, and why (he motion ot the fluid in them is retarded, but would be satisfied with a knowledge ofthe fact*, so as to elude a source of endless controversy, viz. the ques- tion, whether these changes proceed from debility of the said vessels, or other causes ? In the view, winch I take of the nature of phlegmonous inflammation, 1 consider the following circumstances proved: 1. The dilated state of the capillaries in the imme- diate seat of inflammation. 2. The retard- ation, or even stagnation of the circulation in them. 3. The increased action, or ex eitement of the larger arterie- leading to the inflamed part. All these three main points seem to me to be fully established by the investigations and experiments both of Dr. M ilson Philip and Dr. Hastings ; and I may make the observation, thouL-.li aware, that the latter gentleman does not regard increa- sed action of the larger arteries, as a consti- tuent and necessary part of inflammation, because cases occur, in which no such ex- citement can be detected . (On Inflammation, p. 104,) for, I here put out of consideration chronic inflammation, whie ii 1 believe is entirely a different process, bearing no re- semblance to the acute forms of the disor- der, either in the state of the capillaries, or of the largerarteries. Assuming the above points as proved, it is to be inquired, whether other fact.-, such as the heat and throbbing in the inflamed part, the instantaneous return of redness to the spot, which has been touched, and the efficacy of common treatment, are re- concileable with '.hem, or not. I am dispo- sed to think they are ; for, it is only asserted. that the passage of the blood is more or loss obstructed in the capillaries in the seat of Ihe inflammation; and the larger arteries, leading to them, are, for the most part, ob- viously in a state ol increased action, where by a greater quantity of hlood must be sup- posed to be determiu-d towards the part. Now, as this augmented quantity of blood eannot pass freely througn the smaller vessel v in the immediate place of inflammation, it must be thrown into such arteries in the •aeighbourhood,as ar- capable of receiving it, so that, in fact, the theory of obstru- tion of the capillaries may not be altogether in- compatible both with increased action; and quickened circulation, n the arteries directlv around the parts, in which there isaretoHed circulation in the capillaries. This view of the subject, I think, is not liable to greater PfrP|"'ty >n the explanation of the heat, throbbing, &.c than former doctrines, involv- ing the contracted notion of there being an in- er-e?uede,actlon'a,,d an augmented velocity «1 the blood's motion, in all the arteries of fte part affected. lAPLAAIMATfOX Resolution being the most favourable; ter- mination of common inflammation, it is 0( "ourse the object at wh.ch the surgeo, generally aims in the treatment. Di. I hilipi very in enious view of inflammation lead) h.m to "suppose that resolution arises from the debilitated capillaries being excited te due action by the increased action o. (he lin-er arteries. (Oh the Vitai bunctom, p 2!)8.) But I am of opinion, Hint Ibe d'icirine of debility of the capillaries, and the hypothesis of their being strengthen- el by tne excitement or increased action ofthe larger vessels are by no means satis- factory, and p rhaps, not very i,.felli?i- ble. On the contrary , if the capillaries are already so weak as to be distended by tie ordinary impulse of the blood, how are they lo be restored to their natural dimensions and functions by any increased action of the lar- ger arteries ? the effect of which I should conceive, would be to gorge them still more with blood, and produce even a greater dila- tation of them. Were the above reasoning correct, it would follow, that a principal in- dication in the treatment would be to pro- mote the increased action ofthe larger ar- leiies, whereby so much supposed benefit is communicated to the debilitated capilla- ries. Yet, such practice is contrary to the dictates of experience, and is even inconsist- ent with the principles, on which Dr. Philip himself thinks the treatment should be found- ed. Indeed, the following d.rections are such, as 1 imagine, will be perfectly appro- ved of by practitioners, who, farfrom looking upon the increased action of the arteries, as a means of relief, are accustomed to do every thing in their power to lessen and re- sist it. " All the local means (says Dr. Philip) are calculated either to lessen the contents of the morbidly distended vessels,or to ex ite these vessels to expel them, ihe general means are regulated by Ihe effecti, produced by the disease on the more distant vessels, through the medium of the nervous system ; tiie objects of this part of the treat- ment being, neither to allow the action of these vessels to fall so low, that it is incapa- ble of supporting any degree of circulation iu tbe debilitated vessels, nor to become so powerful, as fartner to dilend by gorging them with blood. Thus, when the ympl of active inflammation run high, we L ss n the via u tergo ; when gangrene is threatened, we increase it." (W. Philip, „n the Vital Func- inns,p. 28b Ed. 2.) In short, as soon as the fact is established, that a str. ng flow of blood towards an inflamed part tends to aggravate the disorder, all difficulty ceases in reconci- ling the usual means of relief to that theory of inflammation, which takes into tbe ac- count a retarded state of the circulation ia tne distended capillaries. The nea is employed for the relief of in- fl-mtnation have be-en cursorily noticed in a pr.-ceding article. (See Anliphlogistics.) We shall now devote a few more pages to a more particular consideration of ihein. Removal of exciting causes —|n all cases the first circumstance to be attended lo is- Ihe removal of all such exciting catrses a? m«J INFLAMMATION. 123 happen lo present themselves. !f the irrita- tion of a splinter were to excite phlegmo- nous inflammation, who would not of his own accord directly takeaway the extraneous body ? In wounds, foreign sqhstances lre- queuily excilt inflammation, and ought to be taken away as speedily as possible ; -plinlcr- od pieces of bone often, give rise lo the affec- tion, and require removal ; Ihe head of a bone, beinu out of its phue, may press and inflame the partem which it lies; and who does not immediately see the propriety oi putting it bulk into its natural situation? These and other -imilar exciting causes may often be delec!<-J and removed at once, and this is doing a great deed towards the cure and even the prevention of mfl numation. However, many of the exciting causes ol this affection are only of momentaiy application ; yet, though they no longer exis-, the process of inflammation must follow, as a kind of salu- tary operation, wi(bou( whirb, the injured or- ganization, and (one ofthe parts, still remain- ing, could not be rectified again. Hence besides taking away (he remote cnuse, whenever this can be done, it is pioper lo moderate, by other mean-, (he increased aition of the larger arteric-, and lessen the velocity of the blood's motion towards ihe infbimed part. Bleeding—\s theic is reason to believe, thai, in common inflammation, a greale-r quantity of blood is impelled towards the in- flamed part, than in the natural state, and experience proves, that nothing has a more powerful effect in checking the disorder, (bun diminishing the deteimimitiou of blood to the part, bleeding must be a principal means of relieving inflammation : it le.-sens the action ol (he whole sanguiferous system, and, of course, of tha( pari of ii, which is directly concerned in regulating the quantity of blood transmitted to the part atf cted. On the principle also of lessening the whole mass of blood in the circulation, it must have a similar effect. Bleeding, however, is often misemployed, especially when regarded as the only remedy for infl'limitation, and other steps arc ne- glected. Hie general obstinacy and vehe- mence of the process in weak constitutions prove, that bleeding is not invariably proper, and in such individuals it often appears, as it their general irritability and the difficulty of curing the inflammation were in a ratio to their weakness. *.*■ hen inflammation is com- plicated with disorder ot the chylopoietic, blood should be taken away wilh great cir- cumspection. A greal deal of induralion wilh little pain and heat iu (he inflamed pari; the probability of a loug and copious suppuration, as is the case in many compound fractures ; and the connexion of the inflammation, wilh a want of (one in Ihe pari ; are particular instances, in which the practilionersbould be sparing of this evacuation. Bleedin? is sometimes quite unnecessary, when the local inflammation and symptomatic fever are trivi.I, when the patient is feeble or very old, and when the cause of ihe affection can b* entirely remo- ved. (Richter.) On me other hand, bleeding is highly be- neficial when the inflammation is uncompli- cated with any previously existing disorder ofthe gastric system, while it is considerable iu extent and degree, and attended wilh a good deal of febrile disturbance. The same prac ice is also strongly indicated, when ihe pari affected is very sensible, anu highly im- portant, in regard to its e the e in the system. Thus the lancet must he lie^ ly employed in acute ophthalmy, or iuflainnitiiion ot the eye, v\ inch is a moct sensihle part ; and iu inflam- mation of (he lungs, brain, or stomrtcti ; organs, ihe sound stale of which is essential to the regular continuance ol all the various operations in the animal machine; and it a successful elfort oe not promptly made to -op such inflammation by aie most vigorous means, death iiseii will be the result. In general, bieeding may be said to be indicated, wheu ibepalienl is young, robust, and plethoric; when (he cause ol the disor- der can neither he removed nor diminished ; and when ihere is a very strong motive for wishing to avoid the formation o! matter. In- flanuuaiion ol the eye is a case, illustrative of the truth of ibe last observation; tor, if suppuration take place in this organ, the common consequence is so serious a destruc- tion ot ils internal structure and organization that the tulure restoration of sight is totally impossible. In the examples, tailing under the conditions specified as req Tiring blood lo be taken away, it is sometimes necessary irequenily to repeal ihe evacuation. The efficacy of bleeding is greater, the sooner it is practised, and the more suddenly Ibe blood is evacuated. Bleeding near the part affected is usually m-.re effectual, than when done in a remote sit-aiion. Hence, in inflammation of the eye, or bruin, it isotten considered most advantageous to take blood Irom tbe temporal arteiy. '• lu many iuflimmations, particularly those of ihe parts contained in the three great cavities of the head, cnest, and belly, general bloodletting (says a judicious writer) if not Ihe only, is the principal remedy, to which we can trust for a cure, the quantity of blood, which in these inflammations it is necessary to take away, varies according to ihe violence of the inflammation, the temperament, strength, and habits of the patient, and ac- cording to the structure, functions, and situa- tion of the organ in w hich it occurs. From tvelve to twenty ounces, or even more, ought generally to bi drawn every time we have occasion to use the lancet in the. cure of inflammation, and bleeding to this extent may be repeated (wo or three times in the course ofthe first twenty-four hours, according lo the effects which it seems to produce, as well as according to the violence and urgency of the symptoms. In inflammation of internal parts, we judge ofthe effect of bleeding, and of the necessity of a repetition, from the feeling and*continuance of pain, from thu state of the pulse, and also from the appear- 124 ance of (he blood, which has been last drawn. " A partial, and in some instances, an nl- most complete cessation ot pain lake* place even during the operation of blood-letting. This is always a favourable symptom, and indicates, (hat the i fl uimation has made no great, nor very alarmin? progress. In other instances, tbe relief from pan;, though iinon- siderable, at (he (ime of bleeding, becomes afterward more sen-ible, and tbe other symptoms of inflammation abate in nearly the same proportion; whib-, in other in- stances again, the* pain is either not relieved by the bleeding, or, if relieved, the relief is but of short duration. These last are cases, in which (he otb-r symptoms of inflamma- tion continuing unabated, recourse must be had again lo (he use of the lancet, and as much blood drawn, as can be done wilh safety lo the patient "The changes, which take place in the state of Ihe pnbe, either with regard 10 ils fre- quency, or strength, during, or soon atlerlhe abstraction of blood, though they afford crite- ria, bv w hich we may judge ol the siale ot the inflammation, .nd of the effects of (he bleed- ing, are by no mean- marks so sure ol the ad- vantage, which has been obtained, as thai derived from (be cessation of pain. "In some inflammations of tbe head, for example, (he pulse is slower (ban natural, though it bents with its ace ustnnn-d, or even wilh an increased degree of strength. In inflammations also of the perilonamrn, and of the intestinal ca:>al, we find ihe pulse not much quicker thorn natural, small, and con- tracted. We should deceive onrselve-s, therefore, were we to infer, that an increase of inflammation had taken place, because, in (he first instance, the pulse bad become quicker, and in the second, fuller and strong- er, during or soon after (he abstraction of a quantity of blood. " The pulse, it may be remarked, has often a contracted, cord-like feel in inflammation, and it may always be regarded as a favour- able event, when it becomes softer, fuller, and slower, during or soot: after blood-let- ting." (See Thomson's Lectures on Inflam- mation, p. 16fi, lti8.) With respect to the buffx coat of the blood, Dr. Thomson stales, tt.at it is not by (he buffy coat alone, bul by (he buffy coal, in conjunction with the quantity and firmnesi of the coagulum, that we must judge of the propriety of any blither detraction. When the buffy coat bas a firm and tenacious con- sistence, and when (he pain continues mid- bated, we may conclude, ihat the inflamma tion is not subdued. But, when the c >a::uliini is soft and easily broken, and when the colour of the buffy coal is changed from a yellowish to a greeni-h hue, Dr! Thomson thinks, (hat little or no benefit can be derived from bleeding. But, as already mentioned, every practitioner should remember, thai, in particular constitutions, and in pregnancy, the blood taken away naturally exhibits a buffy appearance, independently of inflammation. Tfaa preceding remarks chiefly relate to INFLAMMATION. eeneral bleeding ; for, in phlegmonous inflam- n a. oi . topical bleeding is scarcely eve, inaiion. « /• highly worthy improper. '• ,s hWB>*»_ .?..„,; ' „,i,.,k/. gen bleeding in or near (he part « ill answer bet- ter, than taking (he blood from the gentrf habit ■ for. certainly less may be removed m 111,- w'av, so as lo have equal effect upon (he part inflamed, and probably, upon every other disease that is relieved by bleeding, with lessui|ury lo ihe constitution. Altlioiinji, in many cases, the general hibit is relieved hy bleeding, yet it is the pari affec(ed \vhictl uios( requires this evacuation. I hat local bleeding has very considerable effects on tbe inflamed pari, is proved by Ihe sudden relief which is often produced by the application of leeches in cases of gout. The mere use of leeehes, without other measures, will a|;o sometimes remove a tumour in ihe fueml, Intving all (he appearances of a scirrhus, which cannot be considered as inflammatory, so that topical bleeding extends its power further, than the mere checking of iiiflam- mation. bome part of its effect has been imputed to sympathy. (Hunter.) There are three modes of performing topical bleed- ing: by cupping; by leeches; and by dividing or scarifying the dilated vessel- leading to the inflamed part. (See Bleeding.) Upon the hei.! and face, leeches are commonly em- ployed ; upon the chest, either leechpn or cupping; upon the abdomen, leeches; and upon the joints, either cupping or leeches, When Hie eye is inflamed, leeches may either be applied (o (he adjoining temple ; or the dilated vessels of the conjunctiva may be scarified ; or both methods may be adopt- ed. When the inflammation extends quite to the surlace of the body, leeches are alwayi most eligible, astheir biles cause le-s irritalion in inflamed parts, than (he punctures of (be scarificator, or the pressure of cupping glasses-. Purging. The exhibition of mild laxative medicines, and sulme purgatives, isa principal means of diminishing inflammation. Purging does not produce such lasting weakness as is the consequence of bleeding, and, therefore, it is scarcely ever omilted, even when (be abstraction ot blood is deeme I improper. Saline purges musl lessen the quantity of circulating blood, inasmuch as they increase Ihe secretion from the in'estinal arteries; and therefore, tbey probably operate beneficially iu Ihe cure of local inflammation, much upon (he same principle as bb-eding. Mr. Hunter was of opinion, that purging lowers action, withoiK diminishing sirenglh, by which we are probably to understand, without prod*, cing a veiy lasting or permanent loss of strength. With re.specl to mild laxative me- dicines, none are superior lo manna, rhubarb, oleum rieini, and the like ; and of the saline purgatives, the best re, the sulphate of soda, tartrate of potass, phosph -te of soda, and sulphate of magnesia. It may her- be re- marked, that, besides the benefit, which the local inflammation derives from ihe judicious administration of purgatives, the costivenesi and heat, which usually attend tbe sympto- INFLAMMATION. 125 . malic fever, are alto removed by the same means. ,v " Purgatives (says Dr. Thomson) are more ,or less required in almost every species of inflammation ; but they are more peculiar- ly necessary in those, which are accompa- nied with a high degree of fever, or wilh derangement ofthe digestive, or biliary or- gans In cases of inflammation, which have a tendency to spontaneous resolution, they 'are almost always the best, and often the only remedies that are required." (Lectures on Inflammation, p 171 ) Considering tbe gei.eral approbation of the employment of mild saline purgatives in cases of inflammation, 1 confess thai I was not a little surprised to find merely the fol- lowing short unfavourable notice taken of them by a celebrated foreign professor, in his account of the treatment of inrlaiiuna- 'tion. " As for purgatives, they must be used wilh discretion. There are none of them antiphlogistic, as has been pretended. They always produce more or less irritation, and can only be applicable, when the cause of the inflammation is iu the intestinal ca- nal. In the beginning of the complaint we ought, therefore, in general to abstain from them, and confine ourselves to emollient clysters " (Boyer, Traiti des Maladies Chi- rurgicules, T. I, p. 39.) Diaphoretic and nauseating Medicines. Medicines, which have the power of pro- ducing sickness, lessen, for a time, the ac- ttiou, and even the general powers of life. This is in consequence of every part of the body sympathizing with the stomach ; and the effect may be very quickly excited Sickness lowers the pulse, makes the small vessels contract, and rather disposes the skin to perspiration But, nothing more than nausea should be caused; for vomiting rather rouses than depresses. (Hunter) Nauseating medicines, employed after bleeding has been practised once or twice, are often productive of considerable bene- fit ; but there are some affections, in which they cannot be used, such as inflammation ofthe stomach and intestines. In all super- ficial inflammations, however, they may be safely and advantageously exhibited, as well as in most inflammatory affections in- ternally situated. In inflammation of the dura mater and brain, and, indeed, in every instance, in which there is an urgent reason for putting as sudden a check as possible to the continuance of tbe affection, the em- ployment of nauseating doses of antimony is most strongly indicated. The tartrite of antimony (emetic tartar) is the medicine, on which practitioners place the greatest reli- ance, and it is to be prescribed for the pur- pose of exciting nausea, as follows :—[^. Antimonii tartarisati grana duo ; \quae t s- tilhila* unciasepiatuor. Misce et cola. Dj- sis, Unciadimidia sextiiqiaque horft. The safest diaphoretics are citrate of po- tass, acetate of ammonia, and tartrite of an limony, and James's powder. The two latter,from their effects in producing nausea, and weakening the pulse, are sometimes most efficacious, as already stated. " The warm bath seems to act (as a mo- dern writecsays) no^only by increasing the tendency to perspiration, but also by occa- sioning a determination of blood to those parts of the body to which it is more imme- diately applied. It is in this way that bath- ing the feet seems to relieve inflammatory affections of the head and throat. I have not seen any experiments, nor am I ac- quainted with any, which have been made with a view to ascertain its use iu the in- flammations ofthe chest; but, in all inflam- mations ofthe belly, and of the viscera con- tained within that cavity, there are no other means of cure, blfod-letting excepted, which afford such sudden and permanent relief as that which is obtained from hot fo- mentations and warm bathing." (See Thom- son on Inflammation, p. 173.) Opium. The majority of surgeons enter- tain an insuperable objection to (he admi- nistration of opiates in almost all cases of in- flammation, and the aversion to this prac- tice is for the most part deducible from the recollection of opium being a powerful sti- mulant. The plan, however, has its advo- cates. (B.Bell; Richter, &,>c.) One of its strongest partisans tells us, that opium parti- cularly lessens the disturbance of inflamma- tion, and allays pain, which is at once a principal symptom of the piocess, and a cause of its augmentation, as well as that of the fever. Opium also quiets the inordinate action of the solids, the mental agitation and restlessness so powerfully, that it well deserves the name ofthe grand antiphlogis- tic remedy. It likewise occasions a mois- ture on the surface of the body, which ex- perience shows is eminently serviceable in all inflammations affecting the skin. When given with thi- view, it is usually conjoined with antimonyr, camphor, calomel, or ipe- cacuanha. The administration of opium is a general practice in all painful inflamma- tions arising from external causes, and it is attended with perfect safety when evacuations from Ihe bowels and bleeding have been previ- ously put in practice. Care must be taken to give it in sufficient doses; for small quan tities not only fail in fulfilling the object, but frequently produce quite an opposite effect. During its employment, the bowels should be kept open with glysters. fhe efficacy of opium chiefly manifests itself in the early stage of he affection ; for, as soon as the inflammatory fever has extended it- self to the whole system, it loses il, benefi- cial virtues Hence, in cases of external injuries, it is to be given the. two first day*; immediately after bleeding. It is to be given as soon after the accident as possible, iu order to tranquillize the mental alarm, and. if convenient, towards the evening, for the sake of procuring a quiet night. (Rich- ter.) Evacuations being premised, says tbe other advocate for this medicine, the next object of importance is to procure ease and quietness to the patient, which, in cases of 126 inflammation, ore often of .more real service, than any other circumstame whatever. The most effectual remedy for this purpose is opium, which, when the pain and irrita- tion are. considerable, as very frequently happens in extensive infl,i-i'niatio--s, should never he omitted. In large wounds, espe- r; liy after imputatio s, a,id either capital operations, and in punctures of all kinds, large do*es of opium are always attended with rem.ir!-.ably ood effects In all such cu-es, however, opium, in order to have a proper in luence, should be administered in Very lar.-e doses ; otherwise, instead ot proving serviceable*, it s«*enis rather to have the contrary effect. This circumstance i«, perhaps, the r'.iief reason why opiat -s in general have been very unjust!;, condemn- ed iu every case of inflammation. (B. Belt.) On the contrary, those who are aver-e to the use of opium, remark, that in acute in- flammation daily experience shows, inde- pendently of every tiieory, tha! the exhibi- tion of (his medicine.increases the gener; I fever, and aggravates the local action. Even •given a< a preventive of inflammation, after operations anodynes are almost uniformly hurtful, produc'iiv: restlessness, heat, thirst, and after-vurl headach, sickness and fre- quently troublesome vo.-n;ting. (Burns.) A - -ording to I) ■ Thomson. " those dia phoretics, into the composition of wh eh opium enters, seem t be better adapted for int-himmation attended with fev.r of a typhoid character or for cases where the inllamtnalion has existed for a considerable time before diaphoretics are employed. Given at an early period in acute inflamma- tory diseases, opium never fails to excite vascular action, and to aggravate all (he symptoms of fever. Opium, therefore, is rot to he used, unless to allay the pain and irritation from a surgical operation, or from the recent infliction of an external injury. Indeed, unless when the patient is very nervous, and complains much of pain, its use, even after chirurgical operations, had, I believe, in general, better be abstained from, as it almost never fails to add to the violence ofthe symptomatic fever, which is the necessary consequence of the operation. Its effects are o;ten very beneficial, when the period of this fever has passed over." (Sep Le.-'nreson Inflammation, p. 172.) Vp- on the >\h,il , candour obliges me to own, that the majority of surgeons in this country are decidedly against the general use of opium in inflammation ; but, after the per- formance of severe operatiois, and in all instances attended with excessive pain, truth, I believe, will justify tnv saying, that they are in favour of the exhibition of this remedy. Diet and R"irimen.—In all cases, t'ie sur- geon is to forbid the use of wine and spirits ; and, when the inanimation is at all consi- derable, the same prohibition is to be made in regard to animal food. Watery, cooling, mu, ilaginous drinks are proper; for they keep off thirst and heat, promote perspira- tion, and tend to sooth the increased action LVFL \.V\IVTION. ofthe whole ot tne WllOiej em*. .— pose, whey, buttermilk, ructions of dried fruits, arterial -astern. *»or this p«-. ■'"■ '-irlcy-water,d», water-gruel, *, intended It ma. be given. _ When diluent drinks alh.y thirst, as well as to promote perspir, lion, the addition ot son vegetable acti, such as le.non-juice.or cream of tartar, ro- llers them in general very palatable top,. tients In the earlier stages of inflammathe, and where the o!»j-'Ct is to induce a moil- t ire on the skin, the mineral acida, thoujl liev might serve to quench thirst, are nil to lie* employed, as they tend rather tocbeck, (haa pr- mote the flow of sweat." (Tho* son on Inflammation, p. 172 ) The chamber, in which the patient I'm, should not be warmer than his comfort it- quires ; for heat tends powerfully to keep up an increased'action of the sanguifetor*- ostein. For the same reason, the patieU should not be covered with a superfluotu (in.1 utity of bed-clothes. The whole body, but more especially inflamed part, should be preserved in as complete a state of rest as possible. Every one k ows, that all mot-on, exercise, and muscular exertion, accelerate the circuit tion, and, hence, must have a pernicinm effect on inflammation, by determiningi larger quantity of blood to the part affected. Applications. With the exception of whit has been stated, concerning topical hleedinf, ;.!! the fore oing remarks relate to the go neral treatment of inflammation: tbe iW means remain for consideration. It has been already observed, that pblej- mon is attended with an increase of heat in the part affected, and it is an acknowledged and well-known fact, that the action of tbe arteries, as well as every other operation in the animal economy, is promoted and in- creased by the influence of heat. For this reason, an obvious indication arises, viz.to reduce the temperature of the inflamed part, by the topical application of cold, and,in particular, by continually abstracting tht heat evolved in the part, by keeping up1 constant evaporation from its surface. "Of the local remedies, applied directly to inflamed parts (says Dr. Thomson) w>W is undoubtedly one of the most powerM- In reducing the temperature, cold dimi- nishes the morbid sensibility and pain of in- flamed parts; and, probably,inconsequence of this, the action also of the vessels, jif which the inflamed parts are supplied with blood. The most common mode of em- ploying cold is by the application to lb« part inflamed of cloths, which have been dipped in cold water. These are to be rep* , ed as often as they become warm, or any relief is experienced bv the patient from their use. When tbe inflammation is seat- ed on the remote parts of either the upje; <>.* lower extremities of the body, the in- flamed part itself may be immersed iu **•»* Jer. This immersion, as I shall afters- have occasion to mention, has often bee" found useful in superfici.il burns In order to increase the effect produced by rold-'U HV-Fl/mm\tiont. 127 hhas been proposed,to reduce the tempera- ynture ofthe water below that ofthe surround- er;ing atmosphere, by a proper mixture of sa- line bodies, as some of these are known to ; produce coJd during their solution in water, at- or even in very urgent cases to apply ice or e-^snow. The ice, however, must not be ap- "' plied too Ion-, nor in too large a quantity ; in. for, it very quickly reduces the temperature fir*/ of the part to which it is applied, and, in .some instances, has been known t<> occa- \-. sion gangrene, ike. (On Inflammation, p. .180.) ,; With the cold water applied to phlegmo- in nous inflammation, it is usual lo bb nd some remedies which are astringent, and »uppo- ■ sed to have also a sedative qualily. The ace- , tite of lead, sulphate of zinc, am! vinegar, seem now. indeed, to have acquired p° rma- nent celebrity for the r efficacy in resolving .. inflammation. j"' Extensive experience, and long-establish- ed trials, have now fully confirmed the vir- tue of all (hose local remedies, in which the acetite of lead is the active ingredient. M. Goulard, and other French surgeons, found, " that the objections to the employment of '* many other sedative applications in the "treatment of inflammation, did not exist against the use of this preparation of lead The universal assent of modern practitioners proves, indeed, that the acetite of lead as a local application for genuine phlegmonous inflammation, is certainly unsurpassed, if 'not unrivalled, in point of efficacy. The preparations of lead are recommend- : ed by M. Goulard, as almost equally applica- ble to every stage of inflammation. When - swellings have fully suppurated, the employ- ft'ment, of what he calls, the exlradum Satur- - -ai, will almost always render it unnecessary to open them. Even in gangrene, the solu- tion of lead is represented by this zealous . writer, as a remedy deserving of the greatest confidence. But, notwithstanding the above exaggera- tion, every man of experience and observa- - tion will allow, that, while there is a chance of accomplishing resolution, no local appli- cations to phlegmonous inflammation are in general so proper as cold lotions, contaiuiug the acetite of lead. " The manner in which it operates in curing inflammation (as Dr. Thomson ob- serves) is not known to us, nor is it at all , times easy to distinguish between the share, which the lead has in allaying inflammation, and that which is to be attributed to the coldness of the water in which it is dissolved. No one, however, will doubt of the efficacy of this remedy, who has ever felt it iu his own body, or witnessed in others the sooth- ing and agreeable effects, which it produces in excoriations of the skin, or in inflamma- tion of mucous membranes. Lead is a remedy, which is often highly useful in excoriations from friction, in punctured wounds with inflammation of absorbent vessels, veins, nerves, be. in slight burns, in cutaneous heat, eruptions ol the face, in frac- tures and dislocations, in the inflammation attending scirrhus and cancer, syphilis and gonorrhoea, in wounds accompanied a ith excoriation from the discharges they emit, and in wounds attended with a burning^ sensation of pain." (P. Is2.) Fi oni the poisonous qualities of lead, w hea taken into the system, and from the possi- bility of this mineral lieing absorbed trom the surfae:e of the body, objections have arisen against the free use of its preparaiions, even as outward remedies iu i ases of inflam- mation. Certain it is, however, that though the possibility of s.ich absorption is proved by tbe occurrence ofthe disorder calleu th© colica pidonum, which originates iu pah.lers from the whit lead a isorbed into the sys- tem, yet, any ill effects from the use of lead, as <>ii application to i illumed parts, are so exceedingfy rare, thai they caii hardly form a serious objection to the practice. It is a fact, that, in inflamed parts, there is an im- pediment to absorption, and this circum- stance may tend to render the employment of lead a matter of safety. Mr. B Bell ob- serves, that in all the experience which he had had of the external application of lead and its preparaiions, and in many cases, par- ticularly of burns, where he had known the greatest part of the surface of tie body covered with applications of this description for days, nay, for weeks together, he. did not recollect a single instance of any disa- greeable symptom being ever produced by them. Nor has Dr. Thomson ever seen the colica pictonum follow the use of Goulard. (See Lectures on Inflammation, p. 183.) A lotion composed of acetitt of lead, vine- gar, and water, is very commonly employed. ty.. Plumbi Acetatis ^ss. Solve in Acet. pur. ,^iv. Et adde Aq. Fontanae distill, ftij. The vinegar makes the solution more complete. In all common cases, a teaspoonful of the liquor plumbi acetatis, blended with a pint of water, will be found an eligible lotion. Occasionally, bread-crumb is moistened in the fluid, and applied in the form of a poul- tice ; but linen dipped in the lotion, and kept constantly wet with it, is mostly pre- ferred. Thus a continual evaporation is maintained, and of course a regular abstrac- tion of heat. When the surgeon is afraid of employing a solution of lead, he may try one of the sulpOte of zinc. One drain of this sub- stance is to be dissolved in a pint of wa- ter, and linen, well wet with the lotion, is to be applied to the inflamed part. Many practitioners impute very little real efficacy either to the acetite of leadj or sul- phate of zinc, contained in the above ap- plications : and they attribute all the good that is produced, entirely to the evaporation kept up from the s irface of the inflamed part, and to the coldness of the fluid in which the metallic salts are dissolved Surgeons, who entertain these sentiments, think the application of simple cold water quite as efficacious as that of any medicated lotions. There are particular cases of inflammation, in which the extravasation of blood and lymph, in the interstices of the inflamed 128 INFLAMMATION. part, is exceedingly copious, and the swell- ing considerable, but the pnin and redness not particularly great. In such instances, it is an indication to rouse the action of the ab- sorbents, in order that those vessels may re- in ive the extravasated fluid, and with this view, a more powerful discutient lotion may be employed than in other cases, and some- times, it is even better to use embrocations and linimens, than any sort of lotion. The following discutient lotions are often em- ployed : fl Ammonite Muriates ^ss. *ceti; Spiritus Vini rectificati ; sing Jbi ^ ft- Liq. Amnion. Acet. Spir. \ ini reetif. ; Aq. Distillatue ; sing. ^iv. AI. The Liq. Ammo- nia": Acet. also alone answers very well. When the part affected with inflammation i= not very tender, or when it lies, deep, ap- plications of the vegetable acid are often had recourse to with considerable advan- tage ; and the mosl effectual form of using it seems to be a poultice made with vinegar and crumb of bread. Iu such cases, it has been thought, that an alternate u"se of this remedy, and the saturnine |otion, has produ- ced more benefici I effects, than are com- monly observed irom a continued use of one of them. (B.Bell.) However, surgeons of the present day seen to think, that vinegar oan be as advantageously applied in the form ol a lotion, as in that of a poultice, and, certainly, with less trouble. Alcohol and aether have acquired some celebrity as local remedies for inflammation. No doubt one great reason why they are not more extensively used for this purpose is, the expense attending such treatment, as these fluids evaporate with great rapidity. Alcohol may possibly prove useful from its astringent qualities ; but it seems much more rational to impute both its virtue, and that of ajiher, to the powerful manner, in which their evaporation deprives the infla- med part of its heat. Warm Applications. The absurdity of at- tempting to reconcile every useful practice with a philosophical theory, is, in no in- suuee, more strikingly exemplified, than in tue opposite sorts of local applications, which are of service in inflammation. The g uerality of cases undoubtedly receive most rvhef from the use of cold sedative astringent lotions : butthere are constitutio.sand parts, which derive most service from the local employment of warm emollient remedies Were I to endeavour to define the particu- lar instances in which the latterapplications avail most, I should take upon me a task which has baffled all the most ablr* surgical writers. The first stag« of the acute oph- thalmy, and the hernia humoralis, or infla- med testicle, may be specified, however as examples, in which, generally speaking, warm emolli, nt applications are better than cold astringent ones Yet, even with res pect to inflammation of the testis, there is some difference of opinion about the supe- riority of cold or warm applications. Mr James s sentiments are as follows : in the ^rl^1 lt 1? °.f ilnP°rtance to consider the differences of the cans* : thus, in mumps and rheumatism, the constitution m chiej, lobe attended to, and cold applications «i certainly improper. W hen it (the inflamroa- lion of the testis) arises from a blow, afte, leeches have been freely employd, f(,men. tations are (he best remedy. BufMr.James thinks, that this is not the case, in many instances of hernia humoralis from gone* rhcea, where cold applications are prefer- able ; but, he owns, that the feelings of the patient will best detennine the point, (James on Inflammation, p. 164.) " Fomentations, or embrocations will warm water, (as a judicious writer has re- marked) are often a very powerful meani of abating internal inflammation. ThiseA feet is very apparent in some of the deeper seated inflammations, as in the inflaimuHfiun of the urinary bladd-r, intestines, or other viscera contained within the cavity of the abdomen. The warmth, in this case, nw» be applied to the surface of the abdomen,by bath or fomentation, or. in the way of injec- tion, by the anus, be. In some infiamtna- tionsof the joints, warmth also isfoondto be very useful. These, however, are in- flammations, which have a tendency to the chronic state, (see ThomsononInflammation p. 188.) If we may judge by the feelings of certain patients, there are undoubtedly particular constitutions, in which the local use of warm remedies produces greater relief than that of cold ones This circumstance, however, does not generally happen ; and, as warm emollient applications, of all kinds, havethe most powerful influence in promoting sup- puration, a fact admitted by every experien- ced practitioner, the use of such remedies, while the resolution of inflammation is prac- ticable, must be highly censurable. But, I am ready to grant, that iu all cases of inflammation, which manifestly cannot be cured without suppuration, the emollient plan of treatment ought to be at once adopt- ed ; for, the sooner the matter is formed, the sooner the inflammation itself is stopped. The inflammation attending contused and gunshot wounds, and that accompanyws boils and carbuncles, are of this description. The inflammation,originating in fevers.com- monly ends in suppuration, and, in such instances, perhaps, it might be*advanla{ieous, also, to employ at once the emollient treat- ment. Warmth and moisture together, in other words fomentations, are commonly had re- course to in cases of inflammation; but, when the warmth is as much as the sensitive principle can bear, it excites action. Whe- ther it is the action of inflammation, or the action of the contraction of the vessels, is unknown. We see that many patients cannot bear warmth, and, therefore, it might be supposed to increase the action of dilatation, and do harm. But, if the pain should an*e from the contra.-tion of the in- lamed vessels, benefit would be the result; though we murt doubt that this change is produced, as m .king the vessels contract w ould probably give eose. , //„ %ler -, INFLAMMATION 129 From the preceding observations, we must perceive how vain it is to theorize on this subject, which even puzzled the genius and penetration of a Hunter. In addition to what has been already observed, I feel totally incapable of giving any useful practi- cal advice, with respect to those cases, in which warm emollient applications should be used in preference to cold astringent ones. 1 can, however, with confidence remark, that the surgeon who consulls the feedings and comfort of the patient on this point, will seldom commit any serious error. Hence, in all cases, in which the first kind of topical applications seem not to produce the wonted degree of relief, let the second sort be tried. From the opportunity of com- parison, a right judgment may then be easily formed. The poultice made of the powder of lin- > seed is so easily prepared, that the old bread and milk poultice is now seldom employed. As much hot water is to be put into a basin, as the size ofthe poultice requires, and then the linseed powder is to be gradually mixed with the water, till the mass is of a proper - consistence, frequently, a little sweet oil is also added to keep the application longer soft and moist. Fomentations are only to be considered ; as temporary applications, while the emol- „ lient poultices are the permanent ones. The ; former are, at most, never used more than three times a day, for the space of about half , an hour each time. Two of the best are the following:—{£. Li.ii contusi ^j. Chama*- meli ^ij. Aq. Distill. ft>vj. Paulisper coque , etcola. Or, rx Papaverisalbi exsiccati S'iv. Aq. Puraj Ifcvj Coque usque remaneant Jb'j- et cola. Some practitioners, however, are incli- ned to think warm water alone quite as effi- cacious as the decoctionsof particular herbs. Thus Dr. Thomson observes, " herbs are now seldom used in the way of fomenta- ' tion, unless in compliance with ancient custom, or with the prejudices of particular individuals. The discutient power of the warm water may be increased by the addi- - tion of various substances, such as vinegar, ' spirits of wine; saline substances, such as " common salt, acetite and muriate of ammo- nia. But, these warm and stimulating em- brocations are used chiefly in the passive, '" chronic, or more indolent species of inflam- mation. ' (See Lectures on Inflammation, p. 189.) By pursuing the treatment recommended above, the resolution of the inflammation will in general begin to take place, either in the course of three or four days, or in a shorter space of time. At all events, it may ** usually be known before the expiration of ? this period, how the disorder Vvill terminate If the heat, pain, and other attending symp- toms abate ; and, especially, if lii•■» tumour • begins to decrease, without the occurrence of any gangrenous appearances , we may • then be almost certain, that, by a continu- ance ofthe same plan, a total reqolution will n time be effected. V- II. 17 On the other hand, when all the different symptoms increase, and particularly wheu the tumour bpcomes larger, and sottish, at- tended with a more violent throbbing pain, we may conclude, that the case will pi- ceed to suppuration. Hence, an immediate change of treatment is indicated, and such applications, as were proper while resolu- tion seemed practicable, are to be left off, and others substituted. This remark relates to the employment of cold astringent reme- dies, which, when suppuration is inevitable, only do harm, by retarding what cannot 1 c avoided, and affording no relief of the pain and other sym.'torus. If the inflammation, however, should already be treated wilh emollients, no alteration of the topical ap- plications is requisite, in consequence of the inevitability of tbe formation of matter. Indeed, emollient poultices and fomenta- tions are the chief local means both of pro- moting suppuration, and diminishing the pain, violent throbbing, &*.c. which.always precede this termination of phlegmonous inflammation. But, besides the substitution of warm emollient applications for cold astringent lotions, practitioners have decided, that it is also prudent, as soon as tbe certainty is manifest, to relinquish the free employment of evacuations, particularly bloot-letting, and to allow the patient a more generous diet. When the system is too much redu- ced by the injudicious continuance of rigo- rous antiphlogistic treatment, the progres ofthe ensuing suppuration is always retard- ed in a disadvantageous manner, and the patient is rendered too weak to support ei- ther a lon4-continued,ora profuse discbar;. e, which it may not be possible to avoid. I shall conclude this article with briefly noticing blisters, rubefacients, issues, and ' synapisms, as means often employed for the relief of particular cases of inflammation. " Blisters (says Dr. Thomson) are never applied (o a part which is actually inflamed. They seem to be chiefly useful by exciting inflammation in a contiguous part. It is from this tendency, which blisters have to produce inflammation, and of course a cer- tain degree of fever, that they are seldom to be employed in acute inflammatory cases, till the constitutional symptoms are by other means in some measure subdued."—(P. 187.) " Of the same nature, though milder in their operation, than blisters, are the whole class of rubefacients. They produce a de- termination of hlood to the parts to which they are applied, and in a manner not yet well understood, occasion a diminution in the action ofthe vessels, and consequently in tin quantity of blood with which the in, flamed parts are supplied. This influence is exerted more or less directly in different instances. The extremities of the intercos tal arteries may open-both on the pleura lining the chest, and on the sin face of the skin covering it, and whatever excites an increased flow of blood into one of these tc\(iiro<=. mav be. e-<>nceive-ction, like wiiai probably occur- red in the case relaled by Mr. Spry ; Med. and Phy deal Journal, No. XI Sir E. U>;ne, (Trans, of a Society for Medical and Chir. Knowledge, Vol. 1.) mention- an example of a retrograde introsusception, iu which a worm was tumid coiled up round (he introsuscepled part. The disease (ook place in a boy who h;i 1 swallowed arsenic li (he lollowing mode of accounting for inlrosiisccption be just, it will most frequent- ly happen downwards, although there is no reason why it nny not take place in a con- trary direction ; in .which case, the chance of a cure will be increased by the natural actions of the intestinal canal tending lo re- place the intestine ; and probably from this circumstance it may oftener occur than com- monly appears. When the inlrfJsnsccption is downwards, i( may be called progressive, and when it happens upwards, retrograde. The manner in which it may take place is, by one portion of a loose intestine being contracted, and the part itnmedialely below relaxed and di- lated ; under which circumstances, it might very readily happen by the contracted por- tion slipping a little way into that which is dilated, not from any action in either portion of intestine, bul from some additional weight in Ihe gut above. How far the peristaltic motion, by pushing the contents on to the contracted parts, may force these into the relaxed, Mr. Hunter will not determine, but is inclined to suppose that it will not. By this mode of accounting for an acci- dental introsusception, it may lake place either upwards or downwards; but if a con- tinuance or an increase of it arises from the actmn of the intestines, it must be when it is downwards, as we actually find to be the case ; yet this does not explain those in which a considerable portion of intestine appears lo have been carried into the gut below : to understand these, we must con- sider the different parts which form Ihe in- trosusception. It is made up of three folds of intestine ; (he inner, which passes down, and being reflected upwards, forms (he se- cond or inverted portion, which being reflect- ed down again, makes the (bird or conlain- ing part, that is the outermost, which is always in the natural position. (J. Hunter ) Ihe outward fold is the only one which is active, the inverted portion being perfectly passive, and squeezed down by the outer CEPTION. which inverts more of itself, =o that the da- Kle of inversion in this case is always at (he ano-le of reflection of the outer into ||,f middle portion or inverted one, while A, innermost is drawn iu. From (his wec.r, readily see how an introsuscepdon, once be- gun, may have any length of gut drawnir*. Tne external portion acting upon tbe other folds in the same way as upon any extrane- ous matter, will by its peri-taltic motion urge them funher; and if any extraneous tub stance is detained in (be cavily of the inner portion, that part will become a fixed point for the outer or containing intestine to act upon Thus it will b>* squeezed on, till ut In (he mesentery preventing more of the inner- most part from being drawn in, will act asa kind of stey, yet without entirely hindering the inverted outer fold from going still for- (her. F-jr it being the middle fold that is acted upon by tbe outer, and this action continuing after the inner portion become! fixed, the gut is thrown into folds upon it- self; so that a feiot iu length of intestine shall form an introsusception not more tbu three inches long. The outer portion of intestine is alone ac- tive in augmenting the disease when once begun ; but if the inner one were capableof equal action'in its natural direction, the ef- fect would be the same, that of endeavouring to invert itself, as in a prolapsus auijtbe outer and%inner portions, by their action, would tend lo draw in more ol ibe gut, while the intermediate part only would, by ils action, have a contrary tendency. The action of (he abdominal muscles can- not assist in either forming or continuing (bis disease, as it must compress equally bolk above and below, although it is capableof producing (he prolapsus ani. When an introsusception begins at Ihe valve of the colon, and inverts that intestine, we find the ileum is not at all affected; which proves thai (he mesentery, by acting as a slay, prevents its inversion. (J- Hun- ter.) From the natural attachment of Ihe me- sentery to the intestines, one would, at tbe first view of (he subject, conceive it impos- sible for any one portion of gut to get far within another ; as the greater extent ol me- sentery tin! is carried in along with it would render its further entrance more and mor* difficult, and we should expect this difficulty to be greater in the large intestines than in the small, as being more closely con6nedl their situation ; yet one of the largest intro- susceptions of any known was in thecoknii as related by Mr. Whateley. (Vid. Pti Trans. Vol. 76, p. 305.) The introsuseeption appeared lo have be- gun at the insertion of (he ileum into lb* colon, and to have carried in the ccWH with ils appendix. The ileum passed m into the colon, till the whole of the ascend- ing colon, the transverse arch, and descend- ing colon, were carried into the signup flexure and rectum. The valve of the colt* being the leading part, is at last got as low" the anus; and when the person went" INTROSUSCEPTION. i&J stool he only emptied the ileum, for one half of the large intestines being filled up by the other, the ileum alone, which parsed through the centre, discharged its contents. (J. Hunter.) Two questions of considerable importance present tbems-'lves to the mind in consider- ing this subject; whether there are any symptoms by which the existence of the af- fection can be ascertained during life ? And whether we possess any means of relieving it, supposing that ils existence could be dis- covered? The syinpioms attending an intro- susception are common to inflammation of the intestines, hernia, and obstruction of the canal, from whatever cause, and a volvulus is the least frequent cause of such symptoms. (Langstaff.) In the case published by this gentleman, and in those related h> Mr. Hun- ter and Mr. Spry, the seat of the disease was clearly denoted by a hard tumour on the left side ot the abdomen. This circumstance, together with (he impossibility of throwing up more than a very small quantity of fluid in clysters, (Hevin, Spry, Langstaff,) and the presence ol the other symptoms, would lead us to suspect the nature of the disorder. If the invaginated portion descended so low as to protrude through the anus, and we could ascertain that it was not an inversion of the gut, the case might be considered as clear, and we should have no hesitation in deliver- ing a prognosis, which, by preparing the friends for the faial termination, would exo- nerate us from all blame on its occurrence. (Langstaff.) In the treatment of this disease, bleeding, to lessen tbe inflammation that might be brought on, and quicksilver to remove the cause, have been recommended. Quicksilver would have little effect either in one way or the other, if the introsusception were downward ; for it is to be supposed that it would easily make its way through the innermost contained gut, and, if it should be stopped in its passage, it would by increas- ing its size, become a cause (as before ob- served) of assi-iin^ the disease. In cases of the retrograde kind quicksilver, as-isted by the peristaltic motion, mi^ht be expected 'o press the introsusception back; but even under such circumstances it might get be- tween the containing and inverted gut into tbe angle of reflection, and by pushing it further on, increase the disease it is intended to cure. (J. Hunter.) Every thing ilmt ca i increase the action of the intestine downwards, is to be particu- larly avoided, as tending to increase (he peri- staltic motion of the outer containing gut, and thus to continue the disease. Medicines can never come into contact with the outer fold, and having passed (he inner, can only act on the outer further down, and therefore cannot immediately affect that portion of the outer w hich contains the introsusception ; but we must suppose 'hat whatever affects or comes into contact with Ihe larger portion of the canal, so as to (hrow it into action, will also affect by sympathy any part (hat may escape such application. Mr. Hunter there- fore advises giving vomits, with a view to invert the ppristallic motion of the contain- ing gut, which will have a tendency to bring the intestines in'o their natural situation. If this practice should not succeed, it might be proper to consider it as a retrograde intro- susception, and by administering purges endeavour to increase the peristaltic motion downwards. (J. Hunter.) 1 cannot a^ree with Mr. Langstaff. that it is to be regretted, Hunter's name should be affiled to ihe preceding proposal, or that it is an absurd one; for purgatives and emetics were only recomm- tided to increase the peristaltic action, the former downward, the latter upward, according as the supposed nature of the case might require, and this effect they certainly would have, notwith- standing vomiting is an early and constant symptom of the disease, and an insuperable constipation an equally invariable attendant. The method. I allow, however, is not very hopeful, and may sometimes be frustrated by the formation of adhesions. ■ \ccording to Vlr. Langstaff, the Rccherchis Historiques sur la Gastrotomie dans le cas de Volvulus, par M. II vin, (Mem. de I'Acad. de Chirurgie, Tom. 4, 4to.) contain many interesting facts and sound reasoning. There we find a very ample discussion of the question, concerning the propriety of opening the abdomen, in order to disentangle the introsuscepted intes- tine. ; a proposal which M. Hevin very pro- perly condemns. If the equivocal and uncertain nature of the symptoms of volvulus were not suffi- cient to deter us from undertaking an opera- tion, which, under the most favourable cir- cumstances, could not fail to be extremely difficult, and imminently hazardous to the patient, the state of the invaginated parts would entirely banish all thoughts of such an imprudent attempt; for the different folds of the intestine often become ag- glutinated to each other, so that they can hardly be withdrawn after death ; (Simpson, Edinburgh Med. Essays, Vol. 6, Hevin s -ith Obs. Malcolm, Physical and Lit. Essays, Vol. 2, p. 3(j0. Hunter, Med. and Chir. Trans, and Soemmering in Transl. of Baillie's Morb. Anat) Nay, the stricture on the intfosus cepted part may cause it to inflame, and even mortify. (Soemmering.) It is very- clear that, in this state of parts, the opera- tion of gastrotomy would be totally inad- missible, even if the symptoms could clearly indicate the nature of the case and the affected part could be easily reached and examined. (Langstff) The forcible injection of clysters was found useless by Dr. Monro, and the agglu- tination of the parts must produce an insu- perable obstacle to the bowels beim* pushed back by this means. (Langstaff.) Some have proposed the employment of a long bougie, or a piece of whalebone, to push back the intestine ; and this proposal may be adopted, when we are furnished with an instrument, adapted to follow the windings of the large inte-tine to its origin in tho V34 INT 1RI right ilium, without any risk of perforating the gut in its course. (Lamrst ff.) It murt be confessed, that b-.th surgery and medicine are almost totally unavailing in the present disease. Vet, here, as in many ot.ier instances, the resources of nature are exhibited in a most wonderful and astonish- ing manner, while those of art completely fail The inva-jii ,eled portion of intestine sometimes sloughs, and is discharged per anum while the agglutination of the parts preserves the continuity of the intestinal ca ml. The nnalsof medicine furnish nume- rous instances, in which long pieces of gut have been discharged in this manner, and the patient has recovered. Hence, some hope mav lie .dlowed under the most un- promising circumstances. In a case, related in Duncan's Commentaries, eighteen inches of small intestine were voided per anum, Vol. 9 p. "278. Three similar instances Oc- cur in M. tlevin'sMemoir; twenty-three in- ches of colon came away in one of these, and twenty-eight of small intestines in another. Other cases occur in the Physical and Litera- ry Kssays, Vol.2, p. I-161 ; in Duncan's Annals, Vol. 6 p. 2W ; in the Medical and Chirurgical Transactions, Vol. 2; where Dr Caillie states, that a yard of intestine was voided. The patients did not, however, ultimately survive in every one of these instances. (Langstaff in Edinb. Med. and Surgical Jour- nal.) Langenbeck has recorded an instance, in which a prolapsus of tbe large intestines protruded half an ell out of 'he anus. The disease had lasted thirty weeks. I.angen- b- ck made an incision into, or rather through, the protruded inverted bowel, immediately below the sphincter ani. lie first divided the inner vascular coat, then the muscular, and lastly the outer coat with ?reat caution. He now discoveied, within the protruded inverted bowel, which he had -.pencil, ano- ther part of t" intesti.ial canal, which was not yt'tiuverted. He remarked upon it the ap- pendices epiploica;, and the white shining peritonaeal coat. This la>t portion would also have become inverted had the disease continued. He next reduced the latter tin- inverted part, and afterward succeeded in replacing the rest of the protrusion ; which did not fall down again when the boy had stools. No bad symptoms immediately fol- lowe I ; but, the lad being very weak, survi- ved onlv eight days (See Bibl fur die Chir. B.3 p. 756, Gott. 1811.) Ilecin in Mem. de I'Acad. de Chir. Hunter's Observations, in the Trans, of a Society for the Improvement of Medical and Chirurgical Knowledge. Vol. I, p. 103, et seq. L'Encyclo- pedic MeViodique, Partie Chir. Art. Gastro- tomie A. Voter, De Invaginatione Inteslinor- um:(Hal:er Disp. AmU.\, 181.,, C.H Velse. De Mut'io Iideslinornm In^rcsu, fy-c. Lugd 1742. (Haller, Disp. Anal 7. 97) J. C. Lcltsom, The History of an Extraordinary Intussusception, wi han account of Ihe dissection by Mr. T.Whael- ly, 4to. Lonl. 1786. And Langstaff's Re- warksinthe Edinb. M'd. and Surgical Journal, No. XI. I>VERSION OF THE UTERUS. Sc, Uterus, Inversion of mis, puour*- OF. As long as (he humours, which fill the .™v,ty °.f the,*-7*-* «,7in which the iris is immersed and s„, pended, remain in perfect equilibrium «,th respect to each other, that membrane r,t,,„, its natural position, and a suitable distance from the cornea, and although of a very de- licate and yielding texture, it contracts, and relaxes itself, without ever forming any ir. regular fold. But, when the aqueous he- mour has escaped through an accidental, or artificial, openiig in the cornea, the iriiii pressed forward bv the humours situated be- hind it, and is urged gradually towards the cornea until a portion of it protr ides from the eve, at tbe same opening, through which the aqueous humour made it- escape. Tim-, a small tumour of the same colour as the iris forms on the cornea, sometimes named staphyloma ofthe iris; sometimes procidentia, or prolapsus of Ihe iris. The causes of this complaint are such wounds and ulcers of the cornea, as make an opening of a certain extent into the an- terior chamber of the aqueous humour,and such violent contusions of the eyeball, m occasion a rupture ofthe cornea. If the edges of a wound in this situation, whether accidental, made for the purpose of extract- ing the cataract, or evacuating the matter of hypopium, be not brought immediately af- terward into reciprocal contact, or continue not sulfide.nly agglutinated together to pre- vent the escape of the aqueous humour from the anterior chamber, regularly as this fluid is reproduced ; the iris, drawn by its t-onti- nu il flux towards the cornea, glides between the lips of the wound, becomes elongated, and a portion of it gradually protrudes be- yond the cornea, in the form of a small tu- mour. The same thing takes place, whene- ver he- veba'l unfortunately rece.ves a blow, ■ >r is too much compressed by bandages, dur- i , ;theexistenceof arecent wroundof tliecf-r- .■ea. Also, if the patient should be affected, in this circumstance, with a spasm of the muscles of the eye, with violent and repeat- ed vomiting, or with strong and frequent coughing, a prolapsus of the iris may be caused. When an ulcer of the cornea pene- trates the anterior chamher of the aqueous humour, the same inconvenience happens more frequently, than when there is a recent wound of that membrane ; for, the solution of continuity in the cornea, arising from an ulcer, is attended with loss of substance, and in a membrane, so tense and com- pact as this is, the edges of an ulcer do not admit of being brought into mutual con- tact. The little tumour is likewise necessarily of the same colour as the iris, viz. brown, or grayish, being surrounded at its base by an opaque circle of the cornea, on which membrane there is an ulcer, or a wound of not a very recent description. As if usually happens, that the corneals oily penetrated at one part of its eirciirnfer- IRIS. 135 cuce by a wound, or ulcer, so in practice, only one prolapsus of the iris is commonly met with in the same eye. But if the cor- nea should happen to be wounded, or ul- cerated at m vera} distinct points, the iris may protrude it several different places of the same eye, forming an equal number of small projecting tumours on tiie surface of the cornea, bearpa has seen a patient who hud three very distinct protrusions of the iris on the same cornea, in consequence* of three separate ulcers penetrating the ante- rior cliamber of the aqueous humour ; one iu the upper, and two in the lower segment ot the cornea. If, says Scarpa, the delicate structure of the iris; the great quantity of blood-vessels, which enter it; and the numerous nervous filaments, which proceed to be distributed to it, as a common centre ; be considered, the nature and severity of those symptoms may be readily accounted for, which are wont to attend this disease, however small the portion of the iris projecting from the cornea may be, even if no larger than a fly's head. Tbe hard and continual frictions to which this delicate membrane is then ex posed, in consequence of the motions of the eyelids; together with the access of air, tears, and gum to it; are causes quite ade- quate to the production of continual irrita- tion; and the blood which tends'to the point of the greatest irritation, cannot fad to render the projecting portion of the iris much larger, almost directly after its pro- trusion, than it was at the moment of its first passing through the cornea. Hence it becomes, soon after the prolapsus, more incarcerated and irritated, than it was at first. In the incipient state of Ihe com- plaint, the patient complains of a pain, simi- lar to what would arise from a pin penetra- ting the eye ; next he begins to experience, at the same time, an oppressive sensation of tightness, or constriction, over the whole eyeballs. Inflammation ofthe conjunctiva, and eyelids, a burning effusion of tears, and an absolute inability to endure the light, successively take place. As the protruded portion of the iris drags alter it all the rest of this membrane, the pupil assumes of me- chanical necessity an oval shape, and devi- ates from the centre ofthe iris, towards the seat ofthe prolapsus. The intensity of the pain, produced by the inflammation, and other symptoms attendant on the prolapsus of the iris, does not, how ever, always con- tinue to increase. Indeed, in practice, cases of old protru- sions of the iris often occur, where, after the disease has been left to itself, the pain and inflammation spontaneously subside, and the tumour of the iris becomes almost completely insensible. Scarpa met with a man, fifty years of age, who had had a pro- lapsus ofthe iris in the right eye ten weeks ; it was as large as two grains of millet seed ; the patient bore it with the greatest indiffer- ence, and without any other inconvenience, than a little chronic redness ofthe conjunc- tiva, and a difficulty of moving the eyeball freely, in consequence of the friction of the lower eyelid against the tumour formed by the iris. When the extremity of ihe finger was applied, the little tumour fell hard and callous. In the early stage of his disease, some direct the iris to l>e replaced in ils pK per situation by means of a wnalebone probe ; and in case of difficulty, lo make a dilata- tion of Ihe wound, or ulcer of the cornea, by an incision, proportioned to the exigency of the case, as is done for the return of a strangulated intestinal hernia. Others only recnnme.id stimulating the prolapsed por- tion ofthe iris with the view of making it contract and shrink into the eye; or sud- denly exposing the eye affected to a very vivid light, in the belid, thai as the pupil then forcibly contracts, the piece of the iris, engaged between the lips ofthe wound, or ulcer of tlie cornea, will rise to its proper place. However, Scarpa represents all such methods as absolutely useless, and even dangerous. Supposing it were possible, by such attempts, to reduce the iris to its pro- per situation, without tearing or injming it, still the aqueous humour would est ape again through the wound, or ulcer ol the cornea, so that the iris, when replaced, would fall down the moment afterward, and project from the cornea iu the same way as before the operation. Hence, though Scarpa admits that the prolapsus of. the iris is a se- rious accident, he argues tlia as surgery has no means of suppressing at once, or at least, of suspending tlie escape of the aqueous hu- mour through a wound, much less through an ulcer of the cornea, when either < xceeds certain limits, the prolapsus of the iris, far from being an < v il in such unfavourable cir- cumstan. es, is rather useful, and, perhaps, the only means of preventing the total loss of the organ of sight. for the flap of the iris insinuates itself, like a plug, between the edges ofthe wound, or ulcer of the cornea, and thus completely prevents the exit of the aqueous humour. Here I ought to observe, that Scarpa's unlimited condemnation ofthe plan of ever attempting to replace the iris is contrary to the advice delivered by Beer, as may be seen by referring to the article Cataract, where tne treatment of the protrusion of the iris after the operation of extraction is noticed. And even with respect to the pro- lapsus of the iris from ulceration making its way through the cornea, Beer distinctly states, that a recent prolapsus of this kind, formed in the second still existing stage of ophthalmy, may not only be lessened by- proper treatment, calculated to produce a quick cicatrization of the ulcer, but the iris may be again completely removed from the cornea, without any adhesion to the edge of the ulcer taking place. (B. 2, P. 63) But where the prolapsus of the iris remains. as a consequence of previous inflammation of the eye, Beer confesses that it cannot be cured, without a partial adhesion of the iris to the cornea being left, and a dense scar on 13d IRIS the latter membrane in the situation of the protruded iris. (Vol cit. p 66.) In conformity to .->caipa"s principles, there are two principal indications in the treat- ment of the recent prolapsus of the iris. The first is, to diminish, as speedily as possible, the exquisite sensibility iu (lie protruded part of the iris ; the other is gradually to destroy the projecting portion of this mem- brane to such a depth, as shall be sufficient to prevent the little tumour from keeping the edges of the wound, or ulcer of the cornea asunder, and retarding cicatrization. The adhesion, however, vviiich connects the iris with the inside of the cornea, must not be destroyed For fulfilling these indications, nothing is more effectual, than touching the portion of the iris projecting from the cornea, with the oxygenated muriate of antimony (butler of antimony,) or with what is more expeditious and convenient, the argenlum nitratum, so as to form an eschar of sufficient depth. And, in order that this operation may be effected with quickness and precision, it is necessary that an assistant, standing behind the patient's head, should support tne upper eyelid with Pellier's elevator; and that the patient should keep his eye steadily fixed on one subject. While the assistant gently raises the upper eyelid, the surgeon must depress the lower one, with the index and middle fingers of his left hand ; and with the right, he is to be ready to touch the little prominence formed by the iris, with tne argentum nitratum, scraped to a point like a pencil. This is to be applied to the centre of the little tumour, until an esc har of sufficient depth is formed. The pain which the patient experiences at this moment, is very acute ; but, it subsides as soon as the eye is bathed with warm milk. The caustic, in destroying the projecting portion of the iris, destroys the principal organ of sensibility, by covering it with an eschar, of sufficient depth to protect the part affected from the effect of the friction of the eyelids, and from coming into contact with the air and tears. This is the reason, not. only why the sense of pricking and con- striction in the eye abates after the applica- prominent portion of ihe iris is sufficiently reduced to a level with the edges of (he wound, or ulcer of tbe cornea, and no obsta- cle is left to the granulating process, and complete cicatrization. There is a certain period, beyond which the application of caustic to the protruded iris becomes exceedingly dangerous, though at fir-t it may have been highly beneficial: beyond which, the eschar, which previously soot ied the pain, exasperates it, and repro- duces the inflammation of the conjuncu>i in almost as vehement a degree as in the beginning of the disease. This appears to Scarpa to be the case, whenever the sur- geon continues to employ the caustic, after the little tumour of the iris has been destroy- ed to a level wilh the external edges of (he wound, or ulcer of the cornea, and the application begins to destroy the granula- tions just as they are originating. Hence, as soon as tne surgeon perceives, that the part of the iris, projecting from the cornea, is sufficiently lowered, and that the applica- tion of the argentum nitratum, far from allaying, only irritates the disease, he must desist entirely from using the caustic, and be content with introducing between the eye and eyelids, every two hours, the coilyrium zinci sulphalis with tlie mucilage of quince- seeds. Every morning and evening, Janin's ophthalmic ointment, weakened with a double, or triple proportion of lard, is to be applied. If the stimulus of such local reme- dies should not disturb the work of nature, the ulcer gradually diminishes, and heals in the course of a fortnight. The adhesion, which the projecting partof the iris coutraots to the internal marjn of the wound, or ulcer of the cornea, during the treatment, continues the same after the perfection of the external cicatrix, and of course during the rest of the patient's life. Hence, even afterthe most successful treat- ment of the. prolapsus of the iris, the pupil remains a little inclined toward the place of the scar in the cornea, and of an oval figure. Ihe change in the situation and shape-of the pupil, however, causes little or no diminutiot of the patient's faculty of discerning distinct- ly he smallest objects; and is much less and copious effusion of tears extensive, nor situated exactly in the centre As in the case of ulcer of the cornea, these of this membrane. In the first case, tbe advantages only last while the eschar re- - mains adherent to the little tumour formed by the iris : when it falls off, as it usually does two or three days after the use of the caustic, all the above-mentioned symptoms are rekindled, with this ditterence, that they are less intense and acute, than they were previously, and the tumour ofthe iris is not so prominent as it was before the caustic was applied. When these symptoms make their appearance, the surgeon must once more have recourse to the argentum nitratum, with the precautions explained above ; and be is to employ it a third, and even a fourth time, as orrasion may require, until the S'i^tu,S the less obbtructed, as the pupil, which, on the first occurrence of the pro- lapsus, was narrow, oblong, and drawn considerably toward the wound, or ulcer, gradually enlarges, and forms a less con- tracted oval. As soon as the wound is completely healed, the pupd tends, in some degree, to occupy its former situation in the centre of the cornea, a fact, also noti- ced by Kicbter. ' According to Scarpa, the rccision of the protrusion with scissors can only be practi- -.ed with succesS; when (he ir.s has CQJ|traCt. cd a hrm adhesion to the internal edge of the wound, or ,,'ccr of the cov„,.a; apd, IMS. 137 ^ioie especially, in thai ancient prolapsus , of the iris, in which the projecting portion of tbe iris has become with time almost in- sensible, hard, and callous, with its base , strangulated between the edges of the wound, or ulcer of the cornea, and besides being adherent to them, having also a slen 'K der pedicle. Scarpa indeed has seen an in- ,. carcerated one fall off of itself. In such circumstances, the recision ofthe . old prolapsus of the iris is not attended with •he least dauger ; for, after removing with a . stroke of the scissors, that prominent portion *' of the iris, which has already contracted ,'.', internal adhesions to the ulcerated margin of the cornea, so as to reduce it to a level :* with the external edges of the ulcer, there is no hazard of renewing the effusion of the aqueous humour, or giving an opportunity * for another piece of the iris to be protruded. One or two applications of the argentum nitratum suffice afterward for the produc- : tion of granulations on the ulcer of the cornea, and the formation of a cicatrix. * But, it is "hot so in the treatment of the recent prolapsus of the iris, which has no adhesions to the internal edgesof the wound, or ulcer of the cornea. In four subjects recently affected with : prolapsus of the iris, after Scarpa had re- : moved, with a pair of convex-edged scissors, a portion of that membrane projecting be- - yond the cornea, of about the size of a fly's iead, he found, on the ensuing day, that a -"•■ new portion of the iris, not less than the first, had made its way through the ulcer of x fhe cornea, and that the pupil was very much z contracted, and drawn considerably further t toward the ulcer of the cornea. These i circumstances took place, notwithstanding the wound was touched immediately after- : ward with the argentum nitratum. Hence Scarpa apprehends, that if he were ever to divide such a IfUIe tumour again, it would reappear, and always with an additional protrusion ofthe iris, and a further distortion ofthe pupil. The advantage of caustic in tbe recent sensible prolapsus of the iris ; and ■ the use of scissors only in old callous cases, agree also with the directions given both by Beer and Mr. Travers. (Lehre von den „ Augenkr. B. 2, p. 68 ; and Synopsis, p. 280.) There is a particular species of prolapsus, a much less frequent, indeed, than that of tbe ^iris; but, which does occur, and, in Scarpa's opinion* is very improperly termed by mo- dern oculists, "prolapsus of the tunic of the aqueous humour." (Janin, Peltier, Gutrin, , (ileize, fyc.) Neither do his sentiments upon ., this subject agree with those of Beer, whose explanation of the nature of the case is given in Vol. I. of Ibis Dictionary. We shall there sec, that it is a case, which he terms ceralocele, and which he thinks arises from a yielding ofthe inner layers of the cornea, in consequence of the outer ones not having united. And, in his second vol. p. 59, he has given a description of the same kind of disease from tbe support of tbe outer layers of the cornea being destroyed by ulceration. This is a point, on which the xnoff cxperien- \'r,: jr. I" ced men differ so much, lhat it is difficult to reconcile their statements. Dr. Vetch seems to have full reliance upon the accuracy of the accounts of a protrusion of the mem- brane of the aqueous humour. (Treatise on Diseases of the Eye, p. 54, fyc.) Mr. Travers inclines to Beer's view of the subject, and details reasons for doubting that the vesicle is a distinct texture: "its appearance cor- responds accurately to that of the innermost lamella of the cornea." (Synopsis of the Diseases of the Eye, p. 116.) It is, says Scarpa, a transparent vesicle, filled with an aqueous fluid, and composed of a very delicate membrane, projecting from a wound, or ulcer ofthe cornea, much in the same way as the iris does under similar circumstances. Scarpa has several times seen this transparent vesicle full of water, elongating itself beyond the cornea, shortly after the operation for the extraction ofthe cataract, and sometimes, also, in con- sequence of an ulcer of the cornea, espe- cially after rescinding a prolapsed portion of the iris. The generality of oculists believe that this little transparent tumour consists of the deli- cate, elastic, diaphanous membrane, which invests the inner surface of the cornea, and is described by Descemet and Demours. " As soon as the membrane lining the cornea (they say) is exposed by the wound, or ulcer of the latter, and the delicate pellicle can no longer resist the impulse of the humours pressing behind it, it is necessitated to yield gradually, to become elongated, and to pro- ject from the wound, or ulcer of the cornea. exactly in the form of a pellucid vesicle." But, says Scarpa, how remote this theory is from the truth, must be manifest: 1. The delicate and elastic pellicle, described by Descemet and Demours, is not separable by any artifice from the inner surface of the corneR, except near where the cornea and sclerotica unite. Since these protruded vesicles make their appearance in practice at every point of the cornea, and even at its very centre, where Ihe above pellicle is certainly neither separable, nor distinct from the compact texture of the cornea ; it may at least be asserted, that the tunic of the aqueous humour does not iu every instance constitute the transparent vesicle in question. 2. It is a well-known fact, that this vesicular, pellucid prolapsus happens more frequently- after the extraction of the cataract, than any- other occasion. In this case, since the tunic of the aqueous humour has certainly been divided to afford an exit to the crystalline, no one can be of opinion, that the transpa- rent vesicle, which protrudes from the cornea after this operation, ought to be attributed to the distention and protrusion, of the tunic of the aqueous humour. 3. If, in cases of ulcers of the cornea, the transparent vesicle should sometimes appear after the recision of the prolapsus of the iris, it is obvious, that it it consisted of the tunic of the aqueous humour, it ought invariably to appear before the prolapsus of the iris,. •1. Sbiuld the •'vr-e'on v'/ovetho i**-*1 trader? 1KI-. vrsic !c (o a icvci with the cm «e\ by a slrokc of the scissors, a small quantity of limpid water is seen to ooze out, at the moment when the incision is made, without any part of the aqueous humour escaping from the anterior chamber. This inconvenience would be inevitable, were the protruded vesicle in question formed by the delicate elastic pellicle, which is said to invest the inner surface of the cornea. Besides, the little transparent tumour disappears when (he incision is made; but often another one exactly similar to what was cut off, is found in the very same place the following day. Had the little transparent tumour been com- posed of the tunic of the aqueous humour, elongated out of the wound, or ulcer of the cornea, it could not at all events have been reproduced at the same part ofthe cornea. Actuated by such reflections, it is clear to Scarpa, that the pretended prolapsus of the tunic ofthe aqueous humour is not what it is imagined to be; but strictly speaking, only a forcible protrusion of a portion of the vitreous humour, which, from too much pressure being made on the eye, either at the time of the operation, or afterward, or from a spasm of tne muscles of the eye, in- sinuates itself between the edges of the wound after the extraction of the cataract, and projects in the form of a transparent vesicle. The same thing also happens after ulcers of the cornea, whenever the aqueous humour has escaped, and a portion of the vitreous humour is urged by forcible pres- sure towards the ulcer facing the pupil; or whenever an elongated piece of the vitre- ous humour, after the recision of a prolap- sed portion of the iris, passes by a shorter route than through the pupil, between the lips of the ulcer of the cornea. At length, we understand, why in both these instances a transparent vesicle forms, even after the recision ofthe tunic ofthe aqueous humour, or ulceration ofthe cornea; and why it very often reappears in the same place, though it has been cut away to a level with the cor- nea. It is because one or more cells of the vitreous humour, constituting the transpa- rent vesicle, are succeeded after their re- moval by other cells of the same humour, which glide between the lips of the wound, or ulcer of the cornea, into the same situa- tion. The treatment of this species of prolapsus consists in removing the transparent vesicle, projecting from the wound, or ulcer, by means of a pair of curved scissors with con- vex edges, and bringing the edges of the wound of the cornea immediately afterward into perfect apposition, in order that they may unite together as exactly as possible. But when there is an ulcer of the cornea, as soon as the vesicle is removed, the sore must be touched wilh the argentum nitra- tum, so that the eschar may resist any new prolapsus of the vitreous humour, and at the same time dispose the ulcer ofthe cornea to granulate and heal. If, in some particular cases, the vesicle saould not project sufficiently from the wound, or idcei* oi tue cornea, lo be uti, ded in the scissors, the same object maybe accomplished by puncturing the tumonr with a lancet, or couching-needle; lorwlm the limpid fluid which it contains is dis- charged, the membrane forming it shrink- within the edges of the wound, or ulcer of the cornea, and no longer hinders the union of the former, or the cicatrization of the latter. Should the transparent tumour reappeir in the same situation, the day after its reci- sion, or puncture, it is right to repeatone of these operations, and to adopt further measures for maintaining the edges ofthe wound of the cornea in contact; or if It should be an ulcer, the eschar must be nude to adhere more deeply to its bottom and sides, so as to form a greater obstacle fo the escape of the vitreous humour. In the*- circumstances, the surgeon must take ill possible care to obviate such causes as bare a tendency to propel the vitreous humour towards the wound, or ulcer ofthe cornea fiarticularly too much pressure on the eye- ids, spasms of the muscles of the eye, cough- ing, sneezing, efforts at stool, and other si- milar ones ; and care must also be taken to check the progress of inflammation. The choroid coat is, likewise not exempt from prolapsus. Scarpa has seen this com- plaint in M. Bressanini, an apothecary a'. Bescape. A small abscess, formed between the sclerotica and choroid coats, at the dis- tance of two lines from the union of tht cornea with the sclerotica, in the inferior hemisphere of the globe of the eye, in con ■ sequence of a severe internal and externa! ophthalmy, which had been treated in ib ' incipient stale, with repellent remedie*. The abscess burst, and discharged a small quantity of thick viscid lymph ; then a small blackish body, composed of the ehoroid coat, presented itself on the'outside of Ihe little ulcer of the sclerotica. The treatment consisted in applying the argentum nitratum several times to the projecting portion oi the choroides, until it was consumed, and reduced to a level with the bottom ofthe ulcer ofthe cornea. The part then healed The eye remained, however, considerably weakened, and the pupil afterward became nearly closed. Scarpa sulle Principals Hi- latlie degli Occhi. Venezia, 1802. Rickten Anfangsgrnnde der Wundarzneykunst, B. 3. Von dem Vorfalle der Regenbogenhaut. Pti her, Obs. sur I'CEil, p. 350. G. J. Bta, Lehre ion den Augenkrankheiten, B. 1,§4CS, 518, and 592, and B. 2, § 58, 62,4*. 8r<, Wien. 1813—1817. J. Wardrop, Essays *» the Morbid Anatomy of the Human Eye, F«l- 2. p. 51, Sro. Lond. 1818. J. Vetch, A Practi- cal Treatise on the Diseases of Ihe Eye, p. 33, 4r. Lond. 8vo. 1820. B. Travers, A Synopm of the Diseases of the Eye p. 116, 280> Hro. Lond. 1820. Welter on Diseases of th Eye, Transl. by Dr. Monleath, 8ro. GlasgW, For a description ofthe manner of divid mg the iris, in order to make an artifif* j*53 >l» ... ((.jiiipii, wiicii the natural one is closed, refer lt to Pupil, Closure of. 1ms, Effects of certain narcotics upon, see ,. Belladonna and Catakact. The follow- , -, ing work upon the subject also merits atten- tion. C. Himby de laParalysie de VIris par y. une application locale de la Jusquiaume, et de L-"on utililt dans le Irailemenl de plusieurs ma- ladies des Veux, 2de Ed. \2mo. Altona, 1805. IRITIS. Inflammation of the iris. See ■F'OpHTHAT.MV. 011 ISCHURIA. (From i JOLMi. plaster is to bo removed, und a iinsced poul- tice applied. As soon as the eschar is de- tached, or any part of it is loose enough to be cut away without pain, or bleeding, the peas are to be inserted and confined in their pro- per place with a piece of adhesive plaster. Some use beans for the purpose ; others, beads, which answer very well, and have the advantage of serving for any length of time, when washed and cleaned every day. If the issue is at all of a longitudinal shape, (he peas, beans, or beads, may be more easily kept in their places, when a thread is passed through them. Issues ought always to be made, if possible, in a situation, where the peas will not be much disturbed in the ordinary motions of the body, nor interfere with the actions of muscles. The interspaces between the mar- gins and insertions of muscles, are deemed the most eligible places. Thus, issues in the arm are usually made just n( Ihe inferior an- gle of (he deltoid muscle, by the side of (he external edge of the biceps. In the lower extremities, issues are often made at the inner side of tbe thigh, immediately above the knee-, in a cavity that may be readily- felt there with the fingers. Sometimes, is- sues are made upon the in ide of (he leg, just below the knee. For the relief of any affections of the head or eye, the nape of (lie neck is commonly selected as a good silua- tion. In caries of (he vertebra*, they arc made on each side of the spinous processes. In cases of diseased hips, (hey are formed in a depression just behind and lielowihe Iro- cbanter mnjor. When the nature af (he dis- order does not particularly indicate Ihe silo. (ion for (he issue, (he arm should be preferred to the leg, as issues upon the upper extre- mities, especially the left arm, are much |Css annoying, than upon cither of the lower limbs. The „'rcat art of keeping an issue open, for a Ions: while, consists in maintaining Bn t-ijuil and elf ctual pressure upon the peas, by which means, they are confined in (heir places,little depressions are made for them, and (be gr». nidation.* hindered from rising. Compresses of pasteboard and shee(-lead will of(e«i he found highly useful. This plan is (he surest one of preventing the issue from healing, und (he most likely lo save Ihe patient all (be severe and repeated suffering, which the fresh application of the caustic, or the use of sti- mulating powders, in order to renew Ihe sure mid repress the fungous flesh, unavoidably occasion-'. There is a method of making issues with the caustic made into a sort of paste, which is laid upon (he part left uncovered by the adhesive plaster. It seems to mi- lo be a more tedious and painful plan, and I do not recommend it. It has been suspected; that tiie pain, arising from the caustic, might be lessened, by mix- iug opium wilh the application ; but, the idea seems not at all probable ; the destruction of a pail of the skin must inevitably cause con- siderable pain, with whatever substance ith produced, and opium itse'f, so far from being likely to diminish the agony, is itself a violent stimulus, whenever it comes into contact with the exposed extremities of the nerve* J. JOINTS, DISEASES OF. The joints are subject (o numerous diseases, which are more or less dangerous, according to (heir particular nature. Like all other parts, the joints are liable to inflammation and abscess es; their capsules frequenlly become distend- ed with an aqueous secretion, and the disease termed hydrops arliculi is produced ; hut the most important ot all their morbid affec- tions, are the cases, which, a few years ago, were indiscriminately called white swellings, scrophulous joints, and (he disease of the hip- joint. Here, as Mr. Brodie remarks, the same name has been frequently applied to differenl diseases, and the same disease has received different appellations. And confusion, with respect to the diagnosis, always gives rise lo a corresponding confusion, with respect to the employment of remedies. Although, says he, diseases in their advanced stage ex- tend to all the dissimilar parts, of which the joints are composed, such is not the case in the beginning. Here, as elsewhere, the morbid actions commence, sometimes in one, -ind sometimes in another texture, differing in their nature, and, of course, requiring to be differently (reated, according to (he me- chanical organization,, and vital properties of the part, in which tbey originate. (See Pathological and Surgical Obs. on Diseases tf the Joirds p. 2,8vo Lond. 1818.) It wasthi3 idea, which led Mr. Brodie to trace by dis- section the exact parts, in which several of the principal diseases of the joints commence, and how much light and discriminalioa his successful investigations have produced, it is needless lor me here to insist upon, as his merit will long be appreciated by every sur- geon, who recollects the perplexity and ignorance which prevailed only a few year* ago in this very interesting branch of sur gery. Wounds.—By the wound of ajoint,surgeon« mean a case, where (he capsular ligament •s penetrated, or divided. The injury is often accompanied with a division of Hie lateral, or other ligamenls, and sometimes alsb wilh that of the cartilages and bones. ThRt Ihe capsular ligament is wounded may generally be learned by the introduciion of a probe, and frequently by a discharge of « transparent viscid fluid, called the synovia. Bui, as a similar discharge may proceed from mere wounds ofthe bursa? mucosa?, we might form an erroneous judgment, were we unac- quainted with tbe situation of these little JUIrtlS 141 membranous bags. Boyer has seen several cases, in which a fluid, resembling sy ,ovi8, was discharged from wounds of the sheaths of tendons. (See Traiti des Maladies Chirurg. T. 4, p. 408.) Here, the advce which I have given in another place, (See Wounds of the Abdomen,) respecting the temerity of being too officious with the probe, is equally im- por'ant, inasmuch as the rough introduction of (his instrument into a large joint, like (he knee, would be very likely to excite inflam mation ofthe synovial membrane, and atrain of dangerous and even fatal consequences; while the information, gained by such em- ployment of the probe, is of little use; be- cause, whenever a wound is suspected lo reach into the capsilar ligament, exactly (he same treatment should alwavs be followed, as as if the joint were positively known to be penetrated. Notwithstanding simple wounds even of large joints often heal favourably, without any bad symptoms, this is not constantly the case, and ihe records of surgery furnish many examples, in which the most alarming and fatal consequences ensued. (See Hunter's Commentaries, Part, I, p. 69) When pro- perly treated, punctured wounds of the joints (says Boyer) are not in general attendee! with danger ; but, as some of these wounds, which were apparently quite simple, have been fol- lowed by very bad symptoms, and even death, we should always be extremely circumspect in the prognosis. (See Traiti des Mai. Chir. T. 4, p. 409.) The treatment consists in endeavouring (o heal (he injury by tbe first intention; in applying cold lotions; forbid-' ding all motion of the part; and employing bleeding and other antiphlogistic remedies. Baron Boyer relates two cases of punctured wounds of the elbow joint, which healed up in a few days, without any unfavourable symptom. He acknowledges,however, (hat these accidents do not always go on so well, and that the consequences are sometimes pe- rilous. Simple incised wounds present only one indication ; viz. (bat of healing the part by the first intention. At the moment of the accident, some of the synovia is discharged, indicating that the capsular ligament i wound- ed. Should this circumstance not have been noticed at first, tue surgeon may see (he syno- via flow out again, if he move, or press upon the joint. But, in making (his examination, tbe greatest gentleness should be used, le-t the irritation of the capsular ligament lie in- : creased. When the wound is large, ami th-re ; is no considerable thickness of soft parts, the articular surfaces are exposed to view. The prognosis of an incised wound of a joint is nol generally unfavourable, vhen the edges have been immediately brought togcthei, the cavity of (be joint has no been long exposed, and blood is not extravasated , in it. This last danger is also exaggerated, as will be noticed, in speaking of collections ol .blood in joints. With these exceptions, says , Boyer, the wound may heal as readily, as if the joint were not opened, and he has cited several facts in proof of this statement. Ils truth is also confirmed by the success which attends operations, practised for the purpose of extracting cartilaginous substances from (he knee. Nay. very bad cases sometimes recover under judicious management, even thou h the joint be large, and ab-cesses fol- low. Thus I have seen in St. Bartholomew's hospital, within the last year (1820) two ex- amples of compound fractures of the patella, where the opening in the capsule was so large, (ha( (he finger could readily be passed into (he cavity of (he joint, yet after large ab- scesses, a great deal of fever, and separation of hone, the patients receive red with stiff joints. But, I would advise surgeons not to let any facts of this kind prejudice their judgment in the treatment of gunshot wounds of the large joints, where, in the circumatance** el-ewhere explained (see Am- putation and Gunshot Wounds'* amputation rs (he safest praciice. In a sabre, or cut wound, the principal object is to bee.l the wound by the first intention. The rest ofthe treatment consists in using every possible means for the prevention ot inflammation, by perfect quie- tude, of the part; the use of cold applica- tions, be. We repeat, however, that wounds of tho joints do not always heal in the above favour- able manner. Even among those cases, which appear the most slight and simple, ,here are but too many, which are followed by such aggrivated symptoms, aseither prove fatal, >r occasion a necessity for amputation. And, in other instances of a less grii-vous description, when the patient is cured, the termination of danger is no' without an an- chylosi-, by which the motion and functions of the joint are permanently desdoyed. The experienced Mr. Hey has noticed wounds of the join(s, and mail*- some perti- nent rem .rks on the subject. He states, (hat in these cases, the utmost care should be taken to prevent i.-. h2 :) and even in Mr. Kirby's own instance, the recovery was not effected, without tbe entire loss of the motions of the knee. As the disorder is often attended with a degree of heat and tenderness in the articula- tion ; as the danger ofthe operation is, in a great measure, proportioned to tbe subsequent inflammation ; and, as much of the danger is at once removed, if the wound unite by the first intention ; the advice to keep the patient in bed a few (Jays before operating, to apply leeches and cold saturnine lotions to the knee during fhe same time, and to exhibit beforehand a saline purgative, is highly prudent. I shall next introduce an account of the plan of operating, as described by several of the best modern surgeons. " As these loose bodies cannot always be found, no time can be fixed for the operation; but the patient, who will soon become familiar with his own complaint, must arrest them when in a favourable situation, and retain them there till Ihe surgeon can be sent for. " Before the operation, the limb should be extended upon a table in an horizontal position, and secured by means of assistants ; the loose cartilages are to be pushed into the upper part of the joint above the patella, and then to one side ; the inner side is to be preferred, as in that situation only the vastus internus muscle will be divided in the ope- ration. Should there be several of these bodies, they must be all secured, or the ope- ration should be poslponed till some more ,I0IM?. difficulty be retained in its .situation it mat. r!!„„:„^„i;Pd The assistant is to end** loose body through (he opening, w" vour to push the ,pening, which must be iriude sufficient), large for that purpose ; but as this cannot alvvays be done, the broad end of an eyed probe mav be passed under it, so as to lift ic out, or a'sharp-pointed instrument may be stuck into it, which will fix it to its situation, and bring it more within the management of the surgeon. " The cartilages being all extracted, the cut edges of the wound are to be brought together, and, by means of a compress of lint, not only pressed close to one another, but also to the parts underneath, in which situation they are to be retained by sticking plaster, and the uniting bandage. " As union by the first intention is of Ibe utmost consequence after this operation, If prevent an inflammation of the joint, (he patient should remain in bed with tbe le-* extended, till the wound is perfectly united. or at least all chance of inflammation at an end." (Home, in Trans, for the Improvement of Med. and Chir. Knowledge, Vol. \,p. 239, In one instance, Desault proceeded in the following manner: the surgeon, after relax- ing the capsular ligament by extending the leg, brought the extraneous body on the in- side ofthe articulation againstthe attachment of the capsular ligament, and secured it in this situation, between the index finger and thumb of tbe left hand, whilst an assistant drew the integuments forwards towards the patella. The parts, covering this extranem body, were now divided by an incision one inch in length, and its extraction accomplish- ed by pushing it from above downwards, and raising it inferiorly with the end of the knife. This substance, on examination, war- found similar iu colour to the cartilages that cover the articular surfaces : it was three- quarters of an inch in length, six lines and a half in width, and three lines in thickness; its surfaces were smooth, one concave and the other convex : its circumference irrego- favourable opportunity, since the leaving of lar, disseminated with red points, formmf one will subject tbe patient to the repetition small depressions ; the inside was ossified, but the outside of a cartilaginous texture. A- soon as the substance was extracted, the assistant let go the integuments which he had drawn forwards; they consequently returned to their natural situation, on the inner side of the knee-joint, in such a man- ner, that the external wound iu the integu- ments was situated more inward, than the one in the capsular ligament. Two advanta- ges were procured by this means : on the one hand, air was prevented from penetra- ting into the articulation ; and on the other, the floating portion of capsular ligament, retained inwards by the skin, was more like- ly to attach itself to the condyle, in case it did not unite to the ether portion ofthe cap- sule divided near its attachment. 1 lie edgei ofthe wound were brought into contact by means of a uniting bandage ; dry lint anil compresses were applied, and retained on the part by a slight bandage ; and the liml) of an operation, not only painful, attended with some degree of danger. " The loose bodies are to be secured in fhe situation above-mentioned by an assis- tant, a task not easily performed "while they are cut upon, from their being lubricated by the synovia ; and if allowed to escape into the general cavity, they may not readily, if at all, be brought back into the same situa- tion. "The operation consists in making an incision upon the loose cartilage, which it will be best to do in the direction of the thigh, as the wound will more readily be healed by the first intention. If the skin is drawn to one side, previously to making the incision, the wound through "the parts under- neath will not correspond wilh that made in the skin, which circumstance will favour their union. Tbe incision upon the cartilage BWst be made with caution, as it will with •J Will vvas kept in a slate of extension. (Desault's Journal, T.2.) According to Mr. Abernethy, the inner surface ofthe internal condyle of the os femoris presents an extensive and , nearly a plain surface, which terminates in front and at its upper part by an edge which forms a portion of a circle. If Ihe points of the finger be firmly pressed upon this edge . so as to form a kind of line of circumvalla- tion round these (cartilaginous) bodies, they cannot pass into the joint in this direction, nor can they recede in any other, on account . ofthe tense state of the internal lateral li- gament. Here these substances are near the surface, and may be distinctly felt: and they may be exposed by simply dividing the inleguments, fascia, aud the capsule of the joint. In an interesting case, which Mr. Aber- nethy relates, the integuments of the knee ■were gently pressed towards the internal condyle, and the fingers of an assistant ap- plied round the circular edge of the bone. Tbe integuments were gently drawn tor wards the inner ham string, and longitudi- nally divided, immediately over the loose substance, to the extent of an inch and an ' half. This withdrawing of the integuments from their natural situation was designed to prevent a direct correspondence of the ex- ternal wound to that in the capsule of the : joint: for, when the integuments were suf- ' fered to regain their natural position, the 1 wound in them was nearer to the patella, than the wound in the capsule. The fascia, which covers the joint, having been expo- sed by the division of the integuments, it was divided in a similar direction, and near- ly to the same extent. The capsule was now laid bare, and .-.entry divided to the ex- tent of half an inch, where it covered one of the. hard substances, which suddenly slipped through fhe opening, and by press- ing gently upon the other, it vvas also dis- charged. The bodies, thus removed, were about three-quarters of an inch in length, and half an inch in breadth. They had a highly polished surface, and were hard like cartilage. The fluid contained in the joint was pressed toward the wound, and about fwo ounces of synovia were discharged. The wound of the integuments was then gently drawn towards the patella, and ac- curately closed with sticking plaster. (Sur- gical Observations. 1804.) When there are several extraneous carti- laginous bodies in tbe joint operated upon, the surgeon ought to extract them all through the same wound, if it can be done without producing too much irritation ofthe capsu- lar ligament, and they will admit of it But, frequently, only one can be made to pre- sent itself at a time, or can h<-easily ex- tracted. Each little tumour will then require a separate operation, which is a far safer plan, than disturbing the part by long and repeated attempts to extract them all at once. (Boyer, Trailed des Mai. Chir. T. 4, p. 448.) The surgeon is also often obliged to make his incision at a particular point, be- <•*-• 'ui** at no other can the extraneous siib- ■-•? 149 stance be fixed. A case continuing all these latter observations was lately published by Dr. Clarke. (See Med. Chir. Trans. Vol. ,% p. 67.) In this instance, the operation was thrice performed upon the same knee-joint. with perfect success. Mr. Brodie also ex- tracted five loose cartilages, by three differ- ent operations, without any subsequent un- pleasant symptoms, although the patient ap- pears to have been previously subject to repeated attacks of severe inflammation of the joint. (Pathological and Surg. Obs. p. 299.) r On the preceding subject some observa- tions and two snccesslul operations have been lately published by Baron Larrey. (See Me moires de Chir.Militaire, T. 2, p. 421,. ^c.) With the exception of a few wrong theories, he appears to have given a fair ac- count of tie disease Hydrops Articuli signifies a collection of se- rous fluid in the capsular ligament of a joint. The knee is more subject, than other joints, to dropsical disease, which h. s been known, however, to affect the wrist, ankle, and shoulder joints. .Boyer, Traiti des Mai. Chir. T. 4,p. 456.) Mr. Kusset adopted the opinion, that some cases of this kind are venereal, and others scrofulous ; but, he has not supported the doctrine on any solid foundation. Hydrops aruculi generally arises from contusions, rheumatism, sprains, exposure to severe cold, the presence of extraneous cartilagi- nous bodies in the joint, and in geueral from any thing, which irritates the capsular ligament; and, as already explained, it is a common attendant on inflammation of the synovial membrane ; the complaint also sometimes follows fevers; but, iu most in- stances, it is purely a local affection, quite independent of general debility, (hover T. 4, p. 467.) " K * ' Hydrops articuli presents itself in the form of a soft tumour; circumscribed by the at- tachments oi the capsular ligament; with- out change of colour in the skin ; accom panied with a fluctuation ; it is indolent, and very little painful; causing hardly any' impediment to the motion of the joint ; yiehiiug to the pressure of the finger, but not retaining any impression, as in oedema. The swelling does not occupy equally every side of the joint, being most conspicuous where the capsular ligament is loose and superficial. In the wrist it occurs at the anterior and posterior parts of the joint, but especially, in the former situation, while it is scarcel perceptible at the s.des. In the ankle, it is more apparent in front of the malleoli, than any where else; and, in the shoulder, it does not surround the joint, but is almost always confined to the forepart of it, and can only be seen in the interspace between the deltoid and gieat pectoral mus- cles. In the knee joint which is the common situation of hydrops articuli, the tumour does not occur behind the articulation ; but at the frot-tand sides Behind, the capsular ligament i- too narrow to admit of being 160 JOIN l'S much distended with the synovia ; while, m front, and laterally, it is broad, so that it can there yield considerably in proportion as the quantity of fluid increases. The swell- ing is at first rircumscribed by tbe atta-h- menis of the capsular ligament ; but, m consequence of the accumulation of fluid, it afterward exceeds these limb- above, and •spreads more on less upward between tbe thi»h bone and the extensor muscles ofthe leg" which are lifted up by it. Boyer has seen it reach to the ipper third of the thigh. The swelling is irregular in shape : it is most prominent where tlie capsular ligament is witeand loose, and it is in some men- .ire 1- vided longitudinally into two lateral portions, by the patella, the liga neut ofthe patella, and the tendon ot the extensor muscles of the leg, all which parts the synovia raises, and pushes forward, though iu a much less degiee than the capsular ligament. Of these lateral portions, the in ernat is broadest and most prominent, because the pari of the capsule between the patella and edge of the inter- nal condyle being larger than that situated between the patella and edge of the exter- nal condyle, yields in a gientcr degree to the distending fluid. The motions of the leg, which are generally little interrupted by this disease, make a difference in the shape and consistence of Ihe swelling. In flexion, the tumour becomes harder, tenser, and broader, and more prominent at the sides of the knee-pan, which is somewhat depressed by its ligament. In extension, the tumour is softer, and the fluctuation plainer. In order to feel distinctly the fluctuation, which is one of the best symptoms of the disease, the ends of two or three fingers should be placed on one side of the swell- ing, while the opposite side is to be struck with the end of the middle finger of the other hand. The patella, being pushed forward, away from the articular pulley, is very moveable, and, as it were, floating. When it is pressed backward, while the leg is extended, it can be felt to move a certain w ay before it meets with the resistance of the articular ptil.ey. And on the pressure being discontinued, it immediately separates from this part again. By such svmptoms, hydrops articuli may easily be distinguished from other diseases ofthe joints, from tumours of the bursa mu- cosa under the extensor tendons of the leg; from ganglions in front of the knee-pan ; from rheumatism ; oedema, be. The prognosis is most favourable, when the swelling is recent and small, and has been quick in its progress. On the contrary, when the tumour is of long standing and large; the effused fluid thick and viscid; and the synovial membrane thickened : the removal ofthe tiuid by absorption, and the restoration ol the parts to their natural state, will be more slow and difficult. The wo.st case is that which is complicated wilh dis- ease of the capsular ligament, cartilages, and bones. The cure of the above-described dropsi- cal affect---m of fhe i'lints. d»ne,nds upon the absorption oi the effused fluid. And, whe, 5?Tease is combined with acute or chro* inflammation ofthe synovial membrane,*, r"atmeut N the same as th-it already reco*- mended for those particular lorms of d» case When inflammation subsides, the absorption of the fluid i- sometimes aho,e. ther spontaneous, and it may always be promoted, by mere friction, by rubbm-jib-, oinl with camphorated mercurial ointmeM, and particularly, by the employiDenl d blisters. The operation of a blister may be verv materially assisted with a moderately tight bandage. Among other effectual means of cure, we may enumerate frictions with flan- nel impregnated with the fumes of vinegar; electricity ; and the exhibition of mercurial purgatives. When hydrops articuli occun during the debility, consequent to typhoid, and other fevers, tiie complaint can hardly be expected to get well, before the patient has regained some degree of strength. As, however, hydrops articuli is generally quite a local disease, Boyer contends, tin: it should be chiefly treated with topical re- medies ; and he sets down diuretics, sudo- rifics, hydragogues, be. as improperorin- efficient. (Op. cit. p. 467.) He is strongly in favour of repeated blisters, both for tht prevention and cure of the disease. Circumstances do not often justify making an opening into the joint: but, excessive distention, in some neglected cases, might certainly be an urgent reason for performing such an operation. Also, if the complaint should resist all other plans of treatment, and the irritation ofthe tumour greatly im- pair a week constitution, the practice would he justifiable. An interesting example of this" kind is related by Mr. Lalta. (Sytlta of Surgery, Vol. 2, p. 490.) It is best to make the opening in such a way, that the wound in the capsular liga- ment after the operation, will not remain directly opposite the wound in the skin For this purpose, the integuments are lobe pushed to one side, before the surgeon di- vides them. (Encyciopedie Milkod. Pttf, Chir. Art. Hydropsie des Jointures.) The operation is not always successful- being sometimes followed by alarniinj symptoms, which either end fatally, or oc- casion a necessity for amputation. The fluid also generally collects again, and a the synovial membrane is mostly thickened, it often inflames, and suppuration in the joint ensues. Hence, when hydrops articuli originates from rheumatism ; when it is* cent, indolent, and not I rge ; and when it does not seriously impair the functioBiof the joint; Buyer recommends the operalioi not to be done. But, he sanctions ils per- formance, when the disease is combing with extraneous cartilaginous bodies inlh« joint: or when it is very considerable, at- tended with severe pain, and impairment of the functions of the joint. (Op. cit. "M p. 473.) Collections of Blood in Joints.—M<"-'t sy* tcmatic writer's speak of this Wind of ™* •lutein. 1*1 though it must be uucommou. Tumours about the joint3, composed of blood, and set down in numerous surgical works, as extravasations within the capsular ligaments are generally on the outside of them. Certainly, if a collection of fluid were to take place in a joint immediately after a sprain, or contusion, and to coutiuue to in- crease gradually for some time afterward, there would be reason to believe-most of the contents of the tumour to be blood. The production of an abscess, and the se- cretion of any fluid, would have required a longer time. Were blood known to be undoubtedly effused in a large articulation, however, no man would be justified in making an open- ing for its discharge. No bad symptoms are likely to result from its mere presence, and the absorbents will, in the eud, take it away. If an incision were made into the joint, the coagulated state of the extrava- sated blood would not allow' such blood to be easily discharged. The best plan is to apply discutient re- medies ; a lotion of vinegar, spirits of vyine, and muriate of ammonia for the first three or four days ; and afterward, friction with camphorated liniments maybe safely adopt- ed. Mr. Hey relates a case, in which the knee- joint was wounded, and blood insinuated itself into the capsular ligament; yet though the occurrence could not be hindered, no harm resulted from the extravasation, which was absorbed, without having created the smallest inconvenience. (Practical Obs. in Surgery, p. 354.) White Swelling.—The white swelling, or spina ventosa, as it was at one time not un- frequently called, in imitation of the Arabian writers, Ithazes and Avicenna, has been a name indiscriminately applied to many dis- eases, which differ widely in their nature, curability,and treatment. Wiseman was (he first who used the term White -Swelling; and if Ihe expression did not confuse to- gether cohiplaints of very different kinds, not much fault could be found with it, because it unquestionably conveys an idea of one mark of some of these distempers, which is, that notwithstanding the increase of size in the joint, the skin is generally not inflamed, but retains its natural colour. (Pott.) The name, therefore, appears objection- able, only inasmuch, as it has tended to pre- vent the introduction of a sufficient number of well-founded and necessary distinctions. Systematic writers have generally been con- tent with a distinction into two kinds, viz. rheumatic, and scrofulous. The last species of the disease they also distinguish into such tumours, as primarily afivct Ibe bones, and then the ligaments and soft parts; and into other cases, in which the cartilages, ligamenls, and soft parts be- come diseased before there is any morbid affection of (he bones. Mr. Brodie has endeavoured (o form a more correct classification of the different complaints, to which (he term wbite-sweliing is applied ; und his descriptions are valuable, because confirmed by extensive observation, and numerous dissections. \\ ilh respect to the disease beginning in the ligaments, it tho capsular ligaments be put out of considera- tion, it is, as this gentleman observes, a rare occurrence, and he lias uevpr met wilh a case, in winch (he but was proved by dis- section. (Pathol, and Surgical Obs. p. 7.J 1. The first case is iiiiiammalioii ot ihe synovial membrane, as described in the fore- going pages, especially that lorm ot the dis- ease which often arises from cold, and con- stitutes the disease formerly "often termed a rheumatic w hate swelling. 2. Anothci form oi disease, ordinarily^ comprised under the general name of while- swelling, has been particularly described by Mr. Brodie : tbe disease originates, in the synovial membrane, which loses ils natural organization, and becomes converted into a (hick, pulpy substance, of a light brown, and sometimes ot a reddish brown colour, inter- sected by white membranous lines, and from 1-4 lo 1-2 of an inch, or even more than an inch in thickness. As this disease advances, it involves all the parts of which Ihe joint is composed, producing ulceration ot the car- tilages, caries ot the bones, wasting of the ligaments, and abscesses in different places. The complaint has invariably proved slow in its progress, and sometimes has remained nearly in an indolent slate for many months, or even for one or two years ; but (says Mr. Brodie) " I have never met with an instance, in which a real amendment was produced ■ much less have I known any in which a cure wad effected." (See Medico-Chir. Tran- Vol.4, p. 220, S,-c.) The whole, or nearly Ihe whole of (he synovial membrane has always been found affecled; though if a very early examination were made, Mr. Brodie conceives that this might not be the case, and in one example, he found only h half of the membrane thus altered, while the rest was ot its natural structure. (Pathol. and Surg. Obs. p. 94.) Tiiis gentleman further acquaints us, that the preceding affec- tion of the synovial membrane is rarely met wilh, except in the knee, that he. has never known an instance of it in Ihe hip or shoul- der; that it is peculiar to the synovial mem- brane of the joints ; that he has never known an instance ol it in other serous membranes nor even in the synovial membranes, which constitute the tmrsae mucosae and sheaths of tendons ; and thai it generally lakes place in young persons, under, or not much above tlie age of puberty. I.i tact, Mr. brodie has not met with more than one instance, in which it occurred after the middie period ot lib*. "In the origin of Uiis disease, there is a slight degree of stiffness and tumefaction, without pain, and producing only the most trifling inconvenience. These symptoms gradually incteas<- : at lasl, the joint scarcely admils of the smallest motion, (he stiffness being greater than where it is ihe conse- quence of simple inflammation. The form of (he swelling bears some, resemblance (o (hat in cases of inflammation of the synovial UJ JOIN IS, membrane, bui il is less ; eguiar. The swell- ing is soft and elastic, and gives to the hand at fensation as if it contained fluid, h only oue band be employed in making the exami- nation, the deception may be complete, and the most ev.perienc.i-d surgeon m.ty tie led lo suppose, there is a fluid in the joint when there is none ; but if both hands be employ- ed, one on e-acb side, the absence of fluid is dl*5tir'g*i'shed by the want (if fluctuation " The patient experie nc-.s little or no pain, until a isce aiiuu.->, reiaiive io uie snare, whim fulouXabrTaUo lhC J°U,tr •I,1SCr°- SCrofulil f™l«enfly has in the origin and of a ioSt i, 'mLh SeemS "•. 'f ,rriiatio" Course of ma"y white-swellings. ?h,£I LT,Ch .r.re ^''y Produced, Mr. Brodie'/ experience leads him to be other patients The doctrine of particular white-su el! i larger at culatiousof a more simple strut- :e rofb- . ry , - "---------.-^, til K.r.I VC.IJ- wppOBlie KttooK 4, states ; sometimes the diseased joint is pecies ot affected with a degree of acute inflamma- tion ; in other instances, the malady « entirely chronic. Ihe mprudenoe of patients in walking about, and disturbing the diseased p.rt, is v< ry otten the occasion of a degree of acute what are called 'i\™m»n"i\"*7£*i?i& ,"*iarni,iati°n- "hich is denoted by thr joints, as late as the age of five an I vven v te'lderness °* the J™' when handled by the but n.,t afterward, unless they aTfferecl fU^l1/a"d ",S°u by the "'teguments feel- <*■ scrofula be*, that pc^ol « ^^^^^ tr^ K chap 4) calls the spina vadosa scrofula, and tells us, that infan s and children are generally the subjects of this disease. The disorder is said by Severinus to be exceedingly frequent in v oung s,ib- leC/u' Ketrus de Marchettis has observed both male and female subjects infected with JOINT: 157 doubt, that' topical bleeding, fomentations, emollient poultices, or cold saturnine lotions, nre means which may tie eminently service- able. The antiphlogistic regimen is now strongly indicated. Cooling purges of the saline kind should also be exhibited. Blood may be taken from the arm, and also from the diseased part, either by means of leeches or cupping. Mr. Latta gives the preference to the latter method, whenever it can be employed ; and he very properly remarks, that little advantage can be expected from topical bleeding of any kind, unless the quantity of blood taken away be consider- able. Ten or twelve ounces by cupping should be taken away at a time, and the operation should be repeated at proper intervals, till the tenderness and heat of the skin have entirely subsided. When leeches are used, the number ought to be consider- able, and Mr. Latta recommends the appli- cation of at least sixteen or twenty. (System of Surgery, Vol. 1, Chap. 6.) Although antiphlogistic means are judi- cious when acute inflammation prevails; yet such practitioners as lose weeks and months in the adoption of this treatment, are highly censurable. While the skin is hot and tender, while the joint is ail" cted with very acute and general pain, and while the patient is indisposed with the usual symptoms of inflammatory fever, great benefit may be rationally expected from the above plan. When, however, the disease is truly chronic, different plans are indicated. In ordinary cases of scrofulous disease of the joints.. Mr. Brodie considers topical bleeding as usually unnecessary. (Pathol. and Surgical Obs. p. 240.) It is quite unnecessary to expatiate on the mode of treating white-swellings, compli- cated with acute inflammation, particularly as the treatment of those cases, which con- sist of inflammation of the synovial mem- brane, has been already noticed, and may be said to be applicable to other forms of white-swelling, when they are attended with heat and inflammation of the soft parts. The most eligible plan of arresting the mor- bid process in the bones, cartilages, and soft parts surrounding the articulation, and the most successful method of lessening the chronic enlargement of the joint, are the subjects at present demanding our earnest investigation. The works of Hippocrates, Celsus, Rhazes, Hieron, Fabricius, be. compared wilh modern surgical books, will soon convince us that the practice of the ancients, in the treatment of diseased joints, does not differ much from the plan now pursued by the best modern surgeons. Mr. Crowther remarks, that the ancients used local and general blood-letting, the actual and potential cau- tery, with vesicating and stimulating applica- tions to the skin. They further maintained, that sores, produced by these means, should have theirdischargepromoted, and continued tor n considerable length of time. With regard to the cases which Mr. Brodie describes as depending upon a total loss of the natural structure of the synovial mem- brane, which is converted into a pulpy sub- stance, one quarter or one half of an inch in 'thickness, though the progress of the disease may be somewhat checked by rest and cold lotions, it is, according to this gen- tleman, incurable, and at length it ends in ulceration of the cartilages, abscesses, be. When there is considerable pain, in conse- quence of the cartilages beginning to ulce- rate, partial relief may be derived from fomentations and poultices : but nothing will effect a cure Hence, when the health begins to suffer, he considers amputation to be indicated. (Med. Chir. Trans, p. 254.) When white-swellings are accompanied with ulceration of the cartilages, all motion of the joint is extremely hurtful. Indeed, as Mr. Brodie well observes, keeping the limb in a state of perfect quietude is a very im- portant, if not the most important circum- stance, to be attended to in the treatment. According fo this gentleman, it is in these cases, in which ulceration of the cartilages occurs as a primary disease, that caustic issues are usually productive of singular benefit; but he deems them of little use in 9ny other diseases of the joints. He thinks setons and blisters, kept open with savine cerate, may also be used with advantage. Bleeding is indicated only when, from improper exercise, the articular surfaces are inflamed, and there is pain and fever. Mr. Brodie asserts, that the .varm bath re- lieves the symptoms in the early stage, if it does not stop the progress of the disease; but he condemns plasters of gum ammoniac, tiinbrocatioiis, liniments, and frictions, as either useless or hurtful. (See Medico-Chir. Trans. Vol. 6, p. «32—334.) Topical applications, consisting of strong astringents of the mineral and vegetable kingdom, are of no service in examples of ulceration of the cartilages, or of the scro- fulous form of the disease, though they often suffice for the cure of some mild de- scriptions of white-swelling, depending upon a thickening of the synovial mem- brane. A decoction of oak bark, containing alum, was recommended by Mr. Russel My own experience will not allow me to say any thing in favour of electricity, as an application for the relief of white-swel'i. • and it must be more likely to do harm than good, whenever the indication is to lessen irritation. "If the tumour is quite indolent, (snv* Richerand; the application of galvanism may be proposed ; it is not, however, ex- empt from danger. and, on one occasion w '.-icre I employed it, lancinating pains aid swelling ot the joint were brought bn by it' (Msogr. Chi,. T. 3,p. 174, Ed. 2.) Mr. John Hunter had confidence in cicuui and sea-bathing, as possessing power over many scrofulous diseases; and that such diseases of the joints are often materially benefited by the patient's going to (he sea side and bathing, is a fact which cannot be doubted, whatever may be the mode of explaining the benefit tint-? obtained I fullv 158 JOINTS believe that sea-air and sea-bathing have a beneficial influence over scrofulous dis- eases of the joints; but probably their effects are produced on the part through the medium of the constitution, and they should only be recommended as an auxiliary plan, to be adopted in conjunction with other still more efficacious measures. Every one is well acquainted with the efficacy of friclion in exciting the action of the absorbents. To this principle we are to impute the great benefit which arises from what is termed dry rubbing, in cases of white-swellings. This kind of friction is performed by the mere hands of an attend- ant, without using at the same time any kind of liniment, or other application what- soever, excepting sometimes a. little flour, or powdered starch, and the rubbing is con- tinued several hours every day. \t Oxford many poor persons earn their livelihood by devoting themselves to this species of labour, for which they are paid a stipulated sum per hour. This practice, however, is chiefly advantageous in the chronic stage of white-swelling, arising from inflammation ofthe synovial membrane. I look upon all mere emollient applica- cations,such as fomentations and poultices, as quite destitute of real efficacy, except when great pain or active inflammation is present, and, though they serve to amuse the patient, they ought not to be recommended. That surgeon, who merely strives to please his patient's fancy, without doing any real good to him. in regard to his affliction, may be considered as doing harm, because the semblance of something being done too often hinders other really useful steps from *.>eing pursued. The French surgeons are particularly liberal in the praises which they bestow on warm emollient remedies, poultices, steam of hot water, fomentations, be. and they adduce instances of white- swellings being cured in this manner. But (he cases to which they refer were no doubt mere inflammations, and thickening of the synovial membrane; a disease vvhich in general readily yields to several other plans. The only method of treatment which my own personal experience enables me to recommend for scrofulous white-swellings in a chronic state, consists in keeping up a discharge from the surface of the diseased joints. The opportunities which I have had of observing the effects of blisters, and caus- tic issues, rather incline me, however, to prefer the former to the latter. I have seen great good derived from both; but more from blisters than the other kind of issue. There are instances in which I should employ vesicating applications; there are others in which I should prefer making an eschar with caustic. In particular indivi- duals blisters create so much irritation, heat, fever, and suffering, that a perseve- rance in them would be rashness. The blister should always be large. Many surgeons, instead of following Mr. Crow- ther's plan, prefer blistering, first one side of the joint, and then the other, alter nately for a considerable tengtli ol tune "Blisters (says Mr. Latta) may be put upon each side ofthe patella, and ought to be of such a size and shape as to cover the whole of the s veiling on the inside, from the hinder part of the joint, at the edge of the hollow of the thigh, to the edge of the patella, over the whole extent ofthe swell- ing above and below. As soon as the blister is taken off from one side, it ought to be applied to the other, and thus repeated, alternately, until both swelling and pain be completely removed. When this is the case, the patient ought to be directed to rub the joint well with a liniment, compj sed of half an ounce of camphor, dissolved in two ounces of oil, with the addition of half an ounce of spir. sal-ammon. caust. or as it is now called, liquor ammonia;. This is to be used three times a day ; and in this way, (continues Mr. Latta) I have success- fully treated many cases of white-swellings.' (Syst of Surgery, Vol. 1. chap. 6.) In the beginning, caustic issues are even more painful than blisters; but they after- ward become more like indolent sores, and are more easily kept open for a length of time than blisters. Such issues are com- monly made on each side of the diseased joint, and of about tbe size of a half crown. The manner of making the eschars, and keeping these issues open, has been already explained. (See Issue.) The question has been contested, amon-> surgical writers and practitioners, whether blisters and issues produce benefit upon the principle of counter irritation, or in conse- quence of the discharge which they occa- sion. They probably operate efficaciously in both ways ; for there is no doubt that mere rubefacients possess the power of rousing the action of the absorbents, and they may also modify the vascular action in diseased parts. These application! ran obviously only act upon the principle of counter irritation, and they have not beei here recommended particularly for white- swellings, because, it seems to me, that whenever some good might be derived from their employment, much more benefit might always be obtained from blisters and issues This sentiment is confirmed byes- perience, and we must, therefore, impute a great degree of efficacy to the maintenance of a purulent discharge from the vicinity<* « the diseased part. P Though my own observations have led me to think issues and blisters as efficient as any means hitherto devised for stopp'mj the progress of scrofulous disease of the heads of the bones, I am far from meaning to say, that such disease can generally be stopped by these or any other remedies, ocal or general. Mr. Brodie has seldom known any benefit derived from blisters ot stimulating liniments ; nor has he seen the same degree of good produced by issues « scrofulous cases, as in examples of primaO* ulceration of the cartilage*. Cold evapo- rating lotions in the earlv stage ofthe com- "'JOINTS. iol> plaint; perfect quietude ofthe joint; atten- tion to the patient's health ; and riding in a carriage in the fresh air; are the means which this gentleman particularly recom- mends in scrofulous diseases of the joints. During the formation of abscesses, he ap- proves of fomentations and poultices. (Pa- thol. Obs. p. 242.) We have noticed the efficacy of friction in exciting the action of the absorbents, by which the thickened state of parts around the affected joint may be considerably less- ened, and, on this principle, the utility of dry rubbing arises. We have now to notice ihe method of producing the same effect by pressure, a plan which yet seems to merit a more extensive trial. I have seen in St. Bartholomew's Hospital, a few cases in which the swelling of the joints was mate- rially diminished, by encircling the morbid articulations with strips of adhesive plaster, applied with moderate tightness. A somewhat similar plan, though its mo- dus operandi is differently accounted for, appears also to have been tried in France. " J'ai dans quelques occasions (says Ri- cherand) obtenu les plus grands avantages de l'application d'un taffetas cire autour de ('articulation tumefiee. On coupe un mor- ceau de cotte etoffe, assez large pour enve- lopper la totalite de la tumeur; on enduit les hords d'une gomnie dissoute dans le vinaigre, et susceptible de la faire adherer intimement a la peau; on l'applique en- suite de maniere que toute l'acces soit inter- dit a l'air entre lui et les teguments. Lors- qu'au bout de quelques jours on leve cet appareil, on trouve la peau humide, ramollie par I'humeur de la transpiration condensee en goutelettes a la surface interieure- du taffetas. Dans ce procede, on etablit un espece de bain de vapeur autour de l'articu- Jation malade." (Nosogr. Chir. T. 3,p 175, Edit. 2.) My friend, the late Mr. Clement Wilson Cruttwell, of Bath, sent me a very excel- lent case, illustrative of the efficacy of treatment by pressure. He remarks that, " After cupping the part, and endeavouring to quiet the inflammation, I used blisters ; but they excited such intolerable pain, and produced so great a degree of swelling and inflammation, that I was under the necessity of healing them immediately. After two months strict confinement to bed, and the use of leeches and refrigerant washes, the inflammation having again subsided, and the pain being removed, I again ventured to apply one small blister, and again a similar attack of pain, swelling, and inflam- mation was produced. The joint became distended with fluid, of which it had always contained a large quantity, and the irritation of the constitution was excessive. By the liberal use of opium I once more succeeded in quietiug the disturbance, and, convinced ofthe hazard of using blisters in such a sub- ject, I applied moderate pressure, by means of a roller, together with a wash, containing a large proportion of spirit, in order to keep tip a constant evaporation. The skin, which was before much inflamed, and bard, bas be- come natural and flaccid, the pain bas cea- sed, the swelling has diminished, and I have every prospect of effecting a cure, with the -preservation of tolerably free motion in the joint." Mr. Cruttwell, in a subsequent letter, in- formed me, that this case got completely well by the treatment with pressure, and had remained so for upwards of six months, under full and free exercise. This example clearly evinces the impro- priety of using blisters in certain constitu- tions. In some remarks, annexed to the above case, Mr. Cruttwell expresses his con- viction, that absolute rest, cold applications and pressure, would succeed in very many cases, without local counter irritation. Pressure, he adds, succeeds best when fluid is effused, and the disease is indolent; but he is convinced that it may be used with advantage in later si ages, when abscesses have formed, and sinuses already exist; and he reminds me how very serviceable con- tinued pressure is to the scrofulous finger- joints of children. The good effects of pressure in scrofulous cases are confirmed by the observations of Mr. Brodie: when, says he, after several abscesses have taken place, the tendency to suppuration has ceased, and the swollen joint has become diminished, anchylosis is probably disposed to take place. At this period, pressure, by means of strips of linen, spread with soap-cerate, or some other mo- derately adhesive plaster, and applied in a circular manner round the limb, will be productive of benefit. (Pathol, and Sur* Obs. p. 243.) "' When the knee is affected, the limb has a tendency to become permanently bent. It must undoubtedly be judicious to pre- vent this position, by means of splints which will also serve to prevent all motion of the diseased joint, an object of the very- highest importance. Were the disease to end in anchylosis, the advantage of having the limb in a state of extension need scarcely be mentioned. In cases which commence in the cancel- lous structure of the heads of the bones it seems rational to combine, with the local treatment, the employment of such internal remedies as have been known to do good in other scrofulous diseases. " It is to be sup- posed, (as Mr. Brodie observes) that the air of a crowded city must be more or less unfavourable ; and that a residence on the seacoast is likely to be more beneficial than a residence in the country elsewhere. The patient should live on a nourishing, but plain diet; he should be in the open air in summer, as much as he can, without exer- cising the joint. His mode of life should, in all respects, be regular and uniform.'' Mr. Brodie has found more benefit derived from the long use of steel medicines than any others, suspending their use, however, and substituting the mineral acids for them' when the formation of abscesses excites' febrile action. With such means, in child JOLMS. rcn.hecombincsliie occasion exhibition of prospect ol' *a-vi-nS l|™* '^entlv in^he mno mercurial purgatives. (Pathol. Obs.,p.24b) Many diseased joint ,nppale"^»J™JJ In a work, which Mr. Lloyd has just pub- hopeless cond.ion,J^1*^Q™ a "J-* lished, it is assumed as a fact, that, in scro- able turn, and, after all, allow the limb to fula there always is more or less disorder be saved. ,. of he f,mctmns of (he digestive organsTand The proposal of cut ing ou .diseased primarily of no other important function, joints, has been considered in the article Hence, the regulation of diet, the state of Amputation. T. . ■ . ..,, . , . (he bowels, and the hepatic secretions, is Disease of the Ihp-jomt.— Ibis compami with this gentleman a principal object; and, is very analogous in its nature to the white- with the latter views, he employs, after swelling of oilier articulations. In the sane Mr. Abernethy's plan, five grains of the way as the latter disordmyt seems probabV blue pill every night, and half a pint of that the disease of the hip has Us varieties, decoct, sars. twice a day, with opening some of which may be connected with medicines, if necessary, to" procure regular scrofula, while others cannot be suspected daily evacuations. When acidity of (he to have any concern with it. Mr.'Brodie'j stomach is present, he gives soda, and, investigations lead bim to believe, however, when the stomach is weak, cinchona, steel, that the disease is of that nature, in which and mineral acids. (On Scrofula, p. 37, the first change is disease and ulceration of fyc.) However, no doubt can be entertain- the cartilages. The present complaint U ed,that these means, like many others, have most frequently seen in children under tht no specific power over scrofulous diseases, age of fourteen ; but, no age, no sex, no and, like sea-air and sea-bathing, only rank, nor condition of life is exempt from answer by sometimes improving the state the possibility of being afflicted, so that ofthe constitution. In the local treatment though children form a large proportion aj of scrofulous joints, Mr. Lloyd commends those subjects, who are attacked; yet th quietude of the limb, which is to be confi- number of adults, and even of old persons, h ned in a sling, or in splints, the occasional considerable. resistance of inllammatoryaction by leeches, The approach of the disease of the hip- and a diminution of temperature ; poul- joint is much more insidious, than that of a (ices when abscesses form ; opening such white-swelling. Some degree of pain alvfays collections of matter early; and, after all precedes the latter affection ; but, the only irritation has ceased, issues, setons, blisters, forerunner of the former is frequentlya slight or the antimonial ointment; or compres- weakness, and limping of the affected limb, sion upon Mr. Baynlon's plan. (P. 152, £>-c.) With respect to opening these ab- scesses early, Mr. Lloyd differs from many excellent surgeons, especially Dr. Albers, who distinctly states, that it is generally treated according to the dictates of surgical best to allow them to burst of themselves, scie-ice. As there is, also* sometimes an On this subject, however, great diversity of uneasiness in the knee, when the hip i: opinion prevails, and Langenbeck is among affected, careless practitioners frequently tlie advocates for makin;, an early opening, mistake the seat of disease, and I have many (Bibl. B.2,p.39.) Hectic symptoms are times seen patients, on their entrance into those which we commonly have to palliate an hospital, having a poultice on their knee, in these cases. When the appetite is im- while the wrong state of the hip was not at paired and the stomach will bear bark, this all suspected. medicine should be given with the aromatic This mistake is extremely detrimental to confection. Above all internal remedies, the patient, not on account of any bad effecf, opium claims the highest recommendation, resulting from the applications so employed; as it at once tends to keep off and relieve buf, because it is only in the incipient period a debilitating diarrhoea, which too frequently of the complaint, that a favourable prognosis \ prevails, at the same time that it alleviates can be made. In this stage of the disease, pain and procures sleep. The objection, mere rest and repealed topical bleeding,will made against its exhibition on the ground do more good in the course of a fortnight, These trivial symptoms are very often not sufficiently urgent to excite much notice, and, when observed by superficial practition- ers, are commonly neither understood, nor that it increases perspiration, seems exceed- ingly frivolous, when tbe above important benefits are taken into consideration. Too often, however, the terrible disease of which we are now treating, baffles all than large painful issues will afterward generally accomplish iu the long space ol a twelvemonth. The symptoms of the disease of the W| joint, when only looked for iu the situatiu" human skill and judgment, and the unhappy of that articulation, are not very obvious to patient's health having declined to the lowest the surgical examiner. Though in some state, he is necessitated to submit to ampu- instances, the attention of the surgeon m tation as the only chance of preserving life, soon called to the right situation of the It has been explainedin speaking oi Amputa- disease, by the existence of a fixed pain ,«i'c.h a . c'>"d,t,1l.)" of, ^ Pilt]e"t,s behind the trochanter major ; yet, it is too health, and not of the diseased joint, forms often the case, that mere pain about an l!* « ,paVreM?n l0r r.ecur,r,nS. *? Uje articulation, entirely destitute,of visibleea- iKtiJffrronii?* rem.°™g [he limb. If largement and external alteration of colour, • raffiPntsconsUtul'0»^ equal to a longer is quite disregarded, as a complaint of no ™t.g'e, no man can pronounce that every importance iu young subjects, and as a flier* JOINTS. 161 rheumatic, of gouty affection, in adults. Patients frequently complain of their most painful sensations being in the groin, and all accurate observers have remarked, that, in the hip disease, the pain is not confined to the real seat of disease, but shoots down the limb, in the course of the vastus externus muscle to tbe knee. The pain, says Mr. Brodie, is at first trifling, and only occasional ; but, it after- ward becomes severe and constant. It re- sembles a good deal the pain of rheumatism, since it often has no certain seat. As the disease advances, the pain becomes exceed- ingly severe, particularly at night, when the patient is continually roused from his sleep by painful startings of the limb. Sometimes he experiences a degree of relief in a parti- cular position of the joint, and no other. As the pain increases in intensity, it becomes more fixed. In the greater number of in- stances, it is referred both to the hip and knee, and the pain in the latter joint is gene- rally the most severe. At other limes, there is pain in the knee, and none in the hip. A boy, in St. George's hospital, complained of pain in the inside of the. thigh near tbe middle; and another patient referred the pain to the sole of the foot. Wherever the pain is situated, it is aggravated by the motion of the joint, and especially by what- ever occasions pressure of the ulcerated cartilaginous surfaces against each other. (Brodie's Pathol. Obs. p. 139.) The early symptoms of disease in the hip- joint are only strongly delineated to such practitioners, as have acquired the necessary information relative to this part of surge- ry, from careful study and extensive experi- ence. We shall next trace those characters of the present disease, which serve to denote its existence. It is a curious circumstance, that when the functions of a limb are obstructed by dis- ease, the bulk of the member generally diminishes, and (he muscles become emacia- ted. Nearly as soon as the least degree of lameness can be perceived, the leg and thigh have actually wasted, and thei-j circumfer- ence has diminished. If the surgeon make pressure on the front of the joint, a little on the outside of the femoral artery, after it has descended below the os pubis, great pain will be experienced. " Soon after the commencement of the complaint, (as Mr. Brodie remarks,) the hip- joint is found to be tender, whenever pres- sure is made on it either before or behind. The absorbent glands become enlarged, and occasionally there is a slight degree of gene- ral tumefaction in the groin." The same gentleman has also adverted to the curious circumstance of there being in some cases a tenderness of the parts, to which, though not diseased themselves, Ihe pain is referred from sympathy with the disease ofthe hip. This occurrence he has observed in the knee several times, and in one instance in the course of the peronaeal nerve. He has also pen a slight degree of puffv -welling of the Vor H ■?) knee in a case, in which pain was referred to this joint, in consequence of disease of the hip. (P. 142, 143.) The limping of the patient is a clear proof, that something about the limb is wrong, and, if such limping cannot be imputed to disea- sed vertebra?, or some recent accident, and if, at the same time, the above-mentioned emaciation of the limb exists, there is great cause to suspect, that the hip is diseased, particularly when the paiu is augmented by pressing the front,of the acetabulum. Diseased vertebrae, perhaps, always pro- duce paralytic affection of both legs at once, and they do not cause painful sensations about the knee, as the hip disease does. The increased length of the limb, a symp- tom that has been noticed by all practition- ers since De Haen, is a very remarkable and curious occurrence, in t-ie early slage of the present disease. This symptom is easily de- tected by a comparison of the condyles of the os femoris, the trochanter major, and malleoli, of the diseased limb, with those parts of the opposite member, taking care that the patient's pelvis is evenly situated. The thing is the more striking, as the in- creased length of the mem*>eris frequently as much as four inches. The rationale of this fact, John Hunter used to explain by the diseased side of the pelvis becoming lower than the other. (Crowther, p. 266.) The same thing had also been noticed by Falconer, (On Ischias, p. 9) long before the period, when Mr. Crowther printed his se- cond edition. ^ It is easy (says Mr. Brodie,) to understand how the crista of one ilium becomes visibly depressed below the level of the other, when the position is remembered, in which the patient places himself when he stands erect. " He supports the weight of his body upon the sound limb, the hip and knee of which are in consequence maintained in the state of extension. At the same time, the oppo- site limb is inclined forward, and the foot on the side of the disease is placed on the ground considerably anterior to the other, not for the purpose of supporting the super- incumbent weight, but for that of keeping the person steady, and preserving the equi- librium. Of course, this cannot be done, without the pelvis on the same side being depressed. The inclination of the pelvis is necessarily attended with a lateral curvature of the spine, and hence one shoulder is higher than the other, and the whole figure in some degree distorted." (Pathol. Obs. p. 146.) These effects, says Mr. Brodie, are in general all removed by the patient's lying in bed a few weeks, except when the deformity has continued a long time in a young growing subject. In justice to the memory of the late res- peeled Dr. Albers, of Bremen, I ought here to mention, that he appears in his work on Coxalgia, to have first pointed out the de- formity of the spine in this disease, and the reason of such change, the tenor of his ob- servations upon this point agreeing with those subsequently made by Mr. Brce!i<-- it*.: J01N1S. An appear-aace of elongation of the limb is not exclusively confined to the early stage of the morbus coxarius: it may attend other cases. I remember seeing in one of the wards of St. Bartholomew's Hospital, a little girl, with a diseased knee, whose pelvis was consideiably distorted in this manner, so that the limb of the same side appeared much elongated Her hip-joint was quite sound. This case was pointed out to Mr. Lawrence and myself by Mr. Cother, of Gloucester. Volpi, Albers, and several other foreign writers, point out the fact, th it the early stage of this disease is sometimes attended with an appearance of elongation, sometimes with that of a shortening of the limb. An explanation ofthe circumstance is given by Mr Brodie, as follows: "In a few cases, where the patient is in the erect position, it may be observed, that the foot, which be- longs to the affected limb, is not inclined ■more forward than the other, but the toes only are iu contact with the ground, and the heel raised, at the same time that the hip and knee are a little bent. This answers to the patient the same purpose of enabliu; him to throw tbe weight of his body on the other foot; but it produces an inclination of the pelvis in the opposite direction. The crista of the ilium is higher than natural, and there ia an apparent shortening, instead of elonga- tion of the limb on the side of the disease." (Pathol, and Surg. Obs. p. 147) Mr. Ford has very accurately called the attention of surgeons to the alteration, wilh respect to the natural fulness and convexity of the nates, that part appearing flattened, which is usually most prominent. I he glu- taeus magnus becomes emaciated, and its edge no longer forms so bold a line, as it na- turally does at the upper and back part of the thigh, in tbe sound state of the limb. Although this symptom, in combination with others, is of importance to be attended to, it bas been explained by Mr. Brodie, that " it is not in itself to be regarded, as a certain diagnostic mark of disease in the hip; since, in its early stage, this symptom is wanting ; and it is met with in other diseases, in which the muscles in the neighbourhood of the hip are not called into action, although the joint itself is unaffected. (Set Medico-Chir. Trans Vol. 6, p. 312.) Though there may be more pain about tbe knee than the hip, at some periods of the malady in its incipient state, yet the former articulation may be bent and extend- ed, without any increase of uneasiness ; but, the os femoris cannot be moved about, without putting the patient to immense tor- ture This is the first stage ofthe- disease, or that which is unaccompanied with suppU. ™The symptoms which precede the forma. tion of dus. vary in different cases, accord- ing as there is acute, or chronic liiflamau. tion present. When the diseased joint it affected with acute inflammation, as gene- rally happens, the surrounding parts become tense and extremely painful ; the skin is even reddish ; and symptoms of inflamma- tory fever prevail. When the severity of the pain abates, a swelling occurs in the vicinity of the joint, and a pointing quickly follows. In this stage startings and catchinga during sleep are said to be among the moat certain signs of the formation of matter. " The shortening of the limb," says Mr. Brodie, " which usually takes place in the advanced stage of the disease, is usually, but not always the precursor of abscess. The formation of matter is also indicated by sa aggravation of the pain ; by more trequent spasms of the muscles, by a greater wasting of the whole limb, and by the circumstance of the thigh becoming bent forward, and being incapable of extension," and by the pulse becoming quick, tbe tongue furred, and the whole system being in a stateof pre- ternatural excitement. "The abscess usu- ally shows itself in the form of a large tu- mour over the vastusexteruus muscle; some- times on the- inside of the thigh, near the middle ; and occasionally two or three ab- scesses appear in different parts, and burst in sm-cession " (Brodie'a Pathol. Obs. p. 162.) We have noticed the commonly lengthen- ed state of the limb, in the first periods of the hip disease. This condition is not of very long duration, and is sooner or later succeeded by a real shortening of the affect- ed member. The foot may be turned in- wards; but, as Mr. Brodie observes, if left to itself, it is generally turned outwards. In other cases, the limb is shortened ; the thigh is bentforwards ; tbetoes are turned inwards, and do not admit of being turned outwards; (Pathol. Ob*, p. 148 ;) and all the symptoms of a luxation of the thigh upwards and out- wards may be observed, the bead of the bone, indeed, being" actually drawn into the external iliac fossa, and carried betwixt the os inno- minatum and glutaeus minimus, which is raised up by it. (See Richerand Noiogr- Chir. T. 3, p. 171, 172,JEd.2.) When the retraction is very considerable- it arises from nothing less than an actual dis- location of the bead of the thigh-bone, in consequence of the destruction of the car- tilages, ligaments, and articular cavity. This retraetion sometimes comes on long before head of mm%B^wmm?4 beari the affected side is bent a little forward, that the ground may only be partially touched with the foot. This position is found to be the most comfortable, and every attempt to extend the limb occasions an increase of patn. any abscess whatever. However, if sup- puration has not taken place, Mr. Brodie be- lieves, it rarely happens, that the limb, after tne cure, does not regain its natural degree of mobility. (See Med. Chir. Trans. I'olA p. ozo.) Jt h worthy of particular noH^p, that tbe JOINTS. 163 Dead of tbe bone is always luxated upwards and outwards; and the only exception lo this observation, upon record, is a case re- lated by Cocchi, in which a spontaneous dis- location of the thigh-bone, as it is termed, happened upwards, forwards, and a little inwards. (See Leviilli, Nouvelle Doctrine Chir. T.3. p.b9b.) On a egalem, nt vu la tete du femur Juxoe en dedans et en bas, et placee sur le trou obturateur, mais cette mode de de'placement conseculif,dans lequel le niembre est alongc, est infiniment rare. (Richerand, Nosogr. Chir T 3, p. 172.) The hip disease generally induces hectic symptoms, after it has existed a celHain time. In some subjects, such symptoms soon come on ; in others, the health remains unaffected a very considerable time. " The health of the patient (says Mr. Bro- die) usully suffers,even before abscesses have formed, from the want of exercise, pain, and particularly from the continued disturbance of his natural rest. I recollect no instance of an adult, in whom abscesses had formed, and who did not ultimately sink exhausted by the hectic symptoms which these indu- ced. Children may recover in this ultimate stage of the disease ; but, seldom without a complete anchylosis of the joint." (Med. Chir. Trans. Vol. 6, loco cit.) When abscesses of the above description burst, they continue, in general, to emit an unhealthy thin kind of matter for a long time afterward. With respect to the morbid anatomy of the disease in its incipient state, until lately little was known. A few years ago two dis- sections related by Mr. Ford were, perhaps, the only ones throwing light upon this point. In one, there was a tea-spoonful of matter in the cavity of the hip joint. The head of the thigh-bone was a little inflamed, the cap- sular ligament a little thickened, and the ligamentum teres united iu ils natural way to the acetabulum. The cartilage lining the cotyloid cavity was eroded in one place, wilh a small aperlure, through which a probe might be passed, underneath the cartilage, into the internal surface of the os pubis on one side, and on the other, into the os ischii; the opposite, or external part of the os in- nominatum showing more appearance of disease, than the cotyloid cavity. In the other instance, the disease was more advan- ced. These examples are important, inas- much as they prove that w hat is commonly called the disease of the hip joint, primarily affects the cartilages, ligaments, and bones, and not the surrounding soft parts, as De Haen and some others would lead one to believe. As the disorder advances, the portions of the os ischium, os ilium, and os pubis, com- posing the acetabulum, together with the in- vesting cartilage, and synovial gland, are destroyed. The cartilage covering the head of the os femoris, the ligamentum teres, and capsule of the joint, suffer the same fate, and caries frequently affects not only the adjacent parts of the ossa innominata, but abo the head and neck of the thigh- bone. The bones of the pelvis, however, are always more diseased than the thigh- bone, a fact which displays the absurdity of ever thinking of amputation iu these cases. Mr. Ford observes, " In every case of dis ease of the hip Jbint, which has terminated fatally, I have remarked, that the os inno- minatum has been affected by the caries in a more extensive degree, than the thigh bone itself (Observations on the Disease of the Hip joint, p. 107.) Sometimes however, the head and neck of the thigh-bone are annihilated, as well as the acetabulum. Mr. Brodie has had opportunities of dis- secting some diseased hip joints both in the incipient and advanced stage of the com- plaint. From his observations, it appears; 1st. That the disease commences with ulcera- tion of the cartilages, generally that of the acetabulum first, and that of the femur after- ward. 2. That the ulceration extends to the bones, which become carious ; the head of the femur diminishing in size, and the acetabulum becoming deeper and wider. 3. That an abscess forms in the joint, which afler some time makes its way by ulceration, through the synovial membrane and capsu- lar ligament, intothe thigh and nates, or even through the bottom of the acetabulum into the pelvis. Mr. A. Cooper showed Mr. Bro- die two specimens, in which the abscess had burst into the rectum. 4. In consequence of the abscess, the synovial membrane and capsqlar ligament become inflamed and thickened. The muscles are altered in structure; sinuses are formed in various parts, and, at last, all the soft parts are blended together in one confused mass, resembling the parietes of ryi ordinary abscess. (Brodie, in Medico-Chir. Trans. Vol. 4, p. 246,247.) Such are the beginning and progress of the ordinary disease ofthe hip joint; but, il is admitted by Mr. Brodie, that there are other scrofulous cases, in which the mis- chief begins in the cancellous structure of the bones, and also other instances, which consist in chronic inflammation and abscesses of the soft parts in the neighbourhood of the hip. (Op. cit. Vol 6, p. 326.) External violence; lying down on the damp ground in summer time ; and all kinds of exposure to damp and cold; are the causes to which the disease has sometimes been referred. No doubt, scrofula has, frequently, some concern in its origin ; but, often, no rational cause is assignable for ihe complaint. Treatment of the disease of the Hip Joint. —The writings of Hippocrates, Celsus, Cae- lius Aurelianus, - lt>4 .1 OIK IS tive stage. However, had not their accounts been exaggerated, all patients of this kind would long ago have flocked to Bath, and the surgeons in other places would never have had further occasion to adopt a more painful mode of treatment. The plan pur- sued at Bath, is to put the patient in a warm bath, two or three times a week, for fifteen or twenty-five minutes. In the first stage of coxalgia, the late Dr. Albers, however, had a very high opinion of warm bathing, fomentations w ith decoctions of herbs, and of bathing in mineral waters and the sea. But though he commenced the treatment w ith the frequent use of the wirm bath, and continued tiie plan a long while, it is to be remarked, that he also com- bined with it an issue. After the patient had been in the bath a period not exceeding half an hour, he was taken out, and his whole body well rubbed with flannel. It appears to me, that one objection to this practice must be the considerable disturbance occa- sioned by moving the patient in this manner every morning; for if it be true, that most of these diseases commence in the cartilages of the. joint, all motion of the limb must be particularly injurious. In the early period of the disease, entire rest, the application of fomentations, and the employment of topical bleeding, parti- cularly cupping, are highly proper. Such practice, also, is invariably judicious, when- ever the case is attended with symptoms of acute inflammation. When the fomenta- tions are not applied, the lotio aquae lithar- gyri acetati may be used. This method of treatment ought never to be employed, unless manifest signs of active inflammation be present. When no such state existsf this plan can only be regarded as preventing the adoption of a more effica- cious one, and, therefore, censurable. " Where the cartilages of the hip are ul- cerated (says Mr. Brodie,) the patient should in the first instance, be confined to a couch, if not to his bed . and if the disease is far advanced, the limb should be supported by pillows properly disposed, so as to favour the production of an anchylosis, by allow- ing it to vary as little as possible from one po-ition.' (SeeMedico-Chir. Transs. Vol.6 » 835.) 'e' Quibus diutumo dolore, says Hippocrates ischiadico vexalis 8. J. Bums on Inflammation, Vol. 2, p. 311. Wm. Falconer, A Dissertation on Ischias, and on the Use of the Bath Waters as a Remedy, Bvo. Lond. 1805. Russel on Morbid Affec- tions of the Knee, 8vo. Edinb. 1802. H. Park, An Account of a New Method of treat- ing Diseases of the Joints of the Knee and Elbow, 8vo. Lond. 1783 Also H. Park and P. F. Moureau, Cases of the Excision of Ca- rious Joints; wilh Obs. by Dr. J. Jeffray, \2mo. Glasg. 1806. J. A. Albers, Abhand- lungen uber die Coxalgie, oder das sogenannte freywillige Hinken der Kinder, 4to. Wien. 1807. This work includes many valuable re- marks, but owing to the crowded state of this edition, it has been impossible to do his merit sufficient justice. G. Wirth, De Coxalgia, \2mo. Wiceb. 1809. Patella, Adversaria Chir. Prima, 4to. Hey's Practical Observa- tions in Surgery, p. 354, fyc. Edit. 3. Boyer,. Traiti des Maladies Chir. T. 4, Paris, 1814. Reimarus, De Tumore Ligamentorum circa articulos, Fungo artieulorum diclo, Leyde, 1757. Brambilla, in Asia Acad. Med. Chir. Vindob. T. 1. Brodie's Pathological Re- searches, respecting the Diseases of Joints, in Vol. 4. 5, and 6 of the Medico-Chirurgical Transactions. Also his Pathological and Sur- gical Observations on the Joints, 8vo. Lond. 1818 ; a work containing a great deal of cor- red and original iufortnalion. Schreger, Chi- rurgische Versuche, B. 2, p. 209, <^c. Beilrage zur Nosologic der Geleukkrankheitcn, 8vo. Nurnberg, 1818. J. N. Rust, Arlhrokakolo- gie, oder uber die Verrenkungen durch innere Bedingung, 4lo. Wien. 1817. A publication of great merit Dr. Tomaso Volpi, Abhandl. uber die Koxalgie, ausdem Hal. ubersetzt vou Dr P. Heineken. The original I have nol seen, but the translation contains copious ex- tracts from the prize essay, which I drew up some years ago, with additional observations and cases. Richerand's Nosogr. Chir. T. 3, p. 170, fyc. Ed. 4. Langenbeck, Nene Bibl. B. 2, p. 337. G. Gotz, De Morbis Lisamen- torum 4/o. Berol. 1799. Delpech, Pricis Eliment. des Mai Chir. T. 2. p. 377, T. 3, p. 194, p. 470, p. 711, 4-r. Paris, 1816. H. Mayo, on an acute Form of Ulceration of the Cartilages of Joints, in Med. Chir. Trans. Vol. 2, p. 104. J. Wilson, Lectures on the Structure and Physiology ofthe Skeleton, and Diseases of the Banes and Joints, 8ro. Lond. 1820. E. A. Lloyd, A Treatise on ihe Na- ture, fyc. of Scrofula. 8vo. Lond. 1821. The two last publications deserve attentive perusal. JUGULAR VEIN, how to bleed in. See Bleeding. Jugular vein, internal, wounded. Dr. Giraud cursorily mentions a case, in which a French surgeon, at the military hospital of Toulouse, early in the year 1814, passed a ligature round the trunks of the common carotid artery and internal jugular vein. Both these vessels had been wounded by a musket-shot. On the sixth day from the ap- plication of the ligature, nothing unfavoura- ble had occurred ; but the final result ofthe case is not related. (See Journ. Ginirale de Med. §-e. par Sedillot.) K. K .ALl See Potassa. KERATONYXIS The term, keratonyxis, derived from xig*f, a horn, and w£k, a puncture, is employed by the professors in Germany to denote the operation of couch- ing performed through the cornea, or horny coat of the eye, the opaque lens being in this manner sometimes depressed, some- times broken piecemeal, and in other in- stances, merely turned, so as to place its an- terior and posterior surface in the horizon- tal position. The latter method is what the German surgeons particularly imply by the phrase reclinalion. See Cataract. KNFE, DISEASES, AMD INJURIES OF THE. See Dislocations; Fractures; Gunshot Wounds; Joints, tfc. LACHRYMAL ORGANS L. LACHRYMAL »RG*\NS. Diseases of the. The lachrymal gland cannot be said to be a part w hich is frequently the seat of dis- ease. Richerand has s en no instance of an inflammation of this gland, unless by this expression be implied cases in which all the contents ofthe- orbit are more or less affected. (Nosogr. Chir T 2, p. 32.) I be- lieve that the surrounding cellular substance is more frequently attacked wilh inflamma- tion and suppuration, than the gland itself. According to Professor Beer, (Lehre von den Augenkr. B. i, p. 349,) true idiopathic in- flammations ofthe lachrymal gland are very rare, and he declares that in the course of a practice of twenty-seven years, he has but seldom met with them. On this point he differs from Schmidt, who fancied that he had often had under his care cases of this description in gouty and scrofulous sub- jects. (Leber die Krankh. des Thrnnenor- gans, p. 134.) When the lachrymal gland is attacked with inflammation, its secretion, far from being augmented, as Richerand de- scribes, is always considerably lessened, and therefore one of the earliest symptoms is an uneasy dry state ofthe eye, the secre- tion from the meibomian glands, and mu- cous membrane of the eyelids, not being alone sufficient for keeping the eye duly moist and lubricated. This state is succeed- ed by a throbbing acute pain in the temple, shooting*to the eyeball, frehead, upper and lower jaws, and back of the head. In the mean while, the temporal portion of the upper eyelid becomes swelled, tense, red, and exceedingly tender, the tunica conjunc- tiva being scarcely at all affected, and merely exhibiting a slight degree of redness atid tumefaction towards the outer canthus. However, as the swelling of the gland in- creases, the eyeball becomes pushed more or less downwards, and inwards towards the nose. But though there is little or no red- ness, nor any mark of inflammation about the eye, this organ is tense, and extremely tender. The freedom of its movements towards the temple is much lessened in the beginning of the complaint, and, when the tumour has acquired a very large size, is quite destroyed. The impairment of vision is always proportionate to the protrusion of the eyeball, the pupil being diminished, and the iris motionless. The second, or suppu rative stage, Beer describes as ushered iu by fiery appearances before the eye;. an in- creased displacement of tlie eyeball; throb- bing pain; great increase of the swelling of the upper eyelid, and of the conjunctiva, towards the temple ; an annoying sensation of cold, and heaviness in the eye and orbit. Now, under febrile symptoms, rigours, be. a yellowish point presents itself, either on the reddened portion ofthe conjunctiva or on the outside of the eyelid, and a fluctua- tion becomes distinguishable. (Beer Lehre, SfC. B. 1, JJ. 360.) Beer speaks of absre"^ sometimes forming in the vicinity of it,e lachrymal gland, and terminating in a small sinus, v. hich communicates with one of the principal excretory tubes, and discharges occasionally a thin limpid fluid. (Le/it/ron den Au-enkr. B. 2,p. 184.) The experience of this author leads him to consider these sinuses either as a consequence of an un- skilful- treated abscess of the upper eye- lid, or of a similar neglected affection ofthe cellular membrane, near tbe lachrymal gland ; or, lastly, of the presence of a por- tion of the sac of a burst encysted tumour. According to Mr. Travers, the lachrymal gland often suppurates in children, and oc- casions an excessive swelling above the upper eyelid,"*depressing the tarsus sons completely to conceal the eye. The ab- scess, he says, may be conveniently opened, and discharged beneath the eyelid. •Sy- nopsis of the Diseases of the Eye, p. 228.) With respect to the treatment of any local inflammation in and about the lachrymal gland, the best means of relief would be' leeches, fomentations, emollient poultices, and other common an tiph logistic remedies, lo the suppurative stage, Beer recommends mix- ing* with the poultice a good deal of hemlock. Tlie lachrymal gland issubject to scirrhous enlargement, and, in cases of carcinoma of Ihe eye, it is one of the parts in which a re- turn of Ihe disease is apt to occur. Hence, it is .now generally considered right lo re- move it as soon as (he eyeball bas been taken away. (Se-e Eye.) Sometimes Ihe /-land is primarily affectt-d, and Guerin removed cine in the state of scirrhus, and so much enlarged, (hat the eye was entirely covered by it This operation was performed with such dexieri'y, thai the external .'(might muscle was not at all injured. Mi. Travers bas also removed e scirrhous and enlarged lachrymal gland. The vision of the eye bad suffered considerably during the growth of the tu- mour. The only deformity after (he opera- tion, was a slight prolapsus of the eyelid, This gentleman recommends operations of this kind lo be alw ays done, if possible, be- neath the eyelid. (Synopsis, fyc p. 228.) The caruncula laciirymalis is liable lo chronic induration and enlargement, consti- tuting (he disease already spoken of in a foregoing part of this work, under the nam* of Encanthis, of which there is also a scir- rhous, carcinomatous, or malignant form, quickly extending its effects to the eyeball, and the adjacent (bin bones of (he orbit- (Beer, Lehre von den Augenkr. B. 2, p. 188.) Fnnn tliese subject-^ I proceed (o consider the diseases of the excreting parts of Mi* lachrvmal organs; cases which, though of the most various natures, were formerly »U confounded together under the title o\ fistula lachrymalis, and it is only within the last few years, that tliese complaints have been subjected to tht same principles and cJislinc- lions. which are conceived to be highly ore- LACHRYMAL ORGANS. io: ful in other branehes of -surgery. As Mr. M'i-'enaie has j.idiciously remarked, the consequence of not distinguishing the dif ferenl diseases of the excreting part* of the lachrymal organs from each other, ha* been an attempt to discover some single successful method of curing (hem all " Now, there is no one method of treatment by which this can be accomplished; and hence it is, that the several rem-'die-i which have been pro- posed, being eminently suce-essful in one or other of ihese diseases but not ad epted to all tbe rest, have at cliff-rem I limes b en held in sued varicvi-degrees ol * filiation." \ On Diseases of the Lachrymal Organs, p. lo, 8t>o. Lond. 1819.) And .in intelligent critic ob- serves, that in lachrymal diseases, obstruction ofthe nasal duct appeal» to be almost the only circumstance against which the treat- ment recommended by the surgeons of France and England, has been directed. " On sail qu'au retrdcissement ou a I'oblitera tion du canal nasal produits par une cause quelconque, est due, dans pr>sque tous les cas, la cnaladie qui nous occupe; soit que, restees intactes, les parois du sac presentenl une tumeur lachrymale, d'ou les larmes re- fl'i.*nt continuellemeut sur les joues, a. travers les points lachrymaux : soit qu'en partie de truites et ulcfe-^es, res parois presentenl une fistule, qui offre aux larmes un passage eonlre nature., sans cesse entretenue par elles ; en sorte que ces deux etats, lalum»:ur et la fistule, sont presque tnujours des degres differens d'une meme affection, et que le traiti'inent qui convient a, I'une repose sur les inenies bases que celui in lique d<«ns I'mitre." (CEuv- res Chir. de Desault, T. 2 p. 120.) It is evi- dent from the writings of Pott and Ware, that even these authors considered the ob- struction of the nasal duct, as the foundation of all the train of varied symptoms present- ed by the excreting lachrymal organs. " An obstruction in the nasal duct is most fre- quently the primary and original cause of the complaint." " The seat of this disease is the same in almost every subject," says Mr. Pott (06s. on the Fistula Lachrymalis;) and Mr. VVare, in his observations on (he same disease, sets out with (he same assumption. Now, obstruction of the nasal duct is an oc- casional consequence merely of inflamma- tion ofthe excreting lachrymal organs; in most of their diseases, obstruction of the nasal duct has no part ; and one might, with as much propriety, treat all the affections of the bladder and urethra, by Ihe dilatation of the latter part, as treat all the diseases of the excreting lachrymal organs, by dilating the nasal duct. The false assumption in ques- tion bas led to most erroneous treatment. For instance, in blennorrhea of the sac, and in hernia of (he sac, though in both these diseases the nasal duct is patent, the common treatment in this cou,i(ry is to open the sac by the knife, and thrust down a style, or some other instrument into the noser, thus destroying (he organiza- tion of the parts which are affected merely with a gleety secretion in the one case, and with extreme relaxation in the other. Sup- pose (says the same critical writer) that some charlatan should make oath at the Man ion-llouse, Ihal he h*d cured fiftv or a hund ed cases of gonorrhoea by opening (he arethra in the perinicum, and passing a bou- gie through that tube, from behind forwards, who would approve of su< h an operation? Ye( the laying open of the lachrymal sac, and ihrusting a probe down into the nose, when the nasal duet is either perfectly pa- tent, or at the most, -lightly tumid from inflam- mation, i- ne'ilber -ess pr-poste-rons, un- less cruel. (Se-e Quarterly Journ. of Foreign Mediriie Voi. 1, p. 2.'3.) Indeed, il is some- what surpr sing, that errors of this kind should have prevailed so long, particularly as expe- rience had taught Mr. Pott, that slight c a,es miihtbe benefited by the simple employment of a vitriolic coilyrium ; a fact which ought to have convinced him, that (he disease did not always depend upon obstruction of the nasal duct. It is curb-us, therefore, that he did not fully see this mistake ; for, that he knew of these di-eases having great va- riety, is evident from the following remark : As the state and circumstances of this disease are really various, and differ very essentially from each other, the general custom of call- ing (hem all by (lie one name ot fistula lach- rymalis is absurd.'' I believe, tha' one great cause of deception h*s been the fact, tha1, thou-;h laying open the lachrymal sac, >nd the introduction of instruments down Ihe nasal duet, have been frequently practi- sed, when milder plans would have answer- ed every purpose, yet a cure has often fol- lowed Ihe practice, and thus confirmed the supposition of relief having been effected by Ihe removal of (he imaginary obstruction in Ihe nasal duet. Thus the la(e Mr. Rams- den, of Si. Bartholomew's, with whom I served my apprenticeship, always followed the common plan of passing a probe down the nasal duct, and letting the patient keep a piece of bougie, or a style, in the part for two or three months afterward; and I scarcely recollect an instance in which be failed to accomplish a cure, (hough I have no doubt that the same benefit might some- times have been obtained without any opera- tion at all. And a discerning practitioner should never forget that, if no permanent obstruction exist in the nasal duct, a cure will generally follow, on the subsidence of in- flammation, and a change taking place in the actionof the par(s,»vhether a probe,style,can- nula, bougie, or seton, be employed, or not. Erysipelas of the Parts covering the La- chrymal Sac.—Beer considers it highly ne- cessary that this case should be discriminated from infl-ttnmation of the sac itself, which is often but little affected, and this even when an abscess forms. Unless the true nature of (he disease be comprehended/the surgeon is apt to suppose, that (he matter is in (he sac itself, and believes (ha(, when he makes an opening, he is puncturing that receptacle, whereas he is in reality, merely dealing with a superficial abscess of the integuments. Nor, as Beer has observed, is the mistake free from ill consequences; for, imagining 168 LACHRYMAL ORGANS 1 that the wound is made into the sac, the pcned, the slightest pressure upon the sope surgeon pokes about with his probe so long, rior part of the sac P"**™?^*harge „ that a good deal of unnecessary pain and in- pus and mucus from the externa] opening, fla,nmagtion is produced. According to the and, if the lachrjma canals have a heady same author, Ibe case is not very frequent, and is mostly met wilh in scrofulous subjects, who have had for a considerable time a blennorrhoea of the lachrymal sac. The in- flammation partakes of the usual characters of erysipelas, and commonly extends to the eyelids, particularly the upper one. The ab recommenced their functions, tbe discharee will also be mixed with tears. (See M'Kensit on Diseases of Ihe Lachrymal Organt, />. Sftj.) The quantity of matter, which flows out, *s likewise so copious, that it is evident it could not have been all lodged between the skin and orbicularis palpebrarum muscle, but sorption and conveyance of the tears into must have come partly out of the lachrymal sac. The use of a fine probe will reraoie any doubt which may be left. (Beer, Um von den Augenkr. B. 1, p. 332—35.) On the subject ofthe causes of this com- plaint, the preceding author delivers no re- mark worthy of notice. In speaking of the the lachrymal sac are interrupted, because (he inflammation constantly affects the la- chrymal ducts and papilla?, ihe latter appear- ing considerably shrunk. When the inflam- mation spreads over the side of the face, Beer says (here is usually a discharge of thin mucus from the nose; and when the affec- prognosis, he observes, that when the case is tion extends more deeply to the anterior por- not neglected, nor wrongly treated in its first tion of tbe lachrymal sac, ns may easily bap- stage, and the inflammation has not entend pen when the case is neglected, or treated ed to the lachrymal sac, the prognosis is in its first stage with stimulating applications, very favourable ; for, after the subsidence a bean-shaped, circumscribed, hard, painful of the inflammation, a temporary atony of tumour may be felt, oris even denoted by its the lachrymal puncta and ducts, an imper- very red appearance. The puncta lachry- feet conveyance of the tears into the nose malia are now completely closed, ihe papil- lae shrivelled up, and the nostril on the af- fected side very dry and tender. If in the first stage of the disorder, the la- chrymal papillae and canals have not been too violently affected, the lormer parts ex- pand again, and the absorption of the tears recommences with the second stage. But, at this period, according to the observations of Professor Beer, a good deal of mucus is secreted from the caruncula lachrymalis and Meibomian glands, and collects and glues the eyelids tegether, especially during sleep. At the same time, mucus generally accumu- and of course a slight oozing of them over the cheek, most troublesome in cold, wet weather, are the chief inconveniences which remain. But, when the lachrymal sac par- ticipates in the inflammation, the prognosis is much less favourable ; because, when suppuration takes place, ulceration is apt to form an opening in the front part of the sac, or else, during the second stage, a large quantity of mucus may collect in the sac, and, if not skilfully treated, it frequently ends in a very obstinate blennorrhoea of that part. As Beer observes, this is a case which is often, though quite erroneously, named a fistula lachrymalis. (B. 1, p. 336.) The prognosis is also very favourable in lates in the lachrymal sac itself, and may be voided both through the puncta lachry- maliaand nasal duct, by gentle pressure, the second "stage ofthe compVainTaTlon; The mucous discharge from the nostril also as the suppuration is restricted to the inte- acquires a thicker consistence. Should the guments, and it is characterized by desqua- lachrymal papillae and ducts have suffered mation and scabbing ; but, the case is more more severely in the first stage of the dis- serious, when a large collection of matter ease the due absorption of the tears does formS) and particularly when the abscess not begin after the subsidence of the inflam- make3 its way into th£ iachryma, sac. I„ mation, and a dropping of them over the these last circumstances, an obstinate bleu- cheek, a slillicxdium lachrymarum frequently norrhoea from the sac often follows, notwith- continues a long wjiile after the termination standing the fistulous sore be treated in the ile!ry,ra|l , epe''dsT°;nlbe raost skilful manner, ^d sometimes the atony of the lachrymal puncta and ducts, matter spreads so far around, as to spoiled A"nAVKry ,i°U ,les"me,"col ! , ;, .;. Beer terms a spurious fistula of the lachry- ^ Tuf.n'nihJaSd an^ TbTl S mal sac, the matter not being formed in lhat canals are deslr, vIa '•♦ • e^The receptacle itself, but getting into it from the cavftv ofthe ,» y i * !a "eces,sf.ry th*t I»m,wb«m«rfl,eulMiWooeilend.lbnJgli T?„"'*',"'" h'1' «™'t". noticed. LACHKYMAL ORGANS. 169 the parts affected, and the administration of gentle doses of sulphate of magnesia, make up the treatment. In severe cases, it will be found necessary, not only to continue the cold applications, and to open the bowels, but to administer an emetic of tartrate of antimony, fo purge freely, and even some- times to take away blood from the arm." (M'Kenzie, p. 24.) In the second stage, a warm dry air, and a linen compress, are commended, with the exhibition of diaphoretics. In the two first of these means, I cotifes'-, that I should place little or no confidence. When the formation of matter cannot be prevented, poultices are to be used. Beer particularly cautions us not to leave the abscess to burst of itself, but to open it immediately a fluctuation can be felt, so as to prevent an ulcerated open- ing from taking place in the anterior part of tbe lachrymal sac. And, if the surgeon has not been consulted before such a "commu- nication has been established between the sac and subcutaneous abscess, he should avoid all unnecessary disturbance of the parts with probes and syringes, and at most, only wash out the abscess once aday with Anel's syringe, filled with lukewarm water and a little ofthe vinous tincture of opium. Beer also recommends introducing into the superficial abscess, but not into the sac, a small quantity of lint, dipped in the tincture. If the blennorrhoea ofthe sac continue, it is to be treated as will be explained in consi- dering the second stage of inflammation of that part. Inflammation of the Lachrymal Sac.—Ac- cording to Beer, the symptoms of the first stage of this complaint are as follows : in the corner of tbe eye, precisely in the situation of the lachrymal sac, a circumscribed, very hard, tender swelling arises, of the shape of a bean, producing a lancinating pain when it is touched, and gradually acquiring consi- derable redness. The absorption and con- veyance of the tears into (he lachrymal sac, and thence into the nose, are completely in- terrupted ; the lachrymal papilla? are shrunk; the puncta cannot be seen ; and of course the tears fall over the cheek. The nostril on the affected side is at first very moist, but soon becomes perfectly dry, the mucous membrane being a good deal affected. As the inflammation also constantly spreads to fhe orbicular muscle and integuments in the corner of the eye, the complaint often pre- sents an erysipelatous appearance, extending to the eyelids and down the cheek ; but, the circumscribed swelling, caused by the inflamed sac, is still not only capable of being distinctly felt, but even seen. It rarely happens, in cases of common in- flammation, that on the change of the first sta»e into the second, the nasal duct is ren- dered impervious by an effusion of lymph ; but such* an occurrence is more frequent where the inflammation is not of a healthy description,-«nd the patient is scrofulous. Under these- circumstances, the lachrymal •anals may also be permanently obliterated. " ot If Oft In weak, irritable constitutions, tovraTus the end of the first stage of the inflammation, a degree of symptomatic fever prevails, with severe headach, great redness and swelling of the whole inner canthus, involving the caruncula lachrymalis, the semilunar fold, the conjunctiva, the edges of the eyelids, and the lachrymal puncta. Here as in inflammation of every mucous membrane, at the very commencement of' the second stage, a copious morbid secretion takes place, and accumulates in large quan- tity ; for, either in consequence of the ■ thickening of the mucous membrane, the adhesion of the sides of the nasal duct together, or there being no mixture of the tears, the secrelion within the sac cannot escape either into the nostril, or out of the lachrymal puncta, and consequently it dis- tends in a prodigious degree the anterior side of the sac, where it is uncovered by bone. Hence, the swelling is here very manifest, and a fluctuation may be felt in it, even before the suppurative stage has actually begun. According to Beer, whoever is in- duced by the fluctuation to open the lachry- mal sac at this period, will certainly bring on a very hurtful suppuration of the part, exceedingly likely to render the excreting parts of the lachrymal organs completely un- serviceable. At the beginning of the second stage, there is also a morbid secretion from the mucous membrane of the nostril and caruncula lachrymalis. Now not only the swelling of the lachrymal sac increases more and more, the redness acquires a deeper colour, the skin becomes more shining, the fluctuation still more evident; and, at length, in the centre of the tumour formed by the lachrymal sac, a yellowish, soft point presents itself. In this state of things, in order to prevent a true fistula, the surgeon should make an opening in the lachrymal sac, without the least delay ; for, if the ab- scess be left to itself, tbe pus will at la?.. make a passage for itself through the orbi- cular muscle and integuments ; but it will only be a small fistulous opening, surrounded with callous hardness, and merely capable of letting some of the [his and mucus of the sac escape, so that the thicker part of the matter remains behind, and, consequently, though the swelling diminishes after the formation of a spontaneous opening, it does not entirely subside. A quantity of blood is also remarked to be blended with the dis- charge from the sac. This last is the case, which Beer denominates a true fistula of lachrymal sac. When the abscess bursts of itself, the fistulous opening in the sac is not always exactly opposite tlie aperture in the skin, and, though there is commonly but one: communication with the sac, it sometimes happens, that several small external openings are produced more or less distant from the sac. The diagnosis is easy enough; for, on pressing upon the upper portion of that re- ceptacle, mucus and pus, blended together, are immediately discharged from all the fistu- lous apertures. After the disease has lasted a good whi!t% it not '.infrequently happens, no that tears are also voided from the fistulous opening ; a circumstance, indicating the re- stored action of the lachrymal puncta and canals, but, according to Beer, such tears are never duly blended with the mucous and purulent matter. He further remarks, that, when the second period of tbe second stage, or the suppurative process is over, a morbid secretion of mucus still continues in the third period of the second stage, that secre- tion becoming whitish, thick, opaque, and only partly- resembling pus. As, in con- quence of its thickness, and the swelling of the mucous membrane of the nasal duct, the secretion cannot descend into the nose, it collects in (he sac, ind sometimes pushes off any piece of lint, or plaster, with which the external opening iu the sac has been closed. At length, by means of judicious treatment, this third period of the second stage is also brought to a termination ; the mucus is se- creted again in due quantity ; it becomes transparent like white-of-egg, and viscid; but white streaks maybe for some time per- ceived in it. Afterward the mucus becomes thinner, and, if the functions of the lachry- mal puncta arid ducts are not destroyed, it is thoroughly mixed with the tears. The open- ing in the lachrymal sac now either heals up of itself, or under skilful treatment; but, iu general, a minute fistulous aperture still re- mains, from which the tears and mucus are occasionally voided, if the passage through the nasal duct be not free. However, if the small fistulous aperture should happen to heal up completely, the mucus and tears accumulate in the sac, and the patient is obliged to press them out through the puncta lachrymalia several times a day. When the surgeon is consulted early enough, and proper treatment is adopted, Beer sets down the prognosis in the first stage of tne inflammation as very favourable. But, if the practitioner be called in later, it will not be in his power completely to dis- perse tbe inflammation, and prevent the morbid secretion, and accumulation of mu- cus in the lachrymal sac ; the blennorrhea of this part, of professor Beer, or the dacryops bhnnoideus, of Schmidt ; a state, however, which soon gives way to judicious treatment. But, when the case is neglected, or wrongly managed at the period, when the lachrymal sac is violently inflamed, a complete, or par- tial closure of the nasal duct by adhesive inflammation is apt to be the consequence. And, the same effect may also be produced in the lachrymal canals, in which event, the absorption of the tears is for ever impeded, and the patient must remain the rest of his life afflicted with a stillicidium lachrymarum. With regard to the prognosis in the second stage of inflammation of the lachrymal sac, Beer considers it as very dubious, on account of the impairment of the functions of the LACHRYMAL ORGANc the purpose of obtaining information, wouid ided with considerable mischief -. generally speaking, the prognosi< opeful at the first period of the se- be "attended h considerable However, _ is most hopeful — cond stage just when the morbid secretion of mucus is beginning; the: suppuration may vet be moderated by right treatment, and the excreting parts of the lachrymal organ* preserved. But, if the suppurative stage ha-, already come on, much will depend tipon the consideration, whether the matter has been originally formed in the lachrymal sac, has lodged there a good while, and the sac is ready to burst, or whether there is actually an opening in the sac opposite that in tbe skin, or, lastly, whether the openings do not correspond. In the first case, the suppura- tion yet admits of being regulated by judi- cious treatment, and the lachrymal sac can be punctured ; but, in the other circumstan- ces, the management of the case is far more difficult, especially when the patient's con- stitution is not good. However, the surgeon should be careful not to disfigure the patient with a large scar ; and the aim should be to prevent atony of the lachrymal puncta and ducts, and a consequent stillicidium laclny- marum. These are the least serious evils to be apprehended from mismanagement; for, if the case be ill-treated, or neglected, in the latter stage of the suppurative process, ne- cessarily attending a fistulous state of the sac, the lachrymal organs may be rendered quite useless, or even entirely destroyed, and the nasal duct obliterated, or obstructed by the effects of caries. In some few in- stances, indeed, the whole lachrymal sac is destroyed, or will require to be so by art,as will be presently explained. It is always a favourable circumstance when the tears are seen to issue from the fistulous opening with the mucus and pus, as it is a proof that the absorption and conveyance of ihe tears into the lachrymal sac are established again, and that now the only question is about the state of tbe nasal duct, which point cannot be determined before the fistula is com- pletely healed, and the third period of the second stage is entirely obviated. (But. Lehre von den Augenkr. B. I, p. 356—367.) In the first stage, the indication is to en- deavour to resolve the inflammation. "It is, (as Mr. M'Kenzie observes) by combat- ing the inflammation, that we are to cure this disease, and not by attacking merely one, or even several ofthe symptoms. Di- latation, for instance, by the introduction of probes through the canals into the sat and even into the nose, would only be sub- jecting the inflamed parts to a new cause of irritation, and might thus produce effects which would render a complete cure diffi- cult, if not impossible. On the contrary in the first stage, Mr. M'Kenzie joins Beer excreting parts of the lachrymal organs; for", ^atTonl^^ says he, no surgeon can exactly know, what in severe cases venesection «ndleecbe< TrJSS l* ib^ reS-UU °f *"?*? ^ ™ SCt d™<™\^pT$£* witi P«* duct In-YTJhJ^ Pem0,USneS3,0f ^e nasal ing and diaphoretic medicine (On Kf duct and lachrymal canals, and an officious eases of the Lachrymal Oreaw» 4 341 examination ot tbe part, with a probe, for la t£. iJ^SJi, SSI' Jffl I- LACHRYMAL ORGANS. 171 i longer practicable, emollient applications are the most beneficial, and all debilitating means are to be stopped, by (he further use of which an incurable blennorrhoea of the lachrymal sac would be likely to be indu- ced. And, as soon as the sac is so distended with mucus and matter, that the centre of the '•welling begins to be soft, and a fluctu- ation is perceptible, the sac should be freely opened, so as to let its contents have a rea- dy outlet. II, after this evacuation, there should be any deep seated hardness of the lachrymal sac, Beer recommends the ap- plication of a camphorated hemlock poul- tice. Afterward, the wound in the skin and sac is to have introduced into it a little bit of lint, dipped in the vinous tincture of opi- um, over which dressing a piece of diachy- lon plaster may be placed. When, under such treatment, the suppuration diminishes, but a preternatural secretion of mucus yet continues, Beer introduces into the wound every day a piece of lint, on which is spread a little bit of the following ointment: ft Butyri recentis insulsi, ?ss. Hydrargyri M- trico-Oxydi, gr. x. tutiae, ptt. gr. vj.'M. And, on changing the dressings, some of the fol- lowing lotion may be dropped into the in- ner canthus, and injected lukewarm into the sac itself: ft Subacetatis Cupri, Potas- sa; .Nitratis, aluminis, a a gr. iij.—vj. Cam- phorae tritae grij.—iv Aquae distillatos gss. Solve et cola. Liquori colato adde Vini •°P" 3j—3'j Aquae Rosas -|iv. M Pro- fessor Beer makes a mass of the three first articles melted together in equal propor- tions, and terms it the lapisdivinus, of which he makes the lotion, and then adds the other ingredients. When, by meansofsuch treatment, the mucous secretion from the sac has been brought into a healthy state, and all the induration has subsided, the pe- riod has arrived for the surgeon to think of taking measures for the re-establishment of (he passage through the nasal duct, if it should not already have become pervious of itself, which, when the inflammation has been of a healthy kind, and the treatment judiciuus, very frequently happens. (Beet, Lehre, fyc. B.X.p. 369—371.) Chronic Blennorrhoea of the excreting Parts ofthe Lachrymal Organs.—Mr. M'Kenzie, whose Essay contains a faithful account of Beer's opinions upon the present subject, describes the inflammation, with which this form of disease commences, as seldom con- siderable, and in scrofulou s patients, it is said to be not unfrequently quite disregard- ed, no advice being taken until the lachry- mal sac is much distended wilh mucus. By means of pressure upon the bean-shaped tu- mour, caused by such distention of the sac, a quantity of puriform mucus is forced out of the puncta lachrymalia, and overflows the eye ; and so far are the lachrymal ca- nals from being obstructed, that, excepting when any return of inflammation happens) they even absorb, and convey the tears into the sac. Pressure, however, will rarely make the contents of the sue pass through fhe nasal dnct, on account of the thickened state of the mucous membrane, and there- fore the nostril is generally very dry. •' In the course of this tedious disease, the accu- mulated mucus varies much both in quantity and quality. For instance, the mucus ac- cumulates more rapidly, and is much thick- er after a good meal, than at other times. The secretion of it is very plentiful, but thinner than usual, when the patient con- tinues long in a moist cold atmosphere. In this case, the overfilling of the sac takes place so rapidly, that the compression of the orbicularis palpebrarum in the action of winking is sufficient to evacuate the sac through the canals to such a degree, that the whole surface of the eyeball is suddenly overflowed^ and the puriform fluid runs down upon the cheek. After the patient remains for a short time in a warm and dry atmosphere, the morbid secretion becomes sparing and ropy. We find, that this chro- nic blennorrhoea almost completely disap- pears in many individuals during warm weather, upon which the yet unexperienced patient and the unexperienced surgeon are apt lo express a great, but a premature joy, for, on the very first change to cold and wet weather, the disease most frequently re- turns." During chronic blennorrhoea. the lachry- mal sac is extremely liable to repeated at- tacks of inflammation, and sometimes a fis- tula, with a good deal of induration of the surrounding cellular substance, is produced. Mr M'Kenzie represents this disease as the most frequent of all those to which the ex- creting parts of the lachrymal organs art- liable, and as consisting in inflammation of these organs, modified by scrofula, gene- ral debility, disorder of the digestive or- gans, or other constitutional causes which prolong its second stage. " Even regarded locally, the present disease is seldom a pri- mary affection, but is most frequently ex- cited by catarrhal inflammation of the Schneiderian membrane, or by a long-con- tinued disorder of the Meibomian glands." (M'Kenzie on Diseases of the Lachrymal Or- gans, p. 37—40.) Scarpa's opinions on the present subject are in some degree peculiar to himself; for he considers theaffeetion ofthe Meibomian glands and inside of the eyelids, the puri- form palpebral discharge, as he terms it, as consliluting the first degree of all those complaints which have usually gone under the name of fistula lachrymalis ; the second degree, or effect, being the tumour of the lachrymal sac ; and the third, the fistula, or ulcerated opening in the latter part. Scarpa asserts, that the chief part of the yellow- viscid matter, which accumulates in tlie lachrymal sac, is secreted by the lining of the eyelids, and by the little glands of Mei- bomius; and that the altered quality of this secretion has a principal share in the cause of the disease. He states, that the truth of this fact may at once be ascertained by everting the eyelids, and especially the lower one of the affected ride; and by com- paring them with those of the opposite eye. 17*J .ACHKYMAL ORGAN: The former will always c \hibit an unnatural redness of the internal membrane, which has a villous appearance all over (he extent- of the tarsus; while the edge of the lid is swollen, and numerous varicose vessels are distinguishable on it. The follicles of Alci- bomius are also turgid and prominent, and when examined with a magnifying glass, not uitrequeutly appear to be slightly ulcer- ated. '• The villous structure then, which the surface of the internal membrane of the palpebra assumes in these cas<-s, becomes an organ secreting a larger quantity of fluid than usual, resembling viscid lymph, .vhich, as before stated, being mixed villi the seba- ceous matter, copiously effuied from the glands of Meibomius, constitutes the whole of the viscid fluid, with which the eyelids are imbued, and which is continually car- ried by the puncta lachrymalia into the sac, so as to fill and also frequently distend it, until it forms a tumour. " If, indeed, the lachrymal sac is emptied of this matter, by means of compression, and (he eye and internal surface ofthe pal- pebra* are carefully "washed, so that none of the glutinous humour, pressed from the sac, may remain upon them, and the eyelids are everted half an hour afterward, the internal surface, especially of the lower one, will be found covered with a fresh effusion of mu- cus mixed with sebaceous matter, which has evidently not (lowed back from the lachrymal sac to the eye, but has been generated between the eye and the pal- pebral." Another argument, brought for- ward by Scarpa, in support of his theory, is, that, if the morbid secretion of the eyelids be retarded, or suppressed, either accident- ally or by means of astringent applications, little or none ofthe viscid secretion collects in the lachrymal sac, or can be forced out of the puncta lachrymalia. He has also constantly observed, that the puriform dis- charge may be radically cured at its com- mencement, and before it has induced any flaccidity of the sac by a timely correction of the morbid secretion from the inside of the eyelids, and keeping the lachrymal pas- sages cleansed, by means of injections of simple water through the piinc'a lachryma- lia into the nose. As for the internal mem- brane of the sac itself, fit; argues, that its structure does not quaiiiy it for secreting a tenacious unctuous matter, like what is chiefly discharged from it, a» it is entirely destitute of sebaceous ghnds, and can in reality only furnish a thin mucus. However he admits, that if the sac happen to be in- flamed and ulcerated, a turbid matter may issue from it with the tears; but, says he, this matter is true pus, and quite differ- ent from the curdy unctuous fluid which takes place in the puriform palpebral dis- charge. (On Ihe Principal Diseases of the Eyes, Transl. by Briggs, Ed. 2 p. 3—7) The foregoing opinions of Scarpa have not met with universal assent, and though there is probably much truth in them, be may have overlooked too much the possible simultaneous affection ol the mucou: men. Irani of the lachrymal sac and nasa duct. To Scarpa's hypothesis, Himly and H.jani have made the following objec mus: !,„,, that they have observed the fistula lachry. malis, without the least morbid alteration of the eyelids and Meibomian glands. Se- rondly, that every puriform discharge of the eyelid's is not succeeded by a fistula lachryma- lis. J.i.stly, that the fistula lachrymalis is cured by iijca.is of the operation alone, without any attention being paid to the morbid state of the eyelids, when it exists. And Mr. Travers also regards Scarpa's account of the origin of the disease, independently of a permanent stricture, as hypothetical; for if founded in fact, the distention ofthe lachry- mal sac, and the regurgitation of the fluid on pressure, would attend every severe lip. pitudo, or ophthalmia with puriform dis- charge, which is not the case. If Scarpa's account were correct, Mr. Travers sees no reason why the fluid, once admitted, should be arrested, or regurgitate, instead of piss- ing into the nose, (see also Nicod. in Htm Med. T.m\, p. 155,) and he thinks there b every reason to believe that the fluid, su discharged, is the proper secretion of the sac, and cases are frequent, in which it is retained and cannot be expressed, owing to strictures both of tlie lachrymal and nasal ducts. (Synopsis of the Diseases ofthe Eye, p. 360.) Some of the arguments with which Scarpa meets this reasoning, are already anticipated, especially that which refers to the difference between tb^e secretion of the sac itself, and thai of the sebaceous glands of the eyelids. Also, iu asserting tjiat the origin of the fistula lachrymalis generally manifests itself on the eyelids, before the lachrymal passages are affected, Scarpa de- clares, that he does not pretend thereby to exclude altogether the possibility of a case, iu which the membranes of the nasal duct and lachrymal sac may not be thickened and ulcerated, independently ofthe disease ofthe eyelids. That this is the case, 1 think is evident from the account already deliver- ed in the two first sections of this article, of Beer's opinions, respecting the consequences of inflammation of the integuments and other parts about the inner angle of the eye, as well as respecting the effect- of acute in- flammation of the lachrymal sac itself. How- ever, Scarpa admits the fact, and the ques- tion left is, whether he is right in assigning the morbid secretion from the inside ofthe eyelids, as the most common cause of the swelling, ulceration, be. of the lachrymal sac ? That every puriform discharge fro" the eyelids is not followed by fistula lacbry- malis, he allows, is unquestionable; «fd this, he conceives, most probably happe* because the lippitudo has not been entirely neglected, or because the secretion being less dense and viscid than usual, descend' freely with the tears into the nose through the lachrymal canals, which are large ^ pervious. But in the acute stage ofthe pu- rulent ophthalmia, he asserts that the retuoa why the discharge is not conveyed into hV LACHRYMAL ORGAX&. 171i ac is, that the inflammation and swelling ac- tually close the puncta lachrymalia, and change their direction, so that both the pu- riform matter and the tears fall over the cheek, and cannot descend into the sac. As for the instances of cure, without any remedies being applied for the correction of the state of the eyelids, Scarpa deems the argument inconclusive, because particular vices ofthe constitution, under the use of ap- propriate internal remedies and a well-regu- lated diet, disappear, or are transferred to other parts, without the use of topical re- medies. For my own part, I am disposed to believe, Ibat, whether (he disease begin in the eyelids, or elsewhere, gene ally bolh their lining, and thai of the sac and nasal duct are also more or less affec Ud ; and, consequently, though Scarpa's theory may not be in every respect satisfactory, nor at all applicable to certain disorders of (he excreting parts of (he la- chrymal organs, the piaelice, to which his senliments lead, will, in (he generality of cases, which Beer denominates chronic blen- ■norrhcea, be highly advantageous. According to Mr. M'Kenzie, he local treatment of chronic blennorrhoea does not differ essentially from that of inflammation of the excreting parts of the lachrymal or- gans. But, every possible means must also be employed for improving the general health ; for, otherwise all local remedies will be unavailing. In scrofulous cases, particu- lar attention must be paid to di«-t and mode of living. In weakly persons, Ihepreparations of iron will be highly beneficial; and, when (he disease is connected with disorder of the digestive organs, the treatment recommended by Mr. Abemethy is (bat to which Mr. M' Kenzie expresses a preference. The employ- ment of Anel's syringe and probe are strongly reprobated. «' I grant, (says this author,) that the application of certain substances to (he mucous membrane affected, is one of the most powerful means, which we possess, of correcting ils disposition to chronic blennor- rhoea. But, he who believes, that the best man- ner of applying these substances, is to inject fhem with Anel's syringe, introduced through the puncta, is lamentably mistaken. He is, in fact, closing his eyes upon what he must- know of the functions of the several parts of Ihe lachrymal organs, and is doing (hut very thing, which is calculated to prolong and ex- asperate the diseaje. Except ut the time of a smart renewal ut' the inflammation, the puncta and canals, during this dise.-se, con- tinue in Ihe cxercse of their functions. What- ever fluid, therefe-- is dropped into the lacus lucbryuiarttrn, will li. Alter remaining lor a quunec ol an hour hi dial position, he ought to rise, but without wiping away any ot tbe coily- rium, which may remain. Alter another quar- ter ot an hour, the eyelids are to be carelully dried, and a little ot Janius's ophthalmic oint- ment applied with a camel-bafr pen il to the caruncula lachry uiai is and edges of the eyelids. All this is to m c.netuily repealed twice a day." Proies-or Scnimdl recommends (he loliovviiig coilyrium. ft. Aq. rosse -|vj. acid inlrici 3j. atchonolis 3j. -*t- For Me remo- val ot tie induration over the sac gentie fric- tion, vvitn cuuiptiorated mercurial ouit...cut is recommended. And, says Mr. M'Kenzie, it the- bietiuorihcEo depend upon chronic in- flammation ot ihe Meibomian glands, the diluted curat] ointment is to be applied every evenmg at beii-iime. (On Diseases of the Lachrymal Organs, p. 43, fyc.) In tiie first stage 01 what oca*).* lenrjs tut puniorm discharge ot the palpi-bias, wtieu ihe weeping is incipient, Ibis .iutlioe slates, that a cure may be effected, without dividing tht sac, or any older painful operation. His practice consists in restraining tne iminodeiate secretion Irom the Meibomian glands and internal membrane ol the palpebiee, and in cleansing the viae laciirymales through Ibeir whole extent by means if injec- tions of warm water, rendered more ac- tive by the addition of a little spirit ol wine, and thrown into the puncta lachrymalia every morning ind evening; a measure, which, as already stated, is disapproved of by Mr. M'Kenzie, Schmidt, be. Scarpa considers Janius's ophthalmic oiutmeut, weakened with lard, or fresh butler, as the best application tor correcting (he morbid secretion of (he eyelids. A portion, equal to the size ot a barley corn, is to be introduced upon the point ot a bluul probe, every morn- ing and evening, between the eye and eye- lids, near the external angle, and the edges of the eyelids are to be smeared with it. The eye is (hen to be shut, and the eyelids gently rubbed, so thai the ointment may be distri- buted upon the whole of their internal sur- face. A compress and bandage should be applied, and the eyelids kept closed for two hours. At ihe end of this time, the eye should be washed with the zinc coilyrium. When ihere are superficial ulcerations at the edges of the eyelids, Scarpa applies to ihem either Janius's ointment, or die ungue.ntum hydrarg. nitrat., and iu very obstinate eases, the argentum nitratum itself. If (he vessels ofthe conjunctiva are varicose, he drops into Hi,* ey« ine (incjir.i liiebaica. (Scarpa, Ed. 2,byBriggs,chap. 1.) The iate Mr. Ware was earlier than Scar- pa in pointing o,n the advantage of making applications to die inside of the eyelids, for the relief of certain forms of disease, usually classed wilh fistula lachrymalis. *' When an epiphora (says he) is occasioned by an acrimonious discharge from the seba- ceous glands on ihe edges of die eyelids, it must be evident, that injections into the sac LACHRYMAL ORG\N du< t; and a- w.- i ontinue (o pres.- il ^enllj downwards, llie i is'rume-nt, if the sac is per- vious e-uters tbe nose. If its point meets with some oboruciio. , we must not immediately conclude, that there is an obliteration ofthe duct. We must press down the probealit- «ecreti..n thai is made by tl..m ; and tor (his Beer recommends, or ol .. ver , l.ut, 1U, j, purio'e, I do nn. kno.v any .ppli.at.on -hat should n-,( be too thick -s a (b.ng certainly de- taso ukelv to,.roveso effe-e-.ual\'s Iheunguen- serving greater attention. Supposim-theiei, turn hydrargyri nilratri, of (he new London no direct opening (hrough the skin into the Dispensatory, which should he used here in lachrymal sa.-. one should be m.ide with a th.- same manner, in which il is applied in lancet. However, h mere puncture wili„f. common cases of the psorophlhabnv. It will fice, as a lar.e incision, beginning just below be proper to cleanse the eyelids every morn- the tendon of the orbicularis palpebrarai ing, from the gum that collects on their edges muscle, and extending in a semilunar form, during the night, with some soft unctuous nearly an inch dow nwards and ouiwardi,» appin etions ; and I usually advise to apply to used to be the old practice, can here answer the.o, two or (hree time.-, in the course of no rational object, the surgeon merely having the day, a lotion composed of three grains of occasion for a small direct opening, through white vitriol, in iwo ounces of 'ose or elder- which he may conveniently pass a small flower water." (Additional Remarks on the probe, for the purpose of ascertaining the Epiphora.) slate of the nasal duc(. " The probe, (ai Mr. In a modern periodical work may be pe- O'Kenzie observes,) i- to be introducedhori- rused some interesting remarks by M. Nicod, zontally till it louches the nasal side of the whicii perfectly accoid with the sentiment sa< ; it should then be raised into a vertical already expiessed, thai whatever may be its position, and its point directed downwards primary seal, (he chronic inflammation is not and a lit'b backwards. Turning (he probe generally limited to the inside of the eyelids, upon its axis, we pass it from (he ski: into (he Out e.K(euds throughout the membranous li- ning of die sue and nasal duel, and (hat (his circumstance, in conjunction .villi tlie altered and viscid nature of the secrelion-, accounts for iheir noi re.idily descending into the nose, but regurgitating ttirough the puncta. M. Nicod also relates cases enempliiying that (he tie more sirongly,ye( without violence, turn- ointment applied (o the inside- of (he eyelids ing it round between (he fingers, and giving aclually passes with the matter into the la- it differeni directions. By (hese means, the chrymal sac, and thence into the nose, so as obstacle is frequently excredng parts of tlie lachrymal organs rectified *i;ain ; object* whh h cannot be performed b\ air, me. tianicnl means. Hence, B* r places cou-iderablf stress upon tin- ne- cessity ot obvi-insr everv un.av ur.ible stale of du health,'ikedy to affi'i-t ihe mucous membrane ot (he larh.-ynial sac. F->r tne pui"iieol restoring (he natural diameter ol th nasal duct, tin-experience of many \ears has convinced him, thai pif-re- of violin cat- gut, which are lo b«- grat-uuily increased in siz. , are the best. Th- end of the piece, which it to be introduced, is 'o br first sof- tened a little between the teeth, straightened, and dipped in sueel oil. Then at least six inches of il are (o he introduced, so that its lower end may be easily draw n out of the nostril; a business, which Beer always lets he patient do himself. The upper portion of tbe catgut is coiled up, and kept within a lit- tle linen compress, on the patient's forehead. Beer also places in (he opening of the sac a small dossil of lint, and covers it with i bit of sticking plaster. In two houis, the patient is totryto force he lower end of the catgut out of ihe n-»-tiil, by d iving tin* air through the opening, while th<- mouth and opposite nostril are shut. As «oon ns ihe end of the catgut is secured, it is to be turned over Ihe side of the nose, and fixed there u itb a piece of sticking plaster. The next day, the bil of plaster over the sac is to be loosened wi(h warm water, and together wilh the dossil of lint, (aken away, and one of the lotions, hereafter specified, injected.down (he pas- sage. The upper end of the catgut on Ihe forehead is next lo be unfastened, and a fresh portion of it covered wilh some of the ap- plications, presently mentioned, when the patient is to draw it into (he sac and duct, bv gently pulling the end, which hangs out U the no-tril. The superfluous lower piece of catgut is now cut away, and the new piece turned up, and fixed to (he side of (he nose. The injection is again repeated, and the dressings applied, as before. The same me- thod i • to be continued, until (he w hole of (he first ii-'ce of catgut is expended. Some wa- ter, coloured with the vinous tincture of opium, is now to be thro \n down .he sic, in order to aee, whether any part of (he .fluid will pass into (he nose, and what progress has been mnde. Tl en a larger piece of cat- gut is to be employed, exactly in the manner of the first, and when it is all exhausted, tbe coloured injection is to be used again, in or- der to learn what advance has been made in the re-est.iblishment of the naluial diameter of the pass tge Lastly, a cnlgut of still larger size is to be used, after which the coloured injection will be found, when the patient in- clines his head forwards, lo run freely out of the nostril, and not merely i. ,>p into it, as it rfld previously. When this is (he slate of things, all further dilatation becomes unne- cessary. (Beer Lehre von den Augenkr. B. 2, p. 169—172.) This author then repeats his decided opinion, that the mechanical treatment with catgut, bougies, cannula-, be., will only answer, when attention is paid to rectifying the morbid st ite of the mucous membrane of the lachrymal sac by means of suitable applications, the use of which, he thinks, ought to commence witii the first employ- ment of the catg't. Am1, he adds, that even such treat n ent Wil! only sncci ed, when the diseased state of he membrane of the sac is entirely a local complaint, and uncomplica- ted with any unfavourable conditio: of (he heaHh In the beginning, if the probe can be introduced without any great trouble, and th- linim. of the duct is only trivially thickened, Beer moistens the catgut, on its daily introduction into the passage, with the vinous tincture ot opium, and injects into the sac a lukewarm lotion, containing the proportions of subacetate of coppen, nitrate of potass, alum, camphor, and vinum opii, specified in one of the preceding columns. The lint, which Beer places in the orifice of (he sac, is also dipped in the vinum opii. When the probe meets with more resist- ance, the catgut is smeared with the ungu- entnm hydrargyri nitrati, which is to be at first weakened, and afterward gradually in- creased in slrengih. The wound is also to be dressed with the same application, and some of the following lotion injected down the sac twice a day : ft. Aq Ros ^iv. Hy- drarg. Oxymur. grj. ss. gr. j. Mucil pur. 3j- Vini opii 3j. M. When any irregularities and indurated points are felt with the probe in the course of the nasal duct, Beer smears the catgut with an ointment, containing a small quantity of red precipitate, and directs frictions with a little camphorated mercurial ointment to be employed every day round the external opening. Beer joins Ihe generality of writers in be- lieving, that a long perseverance in the me- chanical means is necessary, in order to re- move all disposition in the nasal duct to close again. (P. 176.) And, as the use of the probes, syringe, catgut, and dossils of lint, may be supposed to have done more or less injury to the lachrymal ducts, so as to cause some impediment to the due convey- ance of the tears into the lachrymal sac, Beer advises a trial to be made, whether a couple of drops of some coloured fluid, in- troduced into the inner canthus, while the patient is lying upon his back, will pass into the b ehrymal sac ; and, if they will not do so, th-* same author thinks, that an attempt should be immediately made to clear the la- chrymal ducts, by means of Anel's probe, (P. 177.) According to Beer, the foregoing treat- ment is perfectly useless, whenever the la- chrymal puncta and ducts are obliterated ; because, even if it were practicable to re- store their perviousness, it would yet be im- possible to communicate to the new-formed apertures and canals tbe power of absorbing 176 ZACHRYMAL ORGANS. the tears and conveying them into the la- chrymal sac. He thinks, that, in this state ofHhings, the practitioner need not trouble himself about the condition of the nasal duct; because, even if it were rendered duly pervious, this improve merit would not continue long, as Beer" experience has fully convinced him. that, when ihe mucous se- cretion of the Itt'-hrym I sac is not blended with the tears, a closure of the nasal duct sooner or later ensues and of course an ac- cumulation of tue mucus of the sac, a dis- ease someti- es termed, under such circum- stances, hydrops sacculi l-chry. ulis. And in order t-1 prevent this comphiint in the state of thi ,gs just now described, Beer is an ad- vocate for ihe :otal obliteration of the cavi- ty of the sac with e-charotics. (B. 2, p. 181.) S:ich is the practice of Beer, with tbe view of clearing away obstruction in the nasal duct, and restoring its natural diame- ter. Let us now consider what methods have been suggested by others. Beginning then with the screw, invented by Fabricius ab Aquapendente, for compressing the dis- tended lachrymal sac, I need only remark with M. Nicod, that, as this plan was not di- rected against the cause of 'he disease, it is not surprising, that it should have been una- vailing, and ultimately banished from prac- tice. In the year 1716, Anel invented a probe of so small a size, that it vvas capable of passing from the upper punctual lachry- male into the lachrymal sac, and nasal duct, the obstructions in which'latter passage it was intended to remove And also invented a syringe, whose pipe was sm-dl enough to enter one of tbe puncta, and by that means to furnish an opportunity of injecting a liquor into the sac and duct ; and with (hese two instruments he pretended to be able to cure the disease whenever it consisted in obstruc- tion merely, and the discharge was not much discoloured. " The fi'-st of these, viz. the passage of a small probe through die puncta, (says Mr. Pott) has a plausible appearance, but will, upon trial, be found very unequal to the task assigned ; the very small size of it, its necessary flexibility, and the very little resistance it is capable of making, are mani- fest deficiencies in the instrument; the quick set sation in the lining of the sac and duct, and its diseased state, are great objections on the side of the parts, supposing that it was capable of answering any valuable end, which it most certainly is not." (Poll.) It must be at once obvious, that Anel's instruments were devised with the view of avoiding a puncture in the lachrymal sac ; but the principle has been strongly objected toby Beer, there being no comparison be- tween the inconveniences of a small open- ing made in the sac, and the injury done to the lachrymal puncta and canals by the long and repeated introduction of instruments through them, whereby their functions are likely to be for ever ruined, of Which Beer bas seen some sad examples. (Lehre, i'C. B. 1, p. 169.) The nc*xt pnciice deserving notice, is that of Laforest, who used to introduce info lie termination ofthe nasal duct m the nostrila Se whh which he cleared away the* struction in the passage He also introdc, ced into the same orifice a curved tube, which was left in the part three or four months, for the purpose of employing mjec tions. The method, however, was found not only troublesome and difficult, on account of the anatomical varieties to which (lie ter- mination of the nasal canal was liable, bat also on account of the treatment, when practised, being subject to frequent failures. Following up the principles of Anel, another French surgeon, Me jean, dilated the nasal duct w ith a seton, which was drain up into the lachrymal sac by means of a thread first introduced from the upperpu«- turn lachrymale. But it was soon discover- ed, that what vvas gained on one side, wru lost on tbe other; the lodgment of (he thread in the lachrymal duct for several months, and the irritation of its orifice ia changing the seton every day, not only causing inflammation of the punctum lachry- male, but even such ulceration and cicatri- ces, as sometimes destroyed the functions of the parts. J. L. Petit, sensible of the inconveniences of Mejean's practice, and disgusted with the barbarous imitation of the ancients in cauter- izing the fistula, sac, and os unguis, concei- ved that, instead of these plans, or that of perforating the os unguis, as proposed by Woolbouse, it would be better to endeavour to restore the natural passage, by removing tbe obstruction in the nasal duct, which ob struction Petit regarded as the cause of the disease. His method consisted in opening the lachrymal sac with a small bistoury, in- troducing through the wound, sac, andnasil duct a probe, down into the nostril, ani then using bougies for the dilatation ofthe passage. This method may be said to be the model of that, which has been mostei- tensively followed even down to the present time. Pellier and Wathen recommended introducing a metallic tube down the dnctu.* nasalis, and leaving it for a time in that situa- tion, with a view of preventing the duct from closing again ; and the use of a cannula is even now preferred by Dupuytren, the greatest surgeon of France. The desire of avoiding any punctnrefli the sac has influenced many practitioner besides Anel, and given rise to various inge- nious inventions. Thus, in 1780, Sir William Blizafd proposed, instead of injectiagwater. to introduce quicksilver through a small pipe, communicating with a long tube foil of this fluid. 'Ihe specific gravity of tb« quicksilver, when the sac was distended with it, he believed would have more power than water propelled through a syringe, tt remove the lachrym; I obstruction. The late Mr. Ware, after trying Sir Wil- liam Blizard's plan, gave the prefereoe**' Anel's syringe, with which he generally^- jected warm water, through the lower punC- turn lachrymale, into the lachrymal sac,atW put a finger over the ?hperior puucttfni 'f 'lACIjWMaL ORG v \ - 177 prevent the fluid from escaping through it. With his finger he also occasionally com- pressed the lachrymal sap, in order to assist in propelling the water down info the nose, Mr. Ware sometimes used the injection thrice a day, though, in general, much less frequently. (See Ware on the Epifora.) " I in general begin the treatment by in- jecting some warm water through the infe- rior punctum lachrymale, and 1 repeat the operation four or five days in succession. If in this space of time, none of the water pass through the duct into the nose, and if the wateringof the eye continue as trouble- some as it vvas before the injection was em- ployed, 1 usually open the angular vein, or direct a leech to be applied near the lach- rymal sac; adding here a caution, that the leech be not suffered to fix. on either ofthe eyelids, lest it produce an extravasation of blood in the adjacent cells. About the same time that blood is takeaway in the neigh- bourhood of the ey^I usually vary fhe injection, and try the effects either of a weak vitriolic, or anodyne lotion. In some instances also, when I have found it impos sible, afler several attempts, to inject any part of the liquid through the duct, I have introduced a golden probe, about the siae of a bristle, through the superior punctum lachrymale, and, attending to the direction of the duct, have insinuated its extremity through the obstruction, and conveyed it fully into the nose; immediately after which 1 have found that a liquid, injected through the inferior punctum, has passed without any difficulty; and by repeating these ope- rations for a few successive days, I have at length established the freedom of the pas- sage, and completed the cure. In other in- stances, I have recommenced a strongly stimulating sternutatory to be snuffed up the nose, about an hour before the time of the patient's going to rest, which, by exciting a large discharge from the schn°iderian membrane, has sometimes also greatly con- tributed to open the obstruction in the nasal duct " Cases occur very rarely which may not be relieved by some ofthe means above re- lated." (Ware's Additional Remarks on Ihe Epiphora.) • VVhen tlie discharge was fetid, Mr. Ware sometimes found, that a vitriolic lotion in- jected into the sac, quickly corrected the quality of the matter. In a subsequent tract, Mr. Ware observes, that if, after " about a week or ten days, there be not some perceptible advance to- wards a cure, or, if, from the long continu- ance of the obstruction, there be reason to fear, that it is too firmly fixed to yield to this easy mode of treatment. I do not hesitate to propose the operation which is now to be described. The only persons, with respeet to whom I entertain any doubts as to the propriety of this opinion, are infants. In , such subjects, 1 alwnys think it adviseable (o postpone the operation, unless (he symp- tom-, be particularly urgent, until they are eight or nine vear-* old. Vor. II. ' 23 " If the disease has not occasioned an aperture in the lachrymal sac, or if this aperture be not situated iu a right line with the longitudinal direction of the nasal duct, a puncture should be made into the sac, at a small distance from the internal juncture of the palpebra3, and nearly in a line drawn horizontally from this juncture toward the nose, wilh a very narrow spear-pointed lancet. The blunt end of a silver probe, of a size rather smaller than the probes, that are commonly used by surgeons, should then be introduced through Ihe wound, and gently, but steadily, be pushed on in the direction of the nasal duct, with a force sufficient to overcome the obstruction in this canal, and until there is reason to believe, that il has freely entered into the cavity of the nose. The position of the probe, when thus intro- duced, will be nearly perpendicular; its side will touch the upper edge of the orbit: and the space between its bulbous end in the nose and the wound in the skin will usually be found, in a full-grown person, to be about an inch and a quarter, or an inch and three-eighths The probe is then to be withdrawn, and a silver style of a size nearly similar to that ofthe probe, but rather small- er, about an inch and three-eighths in length, • ith a flat head like that cf a nail, but placed obliquely, that it may sit close on the skin, is to be introduced through the duct, iu place of the probe, and to be left constantly in it. For the first day or two after the style has been introduced, it is sometimes adviseable to wash tbe eye"\vith a weak satur- nine lotion, in order to obviate any tendency to inflammation which may have been exci- ted by the operation ; but this in general is so slight, that I have rarely had occasion to use any application to remove it. The style should be withdrawn once every day for about a week, and afterward every second or third day. Some warm water should each time be injected through the duct into the nose, and the instrument be afterward replaced in the same manner as before. I formerly used to cover the head of the style with a piece of dyachylon plaster spread on black silk ; but have of late obviated the necessity for applying any plaster by black- ening the head of the style with sealing wax." Mr Ware did not. on first trying this me- thod, expect any relief, till the styfe was left off. However, he found, that the watering ofthe eye ceased, as soon a? the style was introduced,and the sight became proportion- ably more useful and strong. The wound, which Mr. Ware makes in the sac, when there is no suitable ulcerated aperture, is only just large enough to admit the end of the probe, or style ; and this soon becomes a fistulous orifice, through which tbe style may be passed without the least pain. In short, in about a week or ten days, the treatment becomes so easy, that the patient, or any friend, is fully competent to do what is necessary. It merely consists in withdrawing the style, two, or three times a week, occasionally injecting some warm ,Tj. LACHRYMAL OUfiA»- water, and Utcn rep.acing'the imminent as nasal side^c^ids ^Jj^ SSk fin-Jin- no inconvenience from the. the. inMrument ; the surgeon neither suff,. stvlelo^ beSg afraid to leave it off, wear it ing the point to recede, nor, on the other for vcare- many others disuse it in about a hand, allowing it to become entangled *„ ks, and continue quite the membrane. Ihe probe now rests, iD| perpendicular direction, upon the eyebrow, toward its inner angle, and, in this direction, it is to be gently depressed, until it striked upon the floor of the nostril, where its pre. seuco is readily ascertained by a common proljf passed beneath the inferior turbinated bone. The probe, of smallest dimensions is of sufficient firmness to preserve its fi^nn; in its passage through the healthly duct, but it is too flexible to oppose any considerate obstruction. For the stricture ofthe lachry- mal ducts, it is of sufficient strength. Very many cases of recent origin, and in nrbtcb the stricture has no great degree of firmness, (Mr. Travels says) ar^ completely cured by three or four introdfiStions of the probe into the nostril, at inte*l||JWs of one, ortwodayi I have seldom met with a stricture so firmas noi to yield to the full-sized probe." When the resistance is not altogether removed, afler this plan has been tried some days, Mr. Travers introduces a style, having a small flat head, a little sloped, through the punc- tum lachrymale into the nose, and leave it in the nasal duct for twenty-four hours. If worn longer, he says, that it causes ulcera- tion of the orifice. A day or two is to elapse, before the style is again introduced, which ■ must now be passed through tbe other lach- rymal duct. On the intervening days, tepid water should be injected with Anel's syringe (Synopsis of the Diseases of the Eye, p.369, 370, 372, 374.) Thus, we see, that Mr. Travers's practice bears a considerable resemblance to that oi Anel, inasmuch as the sac is never opened, except w-hen likely to ulcerate, and nearly every thing is done with probes and injec- tions, introduced through the lachrymal puncta and ducts. I wish that my views of the nature of these diseases, and of the parts concerned, would allow me to think the latter proceedings, in the case of stricture of the nasal duct, as commendable as another part of Mr. Travers's practice, where, in cases*of slighter obstruction, he contents himself with opening the sac, clearing away the stoppage of the nasal duct with a probe, and healing up the wound, without leaving any style, cannula, or seton in tbe paissage Where the obstruction is very slight, such practice must be judicious. Buf if, in other cases, it be deemed right for the prevention of a relapse, that the nasal duct should he either filled with some dilating instrument« certain time, or repeatedly probed, I am decidedly of opinion with Professor Beer, M. Nicod, be. that the object of nut making a small opening in the sac is attended will) no advantage, at all likely to counterbalance the mischief, which must be done to th« achrymal puncta and ducts, not only ty the repeated introduction of probeajand * syringes but by the lodgment of thfSfo*" in them for the space of twenty-four hi month, or six w< well. The ulcerations, sometimes existing over the lachrymal sac, commonly heal, as •■eion as the tears can pass down into tbe nose.; but Mr. Ware mentions two instances, in which such sores did not heal until a weak solution of the hydrargyria munatus, and bark, were administered. (See Hare on the Fistula Lachrymalis.) (ireat as the recommendation ofthe fore- going practice is, as delivered by Mr. W are, Mr. Travers is strongly di.-posed to doubt, whether any permanent benefit was over derived from letting the style remain in the passage. When an abscess over the sac has been opened, this gentleman, instead of the introduction of a style into the di.ctus nasa- lis, recommends simply the examination of the duct with a fine probe. " If tbe probe passes without resistance into the nose, tiie case requires no further operative treatment, the integument recovers its healthy condi- tion under an emollient application, the discharge gradually diminishes, and tbe wound heals. If. on the other hand, upon examination with the probe, introduced through the wound, into the sac-, resistance is offered to its passage into the nose, no more favourable opportunity will he pre- sented for overcoming such resistance. This, therefore, should be accomplished, but to this the operative process should be limited, and the wound should be suffered to heal without further disturbance." When there is what Mr Travers terms a stricture in the nasal duct, and tbe passage of the probe is more firmly resisted, he admits that some means must be employed for keeping the duct pervious, after it has been reopen- ed. He never interferes with the integu- ments, except in the case of abscess disco- louring the skin, and threatening to produce a fistula; and for the purpose of restoring the passage, he uses a set of silver probes, of about five inches long, of various sizes, flattened at one end, and slightly bulbous at the point. When there is no obstruction, these, he says, may be introduced with perfect facility from either of the puncta lachrymalia into the nostril. " If the punc- tum be constricted, it is readily entered, and dilated by a common pin ; and, upon with- draw ing it, by one of the smaller probes. The direction and relative situation of the lachrymal ducts, the sac, and nasal canal, point out the proper course of the instru- ment. It is confirmed by Hs advance, with- out the employment of force, and the sensa- tion conveyed by the free and unincumbered motion of its point. Until tbe point is fairly withiu the sac, it is necessary to keep the eyelid gently stretched aud slightly everted ; the upper lid being drawn a little upward toward the brow ; the lower, as much down- ward toward the zygoma. The point carried bom>: to the sac, anel touching lightly its LACHRYMAL OKGANS. 1<9 together. If I'lc-re be an opening in the sac, its convenience in permitting the easy ue of a probe is generally acknowledged ; and, in order to gain this advantage, and avoid the evils, which are inseparable from taking too much liberty with the lachrymal puncta and ducts, surely a slight puncture in the r-ac, if there be no opening already, must be the most rational, simple, and successful practice. When the perviousness of the nasal duct cannot be restored by any use ofthe probe, and the obstructed part has a very elastic feel, is of inconsiderable extent, and , near fhe termination of the duct in the nostril, Beer recommends a perforation to be made with a trocar-shaped probe, the point of which is to be covered with a bit of wax, in order that it may not hurt the pai-t^in its passage downward. Some discharge of blood from the nose indicates, that the perfo- ration is made. The sharp-pointed probe is then to be withdrawn, a blunt one used for the purpose of dilating the passage, and, at length, the catgut, as -already explained. (Beer, B. 2, p. IS I.) Supposing the nasal duct to be obliterated for a considerable part of its extent, by a firmer substance, what practice should then fie followed? Ought the formation of an artificial passage to be attempted ? On this point, modern practitioners differ, but, as the expedients adopted for this purpose cannot be judged of previously to their description, it will be better in the first place briefly to notice them. As Mr. Pott has re- marked, the upper and hinder part of tbe lachrymal sac is firmly attachefl'to the os unguis, a small, and yery thin bone, just within the orbit, which bone is so situated, that, if it be by any means broken through, the two cavities of the nose and orbit com- municate with each other: consequently, the os unguis forms the partition between the hinder part of the lachrymal sac, and the upper part of the cavity of the fiose ; and it is by making a breach in this partition, that the formation of an artificial passage has been attempted. In Mr. Pott's time, the cautery had long been ..isused for ma- king an aperture in tlie os unguis, and vari- ous instruments were recommended for this object, such as a large strong probe, a kind of gimblet, a curved trocar, be. each of which, says this practical writer, if dexter- ously and properly applied, will do the business very well ; the one necessary cau- tion is, so to apply whatever ipstrument is used, that it may pierce through that part of the bone which lies immediately behind the sacculus lachrymalis, and not to push too far up into the nose, for fear of injuring the os spongiosum behind, while it breaks its way. Mr Pott adds, that he himself has always used a curved trocar, the point of which should be turned obliquely down- ward, from the angle ofthe eye-, toward the inside of the nose. The accomplishment of the breach will be known by the discharge of blood from the nostril, and of air from the wound, upon blowing tbe nose. Caw must be taken lo*apply the instrument to the part of the bone, anterior to the perpendicular ridge, which divides it. As soon as the perforation is ipade, a tent of lint should be introduced, of such size as to fill the aperture, and so long as to pass throus-h it into the cavity of the nose *. this should be permitted to remain in two, three, or four days, and afterward a fresh one should be passed every day, until the dean granulating appearance of the sore makes it probable, that the* edges of the divided membrane are in the same 'file. The business now is to prevent tjae incarnation from closing the orifice ; for which purpose, the end ofthe tent may be moistet-cd with diluted vitriolic acid, or a piece of lunar caustic, so included in a quill, as to leave- little more than the'extremity naked, may at each dressing, or every other, or every third day, be introduced; by which the granulations will be repressed,and the open- ing maintained : and when this has been done for some little time, a piece of bougie of proper size, or a leaden cannula, may be introduced instead of the tent; and leaving off all other dressings, the sore may be suf- fered to contract as much as the bougie will permit; which should be of such length, that one extremity of it may lie level with the skin in the corner of the eye, and the other be within tbe nose. The longer lime (he patient can be prevail- ed upon to wear the bougie, the more likely will be the continence of the opening : and when it is withclBn, the external orifice should be covered only by a superficial pledget, or plaslcr, and suffered to heal un- { der moderate pressure. (Pott.) I After Ihe perforating instrument was wilh- £ drawn, Mr. Ware recommended a nail- I headed stvie about an inch long, fo be in- J- Iroduce.J through the aperture, in the sa:«iu i way in which it is introduced through the j nasal duct, iu cases in which the obstruction j is , ot so great as (o prevent its pissing in 1 (his direction ; and it may remain here with ■ as much safety as in this last-mentioned in- j stance, for us long a time as ils continuance I may be thought necessary to establish (he j freedom of the communication. '* Unfortunately for the scheme of making an i; artificial passage, natu,-j was generally so jjj busy, (hat she completely frustrated the aim a of the surgeon by gradually filling up the \i new aperture again. Hence, some pracli- ;| tioners were not content with drilling a hole ji through Ibe os unguis, but actually removed T a-portion of this bone eh her v. ith the for- }j ceps proposed by Lamorier in 1729. (See *jj Mim. de I'Acad. des Sciences,) or with cutting J| instruments, among which the most celebra- 'f, ted is the sharp-edged kind of cannula de- J vised by Hunter. Wlnfe this vvas being ap- j| plied, however, it was • necessary to sup- \ ■ port the os unguis with something passed no--/ the nose, and a piece of horn was foun/^ answer very well. Instead of these methcV/ '. '. « Scarpa prefers destroying a portion of'*„,, 8 os unguis with the actual cautery passed ■ through a cannula ; apracfire, long ago ba- nisbcd from good surgery, and most justly condemned by Kichter. I do not feel it necessary lo enter very particularly into the details of these methods of forming an artificial passage between the lachrymal sac and nostril. I have never seen a case, in which 1 should have deemed such practice adviseable, and that the neces- sity for it must be rare must be inferred from what Mr. Travers has observed, viz. that he does not believe the perforation of the os un- guis ever really required-It. (Synopsis,p. 379.) Deer's remarks are also decidedly against the practice; Jfor, he states that, in order that the new opening may not be closed with lymph, it must be made too high up to serve the purpose of a d.ain, through which the mucus can descend by its own gravity. He has not met with a single case, either in his own practice, or among the patients whom be has had opportunities of seeing uuder other practitioners, where the per- foration of the os unguis had a successful result. On the contrary, in one healthy lad, the operation, which had been done by an experienced surgeon, was followed by the destruction of the nasal process of the up- per maxillary bone, one of the ossa nasi, and all the bones contributing to tbe forma- tion of the passage from the orbit into the nose. (See Lehre von den Augenkr. B. 2, ■p. 182.) Hence, Beer thinks, that the pa- tient had better either submit to the incon- venience of being obliged to empty the dis- tended sac by pressure sf-etera! times a day, or let the cavity of the -iflPbe obliterated by means, calculated to excite the adhesive in- flammation in it. But, if the lachrymal puncta and ducts, as well as the nasal duct, are obliterated, Beer conceives that there is no alternative, because, if the cavity of the sac be left, the case, which he terms hydropj sacculi lachrymalis, will ensue, whenever Ihe fistula is closed. LACHRYMAL OKOAxNo lachrymnrum and epiphora , Ibe immediate cause of the first complaint being some in pediment to the passage of the tears from the lacus lachryraarum into tlie lachrynni sac ; while the "other affection consists ia a redundant and extraordinary secretion of the tears. The curable form of stillicidiom, here to be noticed, arises from relaxation ol the lachrymal puncta and canals, in conse quence of previous inflammation of th- parts. The puncta are widely open ; butin other respects, have quite a natural appear- ance. When touched with Anel's probe, they do not contract, as in the healthy state. The tears, which from time to time fall over the cheek, are not in considerable quantity, only trickling from the inner can thus by drops at intervals ; and the nostril on the affected side is found to be rather drier than natural. Erysipelatous inflammation ofthe eyelids and parts over the lachrymal sac, and the purulent kinds of ophthalmy, frequently cause this sort of stillicidium. The latter cases indeed the more readily produce the disorder, inasmuch as the semilunar fold of the conjunctiva is relaxed and swelled,so as to push the puncta out of their right po- sition for the due performance of the absorp- tion of the tears, and obstruct this function more than would be the case, if tbe dimi- nished action of those orifices and the la- chrymal ducts were the only thing con cerued. Beer delivers an exceedingly favourable proguosis, observing, that the complaint often disappears of itself on the approachof warm dry weather, and may almost always be readily cured, by means of astrin-jenfi Among other remedies specified by this au- thor, I need only mention a solution of tbe sulphate of iron, to which a small quantity of camphorated spirit, or tincture of opium, has been added. It is to be dropped out of Of Hernia and Hydrops of the Lachrymal a pen into the inner angle frequently Sac.—The diseases, described by Beer under these appellations, are not discriminated in this country, although they are characteri- zed by widely different symptoms, and re- quire opposite methods of treatment. In the case of hernia, or simple relaxation, the lachrymal sac forms a tumour, which never surpasses the size of a common iiorse-bean, the integuments are of their natural colour, the tumour is soft and yielding to pressure, by w hich the contents of the sac are readily dis- charged through the puncta, or nasal duct. Hydrops grows tothe size of a pigeon's egg, is purplish from the beginning, very hard and in- capable of being emptied by the strongest pressure. Hernia is cured by compression, and the application of astriugents to the re- laxed parts ; hydrops requires the incision •f the sac. In hernia, the nasal duct is natural; in hyurop's, it and sometimes the puncta are obstructed. Stillicidium Lachrymarum.—According to Beer, the valuable treatise of Schmidt is'ihe only work, in which the important practical distinction! is drawn between stillicidium course ofthe day, the patient lying iijpoa his back for some time after each application, so as to let the medicine have more effect upon the parts (See Lehre von dtn M- genkr.B. 2, p. 41—43.) Mr. Travers mentions a constricted state of the lachrymal puncta and canals, which is curable by the introduction of a small probe. (Synopsis, fyc. p. 366.) All modern write I agree, that the obliterated puncta and canal; can never'be restored* (See Me'moirttit I'Academie de Chirurgie, T.b, Edit, \2mo.ia which are several essays on fistula lachrynuki vis. one by M. Bordenave", entitled, "Exom des Heflexions critiques de M. MolintUi,** ries duns les Mimoires de I Inslitui de BolcgM, contre le Mimoire de M. Petit, sur la Futvit Lachrymale, insiri parmi ceux de I'Acad.Bo"- ale des Sciences de Paris. Annie 1734. dnolht- essay by M. de la Forest, styled « Nouville M' thode de trailer les Maladies du Sat UA' rymal, nornmies communiment Fistula Lath- rymates." A third by M. Louis, called*& flexions sur I'Operation de la fitiuU Lottf male." G. E. Slahl, Programma dt Fif* LAC Lachrymuli, Hale, 1702. /. C Scholungcr, Be Fistula Lachrymali, Basil, 1730. J. D. Mctzger, (irutionum Chir. qua ad Fistulam Lachnimalemsive usqutfuere adhibile, Hislo- ria Critica, 8vo. Mtr-iu'lerii, 1772. P. A. Jspii, Queslio, fyc. An fistulae lachrymali can- ■eii'um actuate? Paris, 1738. J. L. Petit, Traiti des Mai. Chir. T.\,p. 289, fyc. Sro. Paris, 1774. M. A Maguabal, De Morbis Viarum Lachrymalium, ac pracipue de fistula lachrymali, Monlp. 1765. A. Bertrandi, Traiti des Opirations, p. 297, 8ro. Paris, 1784. Anel has described his plan of treat- ment in various works .- '• Observation singu- Hire sur lafislutc lacrymale, dans laquelle Ion apprendra la milhode de la guirir radicale- menl.''1 Turin, 1713, in 4lo. " Nouvelle Milhode de guirir les fistules lacrymales." Turin, 1713, in 4lo. " Suite de la Nouvelle Milhode," fyc. ibid. 1714, in 4/o. "Disser- tation sur la nouvelle dicouverte de Vhydropisie du conduit lacrymal," Paris, 1716, in l2mo. And, lastly, Anel has published in the Mem. de I Acad, des Sciences, annie 1713, " Pricis de sa nouvelle maniere de guirir les fistules lacrymales." Mijean in Mim. de I'Acad. de Chir. T. 2, p. 193, 4to. Palucci, Methodus curande fistulx lachrymalis, Vindob. 1762 ; a tube preferred. Sabatier, Midecine Opira- toire, T.2, Ed.2. Richter'sAnfantrsgriindeder Wundarzneykunst, B. 2, Kap. 11. Pott's observations relative lo the disorder of the corner of the eye, commonly called the Fistula Lachrymalis, 8co. Lond. 1768. Sir W. Bli- zard, A New Method of treating the Fistula Lachrymalis, 4lo. Lond. 1780. Ware on the Epiphora and Fistula Lachrymalis; 8vo. Lond. 1792—95. Scarpa sulle principali Malatlie dcgli Occhi, Capo 1. Wathen's New and easy Method of applying a Tube fur the Fistula Lachrymalis, Lond. 1781, and 2d Ed. 1792. Sprengel, Geschichte der Wichtigsten Chir. Operationen, p. 105. Nicod, Mimoirc sur la 'feislulc Lacrymale in Revue Med. HisloriqUe, fyc. livr. 1 et 2, 8?;o. Paris, 1820 Founder, Diss, de I'Appareil desvoies lachrymales ; Monlpellier, 1803 J. L. Angely. Commehtatio Medica de Oculo Organisque La- thrymalibus ratione Altatis, Sexus, Gentis, et Variorum Animalium. 8vo. Erlange, 1803. Rcil, Diss, de Chir. Fistule Lachrymalis Cu- ndionc,Bf.ro!. 1812; Flajani, Collezione d'Os- scrrazioni, T 3. Desault, CEuvres Chir. T. 2, p. 119, 8vo. Paris, 1801. J C. Rosenmiil- ler, Partium Externarum Oculi Humani, im- primis Organorvnn lachrymalium, Descriptio Anatomica; iconibus illustrata, 4to. Lips. 18JO. C. H. T. Schreger, Versuch einer Vtrgleichenden Analomie des Auges und der Thranenorgane eles Menschen und der librigen Thiirk!n.vri,,8vo. Leipz. 1810. Beer, Lehre von den Aagenkrankheiten, 2 B. 8vo. Wien, 1813—1817. If m. Mackenzie, An Essay on the Diseases of the Excreting Parts of the La- chrymal Organs, 8vo. Lond. 1819; contains many valuable observations from the writings of Beer. B. Tracers, A Synopsis of the Dis- eases of the Eye,p. 22s—359, tyc. 8to. Lond. 18-*o. Ph. v. Walt'ier ueber die stcinigen ConcrctioTicn der Thruiienflussigkeit, in Journ. far Chimrgic von C. Graefe, B. I,p. 163, LAG 181 8vo. Berlin, 1820. J. A. Schmidt uber c/;> Krankheiten des ThrMneiiorgans ; a work of the highest reputation. L ANOPHTHALMIA, or LAGOPHTHAL MOS. (from Ko-yx, a hare ; and c»Q*.\pioc, an eye.) The Hare's Eye: Oculus Leporinus. A disease, in which the eye cannot be com- pletely shut. The following complaints may arise from it; a constant weeping of the organ, in consequence of the interrup- tion of the alternate closure and opening of the eyelids, which motions so materially contribute to the propulsion of the tears into the nose ; blindness iu a strong light, in consequence of the inability to moderate the rays, which enter the eyre ; on the same account, the sight becomes gradually very much weakened ; incapacity to sleep where there is any light; irritation,pain,andredr,i s of the eye, from this organ being exposed to the extraneous substances in the atmos- phere. An enlargement, or protrusion of the whole eye, or a staphyloma, may obviously produce lagophthalmos. But, affections oi the upper eyelids are the common causes. Heister has seen the complaint originate from a disease of the lower one. Now and then lagophthalmos depends on paralysis of the orbicularis muscle. A cicatrix, after a wound, ulcer, or burn, is the most'frequent cause. When lagophthalmos arises from a paraly- tic affection of the orbicularis palpebrarum, the eyelids may be rubbed with a liniment containing the tinctura lyttae, or the linimen- tum camphorae. Electricity and cold bath- ing are also considered principal means of cure, (Chandler) together with the exhibition of bark, the use of the shower-bath, &c. When the affection arises from spasm of the levator palpebra? superioris, electricity, a small blister on the neighbouring temple, and rubbing the eyelid and eyebrow with the tinctura opii, are recommended, together writh antispasmodic medicines. When lagophthalmos arises from the con- traction of a cicatrix, its relief is to be at- tempted precisely on the same principles as the ectropium. (See Ectropium.) How- ever, when the eyelid is shortened as well as everted, nothing will remove the defor- mity The inconveniences, depending on the eye being unable to shelter itself from the light, ure to be obviated by wearing a green shade. Whoever is acquainted with German, and is desirous of more minute information on this subject, may find an excellent account of lagophthalmos in Richlcr's Anfangsgr. der Wvndarzn. B. 2. Von dem Hasenaugc See also Beer's Lehre von den Angenkr L > p. 239, fyc. Svo. Wien, 1817. - LARYNUO f'OMY. (from K*eyy%, the la- rynx ; and nuvu, to cut.) The operation of making an opening into the larynx. (See Bronchotomy.) LATERAL OPERATION. One mode of cutting for the stone. (See Lithotomy LENTICULAR, (from lentkulaire,doubly * & leu convex.) An instrument, contained in every trephining case, and employed for removing the irregularities of bone from the edge of the, perforation, made in the cranium with the trephine. One side of its blade i^ con- vex, the other concave; and one of its edges is sharp. On the end of the blade is fixed a little shallow cup, with its concavity towards the handle ofthe instrument. Ihi part serves the purposes of receiving the little pieces of bone, when detached, keep- ing the end of the blade from hurting the dura mater, and, when applied under the margin of tbe opening, enables the operator to guide the edge? of the instrument all round it, with steadiness and security. LEUCOMA. (from mukoc, white.) Leu- coma and albugo are often used synonymous- ly, to denote a white opacity of the cornea. Both of them, as Scarpa remarks, are essen- tially different from the nebula of (he cornea ; for, they are not the consequence of chronic ophthalmy, with varicose veins, and an effusion of a milky serum into the texture of the delicate continuation ofthe conjunctiva over the cornea ; but, are the result of vio- lent acute ophthalmy. In this state, a dense coagulating lymph is extravasated from the arteries; sometimes superficially, at other times deeply into the substance of the cornea. On other occasions, the disease consists of a firm callous cicatrix on this membrane, the effect of an ulcer, or wound, with loss of substance. The term albugo, strictly belongs to the first form of the disease; leucoma to the last, more particularly when the opacity occupies the whole, or the chief part, of the cornea. The recent albugo, remaining after the cure of severe acute ophthalmy, is of a clear milky colour; but, when of ancient date, it becomes pearl-coloured. Some cases, which have existed a considerable time, do not seem to have any connexion with the vascu- larity of the cornea ; for they continue insu- lated in the middle of the transparent por- tion of this membrane, without occasioning the least uneasiness to the patient, the least disturbance of the rest of ihe eye, or any attempt of the absorbents to remove them. The recent albugo, provided tbe organi- zation of the cornea be not destroyed, may generally be dispersed by the means em- ployed for the relief of the first and second stages, of acute ophthalmy ; viz. general and topical blood-letting with internal antiphlo- gistic medicines, and topical emollients for the first; slightly irritating and corroborant applications for the second. As soon as the inflammation has subsided, the latter should be employed ; for, by making the absorbents remove the coagulating lymph, deposited in the cornea, they restore the transparency of this membrane. But, though this may often be accomplish- ed in the recent state of albugo, it is more diflicult when the long duration of the dis- ease has paralyzed the absorbents of the af- fected part; or when the deposition of a dense tenacious substance into the cornea ha* subverted its organization. (Scarper.) Lie I be leccm condition of the disease, with- out disorganization of the structure of the cornea; its occurrence in young subjects, whose absorbents are readily excited by ex- ternal stimulants; are circumstances favour- able to the cure. In children, the albugo, arising from severe ophthalmy after (he small pox, and insulated in the centre of the cornea, very often disappears of itself in the course of a few months. Heister, Langguth, and Kichter, make the same observation. The event can only be imputed to the vigor- ous action of the lymphatics in children, and to the organization of the corneh not being destroyed. For promoting the absorp- tion, Scarpa recommends the following coily- rium : ft. Amnion, uiuriatae. 3ij.Cupri acetati gr. iv. Aqua; Calcis^viij. Misce. The fluid isto be filtered, after standing twenty-four hours. He praises also this ointment: Y%. Tutis*. praepar. 3j- Aloes, s. p. gr. ij. Hydrargyri submur. gr. ij. Adipis suilla?. Sjss. Misce. And the unguentum ophthalmicum of Janin. He mentions the gall ofthe ox, sheep, pike, and barbel, applied to the cornea, two or three times a day, with a small hair pencil, if too much irritation should not he produced. In some subjects, when the eyes are very irri- table, and cannot bear the latter applications, Scarpa has found tbe oil of walnuts an use- ful application. But it is generally neces- sary to persevere, at least three or four months, before the case can be reckoned in- curable. All the expedients, proposed for the inve- terate albugo or leucoma from a cicatrix, consisting of scraping or perforating the layers of the cornea, and exciting ulceration there, are unavailing. For, though the en- largement of the cornea should be lessened by such means, its diaphanous state could not be restored ; or should the patient per- ceive a ray or two of light immediately after the operation, the benefit would »nly be transient; for, as soon as the wound had healed, the opacity would recur. The for- mation of an artificial ulcer might prove use- ful, if leucoma depended on a mere extrava- sation of lymph ; but, the fact is, the disease arises from the deposition of an opaque sub- stance, and the disorganization of the tex- ture of the cornea, conjointly : in this lies the difference between albugo and leucoma. See Scarpa sulle Malatlie degli Occhi; Sro. Venezia, 1802. Richter, Anfangsgrunde dtr Wundarzn. B.3. Essays oil the Morbid Ana- tomy of the Eye, by J. Wardrop ; Edinb. 1808: chap. 11. LIGATURE. In the article Hemorrhage, it has been explained, that the immediate effect of a tight ligature on an artery, is to cut through its middle and internal coats, a circumstance that tends very much to pro- mote the adhesion of the opposite sides of the vessel to each other. Hence, I think with Dr. Jones, in opposition to Scarpa, tlmt the form and mode of applying a ligature l'i an artery should be such, as are most certain of dividing the above coats of tlif- vessel, in a regular manner. A broad flit ligature doe* not seem likclv to answer this LIGATURE, 183 purpose well; because it is scarcely possible to tie it smoothly round the artery, which is apt to be thrown into folds, or to be puck- ered by it, and, consequently, to have an irregular bruised wound made iu its middle and internal coats. (Jones.) A ligature of an irregular form is likely to cut through these coats more completely at some parts, than others; and if it does not perfectly divide them, though adhesion may yet take place, it is a slaver and less certain event, and secondary hemorrhage more likely to follow. The fear of tying a ligature too tight may often lead to the same disadvan- lages. 'lhese, and many other important circumstances, are noticed in the article Hemorrhage. Ligatures are commonly made of inkle, and rubbed with white wax. They should be round, and very firm, so as to allow being tied with some force, without risk of break- ing. (See Jones on Hemorrhage, p. 172.) The principles, which should guide the surgeon in the use of the ligature, were not known until the late Dr. Jones published his valuable treatise on hemorrhage. As an able, surgeon has observed, " he has banished (at least in this country) (he use of thick and broad threads, of tapes, of reserve ligatures, of cylinders of cork and wood, linen com presses, and all the contrivancesjwhich, em- ployed as a security against bleeding, only served to multiply the chances of its occur- rence." (Lawrence, in Med. Chir. Trans. Vol. 6, p. 162.) In the article Amputation, I have noticed the method of cutting off both ends of the ligature close to the knot, on the face ofthe slump, with the view of lessening the quan- tity of extraneous matter in the wound, and promoting a complete union of the divided parts, without suppuration This plan has been tried by Mr. Lawrence : " The method I have adopted (says this gentleman) consists in tying the vessels with fine silk ligatures, and cutting off the ends as close to the knot as is consistent with its security. Thus the foreign matter is reduced to the insignificant quantity, which forms the noose actually surrounding the vessel, and the knot, by which that noose is fastened. Of the silk, which I commonly employ, a portion sufficient to tie a large artery, when (he ends are cut off, weighs between one- fiftieth and one-sixtieth of a grain : a similar portion of the thickest kind I have tried, weighs one-twentieth of a grain, and of the slenderest one-eightieth." Mr. Lawrence states, that the kind of silk twist which is commonly known in the shops by the name of dentist's silk, and which is used in making fishing lines, is the strongest material, in proportion to its size, and therefore the best calculated for our purpose, which requires considerable force in drawing the thread tight enough to di- vide the fibrous and internal coats of the arteries. This twist is rendered very hard and stiff by means of gum, which may be removed by boiling it in soap and water; '•ut the twist then loses a part of its strength. The stoutest twist which Mr. Lawrence has used, is a very small thread comp red with ligatures made of inkle. The quantity of such a thread, necessary for the noose and knot on the iliac artery, weighs onf-twenti- etli of a grain; or, if the gum has been removed, about one-twenty-sixth. But the finest twist, kept in the silk shops, is strong enough in its hard state for any surgical purpose ; and the noose and knot, accord- ing lo Mr. LawTeuce's statement, would not weigh one-fortieth of a grain. It further appears, from the report of this gentleman on the subject, that there is no danger of these ligatures cutting completely through the vessel, as some surgeons have apprehended; and that, although he has not yet ascertained what becomes of the. piece of ligature after the wound is united, he has never seen abscess nor any other bad symptom occasioned by them. At the time- when Mr. Lawrence wrote, he had employ- ed this method of securing the arteries in ten or eleven amputations, in six operations on the breast, and in the removal of two testicles. The cases all did well, excepting a man who lost his thigh, and who died of an affeclion of the lungs. (See Lawrence on a New Method of Tying the Arteries in Aneu rism,tyc. in Medico-Chir. Trans. Vol. 6, p. 156, 4-c) The foregoing method was tried by myself in several amputations, which I performed in 1815 at Brussels, and in a larger number of cases by my friend, Mr. Collier Our ligatures, however, though small, were not so sr- ill as those judiciously recommended by Mr. Lawrence ; and, on this account, no accurate inferences can be drawn from our examples which, however, as far as I could learn, were not unfavourable to the practice. This subject was mentioned by Mr. Gu- thrie, as follows :—Some military surgeons, both French and English, have lately adopt- ed the practice of cutting off both ends of the ligatures close to the knot on the artery, uniting the parts, if possible, over them, and allowing the knots to find their way out as they can. The edges of the wound, in some instances, have united thoroughly in a few days, and when the knots have come off the ends of the arteries, they have caused small abscesses to be formed, which point at the nearest external surface, and are discharged with little uneasiness. I know that many cases, treated in this manner, in the cam- paign of 1813, ended successfully, and heal- ed in as short a time as the most favourable ones by the usual method ; and at Montpel- lier, in June, 1814, Mous. Delpech, Professor of Surgery in that university, showed me at least twenty cases in which he had, and was still practising this method with success. I have seen, however, in two or three instan- ces, some ill-looking abscesses formed by them, and I suspect some disagreeable con- sequences will ensue, if this practice be continued. «•* I consider this improvement as very va- luable in all cases, that will not unite by the first intention The ligatures, if there be 164 LIN many, form into rope*, are the cause of much irritation, and are frequently pulled away with the dressings ; by cutting them off» these evils are avoided, and the knots will come away with the discharge." (Sep Guthrie on Gunshot Wounds of the Extremities, p. 93, f>4) With respect to the abscesses, which this gentleman saw produced by the method. i( is properly observed by Mr. Lawrence, (hat as this statement is not accompanied by any description of the material*, or size of the ligature, nor by any details of (he unfavour- able case=, we cannot judge, whether the events alluded to are to be attributed to the method itself, or to the way in which it was executed. (See Med. Chir. Trans. Vol.6 p. 171.) M. Roux has tried the plnn in three ope- rations on the breast; the cases did well ; and no ill consequences arose from the presence of (he bits of thread under the cicatrix. (See Relation d'un Voyage fait a Londres en 1814, ou Parallele de la Chirurgie Angloise avec la Chirurgie Fran^oise; Paris, 1815, p. 134— 136.) For other remarks, connected wilh the foregoing topics, see Amputation, Aneu- rism, and Hemorrhage. LINEMEN l'UM ACIDI SULPHURIf'I. —ft. Olei Olivae 31-s. Acid. Sulph. Z-s. M. Recommended by Mr. B< odie, for the remo- val of (he effects left by inflammation of the synovial membrane. (See Joints.) ' LINIMENTUM AMVlONl^E FORTIUS. —ft. Liq. ammou. ?j. Olei olivoe^iij. Misce. Properties stimulating. LINIMENTUM CALCIS.—ft. Aq^aj cal- cis, Olei olivaB, sing. ^viij. Spirit, vinosi recli- ficati ?i. Misce. A common application to burns and scalds. LINIMENTUM CAMPHORiE COMPO- S1TUM. ft. Cnrnph. §ij. Aq. amnion. gvj. Spirit, lavend. ^xvj Sixteen ounces are to be distilled of the two last ingredient?, from a glass retort, and the camphor (hen dissolved in the distilled fluid. For bruises, sprains, rigidities ofthe joints, incipient chilblains, Sic. LINIMENTUM CAMPHORS JEfHF.- REUM.—ft Camphnrae drach, j. jElheris une. ss. Olei. viperarum drach. ij. Misce. The camphor is to be dissolved in the aether, and the oil afterward incorporated w ith it. The late Mr. Ware sometimes used this ap- plication, in certain obscure affections of (he eye, in which it was not easy to determine, whether the imperfection of the sight pro- ceeded from an incipient cataract, or a defect of sensibility in the optic nerve. The mode of applying it is to moisten the finger with it, and to rub it for two or (hree minutes toge- ther, morning and evening, on the outside and edges of the eyelids. (Pharm. Chirurgica.) LINIMENTUM HYDRARGYRI COM- POSITUM—ft. Ung. bydrargyri forlioris, Adipis suillae, -ing. §i. Camph. 3 j- Snirit. vinos, rectif. 3'j- Liq. ammon. ?j. The camphor being dissolved in the spirifof wine, add the liq. ammon. and the ointment pre- viously blended with fhe hog's lard. (Pharm. Sancli. Barthol.) An excellent formula for nil surgical cases, in whirl* i. ^iv. Olei Amy?. dala; §v'nj. Potassae Sulr*ureti 3vj. Olei Thymi gr. xv. vel 9j. This linim.-nt, used twice a day, will cure Ihe itch in five days, or, ut latest, in eight. It bas very little un- pleasant smell, and would be preferable to sulphur ointment, if equally efficacious. (See London Medical Repository, Vol. 3, p. 242 and Cross's Sketches of the Medical Schools oj Pa- ris, p. 176) LINIMENTUM SAPONIS COMIOSI- TU.V1— ft. Sapon. -pj. Camph. ^j. Spi- rit. rorismar. ibj. Dissolve the soap iu (he spirit, and then add the camphor. Uses Ihe same as those of the linimentum camph. LINIMENTUM SAPONIS CUM OPIO, R. L:n. sapon. comp. z»j. Tinct. epii. ^ii, Mbx-e. For dispersing indurations and swell- ings attended with pain, but no acute inflam- mation. LINIMENTUM TEREBINTHIN^-ft, Ung. resina? flavae "^iv. 01. terebinthii*. q. s. Misce. The well-known application for bin ns, recommended by Kentish.(See Burns.) LINIMENTUM TEREBINTH!^ -JUL- PHURICUM.— ft. Olei olivae 311. 01. le rebinth. 3iv- Acidi Sulph. 3"'j- Misce. Said to be efficacious in chronic affections of the joints, and in the removal of the old effects of sprains and bruises. (Pharm. Chirurgica.) LIP, CANCER OF. Tbe lips are -ubjeei to ulcers, which put on a very maligqaiit as- pect, although some of them are not in re- ality malignant; and many occurring ju«t on the inside of these parts, will be found to depend on the bad stale of the constitution, and the irritation and disturbance which the sores are continually suffering from the inces sant motion of the parts, and their rubbing against a projecting, or rough tooth. Arsenic is frequently useful in subduing the obstinacy and malignity of certain ulcers and diseases of the lip, reputed to be canceroui (Stark, De Cancro Labii Inferioris.) Of this essay, Professor Langenbeck speaks in bigli terms. The following formula is recom- mended. " ft. Arsenici Albi drachm, diroid- Aq. corntti. stillaticiae une. sex. M. Digerantur vase vitreo clauso in balneo arente justi c»- loris ope per boras sex, turn adde Potasss Carbomis pu.-a; drachm, diroid. antea «olut in nq. Cinnamon, simpl. une. duab.'M Dijre- ranlur denuo per aliquot horas in loco (era- perato. ILic solutione bis terve quotidie id gutlH-8—10—15, ufimur." When <:an«:er takes place, it is usually-in the lower, ,and very seldom in the upper lip The disease sometimes puts on the ap*For* ance of an ulcerated, wart-like.excrescen«, occasionally acquiring a considerable siK. sometimes it is seen in the form of a very destructive ulcer, which consumes the sur* LIQUOR. !•>.« rouuuing substance ot the lip ; and, in other examples, the disease resembles a hard lump, which, al length, ulcerates. The disease, in ils infancy, is often no more than a pimple, which gradually becomes malignant. When- ever there is reason to believe, that the dis- ease is of an unyielding cancerous nature, and il does not soon give way to arsenic, hemlock, and mercurials, the sooner it is ex- tirpated the better. For this purpose, some surgeons admit the propriety of using caus- tic, when the whole disease can be com- pletely destroyed by one application. But as the action of caustic is not capable of being regulated with so much precision as the ex- lent of a wound can be, and as caustic will not allow the parts to be united again, the knife is the only justifiable means, especially as it occasions also less pain. Two incisions are to be made, meeting at an angle below (supposing it to be the lower lip,) and inclu- ding the whole of the disease. The sides of the wound are then to be united by the twisted suture. (See Harelip.) When the affeclion is extensive, however, the surgeon is frequently necessitated to remove the whole of (he tip, or too much of it to admit of the above plan being followed. This circumstance is particularly unpleasant, as Ihe patient's spittle can only be prevented from continually running over his chin by tome artificial contrivance. The deformity also is very great, and pronunciation and :wallowing can only be imperfectly per- formed. LIPPITUDO. (from lippus, blear-eyed.) Blearedness. The ciliary glands, and lining of the eyelids, only secrete, in the sound state, a mere sufficiency of a sebaceous fluid to lubricate the parts in their continual mo- tions. But, it sometimes happens, from dis- ease, that this sebaceous matter is secreted in too great a quantity, and glues the eye- lids together during sleep, so that, on waking, they cannot be easily separated. Hence, (he margin of the eyelids becomes red all round, and the sight itself even weakened. The best remedies are the unguenturn by- drargyri nitrati, smeared, at night, on The edges and inside of the eyelid with a hair pencil, after being melted in a spoon ; the unguenturn tutia*, applied in the same way ; and a coilyrium, composed of 3j. of the sulphate of zinc in v?iij. of rosewater. When alterative medicines are requisite, a grain of calomel may be exhibited daily, ur the compound calomel pill, containing one grain of calomel, one ol sulphur anti- inonii pra'cipitatum, and two of guaiacum, put together with soap. Persons who have lippitudo and cataracts together, bear couching much better than one would expect from tlie appearance of the eyes in that disease ; and Mr. Hey never rejects a patient on this account, provided such state is habitual. (Practical Observa- tions, p. 51.) Scarpa, however, recommends tlie lippitudo to be removed before the operation is undertaken. LIQUOR AMMON. ACET. (L. P.)— This is given in the do-a- of half an ounce in Vot.. n oi many surgical cases, in which the object is to keep up a gentle perspiration. LIQUOR ARSENICALIS—ft. Arsenici Oxydi praeparati in pulvereni subtdissimum triti, Potassae Subcarbonatis ex tartaro, sin- gulorum gr. 64. Aq. distill, fljj coque siruul in vase vitreo, donee arsenicum omne liquc- tur. Liquori frigefacto adjice Spiritus Lavan- dula? com. 3'v- Denique adjice insuper Aq. distil, quantum satis sit, ut mensuram octarii accurate impleat. For internal use the dose is iv. drops gradually increased to xx. twice a day. It is frequently given in cases of anomalous ulcers, and cancerous affections of the lip. It is also used as an external application in similar cases, and especially in hospital gangrene. (See Arsenic, and Hospital Gangrene.) LIQUOR CALCIS (L. P.)—Sometimes used as an astringent injection, or lotion, in cases of gonorrhoea, gleet, psora, porrigo, abscesses, &c. LIQUOR CUPRI SULPHATIS CAM- PHORATA.—ft. Cupiisulphatis. Boli Gal- lici sing. une. ss. Camphorae drach. j. Aqua; ferventis. lib. iv. Boiling water is to be added to the other ingredients, and the liquor filtered when cold. It is chiefly employed in a diluted state, as a coilyrium ; but it may also prove of service as an application to foul ulcers. When used for the cure of the purulent ophthalmy, the lotion is to be injected under the eyelids, by means of a blunt syringe, and, if necessary, the application may be repeated once or twice every hour. (See Ophthalmy.) LIQUOR POTASSAE SUBCARBONATIS (L. P.)—1 his remedy is principally deserving of notice on account of its having been given with a view of dissolving calculi in the bladder, so as to remove the necessity of performing the dangerous and painful operation of lithotomy. The principle, on which the liquor potassa* subcarbonatis acts, is by the potassa attracting and combining with the uric acid of the calculus. The medicine may be exhibited in doses of 20 or 40 drops, or of a dram, in a basin of gruel. Experience does not seem to justify the indulgence of much hope, with regard to the complete efficacy of the medicine in dissolving urinary calculi, and on some kinds it is not calculated to act at all, even on chymical principles ; but, it would appear, from the reports of writers, that it has often materially palliated the pain which attends the presence of a stone in the bladder. Some practitioners place more confidence; in the liquor potassa*. LIQUOR KALI ARSENICATL—ft. Kali Arsenicati grana duo. \qua-* Mentha? Sativas uncias quatuor. Spiritus Vino3i tenuioris unciam. Misce et-cola. Two drams of this may be given thrice a day in cases of cancer. My friend, Mr. Barnes, of Exeter, when for- merly a student at St. Bartjiolemew's, show- ed me a case of lupus, or noli me tangere, which was greatly benefited by this remedy externally applied. Mr. Barnes was using the lotion with double the proportion ©f 166 L1TU0T0MI arsenie. There are many ulcerations ronml the roots of the nails of ihe fingers and toe-, to which Plunket's causlic is sometimes applied ; but, the liquor kali nrseuicati >v otild, in all probability, be epiite as effica- cious, and, certainly, it is a neater applica- tion. LIQUOR POTASSjE (L. P.) This ha« been given wiih a view of dissolving urinary ealciili, in considerable doses, for a length of time. The trials, however, have not pro- ved so successful as could have been wish- ed, nor is the exhibition of so active a re- medy unattended with disadvantageous consequences to the system; for which reason, soda water and other alkaline wa- ters, supersaturated with fixed air, have of late been much substituted. The proper dose of the liquor potassa? at first, is from ten to twenty drops twice a day, in some linseed tea. At St. Thomas's Hospital, the following is the way in which the liquor potassa? is prescribed :—ft. Liq. Potass*? gi. Aquae Distillata? ;§ij. Misce. Dosis Drachma una bis die ex unciis quntuor infusi lini. - LIQUOR PLUMBI ACETATIS (L. P.) —Is extensively used, largely diluted with water, as an application to inflamed parts. (See Inflammation.) One dram to a quart of water is quite strong enough for common purposes. Mr. Justamond and Dr. Cheston used to apply it, mixed with an equal pro- portion of a spirit resembling the tinctura ferri muriati, to the edges of cancerous LITHONTR1PTICS. (from xiflsc, a stone ; and Sgvn-re*, to break.) Medicines for dis- solving stone in the bladder. (See Urinary Calculi.) "LITHOTOMY, (from x-6oc, a stone; and rijuvM, to cut.) The operation of cutting into the bladder, in order to extract a stone. It has been correctly remarked, that no bingle operation of surgery has attracted so much notice, or had so much written upon it, as lithotomy. A full and minute account of the sentiments of every writer, who has treated of the subject, and a detail of the infinite variety of particular modes of ma- king an opening into the bladder, would. occupy as many pages as are allotted to the whole of this dictionary. It must be my endeavour, therefore, rather to describe what is most interesting and important, than pretend to offer an article which is to comprehend every thing. May I be allowed to premise, that through- out the following columns, I suppose tbe reader to be already well informed of all that relates to the anatomy of the bladder and adjacent parts, and that of the perine- um ? Without correct knowledge of this kind, a man must be presumptuous indeed, to set himself up for a good litholomist; and if he were to distinguish himself at all, it would only be by the murders which he committed, while his successful feats, if be achieved any, could redound little to h'u honour, since every young student would soon find out, that they were not the effect of science, but of mechanical habit ami inn' tation. 1 would particularly recommend every one. who wishes to understand well the anatomy of (he pelvic visrera and peri iia-tim, -with a view to lithotomy, in the first place to dissect those parts himself, ami then avail himself of the valuable instruc- tions to be derived on the subject from Winslovv's Anatomy ; Le Dran's Parallcle de 'failles ; Le Cat's Deuxieme Recueil, nlanche 5 et 6; Mailer's Inst. Med. of Bo- erhaave, and Elem. Physiol. T. 5 ; Mor- gagni, Adversar. Anat. 3, p. S2, 97; Cam- per's plates; Sabatier's Anatomy; John Bell's Principles of Surgery ; Deschnmp'i Traite Historique, be. de l'Operaiion de la Taille, T. 1, p. 7, be ; and Langenbeck:. description of the parts, and the matchless plate which he has given of them in his valuable work on lithotomy, cited at the end of this article. A few subjects which are closely connect- ed with the present, will be found in other parts of this dictionary. For instance, the nature of stones in the bladder will be consi- dered under the head of Urinary Calculi, where also will be seen some observations on lithontriptics. The manner of searching for the stone, or, as it is now more common- ly expressed, of sounding, will be explainer in the article Sounding. 1 lere I shall principally confine myself to the symptoms of the disease, and the cbiel methods of executing the much diversified operation of lithotomy. SfMrTOMS OF THE STOM. The symptoms*of a stone in the bladder are, a sort of itching along the penis, parti cularly at the extremity of the glans; and hence the patient often acquires a habit ot pulling the prepuce, which becomes very much elongated ; frequent propensities to make water, and go to stool; great pain in voiding the urine, and difficulty of retaining it, and often of keeping the feces from being discharged at the same time ; the stream of urine is liable to stop suddenly, while flow- ing in a full current, although the bladder i* not empty, so that the fluid is expelled by fits, as it were ; the pain is greatest toward' the end of, and just after, the evacuation; there is a dull pain about the neck of the bladder, together with a sense of weight, or pressure, at the lower part of the pelvis; and a large quantity of mucus is mixed with the urine ; and, sometimes, the latter is tinged with blood, especially after exercise. (Short, Earle, Sabatier.) Frequently (says Deschamps) a patient will have a stone in his bladder a long while without the occurrence being indicated by any symptom or accident. Most commonly, however, the presence of the stone is an- nounced by pain in the kidneys, more espe- cially in adults and old persons, children scarcely ever suffering in this way, because in them the stone is hardly at all detained in the kidneys and ureters, but descends im- mediately into the bladder, the prcceninf LITHOTOMY. lj-ij (unes being in tueiu more dilatable, and the rudiment, or nucleus of the stone smaller. It seldom happens, that calculous patients void blood with their urine, before the symp- toms and accidents, usually caused by the stone, have taken place. It is not till after the foreign body has descended into the bladder, acquired some size, and presented itself at the orifice of that viscus, that pain is occasioned, particularly when the surface of the stone is unequal. The patient then ex- periences frequent inclination to make wa- ter, attended with pain. The jolting of a carriage, riding on horseback, and much walking, render the pain more acute. The urine appears bloody, and its course is fre- quently interrupted, and sabulous matterand particles of stone are sometimes discharged with it. The want to make water becomes more frequent and more insupportable. The bladder is irritated, and inflames ; its parietes become thickened and indurated ; and its diameter is lessened. A viscid, more or less, tenacious matter is observed, in greater or lesser quantity, in the urine, and is pre- cipitated to the bottom of the vessel. The urine becomes black and putrid, and exhales an intolerable alkalescent smell, which is perceived at the very moment of the evacua- tion, and is much stronger a little while af- terward. The patient can no longer use any exercise, without all his complaints be- ing redoubled. Whenever he walks in the least, the urine becomes bloody ; the pain about the hypochondria, which was dull in the beginning, grows more and more acute ; the ureters and kidneys participate in the ir- ritation with the bladder; they inflame and suppurate, and very soon the urine brings away with it purulent matter. The fever increases, and changes into one of a slow type *, the patient loses his sleep and appe- tite ; becomes emaciated and exhausted; and death at length puts a period to his mise- ry. (See Traiti Historique el Dogmatique de l'Operaiion de la Taille par J. F. L. Des- champs, T.\,p. 163, Paris, 1796.) It is acknowledged by the most experien- ced surgeons, that the symptoms of a stone in the bladder are exceedingly equivocal, and may be produced by several other dis- orders. " Pain in making water, and not being able to discharge the urine without ttie feces, are common consequences of ir- ritation of parts about the neck of the blad- der, from a diseased prostate gland, and other causes. The urine stopping in a foil stream is frequently caused by a stone alter- ing its situation, so as to obstruct the pas- sage; but the same thing may happen from a lumour, or fungus in the bladder. 1 have seen an instance of this, where a tumour, hanging by a small pedicle, wonld sometimes cause obstruction, and by altering the pos- ture, would retire, and give a free passage. The dull pain at the neck ofthe bladder, and the sensation of pressure on the rectum, are frequently owing to the weight of the stone, ivc.; but these may proceed from a diseased enlargement ofthe prostate gland. Children generally, and <:row u persons frcmiently, ar<' subject to a nrolapsusani, from the irritation of a stone irP the bladder; but it will like- wise be produced by any irritation in those parts." (Earle.) The rest ofthe symptoms are equally fallacious; a scirrhous enlarge- ment of the os tinea?, and disease of the kid- neys ma"y occasion a copious quantity of mucus in the urine, with pain, irritation, be. " The least fallible sign (says Sir James Earle) which I have remarked, is the patient making the first portion of urine with ease. and complaining of great pain coming on when the last drops are expelled. This may readily be accounted for, from the bladder being at first defended from contact with the stone by the urine, and, at last, being pressed naked against it. But, to put the matter out of all doubt, and actually to prove the exist- ence of a stone in the bladder, we must have recourse to the operation of sounding." A stone in the ureter, or kidneys, or an in- flammation in the bladder from any other cause, will sometimes produce the same ef- fects ; but if the patient cannot urine, ex- cept in a certain posture, it is almost a sure sign that the orifice of the bladder is ob- structed by a stone. If he finds ease by pressingagainstthe perina?um with his fingers, or sitting with that part upon a hard body, there is little doubt the ease is procured by taking off the weight of the stone ; or, lastly, if, with the other symptoms, he thinks he can feel it roll in his bladder, it is hardly pos-. sible to be mistaken ; however, the only sure judgment is to be formed from searching. (Sharp on the Operations.) ■ An enlarged prostate gland is attended with symptoms resembling those of a stone in the bladder; but with this difference, that the motion of a coach, or horse, does not in- crease the grievances, when the prostate is affected, while it does so in an intolerable degree in cases of stone. It also generally happens, that the fits ofthe stone come on at intervals ; whereas, the pain from a disea- sed prostate is neither so unequal, nor so acute. (Sharp in Critical Inquiry, p. 165, Edit. 4.) Though, from a consideration of all the circumstances above related, the surgeon may form a probable opinion of there being a stone in the bladder, yet he must never presume to deliver a positive one, nor ever be so rash as to undertake lithotomy, vvith- out having greater reason for being certain that there is a stone to be extracted. Indeed, all prudent surgeons, for centuries past, have laid it down as an invariable maxim, never to deliver a decisive judgment, nor under- take lithotomy, without having previously introduced a metallic instrument called a sound, into the bladder, and plainly felt the stoue. Within the last five years, at least seven rases have come to my knowledge, and at (wo of them I was present, where Ihe pa- tients were subjected to all the torture and perils of this operation, without there being any calculi in their bladders. The maxim, therefore, cannot be too strictly enforced, {bat the operation otight never to be at- I-**' I.ITHui'OM-i tempted, unless the stone caifc be distinctly felt wilh the sound or staff. In one of the examples, of which I was a spectator, not only the symptoms, but the feel, which the sound itself communicated when in the bladder, made the surgeons imagine, that there was a calculus, or some extraneous body in this organ. Most of the above cases, I understand, recovered, which may be con- sidered fortunate; because when the stone cannot be found, the disappointed operator is apt to persist in roughly introducing his fingers, and a variety of instruments, so long, in the hope of catching what cannot be got hold of, that inflammation of Ihe bladder and peritoneum is more likely to follow, than when a stone is actually present, soon taken out, and the patient kept only a short time upon the operating table. In a valuable practical work is recorded an instance, in which what is called a horny cartilaginous state of the bladder, made the sound communicate a sensation, like that arising from the instrument actually touching a stone, and the surgeon attempted lithoto- my. This patient unfortunately died in twenty-four hours. (See Desault's Parisian Chir. Journal, Vol. 2, p. 125.) However, were the symptoms most une- quivocal, there is one circumstance which would always render it satisfactory to touch the stone with an instrument, just 6f/ore venturing to operate ; I mean the possibility of there actually being a stone in the bladder to-day, and not to-morrow. It is said, that stones are occasionally forced, by the vio- lent contractions of the bladder, during fits of the complaint, between the fasciculi of the muscular coat of this viscus, together with a portion of the membranous lining of the part, so as to become what is termed encysted. The opening into the cyst is frequently very narrow, so that the stone is much bigger than the orifice of the cyst, in consequence of which it is impossible to lay hold of the extraneous body with the forceps, and tbe operation would necessa- rily become fruitless. (Sharp's Critical In- quiry, p. 228, Edit. 4.) In the article Urinary Calculi, I have no- ticed the probability of this having occur- red in some of the instances in which Mrs. Stevens's medicine was supposed to have actually dissolved tbe stone in the bladder; for an encysted stone is not likely to be hit with the sound, nor to cause any inconve- nience, compared wilh wbat a calculus, rolling about in the bladder, usually oc- casions. It is remarked by Deschamps, that when the stone is lodged in an excavated corner of the bladder, in a particular cyst, or de- pression ; when it projects but Very little ; when it cannot shift its situation in the blad- der, so as to fall against tbe orifice of this viscus; and when it is also smooth, polished, and light; the patient may then have it a long while without experiencing any afflict- ing symptoms. He may even live to an advanced age, if not without some degree of sfl-JfarHig, at all ay-tuts, with such pain as h very supportable. Daily experience prove- that persons may live a considerable time, with one, two, or even three stones in th- bladder, and, during the whole of their live<. have not the least suspicion of the existence of these foreign bodies. According to Deschamps, this must have been the case of M. Portalieu, a tailor. Thi« individual, eighty years old, was frequently attacked with a retention of urine from pa ralysis, and Deschamps introduced a sound several times, and distinctly felt a stone in the bladder. The patient, however, never had any symptom ofthe disorder, nor even at the end of two years from the time when Deschamps was first consulted. Very large and exceedingly rough stones have also been found in the dead bodies of persons who had never complained of the symp- toms of the disease. Thus, at the anatomi- cal Theatre of La Charite, Richerand found an enormous mulberry stone in the bladder of a person who died altogether of another disease, and never had any symptoms that led to the suspicion of the stone. (JVoso- graphie Chir. T. .3, p. 530, Edit. 4.) Bu* cases of this kind must be rare, because it is well known that the pain, which a stone produces, is less in a ratio to its size than to its shape and situation. A small stone owing to its situation, may be more painful than an enormous calculus which fills the bladder, as is proved by the following case, by Deschamps. Pechet, a watchmaker, until the ageo; forty-five, had never had any infirmity, ex- cept that of not being able to retain his wa- ter a long while. One day, while he was carrying a very heavy clock, he made soni'-. exertions which probably, by changing tht situation of the calculus, caused at the in- stant an acute pain in the hypogastric re- gion. Symptoms of the stone soon came on; the pain became intolerable, and the patient went into tbe Hopital de la Charite. He was sounded ; the stone was felt, and judged to be of considerable size. The in- cision in the neck of the bladder not suffi- cing for its extraction, the patient was put to bed again. The next morning he was operated upon above the pubes by Frere Come, who extracted an oval calculus that weighed twenty four ounces. The patiet* died four and twenty hours after this second operation. This case proves, then, that very large stones may lie in tbe bladder without occasioning any serious complaints, since the preceding patient apparently had had such a calculus a long time without suffering inconvenience from it, and it seems likely that he might have continued well stiU longer, had it not been for the acci- dental effort which first excited the symp- toms. (Deschamps, in Traiti Hisloriqut,$r de la Traille, Tom. I, p. 166, 167.) A priest, in whom Morand had ascertain ed the presence of a stone by sounding, could not be persuaded that his case was of this nature. However, he bequeathed his body at his decease to the surgeons, and the examiiiattoD r'tbe Warlderfuflv jnstrfietjMo- LlTHOTOMi. ia9 ranu A prognosis. The celebrated D'Alem- bert also died with a stone in his bladder, having always refused to be sounded. (Ri- cherand, Op. cit. T.3,p. 638.) A question may here suggest itself: ought lithotomy to be practised where calculi are under a certain size ? Certainly not, be- cause they frequently admit of being dis- charged with the urine, without any opera- tion at all, even from the^ male subject, and how much more likely this is to happen in females, must be plain to every body who recollects the direct course, the shortness, ample size, and dilatability of the meatus urinarius. On this subject, various facts will be adverted to in considering the ope- ration of lithotomy in women. Sometimes, also, when a calculus is too large to pass completely through the male urethra, it lodges in this passage, where it may be more safely cut upon and removed, than from the bladder; and sometimes it is actu- ally discharged by an ulcerative process. Thus, Dr. R. A. Langenbeck has published an example in which a stone made its way out by ulceration, and vvas discharged im- mediately behind the testes. (See J. C. Langenbeck, Bibl. fur die Chir. Gott. 1809.) And G. Coopmahs bas recorded an almost incredible case, in which a calculus, weigh- ing five ounces, one drachm and a half, when being dried, was discharged on the left side of the urethra of an elderly man, a little below the glans penis. In fact, with- out some further explanation, this case would be pronounced impossible ; but it should be recollected, that after a small cal- culus has made its way out of the urethra by ulceration, if the urine have still access to it, it will continue to increase in size in its new situation and this is what happen- ed in the present example ; for the extrane- ous body, when first felt externally, was not larger than a pea. The calculus is now preserved in Camper's museum. (G. Coop- mans, Neurologia, Sro. Franequerx, 1795.) I am not meaning, however, to recommend surgeons to let the patient encounter all the sufferings which must inevitably attend lea- ving the business to be completed by ulcera- tion, because, as soon as the nature of the case is known, an incision should he made into the swelling, and the foreign body taken out. In many cases, also, small calculi may be voided by dilating the male urethra with elastic gum catheters of very large diameter, and then desiring the patient to expel bis urine with considerable force, a plan w hich Baron Larrey has found repeatedly answer. Of late, Mr. Weiss, surgical instrument ma- ker, in the Strand, has invented a kind of sound, the end of which, when in the blad- der, admits of being opened, like a pair of forceps, and closed again, so as to grasp calculi under a certain size, and draw them out through the urethra. The instrument has been tried wilh great success by Air. A. Cooper, who removed with it from one pa- tient at different times 84 calculi. And, e-ven when the stone cannot be drawn com- '-le'elyout ofthe*nr"'hra bit' nnlv into thi" passage, it is a great advantage, because, then it may easily be cut dow n to, and ex- tracted, without any wound or injury ofthe bladder. (See A. Cooper in Med. Chir Trans. Vol. 11.) I shall next describe the various methods of cutting for the stone, beginning with the most ancient called the apparatus minor. and ending with the modern proposal of employing a knife in preference to a gorget, OF THE APPARATUS MINOR, CUTTING ON THE GRIPE, OR CELSUs's METHOD. The most ancient kind of lithotomy was that practised upwards of two thousand years ago by Atnmonius, at Alexandria, in the time of Herophilus and Erasistratus, and by Meges, at Home, during the reign of Au- gustus; and being described by Celsus, i-- named Lilhothomia Celsiana. From cutting directly on the stone, fixed by the pressure ofthe fingers in the anus, it has been called cutting on Ihe gripe, a knife and a hook be- ing the only instruments used. The appel- lation of the lesser apparatus was given to it by Mariauus, to distinguish it from a me- thod which he described, called the appara- tus major, from the many instruments em ployed. The operation was done in the following way. The rectum was emptied by a clys- ter a few hours previously; and, immedi- ately before cutting, the patient was desired to walk about his chamber, to bring the stone down to the neck ofthe bladder; he was then placed in the lap of an assistant, or secured in the manner now practised in tbe lateral operation. The surgeon then in- troduced the fore and middle fingers of his left hand, well oiled, into the anus ; while he pressed with the palm of his right hand on the lower part ofthe abdomen above the pubes, in order to promote the descent of the stone. With the fingers the calculus was next griped, pushed forward toward the neck of the bladder, aud made to protrude, and form a tumour on the left side of the perinaeum. The operator then took a scal- pel-and made a lunated incision through the skin and cellular substance, directly on the stone, near the anus, down to the neck of the bladder, with the horns towards the hip. Then, in the deeper and narrower part ofthe wound, a second transverse inci- sion was made on the stone into the neck of the bladder itself, till the flowing Out of the urine showed that the incision exceeded in some degree the size of the stone. The calculus being strongly pressed upon with the fingers, next started out of itself, or was entracted with a hook for the purpose. (Celsus, lib. 7, cap. 26. J. Bell's Principles, Vol. 2, p. 42. Allan on Lilhotomy, p. 10.) The objections to cutting on the gripe, are; the impossibility of always dividing the same parts; for those which are cut will vary, according to the degree of force em ployed in making tbe stone project in the perina?um. When little exertion is made >f the inci-sion be begun just behind the =■•-■'•< li'O LlliiuioMl. turn, the urethra may be altogether detach- ed from the prostate: if the stone be much pushed out, the bladder may be entered beyond the prostate, and both the vesicula? seminales and vasa deferentia inevitably suffer. Lastly, if Ihe parts are just suffi- ciently protruded, the bladder Will be cut upon its neck, through the substance ofthe prostate gland. (Allan on Lithotomy. Burns, in Edinb. Surg. Journal, No. XIII. J. Bell, . Vol. 2, p. 59.) The preceding dangers were known to J'abricius Hildanus, who attempted to obvi- ate them by cutting on a staff, introduced through the urethra into the bladder. He began his incision in the perinasum, about bait an inch on the side ofthe raphe ; and be continued the cut, inclining the knife as be proceeded towards the hip. He continu- ed to divide the parts till be reached the staff; after which he enlarged the wound to such an extent, as permitted him easily with a hook to extract the stone, which he had previously brought into the neck of the bladder, by pressure with the fingers in the rectum. (Burns.) In this way Mr. C. Bell has operated with success. (J. Bell.) The apparatus minor, as practised by Fabricius, with the aid of a staff, is certainly a very simple operation on children, and some judicious surgeons doubt the propriety of its present neglected state. You cut, says aa eminent writer, upon the stone, and make of course, with perfect security, an incision exactly proportioned to its size. There is no difficult nor dangerous dissection ; no gorget, nor other dangerous instrument, thrust into the bladder, with the risk of its passing betwixt that and the rectum ; you are performing, expressly, the lateral inci- sion of Raw and Cheselden, in the most simple and favourable way. The prisca sim- plicitas instrumentorum seems here to have been deserted, for the sake of inventing more ingenious and complicated operations. (J. Bell.) Celsus has delivered one memorable pre- cept in his description of lithotomy, ut pla- ga paulo major quam calculus sit; and he seems to have known very well, that there was more danger from lacerating, than cut- ting the parts. The simplicity of the apparatus rniuor, however, formerly emboldened every quack to undertake its performance ; and as this circumstance was necessarily followed by the evils and blunders, unavoidably origina- ting from ignorance, and also diminished the emolument of regular practitioners, it be- came the grand cause of the downfall of this operation. (See Heister on this subject.) It was longer practised, however, than all tbe other methods, having been continued to the commencement of the 16th century ; and it was performed at Bourdeaux, Paris, and other places in France, on patients of all ages, by Raoux, even as late as 150 *- ears ago. Frere Jacques occasionally bad recourse to it; and it was successfully exe- cuted by Heister. (Part 2, chap. 140.) A modem author recommend? it always to be preferred on boys under fourteen. (Mm, p. 12.) ArrARATlS MAJOR, So named from the multiplicity of instru- ments employed: or the Marian method, from having been first published by Ma- rianus Sanctus, in 1524, as the invention of his master, Johannes de Romanis. (See Marian us de lapide Vesice per incisionem u- trahendo.) This operation, which came into vogoe, as we have noticed, from avaricious cause--, was rude and painful in its performance, and very fatal in its consequences. The apology for its introduction was the dedi- cation of Hippocrates, that wounds of mm- branousparts are mortal. It was contended, however, that such parts might be dilated with impunity ; and on this principle of di- latation, Romanis invented a complex and dangerous plan of operating; one very in- competent to fulfil the end proposed ; one, which, though supposed only to dilate, really lacerated the parts. (Burns.) The operator, kneeling on one knee, made an incision with his razor along (he peri- na?um, on one side of the raphe; and feel- ing with his little finger for the curve ofthe staff, he opened the membranous part ofthe urethra ; and fixing the point ofthe knife in the groove of his staff, gave it to an assistant lo hold, while he passed a probe alon^the knife into the groove of the staff, and thus into the bladder. The urine now flowed out, and the staff was withdrawn. The operator next took two conductors, a sort of strong iron probes; one, named the ft male conductor, having in il a groove, like one of our common directors; the other the male conductor, having a probe point, corresponding with that groove. The groov- ed, or female conductor, being introduced along the probe into the bladder, the probe was withdrawn, and the male conductor passed along the groove of the female one into the bladder. Then commenced th' operation of dilating. The lithotomist took a conductor in each hand, and by making their shafts diverge, dilated, or, in plain lan- guage, tore open the prostate gland. (J. BtU.) It would be absurd in me to trace the various dilating instruments contrived for the itnprovementof this barbarous operation, by the Colots, Marcchal, La Dran, Pare, J". Among the numerous glaring objections to the apparatus major, we need only notice the cutting the bulb of the urethra, not di- viding the membranous part of the urethra. nor the transversalis perina?i muscle, which forms a kind of bar across the place where the stone should be extracted ; violent dis- tention of the membranous part of the ure- thra and neck of the bladder ; laceration of these latter parts ; large abscesses, extrava- sation of urine, and gangrene; frequent impotency afterward, and extensive fatali- ty. Berlrandi even saw the urethra and neck of the bladder torn from the prostate by tbe violeuce employed ;.: this vil-J n»- LUHOTOM1.. li'i hod of operating. (Operations de Chir. p. 169.) Pare, Le Dran, Le Cat, Mcry, Mo- rand, Marcschal, Raw, and all the best sur- geons in Kurope, most strangely practised this rash method, for two hundred years, till Frcre Jaques, in 1697, taught at Paris the original model of lithotomy, as com- monly adopted at the present day. OF THE HICH OPERATION. This method of cutting for the stone was first published in 1556, by Pierre Franco, who, in his Treatise on Hernia, Ed. 1, says, he once performed it on a child with suc- cess, but discourages the farther practice of it. After him, Rossetus recommended it, with great zeal, iu his book entitled Partus Cesarius, printed in 1591 ; but he never performed the operation himself. Tolet mentions its having been tried in the Hotel Dieu, but without entering into the particu- lar causes of its discontinuance, merely says, thai it was found inconvenient. About the year 1719, it was first done in England, by Mr. Douglas; and after him, practised by- others. (Sharp's Operations) The patient being laid on a square table, with his legs hanging off, and fastened to the sides of it by a ligature, passed above the knee, his head and body lifted up a little by pillows, so as to relax the abdominal muscles, and his hands held steady by some assistants ; as much barley-water as be could bear, which was often about eight ounces, and sometimes twelve, was injected through a catheter, into the bladder. The bladder being filled, an assistant, in order lo prevent the reflux of the water, must grasp the penis, tbe moment the cathe- ter is withdrawn, holding it on one side, in such a manner as not to stretch the skin of- the abdomen; then, with a round-edged knife, an incision, about four inches long, was made between the recti and pyramidal muscles, through the membrana adiposa, as deep as the bladder, bringing its extremity almost down to the penis; after this, with a crooked knife, the incision was continued into the bladder, and carried a little under the os pubis; and immediately upon the water's flowing out, Ihe forefinger ofthe left hand was introduced, which directed the forceps to the stone. (Sharp's Observations.) Sabalicr condemns making the cut in the bladder from below upward, lest the knife injure the peritona?um. (Mid. Opiraloire, T. 3, p. 160.) Although this is one of the easiest, and to all appearance, the safest method of operating, several objections soon brought it into disuse 1. The irritation of a stone often causes such a thickened and contracted state of the bladder, that this viscus will not admit of being distended so as to rise above the pubes. 2. If the ope- rator should break the stone, the fragments cannot be easily washed away, and remain- ing behind will form a nucleus for a future stone. 3. Experience has proved, that the high operation is verv commonlv followed by extravasation of urine, attended with suppuration and gangrenous mischief in the cellular membrane of the pelvis. This hap- pens because the urine more readily escapes out of the wound in the bladder, than through the urethra; and also because when (he bladder contracts, and sinks behind the os pubis, this wound ceases to be parallel to that in the linea alba and integuments, and becomes deeper and deeper. For the prevention of these ill consequences, says Sabatier, it will be in vain to make the pa- tient lie in a horizontal posture, and keep a catheter introduced, as Koussetand Morand recommended : experience evincing, that the bad effects are neither less frequent nor less fatal. (See Midecine Opiraloire, F. 3, p. 161, Edit. 2.) And Sir Everard Home confesses, that while the high operation for the stone had no other channel but the ' wound for carrying off the-urine, it seemed to him a method which ought never to be adopted ; " the urine almost always insinu- ating itself into the cellular membrane be- hind the pubes, producing sloughs, and con- sequently abscesses." (On Strictures, Vol. 3. p. 359, 8ro. Lond. 1821.) 4. The danger of exciting inflammation ofthe peritonaeum. b. The injection itself is exceedingly pain- ful, and however slow the fluid be injected, the bladder can seldom be dilated enough to make the operatiou absolutely secure : and when hastily dilated (to say nothing of the possibility of its bursting,) its tone mav be destroyed. (See Sharp, Allan, Sabatier, 4-c.) In many men, however, we know bv searching, that the bladder is very large, so that there is no risk of meeting wilh it iu a contracted state, and (he objection is of no weight, when the bladder exlends a consider- - able way above the pubes, and will admit a large quantity of injection. Stones are some times known (o be of large size, and they arc less likely to bo broken in (his, than any other mode of lithotomy, so that the objection of (he difficulty of exlracling small calculi and fragments is less forcible. Mr. Carpue even declares, that if the stone should break, Ihe particles can be extracted with much greater certainty, in less (ime, and with considerably- less pain, (nan in the lateral operation. (History of the High Operation, p. 154.) I may add, that some judicious sqrgeons ofthe present day are decidedly of opinion, that when a stone in the bladder is known to be very large, no attempt ought ever to be made to extract it from the perinaeum. Professor Scarpa also declares, that the lateral operation should not be practised when the calculus exceeds twenty lines in its small diameter. (See Memoir on the Cut- ling Gorget of Hawkins, p. 8, transl. byBriggs.) In such cases, it is true, the surgeon might do the lateral operation, and try to break the stone. But it is a question whether one ought not to prefer to this unpleasant, un- satisfactory proceeding, the high operation. I speak particularly of cases, in which the stone is known to be of very large dimen- sions before any operation is begun. Wcr-j LITHOTOMY. ihe lateral opei-aan commenced, the stone, If too large for extraction, must of course be broken; for, it is (hen too late to adopl (he high operation with advantage. That such things have been done, however, and yet the patients escaped, is a truth, which cannot be denied. Deselmmps mentions an in- stance, in whiok M. Lassus, afler using Hawkins's gorget, could not draw out the calculus, and he therefore immediately d:d the high operation, and the patient recover- ed. Indeed, the first example of the high operation on record was done by Franco under similar circumstances, and the patient wns saved. I have also beard of a modern French surgeon, who began with the lateral operation, but, finding a large calculus, end- ed with performing the high operation, with- out the least delay or hesitation : the patient died. Mr. Samuel Sharp, an excellent practical surgeon in his time, after noticing with great impartiality the objections which were then urged against the high operation says, that lie should not be surprised, if hereafter it were revived and practised with success ; an observation, which implied, that Mr. "sharp himself foresaw, that the method was capa- ble of being so improved, as ti» free it from its most serious inconveniences. In fa'ct, since his time, various attempts have been made to introduce the hiah operati -n anew, and upon improved principles. I\ er,; Cdme, | in particular, knew -fery well, that there were circumstances, ns for instance, a calcu- lus above a certain size, disease of the ure- thra, or pro-ttate gland, be., where the late- ral operation was liable to great difficulties and disadvantages, and where the high operation, if it could be perfected, would be a fitter and safer mode of proceeding. However, it was only in such cases, and not in all, that Frcre C6me thought the method better than the lateral operation. He had also discernment enough to perceive, that it was extremely desirable to invent some means, whereby the painful and hurt- ful distention of the bladder, for the purpose of making this organ rise behind the pubes, would be rendered unnecessary, at the ' same time, that some measure was adopted for letting the urine have a more depending outlet, than the wound in the hypogastric region. Iu the former editions of this dictionary, the error was committed of representing C6me to have cut the neck of the bladder, as well as its fundus ; a mistake, which I first became aware of upon the perusal of Mr Carpue's interestitit; work on lithotomy. The fact is, that Ceime did not wound the bladder in two places ; but ope- I rated after the following way : he first intro- duced through the urethra into the bladder a staff, which was then held by an assistant. An incision, an inch in length, was now made in the perinaeum in the same direction, as in the lateral operation. Another incision was made in the membranous part of the urethra along the groove of the staff, as far as the prostate gland. A very deeply grooved director was then passed along the staff into the bladder, and tbe latter bi$jru, ment was withdrawn. By means of the director, a sonde a dard, or kind of catheter furnished with astilette, was now introduced into the bladder, and, when this had been done, tbe director was taken out. An in. cision was then made, about three or four inches in length, just above the symphysis ofthe pubes, down to, and in the direction ol (he linea alba. A trocar, in which (here was a concealed bistoury, was next passed into the linea alba, close to the pubes, and the blade of the knife then started from ils sheath towards the handle ofthe instrument, while its other end remained stationary, hi this manner, the lower part of the linea alba was cut from below upwards, and an aper- ture w as made, which was now enlarged with a probe pointed curved knife, behind which a finger was kept so as to push Ibe peritonaeum out of the way. Cdme then took hold of tbe sonde d dard with his right hand, and elevating its extremity, lifted up the fundus of the bladder, while with the fingers of his left hand he endeavoured Iu feel its extremity in the wound. As soon as the end of tbe instrument was perceived, it vvas taken ho'd of between the thumb ami middle finger, ihe peritoneum was carefully kept up out of the -vay, and the stilette m< pushed by an assistant from within outwards, through the fundus of the bladder. The bladder being thus pierced, the operator ia- troduced into a groove in the stilette a curved bistoury, with which he divided tbe front of the bladder, from above downward.-, nearly to its neck. He then passed his fin- gers into the opening, and keeping up tbe bladder with them, withdrew the sonde a dard altogether. But, as it was useful thai both his hands should be free, the bladder was prevented from slipping away bymean^ of a suspensory hook "held by an assistant as soon as the opening was found to be already ample enough, or had been enlarged to the necessary extent. Cdme next intro- duced the forceps, took out the stone, and passed a cannula, or elastic gum catheter through the wound iu the perinaeum into the bladder, so as to maintain a ready oitle' for the urine, and divert this fluid from the wound in the bladder. In women, of coarse tiie catheter was passed through the meatus urinarius And, I ought here to observe, that Cdme thought the high operation espe- cially adviseable for females, because his experience had taught him, that the division, or dilatation, of the meatus urinaria «*>» generally folio * e i by an incontinence of urine. (See Nouvelle Milhode d'extrmn !• Pierre de la Vessie par dessus le Pui«i«W- Si-o. Bruxelh.s. 1779.) Another modification ofthe high operalioo was suggested by Desc;>amps, who, instead of opening the membranous part of lb* urethra as Cdme did, perforated the bladder from the rectum, and through the cannula of the trocar effected the same objeett, which the latter lithotomist accomplished ty means of the incision in the membranous part of the urethra. f)f (he two plans, th»' Li i hoi CM'; 193 devised by Conic, is unquestionably the best, because not attended with a double wound of the bladder ; a thing which, I conceive, must always be highly objectionable. Dr. Souberbielle, who practices C6me's method, introduces a silver wire through the cannula of the sonde a dard, and passes it through the wound made in the linea alba. The wire is then held while the sonde H dard is withdraw n, and a flexible gum-catheter is passed by means of the wire into the blad- der through the wound in the membranous part of the urethra. The wire is now with- drawn, and the catheter is fixed with tapes, passed round tbe thighs and pelvis, and a bladder is tied to it for the reception of the urine. " A piece of soft linen, half an inch wide, and six or eight inches long, is to be introduced, by means of a pair of forceps into the bottom of the bladder;" the object of which slip of linen is to carry off such urine, as may not escape through the cathe- ter. Lint and light dressings are applied, and a bandage round the abdomen. Great care is to be taken to keep the catheter per- vious, and, usually on the third day, the slip of lir^en m»y be taken out, and the wound closed with adhesive plaster. (See Carpue.'s History of the High Operation, p. 171, 172.) Sir Everard Home made trial of Dr. Sou- berbielle's method in St. George's Hospital, and though some difficulty and delay occur- red in the operation, on account of the stone being encysted, the result was successful. Subsequently to this c-.ase, however, Sir Everard has invented and practised another method, which, as far as 1 can judge, is better than that of Cdme, or Souberbielle, though its principles are the same. When it is considered, that in tha operation of these last lithotomists, the neck of the bladder is not opened, and the catheter enters that re- ceptacle through the prostatic portion of the urethra, it must be immediately obvious, that ihe incision ip the perinaeum cannot answer any material object, because a tube may be placed in the same position by passing it through the urethra from the orifice in the glans. The retainer, or bracelet, invented for keeping the catheter in the bladder, in cases of enlargement of the prostate gland, seemed to Sir Everard Home peculiarly ap- plicable to the high operation, since it keeps (he tube steadily in the natural canal, and renders the wound in the perinaeum unneces- sary. Bracelets, for this purpose, extremely elastic, and producing no irritation, are sold by Mr. Weiss, of the Strand. They are furnished with small rings, to which the outer end of the catheter is fixed by means of string. Sir Everard Home performed his new operation, for the first time, in St. George's Hospital, on the 26th of May, 1820. An in- cision was made in the direction ofthe linea alba, between the pyramidales muscles, be- ginning at the pubes, and extending four inches in length : it was continued down (o the tendon. The linea alba was (hen pierced close to (he pubes, and divided by a probe- pointed bistoury to ♦I"* "-xO-nt of 'hree V-.-c II 25 inches. The pyramidales muscles hod a por- tion of their origin at the symphysis pubis detached to make room. When the finger was passed down under the huaa alba, the fundus of (he bladder was felt covered wilh loose, fatty, cellular membrane. A silver catheter, open at the end, was now passed along the urethra into thwbladder, and when the point was felt by the finder in the wound, pressing up the fundus, a stilet, that had been ■ concealed, was forced through th coats of the bladder, and followed by th end of the catheter. The stilet was the. withdrawn, and the opening, through ih fundus of the bladder, enlarged towards tin pubes, by a probe-pointed bistoury,' suffi ciently to admit two fingers, and then the catheter was withdravvn. The fundus of the bladder was held up by one finger, and the stone examined by the forefinger of the right hand. A pair of forceps, with a net attached, was passed down into the bladder, and the stone directed into it by the finger: the sur- face being very rough, the stone stuck upon the opening of the forceps, and being re- tained there by the finger, was extracted. A slip of linen had one end introduced into the bladder, and the other was left hanging out of the wound, the edges of which were brought together by adhesive plaster. A flexible gum catheter, without the stilet, wt-s passed into the bladder by the urethra, and kfpt there by an elastic retainer surrounding the penis. The patient was put to bed, and laid upon his side, in which position the urine escaped freely through the catheter." As no blood had been lost in the operation, twelve ounces were taken from the arm. The next day the slip of linen was with- drawn, as useless and irritating, the catheter, while pervious, preventing any urine from escaping by the wound- Sir Everard thinks, that in future the linen need only be left in the external wound, so as to prevent col- lections of matter, and carry off any urine, which may issue from the opening in the bladder, when the catheter happens to »e stopped up. For this operation, Sir Eve- raid particularly recommends catheters, with their in-sides polished like their outsides, in order that they may better resist the effects of the urine. Suffice it to add, with respect to the above case, that the boy soon recovered, the bladder having resumed its healthy functions in ten days, although the calculos was of the roughest possible kind. Sir Everard Home has repeated his new method on a gentleman, who went out in bis carriage, with the external wound com- pletely healed, on the 14th day after the ope- ration. The only particulars, which need here be noticed, in regard to the lalter case, are, that some difficulty was experienced in bringing the point of the catheter forwards toward the pubes, and the slit in the front of the instrument made it so incapable of bear- ing lateral motion, that the two sides were twisted over one another. (On Strictures, Vol'3, p. 339, Sro. Lond. 1820.) Whoever follows this method of operating ;VvilH always be p-ovided v, ith ■'■*•■■> , 194 LITHOTOMY lubes and slilcts, of different lengths and ■ urvatures; for, in the only case, iu which 1 have seen the operation attempted, the ex- tremity of the catheter could not be made to project the fundus of the bladder towards lit pubes, and, after long-protracted eudea- urs had been made to bring the end of the '•■ ' t.K-nt upwards and forwards, the tube ,. and the operation was left unfinished. - impression upon my mind was, that no , ,tanceof ihe bladder could account for >-, ;;ut happened, and that the fault lay in the 'run-cut itself, which should have been ^i changed for anotherof-more suitable form, :y3 soon as it was found to be inapplicable. And, I believe,that if attention be paid to this suggestion of always having at hand a suf- ficient number of tubes and stilets of differ- ent lengths and curvatures, Sir Everard Home's new method will be the best moditi- calion of the high operation yet proposed. The slip of linen, however, I think is more likely to do harm by its irritation, than any good, as a conductor of the urine or matter out the wound. At all events, as Sir Eve- rard has observed, it should never be passed into the bladder itself. Whenever I am asked my opinion, respecting the preference, which should be given to the high operation, as a general practice, I venture no further than to express a favourable opinion of it for cases, in which the calculus is known be- forehand to be of very large size, or the urethra and prostate gland are diseased. The reasons urged by Mr. Carpue, in favour of a preference to the high operation in most cases, are : 1. Because, it is generally performed in less time; a point, which may be disputed, though it is perhaps not worth con- gesting, since the dariger of an operation can- not always be twly estimated by the length of time, which the patient remains in the operating room, slow and gentle proceedings sometimes contributing to his safety. 2. There i 'ess pain ; a remark, the justness of which most depend, perhaps, upon the manner in <*. hich each operation is done. 3. There is no tear of a fatal hemorrhage ; a consideration, which I admit is one good reason in favour of "-e high operation; though the lateral ope- r*i -n is only subject to risk of hemorrhage, when the incisions are directed in a manner o'. sanctioned in this dictionary. 4. There no division of the prostate and inferior . rt of the bladder: no, but there is one •'! the fundus, so that perhaps on this point V two operations stand upon an equality, or there being no danger in the high -.;ie;aUon of wounding the rectum, it :-'doubtedly an advantage, though the •"•■•i.-i-.teiit, as far as I have seen, is not I .1, / ed by any serious consequences, and can ...j'y happen from inattention to rules »asi'y followed. 6. The stone, if of a cer- ■•• ze, cannot be extracted by the lateral ;-. .ition, but admits of being so by the high ■pj-r.-jion. Of all the reasons for the latter r-ictice, this appears lo me tbe. strongest, >ih the exception perhaps of disease in the -rethra and prostate. 6. A small stone is more readily discovered in this method, than in the laleral operation : a po.ut whicu I consielcr questionable, and at all events, not sufficiently important to form a ground for (he high operation. 7. If a stone breaki, Ibe particles can be extracted with more certainty, than in the lateral operation: on thi* question authors differ. 8. The high opera'o i enables (he surgeon (o remove encysted calculi wilh greater ease : a reason which may perhaps be generally true, but which is somewhat weakened by tbe consi- deration that e ncysted calculi are not verr frequent. Mr. Carpue allows, that the high operation should not be selected when the patient is corpulent, and tbe bladder is thick- ened and diseased, so that its fundus cannot he raised above the pubes. (See Hist, of the High Operation, p. 173, 8to. Lond. 1819) As it is not my object to discourage the practice of (he high operation, under tlupar- ticular circumstances which have been speci- fied, I decline entering into any strict con sideration of the inconveniences to which this method is exclusively subject, especially, the greater vicinity of the wound to the Seritoneum and small intestines, and tbe ivision of that membrane and protrusion of the viscera; accidents,which will be found by any body, who chooses to look over Ibe cases on record, not to have been unfre- quent. On the contrary, as I believe this method is advantageous in certain cases, the recent attempts to bring it to greater perfec- tion give me sincere pleasure. In December, 1818, Mr. Kirby, of Dublin, performed the high operation for the extrac- tion of an elastic gum catheter, which had slipped into the bladder through the cannula of a trocar, with which paracentesis had been performed. No contrivance was found necessary for lifting up the fundus of tbe bladder. The puncture, already made, was enlarged, and after the operation was fin- ished, a catheter was placed in the wound, but was withdrawn on the 4th day, as tbe urine passed out by the side of il. 'fhe case terminated well. (See Kirby's Cases,p. 92, Sfc. 8vo. Dublin, 1819.) LATERAL OPERATION. So named from the prostate gland, and neck of the bladder, being laterally cut. From some quotations made by Mr. Car- pue from the works of Franco, it appears clear enough, that the latter was not onb the inventor of the lateral operation, but that he placed his patients in the position adopted at the present time, used similarin- struments to those now employed, (except ing that his gorget bad no sharp side) and made the same incisions. Now, as this claim of Franco to an invention of such import- ance had been nearly, or quite forgot, wbea Mr. Carpue's work made its appearance,tb« latter gentleman deserves much praise f« reminding the profession of what m»y I* due to the memory of an old surgeon, who* name must flourish, as long as the history ot the rise and progressof surgery isinteresliugto mankind. But, though Franco appears on*- bly to have practised the lateral operation,9 ITHOTOMV 195 something very much like il, he never esta- blished the method as a permanent improve- ment of surgery,which measure was left to be completed long afterward by an ecclesiastic, who called himself Frere Jacques: he came to Paris in 1697, bringing with him abun- dance of certificates of his dexterity in ope- rating; and making his history known to tbe court and magistrates of (he cify, be got an order to cut at the H6tel Dieu, and the (la rile*, where lie performed (his operation on about fifty persons. His success did not answer the promises which he bad made, and from that lime his reputation seems to have declined in the world, if we may give credit to Dionis, who has furnished us wilh these particulars.—(Sharp^ Operations.) Freie Jacques used a lar^e round staff with- out a groove, and when it vvas introduced into the bladder, be depressed its handle, with an intention of making the portion of this viscus, which he wished (ocut, approach the perinaeum. He then plunged a long dagger-shaped knife into (he left hip, near the tuber ischii, (wo finger-breadths from the perinaeum, and pushing it towards the blad- der, opened it in its body or as near the neck as he could, directing his incision up- ward from the anus. He never withdrew bis knife, till a sufficient opening had been made for the extraction of the stone. Some- times he used a conductor to guide the for- ceps, but more comnonly directed them with his finger, which he passed into the wound after withdrawing the knife. When he had hold of the stone, he used to draw it out in a quick rough manner, heedless of the bad consequences. His only object was to get the stone extracted, and he disregarded every thing else ; all preparatory means, all dressings, all after-treatment. (Allan, p. 23.) Totally ignorant of anatomy, and thus rude and indisciminate in practice, Frere Jacques soon sunk into disrepute. However, there were several eminent surgeons, who conceived, from considering tbe parts which he cut, that his method might be converted into a most useful operation. (Sharp's Ope- rations.) The principal defect in his first manner of cutting, was (he want of a groove in his staff, which mode it diflicult to carry the knife into the bladder. At length, Frere Jacques was prevailed upon to study anatomy, by which his judgment being improved, he readily embraced several improvements, which were suggested to birn. Indeed, we are informed that he now succeeded better, and knew more, than is generally imagined. Mr. Sharp says, that when he himself was in France in 1702, he saw a pamphlet, published by this celebrated character, in which his me- thod of operating appeared so much impro- ved, that it scarcely differed from the practice of that time. Frere Jacques had learnt Ihe necessity of dressing (he wound afler the operation, and had profited so much from the criticisms of Mery, Fagon, Felii, and Hutniuld, that, he then used a staff with a groove, and v-ha- is more extraordinary, had cut thirty-eight patients successively, without losing one. (Sharps Operations.) In short, as a modern writer has observed, be lost fewer patients than we do at the pre- sent day, in operating with a gorget. He is said (o have cut nearly 5000 patients in Ihe course of his life, and though persecuted by the regular lithotomists, he was imitated by Marechal at Paris, Raw in* Holland, and by Bamber and Cheselden in England, where his operation was perfected. (Allan.) For a particular history of Frere Jacques, and bis opera(ions, Allan refers us to Bus- Here's Letter to Sir Hans Sloane, ^Philos. Trans. 1699. Observations sur la Maniire dr. tailler dans les deux Sexes, pour I'Extraction de la Pierre, pratiquie par F. Jacques, par J. Mery. Lister's Journey lo Paris in 169S. Cours d'Operations de Chirurgie, par Dionis. Garengeot Traiti des Operations, T. 3, Mo- rand, Opuscule Chirurgie, Part 2. Among the many who saw Frere Jacques operate, was the famous Prufessor Raw, who carried his method into Holland, and practi- sed it with amazing success. He never pub- lished any account of it himself, though he admitted several to his operations; but afler bis death, his successor Albinus, gave the world a very e ircumslantial detail of all the processes, and mentions, as one of Raw's improvements, that he used to open the blad- der, between its neck and the ureter. But either Albinus, in his relation, or Raw him- self in his supposition, was mistaken ; since it is almost impossible to cut (he bladder in that part upon the common staff, without also wounding the neck.'* (Sharp in Opera- tions and Critical Inquiry.) Raw's method was objectionable, even when accomplished, as the urine could not readily escape, and became extra vasal ed around the rectum, so as (o produce terrible mischief. Tliere is little doubt, that Raw's really successful plan was only imitative of Frere Jacques's second improved one, though he was not honourable enough to confess it. (See Ferhius de Colculo Vesice.) Dr. Bamber was (he first man iu P.ngland, who made a trial of Raw s method on the living subject, which he did in S(. Bartholo- mew's Hospital. Cheselden, who had been in the habit of practising the high operation, gladly abandoned it, on receiving the ac- count of Raw's plan and success, and a few- days afler Bamber, he began to cut in (his way in St. Thomas's Hospital. Cheselden used at first to operate in the following manner. The patient being pla- ced, and tied much in the same way, as is done at this day, the operator introduces a hollow grooved steel catheter into the blad- der, and with a syringe, mounted with an ox's ureter, injects >is much warm water into i(,as fhe patient can bear without pain. Tbe water being kept from running ouf by a slip of flannel tied round the penis, the end of the catheter is to be held by an assistant, whose principal care is (o keep it from rising, but not at all to direct the groove to the place where (he incision is to be made. With a pointed convex-edged knife, (he •<6 MTH.'iOiiT. operator bcginnin; about an inch above (be anus on (he left side of (he raphe, between the accelerator urinn-, and erector penis, makes an incision downwards, by (he side of the sphincter ani, a litlle o-liquely outwards a* it descends, from two and a half to four inches in length, according to (he age of (he patienl, or size and structure of the parts. This incision he endeavours to make all at one stroke, so as to cut through the skin, fal, and all, or part of the levator ani, which lies in bis way. This done, he passes his led fore-finger into (he middle of the wound, in order to press the rectum (o one side, (bat it may be in less dunger ot being cut; and taking a crooked knife in bis other hand, with ihe edge on the concave side, he thrusts the point of it through the wound, close by bis Giiger, info (he bladder, between the ve- sicula seminalis and os ischium of (he same side. This second incision is continued up- wards, till the point of (he knife comes out at Ihe upper part of*the first. The incision be- ing completed, the operator passes his left fore-finger through the wound into the blad- der, and having felt, and secured (he slone, he introduces the forceps, pulls out bis finger, and extracts the stone. As (he bladder was distended, Cheselden thought it unnecessary to cut on tbe groove of the staff, and that, as this viscus was suffi- ciently pressed down by the instrument, the forceps could be very well introduced with- out the use if any director, ex-epl the finger. (Postscript to Douglas's History of the Lateral Operation, 1726.) With respect to this first of Cheselden's plans, Sharp says, the operations were ex- ceedingly dexierous; but the wound of the bladder retiring back, when it was empty, did not leave a ready issue for (be urine, which insinuated itself among the neighbour- ing muscles and cellular substance, and four out ofthe ten patients on whom the operation was done perished, and some of the- others narrowly escaped. (Sharp's Operations.) Cheselden, finding thai he lost so many patients in imitating Raw, according to tbe directions given by Albinus, began a new manner of operating, which he thus de- scribes : " I firs! make as long an incision as I well can, beginning near the place where the old operation ends, and cm ting down between the musculus accelerator urina* and erector penis, and by the side of the intesti- num rectum : I then feel for tbe staff, and cut upon it the length of the prostate gland straight on to the bladder, holding down the gut all (he while with one or two fingers of my left hand." (Anatomy of the Human Body. Edit. 1730.) "* Ii deserves remark, that it was Cheselden's second manner of cutting, which was descri- bed in the Opuscules de Chirurgie, of Morand, who was deputed, and had uis expenses de frayed by the Koyal Academy of Sciences in Paris, to come over to England, and learn trom Mr. Cheselden himself, his way of ope- ra(ing for tbe stone ; and, accordingly, we find,that most Fie;,(:h authors, taking their ac- count U -n Morand, describe Cheselden's se- cond, not his third operation, as that which he invented, and bears his name. But, that Mr Cheselden never resumed his second manner of cutting may be inferred from hi-, continuing lo describe tbe third only in «|| the editions of his anatomy published after 1780. (See a note by J. Thomson, M. D. an- neiw to his new edition of Douglas's Appen- dix. Edinb 1808.) The instruments which Cheselden employ- ed in his third, and mosl improved mode of cutting for Ihe stone, were a staff, an incision knife, a gorget, a pair of forc-ps, and fa crooked needle carrying a waxed thread. The patient being placed on a table, his wrists are brought down to the outsides of his ankles. and secured there by proper bandages, bit knees having first been bent, and his heels brought back near his buttocks. Cheselden used then to lake a catheter first dipped in oil, and introduce it into the bladder, where having searched for, and discovered tht slone, he gave Ihe instru- ment to one of his colleagues, whom he de sired to satisfy bimself, whether there was a stone, or not. The assistant, standing on his right hand, held the handle of the staff be- tween his fingersand thumb, inclined it i little towards the patient's right thigh, and drew (he concave side close up to tbeos pu- bis, in order to rem»ve the urethra as far as po-sible from the rectum. The groove of the staff being thus turned' outwardly and laterally, Cheselden sat down in alow chair, and keeping (he skin of the> perina?um steady with ihe thumb and fore- finger of his left hand, he made (he first or ou(ward incision, through the integuments, from abave downwards, beginning on the left side of the raphe, betveen the scrotum and verge of the anus, alntost as high up ai where the skin of the perinaeum begins to form the bag containing the esticles. Thence be continued the wound obliquely outwards, us low down as the middle of the margin of Ihe anus, at about half an inch distant from it, and consequently, beyond tht tuberosity of the ischium. He was always careful to make this outward wound as large as be could with safety. Having cut (he fat rather deeply, especially near the rectum, he used to put hii left fore-finger into (he wound, and keep it there till the internal incision was quite 6nish- ed ; first to di.-ect the point of his knife into Ihe groove of the staff, which he now felt with tlie end of his finger ; and secoadly, to hold and prevent the rectum from being wounded, by tbe side of which his knife was to pass. This inward incision Cheselden made with more caution, than tbe former His knife first entered the groove of the ros trated, or straight part of the staff, through tbe side of tbe bladder, immediately above the prostate, and its point was after»arJ brought along the same groove in the direc- tion downwards, and forwards, or towards him-ielf. Cheselden thus divided that part Oi the sphincter of the bladder, which l»f upon the prostate -land, of which he neil cut the outside of one half obliquely, acconi- «ng to (he direction and wholet lenefh of the HO'loAli 1^7 urethra within it, and finished the internal in- cision, by dividing the membranous portion of tbe urethra, on tbe convex part of his staff. A sufficient opening being made, Che- selden used to rise from his chair, his finger still remaining in the wouud. Next he put the beak of his gorget in the groove of the staff, and then thrust it into the bladder. The staff was now withdrawn, and while he held the gorget with his left hand, he intro- duced the forceps with the flat side upper- most, with great caution along the concavity of the gorget. When the forceps was in the bladder, he withdrew the gorget, and taking hold ofthe two handles of the forceps with both his bauds, he searched gently for the stone, while the blades were still kept shut. As soon as the calculus was felt, the forceps was opened, and an attempt made to get the lower blade under the stone, in order that it might be more conveniently laid bold of. This being done, the stone was extracted with a very slow motion, iu order to give the parts time to dilate, and the forceps was gently turned in all directions. When the stone was very small, and did not lie well in the forceps, Cheselden used to withdraw this instrument, and introduce his finger into the bladder, for tbe purpose of turning the stone, and disengaging it from the folds of the lining of the bladder, in which it was sometimes entangled. Then the gorget was passed in again on the upper side of his finger, and turned as soon as the latter was pulled out. Lastly ; tbe forceps was introduced, and the stone extracted. With the view of hindering a soft stone from breaking during its extraction, Chesel- den used to put one or more of his fingers between the branches of his forceps, so as to prevent any greater pressure upon it, than what was just necessary to hold it to- gether. But when it did break, or there were more calculi than one, he used to extract the single stones, or fragments, one after another, repeating the introduction of his fingers and forceps, as often as there was occasion. Cheselden took care not to thrust the forceps so far into the bladder as to bruise or wound its opposite side; and he was equally careful not to pinch any folds of its inner coat. In this way, Cheselden saved 60 patients out of 52, whom he cut successively in St. Thomas's Hospital. (Ap- pendix to the History of the Lateral Opera- tion, by J. Douglas. 1731.) Cheselden, with all the enthusiasm of an inventor, believed, that he had discovered an operation, which was not susceptible of improvement; yet, he himself changed the wanner of his incision not less than three imes, in the course of a few years. 1st, He ut into the body of the bladder, behind the rostate, when he imitated Raw. 2dly, He >:ut another part of the bladder, viz. the neck and the thick substance of tbe pros- tate ; this is his lateral mode of incision. 3dly, He changed a third time, not the es- sential form of the incision, but the direc- tion, in which he moved the knife ; for in his first operation- when imitating the sup- posed operation of Raw and Frere Jacques he struck his knife into the body of the bladder, betwixt the tuber ischii and the vesiculae seminales, and all his incision lay- behind the prostate gland. In this second operation, he pushed his knife into the membranous part of tbe urethra, imme- diately behind the bulb, amd ran it down through the substance ofthe gland ; But his incision s opped at the membranous part; or body, of the bladder. But in his (hird operation, after very large external inci- sions, he passed his knife deeply into the great hollow under the tuber ischii, entered it into the body ofthe bladder immediately behind (he gland, and drawing it towards himself, cut through the w hole substance of the gland, and even a part of the urethra, " cutting the same parts the contrary way." By carrying the fore-finger ofthe left hand before the knife, in dissecting towards the body of the bladder, he protected the rec- tum more perfectly, than he could do in running the knife backwards along the groove of the staff; and by striking his knife into the body of the bladder and drawing it towards him, through the whole thickness of the gland, he was sure to make an ample wound. (J. Bell's Principles of Surgery, Vol. 2, Part 1, p. 152.) LATERAL OPERATION AS PERFORMED AT THI' PRESENT DAV WITH CUTTING GORGETS. The gorget has the same kind of form as ene of the instruments used by F. Colo* and others in the performance ofthe appa- ratus major, and the common opinion, that the conductor of Hildanus was the first mo- del of it, is not exactly true ; but it differ, from the instruments employed by these older surgeons in having a cutting edge. Sir Cesar Hawkins thought that, when its right side was sharpened into a cutting edge, it might be safely pushed into the blad- der, guided by the staff, so as to make the true lateral incision in the left side of the prostate gland more easily, and with les.; risk of injuring the adjacent parts, than Cheselden could do with the knife ; and surgeons were pleased with a contrivance, which saved them from the responsibility of dissecting parts, with the anatomy of which all were not equally well acquainted. (J. Bell. Allan.) As Scarpa observes: To render tbe exe- cution of the lateral operation easier to surgeons of less experience than Chesel- den, was the motive which induced Haw- kins to propose his gorget. He thought, that two great advantages would be gained by the use of this instrument; one of exe- cuting invariably the lateral incision of Cheselden ; the other, of constantly guard- ing the patient through the whole course of the operation, from injury of the rectum, and of the arteria pudica profunda. The utility of the latter object (says Scarpa) cannot be disputed, as it is evident,'that the convexity ofthe director ofthe instrument de- fends the rectum from injury, and that its cutting edge not bring inclined horizontally. LITHOTOMY. towards the tuuerosiiy end ramus of the ischi- um, but turned upwards in the direction ofthe lomriindinul axis of the neck of the urethra, cannot wound the pudic artery. But, with respect to the first advantage, or that of executing precisely the lateral incision of Cheselden, it must be admitted that it does not completely fulfil the intention which he prop-Hed, not only on account ofthe cutting edge of his instrument not being raised enough above the level ofthe staff, to pene- trate sufficiently the substance of the pros- tale gland, and consequently to divide it to a proper depth ; but, because being too much turned upwards at that part of it, which is to lay open the base of the pros- tate gland, it does not divide it laterally, but rather at its upper part, towards the summit of the ramus of the ischium, and the arch of the pubes ; an opening, of all others in the7 perinaeum, the most confined, and presenting the greatest impediment to the passage ofthe stone from the bladder. The breadth of the point of the director is, be- sides, so disproportionate to tbe diameter of the membranous part of the urethra, that, from the great resistance with which it meets, the instrument may easily slip from the groove of the staff, and pass between the bladder and rectum, a serious accident, which has very often happened even in the hands of experienced surgeons. Scarpa considers all the modifications of Hawkins's gorget, proposed by B. Bell, Desault, Cline, and Cruikshanks, as deteri- orations of the original instrument. B. Bell (he observes) has diminished the breadth et the director, but has given the cutting edge an horizontal direction. The horizon- tal direction ofthe cutting edge is also pre- ferred by Desault, Cline, and Cruikshanks ; but they have enlarged the director, and flattened the part which was previously concave. Aware of the danger of wound- ing the pudic artery, by the horizontal di- rection of the gorget, they direct the handle of the staff to be inclined towards the pa- tient's right groin, and the gorget to be [lushed along it, inclined in such a manner, that its obtuse edge may be directed towards the rectum, and its cutting edge placed at a sufficient distance from the tuberosity and ramus of the ischium to avoid wounding the artery. Scarpa contends, however, that it is difficult to give a proper degree of obliquity to the staff, and that such inclina- tion of the instrument must be incommo- dious, arbitrary, and unstable, in comparison with that position of it, in which the handle of the staff is held in a line perpendicular to the body of the patient, and its concavity placed against the arch of the pubes; on which stability ofthe instrument (says Scar- pa) the safety and precision of the lateral operation depend. According to this emi- nent professor, the defects of Hawkins's original gorget arise from tbe excessive breadth of the director, particularly at the point ; the want of sufficient elevation of the cutting edge, above the level of the groove of the staff, and the uncertain incli- nation of the edge to the axis of the urelhn and prostate gland. The cervix of theure- thru, in a man between thirty and forty years of age, is only three lines in diameter at the apex of the prostate gland, four linea in its centre, and five near the orifice of the Madder. The apex of the prostate gland ii rather more than two lines in thickness, tbe body or centre four, and the base sii, and sometimes eight, which surrounds tbe orifice of the bladder. In an adult of middle sta- ture, from eighteen to twenty years of age, the thickness of the base of the prostate gland is about two lines less, compared with that of a man of forty, and of a large site. The precise line in which the lateral incision ofthe prostate gland should be made in an adult, (says Scarpa) is found to be inclined to the longitudinal axis of the cervix of the urethra, and of the gland itself, at an anile of 69°. Now, from these data, drawn from the structure of the parts, Scarpa makes the director of his gorget only four lines broad, and two deep j the breadth decreasing at the beak. The cutting edge of the instru- ment is straight near its point, but gradu- ally rises, and becomes convex above the level of the staff, so that its greatest con- vexity is seven lines broad. Lastly; the inclination of the cutting edge to the lon- gitudinal axis of the director, is exactly at an angle of 69° ; that is to say, the same as the left side of the prostate gland to the longitudinal axis of the neck of the urethra. (See Scarpa's Memoir on Htm- kins's Gorget; transl. by Mr. Briggi, p. 12, 17.) For nearly twenty years past, the instru- ment-makers in London have been in tbe habit of selling a gorget, which Mr. Aberne- thy first had constructed, and which in the particularity of having its cutting edge turn- ed up atari angle of 45°, bears much analo- gy to the instrument lately recommended by Scarpa. The cutting edge is straight, and that useless and dangerous part of a gorget, sometimes called the shoulder, is re- moved. Admitting that tbe principles ol the lateral operation as inculcated by Scar- pa, are correct, and of which 1 shall present- ly speak, it appears to me, that Mr. Aberne- thy's gorget is far preferable to that very re- cently proposed by Scarpa. Its edge is not so immoderately turned up, and it will enter with more ease, and less risk of slipping from from the staff, because it has not any pro* jecting shoulder, which, while the staff * firmly held with the beak of the gorgetiah. can have no other effect but that o( obstruct- ing the passage of the last instrument. Gorgets, which cut on both sides, have also been sometimes employed in England. and as a larger opening can be obtained by them, even without trespassing tbe limits oi the incision, fixed by Scarpa, that is to say, without cutting any part of the body of the bladder, they appear to promise utility, es- pecially when the stone is suspected to be large. However, they are less used now, than they were some years ago, whea S'n Astley Cooper employedthero in Guv's Ho* LI 1 HO pilal ; but I am unacquainted with the par- ticular reasons of this change. Some criticisms on Scarpa's method of operating, and a few remarks on the size and direction of the lateral incision, will be found in a subsequent section of the present article. As inflammation of the bladder and peri- tonaeum is the principal danger of this ope- ration, and, under an equal degree of injury and violence, is most likely to happen in a plethoric subject, it has been a question, whether venesection should not be practised a day or two before the patient is operated upon, supposing that his age and weakness form no prohibition. The chief reason, which prevents the common observance of this practice is, that a great deal of blood is sometimes lost in the operation itself. But when this has not happened, and the patient is young and strong, and particularly when the operation bas been tedious, and the bladder has suffered a good deal, I am dis- posed to think very favourable of the rule, which is followed by many surgeons, of bleeding the patient as soon as he is put to bed, and recovered from the first depressing effects of the operation. An opening medi- cine should also be given the day before the patient is cut, and a clyster injected a cou- ple of hours before the time fixed upon for the operation, in order to empty the rectum, and thus diminish the chance of its being wounded. As it is advantageous to have the bladder somewhat distended, the patient should be requested to retain his urine a certain time before being cut. Formerly, a jugutn penis was sometimes used for confining the urine in the bladder; but, since my entrance into the profession, I have never heard of this contrivance being employed. Before the operation, the following instru- ments should all be arranged ready on a table : a staff of as large a diameter as will easily admit of introduction, and the groove of which is very deep, and closed at the ex- tremity. A sharp gorget, with a beak nicely and accurately adapted to the deep groove of the preceding instrument, so as to glide easily and securely. A large scalpel for making the first incisions. Forceps of va- rious sizes, for extracting the stone. A blunt-pointed curved bistoury for enlarging the wound in the prostate, if the incision of the gorget be not sufficiently large, as the [•arts should never be lacerated. A pair of Le Cat's forceps with teeth for breaking Ihe stone, if too large to come through any wound reasonably dilated. A syringe for washing out clots of blood, or particles of the stone. A scoop for the removal of small calculi or fragments. Two strong garters, or bands, with which the patient's hands and feet are tied together. The curvature of the staff is a matter of considerable importance ; because the di- rection of the incision through the prostate gland and neck ofthe bladder is partly de- termined by it. The French surgeons, con- vinced of the advantage of introducing the UivIV. L99 gorget in the direction of the axi3 of the bladder, always use a staff, which is much more curved than what English surgeons employ. (See Ronx, Voyage fait a Londres en 1814, ou Parullile de la Chir. Angloisc, fyc.p.319) But, 1 am inclined to believe with Scarpa, that, upon the whole, it is best to let the curvature of the staff correspond exactly to that of the axis of the neck of tho urethra and prostate gland. (JHemotV on Hawkins's Gorget, fyc.p. 17.) After introducing the staff, and feeling that tbe stone is certainly in the bladder, the patient is to be secured in the same position, as was described in the account of Chesel- den's latest method of operating. The assistant, holding up tbe scrotum. with his left hand, is with his right to hold the staff, inclining its handle towards the right groin, so as to make the grooved con- vexity of the instrument turn towards the left side of the perinaeum. Some operators, also, like the assistant to depress the handle of the staff towards the patient's abdomen, in order to make its convexity project in the perinaeum, while others condemn this plan, asserting, that it withdraws the instru- ment from the bladder. (Allan, fyc<) Professor Scarpa disapproves of inclining the handle of the staff towards the patient's right groin, (p. 15.) and he expressly recom- mends this instrument to be held firmly against the arch of the pubes, in a line per- pendicular to the body of the patient, so that the convex part of the director may be placed towards the rectum, and take the exact course of the axis of the neck of the urethra and prostate gland. (P. 20.) This position of the staff is the firmest and most commodious to the surgeon, and Scarpa maintains, that on such stability of the instru- ment the safety and precision ofthe lateral operation depend. (P. 15.) The first incision should always com- mence below the bulb of the urethra, over tbe membranous part of this canal, at the place, where the operator means to make his first cut into the groove of the staff, and the cut should extend at least three inches, ob- liquely downward, to the left of the raphe of the perinaeum, at equal distance from tho tuberosity ofthe ischium and the anus. In a large man, the first cut should pass the anus an inch and a half or more ; for it is a general rule in surgery to make free exter- nal incisions, bywLich the surgeon is ena- bled to conduct the remaining steps of his operation with greater facility, and nowhere is it so necessary, as where ajstone is to bo extracted. (Allan.) That excellent sur.i cal writer, Callisen, lays it down as a rule to be observed in the lateral operation, that the incision ought not to extend lo such parts as can make no impediment lo the extractic-,% of the stone ; and therefore, (says he) the bulb, and that part of the urethra, which is sur- rounded by Ihe corpus spongiosum, should never be cut. Only those parts ought to be divided, which firmly resist the safe intro- duction of instruments into the bladder, and the extraction ofthe ston-*. H'-nce, Mie ir -1*1 i.uHuiur.it tegument* must be opened by an ample in- cision, and the membranous part ofthe ure- thra, transversales perina-i muscles, levater ani, and prostate gland, be properly divWed. Catlisr i ;ystema Chirurgie Hodierne, Pars 2, p. 655.) Like Scarpa, however, he is tearnil of making a free cut through the neck of the bladder, and in lieu of doing so, prefers a slow and cautious dilatation ofthe parts. When the external cut through the integuments has been executed, the next object is to divide the transversales perinaei muscles, which stand, like a bar, across the triangular hollow, out of which alone the stone can be easily extracted. A part ofthe membranous portion of the urethra, adjoin- ing the prostate gland, is next to be laid open ; but an extensive cut through it, as far forward as the bulb, is quite unnecessary, because it will not at all facilitate the pas- sage of the stone outward. Having placed the beak of the gorget in the groove of the staff, the operator takes firm hold of the latter instrument with his left hand, raises its handle from the abdo- men, so that it may form nearly a right an- gle with the body, and stands up. Before attempting to push the gorget into the blad- der, however, he should slide it backwards nnd forwards, with a wriggling motion,that lie may first be sure of its beak being in the groove of the staff. The bringing forward of fhe handle of the latter instrument, so as to elevate its point, before introducing the gor- get into the bladder, is also considered of great importance : for it is by this means, lhat the gorget is . .: ' ■■01 bnuness to keep it from slipping away from the blades, but not so forcibly as to incur the risk of ils breaking. Sometimes the extraction of the stone is attended with difficulty, owing to the ope- rator having chanced to grasp it in a trans- verse position, in which circumstance, it is better to try to change its direction, or let it go altogether, and take hold of it in ano- ther manner. When the stone is so large, that it cannot be extracted from Ihe wound without violence and laceration, the surgeon may either break the stone by means of a strong pair of forceps, with teeth construct- ed for the purpose ; or he may enlarge the wound with a probe-pointed crooked bis- toury, introduced under the guidance of the fore-finger of the left hand. The latter plan is generally the best of the two ; for, break- ing the stone is an exceedingly unpleasant circumstance, as it creates serious danger of calculous fragments remaining behind. However, as-nothing can justify the exer- tion of force in pulling out a stone, if the operator should be afraid of making the wound more ample, (it being already lar^e and direct) he must break the stone as above described. As many of the fragments are then to be extracted with the common li- thotomy forceps, as can be taken away in this method, after which the surgeon should introduce his finger, in order to feel whether any pieces of the stone still remain behind. Perhaps some of these may be most conve- niently taken out with the scoop , but if they are very small, it is best to inject luke- warm water with moderate force into the wound for the purpose of washing them out. The surgeon however, cannot be to) strongly impressed with the absolute ne- cessity of using the greatest care not to re- move the patient from the operating table, while any calculus, or fragment, remains in the bladder. For, the distressing pain of the disorder has been known to recur upon the healing of the wound, and a second operation become necessary. It is a me- lancholy truth, however, that a fresh calcu- lus may form again in the short space of a few months. I have seen several patients who have been cut for the stone, more than once; and Richerand mentions the case of a surgical instrument maker, resident at the gate of La Charite, in Paris, who has undergone the operation three times in the course of a year and a half, although after each operation several eminent surgeons carefully examined the bladder, and could not find any calculus remaining in it. (See .YoMgr. Chir. T. 3, p. 549, Edit. 4.) Thestone should always be attentively ex- amined immediately it is extracted ; because its appearance conveys some information, though not positive, concerningthe existence of others. If the stone is smooth on one surface, the smoothness is generally found to arise from the friction of other stones still in the bladder; but, when it is uniformly rough, it is a presumptive sign, that there is .v.) other one remaining behind. Iu every instance, however, the surgeon should gently examine the cavity of the bladder with his fore-finger ; for, it would be an inexcusable neglect to put the patient to bed with ano- ; ther stone in his bladder. , After the operation, a simple pledget should be laid on the wound, supported by a T bandage ; the patient should lie in bed on his back, with his thighs closed ; apiece of oil-cloth, and some folded napkins should be laid under him for the reception of the j urine, and, if there be much pain, a large J opiate should be administered ; but, as the latter medicine is a stimulant, if it can be dispensed with, so much the better. An occasional embarrassment to lithoto- i mists is the circumstance of stones in the bladder not being always free and detached : , some are embraced very tightly by tbe coats I of this viscus ; others are partially engaged in the ureters; they are sometimes fixed in ] the neck of the bladder; and are not un- j frequently found lodged in sacculi accident- ally formed. Thess cyrsts are of different i sizes : some are small, and exist in a consi- derable number; some are deeper, with an orifice smaller than their base. They appear ** to be formed by a prolongation ofthe in- j ternal coat of the bladder. Other sacculi are occasionally found which seem to be com- -1 posed of all the tunics of the bladder, and i they are sometimes of such magnitude, that jj the bladder appears as if it were divided into \ two or more cavities of nearly equal size. 1 Stones, found in these sacculi, sometimes J present depressions and irregularities, in T which fungi of the bladder have been re- i coived. When this happens, a portion of 1 such fungous productions is often extracted | with the stone ; a circumstance that has \ deceived some practitioners, and led them \ to suppose, that the calculi actually adhered 1 to the coat of the bladder. (See Desault's 1 Parisian Chirurgicale Journal, Vol. 2, p. 386. 387.) i The extraction of encysted stones requires -j different modes of proceeding from those $ which have been related. Littre conceived fl that they might be removed in two ways. When they made only an inconsiderable I projection into the bladder, he recommended the introduction of a probe, with which the membrane, covering the calculus, was to be rubbed, a finger being put into the rectum, in order-to keep it down, and facili- fy tate the action of the probe in opening the fe cyst. When the calculi were very prominent, 8 Littre recommended taking hold of them £ with a pair of forceps, and contusing and ,8 breaking the membranous pouch, with the u points and asperities upon the inside of the 9 blades of the instrument. He conceived jj (bat suppuration would then destroy the in- j| ternal parietes of the cyst, and that the stone I- would fall into the bladder, and admit of be- t ing easily extracted. As Sabatier observes, I it is plain, that thi3 theory, which is found- * ed on the idea entertained by Littre of the ij manner in which stones become encv?'<*'! J* is totally inadmissible in practice. '*-* LITHOTOMY Garengeol ventured to pas-* a bistoury into the bladder for the purpose of disengaging a calculus lodged in a particular cyst at the fundus of (his organ, behind the pubes. The nife had some tape tw isted round the greal- st part of its length, and was introduced under the guidance of the left index finger, which was passed in as far as it could reach. The patient was not more than ten, or eleven years old, and consequently of a size, which favoured the operation. The stone was loosened and taken out, and the child re- covered However, as Sabatier remarks, there are many instances, in which this mode of proceeding cannot be imitated ; for, if the calculus should be in a sort of cul-de- sac, as often happens, the entrance of which is narrower than its bottom, and the stone be of considerable size, the incision cannot be made large enough, without risk of cut- ting through the whole thickness of the blad- der, and producing certain death by the effusion of urine in the abdomen. Other practitioners fancied, that the cal- culus might be taken hold of wilh the for- ceps, and turned about in different directions so as to lacerate its connexions, or even that it might be forcibly extracted, with any serious ill consequences. Houstet mentions, (See Mem. de I'Acad. de Chir. T. 2, p. 307, fyc. Edit. 12mo.) that Peyronie adopted this me- thod on a patient, thirty-one yeBrs of age. The calculus did not resist long, and its sur- face was found covered with fleshy substan- ces, which formed the adhesions to the blad- der. The operation was painful, follow- ed by considerable hemorrhage, tension of the belly, hiccough, cold extremities, and death. ^There are some examples, however, in which this bold practice bad better success. In 1730, Le Dran extracted from a woman an enormous stone, adherent to that part of the bladder which lies upon the rectum. The irritation of the inequalities of the stone had produced ulceration of the blad- der, and fungous growths, which insinuated themselves into the substance of the extra- neous body. The adhesions readily yielded, and tbe excrescences came away with the calculus. Ten days afterward, some thick membranous sloughs were voided. this calculus is engraved in Le Dran's Treatise on the Operations. Le Dran afterward extracted similar stones, which adhered by a less extensive surface ; and he relates an operation done by Marechal, who, in 1715, extracted with a pair of forceps a stone shaped like a cala- bash, and having its narrow part surrounded by a fungus. In one case, the position of the calculus led Le Dran to suspect (hat it was fixed in the extremity of the ureter; he shook it occasionally with a pair of forceps; and, lastly, it fell into the bladder, whence it was extracted without difficulty. It re- sembled a cucumber in shape, and its large extremity had been lodged in the ureter, from which it could only be gradually re- moved. £abatiec believes,, that a case of this description, winch must be very tin. common, is the only one in which there ie any prospect of removing an encysted stone with success. In other examples, he con- ceives, that it is more prudent to leave the stone, and let the wound heal, than expose the patient to an almost certain death by repeated attempts to extract it. (Mcdecint Opiratoire, T. 3 p 190, 194, Edit. 2.) Dc sault employed a sort of concealed knife called a coupe-bride, for opening the cavity or cyst; and he has recorded one example in which he thus successfully extracted from a woman, aged sixty-two, a stone, lodged at fhe insertion of the ureter into the blad- der Tlie bistoury, used by Garengeot De sault did not consider a safe instrument »= the stones are round, and the knife may slip and pierce tbe bladder; an objection t» which, be - y .. the coupe-bride is not liable. No injury ,;an be received from its point, as the blade iu concealed, nor can any pari be divided, except w hat the surgeon intends. If the incision should not be completed at first, the blade maybe withdrawn, the semi- circular notch of the instrument pushed more forward, and the incision prosecuted to any extent. This instrument was invent- ed for the express purpose of dividing mem branous bands in the rectum ; but it was afterward employed with the greatest suc- cess for the excision of diseased tonsils and fungous tumours situated in cavities. The blade is so contrived, that when it passe? through the semicircular notch, it firmly fixes the parts which are to be divided: i thing that cannot be done either with the scissors or bistoury, as the moveable parts recede, and render the section difficult. (See Desault's Parisian Chirurgicale Journal, Vol. 1, p. 33, fyc.) \ stone perfectly encysted would not be expected to produce symptoms equal in severity to those which arise from an eitra- neous body actually in the cavity of the bladder. And yet, in Houstet's interesting dissertation, several cases are recorded, which prove that encysted stones do some- times cause the same distressing symptoms which proceed from the presence of a loose calculus in the bladder. Hence, tbe pa- tients were sounded, and in consequenceof tbe sacs, or pouches, in which the stone; lay, not being entirely closed, the calcub were distinctly struck by the instrument, and lithotomy attempted. It deserves par- ticular remark, also, that, in a large proper tion of these cases, the pouches, or cysts, were not single, but numerous, occupying different parts of the bladder. In some dis- sections, referred to by Houstet, cj*t¥ this kind were found, not containing,# stones whatever; a circumstance that would rather lead one to suspect, that, in general the formation of these sacs precedes that of «■! commonly found in them. (S« Observations Sur les Pilrres Enkisliet d -W herentes a la Vessie par M. Houstet, in M'."- «e I'Acad. de Chir. T. 2, p. 268, Edit. if. l2mo.) LITHOTOMY 203 01 &OM£. PAHriCLLAK METI1011S ASP IN- STRUM L.NTS. M. Foubert, a very eminent surgeon at Paris, devised and practised a plan of his own, which, however, has not been consi- dered by others as worthy of being imitated. The patient having retained his urine, so as to distend his bladder, an assistant, with a convenient bolster, presses the abdomen a little below the navel in such a manner, (hat, by pushing the bladder'forwards, he may make that part of it protuberant w hich lies between the neck ami the ureter. The operator, at the same time, introduces the fore-fiuger of bis left hand up the rectum, and drawing it down towards the right but- tock, pushes in a trocar on the left side of the perinaeum, near the great tuberosity of tbe ischium, and about an inch above the anus. Then the trocar is to be carried on parallel to the rectum, exactly between the erector penis and accelerator urina? muscles, so as to enter the bladder on one side of its neck. As soon as the bladder is wounded, the operator withdraws his fore-finger from the anus. In the upper part of the cannula of the trocar, there is a groove, the use of which is to allow some urine to escape, immediately tbe instrument enters the bladder, so that the trocar may not be pushed in any fur- ther; but its principal use is for guiding the incision As soon as the urine began to flow, Foubert, retracting the trocar a little, without drawing it quite out of the cannula, introduced the point of a slender knife into the groove in the cannula; and by the gui- dance of this groove he ran it onwards into fhe bladder, and was aware of the knife having actually entered this viscus, by the urine flowing still more freely. Then rai- sing the knife from the groove, he made his incision about an inch and a half in length, '.hrough the neck ofthe bladder, by moving Jhe knife from that point at which it had entered upwards towards the pubes. And finally, by moving the handle more largely than the point of the knife, he opened the outer part ofthe wound to whatever extent the size ofthe stone seemed to require, and then, withdrawing the knife, he introduced a blunt gorget to guide the forceps. An effort was made by Thomas to im- prove this method; but he failed, and it was never much adopted. The inability of many bladder* to bear being distended, is an insuperable objection ; for, without this, the trocar is liable to pass between the blad- der and rectum, and even through the blad- der into the pelvis. (Mimoires de I'Acad. de Chir. 663, Vol. 1. Le Droit's Parallele. Sharp's Critical Inquiry. J. Bell's Princi- ples, Vol. 2.) In the year 1748, Frere Come's method of performing the lateral operation began to .ittract considerable notice. The operation was done wilh a particular instrument, call- ed the lithotome cachi, by means of which the prostate gland and jieck of the bladder lyere divided, from within outwards. The lilhotome cachi is entitled to much atten- tion, because it is still generally used in several parts of the continent, and some- times in this country, especially by the sur- geons of the Westminster Hospital. " In France (says M Roux) if there is any mode of operating more common than others, and preferred by the majority of practitioners, it is that in which the instru- ment, named the litholome cachi, is employ- ed." (See Parallile de la Chi.urgie Ang- loise, fyc. p. 3IS. Frere Come does not ascribe the invention of this instrument to himself; but acknowledges that it resembles ihe knife for operating upon hernia, said to have been devised by a French surgeon of the name of Bienaise. It consists of a han- dle and the blade part. Tbe latter is slightly- curved, about as thick as a quill, furnished with a beak, and excavated so as to form a sheath for a knife of its own length By means of a kind of lever, the knife can be made to pass out of the sheath, and the distance to which the blade projects also admits of being regulated with precision. For this purpose, the handle is divided into six sides, numbered 6, 7, 9, II, 13, and 15, and which, according as they are more or less elevated, allow the lever to be depress- ed in different degrees, and the knife to move out of its sheath in the same propor- tion. Thus the surgeon can at his option make an incision tnrough the prostate gland and n.-ck of the bladder of six different lengths. VVhen the lithotome cache is to be used, the patient must be placed in the same pos- ture as in every other mode of practising the lateral operation ; and after a staff has been introduced, an oblique incision is to be made from the raphe of the perinaeum, to a point situated rather more towards the anus, than (he innermost part of the tuberosity of the ischium. The bulb of ihe urethra should not be cut, and not too much of the mem- branous part of the urethra The fat and transverse muscles having been divided, and the urethra opened, exactly as in the com- mon operation, the scalpel is to be put down, and the beak of the lithotome introduced into the groove ofthe staff. Of course, the surgeon, previously to the operation, will have settled the distance, to which the blade of the instrument is to pass out of the sheath, and which must necessarily depend upon the age of tbe subject, and tne presumed size of the calculus. When the beak of the lithotome has been inserted in the groove of the staff, the surgeon is to take hold of the handle of the latter instrument with his left hand, and bring it a little towards himself at the same time pushing the lithotome into the bladder, with the handle depressed as much as possible. The staff is now to be withdrawn, and the surgeon is to try to feel the stone with the sheath of the other in- strument, in order to be able to judge ofthe size of the calculus, and whether the dis- tance, to which the blade of the knife is in- tended lo move out ofthe sheath, is such as is likely to make an opening of due, but not 204 LI1TI0T0MY. unnecessary magnitude. Things being pro- perly determined, tbe lithotome is to be held iu a position calculated to make a division ofthe parts which is parallel to (he cut in the integuments, and. by means of the lever, the cutting blade of (he instrument is then to be disengaged from its sheath. The surgeon is next to draw the opened lithotome towards himself, in a perfectly horizontal manner, so as to make the requisite division of the pros- tate gland and orifice of the bladder. As Sabatier observes, Frere Come's me- thod undoubtedly possesses all the advanta- ges of the lateral operation, besides being more easy than Cheselden's plan, and most ofthe other modes, subsequently proposed, tor cutting the neck of the bladder with per- fect smoothness, and to a sufficient extent to allow the calculus to be removed, without any laceration of the parts. (Midccine Opi- raloire, T. 3, p. 19e of the lilhotome cache. 1. It is said that the size of the incision is notl always proportioned to the distance, to which tbe knife moves out of the sheath, and that the instrument, when opened to No. 13 or 16, sometimes makes a smaller in- cision, than when opened only to >io. 5 or 7. This uncertainty is said to depend upon the greater or less contraction of the bladder in different subjects. For my own part, I confess,that lam not inclined to put much credit in the accuracy of this last explanation, and suspect the dif- ference sometimes observed must depend upon the operator not taking care to draw out the instrument in a horizontal direction, a thing which is always easy to be done. 2. Frere Come himself made his incision too high, so that an extravasation of urine in the scrotum followed some of his opera- tions; but the above method of operating is free from any objection of this kind. 3. Some surgical writers have exaggera ted the danger of cutting the body of the bladder too extensively with the lithotome, and thus producing internal hemorrhage. However, this cannot happen, unless the surgeon raise the handle of the instrument improperly at the moment of withdrawing it, and as Sabatier himself allows, it is rather the fault of the operator than of the opera- tion. 4. The arteria pudica profunda and the rectum, which some authors conceive to be endangered, must always be in absolute safety, if the edge of the knife of the litho- tome be turned in the direction above re- commended. 1 think that for a surgeon, who under- stands the right principles of lithotomy, this is one of tbe best ways of performing the operation. When I was at Paris in 1815, I saw Dr. Souberbielle operate very skilfully with the lilhotome cache. A stone of considerable size was extracted from a gentleman, who Was, I should think, not less than 70. No apprehensions were entertained of ill suc- rcss, as I understood that this operator hard- ly ever lost a paticut. .,_,,. " M. Roux. when he visited Lngland,je*m» not to have been informed, that at the Went minster Hospital, tbe lithotome cache ha< been commonly employed for many year past. It has also been sometimes u>ed at Guy's Hospital by Sir A. Cooper. When M. Koux likewise finds fault with the bad construction of this instrument, as made in London, I suspect, that he cannot have seen those which are made and sold by Mr. Evans. (See Voyage fait it Londres, ouPa- rallile de la Chirurgie Angloise, fyc. p. 318.) Le Cat, a surgeon of Rouen, in Norman dy, devised a mode of lithotomy which would be too absurd to be described, wen- it less renowned. He thought the neck oi the bladder might be dilated, like the wound, and his operation vvas deformed with all tbe cruelty ofthe Marian method, and every er- ror attendant on the infant state of the late- ral operation. He first introduced a long wide staff; he cut forward with a common scalpel, through the skin and fat, till he could distinguish the bulb, the naked urethra, anil (he prostate gland. Secondly, with another knife, the urethrotome, having a groove on one side, he opened the urethra, just before the prostate, and fixing the urethrotome in the groove of the staff, and holding it steady, rose from the kneeling posture, in which he performed the outward incision. Thirdly, holding the urethrotome in the left hand, he passed another knife, the cystotome, along the groove ofthe urethrotome, and the beak of the cystotome being lodged in the groove of the urethrotome-, it was pushed forwards, through the substance of the prostate gland into the bladder. Fourthly, drawing the cystotome a little backwards, he gave the staff to an assistant to be held steadily, and , lifting a blunt gorget in the right hand, be placed the beak of it in the groove of the ' cystotome, and pushed it onwards, tjjl it \ glided from the groove of the cystotome, along the groove of the staff into the bladder. ] Then, true to the principles of the apparatu« major, and never forgetting his own pecu- liar theory, little incision, and much dibit- lion, he forced his fingers along the gorget, dilated the neck of the bladder, and so mad* way for the forceps. (J. Bell's Principki, Vol. 2) In 1741, Le Dran described an operation, the introduction of which has been claimed by several since his time. A staff being ia- troduced, and two assistants keeping open , the patient's knees, while a third stands on 1 one side of him on a chair, (Le Dran says,) " I then raise up the scrotum, and directing the last assistant to support it with both hands, so as to avoid bruising it, by presses it either against the staff, or the os pubis, J place his two fore-fingers on each side of the part, where the incision is to be o>ait'> one of the fingers being laid exactljr ato** that branch of the ischium, which rises to- wards the pubes, and the other pressed upo* the raphe, that the skin may be kept fod and tight. While I thus place the fingers c LITHOTOMY. iIOS Ibe assistant, who supports the scrotum, I still keep hold of the handle of the staff, and direct it so as to form a right angle with the patient's body; at the same time taking care that the end of it is in the bladder. This position is the more essential, as all the other instruments are lo be conducted along the groove of this. If the handle of the staff were kept inclined towards the belly, the end of it would come out of the bladder, and the gorget, missing its guide, would slip between (hat and the rectum. " The staff being rightly placed, I take the kniie from the assistant, who holds the instruments, and put it into my mouth; then pressing the beak of the staff against the rectum, I feel the curvature of it through the perinaeum. The incision ought to ter- minate an inch and a hab below where we • feel the bottom ofthe curvature. If we do not carry this incision sufficiently low, it may happen not to be of a size to allow the ex- traction of a large stone, and might lay us under the necessity of extending it further afterward,for the skin will not lacerate here nor easily give way for the passage of the slone. 1 therefore begin the incision from the lower part of the os pubis, continuing it down to the place that I before directed for ils termination ; after which I pass ihe point of the knife into the groove of the staff, and cutting from below upwards, without taking the point out of the groove, I open the an- terior part of the urethra as far as the inci- sion that is in the skin. " Tbe beak of the staff, which was press- ed upon the rectum, must now be raised and pressed against the os pubis. At the same time, I turn the handle towards fhe right groin, that the groove, which is at the beak of the stuff, may face the space be- tween the anus and the tuberculum ischii on the left side. Then carrying the point of the knife down the groove, I slide it along the beak, turning the edge, that it may face the space between the anus and tuberosity of the ischium. By this incision, I exactly divide the bulb of the urethra, and by doing this on its side, we are sure to avoid wound- ing the rectum, which for want of this pre- caution has been often cut. This first inci- sion being made, I again pass the point of the knife into the curvature of Ihe staff to the part where it bears against the peri- naeum, and direct it to be held there by the assistant who supports the scrotum. This done, I take a large director, the end of which is made with a beak, like that of a gorget, and conveying this beak upon the blade of the knife, into the groove of the staff. I draw the knife out I then slide tbe beak of (his director, along the groove of the staff, into the bladder, and I withdraw (lie staff, by turning tbe handle (owards the pa- tient's belly. The following circumstances will sufficiently satisfy us, that the director is introduced into the bladder. first, if itstrikes against the end of tbe staff, which is closed ; secondly, if the urine runs along the groove. I next feel for the stone with this director, ■md having found it, endeavour to distin- guish its size and surface, in order to make choice of a proper pair of forceps ; that is, one of a stronger or weaker make, or of a large or small size, agreeably to that of the stone ; after which I turn the groove towards the space, between the anus and tuberosity of the ischium, and resting it there, convey a bistoury along the groove, tbe blade of which is half an inch broad, and about three quarters of an inch long. I continue the in- cision made by the knife iu the urethra, and entirely divide the prostate gland laterally, as also the orifice ofthe bladder; and, I am very certain, that the introducing the use of these two instruments, which are not em- ployed by other lithotomists, does not pro- long the operation a quarter of a minute, but rather shortens the time, both by facili- tating the dilatation, that is afterward to be made with the finger, and by rendering the extraction of the stone more easy. The bis- toury being withdravvn, the groove of the director serves to guide the gorget into the bladder. I then introduce my fore-finger along (he gorget, (which is now easily done, as the urethra and prostate, being divided, do hot oppose its entrance) and w ith it I di- late the passage for the stone, in proportion to the size, of which I discover it to be. This dilatation being made, I withdraw my finger, and use the proper forceps." (Le Dran's Operations, Edit. 5, 1784, London.) Professor I'ajola, ot Venice, was the pupil of Le Cat, and his method resembles (hat of his master. He is stated to have cut for (he stone 550 patients wilh success; which de- serves notice, because his operation has for its principles, dilatation, and no division of any part of the bladder. He makes an inci- sion inlo the groove of the staff, with a lan- cef-pointed, double-edged knife, called an urethrotome, the blade of which has upon its centre a groove, that is continued to its very - point, and serves to guide (he beak of ano- ther instrument, called the cystotome, into the groove of the staff. As the professed in- tention of the cystotome is only to cut (he prostate gland, its name is ridiculous. It consists of a handle, and very slender blade, which is not connected with the handle, but with its sheath, by means of a little joint, close to the beak of the instrument. When the cystolorne is opened as far as possible, the end of the blade furthest from the beak, is twelve lines from tbe sheath. In this po- sition, it is held by a transverse piece of steel, which admits of being pushed more or less out at the option of the surgeon, and can be fixed by means of a screw. Pajola, like Scarpa, considers cutting the neck of (he bladder dangerous, and he merely divides the p-'oslate, after which he introduces a blunt gorget, and along (his a species of forceps for dilating (he neck ot the bladder in all direc- tions. (X. F. Rudlorffer aber die Operation des Blasensteins nach Pajola's Methode ) As Ltngeiibei kobserve- , great as (he success of this lithotomist bas been, his method ol ope- rating has little (o recommend it; and every thing must be ascribed to his individual skill, and intimate knowledge of the parts. Lan- iX>6 LITHOTOMY. genbeck even prefers Le Cats method, in which there is no need of such a multiplicity of instruments. Ihe blunt gorget and dila- tor are perfectly unnecessary, as the finge.- wouid do the purpose ot both. In the former editions ol (his Dictionary, I have not taken any notice of ivi.nl ha- I.eon termed by be Fn-ncli, " Operation a deux temps," and which was first mentioned by Franco. Il, by this plan, il be intended, that the incision should be ma,leal one period, and the extraction ol the sto. e not attempted till a subsequent period, I cannot too strongly re- probate the praclice. But, if I am to under- stand, (hat tbe postponement ot tbe comple- tion ot the operation is only to be adopted, as a mailer of necessity, when the patient cannot bear the longer continuance of the unsuccessful efforts 10 extract the stone, of course, I can only say, that every endeavour should be used to avoid Ibis very disagreeable dilemma, by making in the first ins:ance an adequate opening,ami (if (his cannot be done) by breaking (tie calculus, and caretuily remo- ving all the (raiments, some fuith, i consi- derations against delaying the completion of the operation will tee tumid iu the 2ii vol. of tbe First Lines ot Surgery . Tiie danger of tne beak ot the gorget slip- ping out 01 (he groove ol die stall, is one of the chii-l objections uiged against ihe em- ployment ot Hie first of these iiislruun-iiis. In order to obvint. this inconvenience, an Charles Bhckt bad ihe groove ol tlie staff, and the beak of tbe gorget, so constructed that tbey locked into each other, and conti- nued fixed nil near (be extremity of tne slaff. Tht contrivance, though plausible ai.d inge- nious, is ii«ji much Used : ihe point ol con- tact ol the; beak and body or ihe nstruiuent is necessarny so small, thai it is liable to break. It i= allowed, however, that this objection •might be removed , but aiiotlie r om- i, still urged, viz. the beak and groove catching on each other, -o as lo resist the efforts made to introduce the gorgei into ihe- bladdei. Everv operator knows, that much ol the salety of the lateral operation, as performed at present, depends on Ihe ease wilh which ihe bean ol the gorget s ides along tbe groove of the slaff. Le Cai, iu 1747, is said to have devised a -si- milar inteiition. Some operator.- have a good deal of trou- ble in oissecling into ihe gioove ot the staff. Sir James h.arle invented an instalment to render ibis part oi ine operation more easy. It consuls ol a short s ..tf. «ith an open groove, connected by a h.nge with tfie han- dle ol another staff, ol (he usual size, shape curvature, nid leiiglh, which m.) be called the long slaff. The hinge, by means oi .,inj is capable ol being di-joiiilto at pleasure. The short stuff is sufficiency curved to go over the pens and scrotum, and long enough to reach to mat pari ol the long slaff which is just below (be beginning ol its curvature. The end of the short staff, made somewhat like a pen, with the sides sharpened and finely pointed, is adapted to shut into tne groove of ihe long staff, and its cutting edges are de- fended horn being injured bv a proper recep- (acle which is prepared for it in the groovi of the long staff. When the instrument ij shut, the groove of ihe -.ort staff leads into that of the long one, so as to form one con- necte I and continued groove. The sho,*t >taff is rendered steady hy the segment of niareh projecting from the long one through it The long staff, separated Irom (lie short one, is first introduced in the usual manner. and, (he stone having been felt, the short M ,ff is to be put on the other al the hinge. The incision is then to be made in the usual man- ner, tbroug'i the skin and cellular membrane, and a second incision through ihe muscles, so as nearly to lay bare the urethra. The operator then :i *.ng perfect!. convinced that the extremity »f the long staff is sufficiently within the b' i.ler, must bring (he end ofthe short staff <• ,wii, and press it against the urethra, whi ' it will readily pierce, and pass into (he cavi y prepared for it in the groove of (he long st-tf. Tne two pieces being now firmly held together by the operator's left hand, nothing remains lo be done, except applying the beak of the gorget to (lie groove of th short staff, and pushing it on (ill it i- receiv, d iu the groove of tbe long one; and if this latter be made wilh a contracted groov, it will just enter where the contrac- tion begins, and thus must be sa ely conduct- ed in o the bladder. (Earle on the Stont; Appendix; Edit. 2, 1796.) Dt scnaiiips des- cribes an in trumenl, invented by Jardaa, surgeon of ;VI')n(pelier, which bears a resem- blance to C lie's double staff, but was more complicated, being ue.signed to support the s.rotum, and also press the reciutn out of the way. The late Mr. Dease, of Dublin, and Mr iVluir, of Glas^ei.v, considering that the goi- get was more apl to slip froeo 'lie staff in con- sequence ot tne latter bem6 curv-J, and that iis beak never slips irom the gmove of tlie staff in operating on women, proposed, like Le Dran, to convert (he male into the female ur< thra. They introduce, as usual, a curved grooved slaff into ihe bladder, make tbe common incisions, and open the membra- nous pari ot the urethra ; but iustead of in- troducing a gorget on the curved staff, they conduct along (be groove a straight director, or staff, into the bladder, and immediately withdraw the oilier Ihe gorget is then in- troduced. In this manner the operation may be very well performed with a narrow bi-j- lo iry. a-, was auvised by Mr. A. Burns. LITHOTOMV, AS PERFORMED WITH A KNIFE, J.NSTJiAD OF A CcJTIiKG GORGET, UT SE- VERAL OF THE BIOUtHNS. We have already described, bow Frere Jacques and Ches. Iden, used to operate with a knue, without any cutting gorg*:t, in the early state of the lateral operation. The success which attended the excellent prac- tice of the latter surgeon, cer,airily far ex- ceeds what auenus the present employment of the gorget, for, out of 52 patients whom be cut successively for the stone, be only lo-rt two: and out of 213. of nil n»es, coir LITHOTOMY. 'Jl*. s'ifutions, be. only £0. These facts are strongly in favour of abandoning the use of the gorget, and doing ils office with a knife. The objections to the gorget are nume- rous and well founded. In the hands of many skilful operators, its beak ha- slipped out of the groove of the staff, and (he in- strument has been driven either between (he rectum and the bladder, or into the intestine instead oi the latter viscus. Sir James E n-le remarks: '• I have more than once know u a gorgel, though passed in the right direction, pushed on so far, and with such violence, as to go through the opposite side of (be blad- der." Bromfield, even when operaling with a blunt gorget, perforated the bladder and peritonaeum, so that the abdominal viscera came out of the wound. (P.'270.) I now know of at least three instances, in which the gor- get, slipping from the staff, completely sever- ed the urelhra from the bladder; the stone was not taken out; and the patients died. We will suppose, however, that the pre- ceding dangers of the gorget are surmounted, as tbey certainly may be, by p irlicular dex- terity, seconded by (he co ifidence of expe- rience. The gorget is introduced, but what- ever kind of one has been used, the wound is never sufficiently large for the easy pass- age of any stone, except such as are below the ordinary size. Camper has noticed Ibis fact: "Hawkensius solo conduclore, cujus margo dexler in m-iem assurgh, idem prees- tat: omnts plagam dilatant, ut calculum ex- frahant : dilacerentur igilur semper oesice ostium et prostata." (P. 114.) D- ase says : " In all the 'rials thai I nave made: with the gorget on the dead subject, I have never found ihe opening into the bladder sufficient- ly large for the extraclion of a s(one of a middling size, without a considerable lacera- tion of the parts. I have frequently t ken the largest-sized gorgel, and could not find, in the adult subject, I ever entirely divideo the prostate gland, if it was any wiy lar^t ; and in (he operations thai were performed fiere on the living subject, if the ?itour- w«s large, the extraction was painfully tedious, and effected with gre.it difficulty, and, in some cases, not at all " I shall dismiss this part of the subject with referring the reader to the spirited and cor- rect remarks on the objections to the gorget in Mr. John Bell's Principles, Vol. 2. Fart 2. The latterauthor recommends the external incision, in a large man, to commence about an inch behind the scrotum, and to be car- ried downwards three inches and a half, midway between the anus and tuberosity of the ischium. The fingers of the left hand, which at first kept the skin tense, are now applied to other purposes. The fore-finger now guides the knife, and the operator pro- ceeds to dissect through fat and cellular substance, and muscular and ligamentous fibres, till the wound is free and open, till all t ense of stricture is gone ; for it is only by feeling opposition and stricture that we re- cognize the transverse muscle. When this hollow is fairly laid open, the external inci- ion, icuhh Tt\ LiTHOTOMi 209 last edition of the First Lines of Surgery, ac- companied with many valuable practical observations made by tliese judicious and skilful surgeons. That the performance of lithotomy wifh a knife, when tbe operator has the assistance of a proper staff, cannot be difficult, may be inferred from there being no particular difficulty in the method, even when no staff at all is employed. In tiie spring of the year 1814, when at Oudenbosob in Holland, I was requested by Sergeant liyan, of the 1st Foreign Veteran Battalion, to see his little boy, about four years old, who was troubled with symptoms, which made me immediately suspect, that there was a stone in the bladder. As I had no sound, I in- troduced into this viscus a small silver cathe- ter, which distinctly struck against a cal cuius. Without taking the instrument out again, I determined to perform lithotomy with a common scalpel. Indeed, no other mode could be adopted, as we had neither staff, gorget, nor lithotomy instruments of any kind. After making the external part of the incision in the common way, I found that the catheter afforded me no guidance. I therefore withdrew it, and dissected deeply by the side of the prostate gland, till the fore-finger of my left hand passed rather be- yond it. The scalpel was then plunged into the bladder, behind this gland, under the guidance of my left fore-finger, and with the edge turned towards the urethra. The ne- cessary division of the prostate and neck of the bladder was then made by cutting in- wards and upwards in the direction of the rest of the wound. With a small pair of ordinary dressing forceps, a calculus, rather larger than tbe end of the thumb, vvas easily extracted. This operation was done at the Military Hospital, in the presence of Dr. Shanks of the 56th regiment, and several other medical officers. Not a single bad symptom ensued, although the army unex- pectedly moved into the field three days afterward and the child travelled about for some time in a baggage cart, in an exposed and neglected state. The wound was conse- quently rather longer in healing than usual; but, this was tbe only ill effect. The litlle boy in the end completely recovered. Of late years, many surgeons have chosen fo perform lithotomy with several kinds of beaked scalpels. The practice, indeed, is still gaining ground. Mr. Thomas Blizard's knife is one of the best. Its blade is long, straight, and narrow, and, like the gorget, is furnished with a beak, by means of which it admits of being conducted along the groove of the staff into the bladder, after the ex- ternal incisions have been made. The staff is then withdrawn, and the operator has now the power of making the incision through tbe prostate aud neck of the bladder down- wards and outwards (o any extent, which the parts will allow, or the case require. this is one of the principal advantages which beaked long narrrow knives have over gorgets, which, after (heir introduction, can- not be further used for the enlargement ofthe v.-1. H. 27 wound. The narrow knife will also cut more safely downwards and outwards than any gor- get ; nor is it subject to the serious danger of slipping away from the staff, and going we know not w here; because the moment its beak and extremity have entered the bladder, the staff is no longer necessary, as the proper extent of the blade will then readily pass in without the aid of any conductor at all. I need hardly observe, also, that, in this method, we have nothing like the perilous and violent thrust of the gorget, which, in the event of a little unsteadiness in the ope- rator's band, or of any fault either in the position of tlie staff, or the direction of the gorget, will do irremediable and fatal mis- chief. A FEW Gr. SERAI. ICE MARKS ON THE BEST MODE OF MAKING THE INCISION IN THE LATERAL OPERATION : AND SOV1E REFLEC- TIONS ON THE PRINCIPLES INCULCATED BY PROFESSOR SCARPA. Perhaps of all the great operations in sur- gery, lithotomy is that, in which great awk- wardness, mortifying failures, and dangerous blunders, are most frequently observed. Many a surgeon, who contrives to cut off limbs, extirpate large tumours, and even tie aneurismal arteries, 'with eclat, cannot get through the business of taking a stone out of the bladder in a decent, much less, a masterly style. This fact is so familiarly known in the profession, and its truth so often exemplified, that I may well be excused the unpleasant task of relating in proof of it all (he disasters, which have come to my own personal knowledge. But, I must take the liberty of remarking, that, in this branch of surgery, a great number of individuals do not profit by these instructive lessons of ex- perience. The more they see of lithotomy, the more they are convinced of its dangers ; yet, too often, instead of studying the causes of ill success, they merely derive from the examples before them, a suspicion of the uu- skilfulness of the operator, or some dis- couraging conjectures about the difficulties of the operation. The establishment of certain principles to be observed in lithotomy, appears the most probable way of diminishing the frequency of the accideuts and failures of this common operation. If these principles are not viola- ted, it is of less consequence what instru- ment is employed, for the surgeon may do nearly the same thing with an ordinary dis- secting knife, a concealed bistoury, a beaked scalpel, or a well-made gorget. After the very opposite principles, and different methods of cutting for the stone, which are explained in the preceding columns, as preferred by different surgeons, I think it may be useful to offer a few gene- ral observations oi: the proper direction and size of the incision. These points, which are of the highest practical consequence, jn regulating the principles, w hich ought to be observed in lithotomy, are far from being settled, as must be plain to every body who L'10 LITHOTOMI. recollects that Desault, Mr. John Bell, Klein, and Langdenbeck, have recommended a free openiog ; Scarpa, Callisen, and others, a small one ; that Mr. Ahernelhy and Scarp* eranlov gorgets whi'h cul upwards and outwards, at angles of 45° aid 69° fro'n the a*-.is of the urethru ; «iid 'bat the gorgets of of Cr-iickshank, B. Boll, D.-sault, Mr. Cline, and most <>:laei surgeon- uc i-on-tructed for cutting either directly outwards, or outwards and inwards. It appear* to me, that the incision, through the whole of the parts cut in lithotomy, should always be made iu a straight, regular, direct manner, from (he mrface of (be skin in tbe perinamm to the termini.on of the wound in the urethra and bladder. In an adull subject, the external wound should commence about an inch above the anus. The impropriety of begim ing it higher up has been duly insisted upon by Sharp, Ber- truidi, Callisen, and every good writer on the ope ration. " II ne faut couper I'uretre que le moins, qu'on peut, parcequ'ou obtient par ce moyen une meill.mi-e voie pour pen6- trer dans la vessie sous Tangle du pubis. ("est avec ra'non que Sharp dil que I'incision de I'uretre f lite mi dessus de cet angle est si peu utile pour l'extractinn de la pierre, qu'on n'en r tireroit pas plus d'avantage en le cou- pnnt presque dans lou(e sa longueur." (Ber- trandi, Traits des Opirations, p. 127.) Aid Callisen lays it down as a maxim: " Ut eae partes baud sectione attingantur, qua? pro calculi egressu nihil laciunl ; adooque bulbus urethiae, et bujus pars »-.orpore spongio-o cir- cumdata in'acta relinquatur." (Systerna Chi- rurgie Hodierne ; Pars Posterior ; p.655.) Extraordinary as it may seem, it is not the less (rue, that cutting too much of the ure- thra is one of the most common faults still committed by modern surgeons. The inci- sion i i (he integuments is to be large, that is to say, at least, three inches in length in an adult subjec(, because a free opening in the skin is not only exempt from danger, but at- tended wilh many advantages, especially those of facilitating the other st.-ps of the operation, and preventing any future lodg- ment and effusion of urine. The external wound ought to be directed towards a point situated a vi-ry little towards the anus, from the innermost part of the tuberosity of the ischium. From the line, thus made, the in- cision should he carried inward and upward, through all the parts between it and the side of the prostate gland. Another line, extend- ing from the inferior angle of the wound to the termination of the cut iu the bladder, forms the precise limits, to which the depth of the incisions should reach, and no further. The great principle of making the axis of the wound as straight and direct as possible, should always be kept in view, whether ihe surgeon employ a common scalpel, which cuts into the bladder.from without inwards, orotlieriustruments. which divide the pros- la.e gland, and neck of tbe bladder, from within outvs :alcul avec les euettes ; on voyoille perin6 se tumefier par la pression, qu'y faisoil la pierre ; en ce cas, quelques opptnipun plus sages abandonnoienl la pierre, iniroduis- oient de nouveau le gorgerel, e(en tournant en dessous la cannelure de- celui ci,prolonsfoi ent I'incision obliqueme-'it vers la tuberosile de I'os ischion ; et eofin a la faveur de r.-tte plus grande ouverture, retiioient la pierre san<= causer de dechiremens." (Berlrandi, Traiti des Opirations, p. 133.) Larger stones may likewise be thus extracted, with out being broken, than in any other mode of making the lateral incision, as must be ob- vious to every practitioner, who recollecU the very limited room, afforded at the upper part of the triangular space, between ibe arch of the pubes. the ramus of the ischium, and the neck of the bladder. This conside- ration cannot fail to have great weight with all surgeons, who feel duly convinced, bow unsatisfactory a method it is to break acal- cuius, in order to get it out of the bladder The measures necessary for the removal of all the fragments protract the completion of the operation, and seriously increase it'dan- ger; while the continuance of a single part of the stone behind may cause a reiic-w»l °f all the grievances, for the cure of which the patient submitted to the operation. By these remarks, however, I am far from meaning to say, that large calculi should not be brok-»i". on tbe contrary, my only wish is, thai the necessity for the practice may be avoided, as much as possible, by making a free inci- sion into the bladder, and even enlargingtbe opening, if necessary, as far as can be done LITHOTOMY. 211 wilh safety. In snort, instead of breaking the s(one, I prefer the practice of Mr. Marti- tieau, of Norwich, perhaps the most success- ful lithotom'ut now living in thi3 country, as out! of 84 patients, whom he has cut, only two have died ; a statement highly favourable to op.-rating with a knife, and making an adequate opening. " Should the stone be large, or there be any difficulty in the ex- traction, rather thin use much force, while (he forceps have a firm hold of the stone (says Mr. Martiiip.ui,) I give the handles to an a>si tant, who is to draw (hem outwards and upwards, while the part forming the stricture is cut; which is easily do-ie, as the broad part of the blade becomes a director to the knife ; and rather than lace- rate, I have oflen repeated this enlargement of the inner wound (wo or three liiiifx." (See Med. Chir. Trans. Vol. 11, p. 411.) The great advantage of the knife over tlie gorget, and even the necessity of employing it for adapting (he size ofthe opening in the blad- der to the magnitude of the stone, or its fragments, are most convincingly exemplified in several cases recently put upon record. Thus Klein, with the aid of a common scalpel, extracted a calculus, which weighed twelve ounces, thirty grains ; und the. patient recovered. (Prad. Ansir.hlen Bedeutendslen Operalionen, H. 1.) In 1818, Mi. Mayo, of Winchest'-r, operated with a knife, and exacted a calculus, which broke in the for- ct^iSjWeighin-*; fourteen ounces, two drachms, avolrdupni.e, and the patient recovered. (See Med. Chir. Trans. Vol. 11, p 54, fyc.) Mr. W. B. Dickenson, of Macclesfield, »l,o succeeded with Mr. Gibson's knife, in taking out of the bladder a calculus, the fragments of which weighed eight and a half ounces, and the patient was saved. (Vol. cit. p. 61.) An iinthe same volume may be seen olher ins(ances, in which immense calculi were removed from the bladder wi(h various re- sults, but particularly one which weighed sixteen ounces, and which Sir A. Cooper could not succeed in breaking: he vvas therefore obliged to enlarge the wound, first made with the gorget " to the sacro-sciatic ligament," when with (he aid of a hook applied lo the forepart of the stone behind the pubes, and tbe simultaneous assistance of the forceps, he- succeeded wilh consider- able difficulty in removing (his immense mass. The patient lived, however, only four ho ii- alter the operation. (See Med. Chir. Tr.ms. Vol. 11, p. 73) 2. flic- arteriu pudica profunda enn never be injured, because the surgeon does not let the knife, or gorget, approach nearer lo the ischium, than a poinl which is situa(ed a lit- tle way from the tuberosity of that bone to- wards the anus; and consequently tbe edge of the in-tniineut cannot come into contact wilh (he inside of the tuberosity and ramus ot (he ischium where the great pudic artery is situated. 3. The rectum will not be wounded, because the direction ol (he axis of the inci- sion, either downwards and outwards lo (be above-menlioned point, or from* that point inwards and upwards, sufficiently removes the edge of the knife, or gorget, from the intestine. But, the rectum will be in still greater safety, if it be pressed down- ward with tbe fore-finger of the left-band in the wound, and (he prudent custom of emp- tying it. by means of a clyster, a short time before the operation, be not omitted ; for, no lithotomist should ever forget, that, when this bowel is considerably distended with feces, it rises up a little way on each side of the prostate* gland. 4. As the seminal duct penetrates the lower part of the substance of the prostate gland, in order to reach the urethra, and (he knife, or olher instrument, employed, divides the upper portion of (he side of that gland in- ward and upward, or outward and down- ward, it is obvious that (be duct will not be in the leasl danger of being cut. Tbe judicious Callisen is well awar« of the advantages of making a smooth, even, direct incision in(o (he bladder ;* but, like Professor Scarpa, he is averse to making a free cut through the neck of (hat viscus. In- deed, as we shall presently notice, Scarpa docs not sanction cutting any portion of (he bladder at all. Every practitioner, who will take the trouble (o look over the history of the late- ral operation, will find, that the greater num- ber of lithotomists, who have particularly distinguished themselves by their unparallel- ed success, as Frere Jacques, Cheselden, Cosme, Mr. Martineau, Dr. Souberbielle, be. made a free incision into the bladder. This fact alone is enough to raise doubts of the goodness of the advice delivered upon (his subject by Callisen and Scarpa ; espe- cially, as neither they, nor any other modern surgeon (with ibe exception, perhaps, of Pejola, whose individual skill is said by Langenbeck to make amends for the disad- vantages of his method,) can boast of having cut patients for the stones with a degree of success at all equal to that e>f the above-men- tioned operators. The extraordinary success which characterized Cheselden's practice we have already detailed in this volume. The accounts, which we 'lave, of the succ-ssful operation done by Frere Jacques and Cosine, Bre equally eiiiaikable. Mr. Martineau, as I have noticed, has lost"" bu( two patients out of 84, on whom he has operated, and this without making any se- lection, as he never rejected any one who was brought for operation. flis patients were always kept a week in the house be- fore operating ; and this precaution, with a regulated di*.-t, and perhaps a dose or two of opening medicine, was the only preparatory treatment. (Med. Chir. Trans. Vol. 11,/*. 409.) During my stay at Paris, in 1813, I saw Dr. Souberbielle extract a stone of consider- # Vulnns sit a*quale, baud angulation, coniae Rgu- ras apice vesicani respiciente, externa pla^a amp'a, et quatuor pollicum longiludine, und<*eifluxu< sangui- nis, pnris. loti-, arena*, faciiitatur- See; Sysle-ma Clii- nirgia* H■xlii.-'-en-; P*rs Posterior, \i. >*<,''-, flafniTe', I Son. 212 LITHOTOMY. able size, on the plan of his well-known an- cestor. The incision vvas ample and direct, so that the calculus was taken out wilh per- fect ease. Now, as the operations of this professed lithotomist are very numerous, and he enjoys the repulatiou of scarcely ever losing a patient, are we not justified in in- ferring, that the advocates for a small open- ing are promulgaling the worst advice which can be offered to (he praclilioner? My own observations certaiuly tend to such a con- clusion as will be presently explained. The trart recently published by Scarpa (Memoir on the Cutting Gorget of Hawkins, -la la possibi- lil-* de3 in tilt ratio ns par les obstacles qui les urines trfnveront a s'ecoulcr." No doubt also some ofthe worst, and most dangerous urinary extravasations after li- thotomy, have proceeded from another cause, pointed out by the same excellent surgeon. " Imprudemment porte dans la vessie, le gorgeret peut aller, par le stylet **-* beaucoup trip loug qui le termine, heurter, decbirer, perforer meme la membrane de la vessi**, et donner lieu a des infiltrii'ions d'au- tant plus daugereuses, que le lieu d'ou elles partent est plus inaccessible. Cet accident est surtout a craindre, lorsqne, c omme Its Anglais, on se sert de c>ilueter sans cul-de- sac." (Sec OZuvres Chir.de Desault par Bi- chat, T.2, p. 460,461.) LITHOTOMY THROUGH THE RECTIT3I. This method may be said to have been first suggested in a work published at Bale, in the 16lh century, by an author who assu- med the name of Vegelius : " Jubet per vul- nus recti intestiui, ci vesica? aculeo lapidem cjicere," says Haller, in speaking of this w ri- ter. (Bibl. Chir. Vol. 1, p. 102.) But the proposal never received much attention un til the year l81o, when M. Sanson, in France, gave an account of this manner of operating, and urged several considerations in favour of the practice. In that country, however, the operation has been performed only by Dupuytren, and, though the opera- lion proved successful, the other French surgeons do not appear to have imitated him. Nor am I aware, that Dupuytren him- self now continues the practice. Almost as soon as this method was heard of on the other side of the Alps, it was put to the test of experience by Barbantini, in a case where every other plan of operating appeared hard- ly practicable. '• The connexion of the ure- thra with the rectum, prostate gland, and posterior part of the bladder, (says M. San- son) made me easily perceive, that by divi- ding the sphincter ani and some of the rec- tum near the root of the penis, i should ex- pose, not only the apex of the prostate gland, but a more or b-s^ considerable por- tion of this body, and that I should then be able lo penetrate into the cavity ofthe blad- der, either at the neck through the prostate, or at its posterior part." It was the lat'er method, which M. Sanson first tried upon the dead subject, fhe body was placed in the position usually chosen for the common ways of operating, and a staff was introdu- ced, and held perpendicularly by an assist ant. A bistoury, with its blade kept flat on the left fore-finger, was now introduced into tbe rectum, and the edge being turned up- wards, M Sanson, with one stroke, in the direction of tbe raphe, cut tbe sphincter ani, and the lower part of the rectum. The bot- tom of the prostate gland being thus expo- sed, the finger was next passed beyond its =olid male urethra, they c,ispected that it would be a good practice -Id LITHOTOMY to dilate this passage by mechanical con- trivances, until it would allow the stone to be extracted, and thus all occasion for cut- ting instruments might be superseded. With this view, Tolet first proposed suddenly di- lating the passage with two steel instru- ments, called a male and female conductor between which the fingers, or forceps, were passed for the removal of the calculus (Traiti de la Lithotomie, Paris, 1681.) But as it was afterward rightly judged, that the dilatation would produce less suffering and injury, if more gradually effected, Douglas suggested the practice of dilating the mea- tus urinarius with sponge or dried gentian root. Mr. Bromfield bas published the case of a young girl, in whom he effected the ne- cessary dilatation by introducing into the meatus urinarius the appendicula cceci of a small animal in a collapsed state, and then filling it with«water by means of a syringe ; thus furnishing a hint for the construction of instruments on the principle of Mr. Arnott's dilator. Tbe piece of gut, thus distended, was drawn out in proportion as the cervix vesica7; opened, and, in a few hours, the dila- tation was so far accomplished, that the calculus had room to pass out. (See Chir. Obs. and Cases, Vol. 2, p. 276.) Mr. Thomas met with a case, in which, after dilating the meatus urinarius with a sponge tent, he succeeded in extracting an earpicker which lay across the neck of the bladder. The passage was so much enlar- ged, that the left fore-finger was most easily introduced, and (says this gentleman) " I believe had the case required it, both thumb and finger would have passed into the blad- der without the smallest difficulty." After adverting to this, and other facts, proving the ease with which the female urethra can be dilated, Mr. Thomas remarks: "If these relations can be credited, and there is no reason why they should not, I can hardly conceive any case, in a young and healthy female subject, and where the bladder is free from disease, where a very large stone may not be extracted, without the use of any other instrument tnan the forceps, the urethra having first been sufficiently dilated by means of the sponge tents. For this !>urpose, the blades of the forceps need not >e so thick and strong; as those commonly employed. (See Medico-Chir. Trans. Vol. 1, p. 123—129.) Many facts of a similar kind are on record, and one in which a large needlecase was extracted, is referred to in' a modern periodical work. (See Quarterly Journ. of Foreign Med. Vol. 2, p. 331.) Some surgeons have extracted stones from the female bladder in thefollowing manner: the patient having been placed in the posi- tion commonly adopted in the lateral opera- tion, a straight staff, with a blunt end, is in- troduced into the bladder, through the mea- tus urinarius. The surgeon then passes along the groove of the instrument the beak of a blunt gorget, which instrument becoming wider towards the handle, effects a part of the nece=*R>-v dilatation. The *t3ff being withdrawn, and ihe handle of the gor- get taken hold of with the left hand, th? right fore-finger with the nail turned down wards, is now introduced slowly along the concavity of the instrument. When the urethra and neck of the bladder have thu< been sufficiently dilated, the finger is with- drawn, and a small pair of forceps passed into the bladder. The gorget is now remo- ved, and the stone taken hold of, and ex- tracted. (Sabatier, Midecine Opiratoirt, T 2, p. 103.) This plan, however, is liable to the objec*. tions arising from the dilatation being too suddenly effected ; and the practice now generally preferred is that of gradually ei- panding the meatus urinarius with sponge tent. And, as the retention of the urine, during the continuance ofthe sponge, causes great irritation, I consider Mr. C. Hutchin- son's suggestion of placing a catheter in its centre, as mentioned by Sir A. Cooper, as meriting attention. (See Med. Chir. Trans Vol. 8, p. 433.) Notwithstanding these favourable ac- counts of the practice of dilating the female urethra, for the purpose of removing cal- culi from the bladder, there are very good surgeons who deem an incision the he.'t practice. It is certain, that some patieuts have found the method insufferably tedious and painful. But the strongest objection is the incontinence of urine, which occasion- ally follows any great distention of the ure- thra and neck of (he bladder. Klein, one ofthe most experienced operative surgeons in Germany, stales that he has tried both plans, and that the use of the knife is much less frequently followed by incontinence of urine. On the other hand, Mr. Thomas be- lieves, that this unpleasant symptom is quite as often a consequence of the operation of lithotomy, as now usually performed. (Mtd Chir. Trans. Vol. 1, p. 127.) When tbe Btonc is not very large, perhaps dilatation should be preferred ; and, in other cases, an inci- sion. In females, lithotomy is much more easy of execution, and less dangerous, than in male subjects. It may be done in varions ways ; but the surgeons of the present tine constantly follow the mode of making the requisite opening by dividing tbe urethra ' and neck of tne bladder. Louis employed for this purpose a knife which cut on each side, and was contained in a sheath; Le Blanc, a concealed bistoury, w hich bad only one cutting edge ; Le Cat, his gorgeret-cy**' titome ; Frere Come, his lithotome cache; and Fleurant a double-bladed lithotome cache. Of these instruments, the best, I think, is that of Frere Come. But, atprt sent, every surgeon knows, that the opera- tion may be done, as conveniently as possi- ble, with a common director and a xnifei that has a long, narrow, straight blade. A straight staff, or director, is introdaeid through the meatus urinarius; the groove *• turned obliquely downwards and outward* in a direction parallel lo the ramus of tb» left os pubis : and the knife i« (bus conduct LI'lHOlOMl*. 217 ed into tne bladder,and makes the necessary incision through tlie whole extent of the passage, and neck of th-^bladder. Louis and Fleurant, as I have said, were the inventors of particular bistouries for di- viding both sides of the female urethra at once. The instrument of Ine former effect*. ed this purpose, hi passing from without inwards; that ofthe latter, iu passing from within outwards. Fleurant- bistoury b-ars some resemblance in principle to Fivre Come's lithotome cache or to the cutting forceps, with which Franco divided the neck of the bladder. The reason assigned in recommendation of these bistouries is, that they serve to make a freer opening for Mie passage of large stones, than can be safe- ly made by cutting only in one direction. When tlie calculus islarge. it is certainly dif- ficult to procure a free opening, without cut- ting (he vagina, in front of which passage, there is but little space under the pubes for Ihe removal of the stone. Hence, Dubois invented a.new method, which consists in dividing the meatus urinarius directly up- wards towards tin* symphisis of the pubes, dilating the vyound and keeping the vagina out ofthe way by means of a blunt gorget, and then taking out the calcul is wilh the forceps. This method seems to-me better devised for the protection ofthe vagina, than the acquirement of more room for the cal- culus, and whatever space is gained, is onJy gained by the distention of the parts, and the propulsion of them downwards. The plan is acknowledged to be very painful, yet generally successful, and not followed by any serious symptoms or incontinence of urine. (See Did. des Sciences, Med. T. 28, p. 436.) When the stone is known to be very large, Sabatier and some other modern surgeons prefer the apparatus altus. A case may present itself, in which the posterior part of the bladder, drawn down- wards by the weight of the stone, may dis- place a portion of the vagina, and make it protrude at (he vulva in the form of a swell- ing. Here, there w ould be no doubt of the propriety of cutting into the tumour, and taking out the foreign body contained in it. Konsset performed such an operation, and l-'abricius Hildanus in a case, where the stone had partly made its way into the va- gina, enlarged the opening, and successfully extracted the foreign body. Mery proposed to cut into the posterior part of the bladder through the vagina, after introducing a common curved slaff; but the iqiprehension of urinary fistula? made him abandon the project. The existence of extraordinary circum- stances may always render a deviation from the common modes of operating not only justifiable, but absolutely necessary. Thus, Tolet met with a case, where a wo- man had a prolapsus of the uterus, with which the bladder was also displaced. In the latter viscus, several calculi were felt: in incision was made into it, and tbe stones extracted, after which operation, the dis- placed part' wt'.rv reduced, and a speedy Vor, If 2* cure followed. (Sabatier, Mtdecinc Opira- loire, T. 2, p. 107.) The incont .- nee of urine, consequent to lithotomy iu women, is by no means an nnfrequent occurrence. Mr Hey cut two* female patients for the stone, both of whom were afterward unable to retain their urine, and were not quite well when discharged from the Leeds Infirmary. These casesjed Mr. Hey in a third example to endeavour to prevent the evil, by introducing into the va- gina a cylindrical Ijnon tent, two inches fong and one broad, with a view of bring- ing the edges of the incision together, with- out obstructing the passage of urine through the urethra. The [dan answered, if it be allowable to make such an inference from a single tri -A. (See Hey's Practical Obs. in Surgery, p. 56). Ed. 181U.) TREATMENT AFTER THE OPERATION. If the internal pudendal artery should be wounded, and bleed profusely, the: best plan is, if possible, first to take out the stone, and then introduce into the wound a piece of firm sponge, writh a large cannula passed through its centre. The expanding property of ihe sjionae, on its becoming wet, will make the necessary decree of compression of the vessel, which lies too deeply to be tied. When there is much coagulated blood lodged in the bladder, it is customary to wash it out by injecting lukewarm water. 1 cannot say that it has fallen to my lot to see any cases (out of the great number which I hive seen in Bartholomew's Hos- pital,) in whicti death could be imputed to hemorrhage, notw itbstanding the bleeding has often been so profuse, and from so deep a source, just after the operation, as to cre- ate suspicion (hat it proceeded from the in- ternal pudendal artery. Such hemorrhage generally stopped before the patient was put to bed. The majority of patients who die after lithotomy perish of peritoneal inflammation. Hence, on the least occurrence of tender- ness over the abdomen, copious venesection should be put in practice. At the same time, eight or ten leeches should be applied to the hypogastric region The belly should be fo- mented, and t t. bowels kept open with the oleum ricini. The feebleness of the pulse should not deter the practitioner from using the lancet ; this syuyitom is only fallacious; and it is generally attendant on all inflam- mation within ihe abdomen. It is a curious fact, that Mr. Martineau, who has lost only 2 out of 84 patients, whom he has operated upon for the stone, should never have found it re- quisite to bleed ; but it appears to me, that, it is a much better argument in favour of the superior safety of operatug with the knife and making a free opening, than reason for discouraging venesection, when inflamma- tion ofthe peritoneum has come on, which, however, may not be this gentleman's mean- ing, as he says, " I believe, it will be found in adults, that death follows oftener from ex- haustion, after a tedious operation, or from ■AS Lli despondency, be. than from acufe disease ; (Med. Chir. Trans. Vol 11, P 412.) a senti- ment, which 1 am sure this gentleman would not have entertained, had he been present liith me at the opening of the many unfor- tunate cases, which used formerly to occur in the practice with badly made iiorgets in St. Bartholomew's Hospital. Together with the above measures, the warm bath, a bl ster on the lower part of the abdomen, and emollient glysters, are highly proper 1 have seen several old subjects die of the irritation of a diseased thickened bladder, continuing after the stone was extracted. Tbey had not the acute symptoms, the inflammatory fever, the general tenderness and tension of the abdomen, as in eases of peritonitis ; but they referred their ui,easiness to the lower part ofthe pelvis; and instead of dying in the course of two or three days, as those usually do, who perish of peritoneal inflammation, thev, for the most part, lingered for two or three weeks after the operation. In these cases, opiate glysters, and blistering the hy- pogastric region, are the best measures. In some instances of this kind, abscesses form about the neck ofthe bladder. Whoever v\ ishes to acquire a pefrfect knowledge of the history of lithotomy should consult the following works : Celsus de Re Medico, lib. 7, cap. 26. Remarques sur la Chirurgie de Chauliac, par M. Simon de Mitiixclouzeaux, torn. 2.; Bourdeaux, 1663. La legende du Gascon par Drelincourl; Paris, 1665. Van Home's Opuscula. Mariauus de Ijipide Vesice par Incisionem exlrahendo; 1552. G. Fid/r. Hildanus, Lithotomia Vesice, Sio. Lond. 1640. M. S. Barolilanus, De Lapide Renum. Ejusdem de Lapide Vesice per Inci- sionem extrahendo,4lo. Paris, 1540. Le Dran, Parallile des Differences Maniires de tirer la Pierre hors de la Vessie, 2 Vol. 8vo. 1730. Sharp's Operations. Sharp's Critical Inqui- ry. Le Dran's Operations, Edit. 5; London, 1781. Franco's Traiti des Hernies, 1561. Roselus de Partu Cesario. Traiti de la Litho- iomie, par F. Told, Paris, bme Ed. 1708. Htister's Surgery, Part 2, Lithotomia Doug- lassiana, 1723. J. Douglas, History of the Lateral Operation, 4to. Lond. 1726. Fr. M. Colol, Traiti de I'Opiration de la Taille, fyc. V2mo. Paris, 1727. Morand; Traiti de la Taille au haul appareil, l2mo. Paris, 1728 J. Mery, Observations sur la Maniire de Taitler, tfc. praliquie par Frere. Jacques, \2mo. Paris, 1700. Cours dOperations de Chirurgie par Dionis. Traiti des Operations par Garengeot, Tom. 2. Morand Opuscules de Chirurgie. Bertrandi Traiti des Opirations. Index Su- pelleclilis Anatomice Raviane ; Leide, 1725. J. G. hsemann, Dc Lithotomia Celsiane Prestantie; Helmst. 1745. Le Cat, Recueil de Pieces sur I'Opiration de la Taille Part 1; Rouen, 1749. 6'o*me, Recueil de Pieces Ana- tomiques imporlantes sur I'Opiration de la Taille; Paris, 1751—1753 J. Douglas, Postscript to Hist, of the Lateral Operation; 1726. J. Douglas, Appendix to Hist, of the Lateral Operation ; 1731. A short Historical Account of Cutting for the Stone, by W. Che- stlden,m Ins own Inst edition of his Anatomy. LOi Valcond in Thes. Chirurg. Halleri; the,. 103 T. 4. P- l-'fi- Hartinkeu; Tractatutdt. Vestce Urinaria Ca$pulo, •$•*• 1TH5. Trosf-j Hislorique et Dogmalique de I'Opiraticn it It Taille, par J. F. L. Deschamps, 4 Tom. 8ro. Paris, 1796. This last work is a very com- plete and full account of the subject up to tt* lime of Us publication, and well merits a rare- ful perusal. Richerands Nosogr. Chir. T. 3, p. 538, e^c Ed. 4. Leviilli, Nouvelle Dot- trine Chir. T. 3, p. 533. John Bell's Princi- ples of Surgery. Vol. 2, Part 1. A. Runs, in Edinb. Med. and Surg. Journal, January, 1808. C. Bell's Operative Surgery, I'ol \, 1807. Sabatier, de la Midecine Operaloirt, Tom. 3. Edit. 2, 1810. Dr John Thomson's Observations on Lithotomy; Edinb. 1806 Also an Appendix to a proposal for a nru manner of cutting for the StontfSro. Edinb, IS 10. Allan's Treatise on Lithotomy; Edinb. 1308. Earle's Practical Observations on Ope- rations for the Stone ; 2d Ed. wilh an Appen- dix containing a description of an instrument calculated lo improve that operation, Sro. Lorn/ 1803. Wm. Dease, Obs. on the different me- thods for the radical cure ofthe Hydrocele, 1,-c. To which is added a comparatite view of tht different methods of cutting for the Stunt, cyr 8vo. Lond. 1798. (Euvres Chir. de Desault par Bichat; Tom. 2. Wm. Simmons, Cam and Obs. on Lithotomy, 8vo. Manchester, 1808, C. B. Trye, Essay on some ofthe Stages ofthe Operation of cutting for tbe Stone,8to. Lond. 1811. Roux, Voyage fail a Londres en 1814, ou Parallile de la Chirurgie Angloise am la Chirurgie Francoise, p 315, fyc. Paris, 1815. Schreger, Chirurgis'he Vewuht, B. 2. von Steinschnitten an Weibern, p. 135, f,+. 8vo. Ntirnberg, 1S18. C. J. M. Langenbeck, uber eint einfache und sichere metliodtdts Steinschnittes, 4lo. Wurzburg, 1802. F. X Rudlorffer, Abhandlung fiber die Operation des Blasensleines nach Pajola's Meihodt, 4/o. Leips. 1S08. A. Scarpa, A Memoir on tht Cutting Gorget of Hawkins, fyc. Transit]) J. H. Wishart, Qvo. Edinb. 1816. H. Map, W. Dickenson, H. Earle, and P.M.Marti- neau in Med. Chir. Trans. Vol. 11. M«»- Pracl. Ansichten bedeutendslen Operatmer, 4to. Stulgart, 1816. J. S. Carpue, Hist. •/ the High Operation, and An Account of tht various Methods of Lithotomy, Sro. Lond. 1819. Sir E. Home on Strictures, tyc. Fol 3, 8ro Lond. 1821 For a minute description and delineations of the parts concerned in the operation, see Camper's Demonstration" Analomico-palhologire, lib. 2. Also L.F Von Froriep uber die Lage der Eingeweidt *« Becken, ncbsl ciner Darslellung derselbin,4lo. Weimar, 1815. LOTIOA LUMINIS.—ft. Alutninis purif ■^ss. Aquae distillatai ftj. Misce.—Some times used as an astringent injection; some- times as an application to inflamed parts. LOTIO AMMONiiE ACET AT*.-ft- Liq. ammon. acetata*: Spirit, vin. rectil'i Aqua? distillatse; sing. 3'iv. Misce.—Proper- ties discutient. LOITO AM.MOM.-i: MURIATE-R Ammon. muriataj "f j. Spirit, rorismarini ftj . —Has the same virtues as the preceding LOT LUM 219 Juslamond recommended it in the early stage of the milk-breast. LOTIO AMMONLt: MURIATE Cl'M ACETO.—ft. Ammon. Mur. •"■•<*. Aceli, Spiril. vinos, rectif. sing. fbj. Misce. This is one of the must efficacious discutient lo- tions. It h, perhaps, Ihe best application for promoting the absorption of exlravasa- ted blood, in cases of ecchyuiosis, contu- sions, sprains, be. LOilO AMMONME OPlATA.—ft. Spi- ritus ammon. comp. 3'iiss. Aqua? distillate 31V. Tinct. Opii. ^j. Misce.—It is used in the same cases as the preceding application. LOTIO OPII.—ft. Opii purif. 3jss. Aqua; distillata- ftj Misce.—A very excellent ap- plication lo irritable painful ulcers of every description. It is best to dilate il, es- peciidly at first. LOTIO PICJS — ft. Picis liquida; giv. C.-.\)im ~vj. Aqua* tciveutis Hy*i—'!'•• be boiled till half the water is evaporated. The rest is then lo be poured off for use. This applicalion is sometimes employed for (he cure of tinea capitis; it is also of singular service in removing an extensive scorbutic redness, frequently seen on the legs, accom- panying old ulcers. LOTIO ZLMCI SULPH \TIS.—ft. Zinci sulphatis 3j- Aq. ferventi- jkj. Misce. This is souifdmes used by practitioners in lieu of Ihe lotio plumbi acet. It lorins a good as- tringent application for a variety of cases. When diluted, by adding (wo pints more water, il forms the common injection, so much recommended in cases of gonorrhoea. LUES VENEREA. See VENEREAL UI.-EASE. LUMBAR ABSCESS. Psoas Abscess. By these terms are understood chronic collec- tions of matter, which form in tbe cellular substance of the loins, behind the peritonae- um, and descend in the course of the psoas niusede. Patients, in ihe incipi- ent stage of the disease, cannot walk so well as usual; (hey feel a degree of uneasi- ness about the lumbar region; but in gene- ral, there has been no acute pain, even when Ihe abscess has acquired such a size as to form a large tumour, protruding externally. In short, the psoas abscess is the best in- stance, which can possibly be adduced, in order to illustrate the nature of those collec- tions of matter, which 'are called chronic, and which form in an insidious manner, wilhout serious pain, or any olher attendant of acute inflammation. The ab-ce-s sometimes forms a swelling above Poupart's ligament ; sometimes below it ; and frequently (he matter glides under the fascia of the thigh. Occasionally it makes its way through (he sacro-ischiatic foramen, and assumes rather the appearance of a fistula in ano. When the matter gravi- tates into the thigh, beneath the fascia, .Mr. Hunter would have termed it a disease in, not of, (he part. The uneasiness in (he loins, and Ihe impulse communicated to (he tumour by coughing,~evince, that (he disease arises in the lumbar region ; but, it must be confessed, that we can hardly ever know the existence of (he disorder, before the tumour, by presenting itself externally, leads us to such information. The lumbar abscess is sometimes connected with disease! verte- bra;, which may either be a cause, or an effect, of the collection of matter.—The disease, however, is frequently unattended wi(h this complication. The disease of the spine, we may infer, is not of the same nature as that treated of by Poll, as there is usually no paralysis. When the bodies of patients with lumbar abscesses are opened, il is found, that the matter is completely enclosed in a cyst, which, in many cases, is of course very extensive If the contents of such abscesses were not circumscribed by a membranous boundary in this manner, we should have them spread- ing among (be cells of (he c-llular substance,, j.isi like ihe water in anasarca. The rysls are both secreting and ahsorbifi;*-; surfaces?, as LITHOTOMY. il proved !y ihe grant quuniity of matter, winch soon codecis again alter the abscess has been empiieU, and by die oce ..lsional dis- appearance i>( large palpable colleeiions of •u-tlerof this kind, either spontaneously, or in consequence ot means which are known tc op--ru'e- l>\ exciting (he action of Ihe ab- sorbe is. In sin rt, tiie cyst becomes (he suppurating siin.ice-, and siippuralion is now weil a.sceit.'iui-d to be a process, -imilar lo gbuidulai secrelion. While Ihe abscess re- mains unopc ned, ils contents are always un- der.oing a change*; Iresh matter is continu- ally forming, anil a portion of what was pre- viously in the cyst is undergoing the neces- sary removal by the absoi bents. Tuis is not peculiar to lumbar abscesses; il is common to all, both chronic and acule, buboes and suppurations in general. It is (rue, that, in acute absce-ie,, there often has not been time for the formation of so di-linct a mem- brane as the cyst ol a large chronic abscess ; but their matter is equally circumscribed by the cavities of ihe cellular sub (auce- being filled with a denfe* coagulating lymph ; and (hough it genera'ly m> n makes ils way tothe surface, it also is occasionally absorbed. The best modern surgeons make it a com- mon maxim to open very few acule ab- scesses ; lor Ibe mutter naturally (ends with gnat celerity lo the surface of (he body, where ulceration allows it lo escape sponta- neously; a;ier which, the case generally goes on better, than if it had been open-d by art. But, in chronic nbscesse«,the matter has not that strong tendency lo make its Way outward ; its quantiiy is continually in- creasing; the cyst is. of course, incessantly growing I nyer and larger; in short, the malter, from one ounce, often gradually in- creases to the quantity of a gallon. When Ihe disease is at length opened, or bursts by ulceration, (he tuifice of the cyst, irritated by the ch..n>;e, inflames; and ils great ex- tent, in (his cii i umstnnce, is enc/u^h to ac- count Iorthe terrible constitutional disorder, and lalal consequences, which too frequently soon follow the evacuation of Ihe contents of such an ab-cess. Il» ne;e, iu cases of chronic suppurations of every kind, and not merely in lumber abscesses, it is the sur- geon's duty (o observe the opposite rule io that applicable to acule case-,; and ne is called upon to open ihe collection ol malter, as soon as'he is aware of its existence, and its situation will allow it to be done. Certainly, it would be highly advanta- geous to have some meai.s of a-cerlairiiug whether (he verebiae are also diseased ; for as in (his instance-. the morbid hones would keep up suppuration, until then affection had ceased, and there would be no reasonable hope of C111111& the ab u-s sooner, il mi^hl be beid-r to avoid puncturing i! uiid--r such ciicunisiances. The propriety of this con- dui t stems the more obvious, a3 issues, which are tin* mean< most likely tostop am) remove the d.-ease oi the spine, are al-6 such as afford mosl chance of bringing aliout (he ab- sorption ol ihe abscess it -elf. However, if the collection cannot be prevented from dis- charging itself, and ulceiuiion is at hand,it is best so meet tbe danger, make an ojieninj with the lancet, in a place al some distance from where (he pointing lbreateiis,andtifiei. ward heal it, in the way which will be pre sentlv detailed. Though we have praised the prudence of opening all chronic nb-ccsses while sii,all,ihe deep situation of Ibe lumbar one, and ibe degree of doubt always involving its -.„,). stale, unfortunately prevent u> trum taking Ihis bene ficial s(ep iu Ihe present case. But still the principle is equally praiseworthy, and should uigt* us lo op.-n ihe tumour as uch flakes seem tucon- sist of a part of the coagulating matter of Ihe blood, and are very commonly secreted by the peculiar cysts ol scrofulous ab- scesses. I he puncture- must also be ol ace ■ tain size, in order to allow the clots of hlood, occasionally mixed wilh the matter, to escape. Mr. Abernethy considers tbe open- ing of a lumbar abscess a very dehcale ope- ration. Former surgeons used to make l»r;e openings in these cases; let nut tlie con lenls; leave the wound open; the usual consequences of which were, great irritalion and inflammation of the cyst; immensedis lurbance of Ihe constitution ; putrefaction of the contents of the abscess, in conse- quence of the entrance of air into its cavity; an , too often, death. While such practice prevailed, very few, afflicted wilh lumbar abscesses, were fortunate enough to escape, The same alarming effects resulted from allowing (he abscess io attain its utmost magnitude, and then burst by ulceration. If then a more happy train of events depend upon the manner, in which lumbar ahscessr! are punctured, the operation is certainly a matter of great delicacy. Until the collection is opened, or bursb, the patient's health is usually little, or not al all impaired ; indeed, we -ee in the faces of many persons with such abscesses, what-is usually understood by (he picture of health. Hence, how likely our professional conduct is io be arraigued, when great changes f»f the worse, and even death occur very -o«n at er we have let out tbe matter, sceroinglyi and truly, in « oiisi-quencc; of Ihe operation. Every plan, then fore, which is most likely to prevent these alarming effe-cts, is entitled to infinite praise; and such, I conceive,!! Ibe practice recommended by Sir. Aber- nethy. ' This gentleman's method is to let out tbe matter, and heal the wound immediately alterward by the first intention. He justly condemns all introductions of probes, and other instruments, which only irritate the edges of the puncture, and render them un- nicely to grow together again. The wound LUMBAR ABSCE-5- is to be carefully dosed with sticking plaster, and it will almost always heal. These proceedings do not put a stop to the secretion of matter within Ihe cavity of the abscess. Of course, a fresh accumula- tion lakes place ; but, it is obvious that (he malter, as fa.-t as it is produced, will gravitate to the lowest part of the cyst, and, conse quently, the upper part will remain for a certain (ime undistended.and have an oppor- tunity of contracting. H hen a certain quantity of malter has again accumulated, and presents itself in the groin, or elsewhere, which may be iu about a fortnight after the first puncture, the ab- scess is to be punctured again, in the same manner as before, and the wound beah-d in the same way. The quantity of matter will now he found much less, than what was at first discharged. Thus the abscess is to be repeatedly punctured at intervals, and the wounds as regularly healed by the first intention, by which method, irritation and inflammation of the cyst will not be induced, the cavity ofthe matter will never be allow- ed lo become distended, and it will he ren- dered smaller and smaller, till the cure is complete. In a few instances, the surgeon may, per- haps, be unable to pers vere in healing the repeated punctures which it may be neces- sary to make ; but, after succeeding once or twice, the cyst will probably have had sufficient opportuuit) to contract so much, that its surface will not now be of alarming extent. It is also a fact, that the cyst loses its irritability and becomes more indolent, and less apt to inflame, after the contents have been once or twice evacuated, in the above way. Ils disposition to absorb be- comes also stronger. 'Ihe knowledge of the fact, that the cysts of all abscesses are absorbing surfaces, should lead us never to neglect olher means, which Mr. Abernethy suggests, as likeiy to promote the dispersion of the abscess, by quickening the action of the absorbents. Blisters kept open with savine cerate, issues, electricity, occasional vomits of the sulphate of zinc, are the means most conducive to this object. When the vertebra; are diseased, issues are doubly indicated. In the latter complication, the case is always dangerous. If an opening be made in the abscess, the cyst is at first more likely lo be irritated, than when the bones are not diseased, and the affeclion of the spine is rendered much less likely to undergo any improvement, in consequence of tbe mere formation of an outward communication. The same bad effect attends necrosis ; in which case, the absorption ofthe dead bone is always} retarded by the presence of un- healed fistulas and sores, which lead down to the disease. Mr. Crowther succeeded in dispersing some large lumbar abscesses without opening them. Large blisters, applied to the integu- ments covering the swelling, and kept open with the savine cerate, effected the cure. When this gentleman punctured such collec- tions of matter, he used a small trocar, w hich he introduced at the same place as often as necessary. He observes, that the aperture so made does not ulcerate, and allows no matter to escape after being dressed. I cannot, however, discover any reason for his preferring (he trocar to the abscess lan- cet, except that the cannula enables the surgeon to push back wilh a probe any flakes ot lymph, be. wliich may obstruct its inner orifice. But, this is scarcely a reason, when Mr. Abernethy informs us, that the opening, made with an abscess lancet, is large enough to allow such flakes to be dis- charged ; and when they stop up the aper- ture, a probe might also be employed to push them buck. \ wound made wi h a cutting instrument will, ceteris paribus, always unite more certainly by tne first intention than one made wilh such an in- strument as a trocar. Mr. t'rovvtber may always have succeeded in healing the aper- ture ; but, I do not believe, that other prac- titioners would experience equal success. Were the tumour not very prominent, from the quantity of matter being small, suddenly plunging in a trocar might even endanger parts, which should, on no account, be in- jured. Some writers recommend opening lumbar abscesses with a seton. The matter being made to form as prominent a swelling as possible, oy pressing the abdomen, and putting the patient in a position, which will make the contents of the abscess gravitate towards the part where the seton is to be introduced, a transverse cut is first to be made in the integuments down to the fascia. A flat trocar is next to be introduced within the incision, which should only be just large enough to allow the instrument to pass freely up under tlie skin, for at least three quarters of an inch ; when the hand is to be raised, and the trocar pushed obliquely and gently upwards, till the cannula is within the lower part of tbe sac. The trocar must now be withdrawn, and the matter allowed to flow out gently, stopping it every now and then for some minutes. The assistant must now withdraw his hand, to take away the pressure, and the thumb of his left hand upon the opening of the cannula, holding it between his fore and middle fingers. It must then be pushed upward, nearly to the top of the tumour, where its end may be distinctly felt with the fore-finger of the right hand. As soon as it can be plainly felt. it must be held steadily in the same position! and the trocar is to be introduced info it again, and pushed through the skin, at the place where it is felt, and the.cannula along with it. The trocar being next withdrawn, a probe with a skein of fine soft silk, dipped in oil, must be passed through the cannula wliich being now taken away, leaves the seton in its place. A pledget of mild oint- ment is then to be applied over the two opening?, the more completely to exclude the air. A fresh piece of the silk i<- to be MAMMA. drawn into the abscess, and thai which was in before cut off, as often as necessary. (See Latta'a System of Surgery, Vol. 3, p. 307.) Mr. Crowther states, that Deckers, who wrote in 1696, discharged a large abscess, in a gradual manner, with a trocar, (he cannula of which was not withdrawn, but was stopped up with a cork, and the latter let out at intervals. B. Bell also advises tbe cannula not to be taken out. I cannot quit this subject without mention- ing a remarkable case of lumbar abscess, vvnich I once siw in C'nrist's Hospital, under the care of the late Mr. Ramsden. The tumour extended from the ilium and sacrum below, as high up as the ribs. The diameter of (he swelling from behin i forward, might be about six or eight inches, It was attended with so strong a pulsation, corresponding wilh that of the arteries, that several emi- nent surgeons in this city considered the case as an aneurism of the aorta. After some weeks, as the tumour increased in size, Ihe throbbing of the whole swelling gradu- ally became fainter and fainter, and at length, could not be felt at all. The tumour was nearly on the point of bursting. Mr. Ramsden suspected that it was an abscess, and determined to make a small puncture in it. The experiment verified Ihe accuracy of his opinion ; a large quantity of pus was ovacuated at intervals ; but the boy's health suffering, he went to.his friends at Newbury, and I clid not afterward hear the event. I have never seen uny popliteal aneurism. whose pulsations could be more plainly seen, and strongly tell, than those of (he abscess we have just been describing. A singular case is related by Mr. \\ ilmot of a psoas abscess, the matter of which was ai length absorbed, aud its cavity filled with uir, attended with a considerable increase in the size of the tumour, a conical elongated shape, and elastic feel, instead of a fluctua- tion, previously quite evident, and the subsi- dence of all the hectical symptoms. A complete dispersion of the swelling was effected by a bandage and compress wet with a strong decoction of oak bark and alum. (See Trans, of the King'sand Qu«n'i College of Physicians in Ireland, Vol. 2, p. 26, fy-c. 8vo. Dublin, lbl8. F. Schoenmatl, Obs. de Muscutis Psoa et lliaco suppundi/. Frank. Del. Op. V. R. Beckwdh de Murbu Psoadico. Edinb. 17S4. Abernethy's Surgical and Physiological Essays, Part 1 aiid 2. Crowther's Observations on White-swelling, i,-c. 18o8. Lalta's System of Surgery, Vol. 3. Calliscn's Systerna Chirurgie Hodierna, Vol. \,p.370. Pearson's Principles of Surgery, p. 102, Edit. 2. Richter's Anfanggrunde der Wundarzneykunsl, B. 5, 1 lo, G'dlingen, 1801.) LUNAR CAUSTIC. (See Argentum ni- tratum.) LUPUS. Sec Noli me tangcrr. LUXATION. Sec Dislocation. M. MAMMA, REMOVAL OF. The opera- ration of cutting away a diseased breast, is done, nearly in the same manner as the removal of tumours in general, and is indicated whenever the part is affected with an incurable disease, which admits, how- ever, of being entirely removed with the knife. When the breast is affected with scirrhus, or ulcerated cancer, the impru- dence of tampering with the disease cannot be too severely censured. Were the disor- der unattended with a continual tendency to increase, some time might properly be dedicated to the trial of the internal reme- dies, and external applications, which have acquired any character for doing good in these unpromising cases. But, unfortunately, by endeavouring to cure the disease by medicine, we only afford time for it to in- crease in magnitude, and, at length, attain a condition, in which even the knife cannot be employed so as t> take aw-ay the whole of the diseased parts. When the case is marked by the characteristic features of scirrhus, noticed iu the article Ctncer, the sooner the tumour is cut out, the better. There are also some malignant kinds of sar coma, to which tbe female breast is subject, (as will be explained in tbe article Tumour,) which cannot be removed at too early a period after their nature i" suspected, or known. Indeed, though there is not equal urgency forthe operation when the tumour ia only an indolent, simple, fatty, or sarco- matous disease, yet as aH these tumours are continually growing larger, and little success attends the attempt to disperse them, the practitioner should never devote much time to the trial of unavailing medicines and applications, and let the swelling attain a size, which would require a formidable operation for its excision. Besides, many simple, fleshy, indolent tumours, are accom- panied with a certain degree of hazard of changing into very malignant forms of disease. It is not meant to be denied, however, there are many swellings and indurations of the breast, which if would be highly injudi- cious aud unnecessary to extirpate, because they generally admit of being discussed. Such are many tumours, which are called scrofulous, from their affecting patients of this peculiar constitution ; such are nearly alltho.se indurations wliich remain after a sudden and general inflammatory enlarge- ment of the mamma ; such are most other tumours, which acquire their full size in a few days, attended with pain, redness, be.; and, of this kind, also, are the bardnessei in the breat. occasioned by the mammary ab're-ii- V MAMMA. in the removal of all malignant or cance- rous tumours, their nature makes it neces sary to observe one important caution in the operation, via. not lo rest satisfied with cutting away the tumours just at their cir- cumference ; but to take away also a con- siderable portion of the substance in which they lie, and with which they are surrounded. In cutting out a cancerous breast, if the ope- rator were to be content with merely dissect- ing out the disease, just where his eyes and fingers might equally lead hir.i to suppose its boundary to be situated, there would still be left behind white diseased bands, ivhich radiate from the tumour into the sur- rounding fat, aud which would inevitably occasion a relapse. In a vast proportion of the cases also, in which cancer of the breast unfortunately recurs after the operation, it is found that the skin is the part, in which the disease makes its reappearance. Hence the great prudence of taking away a good deal of it in every case suspected to be a truly scirrhous or cancerous disease. This may also be done so as not to prevent the impor- tant objects of uniting the wound by the^first intention, and covering the whole of its sur- face with sound integuments. So frequent- ly does cancer recur in the nipple, whenever it does recur any where, that many of the best modern operators always make a point of removing this part in every instance, in which it is judged expedient to take away any portion of the skin at all. The surgeon, indeed, would be inexcusable, vvere he to neglect to take away such portion of the in- teguments covering scirrhous tumours, as is evidently affected, appearingto bediscolour- ed, puckered, and closely attached to the diseased lump beneath. Nor should any fiend, in the axilla, at all diseased, nor any fibres of the pectoral muscle, in the same rtate, be ever lefl behind. There is no doubt, that nothing has stamped operations for can- cers with disrepute, so much as the neglect to make a free removal of the skin, and parts surrounding every side of the tumour. Hence,-the disease has frequently appeared to recur, when, in fact, it has never been thoroughly extirpated ; the disease, though entirely a local affection, has been deemed a constitutional one ; aud the operation frequently rejected as ineffectual and use- less. But, strongly as I have urged the pru dence, the necessity of making a free remo- val of the skin covering, and of tbe parts surrounding, every cancerous or malignant tumour, the same plan may certainly be re- garded as unnecessary, and therefore, unsci- entific, in most operations for the removal of simple, fatty, fleshy, or encysted tumours, to which the breast and almost every other part are liable. However, even in the lat- ter cases, when the swelling is very large, it is better to take away a portion of skin ; for, otherwise, after the excision of the tu- mour, there would be a redundance of in- teguments, the cavity of which would only serve for the lodgment of matter. The loose superfluous skin also would lie in folds, and noi apply itself evenly to the parts beneath, so as to unite favourably by the first intention ; nor could the line of the cicatrix itself be arranged with such nice evenness as it might be, were a part of the redundant skin taken away at the time of operating. The best method of removing a diseased breast is as follows: The patient is usually- placed in a sitting posture, well supported by pillows and assistants ; but the operator will find it equally convenient, if not more so, to remove the tumour with his patient in a recumbent position ; and this posture is best whenever,the operation is likely to be long, or much blood to be lost, which circumstances are very apt lo bring on fainting. I remember that Mr. Abernethy, in his lectures, used to recommend the latter plan ; which, however, without the sanction of any great name, or authority, possesses such obvious advantages, as will always en- title it to approbation. The arms should be confined back, by- placing a stick between them and the body, by which means, the fibres of the great pectoral muscle will be kept on the stretch. a state most favourable for the dissection of the tumour off its surface. The stick also prevents the patient from moving her arm about, and interrupting the progress of the operation. When the tumour is not large, and only a simple sarcoma, free from malignancy, if will be quite unnecessary to remove any ol the skin, and, of course, this need only be divided by one incision, of a length propor- tionate to the tumour. The cut must be made with a common dissecting knife; and as the division ofthe parts is chiefly accom- plished with the part of the edge towards the point, the instrument will be found to do its office best when the extremity of the edge is made of a convex shape, and this part of the blade is turned a little back, in the way in which dissecting knives are now often constructed. Ibe direction of the incision through the skin should be made according to the greatest diameter of the tumour to be removed, by which means it will be most easily dissected out. The direction of the incision is various with different practitioners; some making it perpendicular, others transverse. In ge- neral, the shape of the tumour must deter- mine which is the best. In France, it has been said, that when the incision follows the second direction, it heals more expedi- tiously, because the skin is more extensible from above downward, than laterally, par- ticularly towards the sternum, and conse- quently allows the sides of the wound the more readily to be placed in contact; and that the action ofthe pectoral muscle tends to separate the edges of the wound when it is perpendicular. On the other hand, it is allowed that the wound, made in the latter manner, is the most favourable for the escape of the discharge, if suppuration should occur. (See CEuvrev de Desault per,- Bichat. p. 312. T. 2.1 22/i MAMMA The cut through the skin should always be somewhat longer than the tumour; and as it is perhaps, the most painful part of the operation, and one attended with no danger whatever, it should be executed with the utmost celerity, pain being more or less dreaded, according io its duration, as well as its degree. The fear, however, of giving pain, has probably led many operators to err, in not making their first incision through the integuments large enough, the conse- quence of which has often been that there was not sufficient room for the dissection of the tumour with facility; the patient has been kept nearly an hour in the operating room, instead of five minutes, aud the sur- geon censured by the spectators, as awk- ward aud tedious. It is clear also, that, besides the great deal more blood lost, from this error, than would otherwise happen, the vessels being commonly not tied till all the cutting is finished, the avoidance of pain, that fear, which led to the blunder, is not effected, and the patient suffers much more, and for a much longer time, inconse- quence of the embarrassment and obstacles in the way of the whole operation. When the disease is of a scirrhous or ma- liguant nature, the skin covering the tu- mour should at all events, be in part remo- ved. As I have said before, all that portion which is discoloured, puckered, tubercula- ted, or otherwise altered, should betaken away. Some must also be removed, in order to prevent a redundance, in all cases in which the tumour is large. We have said too, that in cases of scirrhus and cancer of the breast, the nipple is considered a dangerous part to be left behind. For the purpose of removing the necessary portion of skin, the surgeon must obviously pursue a different mode from that above described; and, instead of one straight incision, he is to make two semicircular cuts, one immedi- ately after the other, and which are to meet nt their extremities. The size of these wounds must be determined by that of the disease to be removed, and by the quantity of skin, which it is deemed prudent to take away ; for the part, which is included in the two semicircular cuts, is that which is not to be separated from the upper surface of the swelling, but taken away with it. The shape ofthe two cuts together may approach that either of a circle or oval, as the figure of the tumour itself may indicate, as most convenient. The direction of the incisions is to be regulated by the same consideration. In the above ways, the first division ofthe integuments is to be made iu removing tu- mours of every description, covered with skin. The same principles and practice should prevail in all these operations; and, whether the swelling is the mamma, or any other diseased mass, whether situated on the chest, the back, tbe bead, or extremities, the same considerations should always guide the operator's hand The incision, or incisions, in the skin having been made, the next object is to /h»tacb every sid«» of the tumour from it« connexions, aud tue separation ot its ha-i will then be the last and only thing remain ing to be done. When the tumour is a scirrhus, or other maligna!.! disease, the operator must not dissect close to the swell- ing, but make his incisions on each side, at a prudent distance from it, so as to be sure to remove, with the diseased mass, every atom of morbid inise iiief in its vicinity. But when the tumour is only a mere, fatty, or other mass, perfectly free from malignancy, the cellular bands and vessels forming its connexions, may be divided close to ils circumference. It is astonishing with what ease fatty tumours are removed, after the necessary divjsion is made iu the skin ; they may almost be turned out with the fingers, without any cutting at all. When they have been inflamed, however, they are then more adherent to the surrounding parts. Thus we see, that the first stage of the operation of removing a tumour, is the divi- sion ofthe skin ; the second, the sepnratirtn of the swelling from the surrounding parts on every side; the third and last stage is (be division of the parts to which its under surface, or base, is attached. The hitter object should be accomplished by cutting regularly from above downward,, till every part is divided. It is a common thing io see many opera- tors constantly embarrassed and confused, whenever they have to remove a large tu- mour, on account of their having no parti- cular method in their proceedings. They first cut a few fibres on one side, then on another ; and, turning the mass of disease now to this side, now to that, without any fixed design, they both prolong the opera- tion very tediously, and present to the bystanders a complete specimen of surgical awkwardness. On the contrary, when the practitioner divides the cutting part of (he operation iuto the three methodical stages above recommended, in each of which there- is a distinct object to be fulfilled, he pro- ceeds with a confidence of knowing what he is about, and soon effects what is to be done, with equal expedition and adroitness. Having taken out the tumour.the operator is immediately to lie such larue vessels as may be pouring out their blood ; indeed, when the removal of the swelling will ne- cessarily occupy more than three or four minutes, it is better to tie all the large arte- ries a, soon as they are divided, and then proceed with their dissection. This was the celebrated Desault's plan, and it is highly deserving of imitation in this country, not only because many subjects cannot afford to lose niuch bfood, but also because the profuse effusion of this fluid keeps the ope- rator from seeing what parts he is dividing The largest arteries beiuglied, the surgeon should not be immediately solicitous about tying every bleeding point which may be observed. Instead of this, let him employ a little while in examining every part of tbe surface ofthe wound, in order to ascertain that no portion of the swelling, no hardened lump, nor di*ea down by two tape**, one of which is to go from behind forward, over each shoulder, and be stitched to the upper part of the bandage, both in front and behind. The arm on the same side as that, on w hich the operation has been done, should be kept perfectly motionless in a sling; for, every motion ofthe limb must evidently disturb the wound, by putting the great pectoral muscle into action, or rendering its fibres sometimes tense, sometimes relaxed. It is scarcely ne- cessary to say, that, after so considerable an operation as the removal of a large breast, or any other tumour of magnitude, the pa- tient should be given about thirty drops of the tinctura opii. A smaller dose always creates restlessness, headacb, and fever, af- ter operations, instead of having the desi- red effect. Here it becomes me to state, that as I could not find in any surgical book with which I am acquainted, what I conceived to be a proper description of (he mode of re- moving a diseased breast, and tumours iu general, the foregoing remarks are given chiefly on my own authority. Whetherthey are* just, or not, must be decided by the pro- fession. The removal of a diseased breast rarely proves fatal of itself, unless the parts cut away extend to a considerable depth, and occupy a very large space, or the patient is much reduced before the operation. How- ever, about two yea s ago, a patient in St. Bartholomew's Hospital died, without ai.-y very apparent cause, very soon after being operated upon ; and Schmucker has record- ed an instance, in which the operation was followed by tetanus. iWahrnehmungen, B. 2, p. 80.) With respect to the average success, fol- lowing the removal of cancerous diseases, this is a topic, which has been noticed in the article Cancer. The statement lately made by Baron Boyer is exceedingly unfavoura- ble ; for, in one hundred cases, in which ho has removed the diseased parts, only four or five of the palien(s continued radically cu- red. (Traiti des Mai. Chir. T 7. p. 237, 8i<* Paris, 1821.) The principal writers on the removal of the mamma are, Garenae«t, Oionis, Le Dran, Bertrandi, Sharp, and Sabatier, in their res- pective treatises on the operations. B. Bell, Latta, be. have also treated on the subject in their Systems of Surgery ; and there is a memoir Sur I'Operation du Cancer auSein, in Les CEueres de Desau't par Bichat. T. 2 MAMMARY ABSCESS. Milk'Abscess. With regard to inflammations of (he mamma, as my friend, Mr. James has observed, there is " either simple phlegmon, or mammary abscess, which, as it depends upon a peculi- arity of state and function, ought to stand alone. Mr. Hey also describes a deep-seat- ed abscess, to which this gland is liable, of rather a chronic character, and is the same, perhaps, as (hat which Dr.Kirkland has de- scribed as the encysted. Dr. K. describes also two others, under the titles of chronic und encysted ' Certain ■■:isfe circumstances being known, inercu ry becomes a much more efficacious, ma- nageable, and safe medicine, than it was formerly thought to be ; but, unluckily, i>„ visible effects upon Ihe mouth and the intes- tines are sometimes much more violent, than its general effect upon the constitution at lanr,e. These parts must theretore not be sti- mulated so quickly as to hinder the necessary quantity of mercury from being used. The constitution, or parts, are more sus ceptibleof mercury al first, than afterward. If the mouth is made sore, and allowed to recover, a much greater quantity may be thrown iu, a second time, before the suae soreness is produced. How ever, anomalous cases occur, in which, from unknown causes, mercury cannot at one time be made to pro- duce any visible effects ; but, afterward, Ihe mouth and intestines are all at once affecled (Hunter, p. 342.) Mercury occasionally ailacks the bowels and causes violent purging, even of blood. This effect is remedied by discontinuing the use of the medicine, and exhibiting opium. At other times, it is s uddenly determined to ihe mouth,fand produces inflammation, ulce- ration, and an excessive flow of saliva. To obtain relief in this circumstance, purga- tives, nitre,suljiliur, gum-arabic, lime-water, camphor, bark, the sulphuret of potash, blisters, be. have been advised. Mr. Pear son, however, does not seem to place much ■±Hj MERCURY. confidence in the efficacy ot ,-uch means, and (be mercury being discontinued for a time, he recommends the patient (o be freely exposed to a dry cold air, wilh the occa- sional use of cathartics, peruvian bark, and mineral acids, and the assiduous application of aslringent gargles. <•' The most material cbjection, (says Air. Pearson,) which I fore- see against the method of treatment I have recommended, is the hazard to which the patient will be exposed, of having the saliva sudden'y checked, and of suffering some olher disease, in consequence of it. " That (he hasty suppression of a ptyalisra may be followed by serious inconveniences, has been proved by Dr. Silvester, (Med. Obs. and Liq. Vol. 3.) who published the cases of three persons, who had been under his own rare ; two of whom were afflicted wilh vi- olent pains; and the third scarcely retained f.ny food in her stomach for the space of th'-ee months. I have seen not only pains, but even general convulsions produced from the same cause. But, (his singular kind of metastasis of (he mercurial irritation does not appear to ine to owe its appearance (o simple exposure to cold and dry air ; be- cause I have known it occur in different foims, where patients continued to breathe a warm a(mosphere, but used a bath, the water of which was not sufficiently heated. Cold liquids, taken in a large quantity into. the stomach, or exposure of the body (o cold and moisture, will also prove extremely in- jurious to those, who are fully under the influence of mercury ; whereas breathing a cool air, while the body is properly covered wilh apparel, ha3 certainly no (endency (o produce any distressing, or dangerous con- sequences. " If, however, a suppression of the plya- lism should be occasioned by any act of in- discretion, the remedy is easy and certain ; il consists only in (he quick introduction of mercury into (he body, so as to produce a soreness of the gums, with the occasional use of a hot bath." (Pearson on the Effect of various Articles in the Cure of Lues Venerea, Edit. 2, p. l&J, 164.) Mercury, when it falls on (be mouth, pro- duces, in many constitutions, violent inflam- mation, which sometimes terminates in mortification. In these habits, great caution is necessary. The ordinary operation of mercury does not permanently injure Ihe constitution; but occasionally, the impair- ment is very material; mercury may even produce local disease, and retard the cure of chancres, buboes, and certain effects of the lues venerea, after the poison has been des- troyed. (Hunter, p. 342 ) From mercury occasionally acting on tbe system, as a poison, quite unconnected with its agency as a remedy, and neither propor- tionate to the lb flam mat ion of the mouth, nor the actual quantity of the mineral ab- sorbed, Mr. Pearson noticed that one, or two patients in general died suddenly every year in Ibe Lock Hospital. The morbid stale of Ihe system, which tends to the fatal event, ■-hiring a mercurial cn-jrse i= named by Mr Pearson crethismus, and is characterized by great depression of strength, a sense of anxiety about the pnecordia, Irregular ac- tion of (he heart, frequent sighing, trem- bling, a small, quick, and sometimes an in- termitting pulse, occasional vomiting, a pale contractbd countenance, a sense of coldness ; but the tongue is seldom furred, and neither Ihe vital, nor natural functions are much disordered. They, who die sud- denly of (he mercurial erethismus, have freqiently been making some little exertion jusl before. To prevent tbe dangerous con- sequences of this state of the system, the use of mercury must be disconlinued, what- ever may be the stage, extent, or violence of ibe venereal symptoms. The patient should be directed to exjnise himself freely to n dry and cool air, in such a manner, as shall be attended w ith the least fatigue, and he should have a generous diet. In this manner, pa- tients often recover sufficiently in ten or fourteen days, to resume (he use of mercu- ry with safety. In the early stage, the mercti rial erethismus may often be averted by leaving off the mercury, and giving the mis- tura camphorata with large doses of ammo- nia. When the stomach is unaffected, sar- saparilla sometimes does good. (Pearson. p. l.-.4,4-c.) Occasionally, the use of mercury brings on a peculiar eruption, which has received the several names of hydrargyria, mercurial rash, eczema mercuriale, eczema rubrum, lepra mcrcurialis, mercurial disease, and erythema mercuriale. *"* Eruptions of various kinds are very- common symptoms of syphilis, but a very unusual effect of mercury. Therefore, until the real nature of this erythema was lately discovered, whenever it occurred in patients undergoing a mercurial course for syphilitic complaints, it was naturally enough consi- dered, asan anomalous form of lues venerea. The mercury was consequently pushed to a greater cx;ent, in proportion to the violence of the symptoms, and, from the cause of the disease being thus unconsciously applied for its removal, it could not fail to be aggrava- ted, and hurried on to a fatal termination- The observation of this fact, conjoined with another, of less frequent occurrence, name- ly, that a similar eruption did sometimes ap- pear in patients using mercury for othercom- plaints, and in whom no suspicion of syphilis could be entertained, at last led some judi- cious practitioners in Dublin to the impor- tant discovery, that the eruption was entire- ly an effect of mercury , and not at all con- nected with the original disease. This dis covery was not published till 1804." (M'Mul- Hn in Edinburgh Medical and Surgical Jour- nal, No. 5.1 Mr. Pearson states, however, that he ha3 been acquainted with the disease ever since 1781, and has always described its history and treatment in his lectures, since 1783. The eruption is attended with more or less indisposition, is not confined lo either sex. or any particular constitution, and seems to be eepially produced by mercury applied hi^h-uKY. *3l oAternaliy, and by any of its preparations taken inwardly. Mr. Pearson has never seen it in subjects above 50; and he says, its occurrence is more common about eight, or ten days after beginning a mercurial course. (P. 166.) Dr. M'Mullin has described three distinct stages of the erylhema mercuriale. " The first stage commences vvilblanguor. lassitude, and cold shiverings ; these symptoms are succeeded by increased tempeiature of the body, quick pulse, nausea, headach, and thirst. Tbe patient is troubled with a dry cough, and complains of difficult respiration, anxiety, and sense of stricture about the pnecordia. The tongue is usually moist, aud covered with a white glutinous slime : il sometimes appears clean, and brightly red iu the centre, whilst the margins remain foul. The skin feels unusually hot and itchy, with a sense ot prickling, not unlike the sensation experienced from the application of nettles. The belly is generally costive ; but a diarrhoea is often produced by very slight causes. " On the first, or second day, an eruption most commonly shows itself, the colour of which is either dark or bright red : the pa- pula? are at first distinct and elevated, re- sembling very much those in rubeola. Some- times, but rarely, (he eruption appears like urticaria, and in such instances the disease is observed to be very mild. The papulae very speedily run together in such a manner as lo form a suffused redness, which disap- pears on pressure. In most cases, it begins first on tbe scrotum, inside of Ihe thighs, forearm, or where mercurial friction has been applied, and the integuments of the parts affected become much swoln. There have also been observed instances, where an eruption of a purplish colour.and unaccom- panied by papula*,has diffused itself suddenly over the entire beidy. Thi-, how ever, may be considered as uncommon. In every instance, which came under my observation, it was confined al first to a few places, and from thence gradually extended, until the differ- ent portions of Ihe eruption had united, and the papula? were also rou^h to (he feel. But in (hose cases, which resemble urticaria, a number of minute vesicles, which contain a serous fluid, appear from the commence- ment, interspersed among the papulae. Contrary to what happens in most diseases accompanied with cutaneous affections, the febrile symptoms are much aggravated, and continue to increase alter the eruption has been completed. The pulse in general beats from 120 to 130 in a minute, the thirst con- tinues urgent, and the paiient extremely resiles-, seldom enjoys quiet sleep. When the eruption bas continued in Ibis manner for a certuin period, the cuticle begins to peel off in thin, whitish, scurfy exfoliations, not unlike those observed in rubeola. This desquamation lias not been attended to by Dr. Moriarty or Mr. Alley, if they have not, by giving the same naun. to the decruslatiou which occurs iu the last stage, confounded both together. It commence'' in those places w hire; the erupiion first made its np- pearance, and in (his order spreads to other parts. About this period the fauces become sore, ihe longue swells, and Ihe eyes appear somewhat inflamed. "The duration of this stage is very va- rious; sometimes it continues from ten to fourteen dey.-, and, in other case—, it termi- nates in bait thai time. When ibe disease has appeared in its mildest form, the patient recovt-rsimmediHtely atterthe desquamation, a new euliele having formed underneath; but, if severe, he has omy experienced ihe smallest part ol his sufferings, mid the skin now assume* a new appearance, which 1 have considered as (he second staue. "The ski.i at this period appears as if studded with iunumeral'le minute vesicles, which are filed v» ith a pellucid fluid. These vesicles may be expected, if the patient, at the close of the first stage, complains of in- creased itching, and sense of burning heat, in those parts irom which the cuticular ex- foliations have fallen. They remain some- times for a day or iwo, but are most com mouly burst, immediately afler their formr,- (ion, by the patient rubbing them, in order to relieve the troublesome itchiness with which (bese parts are affected. They dis- charge a serous, acrimonious fluid, which possess such a very disagreeable odour . s to induce nausea in the patient himself, and those who approach near his bedside. The odour is so peculiar, thai il can easily be re- cognized by any person w ho has once ex- perienced it. "This fluid is poured out most copiously from the scrotum, groin, inside of (he (highs. or wherever (lie skin forms folds, and seba ceous glands are most numerous. The serous discharge from (hese minute vesicles forms, with the cuticle, an incrustation, which may be considered as the third or last slat:*. '• These crusts are generally very large, and, when detached, retain the figure of Tin- parts trorn wliich tbey have fallen. Their colour is yellowish; but sometimes appeal- dark and duty. This period of the disease migiit be termed, I think, wilh much pro- priety, tbe sta^e of decrustalion, in order to distinguish it more fully from the desquama- tion, w hich has been already noticed. From the use of the two last terms indiscrimi- nately, those whj have described the disease have introduced into their descriptions n degrte of confusion which has caused its progress not to be well understood. Wben this stage appears, the fauces become more affected, ti.e eyes intoleiant of light, and the larsi tender, inflamed, and sometimes in- verted. The crusts tormed on the face, as in other parts of the body, before tailing oil', divide asunder, so as to leave cracks and fissures, which produce an hideous expres- sion ot countenance ; and the eyelids are also, from the general swelling of tbe lace, completely closed. The back and hairy scalp are last affected, and, even in very severe cases, tliese parts are sometimes ob- served to escape enti-elv. The natienf. MKKt URY. whilst in (his slate, is compelled to desist ;:nm every kind of motion, on account of the pain which he experiences on the slight- est exertion, and which he describes as if his flesh were cracking. The crusts also fall off in such amndance, that the bed apiiears as il strewed with the cones of bops. Whilst the eruption is oniy making its ;-|>|>earnnce m one place, nuoWicr part may have arrived at ils mosl advanced form : m> that all th dif- ferent stages ol tbe disca»e may be present at one lime in the same individu d. It i~ attended with typhus through its entire ■:ourse ; bul it is very curious to observe, that the appetite for food, in most cases, re main.* uoimpa-ie i, and sometimes is even voracious. This circumstance was particu- larly remarkable in a patient who laboured under Ihe disease, in its wOrst foim.for Ihe •pace of three months, in the- Koyal Infirm ary of Edinburgh ; lor double Ihe usual hos- pital allowance ot tood was scarcely suffi- cient to satisfy his hunger. When the catarrhal symptoms buve continued during the progress of the complaint, ihey are, at (his advanced period, pat ticularly aggrava- ted : the anxiety and pain of the breast are also very severe, attended with cough, and blood) expectoration, and the patient always feels languid and dejected. The pulse be- comes frcpient, feeble, and irregular, the tongue black and parched, and al length di.nno'a, delirium, convulsions,gangrene of the surface of -lie bod), and death, -uper- ene. In its mild form, it only \ve- through ihe first stage, and terminates, as we have beady slated, in a few d-iy-., by a slight 'lesquamalion. But, when severe, il is often protracted more than two months, every •age of the eruption continuing propuriion- ibly longer; and when, in this manner, it has run its course, it repeatedly breaks oul on Ihe new surface, and passes through the same stages." (M-Mutlin in Edinb. Med. •uul Surg. Journal, No b.) Wub respect lo the remote cause, this is the employment of mercury. Dr. M'Mullin is inclined to believe wilb Dr. Gregory, that 'he application of cold lo tbe body,"while iinder the action of mercury, is ab.-o! ii«-|y necessary, for its production; an opinion strengthened by the constant prevalence of catarihal symptoms. However, Mr. Pearson thinks, that cold has no concern iu biiugiug on the complaint it. patients under the influ- ence of mercury At the same lime it merits particular attention, mat the disease is not exclusively occasioned by mercury either in its general, or mr.re pa. ii. I attacks: it bat i^eeii observed to follow exposure to cold, and to recur in ibe same individual, at irre- gular intervals, wi hout any obvious or ade- quate cau-c. (Bateman's Synopsis, p 2o6, Tld. 3 ; R.ittJr in Ldiu. Med. and Surg. Jour.i. V.,l.b,p. 143; Mi'-cet in Med. Chir. Trans. Vol. 2, urt. 9.) In (be early stage, Mr. Pearson recom- mends small doses of amimenia) powder, vitii saline draughts, or the ammonia acelata. V gentle purgative should be given every 'h-e-. ,)r foUraa-,Si an(j opium lo procure sleep. The laffer medicine sometimes doe? most good, when joined with camphor, or Hoffman's anodyne liquor. Sarsaparilla and bark may be given, when the discharge is no longer ichorous, and the tumefaction has subsided. Vitriolic acid has seemed to give relief. The diet may be light and nutritive, without fermented liquors, however,till Ihe desquamation has somewhat advanced. Fre- quent use of the warm bath, and often chan- ging tbe patient's linen and sheets, wliich soon become stiff and rough with the dis- charge, afford much benefit. If the warm bath cannot be hud, Mr. P,'arson advises washing the body very tenderly with warm water-gruel; he also covers parts, from which the cuticle is detached, with a mild cerate, and renews the application twice a day. (P. 178 ) Dr. M'Mullin advises the immediate dis- continuance of mercury; the removal of the patient from wards, where this mineral is in use , emetics aud diaphoretics; but on account of the very irritable state of tho bowels, he says anlimonials are hardly ad- missible, and that when purgatives are indi- cated, only the mildest ones, such as ol. ri- cini, sulphate of magnesia, &c. i.ugut lo he given. He advises mucdagiuous draughts with opium for relieving the soreness of the fauces. In the second stage, the cold infu- sion of bark wilh aromatic* and opium, or what is more praised, wine, porter, 4ic. To relieve the ophthalmia tarsi, the unguenturn oxidi zinci, and-to appease (he painful sensa- tion of the skin cracking, the liniraeutum calcis, which should be liberally applied as soon as crusts appea. Consult Essay on a Peculiar Eruptive Dis- ease, arising from the Exhibition of Mercury, by G. Alley, 8vo. Dublin, I8u4; also Obser- vations on the Hydrargyria, or that I esicular Disease arising from the Exhibition of Mer- cury, 4to. Lond. I81u. A Description oj the Mercurial Lepra, by Dr. Moriarty, l2mo. Dublin, 1804. Spens and M'Mullin, in Edin- burgh Med. and Surgical Journal, No. 1, and b. Pearson on Lues Venerea, Edit. 2. Bale- man's Synopsis, p. 266, ty-c. Ed. 3. Frictions wilh Mercurial Ointment. No metal acts in its pure metallic state, it must first be more or less combined with oxygen. The mercury, contained in the: tiugueutum byorargyri, becomes in a cer- tain degiee oxydated, when triturated for tbe purpose of bleudin. it with the fat The metal, however, in mercurial ointment, is in the most simple, ami least combined form, ci II its preparations, nd hence, it not only gencralf, operates with more mildness .m the system, but with more specific effect on the disease. Various sails ot mereur , when given internally, operate more quickly than mercurial iricti ns . yet there are many practitioners, w ho do not like to confide solely in any internal preparations for curing the venereal dise.i e, particularly, when the virus has produced effects in consequence ol absorptiuu. We shall only just mention in trti., part of the iM-k, that rubbin« in MERCURY. 233 mercurial ointment is the mode of affecting the system with mercury, which is gene- rally considered to agree best with most constitutions, and to act with most certainty on the venereal disease. Mercurial Fumigations. We have mentioned this method, as being one of the most ancient plans of affecting the constitution with mercury, and Lalo- nette and Abernethy have stated circum- stances in its favour, which certainly render it sometimes a very eligible mode. The latter is of opinion, that if the peculiar ad- vantages of mercurial fumigations were ge- nerally known to practitioners, they would be much more frequently employed. The advantages of the method consist in its af- fecting the constitution, when other means have failed, and in producing its effects in a much shorter time than any other mode re- quires. How desirable this celerity of ope- ration must often be, when venereal ulcera- tion is making great ravages in the palate, throat, be. it is needless to insist upon. In patients, who have not strength to rub in ointment, and whose bowels will not bear tbe internal exhibition of mercury, the mode of fumigation may prove of great service. " In the year 1776, the Chevalier Lalo- nette, a physician at Paris, laid before the public an account of a new mode of mercu- rial fumigation, free from the inconvenien- ces of former ones, and which in the space of thirty-five years, he had successfully em- ployed in more than four hundred cases, that had resisted all the ordinary methods of cure. His method consisted in enclosing the patient, previously undressed, in a kind of box resembling a sedan chair, with an opening at the top to let out the head, and another at the bottom, to which was fitted a small grate or furnace, having in it a heated iron for converting the mercurial remedy into fume. The preparation he made use of was a kind of calomel, which by repeated sublimation from iron filings, was so far de- prived of its muriatic acid, as to be in part reduced into running quicksilver; and, while it possessed considerable volatility, was per- fectly unirritating. Some of this powder, being strewed upon the hot iron placed be- low, was immediately converted into smoke, which surrounded the patient's body, and nfter some time settled on his skin in the form of a white and very fine calx of quick silver : a complete dress, having its inner surface fumigated with the same powder, was then put on.—The remedy being thus generally applied to the mouths of the cu- taneous absorbents, soon got admission into the circulating fluids, and the constitution became thereby more speedily affected than by any other process known before." (Aber- nethy's Surgical and Physiological Essays, Part 3.) As the fumigating powder used by M. La- lonette was very operose, and consequently a very expensive preparation, and appeared to have no advantage over one made by abstracting the muriatic acid from calomel Vol. 1! SO by means of ammonia. Mr. Abernethy has always employed the latter, which is pre- pared at the hospital in the following man- ner: Two drachms of liquor ammoniac are added to six ounces of distilled water, and four ounces of calomel are thrown into this liquor, and shaken up with it; the powder is afterward separated by a filter, and dried. The powder thus obtained is of a gray co- lour, and contains a good deal of quicksilver in its metallic state, which of course is ex- tremely volatile,but becomesoxydafed when raised into fume, and afterward condensed into a white subtile powder. In local disease of the joints, such, for in- stance, as frequently takes place in the knee, and in sarcomatous enlargements of the breast in women, the late Mr. Sharp and Sir C. Blicke were accustomed to direct fumi- gated stockings, or under-waistcoats, to be worn ; by which these complaints were re- lieved, and the constitutions of the patients) affected, without the trouble and unplea- santness arising from the use. ofthe common mercurial ointment. (See Abernethy's Sur- gical and Physiological Essays, Part 3.) Mr. Pearson procured Lalonette's ma- chine, and made a considerable number of experiments to determine the comparative advantages of this method, and mercurial frictions. He found, that the gums became turgid and tender very quickly, and that the local appearances were sooner removed, than by the other modes of introducing mercury into the system ; but that it soon brought on debility, a rapid and premature salivation, and, of course, that the medicine' could not be steadily continued. This gen- tleman concludes, that where checking the progress of the disease suddenly is an object of great moment, where the body is covered with venereal ulcers, or where the eruptions are large and numerous, so that there scarce- ly remains a surface large enough to absorb the ointment, the vapour of mercury will be advantageous. But he thinks it extreme- ly difficult thus to introduce a sufficient quantity of mercury into the system to se- cure the patient from a relapse, and there- fore the plan by no means eligible as a ge- neral practice. The vapour of mercury, he says, is singularly efficacious, when applied to venereal ulcers, fungi, and excrescences ; but this plan requires an equal quantity of mercury to be given in other ways, as if the focal application itself were not a mercurial one. (Pearson on Lues Venerea, p. 145, fyc.) For the purpose of fumigating sores, the hydrargyri sulphuretum rubrum is common- ly used. Ulcers and excrescences about the pudendum and anus in women are said to be particularly benefited in this way; and in these cases Ihe fumes are most conveni- ently applied by placing a red-hot heater at the bottom of a night-stool pan, and after sprinkling on it a few grains of the red sul- phuret of quicksilver, placing the patient on the stool. On other occasions, a small ap- paratus, sold at the shops, is used, which en- ables the surgeon to direct the fumes through a funnel against the ulcer iu any situation. 2U MERCUKV Though mention has just been made of ve- nereal excrescences, I am of opinion with Mr. Abernethy, that it is very questionable, whether any are ever really of this nature. I know, that many excrescences and verru- cas about the anus, and parts of generation, diminish and are cured by a course of mer- cury. This is the only argument in favour of their being venereal ; for, when tied, cut off, or made to fall off by stimulating them with pulv. sabina, and tbe subacetate of copper, they are as effectually cured, as if mercury had been given. In the military hospital at Cambray, I remember a man, on whose scrotum there were several warty ex- crescences of considerable size. Mr. Booty, assistant staff surgeon, prescribed mercury, by which they were certainly cured with surprising expedition In this particular case, I think the plan of treatment adopted was the best, because on account of the number of excrescences, and the situation of some of them at the lower and back part of the scrotum, it would have been difficult to have treated them altogether by local appli- cations. PREPARATIONS FOB ISTERNAI. EXHIBITION. The acetite of mercury is supposed to be a mild preparation, and was the active ingre- dient in the celebrated Keyser's pills. In solution it has also been recommended to be applied externally for the removal of some cutaneous affections. It may be made into pills with crum of bread. The dose is from one to five grains every night. When it is wished to excite a salivation quickly, when mercurial ointment alone will not produce this effect, or cannot be em- ployed, and when fumigations are not con- venient nor agreeable, the hydrargyri oxy- dum rubrum is often prescribed. The com- mon dose is a grain, which may be increa- sed to two, a day. It is apt, however, to disagree with the stomachs and bowels of many patients; an inconvenience sometimes obviated by conjoining the preparation with opium. At present, the hydrargyrus cum creta is rarely or never prescribed for the cure of the venereal disease. But it is frequently prescribed as a mild alterative for children in doses of from gr. v. to gr. x. twice a day, blended with any viscid substance. The oxymuriate of mercury (corrosive sublimate) was a medicine highly praised for its antisyphilitic virtues by the celebrated Van Swieten, and, indeed.there is no doubt, that, like other preparations of mercury, it possesses such qualities. It retains great reputation, even now, and, probably, will always do so. However, like the red oxide, it sometimes deranges the stomach and bow- els, and from some surgeons does not receive < the same degree of confidence, in respect to its power over syphilis, as mercurial frictions. Mr. Pearson remarks, that " when the subli- mate is given to cure tbe primary symptoms of syphilis, it will sometimes succeed ; more especially when it produces a^considerable degree of soreness of tbe gums, and the common specific effect of mercury in the animal system. But it will often fail of re- moving even a recent chancre ; and where the symptom has vanished during the ad- ministrations of corrosive sublimate, I have known a three month's course of that medi- cine fail of securing the patient from a con- stitutional affection. Ihe result of my ob- servations is, that simple mercury, calomel or calcined mercury, are preparations more to be confided in, for the cure of primary symptoms, than corrosive sublimate. The latter will often check the progress of secon- dary symptoms very conveniently ; and I think it is peculiarly efficacious in relieving venereal pains, in healing ulcers of the throat, and in promoting the desquamation of eruptions. Yet, even in these cases, it never confers permanent benefit; for, new symptoms will appear during the use of it; and, on many occasions, it will fail of afford- ing the least advantage to the patient, from first to last. I do sometimes, indeed, employ this preparation in venereal cases; but it is either at the beginning of a mercurial course, to bring the constitution under the influence of mercury at an early period, or during a course of inunction, with the intention ot increasing the action of simple mercury. I sometimes, also, prescribe it after the con- clusion of a course of frictions, to support the mercurial influence in the habit, in or- der to guard against the danger of a relapse. But, on no occasion whatever do 1 think it safe to confide in this preparation singly and uncombined, for the cure of any truly vene real symptom." (Pearson on Lues Venerea.) The dose of oxymuriate is a quarter of a grain. The following is a common mode of or- dering it : ft. Hydrargyri oxmuriatis gr. 1. Aquae Nucis Moschatae 3;ij. Misce. ?ss. Omni nocte sumenda. The muriate of mercury (calomel) is not very much used by modern surgeons for the cure of the venereal disease. Sometimes, indeed, it is given in cases of gonorrhoea, both with the view of preserving the consti- tution from infection, and keeping the bow- els regular. It is more extensively given as an alterative, and for the cure of such surgi- cal diseases as require the system to be slightly under the influence of mercury. It generally proves actively purgative, when more than two or three grains are given. The most simple preparations of mercury have generally been deemed the most effec- tual in eradicating the venereal disease. The pdulae hydrargyri are the most simple of the internal formulae, being merely mercury triturated with mucilaginous or saccharine substances. Next to mercurial frictions, they are, perhaps, most frequently employed Iorthe cure ofthe incipient form of the ve- nereal disease, that is, while a chancre is the only complaint. They are also very commonly given in all stages of the disease, to aid mercurial frictions in bringing thesys- tern under the influence of the specific remedy. Ten grains of the ma<*«, kept fo MOLLITIES OSSIUM. 2.}*j these pills, is the usual dose. When they purge, opium will sometimes prevent this effect. See Venereal Disease. Mercury is employed both constitutional- ly and locally in numerous surgical cases ; for the removal of indolent thickenings and indurations of parts ; for the relief of porri- go, herpetic diseases, tetanus, hydrophobia, hydrops articuli, iritis, and a multitude of other affections, which need not here be spe- cified. MEROCELE. (from pte^oc, the thigh, and zyixh, a tumour.) A femoral or crural hernia. See Hernia. MEZEREON was recommended by Dr. A. Russell for a particular class of venereal symptoms, in the following terms : " The disease, for which I principally recommend the decoction of tbe mezereon root as a cure, is the venereal node that proceeds from a thickening of the membrane of the bones. In a thickening of the periosteum, from other causes, I have seen very good effects from it: and it is frequently of service in the removal of those nocturnal pains, with which venereal patients are afflicted; though, in this last case, excepting with regard to the pain that is occasioned by the node, I own I have not found its effects so certain, as I at first thought I had reason to believe. I do not find it of service in the cure of any other symptom of the venereal disease. (Med. Obs. and Inq. Vol. 3, p. 194,195.) Mr. Pear- son, however, asserts, unequivocally, that mezereon has not the power of curing the venereal disease in any one stage, or under any one form, and if the decoction should ever reduce the venereal node, yet there will be a necessity for taking mercury in as large quantity, and for as long a time, as if no mezereon bad been exhibited. Cullen found this medicine of use in some cutaneous af- fections, but, excepting an instance or two of lepra, Mr. Pearson has very seldom found it possessed of medicinal virtue, either in sy- philis, or the sequela? of that disease, scro- fula, or cutaneous affections. (Pearson on Lues Venerea, p. 55, 59.) As the possibility of curing most forms of the venereal disease, not only without mer- cury, but without any internal medicines whatever, is now well established, it is diffi- cult to know what degree of importance to attach to observations, declaring certain ar- ticles ofthe materia medica efficient or inef- ficient in the cure of that disease ; because, if it admit of a spontaneous cure, but will not get well when mezereon, or any other parti- cular medicine is exhibited, we are necessa- rily obliged to suppose, that such medicine is worse than useless. MODIOLUS. The crown or saw of a trepan. MOLLITIES OSSIl'M. A morbid soft- ness of the bones, wliich become preterna- turally flexible, in consequence either ofthe inordinate absorption of the phospate of lime, from which their natural solidity is de- rived, or else of Ihis matter not being duly secreted into their texture. The bones af- fected become specifically lighter (Sail lant, Hist, de la Soc. Royale de Mid. T. 8.) Dr. Bostock made some experiments, with the view of ascertaining the proportion of earthy matter in bones affected with molli- fies : he examined a dorsal vertebra of a woman whose bones were found soft and flexible after her decease. In one part of the diseased bone, he found, that the quanti- ty of earthy matter only amounted to one- fifth of its weight, and in another, only to one-eighth, while the proportion in healthy bones amounted to more than one half of their whole weight. (See Med. Chir. Trans. Vol. 4, and Wilson on the Bones and Joints, p. 253.) In rickets, the bones yield and be- come distorted only by slow degrees, and retain their natural inflexibility ; but, in the present disease, they may be at once bent in any direction, and frequently admit of being , readily divided with a knife. The mollifies ossium is an exceedingly uncommon disease, and its causes are buried in obscurity. It is supposed, however, to depend upon some peculiar state of the constitution, and the in- dividuals, attacked with it, have been re- marked to be mostly about, or rather be- yond, the middle period of life, (J. Wilson, Vol. cit. p. 252.) and generally, if not always, women. (Neumann in Abhandl. der K. K. Josephs Acad. 2 B. p. 173 ; Portal Cours d'Anatomie, T. 1, p. 15.) One instance, how- ever, is reported, in which the patient was a young man seventeen years of age. (Thorn- massin, iu Journ. de Med. T. 43. p. 222.) Surgical writers have usually considered mollifies and fragilitas ossium as two dis- tinct and different affections. Boyer thinks, however, that this point is by no means well established. He admits, that there have been a few rare instances of mollifies, where the bones were completely flexible, without any degree of fragility. But, he contends, that in almost all the cases on record, the fragilitas and mollifies have been combined. He regrets that bones, affected with fragility, have never been chymically nor anatomi- cally examined, particularly as there have been persons who, while living, merely be- trayed the symptoms of mollifies ossium, yet, in whom unsuspected fractures, evi- dently of long standing, were discovered after death ; while other fractures also hap- pened from the slightest causes during the examination ofthe same bodies. (See Boyer, Traiti des Maladies Chir. T. 3, p. 607—609.) The truth of these observations is well illus- trated in the case lately reported by Mr. Wilsonl (On the Bones, fyc. p. 254.) In the present place, I shall merely describe the pure mollifies ossium, or that disorder of the bones, in which they become completely flexible, and lose all their natural firmness. And in order to give an idea of the disorder, I shall quote the case of Madame Supiot. In the year 1747 she had a fall which occa- sioned her to keep her bed for"some time, and left great pain and weakness in her loins and lower extremities In about a year and a half afterw ard, she began to per- ceive her left leg particularly affected. Along with this weakness, she bad violer.t -*i«» MOLLITIES OSSU'.M pains over her whole body, which increased after a miscarriage, and still more after a natural delivery, in the year 1751. She vvas now seized with startings, great inquietude, and such violent heals, that she was almost continually in a sweat, and could not bear tbe least covering even in the coldest wea- ther, and while her pains continually increa- sed, she took notice that her urine precipi- tated a white sediment. Her pains abated on the appearance of the sediment, but she now observed that her limbs began to bend, and from this time the softness of them gra- dually increased till her death. In the month of April, 1762, the trunk ofthe body did not exceed 23 inches in length ;• the thorax exceedingly ill formed, and the bones ofthe upper part very much distorted ; those of the lower part were very much bent, and the thigh bones became so pliable that her feet might easily be laid on each side of her head. The right side did not, till after some time, become so deformed as the left; but it was surprising to observe the alterations which daily took place, and the different figures assumed by the limbs, in conse- quence of the increased softness of the bones; so that when the sediment in the urine was considerable, the disease of (he bones seemed to be at a stand, increasing considerably when it was suppressed. Be- sides (his, she bad violent pains, starting*, difficulty of breathing, spitting of blood, and lastly, a fever, with convulsions. She died in the beginning of November, 1752 and, on dissecting her body, the following ap- pearances were observed: 1. The muscles in general were of a very soft and pale con- sistence, the vastus extern us, fascialis, qua- driceps, biceps, and external parts of the gracilis, were much shorter than in their na- tural state, and more firm and tense ; while those on the opposite side were much elon- gated, thin, and very tender; in short, the whole muscular system had suffered more or less, according to the action of the mus- cles in her lifetime. 2, The bones were entirely dissolved, the periosteum remaining unhurt, so that they exhibited only the form of a cylinder. 3. The heart and large blood- vessels, both veins and arteries, contained large black polypi, of a viscid consistence, and very unlike those usually found in dead bodies. A case of softness of the bones is related hy Mr. Gooch, but considerably different from the above, as it was attended with a remarkable fragility of them before they became soft. It likewise began with pains through tbe whole body, attended with fe- verish symptoms; but after some weeks, these pains were confined chiefly to the legs and thighs, and they were not increased by pressure. This fragility of the bones does not appear to have been Ihe case with Ma- dame Supiot. In the month of June, 1749, Mr. Gooch's patient broke her leg in walk- ing from her bed to a chair, and heard tbe bone snap. No callus, however, formed, though the fracture was instantly reduced, and treated by one of the best surgeons ia ber part ofthe country ; but insfead of thi*. the bones began to grow flexible, and in a few months, were so from the knee to the ankle. The disease still continued to in- crease, so that, in a short time, the other leg and thigh were affected in the same manner, after which both legs became cede- matous. liable to excoriations, and to dis- charge a thin yellow ichor. Scorbutic symptoms began to appear in the winter after the leg was broken, and her gums be- gan to bleed. Tonic medicines were exhi- bited without any success, except that her menstruation became more regular, and her appetite and digestion belter than before; but towards the end of her life, her breathing became difficult, the spine distorted, and a pain in the loins took place upon every motion of the vertebra*.: and as her limbs were now quite useless, she was obliged to sit upright in bed. At last, the ends of the bones on which she sat, having become also very soft, spread much, and the ends of her fingers and thumbs, by frequent endea- vours to raise herself, became also very broad, and the phalanges crooked. The flexibility ofthe bones gradually increased, and became more general, attended with a wasting of the flesh, and excessive difficulty of breathing. 'Ihe menstrual flux totally ceased four months before her death; her legs, which were anasarcous, and excoriated almost all over, became erysipelatous; but she.retained her senses to the last. She ex- pired suddenly, having talked in a composed manner concerning her miserable situation and approaching end only a few moments before. On examining the body, she was found to have lost two feet two inches of her na- tural stature. The heart and lungs appear- ed sound, but bad been much confined, principally by the liver, which was enlar- ged in an extraordinary degree ; it was not, however, scirrhous, nor in any other way diseased. The spleen was very small, and the mesentery had one large scirrhous gland. All tbe bones, except the teeth. were softened, so that scarcely any of them could resist the knife ; but those of the lower extremities were the most dissolved, being changed into a kind of parenchymous substance, like soft dark-coloured liver, without any offensive smell. So complete- ly, indeed, were they decomposed, that the knife met with less resistance in cuttim; through them than in sound muscular flesh, though some bony lamellae were here and there to be met with, but as thin as anegg- .., Ttie most compact bones, and Ihose which contained the greatest quantity of marrow, were the most dissolved; and it was observable, that the dissolution began internally, for the bony lamina} remained l ^ulbere on the outside» a«d nowhere f'se- The periosteum was rather thicker than ordinary, and the cartilages thinner; but not in a state of dissolution. The bones were found to contain a great quantity of oily matter and little earth. No cause could be assigned for the disease; and in the case tnurtlHTCATION. of Madame Supiot, the one assigned, viz. that of her eating too much salt, seems to- tally inadequate to explain the origin of the disorder. All the cases of mollilies ossium on record have proved fatal, and no means of cure are yet known. For additional observations, connected with this subject, refer lo Fragilitas Ossium and Rickets. Boyer and Kicherand treat of the mollifies ossium, and rickets, as one and the same disease. But, as Mr. Wilson ob- serves, the first differs from rickets, in at- tacking people of middle age, or rather older, and not particularly children ; and it differs also iu the change prouuced in the bones themselves, which, when dried, do not appear as if tbey bad been long steeped in weak acid, with their animal part nearly unchanged ; but both the phosphat of lime and the animal matter appear to have been absorbed, so as to leave mere shells, which are also softer than natural bone of the same thickness. Mr. Wilson further informs us, that lar^e cavities are met with in the substance of the bones, and sometimes com- municate with the soft parts surrounding them. In some of these cavities is contain- ed oily matter, like boiled marrow ; and in others, masses of coagulated blood, and a soft inorganic substance. (J. Wilson on the Bones, e"yc. p. 253. Acrel, Diss. Description- em et Casus aliquot Osleomalacie sistens; Up- sal, 1788. Morand in Journ. desSavans, 1792, et Mim. de I'Acad. des Sciences, 1752. Morand, junr. in Mem. de I'Acad. des Sciences, 1764, p. 206. See also T. Lambert, Relation de la Maladie de Bernard d'Armagnac, sur un Ramollissement des Os; Toulouse, 1700. Fer- nelius, in lib. de abditis rerun* causis. Th. Barlholinus, Hist. Anat. Cent. 4. Petit, Histoire di I'Acad. des Sciences, 1722. Hoin, ibid. 1764. Gagliardie, Anatomes Ossium, Rome, 1789. C. G. Ludwig, Programma, quo observata in seelione Cadaveris Fcemina cujusossa emollita erantproponit; Lips. 1737. Fries, Dissert, de Emollilione Ossium; Argent- tor. 1775. Thompson, in Med. Observations and Inquiries, Vol. 6. p. 259. Chirurgical Ob- servations and Cases, by William Bromfield, Vol. 2, p. 50, fyc. Boyer, Traite des Maladies Chir. T. 3, p. 607, i,c. Paris, loll. Riche- rand, Nosogr. Chir. T. 3. p. 14z. What these two writers say, however, chiefly relates to rickets. We meet with cases of Mollities Ossium in the Philosophical Transactions; Act. Haffniens.; Ephem. Nal. Cur.; Saviard's Obs. Chir. ; the writings of Forest us; Gooch's Chirurgical Works, Vol. 2. p. 393—399. Ed. 1792, fyc. James Wdson, Lectures on Ihe Structure and Physiology of the Parts com- posing the Skeleton ; and on the Diseases of the Bones and Joints, p. 2b2, fyc. 8vo. Loud. 1820.) MOINOCULUS. (from ^ovee, single, and oculus, the eye.) A bandage formerly ap- plied to the fistula lachrymalis, aud diseases of the eye. It consists of a single-headed roller three ells long. In order to apply it to the right eye, it is to be held in the hand, and its end in the left, et vice versa. This end is to be put on the back of the neck, and one turn of the roller is to be carried round, over the forehead, so as to meet the ex- tremity ofthe bandage. The roller is then to descend under the ear of the side affected, and to pass obliquely over the cheek under- neath the eye, and next over the root ofthe nose, and opposite the parietal bone, to the nape of the neck. The third turn of the roller is to overlap tho second a little : the third the fourth ; making what the French call doloires; and the application of tlie ban- dage is completed by making turns round tlie head, l'he use of the monoculus was only to retain dressings. (Encyclopidie Mithodique; Parlie Chir.) MORliFICATIONisof two kinds; the one, u ithout inflammation ; the other, pre- ceded by it. To this last species of mortifi- cation, ihe terms inflammatory, humid, or acute gangrene, are often appbed, while the second, or that which is not preceded . by any or much inflammation, has been distinguished by the epithets, dry or chronic, and sometimes idiopathic, when no cause for the origin of the disease can be assigned. \ccording to Mr. Hunter, inflammation is an increased action of that power, which a part naturally possesses ; and in healthy in- flammations, at least, it is probably attended with an increase of power. In cases, how- ever, which are to terminate in mortifica- tion, there is no increase of power ; but, on the contrary, a diminution of it. This, when joined to an increased action, becomes a cause of mortification, by destroying the balance, which ought to subsist between the power and action of every part. There are, besides, cases of mortification, preceded by inflammation, which do not arise wholly from that, as a cause : of this kind, are the carbuncle and the slough formed in the small-pox pustule. (Hunter.) The first general division of mortification, therefore, is into two kinds; first, into the inflammatory,humid, or acute; and secondly, into the dry, or chronic. But the disorder is also subdivided into many species, which are determined by the nature of tueir particular exciting causes, as will be present- ly detailed. However, it is remarked, that acute, or rapid mortifications, are not necessarily hu- mid, as the slough from the application kali purum proves, and the converse also is true iu some cases of sphacelus senilis (James on Inflammation, p. 96.) Another modern writer also asserts, that mortification from wounds and external injuries may be either humid, or dry, or of both «kinds together, where the circumstances are particular. (Guthrie on Gunshot Wounds, fyc.p. 122, Ed. 2.) The doctrine also that any case of mortification is entirely without inflamma- tion, has sometimes been deemed question- able ; and Mr. James expresses his belief that the disorder is generally preceded by inflammation, and invariably accompanied with some degree of it. And, says he., " whether mortification be a consequence of 1238 MORTIFICATION. inflammation, or not, it may, perhaps, with reason be considered, as standing in the same relation to inflammation, as adhesion, suppuration, or ulceration : they may all be preceded by a high degree, or it may be scarcely sensible." (P. 84, 85,) When any part of the body loses all mo- tion, sensibility, and natural heat, and be- comes of a brown, livid, or black colour, it is said to be affected with sphacelus, that is, complete mortification. As long as any sensibility, motion, and warmth, continue, the state ofthe disorder is termed gangrene. This word is here made use of to signify only a degree of sphacelus, or rather the process, by which any local disorder falls into the state of complete mortification. Many authors use both terms synonymously; but it is to be observed, that gangrene does not invariably end in sphacelus ; nor is the latter always preceded by the former. (Richler, Anfangsgr. der Wundarsn. B. 1, Kap.3.) There are some surgical writers, who make the distinguishing circumstance of sphacelus to be the extension of the disor- der to tbe bones as well as the soft parts. (Lassus, Pathologie Chir. T. 1, p. 30, Ed. 1809) At present, however, this last application of the term sphacelus is never made ; for, as Mr. Pearson has rightly observed, the dis- tinctions, " which are founded merely upon tbe parts, that suffer, or upon the profundity, to which the disease has penetrated, seem inadequate and useless." (Principles of Surgery, p. 115, Ed. 2.) The manner, in which Dr. J. Thomson views the subject, may be considered as coinciding with the general sentiments of the best modern sur- geons. " I shall employ the term gangrene, (says be) to express that state of mortifica- tion, in inflamed parts, which precedes the death of the part; a stage, in which there is a diminution, but not a total destruction of the powers of life : in which the blood ap- pears to circulate through the larger vessels ; in which the nerves retain a portion of their sensibility ; and in which, perhaps, the part affected may still be supposed to be capable of recovery. The word sphacelus, I shall use to denote the complete death, or mor tification of a part ; that state, in which the powers of life have become extinct; in which the blood ceases to circulate ; and in which the sensibility of the nerves is lost, whether the dead, or mortified part has, or has not, become actually putrid, or shown any ten- dency to separate and fall away from the living and sound parts Putrefaction orthe spontaneousprdfcess, by which animal bodies are decomposed, is an accidental, and not a necessary effect ofthe state of mortification It takes place at very different p.-riods, after the death of particular parts; and these periods, it may be remarked, are always regulated, not only by external circumstan- ces, such as the humidity and temperature ofthe atmosphere, but also.by tbe jieculiar structure and morbid conditions of the ani- mal texture, or organ, in which the putre- faction occurs. The term sphacelus, has. I know,been employed to express, that a part is not only completely dead, or mortih.'d, but, also, that that part has become putrid, and is in a state of separation from the sur- rounding and living parts. But, as putrefac- tion is not a necessary, or immediate conse- quence of mortification, or partial death in animal bodies, this use of the term sphacelus is obviou ly improper." (See Thomson's Lectures on inflammation, p. 504.) The causes of mortification are either internal, or external. It is ommonly taught in the medical schools on the continent, that the internal causes probably operate after the manner of a deleterious substance, vhich being introduced into the ciiculation, occasions a putrefaction of the fluids. (Lastut, op. el loc. cit.)—Boyer also professes a simi- lar notion, (See Traite des Maladies Chir. T. 1, p. 140.) as wrell as Larrey in his account of traumatic gangrene ; a statement, which has drawn forth 'he criticisms of Mr. Gu- thrie. The doctrine is supported by no sort of proof, and may be considered as entirely hypothetical, if not decidedly erroneous. There are, indeed, as Boyer has noticed, some spontaneous mortifications, the primi- tive cause of which is not always well un- derstood : an inflammation, apparently slight, may become gangrenous immediately it has made its appearance. In scorbutic, venere- al, and small-pox cases, we have daily in- stances of this fact. Other internal causes, without any very evident pre-existing dis- ease, sometimes destroy persons, by gan- grenous mischief, who are but little advanced in years. (Saviard, Obs. 16. Haller, Disput. Chir. T. 4, p. 551.) Certain poisonous, acrid, caustic substances taken inwardly, or intro- duced under the skin, may have the same effect, by annihilating the vital action, or destroying thetexture ofthe parts. (Lassus, Pathologie Chir T. l,p. 31.) But, though these observations may all be entirely cor- rect, they by no means justify the conclusion, fhat the internal causes of mortification ever act like a deleterions matter producing a putrefaction of the fluids. The mortification of the toes and feet so well described by Mr. Pott, is supposed to proceed chiefly from unknown internal causes, though sometime* attended with an ossified state of the arte- ries. Another remarkable specimen of mortifi- cation from an internal cause, is that origin- ating from eating bread made of bad black wheat, or rye. Besides occurring as an ordinal idiopathic disease, and from obstruc- tor of arteries, chronic, or dry gangrene observes Dr. Thomson) may be induced by the action of substances taken into the stomach, which s»*em to produce it as a spe- cific effect in parts remote from the source of the circulation. The most singular ex- ample, which we have of this, is in the gan- grene produced by the eating of a particular kind of unsound or diseased rye. This species of mortification has been rarely observed in F.n .h.nd ; but it has been fre- quently seen on the continent, where it ha, been repeatedly known to prevail in mm TORTIFICATTON 239 i-.istricts, where rye forms a principal article of food, as an endemial disease. It occurs, however, in such districts only after wet seasons, in which that grain is affected with a particular disease, well known in France by the name of the Ergot, or cockspur rye. In this disease, the grains of rye grow to a large size, acquire a black colour, and have a compact .horny consistence. The species of mortification, produced hy eating this substance, was first particularly described by Dodard. (See Journ. des Savans, an. 1676.) The part affected became at first insensible and cold, and, in the progress of the disorder, dry, hard, and withered. In very malignant cases, there was delirium. Dodard s description of the complaint was very imperfect; but he has mentioned a circumstance, tending strongly to prove, that the disease actually arose from (he alleged cause ; viz. that fowls, fed with cock- spur rye, are killed by it Saviard informs us, that he saw this disease in the year 1694, at the Hotel Dieu of Orleans It attacked the upper and lower extremities, which were rendered, in the course of the disorder, as dry as touch-wood, and as emaciated as Egyptian mummies. In 1710, Noel, sur- geon to the Hotel Dieu at Orleans, transmit- ted to tbe Royal Academy of Sciences at Paris an account of this peculiar mortifica- tion. About fifty people, men and children, had come that season into his hospital, with the affliction. According to Noel, the disor- der always began in the toes, and extended itself gradually along the foot and leg, till it sometimes rose to the upper part of the thigh. He had never seen any of the female sex affected with it, and had observed only one instance of it in the upper extremities. The Academy received the history of one case, in which the lower extremities vvere separated from the body in the articulations of the thigh-bones with the acetabula ; the first example, (Dr. Thomson believes) of (his separation upon record ; and it was the oc- currence of this, and of similar cases, that probably first suggested the operation of am- putation at the hip-joint. (See Thomson's Lectures on Inflammation, p. 541.) As Noel's patients did not come under his care, till after the disease had existed some time, he could not describe from his own observation the early symptoms ; but the patients had often told him, that the disease generally began in one, or both feet, with pain, red- ness, and a sensation of heat, as burning as the fire ; and that, at the end of some days, these symptoms ceased, as quickly as they hml come on, when the extreme sensation of heat, which they had formerly felt, was changed into cold. The part affected (adds Noel) was black, like a piece of charcoal, and as dry as if it had passed through the fire. After some time, a line of separation was formed between the dead and living parts, like that which appears in the separa- tion of a slough produced by the cautery ; and the complete separation of the limb wa«, in many cases, affected by nature alone. In others, Noel was obliged to have recourse to amputation. This disease appeared in Switzerland in 1709 and 1716, and its symptoms and pro- gress in that country have been accurately described by Langius in a dissertation, enti- tled, " Dctcriptio Morborum ex esu Clavo- rum Secalinorum." Gassaud, physician in Dauphiny, where this disease appeared also in 1709, states, that many of the patients were affected with swellings of the feet and legs, and of the hands and arms, which degenerated into a gangrene, that penetrated to the bone, and produced a separation of the affected limb. The disorder vvas attended with different symptoms in different individuals. Some suffered very violent pain, accompanied by an insufferable sensation of heat, although the part affected often felt cold to the touch. In other patients redness, with much swell- ing, supervened, attended wilh fever and delirium. Other patients were without any fever, or delirium, though they seemed to suffer equal pain In some patients, the parts affected became withered, dry, and black, like charcoal. The separation of the dead parts from the living took place with the most excruciating pain, and a sen- sation resembling that produced by the di- rect application of fire. This sensation was sometimes intermittent; and, in other in- stances, it was succeeded by an equally harassing sensation of cold. According to Bossau, surgeon to the hos- pital of St. Antoine, in Dauphiny, the cases, which he saw, were not all of the dry kind, the limb sometimes becoming putrid, and maggots being generated. He says that the disease was not infectious, and it attacked indiscriminately men, women, and chil- dren. The degree of fatality caused by this spe- cies of mortification seems to have been extremely various. In the Memoirs of the Royal Academy of Sciences for 1748, M. Duhamel mentions, that of 120 persons afflicted, scarcely four or five recovered with their lives. According to Langius, it was equally fatal in Switzerland. Dr. Thomson believes, that the preceding sort of gangrene has never occurred in this country, excepting, perhaps, the cases re- corded by Dr. Charlton Woolaston, in the Phil. Trans, for 1762; and which proceeded from eating unsound wheat, not rye (See Lectures on Inflammation, p. 548.) For fur- ther particulars relating to this curious kind of mortification, I must refer the reader to this valuable work. The external causes of mortification, which are manifest, and act mechanically or chymically, are burns; excessive cold; the application of caustics; the presence of any ichorous, urinary, or fecal matter effused in the cellular substance ; violent contusions, such as are produced by gunshot wounds, or bad fractures ; the strangulation of a part, as in cases of hernia, or when polypi, or other tumours are tied ; a high decree of in- 240 MORTIFICATION. flammation; and, lastly, everything, that has the power of stopping the circulation and nervous energy in parts. (Lassus, Pa- t thologie Chir. T. I, p. 34, 35.) Inflammation is one of the most frequent occasional causes of mortification. But, as we have already remarked, the death of a part may take place without any well-mark- ed appearance of previous inflammatory disorder ; and the latter even when present bas frequently less share in the mischief, than other incidental circumstances, and is in reality, only- an effect of the very same cause, which produces the sphacelus itself. It is oftentimes a matter of doubt, whether actual inflammation precedes the occur- rence or not; for a part, before it mortifies, is in certain instances only affected with pain, and with no degree of preternatural redness. Lastly, when mortification is, un- questionably, preceded by inflammation, there are so many varieties ofthe disorder depending on incidental causes, that these latter demand more attention than the inflam- mation. (Richler, Anfangsgr. B. 1. Kap. 3.) Mr. James enumerates the following cir- cumstances, as capable of influencing, in a very great degree, the disposition of inflam- mation to terminate in mortification. 1. The powers of the part, in which the in- flammation occurs, being naturally weak, as in fibrous membranes, the scrotum, be. 2. The remote supply of blood, or nervous energy, as in the lower extremities. 3. Ob- struction to the return of blood. 4. To the supply of blood. 5. Disease in the heart or vessels. 6. Debility from age, habits of life, disorder of the digestive organs, or fever. 7. Poor living, foul air, improper food, scur- vy, &.c. 8. Impairment of organization from external injury. 9. Of the nervous power by poisons. 10. Undue excitement of weakened parts. 11. Depressing reme- dies. 12. Pressure and tension. 13. Ex- cessive violence of inflammatory action. 14. Peculiar disposition in the constitution. (James on Inflammation, p. 102.) Healthy phlegmonous inflammation sel- dom ends in mortification, except when it is unusually violent and extensive. Of all the inflammatory complaints, to which the system is liable, erysipelas is ob- served most frequently to terminate iu gan- grene ; and whenever phlegmon is, in any degree, conjoined with an erysipelatous af- fection, which it not unfrequently is, it seems thereby to acquire the same tendency, being more difficult to bring lo resolution or sup- puration than the true phlegmon, and more apt to run into a mortified state. The symptoms of mortification from in- flammation take place variously, yet gene- rally as follows:—The pain and sympathetic fever suddenly diminish, the part •"fffected becomes soft, and of a livid colour, losing, at the same time, more or less of its natural warmth and sensibility. In some places, the cuticle is detached ; while, in other situa- tions, vesicles arise, filled with a clear, or turbid fluid. Such is the state, to which we apply the term gangrene, and which stage of the disorder too oiten rapidly advances io sphacelus, when the part becomes a cold, black, fibrous, senseless substance, called in technical language, a slough. It merits notice, however, that, " in cases, in which gangrene immediately succeeds lo inflammation, these two morbid states may, in some measure.be regarded as stages, or periods, of the same disease. They pass in- sensibly into one another; nor is it possible to say precisely where the one state ends, and tlie other commences. The symptoms of inflammation, in these cases, do not dis- appear before those of gangrene come on; but seem rather to undergo a gradual and almost imperceptible change, or conversion, into one another. The redness acquires « deeper tinge, and spreads further, than for- merly ; the swelling increases and becomts more doughy; and, in this incipient sla^e, the gangrene, particularly when it attacks the cutaneous texture, often bears a consi- derable resemblance to erysipelas." (Set Thomson's Lectures on Inflammation, p. fit Mi.) It is to be observed, also, that " the part of the body which becomes affected with gangrene, does not immediately lose ils sensi- bility ; for the pain, on the contrary, is often very much aggravated by the approach of this state. The blood also still continues to circulate, at least in the larger vessels of the part, but, perhaps, wilh less force .- and from the resistance which it meets with in passing through the capillaries, in less quantity, than formerly. The serous effusion into the cel- lular membrane continuing to increase, and the action ofthe absorbent and sanguiferous vessels to diminish, the part becomes at length incapable of being restored to its former office in the animal economy. It is, therefore, in its earlier stages only, that gangrene is to be considered as an affection admitting of cure ; for there are limits, be- yond which, if it pass, recovery becomes impossible. These limits it may not, in every instance, be easy to define; but they form the boundaries between incipient gangrene and the ultimate termination ot that state in sphacelus." (Thomson, op. cit. p. 507.) The causes which produce mortification by impeding the return of blood from the part affected, for the most part operate by making pressure on the trunk or principal branches of a vein. In these instances, there is always an accumulation of blood in the part which first swells, becomes of a livid colour, tense, and very painful. Soon afterward, blisters arise, and the part be- comes soft, cedematous, cold, insensibfc, emphysematous, black, and fetid. Such are the circumstances which happen in strangu- lated hernia, in tied polypi, and in a limb in which the veins have been so compress*"-*1 by any hard swelling, such as the head of a dislocated bone, as to excite mortification. Other causes operate by preventing the entrance of arterial blood. The application of a ligature to an artery, as practised in several surgical cases, and all external pressure, that closes the artery, or artcrie? -•MORTIFICATION v ~U an wnich a part entirely depends for its supply of blood, have this effect. Mortifica- tion does not, however, always take place when the trunk of an artery is rendered im- pervious, because nature furnishes the ne- cessary supply of blood through collateral ramifications. But when the disorder does happen, the part commonly first becomes pale, flaccid, and cold, and soon afterward shrinks, loses its sensibility, grows black, and perishes. It is usually represented by writers, that mortification may proceed from a mere less- ening of the communication of blood and nervous energy to a part. However, it is to be observed, that parts, deprived of all connexion wilh tbe sensorium, by the divi- sion or paralytic state of their nerves, do not frequently perish on this account. But as their functions are carried on with less vi- gour, and their vitality is weakened, the same causes which sometimes produce mor- tification i- parts differently circumstanced, must much more readily occasion it in them. Among the causes of the present species of mortification, maybe mentioned great universal debility ; extreme old age ; a thickening and ossification of the coats of the arteries, and a consequent diminution of their capacity, and of their muscular and • elastic power. Cowper, the anatomist, was one of the earliest writers who took notice of this ossi- fication of the arteries ofthe leg, in persons who had died of mortification of the feet and toes. (See Phil. Trans. Vol. 23, p. 1195, and Vol. 24, p. 1970.) A similar ca*e was remarked by Mr. Becket, of which he has given an account in bis Chirurgical Obser- vations. The occurrence was also men- tioned by Naish. (See Philosoph. Trans. Vol. 31, p. 226.) Dr. J. Thomson has seen one example of a very complete ossification of the arteries of the leg, accompanying a mortification of the feet and toes. (On Inflammation, p. 537.) Speaking of the same subject, Mr. Hodgson remarks: "Ex- perience has proved this condition of the arteries to be at least a constant attendant upon one species of gangrene, to which the extremities of old subjects are liable ; and I have found the three principal arteries of the leg nearly obliterated by calcareous matter in two fatal cases of this disease. But our knowledge of the pow er of collate- ral circulation, in every part of the body, will not allow us to admit the obliteration ofthe trunks as a sufficient cause of mortifi- cation, from a deficient supply of blood. It is therefore necessary for us to remember, that the same disease may probably exist in Ihe collateral branches, upon which it has produced similar effects. But if an extent of vessel be converted into a calcareous cy- linder, it loses its elasticity and organic pow- ers, so as to be unable to afford any assist- ance to the propulsion of the blood ; and the existence of parts, supplied by vessels in this stale, constitutes a strong argument against Ihe agency ofthe arteries in the cir- culation of the blood Tbe above observa- tions, on the cauue of this species of gan- grene, 'at once expose its incurable nature ; and this state of the blood-vessels renders Ihe danger of amputation very considerable, unless fortunately the disease in the arteries does not extend to the part at which the ligature is applied." (See Hodgson's Trea- tise on the Diseases of the Arteries and Vpins, p. 41.) However, although the ossified state of an artery must certainly be unfa- vourable to its healing, it does not con- stantly prevent this desirable event. (See Case in Medico-Chir. Trans. Vol. 6, p. 193.) The preceding facts are particularly enti- tled to attention, because, as we shall pre- sently find, the opinion that the mortification ofthe toes and feet arose from an ossifica- tion of the arteries, was considered by Mr. Pott as destitute of foundation. It is probable, however, that sometimes other causfes are concerned. Fabricius Hil- danus mentions a fatal case of mortification ofthe feet and legs, where the patient wa-i in the vigour of life, and apparently of good constitution. After death, a scirrhous tu- mour was found surrounding and compress- ing the inferior vena cava, and aorta, near their bifurcation, so as to prevent the free circulation of the blood in the lower extre- mities. Mortification ofthe extremities also sometimes occurs from deficient circulation, in the progress of diseases of the heart. The mortification, arising from long con- tinuance in the same posture, is chiefly attri- butable to the unremitted pressure which parts sustain, and which obstructs the cir- culation Surgeons have frequent occasion to see melancholy examples of this kind of mortification, particularly in cases of frac- tures, paralysis from disease of the vertebra,*, be. The mischief most readily occurs where the bones have the least flesh upon them, and, consequently, where all external pressure has the greatest effect; as, for instance, about the os sacrum, os ilium, spines of the scapula, &.c. The disordered part always first becomes soft, livid, red at ihe circumference, and cedematous, after- ward losing its sensibility, and acquiring ti black appearance : at-length it is converted into a foul sloughing ulcer. I hough long continuance in the same posture is the grand cause of this kind of mortification, yet incidental circumstances are frequently combined wilh it, and have great influence over the disorder. These are. great debility, the same state ofthe system as exists in typhus fever, impure air, unclean bedding, be. There are some causes which produce death in a part at once, by the violence of their operation. A very powerful blow on any portion of the body may destroy the vitality of the fibres and vessels in this sud- den manner. Lightning, strong concentra- ted acids, and gunshot violence, sometimes act in a similar way. When a ball enters the substance of parts with great force and rapidity, many of the fibres, which are in its track, are frequently killed at once, and must be thrown off in the form of sbnighs. -M-J MORTIFICATION- before the wound can granulate and heal. (See Hunter on Gunshot Wounds.) Cold is often another cause of mortifica- tion", and when parts which have been fro- zen, or frostbitten, are suddenly warmed, they are particularly apt to slough. I find in Baron Larrey's valuable publica- tion, some interesting observations on the gangrene from cold. He acquaints us, that after the battle of Eyiau. one of the most grievous events to which the French sol- diers were exposed, was the freezing of their feet, toes, noses, and ears: few of the van- guard escaped tbe affliction. In some, the mortification was confined to the surface of the integuments of the toes or heels; in some, the skin mortified more deeply, and to a greater or lesser extent; while, in others, the whole of the toes, or foot, was destroyed. (See Programma quo frigoris acrioris in corpore humano effectus expendit. Haller, Disp. adMorb. Lips. 1755.) " All the writers, on this species of morti- fication (says Larrey) have considered cold as the determining cause; but, if we attend to the period when the complaint begins its progress, and the phenomena which accom- pany it, we shall be convinced, that cold is merely the predisposing cause. In fact, during the three or four exceedingly cold days which preceded the battle of Eylau, (the mercury having then fallen to 10, 11, 12, 13, 14, and 15 degrees below zero of Reaumur's thermometer) and until the se- cond day after the battle, not a soldier com- plained of any symptom depending upon the freezing of parts. Nevertheless, they had passed these days, and a great portion of the nights of the 5th, 6th, 7th, 8th, and 9th of Feb. in tbe snow, and the most severe frost. The imperial guard especially had remained upon watch in the snow, hardly moving at all for more than four and twenty hours, yet no soldier presented himself at the am- bulance,"* nor did any one complain of his feet being frozen. In the night of the 9th, and 10th of February, the temperature sud- denly rose, the mercury ascending to 3, 4, and 5 degrees above zero. A great quantity of sleet, that fell on the morning ofthe 10th, Was the forerunner of the thaw which took place in the course of that day, and continu- ed in -the same degree for several days. From this moment, many soldiers of the guards and the line applied for succour, complaining of acute pain in the feet, and of numbness^heaviness,and prickings in the extremities. Tbe parts were scarcely swol- len, and of an obscure red colour, in some cases, a slight redness was perceptible about the base of the toes, and on the back of the foot. In others, tbe toes were destitute of motion, sensibility,and warmth, being alrea- dy black, and, as it were, dried. All the * Tbe ambulances of tlie- French army are caravans, furnished with an adequate numher of surgeons, and every requsite for the dressing- of wounds, and tbe im- mediate performance of operations, upon vvbicb last circumstance, in particular, tbe life of ihe wounded soldier often depends. These caravans follow tbe most rapid movements of the army, and are always ennabte Of kfepi,*!"*; up with the vnnyiiarrt. patients assured mc, that liiey had niv e.\pt. rienced any painful sensation during the severe cold to which they had been exposed on the night-watches of the 5th, 6th, 7(h, 8th, and 9th of February, and that it wan not till the night of the 10th, when the tem- perature had risen from 18 to 20 degrees, that they felt the first effects of the cold." It is further noticed by Larrey, thai such pa- tients as had opportunities of warming them- selves in the town, or at the fires of the night-watches, suffered in the greatest de- gree. (See Larrey's Memoires de Chirurgie Militaire, T. 3, p. 60—62.) Sometimes mortification seems to depend either upon the operation of some infectious principle, or, at all events, upon causes which simultaneously affect numerous indi- viduals ; for instances have been known, in which almost all the ulcers and wounds iu large hospitals became nearly at the same time affected with gangrenous mischief (See Hospital Gangrene.) Mortification is very frequently occasion- ed by the injury which parts sustain from the application of fire and heated substances to them. When the heat is very great, the substance of the body is even decomposed, and of course killed at once. On other oc- casions, when the beat bas not been so vio- lent, nor sufficiently long applied, inflamma-i lory symptoms precede the sloughing. Cutaneous texture is that in which we have the best opportunity of observing the phenomena and progress of gangrene. \V hen it occurs as a consequence of inflamma- tion, the colour of the skin changes from the florid red to a darker shade; and in the progress of the disease it acquires a livid hue. The cuticle often separates at certain points from the skin, and the vesications, termed phlydene, are formed, which usu- ally contain a bloody-coloured serum. As sphacelus comes on, the livid hue disap- pears, and a slough, is formed, which is sometimes ash-coloured ; sometimes black. It is not.always easy to judge of the extent of mortification from the appearance of the skin ; for, when the subjacent cellular membrane is affected, the disorder may occupy a greater extent internally, lhaa upon the surface. In a spreading gangrene, the red colour of the affected skin is insensibly lost in the sur- rounding integuments; but, when gangrene, followed by sphacelus stops, a red line, of a colour more lively than that of gangrene, is generally perceptible between the dead and living parts. It' is at the inner edge of this inflamed line, where we usually seethe ulcerating process begin, by which the se- paration of the dead from the livir g parts is affected. (See Thomson's Lectures on Inflam- mation^. 511, 612.) Mortification occurs frequently in cellnlar texture. The skin which covers dead cellu- lar substance, generally has a gangrenous ap- pearance, and afterward either ulcerates, or sloughs. In some cases, the portion of spha- celated cellular texture is small,as in the m- lienant boil : in otl er=. extensivp.,as in ca!?: TfcmTIFICATIO.V. ^43 of carbuncle. In erysipelas phlegmonoides, sions were made four inches above the divi- he cellular membrane, connecting together sion of (lie ue-ad from the living parts. Dr. the muscles, tendons, nerves, blood-vessels, - Thomson has seen a still longer portion of be. often perishes to a great extent. Here large portions of skin are frequently also destroyed by sloughing, or ulceration, so that muscle, blood-vessel, tendon, nerve, be. are exposed to view, quite denuded of their proper coverings, and in different states of disease. Artery is the texture, endowed with the greatest power of resisting its own destruc- tion by mortification. " I have (says Dr. Thomson) in various instances of erysipe- las phlegmonoides, seen several inches of the femoral artery laid completely bare by the gangrene, ulceration, and sphacelus of the parts covering it, without its giving way before death. The arteries in these, and other similar instances, in which I have seen fliem laid bare in the neck and arm, by ab- scess terminating in mortification, had the appearance of raw flesh, and were obviously thicker and more vascular than natural. The blood circulated through (hem, and assisted in supplying with nourishment the parts upon which they were distributed." (P. 513.) I have often seen the truth of (he foregoing slatement sadly illustrated in cases of slough- ing buboes, by which several inches of the femoral ariery vvere exposed. I have seen the throbbing brachial artery denuded for more than a month, nearly its whole extent along the inside of the arm, by the ravages of malignant and pseudo-syphilic ulceration, attended with repealed sloughing ; and yet hemorrhage had no share in carrying off (he unfortunate patient. It is a curious fact,that the blood coagulates in the large arteries, which lead (o a morti- fied part. This occurrence takes place for -ome distance from the slough, and is (lie reason why (he separation of a mortified limb is seldom followed by hemorrhage. The same occurrence also affords an ex- planation, why, in the amputation of a mor- tified limb,there is sometimes no hemorrhage from the vessels, although the incisions are made in the living part. This fact vvas first particularly pointed out by Petit, the sur- geon. (See Mtm. de I'Acad. des Sciences, 1732.) " When a gangrened limb (says this celebrated surgeon) is cut off in the dead part, no hemorrhage occurs, because tbe blood is coagulated a great way in the ves- sels." He adds, •' We have several exam- ples of limbs amputated, on account of gan- grene, in which no hemorrhage occurred, although the amputation whs made a consi- derable way in the living parts; because the ►•lot was not confined in these cases to the dead part, but vvas continued forwards into the living as far as the inflammatory dispo- sition extended." According lo Dr. Thomson*, cases, in con- firmation ofthe foregoing statement, are recorded by other practical writers, espe- cially Quesnay, and Mr. O'Halloran. In one of ihe cases, mentioned by ihe latter gentleman, and in which no hemorrhage followed the removal of »b»* limb, the* inci- femoral artery closed up with coagulated blood, after a mortification of (he foot and leg; and, in one example, where the morti- fication began in (he thigh, he saw (he coa- gulation of the blood in (he exlernal iliac, extending up to the origin of this vessel from the aorta. " So common, indeed, is this coagulation of the blood in the limbs affected with mortification (observes Dr. Thomson,) (hat it has been supposed to be a necessary and constant effect of this disease. This opinion, however, does not appear to be well founded ; for I have now seen seve- ral instances in which a limb has mortified and dropped off, without hemorrhage having occurred from the vessels divided by na- ture : and yef, iu examining the vessels of (he stumps of these patients after death, 1 have not been able (o find any clots, either of coagulated hlood, or of coagulable lymph. In the cases (o which I allude, the adhesive inflammation, occurring in the line of separation between (he dead and living parts, had exletided (o the blood-vessels, and iheir inner surfaces being inflamed and press- ed together by (he swelling which occurs, had adhered so as (o close up their extremi- ties. Il is in this way we shall find, that the common ligature acts, which is applied to (he divided extremities of arteries and veins; and it is this obliteration, by the process of adhesion of the extremities of the arteries and veins in the neighbourhood ofthe spha- celated parts, that in reality prevents the occurrence of hemorrhage, when the morti- fied limbs fall off, or are removed by the knife. The coagulation of the blood in (he canal of the vessel is not alone sufficient. It may tend, in (he cases in which it occurs, for a time (o restrain hemorrhage; but it is by the obliteration by adhesion, of (he canal in the extremities of the arteries and veins, that the occurrence of hemor- rhage can be securely and permanently pro- vided against. Indeed, to me it seems doubtful, whether (hat coagulation of blood, which takes place in mortified limbs, ever takes place in the canal of the vessel, till its extremity and lateral communications have been plugged up by Ihe coagulating lymph, which is extending during the state of the adhesive infl'immation." (See Thom- son's Lectures on Inflammation, p. 554.) When gangrene and sphacelus happen to any extent, the patient is usually troubled with an oppressive hiccough; a symptom well known to the surgeon of experience, and often an indication of the mischief, when exlernal signs are less instructive. The truth of this remark is frequently seen in strangulated herniae. The constitution also suffers immediately a considerable dejection. The patient's countenance suddenly assumes a wild, ca- daverous look ; the pulse becomes small, rapid, and sometimes irregular; cold per- spirations come on, and (he patient is often affected v?idi diarrhma and delirium 244 MORTIFICATION As Dr. Thomson observes, the constitu- tional symptoms '' form fevers, which par- take in individual cases, more or less, of an inflammatory, typhoid, or bilious character But, the degree of these fevers varies, in every particular case, from their almost total absence to the highest degree of intensity. The skin is usually hot, and dry at the com- mencement of the attack; the tongue is without moisture, brown and hard, the pulse is quicker, and less full and strong, than in inflammation ; and this state oi the pulse is often attended by flattering intermissions, and a considerable degree of subsultus ten- dinum. The fever has, in general, more of the asthenic, than of the sthenic character ; or it is more of the typhoid, than of the in- flammatory type ; a circumstance of great importance in the constitutional treatment of mortification. The fever in gangrenous af- fections is often accompanied with great un. easiness and restlessness, dejection of spirits, wildness of the looks ; and, in severe cases, with almost always more or less delirium. In the progress of the disease, cold sweats, palpitations, and convulsions, sometimes oc- cur ; a hiccough, accompanied with nausea, often comes on, and proves a most distress- ing symptom to the patient. Frequently, this hiccough is the forerunner of death. Some patients die comatose ; others, after suffering severe pain, spasms, and delirium. But, iu some, a slow, in others, a sudden abatement of the constitutional symptoms takes place, accompanieel also with the ame- lioration of the local affeclion. The gangre- nous inflammation stops, and a red line is formed by the adhesive inflammation in the extreme verge of the living parts ; the dead part separates, and granulations form ; and when the constitution has strength to sus- tain the injury it has received, recovery takes place." (See Lectures on Inflamma- tion, p. 509.) I n cases of sphacelus, the proguosis chiefly depends on the nature of the cause of the disorder. The more easy the cause is of re- moval, the less room is there for alarm. It is an erroneoussupposition,that mortification arising from an external local cause is more easy to be stopped and cured, than that originating from an internal cause. The lo- cal cause is sometimes exceedingly difficult, or even incapable, of removal ; and a spha- celus, which is at first entirely local, may afterward become a general disorder, by the universal debility and derangement of the system, resulting from the complaint. Hence it is obvious, that a sphacelus may easily ex- tend beyond the bounds of its outward local cause. On tbe other band, a mortification may be reduced to one of a nature entirely local ; though it arose at first from constitu- tional causes. Sphacelus from extreme de- bility, or from such a state of the system, as attends the scurvy, typhoid fevers, be. is constantly perilous, because these causes are very difficult to remove. It is also a fact, that, when numerous causes are combined, it is an unfavourable occurrence, not merely because "he sturgeon is apt to overlook some of them, but because there are in /ealiN more obstacles to the cure. Humid gangrenes, which are frequently accompanied with emphysema of the cellu- lur membrane, usually spread with great ra- pidity. " Some authors, (says a modern writer,) have attributed this lo the influence of t.ie air extricated, and Dr. Kirkland bas described emphysematous gangrene, as dis- tinct from the others, and some have impu- ted this disposition, in a considerable degree, to the putrefaction of the juices, which are effused." With regard to the former, (be author has mistaken an effect for a cause ; yet, " it is important to recognize the fact, that gangrene, when accompanied with em- physema, has a remarkable disposition to spread." (James on Inflammation, p. 96.) Sometimes a mortification spreads so slowly, that it does not occupy much extent at the end of several months, or even a whole year. The case, however, is often not the less fatal on this account. The dan- ger is never altogether over, until tbe dead part has completely separated. The en- trance of putrid matter into the circulation (says Kichter) is so injurious, that patients sometimes perish from this cause, long after the mortification has ceased to spread. (An- fangsg. der Wundarzn. B 1, Kap. 3, p. 78, 79.) 'I his last circumstance is very much insist ed upon, by all the modern continental sur- geons ; but (he doctrine has never gained ground among English surgeons, who enter- tain little apprehension of the bad effects of the absorption of putrid matter in cases of mortification ; and the opinion of Mr. Gu- thrie may be more correct, that nature re- ceives the shock through tbe nervous system, and not through the absorbents. (On Gun- shot Wounds, p. 123, Ed. 2.) The idea of a deleterious principle being absorbed was long ago well refuted by Mr J. Burns, who pointed out, thattheimpression upon the constitution was iu no degree com meiisurate with the size of the slough, and consequently with the epiantity of putrid matter, as the effects produced by a small slough of intestine, or cornea, will exempli- fy. But when the sloughs are of equal size, and in the same parts, the differences of con- stitutional sympathy, as Mr. James observes, may depend upon the nature of the surround- ing inflammation, which, however, he con- ceives, may itself be affected by the quantity of putrid irritating fluids. (On Inflammation, p. 98.) The danger of sphacelus is also propor- tioned to the size and importance of tbe part affected. The Bvent of the distemper like- wise depends very much on the patient's ag' and constitution. Farts, affected with gansrene, do not im- mediately lose the whole of their sensibility: the circulation is still continued in a certain degree ; and when the progress of the dis- temper does not -surpass certain bounds, tbe functions of such parts may be completely re-established. Gangrene, strictly speaking is not a decided mortification : but only tht ^MORTIFICATION 246 forerunner of this latter mischief, and may be regarded as the intermediate link, be- tween the most violent stage of inflamma- tion and sphacelus. The presence of this last implies the total loss of life in the part affected, the destruction of its organization, the abolition of all its functions, and an ab- solute inability to resume them again. How- ever, even when we see the surface of a part manifestly sphacelated, we must not always conclude, that the entire destruction of its whole substance or thickness is cer- tain ; for, in many cases, the disorder only affects the skin and cellular substance. In this state, the integuments frequently slough away, leaving the tendons, muscles, and other organs, perfectly sound. It is only in external affections of the body that the progress of inflammation to gan- grene and sphacelus can be marked with any degree of precision. The approaches of the latter are also not invariably announced by the distinct and manifest symptoms of gan- grene, even when the disorder is quite su- perficial. There are cases, which justify Ihe conclusion, that a small part of the body may be affected with sudden death, just in the same manner as the whole machine. Sphacelus is often seen making its appear- ance in a part, which is apparently quite healthy, without being preceded by any other symptoms, than a sudden acute pain in the seat of the mischief. .Sometimes, in the earliest period ofthe complaint, a black spol, which rapidly spreads on every side, is the only change that can be observed. In order to form a just prognosis, all the above circumstances must be taken into consideration, and, in particular, we must never deliver an opinion, without having closely examined the progress of the disor- der ; for, should we make a favourable prog- nosis from such appearances as might justify us as much as possible in so doing, (here would be great risk of finding ourselves most miserably mistaken by the event of the case. In all cases of considerable mortifica- tion, even when arising from an external cause, the patient cannot be deemed exempt from danger, not only while no separation of the mortified parts has begun, but also, not before such parts have been completely detached. ' TREATMENT OF MORTIFICATION. 1 shall arrange under two heads what is to be said of the treatment of mortification Under the first will be comprehended every thing, which relates fo internal remedies, and such other means, as are indicated by the general state of the system; under the second, topical remedies, and the local treat- ment of the parls affected. In the treatment the surgeon will always have one thing for immediate consideration; viz. whether the case before bim is one of acute mortification, attended with inflamma- tion and inflammatory fever; or whether it is a chronic mortification, beginning with- out fever, or attended wilh a fever of a ty- phoid nature and great prostration of strength ? By making up his mind upon this point, the practitioner will establish an useful general principle for his guidance especially in the commencement of the treatment. 1. When mortification is acute, and seems to depend on the violence of inflammation, tbe first indication is to moderate the inor- dinate aetion of the sanguiferous system, by the prudent employment of such means as are proper for counteracting inflamma- tion. In short, relief is to be sought in the antiphlogistic regimen, which consists in the employment of biood-letling, purgatives diaphoretics, and diluents, and iu abstinence from all vegetable or animal substances, which have a tendency to excite, or to aug- ment the febrile action. It is a regimen which must be pursued, so long as inflamma- tory fever continues. It is only in cases in which the fever from the first assumes a ty- phoid character, or where tbe mortification takes place without ihe previous occurrence of fever, that any deviation from the anti phlogistic regimen can be allowed. Dr. Thomson, from whom I have borrow- ed the foregoing passage, also notices the present common aversion to bleeding in compound fractures, erysipelas, carbuncle, hospital gangrene, burns, and frostbite ;* cases in which the patieiit, it is said, can seldom bear with impunity any considerable loss of blood. " In many instances of these injuries and affections (says he) blood-let- ting, I know, is not required ; but I am doubtful, even if it were generally employed, whether it would produce all the mischiefs, which have of late years been ascribed to it. I believe it to be the mosl efficacious',of any of the remedies that can be employed, in all cases of inflammatory fever threaten- ing to terminate in gangrene, and that its use in such cases ought never to be omitted in the young, strong, and plelhoric." (See Lectures on Inflammation, p. 559.) When bleeding has not been sufficiently practised, during the state of the inflammation antece- dent to the mortification ; when the general symptoms, which point out the existence of this state, continue violent; and, especially, when (he pulse is still quick, hard, or full'; it is absolutely necessary to empty the ves- sels a little more even though mortification may have begun, particularly if the patient be young and plethoric. Bleeding, by dimi- nishing tbe fever, and abating the general heat, is frequently the best means of all. It may then be considered better, than all anti- septics, for stopping the progress of the dis- order. But this evacuation is (a be employed with a great deal of circumspection; for. should it be injudiciously resorted to, from the true stale of the system not being under- stood, the error may be followed by the most fatal consequences. It should also be well remembered, that however strongly bleeding may be indicated, Ihe moment is not far off, when this evacuation is totally inadmissible, especially if the mortification make much progress 246 " MOKTIFICATIOiY In cases of acute mortification, after as much has been taken away as may be deem- ed safe or proper, the other parts ol the antiphlogistic regimen must be continued, as long as any increased action of the heart and arteries continues. "The use of purgatives seems to be particularly required in those cases, in which tbe local inflammatory affec- tion is accompanied wilh derangemenl of the digestive and biliary organs. Anliiuonial diaphoretics are those from which 1 should be inclined to expect most advantage in Mie commencement of the attack; but, after the inflammatory action has been subdued, opiates, either alone, or combined with anti- mony, or what is still better, wilh ipecacuan- ha, as in Dover's powder, are frequently- of singular service, not only by diminishing pain, but also, by inducing a soft and moisl state of Ihe skin." (Thomson,p. 660.) A strict regimen, which may have'been useful, and even necessary, during the inflammatory stage, may have a very bad effect, if conti- nued loo long, by diminishing the patient's strength, which, on the contrary, should be supported by the most nourishing food. A vegelable diet, as Dr. Thomson ob- serves, is to be preferred in the commence- ment both of acute gangrene with inflamma- tory fever, and of chronic gangrene wilh a fever from the first of a typhoid nature. Wine and animal food given too early in dis- eases, which have a tendency to gangrene, increase the febrile heal and frequency of the pulse, oppress the stomach, render the tongue foul, the patient restless and deli- rious, and his situation dangerous, if not hopeless. In (he transition from gangrene lo sphacelus, an abatement of the sympto- matic fever usually lakes place in almost all cases, which have ultiinatel) a favourable termination Dr. Thomson beiieves, that f/iw i* the first period, al which it is safe to allow vinous liquors, or diet, chiefly animal. (P. 561.) I next come to a second very essential and important indication, to be fulfilled, as soon as the symptoms, announcing the ex- . istence of (he inflammatory stale, appear (o abate, and the patient begins to be debili- tated. This indication is to prevent excessive weakness by the suitable employment of cor- dials, and, particularly, of tonics. I hese same means also con ribute lo pbice the system in a proper state for freeing itself from the mortified parts, or, in olher words, for detaching them. For, inflammation is the preparatory step, which nature takes to accomplish the separation of mortified parts from Ibe living ones, and such salutary in- flammation cannot take place, if' the ener- gies of life be^too much depressed. In order to fulfil the above indication, it is necessary to prescribe a nourishing diet, with a certain quantity of good wine, propor- tion, d to the patient's strength, and the symptoms of the complaint. This diet is generally productive of more real benefit than the whole class of cordial and stimu- lating medicines. However, when the pa- tient is much w eakened. when the mcv: lo- cation of the part affected is complete, and the disorder is spreading to others, some o; Ibe following remedies may be ordered; ammonia, aromatic confection, a*lher, it should comprehend tue whole foot, ankle, aud part of tlie leg ; and should always be so moist or greasy as not to be likely to be- come at all dry or hard, between one dress- ing and another." When the toes are, to all appearance, Iierfectly mortified, and seem so loose as to je capable of being easily taken away, it is, iu general, thought right to remove them. But, however loose they may seem, if they be violently twisted off, or the parts, by which they hang, be divided, a very con- siderable degree of pain will most common- ly attend such operation, which therefore had much better be avoided ; for Mr. Pott has seen this very pain, thus produced, bring on fresh mischief, -*ind that of the gangre- nous kind. If the patient does well these parts will certainly drop off; if he does not, no good can arise from removing them. (Pott's Works.) In cases, in which the disorder is attended with a great deal of irritation, many subse- quent practitioners have attested the efficacy of opium ; though it has not always bad tbe same success in their hands, when the mortification depended chiefly on constitu- tional debility. Dr. Kirkland observes, that we must be careful not to force the doses, especially at first ; and that the medicine does more harm than good, when its sopo- rific effects go so far as to occasion delirium, take away the appetite, or cause affections ofthe heart. Some authors have also recommended the use of camphor, which, by reason of its narcotic virtue, has sometimes produced good effects. Pouteau attributes consider- able efficacy to it, especially in the erysipe- latous gangrene arising from wounds. In such cases, he recommends it to be given iu the dose of five grains, with a double quantity of nitre, every four hours. Few surgeons of the present day believe, that opium possesses as much power in the preceding cases, as Mr. Pott represented. While Dr. Thomson allows, that opium is much more entitled to the attention of practitioners than bark, as an useful medi- cine in the treatment of mortification, yet, "in saying so much in favour of opium, (be observes,) I would not by any means have you to place the same reliance on its powers for stopping, even the mortification of tbe toes and feet in old people, which appears lo have been done by Mr. Pott. From the trials which I have made, and which I have seen made by others, I cannot allow myself to believe, that its powers in stopping this particular sort of mortification are greater than in stopping any other form, or variety of the disease. It is obvious, however, from Mr. Pott's account, that his mind was strong- ly impressed with a very different opinion. His opinion seems to me to have been form- eel from the results of a very small number of cases, and in complete forgetfulness of tbe invaluable observations of his preceptor Mr. Sharp, with regard to the frequent spon- taneous stoppage of mortification in cases in which no ineuiciues whatever are Useci. (See Thomson's Lectures on Inflammation, p. 508.) JP. With respect to the external, or local treatment of mortification, the first indication consists in removing, if possible, such ex- ternal causes, as may have occasioned, or kept up tbe disorder ; as the compression of bandages, ligatures, tumours; all irritating substances, be. When mortification arises from inflamma- tion, which still prevails in a considerable degree, it is evident, that the dead part itself only claims secondary consideration, and that the principal desideratum is to prevent the mortification from spreading to the living circumference, by lesseningthe inflammation present. Hence, under such circumstances, the application of linen, wet with the satur- nine lotion, and the maintenance of a con- tinued evaporation, from the inflamed parts surrounding the mortified flesh, must be just as proper as if the mortification itself did not exist, and were quite out of all con- sideration. It has been justly remarked by an eminent man, (Hunter) that the local treatment of mortification, (meaning that in consequence of inflammation) has been as absurd as the constitutional; scarifications have been made down to the living parts, in order that stimu- lating and antiseptic medicines might be applied to them ; such as turpentines, the warmer balsams, and sometimes the essential oils. Warm fomentations have been also applied, as being congenial to life; but, warmth always increases action, and should, therefore, be well adjusted to the case; for, on the other hand, cold debilitates or lessens powers, when carried too far, though it first lessens action. Stimulants are likewise im- proper, as the actions are already too violent. It is proper to keep the parts cool, and all the applications should be cold. In cases of mortification from inflammation, good effects have also been seen to arise from the topical, as well as internal employment of opium. But it must be acknowledged, that how- ever proper the employment of cold appli- cations may be in principle, in cases of mortification, attended with inflammation, fomentations and emollient poultices are most commonly preferred in practice. Besides common poultices, there are several others, which have acquired great celebrity, as topical applications in cases of mortification. Of this kind are the cata- plasma carbonis,* cataplasma cerevisiae,f and the cataplasma effervescens.J These local remedies are, perhaps, in nine cases out of ten, superior to all others. With respect to stimulating and spirituous applications, such as brandy, spirit of wine, * Prepared by mixing about c.z. ij. of finely powder- ed wood-charcoal with half a puuuci of the common linseed poultice. t I'repared by stirring into the grounds of stron; beer as muck oatmeal, as will make die nuut of a suita- ble consistence. X Prepared by stirring into an infusion of malt a( much oatmeal, as will render the substance of a proper Uncknes?; and then adding about a spoonful of >*«••:'• MORTIFICATION 251 wn.sams, resins, and aromatic substances, which have been recommended by a vast number of authors, they are almost entirely laid aside by modern practitioners. Though f>uch things are indeed really very useful in preserving dead animal substances from becoming putrid, a very little knowledge of the animal economy is requisite to make us understand, that they cannot act in this manner on parts still endued with vitality ; but, on the contrary, that they must have highly prejudicial effects, in the cases under consideration, by reason of the violent irrita- tion which they always excite, when applied to the living fibres. It may now and then, however, be justifiable to apply spirituous applications to the dead parts themselves with a view of diminishing the fetid effluvia, which, by contaminating the air, have some share in injuring the patient's lie?Ith; but the greatest care is requisite to l^ ;ep these stimulants from coming into contact with the living surfaces around and beneath the sloughs. There are a few surgeons, however, who still place confidence in certain stimulating applications. "In the less acute and more chronic cases of gangrenous inflammation, as in malignant erysipelas and carbuncle, in the gangrene of the toes and feet of old peo- ple, in the sphacelating state of hospital gan- grene, and in severely contused wounds, in which gangrene and sphacelus have super- vened, the emollient poultice, which is ap- plied to promote ihe separation of the dead parts, may have an addition made to it of a greater or less quantity of the unguenturn l-esinosum, or even of oil of turpentine itself. In the more severe of these cases, where we have reason to dread the extension of the sphacelus, warm dressings, as they have been termed, which are formed by dipping pled- gets of charpie in a mixture of equal parts of the unguenturn resinosum and oil of turpen- tine, may be applied, of a temperature as hot as the patient can bear without pain ; and over these we may lay an emollient poultice, of a large size and soft consistence. " After the sphacelus stops, and the pro- cess of ulceration begins in the inflamed line of contact, between the dead and living parts, it will often be found, that the turpen- tine dressings are too stimulating, and occa- sion a considerable degree of pain. When (his happens, we must either diminish the quantity of the turpentine in the dressings, or remove it altogether, according to circum- stances. Besides the pain, a considerable extension of the ulceration would be, in general, the effect of continuing these appli- cations afler they begin to produce uneasi- ness. The ulcerating surface is, in the pro- gress of separation, liable to pass under every, mode of treatment, into the state of a painful and irritable ulcer; and in this state, it may require to be treated with decoctions of poppy-heads, or with the application of the turnip, carrot, fresh hemlock leaf, stale beer, .JfermeB^ng, poultices, kc." (See Thomson's Lemtres, p. 577, 578.) The* hospital gangrene is undoubtedly a case, which requires powerful applications, like Fowler's solution of arsenic, or the un- diluted mineral acids ; and, in Guy's Hospi- tal, phagedenic sloughing ulcers are usually treated by Sir A. Cooper with the nitric acid lotion, 50 drops to a quart of water, and the internal exhibition of the subcarbonate of ammonia. The cases also termed sloughing phagedcenaby Mr. Welbank, and considered by him as analogous to hospital gangrene, may be cured by dressing (hem wilh the un- diluted nitric acid. (See Med. Chir Trans. Vol. 11.) I conceive, that it has only been in hospital gangrene, and other cases of sloughing phagedenic ulcers, that various acids, diluted, or undiluted, other caustic substances, and the actual cautery, have sometimes proved really serviceable. The muriatic acid, diluted with six times its quantity of water, was particularly recom- mended by Van Swieten, who applied it after making scarifications. In this manner, he stopped a sloughing disease extending all over the serotum and penis. This author strongly recommends the same topical ap- plication to the sloughy state ofthe gums iu cases of scurvy. In, this kind of case, he mixed the muriatic acid with honey, in vari ous proportions; sometimes, he even em- ployed the pure acid itself for touching the parts, which were likely to slough. It is also by supposing, that the diseases referred to, were of a phagedenic character, that I account for the good effects, imputed by Dr Kirkland afnd others, in cases of mortifica- tion, to another still more active caustic-, namely, a solution of mercury in nitrous acid, with which the edges of (he living llesh were touched. At all events, if the diseases were common cases of sloughing, I infer, that such remedies were not really necessa- ry, and that nature triumphed both over the disease and the supposed remedy The fol- lowing is a case related by Dr. Kirkland : A man met with a fracture of the fore- arm, and the ends of the bones projected through the integuments. The fracture vvas very expeditiously reduced ; but, at the end of five or six days, the whole arm seemed to be completely mortified up to the shoul- der. Amputation was performed as near the joint as possible, and the stump, which bad mqrtified as far as the acromion, vvas cauterized. The following day the mortifi- cation had reached the inferior extremity of the scapula. A little of the solution of mer- cury in nitrous acid was now applied, by means of a probe, along the edges of (he parts affected, and from this moment the dis- order made no further progress. This cau- terizing was repeated every day, for seven teen or eighteen days. The sloughs, and even the scapula itself, were detached, and the patient got well. On the continent, liquid causticsare some- limes used as topical applications to gangre- nous disease's, more especially, however, iu ctivcs of hospital gangrene, and malignant carbuncle. Of this last disorder, Larrey has recorded a very dangerous example, in which he effected a cure by first cutting 2b2 MORTIFICATION away as much of the sloughs as possible, and then applying to the disorganized sur- lace underneath liquid causlics. Under the use of emollients, two persons had already fallen victims to the disease in the same family. (See Mimoires de Chirurgie Mili- taire, Tom. I, p. 53.) U ith respect to the actual cautery, Celsus recommended it to be applied to the line, which separates the dead parts from those which are still living, whenever medicines, and, particularly, topical emollient applica- tions, failed iu stopping the. progress of the disorder. Pouteau ventured to revive this practice, which had been entirely exploded from modern surgery, and he vvas of opi- nion, that the method would have the most beneficial effects, in cases of erysipelatous gangrene, which is so often seen in hospitals, in consequence of woundv For this pur- pose, he recommends cauterizing chiefly the edges of such parts, as arc of a dark red colour, and are on the point of perishing . and he advises this to be done v. ith a heated iron, or boiling oil, and to repeat the cauter- izing of the dead parts, at every time of dressing them, until the sensation of heat is even felt with a certain degree of force in the sound parts. The whole of the affected part is afterward to be covered with a large emollient poultice. Pouteau relates a case of anthrax, which took place on a woman's cheek, and which he cured in the above manner. The tumour, which, on the third day, was quite black, and as large as a walnut, was accompanied by an erysipelatous redema, which extended over the whole cheek, eyelids, and front of the neck. Pouteau, after having opened the tumour in different directions with a lancet, introduced the red hot cautery, and repeated the application several times, until the heat was felt by the sound flesh. The patient felt herself very much relieved imme- diately after this had been done ; an oppres- sive beadach, and a very afflicting sense of strangulation, which she had before experi- enced, vvere got rid of, and, in ten days more, the slough was detached on the oc- currence of suppuration. (Encyclopidie Mi- thodique, Partie Chirurgicale, Art. Gan- grene.) But perhaps, of all the species'of mortifica- tion, the hospital gangrene is that, for which the use of caustics and the actual caulery itself, has had the most numerous and respect- able advocates. The heated iron is even now employed by the first surgeons of Paris for this particular case. (See Sketches of the Medical Schools of Paris, by J. Cross, p. 84, and Hospital Gangrene.) ' The foregoing observations are introduced into this work, that the reader may not be left entirely ignorant of what violent mea- sures have been adopted in cases of mortifi- cation, and the account is not given, in or- der that such practice may be again imita- ted, with the exception perhaps of certain cases of phagedcena and hospital gangrene, cases, in which the mo.-t powerful local applications seem indispensable. See Hos- pital Gangrene, and Nitric Acid.) The coin- mon employment of these terrible applica- tions, viz. the actual cautery, the undiluted mineral acids, and boiling oils, is as unscien- tific, and unnecessarily painful, as it is un. productive ot any essential good. The grand object in almost every case of mortifi- cation, is to diminish the irritation of the partsin immediate contact wilhthose already dead. This is indicated, lest the parts still alive, and so situated, should experience the sa ';e tale as the contiguous ones. In most of the olher cases specified by Dr. Thomson, my experience leads me to prefer emollient soothing applications, none of which tire stronger than the cataplasma carbonis, or the stale beer, fermenting, hemlock, or car- rot poultices. When the process, by which a slough,is detached, is somewhat advanced, I have m*»'ii a weak solution of the extract of opium in water put under the emollient poultice, along the line of separation, give considerable ease, at the same time that it seemed to promote the changes, by which the dead parts were loosened. In the gangrene produced by pressure and weakness in persons, who are compelled by diseases and injuries to lie for weeks anil months in one posture, the mode of treat- ment is a matter of extreme importance, and frequently makes the difference of life or death to the poor sufferer. This affection usually has its seat in parts which are but thinly covered with mu-cular flesh. It oc- curs towards the latter stages ol long-conti- nued febrile diseases, as after typhus, or hectic fever, attended with tedious suppu- rations; or even without these fevers,as in paralysis, and in very bad compound frac- tures. However, as Dr. Thomson observes, there are two forms of disease, arising from pressure, which have not always been ac- curately discriminated. One of these is the preceding sort of sloughing; the other is a chafed, excoriated, and ulcerated state of the parts. Sometimes uncleanliness tends to cause this sort of mortification, that is, when the urine wets the patient's clothes. When this is the case, such irritation must be prevented by every possible means. If the skin be ex- coriated and broken, the powder of tufty, or lapis ci.lamiiiaris, should be sprinkled over the part; or if an ointment be required, says Dr. Thomson, those which contain zinc or lead are the best. But, when the ulcera- tion threatens to extend, these remedies are to be laid aside, and an emollient, hemlock, carrot, or fermenting poultice used. (P. 580-) I have seen in the irritable state of such ulceration, the solution of opium under a common linseed poultice do more good than any other application. But no topical remedies will in any of these cases avail, unless the chief cause of the disorder be removed. This is to be ef- fected by change of position, and laying pillows and cushions of the softest materials in convenient places under tlm patie*; not directly under the disease itsW, but in situ- ations where they will tend lo raise the MORTIFICATION parts affected from the contact of the bed- ding. A circular hollow pillow will often accomplish this important object; but, when possible, an entire change of posture is to be preferred. When sphacelus succeeds to gangrene from pressure, I have often seen campho- rated spirit applied ; but never with decided advantage. A common emollient pouItic*b, and in very bad cases, the topical use of the solution of opium along the living margin, are the means upon which I place most reli ance, care being taken to improve the ge- neral health,without which grand indication, neither the removal of the pressure, nor the virtues of any dressings, will answer. Dr. Thomson speaks most highly of the ferment- iug poultice, which I believe to be in these cases an excellent application. He confesses, however, that he has sometimes found it too stimulating, and been obliged to substitute the simple emollient, carrot, or turnip poul- tice. (P. 580.) When mortificatibn arises from cold, every sort of warm emollient application must be avoided, and cold water, or even snow, or ice, employed. See Chilblains. The local treatment of the mortification of the toes and feet, as described by Mr. Pott, has been already considered, and is that to which my observations incline me to give the preference. •*"' The gangrenous affection of the pudenda, to which female children are liable, was successfully treated by Mr. K. Wood by ap- plying the liquor plumbi acet. dilutus in a tepid state, and bread poultices made with the same lotion. As soon as the ulcers be- came clean, they were dressed with the un- guenturn zinci. (See Med. Chir. Trans. Vol. 7.) Other cases, which also ended well, have been dressed with lint, dipped iu cam- phorated spirit, and covered with a poul- tice ; or, at first, poultices made with the opium lotion, and after the separation of the sloughs, the ulcer was dressed with port wine and decoction of bark in equal pro- portions. In some cases, however, mild stimuli proved injurious. (Jameson Inflam- mation,p. 289.) The old practitidners used to give vent to putrid matter, by making deep scarifications in the integuments. The majority of authors who have treated of mortification have very much insisted upon this plan, which they recommend in all cases. They even advbe the incisions to be made down to the sound parts, in order to facifitate the application of topical stimulants Tind to favour the ope- ration of the supposed antiseptic qualities of these dressings. But, with the exception of cases, in which the gangrenous parts lie un- der an aponeurosis, or others in which the integuments, which have escaped destruc- tion, cover a mixture of matter and sloughy cellular substance, either in consequence of foregoing inflammation, or any other cause, such as the extravasation of urine in the scrotum, all scarifications which penetrate as far as the living parts, are often produc- tive of fhe most serious mNchief, instead of advantage. Such incisions cannot be prac- tised, without occasioning a great deal of pain, and producing inflammation, which often makes the mortification spread still further. But, as parts, which are in a com- plete state of sphacelus, are absolutely ex- traneous substances, in regard to those which still retain their vitality, all such portion of them as is already loose should be removed. By lessening the size of the putrid mass, the fetor is diminished, an outlet may sometimes be made for the escape of a great deal of putrid discharge, vvlp'ch, being confined, mi^ht have a bad effect on the neighbouring living parts ; and the latter are enabled to free themselves more easily from the rest of the sloughs. The too common practice of accelera- ting, with a cutting instrument, the separa- tion of the mortified parts, previously to the completion of the process, by which nature breaks the connexion between them and the- living flesh, in general ought to be strongly reprobated, as causing unnecessary pain, and irritation, and creating the risk of a renewal of the sloughing. As far as my experience goes, gangrenous phagedcena is (he only in- stance, in which it seems useful to remove the sloughs, before they are loose, so as to let the topical applications extend their ac- tion without delay to the subjacent living surface. (See Hospital Gangrene.) Pott's sentiments, with respect to the danger and inutility of cutting the tendonsand ligaments, in the mortification of the toes and feet, have been already stated. If the surgeon prudently await the event of things, the separation of the mortified from the living parts will soon follow the establishment of inflammation and suppura- tion at the edges of the slough. But when the whole thickness of a limb is affected with mortification, ought the sur- geon to leave things to nature ? or ought he to have recourse to amputation. In t-cneral, ihe performance of amputation is indispensable; not that nature would not in many instances detach the sphacelated part; but, because a great length of time would be required for lhe> completion of the pro- cess, and a serviceable stump would rarelv be left. ^ Another important question then arises, Should the surgeon amputate, while tlie mor- tification is in a spreading state ? Or ought he to defer the operation, until a line of se- paration begins to form between the dead and living parts ? " Amputation (says a distinguished profes- sor) was long regarded as one of the mos'. effectual means which could be employed to prevent the extension of gangrene. This practice, however, has not received the sanction of experience ; on the contrary, it has been generally found, wherever it has been practised, in either acute or chronic gangrene, to accelerate much the progress of the disease; and, in this way, to hasten the death ofthe patient. The parts, which were divided in amputation, though at a distance from a spreading gangrene and from sphac.e- ah aiottTiriLvnoN. lus, were found speedily to assume the ap- pearance of the affection, for w hich the ope- ration had been performed. Till, therefore, the adhesive inflammation comes on, and a dis- tinctly marked separation ofthe dead from the sound parts takes place, amputation is, in few, if any cases of mortification, admissible. We never know, previously to this, where a gan- grene, or sphacelus, is to stop, nor whether the powers of the constitution be sufficient to sustain the injury that the mortification has inflicted. F.ven when the adhesive in- flammation comes on, it is in most cases best to allow some time to elapse before we operate, partly with a view to give time for the constitutional symptoms to abate, in other instances, to" allow the patient's strength to be recruited by nourishment and cordials ; and partly also with a view to learn whether the constitution ofthe patient be indeed capable of so great a fresh shock, as that which amputation must necessarily occasion." (See Thomson's Lectures, p. 582.) According to Richter, there is never any certainty, that we are amputating in living parts. Mortification rapidly ascends along the cellular substance, surrounding the large blood-vessels, and is frequently much more extensive internally, than external appear- ances would lead one to suppose. The ad- jacent surface, still apparently alive, is often so affected, that it must inevitably slough, though, at present, it may not actually have sphacelated. The surgeon imagines, that am- putation is performed on living parts; but, ?oon afterward discovers, that he has been dividing those which are dead. The opera- tion, he observes, can do no good, while the mortification is in a spreading state, and it may do considerable mischief, l'he disorder enlarges its limits, because its cause still operates, and this is not removable by ampu- tation. If the operation be now injudicious- ly undertaken, the sphacelus invades fhe wound, and is the more certainly mortal, as the patient has been further weakened by amputation, and its consequences. Many mortifications, especially those which arise from external causes, very often spon- taneously stop and separate. But the place where this will happen, can never be fore- seen. By amputating in this circumstance, we run a risk of disturbing nature in her sa- lutary work, and rendering the disorder fatal" The following are the only cases, in which Richter allows that the use of the knife is justifiable and proper. There exists a spe- cies of sphacelus, which rapidly occasions death, before it is yet of great extent. Here indeed, amputation might be really advisa- ble ; but, the nature of the case is unfortu- nately never disclosed,before the fatal catas- trophe. Some external injuries would be, without the operation, inevitably followed by mortification. In such cases, early amputa- tion is evidently proper ; for, the simple in- cision is attended with less danger than sphacelus. Sometimes, says Richter, a spha- celus spontaneously ceases to spread. This happens most frequently in cases which originate from an external cause. <=t!ch as a violent contusion, burn, be. But, (he occur re nee is not restricted to this kind of case. nor is it invariably attendant on it. When there are no other occasional causes present, the mortification does not readily go beyond tbe limits of Ihe contusion,.or violent burn ; but the interference of surgery can hardly ever put a stop to its progress, before it has spread as far as the extent of the local injur**,-. (Anfan-is-irundt der Wundarzneykunst, Band. 1, hup. 3.) How different are the doctrines of Baron Larrey upon this subject from those enter- tained by Richter, and, indeed,tbe generality of eminent modern surgeons " Writers on gangrene, or sphacelus of the extremities, (says Larrey) indiscriminately recommend the amputation of a sphacelated limb never to be undertaken before the mortification is bounded or limited by a reddish circle, form- ing a true line of separation between the dead and living parts. This circumstance can only occur in a case of spontaneous gangrene from an internal cause; or if it happens, as is very unusual, in a case arising from a wound, its progress is different, anil it would be exceedingly imprudent to wait for it. The gangrene from external injuries almost always continues to spread ; the infec- tion becomes general; and the patient dies' (Mim de Chirurgie Militaire, T. 3, p. 142.) Respecting the want of foundation for this hypothesis of infection, I need here offer no remarks, having already expressed my opi- nion upon it in a foregoing page. On the other hand, Larrey asserts, that, in the dry. or spontaneous gangrene, absorption takes place with more difficulty, and it is not un- common to see the sphacelated parts sepa- rate from the living ones by the powers of nature alone, without the general functions being impaired. He argues that there is a manifest difference between what he terms the traumatic and the spontaneous gangrene, or, in other words, between the humid gan- grene from an external cause, and the dry gangrene, which ordinarily proceeds from an internal cause. (P. 14-*.) In cases of mortification, arising from ex- ternal injuries, Larrey maintains, that, " not- withstanding any thing that writers and prac- titioners may ailege to the contrary, we should not hesitate about promptly perform- ing amputation, as soon as the necessity for the operation is decidedly established. There is no reason to apprehend, I hat the stump will be seized with gangrene, as in the spon- taneous mortification,which has not ceased to spread, because the trmmatic gangrene, afttr having arisen from a local cause, is only pro- pagated by absorption, and a successive affec- tion of the texture of parts by continuity of the vessels. Amputation, performed in a proper situation, stops the progress and fatal consequences of the disorder. " Supposing then the lower half of the leg should be affected with sphacelus, in con- sequence of a gunshot injury, attended with a violent contusion of the part, and a forcible concussion of the vessels, nerves, and ligaments, if the «kin i« f*l«evvhere nnin- MORTillLAilu.v 2bu jured, the operation may be done in the place of election, without any fear of the stump becoming gangrenous, notwithstand- ing the cellular membrane of the upper part of the member may be already affected. But, when the skin ofthe whole leg is struck with mortification, the operation must be done on the thigh, and no time should be lost. The same practice is applicable to the upper extremities We must be careful not to mistake a limb affected with stupor for one that is actually sphacelated. In the first case, warmth, motion, and sensibility are still retained, although tbe skin may be blackish and the parts may be swollen. Besides, if there were any doubt, it would be proper to try at first tonic repellent applications, and cordial medicines, be." (See Mim de Chirurgie Militaire, T. 3, p. 152, 153.) When amputation has been practised, this author recommends the exhibition of bark, good wine, tonics, &.c. in order to pro- mote the good effects of the operation. (P. 154.) " The facts (says Larrey) which I shall relate in the course of this dissertation, will prove, d think, in an incontestable manner, the truth of the principle which 1 lay down, that when gangrene is the result of a mechani- cal cause, and puts the patient's life in danger, amputation ought to be performed, without loading until the disorder has ceased to spread. " I have been a witness of the death of several individuals, from too rigorous an ad- herence to the contrary precept; and, at length, grievously impressed with this loss, 1 had long ago determined to depart from an axiom, which was always considered by me as false. Besides, following the maxim of Celsus, I preferred employing an uncer- tain remedy, rather than abandon the pa- tient to an inevitable death. Satius est enim anceps auxilium experiri qudm nullum. " I made the first attempt at Toulon, in the year 1796, upon a soldier, who, in con- sequence of a violent contusion of the foot, was afflicted wilh a gangrenous ulcer, which soon threw tbe whole part into a sphacelated stale. While the mortification was yet spread- ing, I resolved to amputate the leg. The success of the operation surpassed my ex- pectations ; the stump healed ; and, in less than forty-five days, the patient got quite well. This case served to encourage me. " During the siege of Alexandria, in fc-gypt, in 1801, a second case, very analogous to the preceding, occurred in my practice; it happened in a dragoon of the 18th regiment, whose fore-arm and afterward arm sphace- lated, in consequence of a gunshot wound in the articulation of the left arm. The mor- tification had extended nearly as high as the shoulder, and the patient's life was in great danger, when I determined to amputate the limb at the shoulder-joint. The disorder was manifestly spreading, and the patient's brain already affected, for he had symptoms of ataxia ; the operation, however, arrested :bc progress of the sloughing, and Paved tbe patient's life, who, al the conclusion of tho siege of Alexandria, was quite cured. " After the taking of Ulm, M. Ivan, sur- geon to his majesty the Emperor, performed in my presence, and at my ambulance es- tablished at Elchingen, the amputation of the thigh of a soldier belonging to the 76th regi- ment of the line, the leg having sphacelated in consequence of a gunshot injury. The gangrene was not limited, and evidently ex- tending itself; yet, the effects of the dis- order were destroyed, and the patient was quite cured on our re:urn to Austerlitz. " A fourth patient, an officer in the samr* regiment, shot iu the ankle, at the capture of the same town, was conveyed to my ambu- lance, in order to be dressed : it was the third day after the accident; the foot was gangrenous, and the leg was swelled, and threatened likewise with mortification. Fe- brile symptoms had also come on. 1 has- tened to amputate the leg a little above the place of election. The cellular membrane of the stump, of a yellow blackish colour, was already infected with the gangrenous principle (as Larrey terms it.) The opera- tion, however, stopped the progress of the mischief; suppuration took place in the stump ; some sloughs were detached ; the wound assumed a cleaner appearance , and cicatrization was completed on the fifty- second day. The patient could already walk with a wooden leg, when he caught the hospital fever, which was epidemic at Ulm, where he awaited bis regiment, and, to my great regret, he was carried off by this dis- ease, after having escaped the former danger. " After the battles of Austerlitz and Jena, (continues Larrey,) several of mycolleagues, surgeons of the first class, undertook, in consequence of my advice, and the exam- ples of success which I had recited to them, the amputation of limbs equally sphacelated, although the mortification was not limited, rather than abandon the patient to a death, wliich appeared inevitable. In general, these practitioners experienced the same success as I did myself." {Larrey, in Mim.de Chirur- gie Militaire, T. 3. p. 154—157.) In Larrey's memoir upon this subject, there are some additional facts and argu- ments in favour of what he endeavours to prove, viz. that, in cases of mortification from external injuries, if the patient's life is in danger, amputation ought to be performed, although the sloughing may yet be in a spreading state. I must be content, however, w*h having stated the particulars already explained ; and the reader, desirous of more, must refer to Larrey's own publication. Cer- tainly, the facts, which this gentleman has adduced, are highly important: they tend to subvert a doctrine, and to prove the error of a practice, which have been urged in most forcible terms by most of the distin- guished surgeons of modern times. The sentiments of Mr. Sharp are rendered ques- tionable; and the truth ofthe positive assertion of Mr. Pott is yet a matter to be examined. The latter, it i<> well kno\vn: tells us, that he. MURTIFICAIIO.N lias oflen seen tiie experiment made of am- putating,while a mortification was spreading, but never knew it answer. Are we to con- clude, that all these cases, which Polt -alludes to,'were mortifications from an inter- nal cause ? Or, are we to suppose that the operation failed from having been delayed too long ? Or, must We imagine, that the nature of the human constitution has been changed between the era of Pott, and that of Larrey ? It should be remarked, that Ihe practice of amputation, in cases of spreading morti- fication, has generally find some partisans for many years past ; but the weight of au- thorlies has unquestionably been against it, and few surgeons in this country have ven- tured to deviate from the advice of Sharp and Polt. It is curious, however, that Mehee, a writer who wrote for the express purpose of declaring his disapprobation of the early performance of amputation in gunshot wounds, should have admitted of only one case, in which the operation is proper, namely, gangrene succeeding the wound made by a cannonshot. Here he thinks, that am- putation ought to be performed on the first appearance of the gangrene, in order to prevent it from spreading up the limb. (See Traiti des Piaiesd'Armesdfeu. Paris, 1799.) It appears, lhnt abmit the year 1809 Mr. A. C Hutchison performed with success two amputations in cases of spreading gangrene from.gunshot wounds. (See Practical Ob- servations on Surgery, p. 72.) My friend Mr. Lawrence has also success- fully amputated at the shoulder joint in a spreading mortification of the arm, the con- sequence of external violence. " The skin of tbe amputated limb was greenish and livid; but the cuticle not yet detached. The cellular substance distended with air, and with a discoloured offensive smiies ; its ap- pearance was not quite natural, where the incision took place ; it was yellowish and anasarcous. Small effusions of blood were observed here and there in the course of the nerves ; even as high as the amputated part. No coagulation of blood in any of the arte- ries, even down to the ulnar and digital branches. All tbe soft parts were disco- loured, dark red, an I livid, and a frothy reddish fluid issued on incision." This case had the most favourable termination, and it clearly proves, thai the humid kind of gan- grene, which occurs in a healthy subject from severe local injury, which so rapidly affects a whole limb, and reaches the trunk in a few hours, must constitute an exception to the general maxim, that amputation should never be done, before a line of separation is established between the dead and living arts. Mr. Lawrence, however, would not e understood as meaning lo recommend the practice in all instances of mortification from local injury. He conceives, inat a gangrene may arise, in an unsound constitu- tion, from a comparatively slight accident; so that it may be regarded as the result of constitutional disposition, rather than of the focal cause. Amputation would bt hopefo s under such circumstances. II is particularly in mortificution,following very severe injury, in a subject otherwise healthy, that Mr. Lawrence believes Ihe operation to be pro- per. (See Medico-Chir. Trans. Vol. 6, p. 184.) Mr. Lawrence also reports another in- stance, in which he saw the operation suc- ceed, though (he mortification was in a spreading state. About three years ago, I was asked my opinion about the propriety of amputating at the shoulder in a spreading mortification of the arm from external vio- lence. The operation was done, and (he patient lived a fortnight afterward, which is favourable to the practice, inasmuch as be would certainly have perished in a few hours, if the operation had not been done. Among the experienced approvers of Lar rey's advice, I must not omit to mention Dr. Hennen, who has repeatedly amputated, under the circumstances above pointed out, without waiting for Ihe line of separation: " and (says he) although I certainly was not uniformly successful, I have no reason to imagine, that death was occasioned by a de- parture from the rule so generally laid down by auihors." (On Military Surgery,p. 243. Ed. 2.) With regard to the early performance o^ amputation, where the substance of a limb perishes after exposure to cold, I find some difference of sentiment between two very high authorities. {Thus Schmucker observes: " The mortification, which comes on after a part has been frozen, increases so rapidly, it the limb be exposed to wann'h, that, in (he space of twenty-four hours, its vitality and organization are quite destroyed, and no- thing will now avail in restoring its sensi- bility. Here the speedy performance of am- putation is the only means of preservation to be depended upon. In mortification from an internal cause, the case is different." (See Vcrmischte Chirurgische Sehriflen,B.l, p. 15, 8i;o. Berlin, 1785.) According to Larrey, however, thi- species of gangrene at length stops, and a line of separation forms between ihe dead and healthy parts. If the disorder be superficial, the sloughs are usually thrown off between the ninth and thirteenth days, leaving an ulcer of propor- tionate extent, that soon heals up. If the whole of the limb be sphacelated, nature cannot of herself effect a cure, or but very rarely, the patient mostly falling a victim to the effects of absorption, when (he sloughs are detached, and the mouths of the lym- phatics are opened on the occurrence of suppuration. Larrey assures us that he has seen numerous palienis carried off by ibis cause, wutle the examples of a spontaneous cure were exceedingly few, and, in theu; lo amputate the mortified portion of the limb, but n-.d before the extension of tht gangrene has ceased, and the mischief ;' MOR MOX 257 bounded by an inflammatory line. (See Mem. de Chir. Mil. T. 3, p. 65—72.) In tbe article amputation, notice has been taken of a sloughing, which commences in the foot, and extends up the leg, and sometimes .. follows gunshot injuries of ihe thigh, which involve (he femoral artery : this is a case particularly instanced by Mr. Guthrie, as re- quiring the very early performance of am- putation. Sir Aslley Cooper also refers lo cases, in which the rule was successfully de- viated from, of not amputating, before limits are sel lo the spreading of mortification ; the instances in question arose from injury of blood-vessels, and other local violence, in patients of a healthy constitution. In such cases, it is admitted by this very experienced surgeon, that the practice should be different from what is usually pursued in mortification from constitutional causes. (Surgical Essays, Part 2, p. 1S6.) Fabricii Hildani Tract.Methodicus de Gan- grena et Sphacelo. Quesnai, Traiti de la Gangrine, \2mo. Paris, 1749. Encyclopidie Mithodiqur, Partie Chirurgicale, Art. Gan- grene, kirkland on Gangrene, and on the Present State oj Medical Surgery. Richter, Anfangsgr. der Wundarzn. B. 1, Kap. «3. Various parts of Hunter on Inflammation, fyc. Sharp's Critical Inquiry into the. present State of Surgery, Chap. 8. Richerand, Nosographie Chir. T.\, p. 215, fyc. Edit. 4. Lassus Pa- thologie Chir. T. \,p. 30, fyc. Edit. 1809. Leviilli, Nouvelle Doctrine Chir. T. 4, p. 321, fyc. Paris, 1812. Larrey, Mimoires de Chirurgie Militaire, T. 3, particularly the Mim. sur la Gangrene de Congilation,p. 60, and that sur la Gangrene Traumatiqne,p. 141. Callisen, Systema Chirurgie Hodicrne, Vol. 2, p. 374, Edit. 1800. Dr. J. Thomson's Lectures on Inflammation, p. 501, Edinb. 1813.0'Halloran on Gangrene and Sphacelus, Svo. Dublin, 1765. Pott's Obs. on the Mor- tification of the Toes and Feet in his Chirurg. Works, Vol. 3. J. Kirkland, Thoughts on Amputation, fyc. wilh a short Essay on the Use of Opium in Mortification, 8co. [jondon, 1780. J. Harrison, The remarkable Effects affixed Air in Mortifications of the Extremi- ties, Sro. Lond. 1785. J A. Murray, In Gangrenam Scroti Obs. (Frank. Del. Op. 10.) C. While, Observations on Gangrenes and Mortifications, accompanied, fyc. with convul- sive spasms, 8co. 1790. Pearson's Principles of Surgery, p. 114, Edit. 2. Lawrence in Medico-Chir. Trans. Vol. 6, p. 184, fyc. Del- pech, Mimoire sur la Complication des Plaies el des Ulcires, connue sur le Nom de Pourri- ture d'Hopilal; also, Precis Elimentairi des Maladies Rcputies Chirurgicales, T. I, p. 73, fyc. Paris, 1816. Boyer, Trailis des Ma- ladies Chir. T. 1, p. 105, fyc. Paris, 1814. John Bell's Principles of Surgery. Professor Himly's Abhandlung uber der Brand der IVeichen und harten Theile, Gut. 1800. For an Account of the dry gangrene, see particu- larly the Writings of Hildanus, Tulpius, Quesnai Mimoires de la Socieli Royale de Midecine, Tom. 1. Opere di Bertrandi; Me- dical Museum, fyc. For a description of the rtortification caused by eatingcockspur-rye, see ■*••' II. 33 Dodard s letter in Journal des Savans, 1676. Noel, in Mim. de I'Acad. des Sciences, 1710. Langius, " Descriptio Morborum ex esu Cla- rarum Secalinorum." Duhamcl, in Mim. de I'Acad. des Sciences, 1748. Dr. C. Woolaston, in Philosophical Trans. 17G2. Tessier, in Mim. de la Socieli hoyale de Midecine, T. 1, and 2, fyc. 0. Presscott, A Dissertation on the Natural History and Medicinal Effects of the Secale cornutum or Ergot. 8vo. Lond. 1813. D. F. Heffter, Doctrine de Gangrana brevis Expo.ritio, 4to. Lips. 1807. C. L..G. Liessehing, De Gangrena, 4to. Gott. 1811. Hennen's Principles of Military Surgery, p. 241, fyc. Ed. 2, 8t>o. Lond. 1820. G. J. Guthrie on Gunshot Wounds, fyc. p. Ill, fyc. Ed. 2, bvo. Lond. 1820. J. H dames, Obs. on the Principles of Inflammation, p. 84.287, fyc. Svo. Lond. 1S21. Sir Aslley Cooper, Surgical Essays, Part 2, p. 186, 8ro. Load. 1820. MOXA. A soft lanuginous siibslance pre- pared from the young leaves of a species of mug wort. It is used in the following way : A little cone e-f-"Llhe moxa is laid upon the part, previously^lioislened, and sel on fire at the top. It burns dowu wilh a (emperate glowing heat, and produces a dark-coloured spot, the separation of which is promoted by applying a little garlic. The ulcer is left to discharge, or is healed up according to the obje-ct in view. The moxa is famous in the East for curing several diseases; nnd the French are much in the habit of using it ; but, when English surgeons wish to produce a slough, they generally have recourse to caustics, in preference to actual fire. M. Roux. when he visited the London hos- pitals, hid two opportunities afforded him of applying the moxa, in order to convince Ihe rising generation of surgeons in this country of its superior efficacy. The first was in a ca--eof spontaneous paralysis of the deltoid muscle at St. Bartholomew's. Tbe moxa was applied a little below the acro- mion, and a lew days afterward the motion of the arm began lo be restored. This, however, was a cuse, which, according to the account of Roux himself, had relapsed, after having been cured by other means. I think one of the surgeons of St. Bartholo- mew's informed me, that notwithstanding Ihe moxa, the relief proved again only tem- porary. If, however, the moxa had suc- ceeded, a caustic issue, a blister, or volatile liniments, would probably have answered equally well. The second instance, in which M Roux applied tbe moxa, was a case of white swelling at Guy's Hospital ; but the disease had advanced too far to allow any hope of a favourable issue. (See Voyage fait a Londres en 1814, ou Parallile de la Chirurgie Angloise avec la Chirurgie Fran- caise, p. 19, 20.) M. Roux flatters himself that, " les chirurgiens Anglois ripugneront sins doule moins a Vavenir dfaire usage du moxa." The truth is, English surgeons, as well as English farriers, knew very well be- fore (he arrival of M. Roux w hat might be done with moxa aud the actual cautery. But, though the anp,;'.-ition cf fire still p:*-** Ida MlUlAilC AclW. vails in (he veterinary art, as a mode of curing diseases, it has long been abandoned as a means of relief in the English practice of surgery : not on tbe ground of its being always ineffectual-, but, because equal good has been found (o result from measures, which are milder, always less terrific, and frequently less painful. In order to con- vince an English surgeon that moxa and ihe actual cautery ought to be introduced into practice, M. Roux should prove, that there is at least some particular disease, which may in this manner be cured, but which cannot be cured by olher means, ordinarily em ployed in our practice. He should also make us forget, that the application of actual fire was once as common in English surgery as in French ; but that it had not attractions enough to maintain its ground. MURIATIC ACID. Acidum Muriaticum. Gargles, containing this acid, are often made use of with advantage in various cases of sore throat, and the disease known by the name of cancrum oris. The following for- mula is employed at St. Bae^olomew's Hos- pital. £{.. Rosaj rubra? exsiorata* 3'j- Aquffi ferventis Jfcj. Infunde per horam diraidiam, dein colaet adde Accidi murialici 3j- Mellis Rosae f ij. Saccbari purificati 3v'j- Misce. Muriatic acid appears to have been tried in syphilis earlier than the nitric, Dr. Zeller, of Vienna, having employed it as a success- ful remedy for this disease ever since the year 1789. (Vid. Sim. Zeller's Prakt. Bemerk ilber den vorzugl. Nulzen d. allerem. bekannt. Badeschwamens, fyc. Nebst. einem Anhange v. d. Salzaure, fyc. Wien. 1797.) As a medicine capable of improving the appearance of venereal ulcers? and of re- straining for a time the progress of the dis- ease, it has been known to Mr. Pearson many years. He says, that he was first in- duced to give this acid iu venereal ulcers of the tongue,and of the throat, in consequence of the great benefit which he had seen re- sult from its use in examples of cancrum oris: and without viewing it as an antidote for lues venerea, he has frequently availed himself of its useful qualities, when it was desirable to gain a little time previously to the commencement of a mercurial course. (Obs. on the Effects of Various Articles in the Cure of Lues Venerea, p. 193, Ed. 2.) From what he saw, however, he never inferred that tbe sulphuric and muriatic acids could radically cure the venereal disease ; and he ascribed the benefit derived from them partly to their salutary effects on the sto- mach and constitution, and partly to their agency on ulcers of the throat and tongue, as focal applications. (P. 117.) When Mr. Pearson made these observations, the fact, which has now been so unequivocally de- monstrated in the army hospitals,that nearly, if not all, the forms of disease, going under the name of syphilis, maybe cured without mercury, had not undergone the strict and impartial investigations which have of late years been devoted to the subject. (See particularly Obs. on the Treatment of Syphi- lid, with an account of several cases of that disease, in which a cure tvns effected without the use of Mercury, by T. Rose, in Medico- Chir. Trans. Vol. 8, p. 349) If this point be admitted as fully established, (he ques- tion about the antisyphilitic virtues of vari- ous articles of the materia medica requires to be taken up in a very different light, not clouded wilh a notion that the disease will certainly get worse and worse, if no remedy whatever be exhibited, or that it cannot finally get well of itself. While these doc- trines prevailed, the amendment of any sy- philitic affection during the use of muriatic, or any other acid, was entirely referred to some specific effect, supposed to appertain to such medicine. But now the question involves several considerations; first, the actual virtue of the medicine in expediting the cure of the disease; secondly, the changes which might happen if the com- plaint were left to itself; and thirdly, the benefit sometimes ascribable to the improve- ment produced in the constitution, under particular circumstances, by the discontinu- ance of mercury. The latter mineral no longer claims the name of a specific for the venereal disease, either in the sense of the only, or a completely certain, antidote; be- cause nature herself would in time bring most cases to a favourable conclusion; be- cause the cure can be completed hy a variety of other medicines, noticed in this publica- tion; and, lastly, because mercury, though it may be generally the quickest means of cure, is, in particular cases, complicated with much debility and constitutional irrita- bility, the surest medicine for aggravating the complaint, and preventing any progress towards a favourable termination. Here it is enough to know, (and Mr. Pearson him- self acknowledges tbe fact) that in the cir- cumstances above specified, muriatic acid is a safer medicine than mercury. The dose is from ten to twenty drops, which are to be mixed with a proper quantity of water. Muriatic acid has sometimes been em- ployed as the active ingredient in injections for the cure of gonorrhoea, in the proportion of eight or ten drops to four ounces of dia- tilled water. In cases of poison from muriatic acid, the experiments made by Orfila lead him to con- sider calcined magnesia and prepared soap the most fit substances for neutralizing such portion of the acid as may not yet be com- bined with the texture of the oesophagus, stomach, be. They should be given as soon as possible after the corrosive poison has been swallowed, care being taken to let the patient drink copiously of warm water, milk, broth, or some mucilaginous diluting liquid. When, from the symptoms, there is reason to believe that inflammation exists in the viscera, or when spasms and convulsions come on, antiphlogistic remedies, and anti- spasmodics, are indicated. (Traiti des Poi- sons, p.476, Vol. 1. Ed.2, Paris, 1818.) I" order to detect the presence of muriatic acid, when mixed with wine or other fluids, we are recommended to distil a portion of it from a small retort, over a caudle,into * HJEVUb. 259 filial containing a solution of nitrate of sil- ver. The precipitation of muriate of silver, which is soluble in ammonia, but not in nitric acid, will take place if the poison contain muriatic acid. (Thomson's Dispen- satory, p. 434, Ed. 2.) By Morveau, who employed himself in investigating the merits of Dr. Carmichael Smith's mode of destroying infection, the muriatic acid, in the new form of gas, was alleged to have the very important cpiality of neutralizing putrid miasmata. The gas is extricated from common salt by means of sulphuric acid In this way it is often em- ployed in hospitals as a mode of preventing and obviating infection. The use of muriatic acid, as an application to certain cases of sloughing, and phagedce- na, has been explained in the articles Hos- pital Gangrene and Mortification. MYDRI'ASIS. (from pa£*u, to abound in moisture.) A preternatural dilatation of the pupil. N. ■jVT^VUS. (Congenite Note; Envies; JLl Multer-mahl; Mother-spots, fyc.) A mole, or congenital mark, or excrescence of the skin. Naevi materni signify the little spots, excrescences, orswellings, with which many children are born. Some of them (says Dr. Bateman) are merely superficial, or stain-like spots, and appear to consist of a partial thickening of the rete mucosum, sometimes of a yellow, or yellowish brown, sometimes of a bluish, livid, or nearly black colour. To tliese the term spilus has been more particularly appropriated Others again exhibit various degrees of thickening, elevation, and altered structure of the skin itself, and consist of clusters of enlarged and contorted veins, freely anastomosing, and forming little sacs of blood These are some- times spread more or less extensively over the surface, occasionally covering even the whole of an extremity, or one half of the trunk of the body ; and sometimes they are elevate'd into prominences of various form and magnitude. Occasionally, these marks are nearly of the usual colour of the skin ; but most commonly they are of a purplish red colour, of varying degrees of intensity ; such as the presence of a considerable col- lection of blood-vessels, situated near the surface, and covered with a thin cuticle, na- turally occasions. (See Baleman's Practical Synopsis of Cutaneous Diseases, p. 324, Edit. 4.) When a narvus is of a dark red colour, its intensify is generally augmented by every thing which tends to accelerate the circula- tion ofthe blood. Fits of anger, hot wea- ther, fevers, and the period of menstruation, in particular, are observed to be attended with an increased turgescence and disco- louration of the part affected. Indeed the excrescence sometimes bursts, and pours out a dangerous quantity of blood, and in fe- males it has been known to become the seat of a regular menstrual discharge. (Boyer, Traili des Maladies Chir. T. 2, p. 277; and John Bell's Principles, Discourse 9.) Some na?vi, especially those usually called moles, frequently have long irregular hairs grow- ing upon them ; while the surface of others is streaked, and even granulated. Such as appear in the form of a mere red, purplish slain, have been absurdly supposed to arise from a desire for claret, or some other wine of f hat colour, entertained by the mother of the patient during her pregnancy. The granulated naivi have been compared with raspberries, strawberries, mulberries, be. for which (he mother's longing is ascribed by (he vulgfi-.' as a cause. The truth is, howe- ver, that this doctrine, imputing the origin of na*vi to fancies of the mother, is neither consistent with experience nor sound phy- siology. The causes (as Callisen observes) " potius autem in evolutione primorum fla- minum, a natura? solita via aberrante, uti in aliis rebus monslrosis qua?renda* erunt.'' (Syst. Chir. Hoditrve. Vol. 2. p. 201.) From what has been said, then, it appears that certain naevi are merely cutaneous spots, of a red, violet, or purplish colour, of greater or lesser extent, and with scarcely any perceptible elevation. They are an organic malformation ofthe skin, the natu- ral texture of which does not exist, but has substituted for it a plexus of vessels, not en- dued with the natural sensibility ofthe cutis itself. Tliese na*.vi generally continue sta- tionary during life, and may be regarded rather as a deformity than a disease. (Lassus, Pathologie Chir. Tom. I, p. 477.) Other na*vi are either of the same nature as the disease, well known by the name of the aneurism by anastomosis, or bear a consi- derable resemblance to it. They are some- times of great size, and their shape is subject to much variety. They are soft and indo- lent, and of a violet or dark red colour. The skin which covets them is very thin, and, when they are* opened, their structure is like that of a spleen, whose blood-vessels are varicose. Some are covered with a delicate white skin, and do not increase with age. Others are more disposed to grow large. These tumours frequently occur in the skin ofthe face, and in other parts of the integu- ments, on the inside of the labia pudendi, and cheeks, and in the substance ofthe up- per and lower lip, where they sometimes form a kind of elongation, attended with great disfigurement. Najvi of this kind, so situated in new-born infants, may produce a serious obstacle to the action of sucking. M. A. Severinus has particularly described them under (be appellation of " tnberciilum atro-cruentum labii inferioris." (DeAbsc'es suilm natura. Cerp. 2'Kp. 803) ■260 VECROSIr* The nar-vi, which form in the subcutane- ous cellular substance, and vvere named by Petit "* loupes var'upienses," (CEiures Post- humes, Tom. i, p. 276.) are also of the same nature as the aneurism by anastomosis. In time, they attain a very large size. Mr. Latta says, he once saw in a ctiild, two years old, a tumour of this kind weighing fourteen ounces, which, at the time of birth wasonlyequalinsizetoalargebean. During the first year, it did not enlarge much ; but it afterward grew rapidly to the size already specified. (System of Surgery. Vol. 2, Chap. 22.) Lassus has even seen a tumour of this description as large as a man's head. (Pa- thologie Chir. Tom. I, p. 479.) Having treated particularly of the " aneurism by anastomosis," iu another place, (see Aneu- rism,) I shall merely repeat the necessity there is for cutting every particle of tbe disease away, every portion of tbe congeries of vessels and cells of which it consists, whenever it is meddled with at all. Punc- turing the swelling, or the partial removal of it, has cost many persons their lives by hemorrhage, as the records of surgery folly prove. (Petit, Traiti des Maladies Chir. T. 1 ; Lassus, Pathologie Chir. T. 1, p. 484, fyc.) Although the original causes of navi are buried in obscurity, experience proves, that whatever produces irritation in the part af- fected, or an inirea«ed determin-ition of blood to it, has generally the effect of acce- lerating (he srowth and enlargement of Ihe swelling. Ttius, a trifling bruise, or a light hat, will sometimes excite a mere s(ain-like speck, or a minute livid (ubercle, into that diseased action, which occasions its growth. (Baleman's Pract. Synopsis, fyc. p. 327, Edit. 3.) With regard to the trea(mpn( of na»vi, the subject may be explained in a few words. When these marks, or swellings, are super- ficial, without any disposition to enlarge, or spread, and iheir trivial elevation does not expose them lo accidental rupture, there appears to be no good reason for interfering with them. Indeed, tbey could only be destroyed wilh causiic, or the knife, and these severe means would leave scars, ac- companied with nearly the same degree of disfigurement. But, as a valuable writer**bbserves, when naevi evince a tendency to enlarge, or are very prominent excrescences, and either troublesome from iheir situation, or liable to be ruptured, either their growth must be repressed by sedative applications, or the whole congeries of vessels extirpated with the knife. Mr. Ahernetby has proposed (he application of cold washes, and the pressure of a handage. This practice was found by him in several instances lo have the desired effect of checking the growth of the tu- mours, wh^n alterward shrunk, and be- came no longer objects of any consequence. (See Abernethy s Surgical Works, Vol. 2, p. 224.) Boyer also knew of a case, in which a naevus of Ihe upper lip was cured by the mother pressing the part with her finser unremiilingly for seven hours at a time-, and the use of alum wash. (Traiti des Maladies Chir. T. 2, p. 269.) Boyer, how- ever, is not generally an advocate for this mode of treatment ; and Dr. Batemen et- pressly slates, that, in the majority of cases, pressure is (he source of great irritation to these macula?, and cannot be employed (P 329.) For all (hose examples, which partake of (he nature of aneurism by anastomosis, and are disposed (o grow, the bes( general mode of cure is extirpation with the knife. Th * prudence of (his practice, and the ne- cessity of taking away every particle of the disease, has been already explained: this is what was advised by F. Hildanus, (Cent. 5. Obs. 46.) what was strongly urged by the . celebrated Pelit, (CEuvres Posthumes, T. 1.) what was recommended in still more ani- mated terms by Mr. John Bell, (Principles of Surgery, Discourse 9.;) and it is what is particularly insisted upon in another pari of this Dictionary. See Aneurism. In general, stimulating applications can- not be made to naevi, without risk of exas- perating, instead ot lessening them. Mere thickenings, ami discolouration* of the rele mucosum, however, have sometimes been removed by a mixture of spirit and (he liquor potassa*. (Bateman, p. 330.) Formerly caustic was much in vogue for the removal of na?vi; but, unless its action extend deeply enough io destroy every part of the disease, it may cause a dangerous degree of irritation, copious hemorrhages, and a sudden and falal enlargement of the tumour. Therefore, as it is a more painful measure than the knife, and less cer- tain in its effects, it should be on every ac- count discarded from practice. It caiinol be denied, however, that Ihe old surgeons had success with their caustics, where the tiievi were altogether superficial. Thus, in speak- ing of caustic remedies, Callisen observes: " inter quae eximio cum tuccessu adhihetur sapo cum -squall parte calcis vivae subtilissi- ma*rommixtus, na?vo per emplastrum per- foralumadmi vendiis,et alio emplastroimpo- sito firmandus; hoc remedioeschara inurilnr, qua solula, cicatrix alba remanere solel'* (Syst. Chirur-rie Hodierne, Vol. 2, p. 202.) Consult Pelit's CEuvres Posthumes, T. 1. Lassus, Pathologie Chir. T.\,p. 476, fyc. Ed. 1809. Callisen's Systema Chirurgie Hodi- erne, Vol 2, p. 201, Hafnie, 1800. Aber nethy's Surgicul Works, Vol. 2, p. 224, fyc. Lalta's System of Surgery, Vol. 2. Chap. 22. J. Bell's Principles of Surgery, Vol. 1, Z>is- course 9. Boyer, Traiti des Maladies Chi- rurgicales, T. 2, p. 225, fyc. Pans, 1814. A Practical Synopsis of Cutaneous Diseases by T. Bateman, M. D. Edit. 3, 1814. Delpech Precis Elimentaire des Maladies Chir. T. 3, p- 244, Paris, 1816. J. Wardrop, On one Species of Nevus, with the Case of an Infant, wUre the Carotid Artery was tied, in Mid. Chir. Trans. Vol.9, p. 199, fyc. NECROSIS, (from nn^u, to destroy.) This word, the strict meaning of which is only mortification, is, by the general consent of NECROSIS. 261 •urgeons, confined (o this affection of the bones. It was first used, in this particular sense, by the celebraled M Louis, who re- stric(ed its application, however, to exam- ples, in which the whole thickness of a bone was destroyed. (See Mim. dc I'Acad. Roy- vie de Chirurgie, T. 5- 4to.) By the ancients the death of parts of bones was not distin- guished from caries. However, necrosis and caries are essentially different; for, in (he first, the affecled part of the hone is de- prived of the vital principle . but (his is not (he case when i( is simply carious. Caries is very analogous to ulceration, while ne- crosis closely resembles mortification of the soft par(s. Between caries and necrosis, says Weid- mann,there is all that difference, which exists between ulcers and gangrene, or sphacelus of the soft parts. In caries, the nutrition of the bone is only impaired, and an irregular aclion disunites (he elements of (he bony structure, which consequently sustains a loss of substance ; but every remaining part of it is yet alive. In necrosis, on the contrary, the vitality and nutritive functions cease altogether in a certain portion of the bone, the separation of which (hen becomes indis- pensable. (De Necrosi Ossium, p. 7.) I have mentioned that M. Louis coimned the term necrosis lo cases, in which the whole thickness of a bone perished ; but Weidmann judiciously criticises this limita- tion of the word, and maintains, that the nalure of the disorder is the same whether it aff.-ct a single scale, (he whole, or a mere point, of (he bone. He also objects to the definition of necrosis proposed by Chopart, (Dissert, dc Necrosi Ossium, Paris, 1765,) and adopted by David. (Obs. sur une Mala- die connue sous le nom de Nicrose Paris, 1782.) These two authors have defined necrosis to be a disorder, in which a portion of bone perishes, and lurns dry, in order to be soonseparated from the living parts, and rep!ac(§J by a new bony substance, w hich is lo perform ils functions But as Weidmann observes, it may happen, that a piece of bone, which dies and separates, may not be replaced by any new formation of bone, though the disease is of ihe same character, and merely varies in some modifications. He therefore argues, and every rational sur- geon will agree with him, that a true necro- sis must always be said to exist, whenever a dead portion of bone bas eilhei separated, oris about to separate. *' Vera demum nec- rosis semper est, si aliquod ossis ramentum, in quo visvite exlincla est. absccsdt,vel proxime abscessurum, est." (P. 7.) The tibia, femur, lower jaw, clavicle, hu- merus, fibula, radius, and ulna, are the bones most frequently affected with necro- sis. Excepting the lower jaw and scapula, the process of regeneration has only been noticed, in the cylindrical bones. From 12 to 18 years of age, is the lime of life, most subject to necrosis. The necrosis of the lower jaw, however, seldom occurs before the age of so In some persons, the bones are affected at once, owing to constitutional causes. No climate, age, sex, mode of life, nor condition, (says Weidmann) is exempt from this disorder. Childhood and puberty, how- ever, are tht* periods most liable to it. The same thing may be said of persons, who la- bour hard, and are much exposed to externrl injuries. Every bone of (he human body i.i subject to necrosis ; but those which ara siperficial, and enter into the formation of the extremities, are more frequently affecled than olhers whose situation is deeper. Ne- crosis less commonly atlacks the spongy substance of the bones, because this bein^ endued with a higher degree of vascularity and life, suppuration is most apt to occur. Necrosis, on the contrary, is ottener seen in the compact substance, where the vital prin- ciple is less energetic, and more readily ex- tinguished. Lastly, Ihe disorder may affect the long bones, or the broad ; the large or small; and even those of the very least size ; since it is well known, that the ossi- cula of the ear m<<\ be destroyed by necrosis, and separate. I bave seen this happen in two instances, and the fact is recorded by several writers. (See Astruc de Morbis Ve- nereis, lib. 4. cap. 1. Henri, Journal dc Medicine, T. 15, p. 363.) Though necrosis mos'ly attacks the cylin- drical bones, the Ahi ones are noi exempt from the disease. Polt makes mention of a parietal bone, the whole of which was detached, and of an os front is, the greatest part of which came away. In a thc-sis on necrosis, in 1776, aux icoles de chirurgie, may be found Ihe case ol a voung man, a very large part of whose scapula perished and separated. Chopart, who relates the case, mentions, that he saw the patient quite recovered, and felt h new triangular movea- ble bone, firmly supporting the clavicle, but smaller ami flatter than natural, and without any spinous process. The same has happen- ed to the lower jaw, as ram be seen by referrine to (be Ephrmerides Nat. Cur. und jtfe^m. de I'Acad. de Chirurgie. In (he fifth volume of ihe latter work, is an account of ii woman, who applied to be relieved of some venereal complaints. From the beginning of the treatment, the bone was discovered lo be loose ju*t under (he gums, and seemed shortly afterward, to move backwards and forwards with a tooth. M. Guernery look hold of the tooth with a key-instrument, and found it firmly inserted in the moveable jaw ; he made with caution the necessary manoeuvres for extracting the portion of bone ; but vvas greatly surprised on finding what an extensive part yielded to his very moderate efforts. It was the whole of the lower jaw, above ils right angle from its di- vision into the coronoid and condyloid pro- cesses lo the space between the first and se- cond of (he front grinders ofthe left side. On the right, (here only remained the condyle in (he articular cavity of (be temporal bone. This destruction left a considerable empty space, from which great deformity was appre- hended, in consequence of Ihe unsuppor'ed \62 NECROSIS. soft parts falling down. Tbe woman, how- ever, got well in two months, and had the most perfect use of a new jaw. A similar fact is recorded in the Journal de Midicine, 1791. When the body of a cylindrical bone, or (he middle portion of a flat bone, is destroy- ed by necrosis, their extremities, which are of a cellular texture, continue unaffected, so lhatjforexample, in (he cylindrical bones,tbe erticularends are always formed of portions of the original bone, which are engrafted, as it vvere, on ihe new production. There are, however, a few bad cases, in which the necrosis does not altogether spare (he heads of the bones, and the disease communicates with the joint. These examples are very uncommon, and are attended with consider- able danger to the limb: indeed, they se- nerally require amputation. (See Boyer, Tram des Mai. Chir. T. 3, p. 442.) IV1-. Brodie has known an instance, in which, without any obvious cause, a large portion of ihe head of the tibia died, and exfoliated, nnd (he destruction of the knee-joint was Ihe consequence. (Pathol, and Surg. Obs. on the Joints, p. 269.) Besides the differenc.s arising from (he particular bones affected, necrosis also va- ries, according as the portion of bone attacked happens to be thin, and of little extent, or large and of considerable thick- ness. The disease is.limple, when it is con- fined to one bone, and the patient is in other respects healthy ; compound, when several different parts of the same bone, or several rfistinct bones, are affected at the same time; when the health is bad; and other parts of the body are also diseased. It should also be known, because the information is of practical importance in the treatment, (hat necrosis has three different stages, or periods. In the first. Ibe bone affecled pe- rishes ; in the second, ibe process of exfolia- tion or separation of the dead bone from (he living, is going on : and, in tbe thud, the se- paration is completed. iSee Weidmann, p. 8.) The causes of necrosis are not essentially different from those which produce ulcers and gangrene of the soft parts. As, how- ever, tbe vitality of the bones are weaker, we may infer, that necrosis may be occa- sioned in them by causes which are less nu raerous and intense, and such as would only j:ive rise to suppuration in the soft parts. Every thing, whether in the periosteum or the substance of the hone itself, lhat tends (o interrupt the nutrition of the bone, must lie regarded as conducive to the origin of necrosis. It is observed, however, that when the mischief in the periosteum, me- dulla, or substance ofthe bone, is of trivial extent, the consequence is merelyan abscess. Some of the causes of necrosis are external, while others are internal, or constitutional. Sometimes the life of the bone is instanta- neously destroyed by them ; but in other in- stances, the bone is first stimulated and en- larged, so that its death is preceded by true *nP-*rr p»»fion The external causes, which injure ine pt- riosteum and medullary structure, and thus produce necrosis, are wounds, contusions, pressure, fractures, comminutions, acrid sul*- stances, caustics, and extreme degrees of heat or cold. When tbe periosteum, in consequence of an external cause, inflames and sloughs, or is at once deprived of its vitality, as it may be by the action of caustic, fire, or intense cold, the vessels which conveyed nourish- ment to the bone are destroyed, and (he death and exfoliation of the denuded por- tion of the bone are inevitable. But, if (he detachment of the periosteum is of little ex- tent, the patient young and healthy, and (ho treatment calculated to prevent inflamma- tion, and preserve uninjured the vessels distributed to the bone, hopes may be en- tertained that no part of the bone will die, but that granulations will very soon arise from its surface, being adherent to it as the periosteum was, and that they will grow to and cicatrize with the surrounding parts. Weidmann has explained, that (his fact of bones not always exfoliating when deprived of the periosteum, which is of great practi- cal importance in the treatment of wounds, was inculcated by Felix Wurtz, Cesar Mn- gatus, and Belloste, at a time when the con- trary opinion prevailed. Weidmann also adverts to his own experience and to the experiments of Tenon, in further proof of the preceding fact. (Mem de I'Acad. des Sciences, 1758, p. 372.) On the other hand, when the detached piece of Ihe periosteum is extensive; when the bone itself is contused; or when it has been long exposed to the air, the effect of which is to dry up the few vessels which belong to it; when the inflammation is vio- lent and extensive ; when the patient is old, decrepit, or of bad constitution ; and more especially when improper applications are used, as was almost always the case in for- mer times ; necrosis cannot be avoided. An internal necrosis, affecting thUpongy texture of bones, generally arises from con stitutional causes, though sometimes an ex- ternal cause, which seems to affect only the surface of a bone, extends its action to the interior, so as to destroy the medullary membrane, and produce an internal ne- crosis. In external injuries of the head, where the pericranium is lacerated, contused, or otherwise hurt, or where the outer table, or the diploe,of the skull, is injured, the inflam- mation frequently extends to the inner table, and the dura mater becomes detached Hence, a collection of matter forms, which may occasion many bad symptoms, and even death itself; or if the p'atient survive, exfoliation of part of both tables ofthe skull is the consequence. (See Pott's Chir. Works, London, 177y, Vol. 1, p. 32.) The same thing may occur in other bone8, as well as those ofthe cranium. Bromfield had an opportunity of seeing a necrosis of the spongy substance of the upper and in- ternal part of the tibia, brought on bvth* .NECROSIS 263 improper mode iu whicu au issue was dress- ed. In order to keep the peas from slipping out of their places, a compress with a shil- ling in it, and a tight bandage were applied ; hut the part was attacked with excruciating pain, and the spongy texture, of the tibia in the vicinity became affected with necrosis. (Chir. Observations and Cases, Vol. 2, p. 9.) This circumstance, as Weidmann observes, ought not to surprise us : as numerous ves- sels quit the periosteum to descend into the substance ofthe bone, to ramify on the me- dullary cells themselves, and freely anasto- mose there, it cannot be difficult lo con- ceive, how inflammation, which is at first confined to the outside of the bone, may (through the medium of the vessels which serve as conductors to it) penetrate more deeply, and extend its ravages in every di- rection. But necrosis may proceed from another description of causes, which are of a con- stitutional nature. In fevers of bad type, in tbe small-pox. and in the measles, expe- rience has fully proved, that the bones are sometimes attacked with necrosis. Scrofula, lues venerea, and the scurvy, are also dis- eases, which, according to the testimony of all surgical writers, frequently produce such mischief in the bones as terminates in ne- crosis. It is likewise well ascertained, that mercury, the judicious employment of which in venereal cases will prevent necrosis, or cure them when formed, may itself give rise to the disorder, especially in the lower jaw-bone. (See Mim. de I'Acad. de Chir. T. 5, p. 356, 4/o.) This happens either in consequence of mercury having been introduced too quick- ly into the system, or because the patient exposes himself to cold, or deviates in some other respect from a proper regimen. Cer- tain necroses of the lower jaw, however, appear also to have been caused by blows, and the application of acrid substances to carious teeth. But, says Weidmann, " I feel it incumbent upon me particularly to de- clare, that the irrational treatment pursued by the ancient practitioners, who neither understood the nature ofthe bones, nor the differences of their diseases, and which treatment is too confidently adopted in our own days, had frequently the effect of kill- ing these parts, by attacking with spirituous, acrid, or caustic remedies, or even with the knife, diseases which required the mildest applications, and to be left in a great mea- sure to nature. The old surgeons were afraid of laying on the exposed injured sur- face of a bone unctuous emollient dressings, and yet, for what reason I know not, they subjected the part to the action of spiritu- ous, acrid, drying applications. As for my- self, I deem it proved by infallible and fre- quently repeated trials, not only that an ex- posed injured bone may be dressed with a mild ointment without any ill consequences, but even wilh the greatest advantage. Why should that which is beneficial to the soft parti, be so prejudicial to the bones ? In nlc-fr-*- of tbe soft parts, indeed, the employ- ment ofthe remedy which 1 recommend, is less important, because these parts are na- turally humid, and there is no risk of their becoming dry. But with regard to the bones, w hose dry texture is only penetrated by few vessels, which may easily be destroy- ed if they be suffered to become quite dry, it is absolutely necessary to use an emol- lient ointment, as a dressing, well calculated to defend these vessels, which are the sup- port of life, and preserve them from the bad effects of exposure to the air. Therefore, observes Weidmann, if a surgeon would avoid producing a necrosis himself, and not neglect any means that tend to prevent such disorder, he should make it a rule never to apply any thing acrid to exposed bones, but, on the contrary, lo defend them with a dress- ing of some unirritating ointment." (De Ne- crosi Ossium, p. 11.) It was formerly supposed, that purulent matter, collected near a bone, might in time become acrimonious, corrode the bone, and produce necrosis. Hence, it was a rule to open such an abscess as soon as its exist- ence was known. But Weidmann questions whether there was any real necessity for this practice. No doubt, says he, the pre- ceding erroneous opinion arose from the circumstance of the bones being often found bare, carious, or even affected with necro- sis, when abscesses were near them ; but things happened thus, because the inflam- mation which caused the suppuration, had also extended its effects to the periosteum and bone. He affirms, that he has witness- ed ulcers, in which the surface of bones, bare and uncovered by the periosteum, lay bathed in pus for a very considerable time ; yet, being dressed with a mild ointment, they continued entire, granulations grew from them, and cicatrization followed. He had also in his possession portions of bones affected with necrosis, which had Iain for years in pus ; still their surface was smooth, and presented no marks of erosion. If then these pieces of bone underwent no altera tion, how much less likely to do so are bones, which are endued with life ! But though Weidmann wisely rejects the doctrine of pus being capable of destroying the periosteum and bones by any corrosive qualities, he acknowledges his belief, that the matter of an abscess may by its quantity compress and inflame the adjacent parts, and occasion their removal by the absorb- ents. While the periosteum intervenes be- tween an abscess and the bone, he does not see how the latter can be hurt by the pus ; but when the abscess is copious and lodged between that membrane and the bone, the vessels passing from tbe former will be de- stroyed, and either caries or necrosis ensue. The inflammation arising from the causes which excite necrosis, may be either acule or chronic It is chronic, when it begins and passes through its different stages slow- ly, and when the mildness of the symptoms may lead us to mistake the nature of the case. This sort of inflammation chiefly hap- pens in debilitated cons'i'utions, in which ■26+ NECROSIS the necrosis only atfects the external part of a bone, and originates from some chronic cause, such as scrofula, lues venerea, and the scurvy. But when necrosis attacks the interior, and the disease occurs in a strong, irritable, plethoric subject, inflammation is immediately kindled, attended with the most acute symptoms, severe pain, consider- able fever, restlessness, delirium,be. Chro- nic inflammation is more supportable ; but ils duration is longer: acute inflammation is more afflicting, but sooner comes to a crisis. The part in which a necrosis is situated, is affected with swelling. What has been observed, respecting the inflammation, is also applicable to this tumour, which most frequently forms gradually, but sometimes with great rapidity. In the first case, the accompanying pain is dull and inconsidera- ble ; in the second, it is violent. The swell- ing bas not, like that of abscesses, an eleva- ted apex. On the contrary, it is so widely diffused, that the limits which circumscribe it, can hardly be distinguished. This diffusion of the swelling is tbe greater, in proportion as the diseased bone is more deeply buried in soft parts : it may extend over the whole morbid bone, or even over the whole limb. The swelling comes on at the very begin- ning of the disorder, «nd continues to in- crease, until the matter which it contains finds its way out, when the evacuation is followed by a partial subsidence of the tu- mour. The swelling is sometimes also com- bined with oedema, especially in persons whose constitutions have been impaired by the severity of the disease, the violence of the sufferings, and tbe long and profuse dis- charge. When the inflammation is acute, purulent matter of good quality soon collects in the vicinity of tbe necrosis. In the contrary case, the pus forms slowly, and is thinner and less healthy. The abscess which accompanies a necro- sis, naturally soon bursts when it arises from intense inflammation, and is situated near the skin, which is itself inflamed. But when the bone is surrounded by a great thickness of soft parts, and the inflammation is chronic, the quantity of matter daily in- creases, the cavity which it occupies be- comes larger and larger, and considerable pressure is made in the abscess on every :-ide. The bones and tendons resist for a long while the progress of the matter ; but the cellular substance yields, and different sinuses form, which sometimes run to a vast distance from the main collection of matter, especially when tbe abscess lies under an aponeurosis. It was supposed a few years ago, that in cases of necrosis, the matter was invariably sanious, acrid, and fetid. But the celebrated Weidmann exposed the error of this opi- nion. He had often seen abscesses and ul- cers, arising from necrosis, discharge a whi- tish, inodorous, thick pus, absolutely devoid of any bad quality whatsoever. He had particularly seen this happen in patients whose necroses proceeded troin an external cause, or an internal one of a slight nature, and whose health vvas generally good. (Dt Necrosi Ostium, p. 16.) If, says the same ex- cellent writer, we sometimes find in prac- tice the suppuration dark and fetid, wc must not ascribe it to tbe affection of the bone, but to the weakness and bad state of the patient's health. Under the same cir- cumstances, common sores of the soft parts would also emit a discharge of bad quality. After the ulcerated openings have emit- ted for some time a profuse discharge, the sinuses, if considerable, receive the appella- tion of fistulae, on account of their edges putting on a callous appearance, throwing out fungous granulations, and there being impediments to cicatrization. These im- pediments are caused by the dead portions of bone, which, whether loose or adherent, act as extraneous bodies in hindering the sores from healing. In some instances also, the ulcers will not heal though the dead bone has come away, because they run to a great depth, and such a quantity of pus is secreted from every point of their surface, as prevents all contact, and the adhesions which would result from it. The fistulae vary in number; but they arc fewer in proportion as the disease is slighter In an extensive necrosis, several of these openings are seen, either near together, oi separated by considerable spaces; and, when the necrosis affects every side of the bone, the fistulae in tbe integuments occur on every side ofthe limb. Besides the inflammatory fever, which at- tends the beginning of every severe case of necrosis, which is sometimes accompanied with exceedingly violent symptoms, and which usually abates when matter is form- ed, tbe patient is subject to another fever of a slow hectic type. This takes place in tbe decline of the disease, is the effect of the long-continued profuse suppuration, gradu- ally reduces the patient, and at length brings him to the grave, unless the timely removal of the sequestrum be effected either by na- ture or art. Let us next endeavour to trace the sign.:, by which we may not only ascertain the presence of the disease, but its modifications in the first place, we should make our- selves acquainted with every thing, which may have predisposed to the disorder; as, for instance, what accidental circumstances have occurred, and what symptoms followed them. We should also inquire into any pre- vious treatment which may have been adopted; for, as Weidmann truly remarks, injudicious remedies have caused many a necrosis that would not have occurred at all, if the case had been properly treated,or confided to nature. The kind of inflammation with which the disease commences, may afford grounds foi suspecting that necrosis will happen : it's generally slow and deeply seated, passing through its stages tardily, and the attendant symptoms are severer. The skin retains its natural colour a long while; but, at leO'jtlb ■'necrosis. 265 exhibits a reddish, or livid discolouration. The matter does not reach the skin till a considerable time has elapsed, and when tbe abscess bursts, the inflammatory symp- toms are still slow in sul-Meling. When the inflammation is acute, the patient sutlers in- tolerable pain a long time. There are also other symptoms of a ne- crosis; viz. the swelling which accompa- nies the inflammation, is situated upon a bone, or rather tne bone i» included in the tumour; the swelling* is at the same time very diffused ; and the suppuration lies deep- ly, and can only be felt in an obscure way. The ulcers, beneath which a necrosis is situated, discharge a large quantity of mat- ter, and their edges are bent inward. The granulations are either yellowish and pale, or else of an intense red colour; they are also irregular, and generally not very ten- der, though sometimes extreme y painful, and on being slightly touched, they bleed. It has been already noticed, that, some years ago, the discharge from the sores, which attend necrosis, was described as be ing always thin, fetid, and sanious ; and such qualities of the matter vvere regarded as a symptom of the disease of tbe bone. But that excellent practical writer, Weid- mann, has well explained, that it is a symp- tom undeserving of confidence. In cases of necrosis the pus is often thick, white, and inodorous; while other* ulcers, unattended with diseased bone, sometimes discharge thin fetid matter. Weidmann, at the same time, does not mean lo assert, that iu cases of necrosis the sores never emit unhealthy pus; but he firmly believes, that such dis- charge is not always the result of a disease ofthe bone. As far as he could judge, the suppuration from ulcers, situated over dis- eased bones, continues white and laudable as long as the patient's general health is good ; but, that it deviates from these pro- perties, in proportion as the health becomes impaired. Neither is the black colour, imparted to the dressings of ulcers, a circumstauce which necessarily indicates the existence of ne- crosis; for it may occur when the bone is sound, and may not happeu when the bone is affected. None ofthe preceding symptoms convey such information, as leaves no doubt of the positive existence of necrosis, ihe touch is the only thing which can give us this knowledge, when the bone is not too deeply situated, and the sinuses not tortuous, nor bbstructed with fungous growths. When the openings ofthe ulcers are con- siderable, the finger may be introduced. If in this way the bone can be felt to be ex- tensively uncovered by the periosteum, the surgeon may conclude that all such portion of ihe bone has perished. He may be still more certain of the fact, wheu he finds the ed- ges ofthe denuded bone unequal and rough. The examinations, made directly with the finger, give the most correct and exact in- formation of the state of the bone ; but the lot. H 34 orifices ofthe sores are sometimes so small, that the finger cannot be introduced witbout causing great pain. A probe must then be used for the purpose of ascertaining the ex- tent of the denudation of the bone ; whe- ther its edges are rough ; whether the dead portion is loose, and likely to separate soon. Sometimes the dead fragment of bone protrudes from the ulcer, or is visible on se- parating its edges. When it is black, there cannot be a doubt of its being actually dead; but, on the other hand, when its whiteness is increased, the diagnosis is difficult, be- cause bones being naturally white, much experience is necessary to be able to judge whether they are so in excess. It merits attention, also, that the black colour of the bone is not owing to the ne- crosis itself, but seems rather to depend upon the fragment having been exposed lo the air. In fact, dead pieces of bone with which the air comes into contact, turn black, while those which are covered with matter, retain their whiteness. The cylindrical por- tion of a humerus, which was almost totally affected with necrosis, was universally black at the part, which protruded through the flesh ; but the rest, which lay under the in- teguments, remained white. (Weidmann de Necrosi Ossium, p. 19, el Tab. 9, fig. 1.) When tbe early symptoms of tie disease are mild, the surgeon may infer that it is only a superficial portion of the bone which is about to be separated. But this judgment v\ ill be more certain if confirmed by exami- nation with the finger or probe ; or, if the swelling which occurred in the beginning, has not spread beyond the affected point, and if the pain affects only the outer part of the bone. In this sort of case, there is also great probability that the dead bone will be separated within a moderate time. It is also of importance to ascertain the existence of an internal necrosis, and to learn whether it is situated in the spongy substance, or in the internal parietes ofthe canal of the bone ; whether it affects on- ly a part, or extends to the whole body of the bone. When there is an internal necrosis, says Weidmann, the disease is generally more aggravated, and of longer duration ; and in the first stage, the patient is affected with severe symptoms, intolera- ble pain, loss of rest, ardent fever, profuse perspirations, and such disorder of the sys- tem, as may prove fatal, unless the patient be young and strong. The hard swelling which was observable at the commence- ment of Ihe disease, increases but slowly, and extends very gradually over the cir- cumference of the limb, while the skin yet remains free from redness and teusion. If the part be somewhat roughly handled, the pain, which is fixed in the bone, is not ren- dered more acute, as would happen, were the case an exlernal inflammation. In this suffering condition the patient continues a good while, before the formation of matter brings a degree of relief. When the matter is formed, it spreads through tbe adjacent i*66 NECROSIS. cellular substance, among the muscles and other parts, aud the abscess generally bursts after a considerable time, by several open- ings, very distant from the main collection of matter, as also remote from each other, sometimes in diametrically opposite situa- tions, ihe evacuation ofthe matter, how- ever, does not produce any material subsi- dence ofthe swelling. The pus is of good quality, and issues in large quantities from the ulcerated apertures, the quantity, how- ever, not being increased when pressure is made. If some of the openings heal, others are formed; but, in general, the edges be- come callous, and they lose all disposition to cicatrize. When the case presents the foregoing circumstances, and the weakened limb can neither bear the action of the muscles, nor the weight of the body, and by either of these causes, its shape becomes al- tered, the surgeon may conclude that the disease is an internal necrosis. But, iu or- der to avoid mistake, he should introduce into the sinuses a probe, which, passing through the openings in the subjacent bone, will touch the dead piece, which it con- tains, and which will sometimes be even distinguished to be loose and moveable. The extent of the sequestrum must be jwged of by the extent of the swelling, and the dis- tances between the apertures in the bony shell, which includes the sequestrum. The surgeon should also endeavour to ascertain with the probe, whether there is only a single sequestrum, or several. When there are several, they may be felt with the probe iu different places, down to which this instrument is passed, and the removal of one or two of the fragments is not followed by a cure. It ought to be remembered, how- ever, that the same fragment may be touched by the probe in several different places, when it is very extensive. If there are several dead pieces of bone, situated at a distance from each other, each of them is generally accompanied with a distinct swell- ing, and sinuses. Frequently, these frag- ments are so concealed, that they cannot be felt with a probe ; but, their existence may then be suspected from the ulcers not heal- ing, which can be ascribed to nothing else. It is also necessary to distinguish with the greatest attention the different stages of the disease. The first stage may be considered as existing, when the attack is yet recent, and the inflammation and its concomitant symptoms, the pain, swelling, and symptom- atic fever, prevail in a high degree, aud when no suppuration has taken place, or at least no discharge of matter. The second period, in which the dead bone is undergoing the process of separation, is indicated by a diminution of the inflammation, a partial subsidence ofthe swelling, and the discharge of purulent matter. When a probe is passed into the ulcers, the bone is felt bare, and dry, and, towards tbe limits of tbe swelling, it is rough, where, as will be afterward noticed, an excavation is formed. Every part of the bone, however, which is to be detached, still continues adherent to the rest of tbe living bone. At length, the surgeon knows, that the disease has reached its last stage, or that in which the dead portion of bone is entirely separated, when sufficient time for the completion of this separation has expired, and when the dead bone can be distinguished with the finger, probe, or even the eye, to be loose and free from all connexions Although a necrosis must generally be classed with diseases which are serious and of long duration ; yet, the character ol the disorder is not essentially bad, since it is often cured by nature, or with the assistance of surgery. Confident hopes of a cure may be entertained when the necrosis is confined to the external part of a bone; when it is simple and of moderate extent; when it is not situated in a bone, destined for impor- tant uses, or near any viscus, or organ, that may be injured by it; and when it proceeds from an external cause, and (he general health is good. On the contrary, the cure is difficult, and the prognosis doubtful, when the disease is extensive, and complicated with other affections, either of tbe same, or different bones: when it attacks bones, which are of high importance on account of their functions, or situation ; when it is situated in the interior of the bone, and affects seve- ral parts of it; when it arises from an internul cause, for which there is no certain and quick-acting specific ; when the patient is weakened by age, or disease ; and especially, when the sinuses extend into the neighbour- ing articulations. (Weidmann de Necrosi Ossium, p. 22.) The process of cure is said to take place with more celerity in the lower jaw, than any other bone, and may be completed in three months. Mr. Russell has never known a necrosis of the tibia get well in less (hana year; but, in general, nearly two years elapse first; sometimes, the cure is protract- ed to a much greater length of time. Necrosis of the lower jaw and clavicle never proves fatal: that of the lower ex- tremities, which is the worst case, does so very seldom, and only from the violence of ' the first inflammatory symptoms, \yhich ra- pidly bring on a hectic fever, which proves incurable, unless its local cause be removed by a timely amputation. When theviolence of the first stnge, however, has abated, the irritation ceases, and the hectic symptoms, if there are any, are generally moderate. Nor is this state of tranquillity disturbed, till the sequestrum, in making its way outward, again produces irritalion. At this second period of jrgency, extensive inflammation may originate, ulcerations spread all over the surfaae of the limb, assume an unhealthy appearance, violent fever succeed, and the patient either perish, or sink into a state, in which he must consent to amputation, as tbe only means of saving his life. This is the last crisis of imminent danger; but, in gene- ral, it is less perilous, than when the inflam- mation comes on in the incipient stage of necrosis. (Russell.) In tbe treatment of necrosis, the first grand object of the surgeon should be to aid nature NECROSIS. 267 in her endeavours to effect a cure, and not to disturb her operations by any superfluous, or unseasonable interference. The second should be to assist her sometimes by the boldest proceedings, when she loses her way, and cannot by herself accomplish the end. But, in order not to attempt any thing wrong, the surgeon must understand cor- rectly what nature does in this disease, what it is in her power to perform ; what she either cannot accomplish at all, or not with any degree of certainty ; and lastly, the circum- stances in which she may err, and endanger the patient's life. When a portion of bone dies, nature uses nil her endeavours to bring about its separa- tion from the part of the bone which still remains alive. Surgeons have denominated this process,exfoliation, (see this word) which resembles the separation, that occurs be- tween parts affected with gangrene and sphacelus, and the living flesh. An exfolia- tion of bone, however, happens much more slowly, than the separation of a slough of the soft parts. Neither are all exfoliations completed at a regular period ; for they proceed most quickly during youth, when the constitution is usually more full of ener- gy, the bones more vascular, and less replete with solid inorganic earthy matter. On the other hand, the process is slower, in old, de- bilitated subjects, whose vitality is less ac- tive. A thin small scale of bone separates sooner, than a large thick portion ; and the most tedious exfoliation is thai of a thick bone, from which a portion, including its en- tire diameter, is coming away. The separa- tion of a necrosis takes place more expedi- tiously in bones of a light texture, than in those of a solid structure ; and sooner, in the less compact parts of bones, such as the epi- physes and spongy substance, than in those of greater density. When a necrosis has originated from the scurvy, syphilis, Sic. and appropriate reme- dies are not administered, nature cannot ef- fectually accomplish the process, by which the dead bone is separated; the case becomes worse ; and life endangered. The separation happens precisely at the different points where the living and dead parts ofthe bone come into contact; and it is obvious, that the particles of the dead bone, which are at a distance from the part that retains its vitality, cannot be acted upon by it. A variety of opinions have been entertain- ed, concerning the means employed by na- ture in effecting this separation. Hippo- crates believed, that the dead part vvas push- ed away by a fleshy substance, which grew underneath it. (De Cap. vuln. Cap. xxiv.) Ludwig, Aitken, Bonn, and many others, adopted the same idea. (See Adversaria Med. Pract. Vol. 3, p. 63 ; Systematic Ele- ments of the Theory and Practice in Surgery, p. 287. Thesaur. Oss. Morb. p. 1.) Van Swieten conceived, that tbe dead part was forced away by the incessant beating of the arteries. (Comment, in Aphor. Boerrhavii, § 252.) M. Fabre ascribed the separation to the extension and expansion of the vessels. (Mim. de I'Acad. de Chir. Tom. 4, p. 91.) Others supposed that the exfoliating piece of bone became loosened partly by the sup- puration, and partly by the rising of Ihe new granulations. (See B. Bell on Ulcers.) As Weidmann observes, there is unques- tionably a reddish fleshy substance formed between the dead and Iivingbone, and which Celsus has noticed under the appellation of caruncula. (De Medecina, lib. 8, cap. 3.) But, it would be erroneous to refer the ex- pulsion of the dead portion of bone to it, since it can never be produced, before a change has taken place in the structure of bone, there being in fact no space for it to grow in ; and hence, it is never seen before the disunion of the parts has considerably advanced. There must consequently be some other power, which destroys the cohe- sion between the dead and living bone, and produces the groove, or interspace, in which the soft granulations arise. Besides, among other facts proving the falsity of the idea, that the granulations push off the dead bone, Weidmann particularly adverts to the occa- sional exf-*j|jations of the whole circumfer- ence of a cylindrical bone. Here, if the granulations had the power of causing a disunion on one side, they could not have the same effect on the opposite one ; but would tend to make the contact more inti- mate. The separation also cannot be made by the pulsation of the small arteries, nor by the weak expansive motion of the vessels of the bone. Weidmann knows not what mo- tives have induced certain writers to impute the effect to suppuration, and observes, that as the doctrine is not founded upon reason- ing, it is superfluous to offer any arguments against it. If the least attention be paid to what nature really tries and accomplishes in this operation, nothing will be more mani- fest, than that it is completed in a very differ- ent manner. Swelling first affects the peri- osteum and bone, which by degrees softens. (Vid. Trojapassim. Bonn. Thesaur. Oss.Mor- bos,p. 122, and Weidmann de Necrosi Ossium, Tab. 4, Fig. 1, and 3.) At the margins of the necrosis, the bony surfaces, which were smooth, become rough, and irregular. A fissure is there produced, which extends in every direction under the piece of bone, that is about to be detached. The bony texture is also daily rendered less solid, so that the number of adhesions between the dead and living parts diminish, and in the end are to- tally destroyed. Weidmann then explains, that the true mode by which the separation is effected consists in the absorption of the particles, situated betwixt the livingand dead parts of the bone, in such a way, however, that the first loses a great deal of its sub- stance; the last, scarcely any thing. (P. 26.) After the dead bone has come away, the swelling of the periosteum subsides, and the living bone recovers its original hardness and solidity. (Troja, p. 67.) ■♦For a further account of the process, by 268 NECROSIS. which dead portions of bone are separated from the living, see Exfoliation. When dead portions of bone are separated and loose, they still lodge in the cavities of the ulcers, and, like all other extraneous bo- dies, occasion irritation of the soft parts, and keep up a discharge of matter. Sometimes, however, nature of herself succeeds in ex- pelling them. This happens in cases, w here the size and shape of the ulcer are calculated to facilitate the issue of Ihe dead bone, which does not lie too deeply, and is pro- pelled outward by its own weight. In ne- croses of trivial size, indeed, it is asserted, that the small fragments of bone may be dissolved in the p-is, and come av.ay w ilh it; (David ; Bousselin, Hist, de la Societi Royale de Midecine, Tom. 4, p.3t-s ; Weidmann de Necrosi Ossium, p. 26;) but, such an event can never be expected when the dead por- tion of bone is at all extensive The last thing which nature does, is to re- store the loss of substance which the bone has suffered. Although this operation is so extraordinary and wonderful, that one might be disposed to doubt its reality, numerous examples, recorded in the annals of surgery, prove not only its possibility, tjpt, also, its frequency. In works referred to at the conclusion "%f this article, the following authors speak of the regeneration of a part, or the whole of the lower jaw-bone: viz. Bonetus, Baver, Guernery, Belmain, Acrel, Van Wy, Triocn, Bonn, Reiplein, Desault, Henkel, und D.is- saussoir. A student showed Weidmann a lower jaw-bone, which had been thus rege- nerated, and taken from the body of a man, whom the latter distinguished writer had been well acquainted with. The bone could not be freely depressed ; but, yet it per- formed its functions tolerably well. Moreau saw a case, in which tbe clavicle was regenerated, and the new bone vvas pre- sented by Dangerville, afler the patient's decease, to the Academy of Surgery at Paris. (De Necrosi Ossium Theses, Pres F. Chopad, resp. P. G. Robert, ParisUs, 1776.) Chopart had an opportunity of witnessing the death and reproduction of a scapula. Wreidmann saw an instance, in which nearly the whole cylindrical shaft of the hu- merus perished, and was afterward regene- rated ; a phenomenon, that had been obser ved at earlier periods by Job of Mekren, Cajetano Taconi, E. Blancard, Duhamcl, David, Acrel, Bcehmer, Cheselden, and Vi- garoux, whose respective works are cited at the end of this article. Morand, Cheselden, and Bromfield pub- lished engravings, respecting a reproduction ofthe upper part ofthe humerus, where the old dead bone was included in a sort of bony tube. Regenerations of tbe ulna have been ob- served by Ruysch, Duverney, and Fowles. (See Thesaur, X No. 176. Traiti des Mat. des Os. Paris, 1751; and Phil. Trans. No. 312.) A similar reproduction of the lower ends of the radius and ulna was witnessedjby Acrel. (Chirurgische Vorfdlle von Murray, Vol. \,p. 194.) -similar reproductions of the thigh-bone arc recorded by Wedcl, Battus, Kostbius, Hofinann, Scultetus, Diemerbroeck, Wright, Fabricius Hildanus, Raw, Dobyns, M'Ken- zie, Ludwig, David, Rousselin, Larrey, Hutchison, Sic. in publications specified at the conclusion of this subject. The followingcase of necrosis of the thigh- bone is related by Dr. M'Kenzie. William Baxter, a boy thirteen years old, received a blow on his thi^h at school, of which he at first hardly complaii ed ; but, in a few months, he began to have pain in the thigh, which inflamed, swelled, and appeared to have matter in it. The parents being poor, no surgeon was called, and the boy was al- lowed to linger for a great while. At length the matter made ils way through the skin, by a small opening, on Ihe interior part of the thigh, about three inches above fhe knee, and a thin sanies continued to be discharged for eighteen or twenty months. At length, the hole in the skin enlarged, and the point of a bone began to protrude, and give a good deal of pain, when Ihe clothes rubbed against it. After suffering in this manner for two years and a half, the boy, as he lay in bed one morning, felt the bone looser, and pro- jecting more than ordinary. He gave it a strong pull, and brought the piece a vay en- tirily, which proved to be seven inches and a hilf of the thigh-bone. A good deal of bleeding followed ; but, the wound soon healed, mid he has never since found the least iuconveuiiice. Dr. M'Kenzie, hearing of this singular case, sent for the boy, care- fully examined bis Ibigh, and found it as firm as the other. The only difference was,that it was somewhat thicker, and a little more curved. The muscles retained their natural softness, and looseness on the bone. 'Ihe detached piece of bone vvas a portion of its whole circumference. (See Med Obs. and Inquiries, Vol. 2.) We may infer, that (he occurrence is more frequent in the tibia than any other hone, from the accumulated facts, mentioned by Albucasis, La Marche, Muralto, Ue La Motte, Ellincbuys, Ruysch, Tacconi, Laing, Johnson, Hunter, David, Boehmer, Sigvvart, Th Bartholine, Hofinann, Saviard, Le I'ran, Duverney, Trioen, Gunther, Ludwig, Mi- chael, Bousselin, Weidmann, Russell, Whately, Desault, be. See the works refer- red to at the end. Dr. Hunter mentions a tibia which was sent lo him by a Mr. Inett, after amputation. On examinntion, the case at first siyht seem- ed to be a swelling ofthe whole bone, with a loose internal exfoliation. However, it proved to be a remarkable instance of the separation of the greatest part of the origi- nal bone, whose place was supplied by a callus. The external surface of the enclo- sed loose piece of bone was smooth. A small part ofthe surrounding bony substance being removed, the contained piece was taken out, aud found to be the whole body of the tibia. It bad separated from the ept- NECROSIS. 269 pbysis at each extremity. The middle part of the bone had perished, consequently, had lost its connexion with the periosteum, and was gradually thrown off from the living parts of the bone at each end. A callus ex- tended from end to end, united the two ex- tremities of the original tibia, preserved the length, and gave firmness and inflexibility to the part. The exfoliation vvas so encom- passed by the new bony case, that though quite loose, it could not be thrown out. (Med. Obs. and Inq. Vol. 2.) Weidmann saw a shoemaker, who, after much suffering, extracted himself (he great- est part of the diaphysis ot the tibia ; yet, the loss was so well repaired, that the man could walk afterward nearly as ably as ever. (De. Necrosi Ossium, p. 29.) " We are not to imagine, (says Weid- mann) that these regenerations happen by chance : experiments made upon living ani- mals by Troja, Blumenbach, Koehler, De- sault, and myself, prove that they invariably follow certain laws." In fact, whenever the medullary structure of the long bones of pigeons, or dogs, is destroyed, these bones become affected with necrosis, and are afterward reproduced to the full extent of their destruction. The observations and experiments, cited by Weidmann, also prove, that it is the long bones which are usually reproduced ; though the flat ones are not entirely destitute of the power of regeneration, since experience fully evinces, that, when a portion of the skull is removed, either by a wound, by disease, or by the trepan, nature always endeavours fo cover the deficiency, the edges of the aperture extending themselves by means of a bony substance, furnished by the periosteum, the dura mater, and cranium itself. (Tenon Mim. de I'Acad. des Sciences, 1758, p. 4i2, 413, 415, 416, 418.) But still the reproduction is imperfect, as a space unfilled up is always left, even when the bone has lost only a small piece, like what is taken out by the trephine ; aud when the destruction of the cranium is very extensive, no reproduction at all happens. This fact is proved by examples mentioned by savi- ard,Pott, Sabatier, Sic When in a case of necrosis, says Weid- mann, a scale or table, of either a long or flat bone, is separated, no regeneration fol- lows, because the granulations, which rise up under the sequestrum, then serve as a periosteum, and as soon as the dead bone is removed, they become united to the ad- jacent parts. ' Il is likewise ascertained, that the power of reproduction in the bor.es is particularly active in the early periods of life, and in healthy subjects; and that it is languid and even annihilated in old persons, pregnant women, (Bonn* Thesaur. p. 174,) and in ve- nereal, cancerous, and rickety patients. (Callisen, Syst. Chir. Hodierne, Pars 1, p. 636.) In order that a new bone may form, the periosteum and other membranes, concern- ed in the nutrition of the original bone, must have been spared from destruction. In fact, continues Weidmann, we observe that in cases where the lube of a long bone has suffered necrosis, the bone is never repro- duced, when the periosteum has been de- stroyed by inflammation or other causes. Surgeons ought also to understand that it is not always a reproduction which has hap- pened, when a part of a bone perishes ; not even when a tubular portion of a long bone dies, and is contained in the medullary canal. For, says V\ eidmann if the inner- most layers of a long bone perish, while those which compose, as it vvere, the bark, are pieserved, the latter swell and soften, as if they were actually a new bone. Se- veral round apertures are observable upon their surface, which serve for the transmis- sion of vessels, and are larger than those which perform this office in the natural state. There are likewise formed large openings, or fistula?, which, as in a new bone, lead to the medullary canal. Here it would be erroneous to conclude that a new bone has been produced, and a very little attention will discover that all is limit- ed to some changes in the external part of the bone, which the necrosis has not affected. When, therefore, the interior of the canal of a long bone is destroyed by a necrosis, which does not extend to the external lay- ers, the case is not a reproduction of the bone. When, however, we find the tube of any long bone included in a sort of osseous shell, and the surface of this tube smooth, like that of a bone in the natural state, we may be certain that il has been detached directly from the periosteum, and that the bony shell which contains it, is a new production. On (he contrary, if the surface of the dead tube is rough, we may infer that the separa- tion has taken place between the innermost layers of the bone and those which are superficial, the latter composing now the osseous shell, in which the sequestrum is included. (Weidmann De Necrosi Ossium, p. 31.) This last theory, concerning the produc- tion of the osseus shell in necroses of the long cylindrical bones, is adopted by Riche- rand as tbe true one, not only in the in- stances specified by Weidmann, but in every other example w here the old bone seems to be included in another which has the ap- pearance of being a new production, and which was supposed by Troja, David, be. to be formed by the vessels of the perioste- um. (See Nosographie (hir. T. 3, p. 158, 161, Edit. 4) Boyer does not espouse (his theory exclusively ; but represents the thing as sometimes happening. (See Traiti des Mai. Chir. T. 3, p. 426.) As far as the observations of W'eidmann informed him, the short or cuboid bones do not appear to be capable of reproduction. (P. 31.) Duverney mentions an astragalus, which was destroyed by necrosis bu( does not state that any substitute for it was after- NECROSIS. ward formed. ( Traiti des Maladies des Chir. Os. p. 458.) Weidmann also never witnessed a repro- duction of (he spongy substance, such as it was before its destruction, round the me dulla. He always found the substituted matter dense and compact, at least for some time after its formation. It is now admitted, however, that in pro cess of time, the inner surface of the new bone becomes cellular, and is lined with a membrane containing medulla. The rege- neration of the medulla wns first observed by Koehler, and afterward in an extensive series of experiments, which Professor Thomson made with Dr. Alexander M'Do- nald, and which were published in the lat- ter gentleman's inaugural dissertation, in 1799. (See Thomson's Lectures on Inflam- mation, p. 393.) Mr. Russel does not ap- pear to adopt this opinion concerning the regeneration of the medulla; for, he states that, after the absorption or removal of the sequestrum, the cavity of the new bone be- comes filled up with granulations, which are at length converted into bony matter Thus, he says, the new bone differs from the ori- ginal oue, in being solid instead of hollow. Authorities, however, are decidedly against Mr Russell on this point: in the 5th vol. of the Mini de I'Acad. de Chir. is the history of a man, the whole of whose clavicle came away without his being deprived of any of the motions of the arm. The death of this patient, which happened shortly afterward, afforded an opportunity of examining how nature had repaired the loss. Another cla- vicle was found regenerated, which neither differed from the original one in length nor solidity ; but only in shape, being flatter, and not so round. It was connected with (he acromion and sternum, just like the primi- tive bone. The power, which thus reproduces bones, is only a modification of that which unites fractures. Indeed, what consolidates bro- ken bones, and is known by the name of callus, presents all the characters of new bone, begins and grows in the same way, and may be impeded and retarded in its formation by the same causes. (See Callus and Fractures.) It is furthe-r h'nrhly probable, asWreidmann remarks, that the power which effects the reproduction of bones, is the same as that, which in the sound state, nou- rishes and supports these parts. But to what organ appertains the function of reprodu- cing bones ? Many able men have ascribed the whole work to the periosteum. (C. Havers; Du- hamel, Mem. de I'Acad. des Sciences, 1739, 1741, 1742, 1747. Fougeroux, Mem. sur les Os; Paris, 1760. Swencke, Harlemer Ab- handlungen 1, th. p. 39. Berlin, Osteologie. Marigues, Abhandlung von der Fatur und Erzeugung des Callus, p. 199.) Haller, (Elem. Physiol. T. 8, p. 352.) Callisen, (Collect. Hafn. T. 2, p. 187.) Te- non (Mem de I'Acad. des Sciences, 1758, p. 415.) Bordenave, (Mem. sur les Os, p. 227) and many others, have seen a part of the new production spring up from tbe substance of the old bon.*; a thing, says Weidmann, which one is also led to believe by the fact, that, when tbe whole tube of a long bone is affected with necrosis, the epiphyses which remain sound and untouched, unite and grow to the new tube, though no peri- osteum exists in the situation ot the union. Nor does Weidmann think tiia( Ihe speci- men of a fractured thigh, of which Bliiinen- bach has publii-heil an engraving, proves the contrary (Geschithle und Berschreiuung tier Knocher; Gottngcn, 1786, 'lab. \,fig.\.) ibis preparation exhibits an union which had taken place by means of a very broad osseous ring, encompassing the ends of the fracture which lie far asunder. The event appears to Weidmunu to have been the result of rachitis, or lues venerea, with which the young patient, according to Blumenbach himself, had been affected, and by which the nutrition of this bone had been disorder- ed For, says Weidmann, in other exam- ples of united fractures, (he ends of the bone are so connected together by the callus, that there does not exist a single point be- tween them, where this substance is not effused, and the medullary cai al itself is obstructed and filled wilh it. In the Journ. Lump tern, du Did. des Sciences Med. T. 8, may be found some considerations, offered by Larrey, against the doctrime that the periosteum is the organ of ossification. That, however, the periosteum is fre- quently the organ of the reproduction of the bones, seems proved by the experiments of Troja, Blumenbach, Desault, and Koeh- ler, since in these the bones were invariably regenerated, though there was nothing left ofthe old bone that could furnish the new reproduction, except the periosteum. If we examine the new bone, at different periods of its developement, it appears in the earliest stkte in the form of a redidsh fluid, as has been observed by Duhamel. Fougeroux, Bordenave, Haller, Callisen, and others. If we also attend to the pro- gressive changes which this fluid undergoes, we cannot but believe that, as in the em- bryo, an organic and fixed arrangement of parts takes place. Indeed, it would be er- roneous to consider such fluid as destitute of organization and extravasated at random. Thin and little in quantity on its first appear- ance, its consistence and quantity afterward gradually increase (Troja, p. 42, 44,) so that what at first appeared like a liquid, soon becomes a gelatinous substance, in which are developed, especially at its inner surface and towards its lower part, bony fibres, which incessantly become more and more numerous. These fibres in a short time form little layers and cells, and extend themselves every where, so that at length all which was fluid disappears, and the new bone is produced. While young, however, it is still spongy and reddish, (Troja, p. 44;) but soon becomes denser, harder, and more solid, than that was for which it is a substi- tute, and it acquires the ordinary colour of the rest of the bones. NECROSI b. 271 The external surface of the new bone, which, during the period of its formation, was irregular, and studded with several ex- crescences of various sizes, and pierced with apertures of different dimensions, becomes in the course of time smooth and regular, especially after the expulsion of the seques- trum. The sides, or walls ofthe new bone which at first were of considerable thickness, in lime also grow thinuer. (Troja, p. 21.) When the entire dead bony cylinder con- tinues in its cavity, the new bone is neither shorter, nor longer, than the original. But, should one of the ends of the dead tube protrude from the cavity, while by the side of the affected bone, there is not another one capable of resisting the action of the muscles, the new bone will be shortened, and undergo some change in its shape and direction. Indeed, says Weidmann, the new bone in its early state, from want of con- sistence, must yield to the efforts of the muscles. Its shape is not exactly like that of the original bone: the sides are flatter; the usual angles, depressions, and eminences are not observable, and sometimes others are formed. How admirable is the process, by which the muscles, detached from a bone affected with necrosis, have other insertions given to them, and are thus rendered capable of per- forming their functions ! (Troja, p. 2.7.) The periosteum, which swells as soon as the exfoliation of the old bone commences, shrinks, and is not at all thickened, when the exfoliation is finished. Troja, having destroyed the medullary structure of a long bone, found the periosteum swelled at the end of 36 hours; but he observed, that the whole of such swelling disappeared before Ihe 25tb day. (P. 43, 67.) The periosteum, which thus survives, ad- heres to the new bone, as it did to the old one : its vessels, which are now increased in diameter, and convey a larger quantity of blood, dive into large apertures in the re- generated bone, ramify every where in its substance, and nourish it. Dr. Macartney's observations nearly agree with those of Troja and Weidmann, respect iug the formation of the new bone by the periosteum, with this difference, however, that he does not describe the original perios- teum as becoming afterward attached to the new bone, but as disappearing. Dr Macart- ney remarks, *' that the first and most im- portant circumstance is the change, which takes place in t.ie organization of the perios- teum ; this membrane acquires the highest degree of vascularity, becomes considerably thickened, soft, spongy, and loosely ad herent to the bone. The cellular substance, also, wliich is immediately connected with the periosteum, suffers a similar alteration : it puts on the appearance of being inflamed, its vessels enlarge, lymph is shed into its interstices, and it becomes consolidated with the periosteum. These changes are prepara- ♦orv to the absorption of the old bone, and the secretion ofthe new osseous matter, and even previous to the death of the bone, which is to be removed. In one instance, I found the periosteum vascular and pulpy, when the only affection vvas a small abscess of the medulla, the bone still retaining its connexion with the neighbouring parts, as it readily received injection. The newly or- ganized periosteum, Sic separates entirely from the bone, after which it begins to re- move the latter by absorption ;" and, while this is going on, its inner surface becomes covered with little eminences, resembling granulations. " In proportion as the old bone is removed, new osseous matter is dis„- persed in the substance of the granulations, whilst they continue to grow upon the old bone, until the whole, or a part of it, is com- pletely absorbed, according to the circum- stances of the case. What remains of the investment, after the absorption of the old bone, and the formation of the osseous tube, which is to replace it, degenerates, loses its vascularity, and appears like a lacerated membrane. I have never had an opportuni- ty of examining a limb, a sufficient time after the termination of the disease, to ascertain, whether the investment be at last totally ab- sorbed, but in some instances, I have seen very little remaining. During the progress of the disease, the thickened cellular sub- stance, which surrounded the original perios- teum, becomes gradually thinner; its vessels diminish, and it adheres strictly to the new- formed bone, to which it ultimately serves as a periosteum." Dr. Macartney states, that the anatomical preparations, which au- thenticate the above observations, are pre- served at St. Bartholomew's Hospital. (See Crowther on While Swelling, p. 183. Ed. 2.) Mr. Stanley, however, lately showed me in the same museum, a preparation, which tends to confirm the accuracy of Troja's account of the old periosteum becoming adherent to the new bone. In this example, the periosteum is perfectly continuous with that covering the epiphyses. If this were not the fact, we should have to explain in what way the periosteum ofthe new bone is formed. We know that the vessels of the original periosteum enter the new bone, in order to compfete its formation, and it seems more consonant with the uniform simplicity of nature's operations, to suppose that this connexion is kept up, than that the old periosteum should be totally removed, after the production of ihe new bone, and another membrane of the same kind be then gene- rated. An interesting example of necrosis ofthe thigh-bone, published some time ago by Mr. C. Hutchison, tends also to prove, that the new osseous shell is commonly formed by tht periosteum, as, in this case, the medulla- ry bags, or cells, were found completely ossified, (Practical Obs. in Surgery, p. 135) and could not therefore be supposed to be capable of the work. Among the moderns, also, Dr. M'Donald deserves to be mention- ed as one of the most distinguished advo- cates for the truth of Troia's explanation of NECROSIS this subject. (See M'Donald's Thesis de Necrosi ac Callo; Edinb. 1799.) Another late writer has adduced many arguments to firove that the pulpy mass, which extends rom one epiphysis to the other, and is itself at last converted into bone, is formed quite independently of the original bone, or the periosteum. (See Russell's Practical Essay on Necrosis, p. 27, Edinb. 1795.) This ac- count, however, is contrary to the observa- tions of Troja, David, Weidmann, M'Donald, Macartney, and numerous other observers. Indeed, a modern author seems to think the periosteum so essential to ossification, or the production of a new bone, that he attempts to explain the cause of fractures of the patella not becoming united by a bony sub- stance, by adverting to the deficiency of periosteum upon it; a circumstance which he deems also a strong argument against Mr. Russell s doctrine. (See Hutchison's Practical Observ. in Surgery, p. 141, 142.) These very same cases, however, fractures ofthe patella, do sometimes unite by bone, and, therefore, while Mr. Hutchison is urging them as facts against Mr. Russell's opinion, Baron Larrey is actually adducing them in its support. (See Journ. Complim. du Did. des Sciences Mid. T. 8.) The experiments of Breschet and Villerme are decidedly against the periosteum being exclusively the organ of ossification. Professor Boyer does not refer all the work of reproducing bones exclusively to the periosteum in every instance ; but joins Weidmann in believing, that what seems a new bone is sometimes only a separation and thickening ofthe external layers ofthe original bone, which have escaped destruc- tion. He notices the modifications, to which the phenomena of necrosis are sub- ject when the disorder affects the whole thickness, and the whole, or the greater part, of the circu.nference of a long cylindrical bone. When the periosteum is destroyed together with the bone, and the medullary membrane, which does the office of an in- ternal periosteum, is preserved, Boyer represents the latter membrane as under- going similar changes to those which we have mentioned as taking place, under other circumstances, in the external perios- teum, and he describes it as becoming the organ by which the new bone is formed. (See Truite des Maladies Chir. T. 3, p. 432.) But when the whole thickness and circum- ference of alone-, bone are destroyed, together with the medullary membrane, while the periosteum survives, Boyer agrees with Troja, tec. in believing the latter membrane to be the means by which the new bone is generated. The internal surface of the new bone is lined by a new membrane, which serves as a periosteum, and is at first hardly distin- guishable. (Troja, p. 56.) Iu the early- state, it is soft and pulpy ; (ibid. p. 22 ,) but, by degrees, it grows thicker and firmer, and is at length converted into a true membrane, which sends a great number of vessels into the substance of the bone. When this mem- brane is torn off, the surface, which it cover- ed, is found somewhat smooth, the edges of the bony layers, and projections of the fibres being blunt and rounded. The cavity of tbe new bone includes, and almost entirely onceals the dead fragments. Sometimes, however, the new bone forms a sort of bridge over the sequestrum, in such a manner that the cavity is open above and below, in both which situations the seques- trum can be felt (Hunter, in Med. Obs. and Inquiries Vol. 2, p 418.) Sometimes, it is only a narrow cross-piece, which forms the bridge retaining the seques- trum. (Weidmann. rid Tab 5, Fig. I, a.) The new bone may also have an opening in it, out of which the dead portion protrudes. (Ib. p 35.) Sometime^ the cavity of the new bone is single ; while in other instances, there are several successive cavities in the direction of the leiiith of the bone, with transverse interspaces between them ; or else the cavi- (ies are situated laterally with respect to each other, and divided by partitions. (Weidmann, Tab. 7, Fig 2.) These cavities are proportioned in size and shape to the fragments of dead bone, which lodge in them. It occasionally bap- pens, that they open into some neighbouring joint, and brin^ on suppuration there .- a very unfavourable complication. (Ibid.p. 34, and Tab. 6, Fig. 3; also, Boyer, Traiti des Mat. Chir. Tom 3,p. 435.) Let us next follow Weidmann, and take notice of the holes, by which the cavities, including the dead pieces of bone, open externally, which Troja denominated the large foramina, and which the preceding ex- cellent writer preferred calling the cloaca., because they serve to convey outward (he matter and any separated pieces of bone. In the beginning of the disorder, they are not observable, a certain space of time appear- ing to be requisite for their formation. They are noticed in long cylindrical bones, whe- ther original, or of new production, whose cavities contain dead fragments. These openings vary in number: when the sequestrum is small, only one is found; but, when tbe piece of dead bone is exten- sive, there may be two. three, or four. Weidmann never saw more than five. But Troja met with eight. (P. 58.) Weidmann possessed a small portion of the diploe of the os innominutum, which vvas affected with necrosis, and contained in a oony cavity, that bad no external opening what- ever. When there are several distinct cavities in the same bone, containing dead frag- ments, each cavity has at least one external opening. These cloace, or apertures, are commonly situated at the lower and lateral parts ofthe cavities ; pass obliquely outwards; and com- municate with fistulous ulcers, which open on the surface of the skin. (David, p 186.) Some of the cloacae, however, form at the middle, or (what is exceedingly rare) at the upper part of the cavities, and proceeding NECROSIS. 213 outward, without any oblique Irack, go to fhe front, back, or lateral parts of the limb. They are of a round, or oval shape, or nearly so. Their usual size is such, that it will just admit a quill, and they vary very little from this dimension. They terminate internally by converging approaching edges, in the manner of a fun- nel ; while, on the contrary, the margins of their outer extremity expand. The canal between these two orifices is sometimes long, sometimes short, and in certain cases, of no extent at all. Different opinions have been broached, respecting the causes which produce the apertures in the new bone, termed by Weid- mann the cloace. M. David says, that the pus collecting in an early stage of the disease between the bone and periosteum, distends and corrodes this membrane, and that the openings which form in it become afterward a cause of fis- tula; in the new bone. (P. 186.) But it is observed by Weidmann, that this explana- tion is inadmissible, since tbe existeuce of the collection of pus, mentioned by M. Da- vid, is not proved by observation : in fact, it was never met With by Troja, Blumen- bach, Desault, Koehler, and many others, in repeated experiments made on the subject (Troja, p. 56 and 66 ; Wtidmann, p. 36.) K center thought he had seen the new- bone itself destroyed by the pus, and cloace thus produced. (P. 68—72.) Weidman, however, deems this opinion quite as improbable as the preceding, for tbe fact of the surface of these bony aper- tures being always smooth, always formed in one manner, and constantly lined by ,the periosteum, decidedly proves lhal they can- not arise from erosion. Troja, in his third experiment upon the regeneration of bones, remarked, that forty- two hours alter the destruction of the me- dulla, there took place, between the bone and (he periosteum, an effusion of lymph, which was at first thin and little in quantity, bul afterward became thicker. He noticed, in tbe midst of this gelatinous substance, some small spaces, where il was deficient, and which had, instead of it, a subtile whitish, dry in- truslation, which, though tolerably adherent, could be rubbett off. These small spaces, ac- cording to Troja, produce the apertures called the cloace. (Troja, p. 45.) In another experiment, he had an opportu- nity of examining the above little spaces al the end of forty-eight hours ; he affirms, that tbey were replaced by the large aper- tures, or cloacae, of the new bone (P. 47 ;) and that such openings were invariably formed in the place of the small incrusled spaces already described. (P. 58.) As Troja took notice that no lymph was effused at these particular points, he was inclined to impute the circumstance to a defect in the os- sification, and, perhaps, fo the death of some parts of the periosteum. Weidinnnu acknow- ledges, thai ihe mode, in which the forma- tion of tbe cloacae happens, is exceedingly jbseure; and cypresses his belief, that Vol. II 35 Troja's account of it approaches (he nearest to the truth. Bui, says he. one thing is cer- tain, namely, that these openings have no other use, but that of conveying outward ihe pus which collects in the cavity, and the small bony fragments, since, as soon as every atom of dead hone has passed out, (hey diminish, and, al length, are totally obliterated. (Weidmann De Necrosi Ossium, p. 36.) Il is a remarkable circumstance, in the history of necrosis, that, in favomable in- stances of (he disease, the inflexibility and firmness of the limb are preserved during the w bole of the process, by which the new bone is formed. Consequently, ihe new bone must bave begun to grow, and have acquired firmness b< fore tbe old bone sepa- rates, or is absorbed. Were this not the case the limb must become flexible and use- less, (he moment the dead bone is removed. Another consequence of tbe new bone being (ormed, before (he removal of the old one, is that the former must surround and include Ihe latter. For, since the lifeless portion of bone completely occupies the space belween the two living ends, these cannot be imme- diately connected by tbe new bony matter The connexion can alone be completed by the new bone.being deposited on the outside of the old one, from one end to Ihe other, and attaching itself lo the portions which still remain alive. Tlie new bone must also be necessarily larger than (he old one, because externally situated, and hence the affected limb, after the cure is complete, will always continue larger, clumsier, and less shapely than (he olher. The length of il, however, remains unaltered, because (be old bone re- tains its attachment, while the rudiments of the new bone are lying on its outside, and connect the living ends of the old one, by an inflexible mass, equal in length to the portion which is destroyed. Thus we see, that, in the process which nature follows in the formation of the new osseous shell, tho old bone serves as a mould for Ihe new one, and tbe first step of the process is to surround the old bone with an effusion of coagulating lymph. (See Russell on Necrosis, p. 2—7.) When the sequestrum is thrown off slowly, the inflammation is moderate ; but when it separates quickly, while the new bone is in a soft state, the detachment is always preceded by severe inflammatory symptoms, and fol- lowed by a temporary loss of the natural firmness of the limb. This premature sepa- ration of the sequestrum often occurs in ne- crosis of the lower jaw, and the chin conse- quently falls down on the neck.. In certain cases, the sequestrum separates al each end from the living portions of (he old bone, before the new osseous shell has acquired firmness, so that the limb feels as if it were broken in two places. (Russell.) Let us next consider the states and circum- stances of necrosis, in which the art of sur- gery may be advantageously exerted in the assistance of nature, and the means which may be employed for this purpose. &4 NECRO&1S. A common error ot medical and surgical practitioners is always to impute the Cure of every disease to whatever remedies happen to be employed, and successes are too often boasted of, the m--ril of which belongs en- tirely to nature. It is. indeed, not very un- frequent to hear remedies panegyrically spoken of, which counteract the salutary efforts of nature, who, in this case, is obliged lo overcome both the disease, and the itra- tional treatment, which is applied to it. As Weidmann observes, this erroneous mode ol considering things has happened particularly often among surgeons who have had cases of necrosis under their care, all of whom boast of the cures which they have accom- plished, although some employed absorbenl earths, others, aromaiics ; some, spirituous applications; others, balmy remedies; some, acids; others, caustics; and some, armed wilh a wimble, made numerous perforations in tbe dead bone ; while many others rasped Ihe part, or attacked it with (he trepan, cut- ting forceps, tbe gouge and mallet, or even the actual cautery ; and a certain number did nothing more, than apply dry lint. Na- ture, who was lavourable io all, did her own work in silence, whatever were Ihe remedies employed for ber assistance, whether mild and inert; acrid and corrosive; or hurtful and improper. We have already noticed, that a dead portion of bone separates from the living exactly in the same way, as gangrenous soft parts spontaneously drop off, without ihe interference of art. The separation happens precisely at the points to which death has extended ; limits, which are w'ell understood only by nature, and ol course can be mea- sured only by her. Art would incur great risk of either going beyond them, or else of not reaching them at all. Perhaps, it may be deemed unsafe to confide the process of separation, or exfoliation, to nature. But, in what other manner could it be more safely accomplished, without hemorrhage, or pain to the patient—without any risk of a recur- rence of inflammation, or of a fresh necrosis? Is there reason to fear, that, when every thing is left to nature, the separation cannot be finished till after a very long period of lime ? It is true, say Weidmann, that the process frequently requires a considerable time ; but, as the vitality of the bones is not possessed of much energy, and iheir compo- nent parts strongly cohere, slowness is in evitable in an operation, which depends entirely upon the vital power. What is it then which surgery can do to accelerate the process ? Will any of the above-mentioned topical applications have this effect ? They are put upon the inert surface of a dead piece of bone, in which no vital power, or action, can be again excited. When acrid, they prove irritating, inflaming, and destructive of the neighbouring flesh, without any utility— and cause pain to the patient, which is com- pensated by no good. Would the perfora- tions, recommended by Celsus, Belloste, and many others, have the desired effect3 If. says Weidmann, they are confined to the dead bone, they caunot have more effect, than the scarifications, which were formerly practised by ignorant surgeons in cases of gangrene ; and, if they extend to the living bone, this will be injured or at least run tho risk of being so. Lastly; Weidmann demands, if the separation can be accelerated by the actual cautery, which cannot act upon every point of the necrosis, and which, unless applied with the greatest precautions, will burn the subjacent parts, and bring on a new attack of inflammation, without for- warding the exfoliation in the smallest de- gree ? Of what use can rasping and scraping in- struments be, which act merely upon the dead part ? Or will the gouge, and other cutting instruments, do more good? They cannot take away the whole of the dead portion, without injuring the adjacent Jiving bone, and causing a risk of another necrosis. And, if they leave any pieces of the old dead bone behind, nature will be as long in effecting the separation of (hese, as she would have been in detaching the entire ne- crosis Weidmann mentions a case, which occur- red in the hospital of St. Rpch at Mentz. A man's legs were seized with mortification, in consequence of exposure to cold ; the whole of the dead parts separated ; and the bones were sawn through on a level with the living flesh. A portion of tbe end of each bone, however, was afterward thrown off altogether by nature, and Weidmann thence concludes, that the previous use of the saw had been fruitless. Weidmann then cites another case of mortification of the leg and half of the thigh, which was the conse- quence of a putrid fever. The leg sloughed away, leaving the lower portion of the thigh- bone uncovered and projecting. Under a tonic plan of treatment, this part of the bone spontaneously separated. As, however, a considerable quantity of integuments had been destroyed, the ulcer was slow in heal- ing ; but, it cicatrized at last, and the young woman continued well long afterward. Weidmann hasquoted the memorable case, in w hich Mr. Charles White first sawed off the upper part of a diseased humerus. (See Amputation.) As, in this instance, nature accomplished of herself the separation of another dead portion of the same bone, two months after the operation, Weidmann seems disposed to think the cure would have hap- pened equally well w ithout. it. In cases of slight superficial necrosis, sur- geons have frequent opportunities of trying every kind of topical application ; and when the cure takes place, during the use of any of them, the benefit is ascribed to whatever happens to be in use. But, says Weidmann, in numerous more serious examples of ne- crosis, it is impossible to make these applica- tions reach the whole surface of the dead bone; but, notwithstanding this circum- stance, the separation is not impeded. Some exfoliations happen, without our knowing of their occurrence, and. without a thotieh' NECROSI r, S3-> Laving been tntertaincd of promoting them by any vaunted applications. We even see necrosis separate, whose situation rendered them inaccessible to our remedies ; such are the necrosis, which occur within the long bones, and comprehend the whole of their cylindrical shaft or body. What surgeon shall presume to boast of his having effected by topical applications, the separation of the whole lower jaw-bone . a thing, which nature has very frequently accomplished ? And, when, as often happens, the entire diaphysis of fhe thigh-bone, tibia, e>r other long bone, comes away ; or, split longitudinally, such bone loses a half of its cylinder ; how is it possible for any topical applications to reach every point, ar which the separation occurs ? The internal remedies, such as assafcetida, madder, sarsaparilla, hemlock, belladonna, onopordllm, lime-water, Sic. recommended by numerous practitioners, have in reality no direct efficacy in promoting the separa- tion of necrosis : if, says Weidmann, they do any good, it can only be by (heir tonic und alterative-qualities, or rather by keep- ing the patient amused, so as to gain the. re- quisite time for the completion of the pro- cess of exfoliation. The employment of all (hese ineffectual means, VVeidmann con- ceives, must have originated from ignorance of the process, followed by nature in separa- ting dead portions of bone, and from ascri- bring to the arterial pulsations or the power of the granulations, what certainly depends upon the action of the absorbent vessels. A question here naturally presents itself.— Would there be any utility in exciting by stimulants the action of the lymphatic ves- sels, in order to accelerate the separation, of which it is the efficient cause ? Weidmann thinks, that very beneficial effects might result from the plan. But, he asks, what means should be used for this ob- ject ? Cold ? Purgative medicines ? Repeat- ed vomits? Squills? Camphor? Neutral Salts ? Issues ? (Vid. Wrisberg, Comment, Soc. Peg. Gotl. Vol. 9, p. 136, 1789.) He adds, that,perhaps, many valuable discoveries will hereafter be made on this subject. The reasons already detailed, and a varie- ty of experiments successfully made by Weid- mann, lead him to set it down as an esta- blished principle, that the separation of a necrosis is almost entirely the workof nature, nnd that surgery can do very little in the business. Ignorance of this important fact paved the way to the wrong practice of making incisions, for the purpose of exposing the whole surface of a necrosis, immediately the existence of the disorder was known. As such incisions very soon closed up again, so as to leave only a small outlet for the matter, they vvere in many cases repeated- ly practised before the dead bone became loose. The avowed design of the incisions was lomake room for (he topical remedies, which were to render the exfoliation quicker ; but, as these remedies possess no real efficacy, if follows, that making incisions, before (he dead bone is loose, only'torments the patient, without producing the least benefit. The orifices of the ulcers, then, which allow the discharge to escape freely, are, says Weidmann, sufficient as long as the frag- ments of bone are not entirely detached, and the surgeon should all this period ab- stain from the use of the knife. Although Weidmann condemnseverymode of treatment, which is inefficacious, painful, and sometimes even hurtful, he would not have it supposed that he altogether rejects all assistance from medicine. On the con- trary, he approves of all those means, which are consistent with the views of nature, wliich really assist her, and do not tease the patient to no purpose. ,In short, says he, the indications are limiled to removing the origi- nal cause of the disease; to alleviating the symptoms; to supporting the patient's strength, and improving the stale of the constitution, in whatever respect it may be bad ; and, lastly, removing the dead portions of bone, when they become loose. Above all things (continues this sensible practitioner) the surgeon must not regard every piece of exposed bone, as necessarily affected with necrosis, and, in consequence of such idea, have recourse to acrid, dry- ing caustic applications. Such means are not only useless, but absolutely pernicious; because they may actually cause a necrosis,- wbi'di did not exist, before they were used, and which would not have taken place at all, if only mild simple dressings had been employed. \Vlien the disease presents ifself with vio- lent symptoms, the inflammation and fever being iutehse, the severity of the case is to be assuaged by low diet, antiphlogistic reme- dies, emollient applications, and venesection in moderation, the disease being one which is of long duration, and apt lo wear out the patient's strength. Here, perhaps, topical bleeding ought always to be preferred to venesectioii. When the necrosis has arisen- from syphilis, scrophula, or scurvy, Sic. the medicines, calculated for the cure of these affections, must be exhibited, ere any fa- vourable changes can be expected in the state of the diseased bone. Lastly, it is the duty of the practitioner to extract the fragments of dead bone, in order (hat the deficiem-ies produced by them may be filled up, and the ulcers of the soft parts heal. Nature, who succeeds by herself in detach- ing the dead pieces of bone, can do very little in promoting their passage outward. Frequently, indeed, she has no power at all iu this process, and it is only from surgery that assistance can be derived. When a dead piece of bone, is still adherent at some points, its extraction should be postponed, until it has become completely loose. If it were forcibly pulled away, there would be dauber of leaving a part of it behind, which must have time to separate, ere the cure can be accomplished. But, when a fragment is entirely detached", and the orifices of (he sores are ?\i!ncientfv ^;0 NECROSIS large ;f i<= to he taken hold of \vith a pair of adherent to (he adjacent parts ; and, if the v forceps, and extracted. delay too long, the patient may be irrero When the ulcer has only a very narrow verably reduced, while tbe nevy bone, on opening, suitable incisions must be practised, account of the hardness which it has in order'to facilitate the removal of the loose now acquired, cannot be so easily perfora- dead bone. . ted- .,, , , Sometimes, the dead fragment protrudes Patients are met with, who have been from the ulcer, and projects externally, so afflicted with necrosis several years. In that, if loose, it admits of being taken hold such cases, groat circumspection is necessu- of with the fingers, and removed. In this ry, and the practitioner should carefully way, Weidmann took away a large dead endeavour to ascertain, that (he dead pieces piece ofthe humerus, which protruded near- of bone have not been absorbed, or come ly two inches out of an ulcer in the middle away piecemeal in the discharge, les( an ofthe arm. 'Ibe patient was a young lad, useless operation should be done, as once 14 years of age ; and the limb concave happened in the practice of M. Bousselin. within, convex externally, thicker, and one (Mim. de la Sodeti Royale de Midecine. T.4, inch shorter than its fellow. He got quite p. 304.) Therefore, when the disease is of well three weeks after the removal of the long continuance; when (he discharge is dead bone. much less than it vvas at the commencement; We have already adverted to the example, when small pieces of bone have at times recorded by Weidmann, in which a shoe- been voided; and the sequestrum cannot- maker removed by himself nearly the whole be felt with a probe ; it is doubtless, says body of the tibia. Doubtless, the projection Weidmann, most prudent to abandon all idea ofthe bone, arid its looseness, enabled the of operating, and allow nature to finish what man to do this easily with his fingers. But, she has so well begun. In short, when tbe there are cases, which present more difficulty; sequestra are undergoing a gradual absorp- such are those, in which the sequestrum is tiou, without ever making their appearance included in a cavity, either of the original, externally, or giving any considerable elis- or new bone. turbance to the constitution, or, when the The old surgeons were in the habit of am- dead hone is making its way outward, with- putating limbs which were in this state; out occasioning urgent inconveniences; the although instances were not wanting in their surgeon should interfere very little with the days to prove the possibility of relieving the natural progress ofthe case. When the disease, without amputation. This blamable dead bone ddes not tend to make its way custom of removing every limb, thus affect- through the skin, but lies quietly concealed ed, is justly exploded from modern surgery, in the new osseous shell, the occurrence of Albucasis was the first who attempted to extensive suppurations may be prevented, cure such a case of necrosis, by the judicious by occasionally applying leeches, and keep- employment of the knite and saw. (Lib. 2, ing open a blister with the savine cerate, as cap. 88.) The same kind of practice was recommended by Mr. Abernethy in his lec- successfully adopted in two instances by the tures, and Mr. Crowther, in his work on the celebrated Scultetus. vSec Armafnent Chi- White-Swelling. The blister will, at the rurg. Tab. 46, and Obs. 81 ) This commen- same time, have great effect in promoting dable melhod, however, afterward fell into the absorption of the sequestrum, and, disuse, until M.David, by twenty examples of of course, in accellerating the process of success, refuted all tbe objections which had cure. been urged against it. (P. 197.) Since the If the surgeon operate as soon as the se- periodof this distinguished author, the prac- questrum becomes loose, he will, find the tice has been imitated by all enlightened new bone so soft, that it can be divided with surgeons, so that the case is no longer re- a knife; a circumstance, which materially garded as a disease necessarily requiring facilitates and shortens the operation. amputation. M. Bousselin has cut out the Keeping in mind the foregoing precepts, sequestrum eight times from the tibia, and the surgeon is to begin w ith exposing,the four times from the thigh-bone, with per- bone in which the sequestrum is contained. feet success. (Vid Mim. de la Societi Royale When tbe bone lies immediately under the de Midecine, Tom. 4.) skin, Weidmann recommends making such The method consists in exposing tbe bone, incisions as will lay bare the whole of iU and making in it an opening of sufficient surface, and when its situation is deeper size for the removal of the loose dead frag- beneath the muscles, he even sanctions cut- ments. ting away as much of the flesh as may be Experience has proved, not only that, necessary to allow the instruments io be patients affected with necroses, easily bear freely worked upon the bone*. I cannot, this operation, but also that after its perform- however, see the propriety of this advice; ance, the ulcers commonly heal very exposing the whole surface of the bone in favourably, the health becomes re-establish- the first instance, before it is known whether ed, and the functions of the part affected are the saw need be so extensively used as to hardly at all impaired. require such a denudation, certainly appears Surgeons,however, arfc not indiscriminately irrational. And, as for cutting away any to choose any period for doing the operation, portions of muscle, this can be no more ne- If they are too hasty, they will run a risk cessary here, than it is in the operation of of finding the dead portion of bone still trephining. But it h unquestionably proper NJL.CROSIS io make wilh the bistoury sufficient space for the use of whatever instrument is em- ployed for the division of the bone. Vet it is only necessary to make this exposure in the ftrst instance in one place. The surgeon can afterward enlarge the incision or prac- tise others, as circumstances may indicate. The surface of the bone being brought into view, if the cavities, in which the dead frag- ments lodge, present apertures which are too narrow, these apertures must be rendered larger by means of small trephines, or saws constructed on the principles of those des- cribed by Mr. Hey of Leeds. The perpen- dicularly acting wheel-like saw, turned by machinery, and invented by Mr. Machell, here promises also to be of important assist- ance. It has been used by Sir Astley Coo- per, who has given an engraving of it in his Surgical Essays, Part I. PI. 8. Fig. 7. And another saw, constructed on somewhat si- milar principles, has been employed by Graefe of Berlin with great advantage for several years. A tract, giving an account of it, was sent to me by the late Dr. Albers, a little before his death ; but. as I have now lent the publication to Mr. Stanley for the purpose of assisting Mr. Evans in the con- struction of the instrument, I shall merely add, that Graefe's saw i> turned by a handle which projects horizontally from the cutting part of the instrunrefrf, and that it has a frame or fulcrum, on which it works. With such instruments the pieces of bone extend- ing across the above openings, and imped- ing the extraction of the sequestra, may also be removed. But when the preceding cavities are closed on every side, and it is impossible to reach into them in any other way, than through the cloacae, a trephine is to be applied, which must comprise within its circle a half ofthe fistulous opening. The crown of the trephine, however, must not be broader than the cavity of the bone, nor yet narrower than the sequestrum. If, after making a perforation in this man- ner, the sequestrum should be found too large Io pass through the opening, .a small saw must be employed for enlarging the aperture. When the bone is so hard and thick that it cannot.be well cut with a saw, tbe sur- geon has the sanction of authority and ex- perience, for using a gouge and mallet. When the sequestrum is found to be very large, it will be necessary to expose more of the surface of the bone by incisions. In this sort of case, Weidmann recommends applyingthe trephine to the upper and lower parts of the cavity, and then cutting away the intervening portion of bone with the saw or gouge. But there can be no doubt that a more prudent way would be to go on with tbe enlargement of the aperture in the bone, at the place where the first perforation took place, if the sequestrum presented it- self equally well there, because, by pro- ceeding in this manner, the surgeon might discover that the dead fragment could be taken out without so great a destruction of bone as is caused in the olher mode; and, if this were not to be the case, no harm is done, as the necessary removal of bone can be continued. When the bone, which includes tbe se- questrum, is a new production, and the ope- ration is not too long deferred, the soft state of the bone will enable the operator to perform the needful excisions with tha bistoury alone. When the sides of the cavity, in the ori- ginal bone, .are thin, fragile, and pierced with numerousJioles, the surgeon can break away a sufficient portion with a pair of for- ceps. When several sinuses exist in the bone, each may be dilated, in the manner which seems most advantageous. Sufficient openings having been made into the cavities, including the sequestra, Ihe next object is (o extract these dead portions of bone. In accomplishing this part of the operation, Weidmann particularly ad- vises two things; first, that no piece of the sequestrum be left behind; secondly, that no injury be done to the membrane, which lines the cavity in which tbe dead bone is lodged. This author observes, that there are ex- amples, in which tbe vicinity of certain parts impedes the surgeon from making an opening in the bore, large enough for (he extraction of a voluminous sequestrum in an entire sta(e. In this circumstance, he recommends the sequestrum to be broken into pieces by any convenient means, and the fragments to be separately removed. Weidmann has recorded an extremely in- teresting case to.prove how much may sometimes be effected by taking away the sequestrum. A man, 34 years of age, who had an internal necrosis of the tibia, with abscesses and ce fema of the whole limb, and who vvas reduced to the lowest ebb of weakness, was put under this excellent sur- geon's care. A perforation was made wilh a trephine in the upper head of the libia ; but, this opening not proving ample enough, it was enlarged with a small saw, and a gouge and mallet. The sequestrum was then extracted. Tbe palient's state after- ward gradually improved, and in nine months he was completely well. Il is not to be dissembled, however, that cases do exist, in which amputation affords the only chance of saving the palient's life. In fact, it sometimes happens, that the cavi- ties, in which the sequestra are contained, communicate wilh ibiise of tbe neighbour- ing joints, which then become filled with matter, and caries attacks part of tbe hones, to which the necrosis does not extend. On some occasions, the dead pieces' of bone are very numerous, and e*'cb has a sepa- rate cavity ; while, in other instances, the sequestra lie so deeply, that a passage for their extraction cannot be prudently at- tempted. Sometimes, also, a necrosis is complicated with another disease in its vi- cinity. L-istly, such may be the* reduced state of the patient's health, and the parti- 278 NECROSIS cular condition of the necrosis itself, (ha( the constitution cannot hold out during Ibe whole lime which would be requisite for tbe.detachment of the sequestrum. Tiider circumstances like these, amputation is ne- cessary, aud ought not to be delayed. For (he authorities of many of the obser- vationsand cases in theforegoingarticle,aiid for additional information on the subject, see Albucasis, lib. 2, cap. S8. Scultclus, Arma- ment. Chir. Tab. 46, and Obs. 81. Belloste, Le Chirurgien d'Hopital, part \,chap 12. J. Louis Petit, Traili des M-dadies des Os, Tom. 2, chap. 16. Monro's Works by his Son. Tenon in Mim. de I'Acad. des Sciences, 1758. Ait ken, Systematic Elements of the Thtory and Practice of Surgery, Edinb. 1779, p. 2S8. Some interesting cases and re- marks, chiefly about the question of amputa- tion, are contained in Schmucker's Vermischte Chir. Schriften. B. 1, p. 17, fyc. Ed. 2. Cal- lisen, Systema Chirurgie Hodiernec, Vol. 2, p. 893 Gott lson. C. White, Cases in Sur- gery, London, 1770, p 57, fyc. li'risberg, Comment. Soc Reg. Gotl. Vol.9, p. 136, fyc. Bousselin, in Mim de la Societi Royale de M, decine, Tom. 4. Louis, in Mim. de I'Acad. de Chirurgie, Tom. 5. Chopart, DisserL de Necrosi Ossium, Paris, 1776. David, Obs sur une Maladie connue sous le nom de Ni- crose, Paris, 1782. Pott's Chirurgical Works, Lond, 1779, Vol. l,p 32. Bromfield's Chir. Cases and Observations. Vol. 2, p. 9. C G. Korlum, Comment, de Vitio Scrofuloso. Ltm- govie, 1789, T. 2, part 3, cap. 11. Knolli, Dissert, de Carie Ossium venerea; Lips, 1763. S.G.RmdererProgr. dc Ossium Vitiis Qbserva- ttonescontinens; Gaetlinga, 1760. Lind's Trea- tise on the Scurvy, Fabre in Mim. de I'Acad. de Chic TA.p, 91. Bonn's Thesaurus Ossium Morbos Bond, Med. Septenlr. L 2, Sect. 4. cap. 25. Ephemer. Acad. Nat. Cur. Ann. 7 et 8, obs. 4. Guerney, in Mini, dc I'Acad. de Chir. Tom. 5, in 4lo. p. 355—368. Belmain, ibid. p. 363. Acrel, Chirurgische Vorfalle, L'ebers. Von Murray, Vol. 1. p. 194. Van Wy, Vermischte Chirurgische Schriflen, Nu- remberg, 1786, p. 192. Trioen, Obserrat. Med. Chir. Fascic. L. B. 1743, p. 46. Rei- plein in Richter's Chirurgische Bibliothek, T. 7, p. 569. Henkel, ibid. T. 2, p. 42. Dus- saussoir, ibid. T. 8, p. 71. Meckren, Obs. Meet. Chir. cap. 69. Taconi Dc nonnullis Cranii Ossiumque Fracturis, fyc. Bononite, 1751, p. 17 Blnncard, Inst. Chir. p. 549. Duhamel, Mem. de VActid. des Sciences, 1741. Boehmer, Diss, de Ossium Callo; Lips. 1748, p. 17 and 21. Cheselden, Osteographia, or Anat. of the Human Bones, London. 1733, Tab. 49, Fig- 4. Morand, in Plainers Vermis- chte Chirurgische Schriften, p. 447. Ruysch, Thesaur. 10, No. 176. Duverney, Traili diss Maladies des Os, p. -107, Paris, 1761. Phil. Trans. No. 312. Wedcl, in Ephem. Natur. Cur. Dec. 2, Ann. 2, p. 396. C. Bat- tus in Chir. Tract. 4, Cap. 8, p. 275 Kos- chius,in Roonhuysen's Hislorische Heilkuren, B. 1, p. 217 ; Nuremberg, 1674. Hofinann, in Eph. Nat. Cur. Der. 3, Ann. 9 et 10. p. 31o. Diemerbroeck, vid. Wolfii Obs. Chir. Med fih. 2. Obs. 18. p. 212. Wright, in Phil. Trans, abridged, Vol. 9, p. 252. Fabriciua Hildanus, Obs. Chir. Cent. 4, Obs. 91. Raw, ^upelletAnatom. Edit. A B. S. Albino; Ludg. Bilav. 17-5, p 13. Dobyns in Cheselden's Osteographia, Tab. 49, Fig. 4. Mackennie,in Met. Obs. and Inquiries, Vol. 2, p. 299. Ludwig Advers. Med. Prad. Vol. 3, p. 60. Bousselin,in Hist, de la Soc. Royale de Mide- cine, 1780, 1781, Paris, p. 121-r-297—3t>5. Slalparl Van der Wielin Cent. 1, Obs. 9ti. Murallo, in Schriften von der Wundarzn. Bale. 1711 Obs. 202, p. 655 De la Motte, Traiti Complel de la Chirurgie, T. 4, p. 284. Ellinckhuys in Trioen's Obs. Med. Chir.fasc, Ludtr. 1743, p 115. Ruysch Opera Omnia Anat. Med Chir. Amst. 1721, Tom. 1, p. 94. Laing, in Med. Essays and Obs. Edinb. Vol. 1, art. 23. John^n, ibid. Vol. 5, art. 23. Hunter, in Med. Obs. and Inquiries, Vol. 2, p. 303. Sigwart, Diss, de Carie consumpttr. tibie nolabili jaclura, Tab. 1756. T. Batlho- lme. Act. Med. et Phil. Hnfn. Vol. 3,'Obs. 114, p. 287. Hofinann, Mantissa, Qbs. Se- lect. Ohs. 28. Saviard, Nouveau Recueil d'Observ. Chirurgicalcs, Paris, 1702, Obs. 126. Le Dran, Obs. dc Chirurgie, T. 2, Obs. 104. Michael, in Richter's Bibliothek. T. 5. Troja, de Novorum Ossium in inlegris aid maximis, ob morbos, deperdiiionibus, Regcnc- ralione. Experimenta. Lutetie Parisiorum, 1775. Troja's Work, though drctjen up in an incorrect style, as Weidmann remark^,con- tains many highly interesting experiments. Blumenbach, in A. G. Richter's Bibliothek, T. 4. p. 107. .Desault's Parisian Chirurg. Jiumal. Vol 1, p. 100, and Vol. 2, p. 199. Koehler, Experimenta circa Regeneralionem Ossium, Gott. 1786. This is a valuable work, and contains the original discovery of ihe re- production of medullary structure. I. P. Weidmann. De Necrosi Ossium Fol. Franco- furti ad Moenum. 1793; et de Necrosi Os- sium adnolalio ; Frank. Del.4. This publica- tion is, perhaps, the best general accounloftht whole subject of necrosis. It is not only en- riched with the observations of numerous other writers on the disease, but contains the most. approved theoriesandopinionirespecling many other affections of the Eones, Caries, Exfolia- • tions fyc. It was a great assistance to me in the composition of the foregoing article. Con- sult also Richerand Nosogr. Chir. T. 3, p. 153, fyc. Ed. 4, Paris, 1815. Dr. Alex. M'Donald's Thesis de Necrosi ac Callo, Edinb. 1799. Hutchison's Pracl. Obs. in Surgery, p. 180, fyc. London, 1816. James Russell's Practical Essay on a certain Disease of the Bones, termed Necrosis, 1794. Whale- ly's Prad. Obs. on Necrosis of the Tibia, 1815. Macartney, in Crpwther's Obs. on While-Swelling, fyc. Edit. 2. Encyclopidit Mcllwdique, Partie Chir. art. Necrose. I*- viilli Nouvelle Doctrine Chir T. 4, p. 321, fyc. Paris, 1812. Larrey's Mim. de Chirur- gie Militaire, T. 3, p. 367, c^-c. Thomson's Lectures on Inflammation, p. 39. fyc. Edinb. 1813. Boyer's Traiti des Maladies Chirur- gicales, T.3 p. 418, fyc. Paris, 1814. Del- pech, Pricis Elimentaire des Mai. Chir. T. 1, Chap. 3 ; Park, 1816. Some account of an operation in which M Dup-ivtren of IV" SITKlC AND NITROUs ACIDS. 279 removed the menial porlion of tbe lower jaw, may be found in the London Medical Repository, Vol.3, p. 432. The wound heal- ed by the first intention, and the patient recovered. 'NEEDLE. See Appendix. * NEPHROTOMY, (from wef-joc, a kidney ; and Tiy.ia>, to cut.) The opemtion of cut- ting a stone out of the kidney ; a proceeding which, perhaps, has never been actually put in practice. Iu Ihe Abrigi Chronologique del'Historic de France par Miserai, and in the Phil. Trans, for 1696, two cases of what is called nephrotomy are mentioned ; but several circumstances in tbe accounts led Haller and others lo conclude, thai the operation alluded to in the first work was nothing more than the high operation for the stone. With respect to the example in the latter work, the particulars are not de- tailed enough to prove that an incision Was really made into the kidney. There is no doubt that stones have often been extracted from abscesses about the region of the kid- ney, after being touched with a probe. But, wit i regard lo cutting iyto the kidney, the deep s.tuation of this viscous, and the want of symptoms by which the lodgment of a stone in it can be certainly discovered, will always be strong objections to the practice When a stone, from its size, cannot pass from the kidney, and excites inflammation and suppuration, no doubt the surgeon may make an incision into the tumour, and ex- tract the calculus. In this sense, nephroto- my is certainly a practicable operation. Warner contends that it can only be prac- tised in such circumstances, notwithstanding whatever may have been said by Marchetti or others, upon the subject. In such a case, the operation would not be attended with any greater difficulty than the opening an abscess in any other part ofthe body. (See Warner's Cases in Surgery,p. 241, Edit. 4.) NITRIC and NITROUS ACIDS. As these are medicines of considerable import- ance in surgery, Ihey claim particular uo- tice. Nitrous acid is a yellow* or orange- coloured fluid, emitting when exposed to the air, deep orange-coloured extremely suffo- cating fumes. It consists of nitrous gas, loosely combined with nitric acid and wa- ter ; and the colour varies according to the proportion of nitrous gas which is present. Nitric acid is a colourless, or very pale yellow, limpid fluid, emitting when exposed to the air, white suffocating vapours. It is highly corrosive, and tinges the skin yellow, the tint remaining till the epidermis peels off. The constituents of nitric acid, inde- pendent of the water, which gives it the fluid form, are 25.97 azote, and 74.03 oxygen, in 100 parts. (See Thomson's Dispensatory, p. 438, 439, Erf. 2.) Both these acids, in a diluted state, have been extensively tried, as a substitute for quicksilver in the cure of lues venerea; and really upon looking over the mass of evi- dence brought forward in proof of the pow- er which they seem to possess over this dis- ease, it, i? at first difficult to entertain the slightest doubt of their efficacy. The cases adduced are numerous, *sonie jjf them mi- nutely detailed, the gentlemen who have published them, men of reputation and abi- lities, aud (what especially claims attention) these examples of successful treatment are generally allowed to have been syphilitic, or, at all events, complaints, the differences of which from the venereal disease have not been, and could not be, specified. Who- ever impartially considers the immense body of facts published by Dr. hollo, Mr Cruick- shank, Dr. Beddoes Dr. P. G. Prioleau, of Charleston, South Carolina, and others, ex- emplifying (he success witn which the ve- nereal disease may be treated by the nitrous or nitric acid, must be surprised to find, that the accounts delivered by these gentlemen by no means correspond to those of some other eminent practitioners. How to re- concile these seemingly discordant state- ments, whether by supposing some undefined differences iu the nature of the cases addu- ced, or some variation in the goodness of the medicine itself, is indeed perplexing. .Nor is a solution of the question at all faci- litated, by tbe results of later investigations, tending to prove the general curability of syphilis without mercury, or any medicine whatever; because, if we admit this as a fact the circumstance of a considerable proportion of cases not yielding, or being radically cured, when the nitric, and nitrous acids are exhibited, as asserted by Mr. Pearson and others, would argue, that giv- ing such acids is worse than leaving the disease entirely to itself. The more I reflect upon all that we know about the venereal disease, however, ihe more I am inclined to adopt the sentiment, that it is not one dis- order, but probably many, which go under this name their exact shades of difference not having yet been detected nor described. If this supposition be admissible, the con- tradictory statements, given by various au- thors about what their experience has taught them of this or that mode of treating the disease, may all be immediately reconciled. The practice ol exhibiting nitric acid, in lieu of quicksilver, began with Mr. Wm. Scott, a surgeon at Bombay, w ho is said to have been led to the experiment by a sug- gestion thrown out by.Girtanuer, that the efficacy ofthe various preparations of quick- silver probably depended upon the quantity of oxygen combined with them. (Grens. Journ. d. Physick. B. 3, p. 31,1790.) In Au- gust, 1793, Mr. Scott being himself afflicted with chronic hepatitis, resolved to take a quantity of oxygen, united to some sub- stance, for which it has no great attraction, and after some reflection, nothing appeared to him better than nitric acid. September 11th, he took at different times about a dram of the strong nitric acid diluted water. Soon after drinking it, he felt a sense of warmth in his stomach and chest; but no disagree- able sensation, nor any other material effect. The two following days the medicine was continued, the gums beginning to be some- what red, and enlarged. He slept ill: but NITRIC AND NITROUS ACIDs rould lie ur a length of time on his left side, which the disease ofthe liver had pre- vented him from doing during many months previous to this period. He also felt a pain in the back of his head, resembling what he had commonly experienced, when taking mercury. On the fourth day, his gums w ere a little "tender; tbe headach and pain about his jaws still troubled him: but the symp- toms of his liver complaint had already left him. The acid was continued on the 4th, 6th, and 6th days; the soreness of the mouth increasing, and a salivation taking place. On the 7th day, he felt his mouth •so troublesome, that he took no more acid. His mouth got gradually well, and he found his health considerably improved. Mr. Scott likewise administered the nitric acid in several cases of tedious intermit- tents, in two cases ojjdiabetes, and in many syphilitic cases, with the happiest effect. This gentleman's account of the nitrous acid was first published in the Bombay Cou- rier of April 30th, 1T96, and soon afterward republished in this country. (See " An Ac- count ofthe Effects of the Nitrous Acid on the Human Body," by W. Scott, in Duncan's An- nals of Metiiciue for 1796, Vol. 1, p. 375— 383.) The hypothesis suggested by Girtan- ner, in 1790, that the efficacy of mercury in the treatment' of the venereal disease de- pended upon the oxygen combined with this mineral, requited but little extension to lead to the discovery of the antisyphititic virtues of the acids. Yet Girtanner bad all his attention so fixed on mercury, that it never struck him, that the principle on which he explained the efficacy of this me- dicine, might apply to other substances, which abound witb oxygen and are readily separable from it. This vvas the idea, which made Mr. Wm. Scott begin to suspect, that the nitric acid might be as efficacious as mercury in venereal cases; and as he bad already observed a great analogy between the effects of this acid and mercury in the experiments which he- made with the first of these medicines in his own ca»e of chro- nic hepatitis, and other diseases, he ventured to recommend the trial of it in syphilis. The result was, that the acid was found not only to equal the preparations of mercury, but sometimes to surpass them ; for it bad the best,effect in some cases where mercu- ry had been tried in vain, and it was observ- ed to remove the disease in less time than the common remedy. Nor were any of the inconveniences, usually known under the names of mercurial symptoms, mercurial fe- ver, found to be the consequence of its em- ployment, however long continued With it alone many syphilitic cases are stated to have been cured, the disease not having re- turned at the end of two years. (See Dun- can's Annals of Medicine, fyc. Vol. 1, 1796,». 383, fyc.) The letter from Mr. Scott to ?ir Joseph Banks, describing these effects of the nitric acid in India, soon excited the attention of medical practitioners both in Europe and America, the inquiry being taken up with all the zeal which the preceding accouut* were calculated to inspire. In 1797, Mr G. Kellie, a surgeon of the navy, gave (he nitric acid to five sailors affected with go- norrhoea, venereal sores, and buboes. Three of them were perfectly cured. A fourth, who had sores on the glans, and who had been much debilitated by the long use of mercury, recovered nearly his original strength, while taking the acid ; but the sores were not healed, before mercury had been repeatedly exhibited. In the fifth pa- tient, who was also scrofulous, the nitric acid contributed very essentially to heal the sores. On the whole, Mr. Kellie seems to regard this medicine as possessing very efficient power of stopping and eradicating (he venereal disease. (See Letters from G. Kellie, respecting Ihe Effects of Nitrous Acid in the Cure of Syphilis. Duncan's Annals of Medicine for 1797, p. 254, 277.) In the same year appeared a letter, in a German periodical work (Hufeland's Journ. der Prakt. Heilk. 4 Bd. p. 356—359.,) writ- ten by Albers, giving the history of a vene- real ulcer on the breast, successfully treat- ed by tbe nitric acid. The reports of Dr. Prioleau, who tried the nitric acid in the autumn of 1797, are particularly favourable to the practice. " We have seen (says he) every stage and form of syphilis cured by this medicine, and even in habits hroken down by the antece- dent use of mercury, under which the dis- order had gained ground. The patients re- covered their health and strength in a shert time, without the use of diet-drinks, bark, or any other tonic medicine whatever." (See Caldwell's Medical Theses, p. 103, 8ro/ Philadelphia, 1805.) The praise of the nitric acid from nume- rous quarters induced Dr. Rollo to try it in the military hospital at Woolwich, and in conjunction with Mr.Crnikshank to examine further into the antisyphilitic virtues of oxy- genated substances. The results of Mr. Cruikshank's investigations constitute the second part of Rollo'3 work on diabetes, published in 1797 The medicines which were selected for the experiments, were the nitric, citric, and muriatic acids, and oxyge- nated muriate of potash. Of these, the nitric acid and the oxygenated muriate of potash were found to possess the greatest efficacy; the first acting in many cases with remark- able mildness; the second, with greater ex- pedition and certainty. The new plan was tried upon young persons, affected witb pri- mary venereal complaints, who had never used mercury, and no other internal medi- cine was given, except opium, when requi- red for diarrhoea, or colic. The liquor plumbi acetatis dilulus was used as a wash for chan- cres. In debilitated subjects, sure and spee- dy good effects were observed uniformly to folio v., and hence, previously to giving the acid to strong, plethoric patients, the me- thod of preparing them for this treatment by purging and bleeding was adopted, as is alleged, with great success. In some cases, after the nitric acid had been continued, a NITRIC AND good while without producing a salivation, the exhibition of mercury for a short time completed the cure. Mr. Cruikshsr.k's opi- nion in favour of tbe new remedies was on the whole extremely sanguine, as he ven- tures to express his pnnviction, that they would render the employment of mercury in the cure of the venereal disease un- necessary. (See An Account of two Cases of Diabetes Mellitus, with Remarks, fyc, by John Rollo, M. D. Vol. 2, Sro. Lond. 1797.) In the same year, Dr. Beddoes published a valuable work, comprising all tbe informa- tion, which had then transpired respecting the antisyphilitic virtues of the nitric acid, with additional communications from his medical friends. (See Reports principally concerning the Effects of Nitrous Acid in the Venereal Disease, by Thorn. Beddoes, Bristol, 1797.) And two years afterward, the same author finished a still more comprehensive volume on the subject. (A Collection of Testimonies, respecting the Treatment of the Venereal Disease by Nilrious Acid. Lond. 1799.) From the preceding work we learn, that, in the Plymouth hospital, Mr. Hammick, gave the nitric acid to between sixty and seventy venereal patients, and that the cures were generally more speedily accomplished, than with mercury, no ill effects being pro- duced on the system, similar to those usually remaining after the use of the latter mi- neral. He assures us, that, after the remo- val of the symptoms, the disease never re- turned, and that for debilitated, scorbutic, or scrofulous patients, affected with vene- real complai.its, the acid was found a most valuable means of relief. Dr. Geach of the same hospital is also stated to have employed the nitric acid with such effect that he rarely had occasion for mercury, the livid colour of the counte- nance, sordid fetid excoriations of the scro- tum, and olher symptoms, which had long resisted the latter mineral, all quickly giving way to the new medicine. Another practitioner of the name of Giedlestone, however, had not equal success in his expe- riments, for, in several cases, the acid did not bring about a cure, and, after being con- tinued eight or ten days, and inducing a sa- livation, il even rendered the condition of some patients worse. On the other hand, .Mr. Sandford, a surgeon at Worcester, found ihe acid a very useful and effectual medicine in venereal cases, where mercurials had been long exhibited in vain. The trials of the nitric acid, made by Professor Ruther- ford at Edinburgh, had various results ; the medicine sometimes proving completely- in- effectual ; and, in other instances, appearing to be a perfect antidote for the worst syphi- litic complaints. Dr. Beddoes concludes with some obser- vations in answer to Mr. Blair, who had become averse to the new practice. In 1798, Dr. Ferriar published some re- marks on the nitrous acid. (See Medical Histories and Reflections, Vol. 3, p. 290—310.) He tried this medicine, in various ways, either alone, or after, or in con juuetion with, Vol. If. ^ MTROLS ACIDS 281 the exhibition of mercury. His inferences are, that, iu the treatment of the venereal disease, the nitrous acid is useful only in protracted cases. He corroborates, how- ever, the generally received opinion, that where the patient has been considerably re- duced by tbe long, or injudicious employ- ment of mercury, the nitrous acid is a most beneficial medicine. In the same year, Mr. Blair wrote some observations on the venereal disease,and the new method of treating it. (Essays on the Venereal Disease, and ils concomitant Affec- tions, Lond 1798.) In this work, the new remedies are generally condemned, as inef- fectual, and hence originated a paper-war between this writer and Dr Beddoes, " lite- ■ rarium crtamen, non sine b le gestum," as Dr. Hoist has expressed it. (De Acidi Nitrici Usu Medico, p. 73, 8vo. Christiana^, 1816.) In this controversy, numerous other practi- tioners readily joined, as for instance, Ma- cartney, Rowley, Philips, Hooper, Lidder- dale, be., all of whom adduced cases, in proof of the frequent inefficacy of nitrous acid, and these were collected and published by Mr. Blair, who suspecting the cases of failure with this medicine to be more nu- merous, than those of success, considers himself unjustified in regarding it as an antisyphilitic to be depended upon. At the' same time, he bears testimony to the virtues ofthe acids,exhibited in venereal cases either singly, or alternately with mercury, where the patient's strength had been much redu- ced ; and he confesses, that venereal buboes, indurated silands, nocturnal pains in tbe bones, and gonorrhoea, yielded to these remedies. Seven years after the appearance of Mr- Blair's work, Mr. Pearson delivered his sen- timents in a book of considerable merit. (Observations on Ihe Effects of various Articles of the Materia Medico in the Cure of Lues Venerea, 2d Ed. Lond. 1807, p. 198, <^c.) He relates a very few examples, in which the nitrous acid appeared effectual in curing chancres, and one of its virtues in gonor- rhoea ; the only one, which this gentleman had ever seen. The rest of his observations are unfavourable to the character of the medicine, as an antisiphylitic meriting con- fidence. The first trials, which Mr. Pearson made, were of the nitric acid ; but, as he did not remark any of its effects to be dif- ferent from those produced by the nitrons acid, he commonly' employed the latter in the following form. Nitrous acid, two drachms, pure water a pint and a half, syrup four ounces. This mixture vvas usually ta- ken in the space of twenty-four hours. As local applications, he employed a saturnine lotion to the sores ; and emollient poultices to tumours and inflamed parts. All mercu- rial applications were absolutely prohibited. (P. 200.) In making his inferences, in a sub- sequent page, be says, " The nitric and ni- trous acids have removed both primary and secondary symptoms of syphilis; and, in some instances, it seems that tbe former have not recurred, nor have secondary symptoms appeared at the period they commonly show 282 NITRIC AND NITROUS ACIDS. themselfte*, when the euro bas been imper- fee-t. But. as far as my own experience ex- tends, and that of many respectable friends, who are connected with large hospitals, a permanent cure has never been accomplish- ed by these acids, where secondary symp- toms have been present. The same acids, when exhibited w ith the utmost care and at- tention to many patients, labouring under the primary symptoms of the venereal dis- ease, and w here tbey have agreed perfectly well with the stomach, have been never- theless found inadequate to the cure of those symptoms. Indeed, the failures wliich have occurred, both in my own practice, and that of many of my surgical friends, have been so numerous, "that I do not think it eligible to rely on the nitrous acid, in the treatment of any one form of the lues venerea." How- ever, Mr. Pearson joins several other writers in bearing witness to (he good effects of this medicine, where impairment of the constitu- tion renders the employment of mercury in- convenient, or improper. Here, he says, it will restrain the progress of the disease, and improve the health and strength. On some occasions, he thinks, that it may be given, in conjunction with a course of mercurial' in- unction, and he agrees w ith other practition- ers about its supporting the tone of the sto- mach, acting as a diuretic, and counteracting the effects of mercury on the mouth ana fauces. (P. 236—238.) While these inquiries were going on in England, numerous experiments on the same subject were undertaken in France. In a work, published in 1797, Alyon positively declares, that mercury ought to be entirely relinquished iu the cure of the venereal dis- ease. (Essaisur les Propriety Midecinalesdt I'Oxygine, et sur Vapplication de ce principe dans les maladic» viniriennes, psuriques, et dartre uses ; Paris, an. 5,8ro.) Here we find a relation of many cases, successfully treat- ed in the hospitals of Val-de-Grace and St. Dennis, by the oxygenated muriate of pot- ash, (he nitric, oxymurialic, and citric acids, an ointment of (he author's own invention, called the unguenturn oxygenatum, being ap- plied to the sores. (See Unguenturn.) In a second edition of the above book, which came out iu 1799, tte same doctrine and practice are corroborated by further obser- vations. In 1798, Dr. Swediaur brought out the third edition of his treatise on the venereal dis- ease, (TraiUComplet sur les Symptomes, Irs EffUs, la Nature, et le Tmitement des Mala- dies Syphilitiques,) in which he highly com- mended the virtues of the nitrous acid, and oxygenated acid, as expediting the cure, with very few exceptions. But, in the fourth edition, he retracts, and details the results of the new practice, as tried upon twenty-six venereal patients in tbe Hospice d'Humaniti .- of these only seven cases remained perma- nently cured ; the issue of seven others was doubtful; and,in twelve, no amendment was observed. Nor were the statements of Lagneau much more favourable to the reputation of the ni- trons arid as an antisyphilitic ; for, from tbe trials wh eh he had seen made of it, he con eluded, that it was not unfrequently ineffec- tual, while it vvas apt to excite an obstinate cough and haemoptysis. (Exposi des Symp- tomes de la Maladie Ve'nirienne, des diverses Mithodes de traitement, fyc. 3me Ed. Paris, 1812) The reports of Dr. Odier, of Geneva, how- ever, were rather more propitious, as he says, the nitrous acid increases ihe efficacy of mercury, and lessens or removes the in- conveniences arising from its unskilful ad- ministration. But he candidly acknowledged, that his experience had not been great enough to enable him to pronounce, what degree of confidence ought to be put in the acid as a remedy for syphilis. (Alan, de Mid. Pratique ; Genive, p. 249.) The practice of exhibiting the nitric acid for the cure of syphilitic affections was not tried in Germany so soon as in England and France. Albers, however, in 1797, gave an account of Scott's successful experiments, and of the efficacy which they evinced in some cases seen by that gentleman in the Infirmary at Edinburgh. (Hufeland Journ. d. Prnkt. Heilk. Vol. 20, p. 68 ;) while Behn, who had visited Paris in the winters of 1797 and 1798, briefly noticed the various results of the trials, which be had seen made of this acid, in tbe "Clinique de Perfectionne- ment," for ihe cure of obstinate syphilitic cases. (Erinnerungen an Paris, xunachst far Aerste gescrieben von G. H. Behn Erst. Heft. Bcrl. 1799, p. 110.) At length, in 1799, Strove, who translated Mr. Blair's first pub- lication into German, communicated lo the profession the particulars of some experi- ments made by himself with the acid; he declares, that he bad very often found it an excellent remedy for inveterate pains in the bones, and derangement of the constitution, produced either by the syphilitic virus or the injudicious employment of mercury. How- ever, in common cases, mercury is repre- sented as the best antisyphilitic medicine. Afterward Professor Wurzer was induced to try the nitrous acid in a case, that had re- sisted mercury for six months, the patient having got rid of some chancres and a sore throat, but being left witb violent noctur- nal pains, blotches, and sores all over his body, and in a very reduced condition, with- out the least appetite. Here, in 27 days the acid, together with sarsaparilla and the warm bath, not only removed all the complaints, but actually restored the patient's original strength, and healthy appearance. In • short note annexed to this case, Hufeland gives it as bis opinion, derived from experi- ence, that the nitrous .acid is effectual in ob- viating the sequelae and anomalous diseases induced by lues venerea, but that it does not permanently cure the latter affection itself (Etwas uber die Keilkrafl der Salpetersatire in venerisehen Krankheiten, Hufel. Journ. I Prakt. Heilk. 8 Bd. 4 St. p. 139—143.) These vague and endless contradictions induced Schmidt, an eminent professor at Vienna, to make a series of experiments with NITRIC AND NITROUS ACIDS. 283 the nitric acid, for the purpose of ascertain- ing ils power in cases of syphilis. (See Beo- bacht, der Kaiserl. Konigl. Med. Chir. Josephs Akademie zu Wien. 1, Bd. Wien 1807,p. 147— 189.) Under his directions, the acid was given in the winter of 1799 to five soldiers, affected with the venereal disease in various degrees and forms. In every one of these cetses, the medicine was found efficacious; but the degree of efficacy was remarked to vary considerably according to the nature of the constitution, and the kind of local complaints. Thus, in robust patients, mode- rate doses of the acid soon produced bene- fit ; while, in weak persons, disposed to scurvy or scrofula, a larger quantity ofthe medicine, and more time were requisite. This asser- tion we see is exactly the reverse of what appeared to happen in the cases treated by Mr. Cruikshank. However, Professor Schmidt entertains strong doubts, whether the nitric acid is adequate to the cure of all the forms of syphilis, and he thinks, that neither this nor any similar medicines will ever supersede the necessity for mercury. Ontyd, a Dutch practitioner, approves of the use of the nitric acid, with some limita- tion : while he admits its efficacy in remo- ving focal symptoms, he is strongly against its employment in cases of confirmed lues, as they used formerly to be termed. The latter assertion, I conceive, is exactly cou- (rary to the results of modern experience, most of these protracted bad cases being those, which are particularly benefited by this acid. (Nieuwe scheidekundigc Bibl. le Amsterdam; by Dolt. 6de St. 1799, p. 166.) The tracts of Boetticher, (Bemerk. uber Medi- rinal-verfass. Hosjiit, u. Cururten. 2ies Hefr. Konigsb 1800, 8,) of Ritter (Erfnhr aber die iunerlu. aiisserl. Anwenduugd. Salpeters. Hufel. Journ. 10 B 3 St. p. 191—197,) and of Frankenfeld (Hufeland's Journ.der Prakt. Heilk. 22 Bd. 4 Si. p. 96—98) need only be specified here, as decidedly unfavourable to ihe character of the nitrous acid, as a reme- dy for syphilis. The following German practitioners are to be classed with the model ate approvers of the medicine, (hough as Hoist observes, (De Acidi Nitric Usu Medico, p. 88 ; Chrisliane, 1816,) they do not appear to have made any new experiments of their own with it, viz. iVJunchineyer (Comm. de Viribus Oxyge- nii inpracrcandis el saiandis Morbis; Goell. \Wi,p.bA;) Burdach (Hdb. d. neuesl Ent- deck.ind. Heilmitteltthre ; Leipz. 18<'6, p. II, 12;) Aronsson (Votlsl. Abhdl. aller vene rischen Krankh. Bed. 1808, p. 211 ;) Horn (Hdb der Prakl. Arzneymitlellehre, 2le.Aufl. Berl. 1806, p. 95;) Consbruch (Taschb. d. Arzneyniitteilehre, 2le. Aufl. Leipz. 1810, p. 283 ;) 1 oepelmanu (Neuere Erfahr. uber zweckcm. Behdl. venerisch. Schleim ausflnsst, fyc. Leipz. 1809, p. 151 ;) and Wolikopfs (Phaimac.extemp. Leipz. 18.11, p. 92.) Another German author, who has entered into the present inquiry, is F. A. Waleh, whose statements ale very unfavourable to the use of the nitrous acid, as he absolutely denies, thai it ever accomplishes a lasting cure. (Ausfohrl. L'arslell. d. Urspr. fyc. d. Venerisch. Krankh. Jena, 1811, p. 197, 198.) In a periodical work, mention is made of one case, which, after resisting a long course of mercury, and also the nitric acid, was ul- timately cured by restricting tbe patient for a lew weeks to a very reduced diet. (Hufel. Journ. d. Prakt. Heilk. 34, Bd. 2 St. p. 56.) lor much of the foregoing historical ac- count, 1 am indebted to Hoist's Diss. deAcidt Nitrici Usu Medico, bvo. Christ. 1S16; in which an explanation of the results of fur- ther trials of the medicine in Denmark and Sweden may be perused. From these coun- tries, the reports are mostly less favourable to the reputation of the medicine, than the accounts already delivered. According to Hoist the following are (he chief circumstances, under which the em- ployment of nitrous, or nitric acid is gene- rally sanctioned. 1. Where the disease is complicated with scurvy. 2. Where it is attended with scrofulous en- largement of the glands, and other strumous symptoms. I may remark, however, that these complaints are often as uudefinable, as some of the forms of syphilis, and therefore the rule is frequently difficult of application. 3. Where the disease is accompanied with considerable debility, either brought on by- mercury, or febrile indisposition. 4. Where from idiosyncrasy, mercury can- not be safely exhibited. Experience fully proves, that there are some patients, more especially females, in whom a few grains of mercury taken inwardly, or mercurial fric- tions on the most limited scale, bring on vomiting, rheumatic pains, nervous febrile symptoms, colic, spasms, severe headach, and a rapid immoderate salivation. 6. \V here pregnant women are Ihe subjects of the disease, several practitioners forbid the use of mercury, during the lalter months of pregnancy. (Bangii, Prax. Med. Hafn. 1789, p. 570; Swediaur ; Aronsonn Vollsl. Abhdl. aller Ven. Krkht. Berlin, 1811, p. 211.) Hoist observes, that the reason of this ad- vice is not stated, though no doubt it musl proceed from an apprehension of mercury exciting a miscarriage. Mr. Pearson's mode of exhibit ing the nitrous acid has been already mentioned. Some practitioners give it as follows: IJ.. Gum. Arab. 3'v. aqua* menlh. ^viij. acid, nilrosi, vel nitrici 3IJ- 3''j- F. M. Of this mixture, a table spoonful is to be taken every hour mixed with some sweetened water. Should the acid occasion colic, or diarrhoea, its quantity must be lessened, and ppium added to the mixture. -« As the nitrous and nitric acids decompose and destroy the teeth, some care must be taken to prevent so serious an effect. Their being properly diluted, and blended with sugar, syrup, or mucilage, will materially tend to hinder the evil. But the safest way is nlways to drink the mixture through a glass tube, and wash the mouth well imme- diately after every dose-. Strong nitrous acid, extricated in the 2S1 Nil form o£ vapour, is often employed as a means of purifying the air of large crowded hospi- tals and sick-rooms ; a subject on which the observations of Dr. J. C. Smyth and G. de Morvcau are particularly interesting. The nitrous acid is sometimes taken by accident, or design, as a poison. Here, according to the observations of Tarfia. Orfila, be. the best antidote is calcined magnesia, or soap. If the first of these articles be at band, a dram of it, suspended in a glass of water, is to be instantly give it, followed by copious draughts of some mucilaginous drink, the design of which is to fill the stomach, and excite it to reject the diluted poison. While Ihe vomiting is going on, the doses of mag- nesia are to be repeated, and followed as in the first instance by draughts of linseed tea, solution of gum arabic, milk, or broth. The nitrous acid has also been extensively fried as a means of curing syphilitic com- plaints, in the form of what is termed the nilro muriatic bath, of which a description will be given in speaking of the Venereal Disease. W hen reiterated courses of mercury in- duce dropsy, as not nnfrequently-happens in very impaired constitutions, Mr. Carmi- chael prescribes the nitrous acid, in as large doses as the stomach will bear, conjoined with digitalis. (Essays on Venereal Diseases, fyc.) Taken in doses of eight, ten, or fifteen drops, two or "three times a day, it is alleged to be efficacious in the cure of some erup- tive complaints, especially of the lower ex- tremities, connected with disorder of the liver. (Wihon's Pharm. Chir. p. 6.) Another well-informed writer also bears testimony to its good effects when used together with mercury, for old obstinate ulcerations ofthe legs, though no venereal taint can be sus- pected ; and, he says, it may be applied with benefit as a local stimulant to fetid ulcers, attended with a thin ichorous dis- charge, and in some examples of caries. In such cases 3ij. of the diluted acid is to be mixed wilh *$j of water. (See A. T. Thom- son's Dispensutory, p. 441, Ed. 2.) With respect to caries, in the sense of necrosis, however, the reader will understand from what is stated in the article on that subject, that it can rarely be adviseable to apply this or any other acid either to the exfoliating portion of bone or to that which is yet alive. The nitrous acid has sometimes been used for destroying warts, condylomata, and other excrescences. By Sir E. Home it is praised as a local application for certain ulcers when properly diluted. (See Ulcers.) It is likew ise commended by some writers as a very useful local application in cases of hospital gangrene. And an interesting paper has been just published by Mr. R. Welbank detailing the excellent effects of (be undilu- ted nitric acid as an application to diseases which he has described under the name of sloughing phagedena, and which he consi- ders as identical with hospital gangrene. " If the disease be not far advanced, (says this gentleman) I at once apply the undiluted acid, after eleansing the surlace with tepid NOL water, and absorbing the moisture with lim Where, however, there is a thick and pulpy slough, it is better to remove as much of it as possible, with forceps and scissors, before tbe application is made. The surrounding parts being then protccled by a Ihick coat- ing of lard, or cerate, 1 proceed to press steadily, and, for some minutes, a thick pledget of lint, previously immersed in (he undiluted acid on every point of the disea- sed surface, till il appears converted into a firm and dry mass. The parts may be then covered with simple dressings, and evapora- tion kept up externally by cooling lotions," An opiate is afterward given, and the eschar removed at the end of 16 or 20 hours. When there is no pain, and the subjacent part- present a florid healthy appearance, the sore may now be treated as a common wound, though stimulant dressings are generally best. Mr. Welbank uses the ceratum lap'nli, calaminaris, or a solution of the argentum nitratum, in the proportion of two or three gr. to an ounce of distilled water. But, if there is any recurrence of pain, whether the affection be slight or severe, and the remain- ing slough deep or superficial, Mr. Welbank advises the reapplicatiou of the undiluted acid. (See Med. Chir. Trans. Vol. 11, p. 369.) The cases* reported by this gentle- man are highly favourable to the practice which, as may be seen by reference to the article Hospital Gangrene, is not entirely new with respect to this disease, and in speaking of Mortificalion, I have mentioned, that it was Dr. Kirkland's practice some- times even to dress certain sloughing disea- ses with a solution of mercury in nitrous acid. But, notwithstanding these facts, and the well-known custom of Sir Astley Cooper to apply to sloughing phagedenic ulcers the nitric acid lotion, composed of 60 drops ofthe acid, and a quart of distilled water, I foel that Mr. Welbank has rendered a ser- vice to the profession by drawing their attention still more particularly to the use of undiluted nitric acid in the forms of phagedcena, which he has so well descri- bed. NODE. A swelling of a bone; a thick- ening of the periosteum, or a fascia ; or a tumour on a tendon, from a venereal cause. See Exostosis and Venereal Disease. NOLI ME TANGEHK. A species of lupus, under which term Dr. Willan intend- ed to; comprise, together with the noli m>. teingere affecting the nose and lips, other slovv tubercular affections, especially about the face, commonly ending in ragged ulcer- ations ofthe cheeks, forehead, eyelids, and li|>s, and sometimes occurring in other pHrts of the body, where they gradually destroy the skin and muscular parts to a considera- ble depth. (Bateman's Synopsis of Cutane- ous Diseases, p. 296, Ed. 3.) S.lr t;- Home says, that the- ulcers, for which he has been led to employ arsenic, are named, from the virulence of their dis- position, noli me tangere, and are very nearly allied to cancer ; differing from it in not contaminating the neighbouring parts by NOLI ME TANGERE. 2b» absorption, but only spreading by immedi- ate contact. Ulcers'of this kind differ ex- ceedingly from one another in their degree of virulence ; but they are all so far of the same nature that arsenic in general agrees with them, and ptilsa stop to their progress, while they are aggravated by milder dress- ings. (Home on Ulcers, Edit. 2, p. 267.) The disease generally commences with small tubercles w hich change after a time into superficial, spreading ulcerations on the alae ofthe nose, more or less concealed be- neath furfuraceous scabs. The whole nose is frequently destroyed by the progressive ravages of this peculiar disorder, which sometimes cannot be stopped or retarded by any treatment, external or internal. The specific ulcerations do not generally extend to the parts far within the nostrils ; but, at the time that 1 am writing this article, there is, under Sir L. Harvey, iu St. Bartho- lomew's Hospital, a curious example, in which the greatest part of the nose is de- stroyed, and the ulceration proceeds even through the front part of the palate into the mouth. The morbid process sometimes stops for a considerable time, and then is renewed with increased violence. The follow ing case illustrates the nature of noli me tantere, and one mode of treatment, to which it yielded. June Chatillon, 45 years of age, was attacked, in the course of Sep- tember, 1788, with an inflammation on the left ala of the nose. Some time afterward the part ulcerated, which occasioned a trou- blesome and sometimes a painful itching ; different means were unsuccessfully employ- ed, and the case remained nearly in the same situation till the month of September in the following year. At this period "the ulcer spread very fast; the septum nasi, the muscles and cartilages of both sides were, in a short space of time, destroyed. The ulceration extended on the left side, along the loose edge of the upper lip. This was the state of her cas*e on her admission into the Hospital or St. Louis, in the month of October, 1789, A poultice moistened with aq. veg. was applied twice a day to the ulcer; a sudorific ptisan prescribed, and a pill, composed of one grain of calomel and one grain of sulph. aurat. antimonii, ordered to be taken every day. From the fifth day, the inflammation lessened. !\n other sensible alteration took place till the 21st. The suppuration, which till this time had been black and putrid, now became white and inodorous. On the 37th the discharge was trifling, and the part was dressed wilh pledgets dip- ped in a solution of verdigris and corrosive sublimate, in (he proporfioh of six grains of each lo a pint of water. On the 4'Uh day, cicatrization began to take place, and was finished by the 60th. Some time before the di-ease was com- pletely cicatrized, an issue was made in the arm, which was healed up without any in- convenience to the patient, six months after the cure. (Parisian Cbirurgicnl Journal, Vol. 1.1 One of the best external applications to noli me langere is the following lotion : JJ;, Kali ar«enica(i, gr. iv. Aq. menthaj sativa*, ■^iv. Spiritus vini tenuioris, ^j. Misce et cola. 1 have seen several cases in St. Bar- tholomew's Hospital, which were either cured or seemed disposed to get well with this useful application. The solu- tion of arsenic, which Sir E. Home has always used, is made by boiling while arsenic in water for several hours, in a sand heat. When given internally, the dose ii from (hree to ten drops; when for external application, a dram is to be diluted with ft>ij. of water ; and this solution is gradually tnado stronger, as the parts become accustomed to it, till it is of double strength. However, this mode of using arsenic is by no menns a well-regulated one ; and Plunket's caustic (see Arsenic) for outward employment, is not nearly so neat an application as the above-mentioned lotion. At St. Bartholo- mew's Hospital, arsenic is administered in- ternally in the following formula: IJ;. Kali arsenicali, gr. ij. Aqua* mentha? sativa;, ?iv\ Spiritus vin. ten. -Jj. Misce et cola. Dosis 3ij- ter quolidie. "In (his way, the quantity of arsenic is nicely determined. We shall only just add, wilh regard to this medicine, that, bolh as an external application and an inward remedy, in cases of noli me tangerc, it perhaps deserves (be highest rank. One scruple of the argentum nitratum, dissolved in half an ounce of distilled water, makes a very good application, which, although ge- nerally inferior, in point of efficacy, "to ar- senical ones, in the present disease, occa- sionally does good, when nothing else seems (o produce any benefit. The above case makes us acquainted with another lotion, which deserves further trial All fluid reme- dies must be applied to the part, by dipping little bits of lint in them, placing these on the ulcerations, and covering the whole with a pledget. The ointments which seem most likely to prove useful applications to noli me langere, are the unguenturn hydrargyri nitrati, the unguenturn picis, and unguenturn sulphuris. As far as my experience extends, they are generally less efficacious than lotions in the present cases ; but, in particular instances, they prove superiorly useful, and it deserves especial notice,that surgeons can often make no progress again.-t this inveterate disease, unless they apply a different sort of dressing everyday; sometimes a lotion; at other times an ointment. The little ulcers mav occasionally be touched with the argentum nitratum. The small furfuraceous scabs, which are continually forming on the part affected, should be softened with a little of the ungnentnm spermatis ceti,and removed wilh as much tenderness as possible. We have already remarked, that arsenic is a good medicine to be given internally, and the best mode of exhibiting it has been already explained. Another medicine, which is often useful in these cases, is what is known by the name of Plummer's pill, or the compound calomel pill. R;. Hydrargvri 2ko NYCTALOPIA. submuriatis, sulphuris antimonii praecipitati, singulorum gr xii. Guaiaci gum mi resinae, gr. xxiv. Saponis quod satis sit Misco ; fiant pilulae duodecim. Dosis una bis quotidie.— In other instances, we may try the decoctum ulmi, or sarsaparilla*, with one of tbe fol- lowing pills thrice a day: IJ;. Hydrargyri submuriatis gr. vj. Succi spissati cicutse 3j- M^ce ; fiant pilula; duodecim. The hy- drargyrus sulphuratus has occasionally been given as an alterative medicine, for the relief of noli me tangere ; with what good effect 1 cannot pretend to say. In three or four less severe cases of lupus tubercles on the face, which had made no progress towards ulceration, Dr. Bateman saw the solution of muriate of barytes, taken internally, materially amend the complaint. Sometimes, also, a separation of the diseased parts from the sound has been effected with the knife, or caustic, and the progress ofthe complaint been stopped. (Synopsis of Cu- taneous Diseases, p. 296,, Edit 3.) NYCTALOPIA, (from vwf, night; and u-l, the eye ; or ovret, to see.) An affection of? Ibe sight, in which the patient is blind in the daylight, but sees very well at night Nyctalopia, visus nocturnus, or day-blind- ness, vulgarly called owl-sight, (says M. Lassus) is an affection in which the patient either cannot see at all, or sees but very feebly, objects, which are in the open day- light, or situations where there is a strong light; but discerns ihem very well, when they are in a darkish ph.ce, or at sunsel, or in the nighttime, if not immoderately dark. fSee Pathologie Chirurgicale, T. 2, p. 539, 540.) The Greek physicians are divided in their opinions concerning Ihe now uncommon disease nyctalopia. Hippocrates expressly says, " we call those nyctalopes who see by night.'' The author of Defin. Medic, "that (hey see nothing in the daytime, but have the'.r sight by night." On the contrary, Paulus JEginela and Xctuarius are as explicit in asserting, that they have their sight perfect in the daytime, but are blind by night. .Etius is of the same mind, though he is thought to favour the contrary opinion, when he says, "they see better by night than in ♦he day, and if the moon shines they are blind." The author of Isagoge embraces both opinions, when he says, " they call (hose nyctalopes who, in the daytime, see more obscurely, at the setting of the sun more clearly, but, when it is night, much lietter ; or, on the contrary, by day they see a little, but, in the evening, or at night, they are blind." Galen explains Ihe word by a night blindness. Pliny, Varro, Nonius, Fes- lus, Celsus, and olher writers, give equally opposite definitions of the disorder. Dr. Pye questions, whether these two descrip- tions of nyctalopia, so diametrically opposite lo each other, may not be reconciled by considering the disorder us an intermitleiit one. The difference thru will only consist in the different times ofthe approach ofthe disease ; that of Hippocrates came on in the mornine : that of -Eginela, in the evening ; both were expressly periodical, and the dis- tance of time between the paroxysms, in both, was respectively the same ; a whole day, or a whole night. The various shapes, in which intermittents appear, very much favour, says Dr. Pye, such an opinion ; and the apparent success of bark in the case-, which he has related, notwithstanding the. unfavourable circumstances of the evacua- tions his patient laboured under, and the consequent necessity of its disuse, seem to confirm il in this gentleman's mind. (Med. Obs. and Inq. Vol. 1.) In this work I shall follow Callisen, Rich- ter, and the best modern surgical wi iters, in calling day-blindness, nyctalopia, and night- blindness, hemeralopia. (See Callisen, Syit. Chir. Hodierne, Vol. 2, p. 392. aud Richter, Anfangsgr. der Wundarzn. B. 3, p 479.) Nyctalopia, in tbe sense of day-blindness, is a very rare disease, in comparison with hemeralopia, which is a very common disor- der in warm climates. According to Dr. Hillary, there are a people in Siam, iu the East Indies, and also in Africa, w ho are all of this cat-eyed species, or subject fo the disease of being blind in the daytime, and seeing well by night. (Mod. Univ Hist. Vol. 7.) The same author notices the general rarity of the disorder, and mentions bis having met with but two examples of it. With respect to the causes of the com- plaint, Dr. Hillary observes, that it proceeds from too great a tenderness and sensibility of the iris and retina. M. Lassus thinks (ho causes may be of different kinds. " If, for instance, (says he) there were a very small opacity, like a point, exactly opposite the pupil, or centre of the crystalline lens, the pupil, contracting in the open daylight, would stop the entrance of the rays of light into the eye,and a day-blindness arise, which would be diminished by the expansion ofthe pupil in the shade. Here, (he cure would depend upon (he removal of the opacity. " Persons, whose pupils do not move freely, but remain much-dilated, and do not sufficiently contract in light situations, are also affecled with nyctalopia ; for, so large a quantity ofthe rays of light pass into their eyes, that it serves rather to destroy, than assist vision. Such persons see tolerably well, and better than the preceding class nf patients, in a darkish place, and they ought to wear green spectacles iu the daytime, in order to weaken the impression of the rays of light. \\ hen a person is shut up a long while in a dark place, Ibe pupils become habitually dilated, and il he exposes himself suddenly and incautiously to a strong light, the eyesight may be destroyed. There are other individuals, who, from excessive sensi- bility of the iris, cannot bear much light; their pupils in-tautly contract, and close This case (continues M. Lassus) may be brought on by too great indulgence in vene- real pleasures, and in persons, who have debilitated their constitutions during theii youth." The same author mentions other cases, which seem to depend upon a species of irritability of fhe iris. In in,..- instance, an CEDE IESO issue in the arm effected a cure, and he mentions the utility of blisters. He admits likewise with Dr. Pye cases of intermittent or periodical nyctalopia, which begin regu- larly in the morning, and go off in the even- ing, the patient continuing blind, whether he keep himself in a dark or a light place. The cause of these instances, which, he ob- serves, are very uncommon, is generally seated in the prima? viae, and requires eme- tics, resolvents, purgatives, and bark. (See Pathologie Chir. T 2, p. 540—542. Also Richter, Anfangsgr. der Wundarzn. B. 2, p. 481.) In 1787, Baron Larrey met with a oase of day-blindness in an old man, one of the galley-slaves at Brest, who had been shut up incessantly for thirty-three years in a subterraneous dungeon. His long residence in darkness had had such an effect on the organs of vision, that he could only see in Ihe dark, and was completely blind in the daytime. (See Mim. de Chir. Militaire, T. I, p. 6.) Nyctalopia may sometimes depend on a peculiarity in the structure and Organization of the eye ; by reason of which, the quantity of light, which only suffices for vision in an eye of natural formation, proves too abun- dant for a nyctalops, and absolutely prevents him from seeing at all. We know, that in the eye there is a black substance, named the pigmenlum nigrum ; one supposed use of which is to absorb the redundant rays of light, which enter the pupil. A deficiency of it might perhaps account for a nyctalops being blinded with daylight, and seeing best at night. For an account of nyctalopia, in the sense of night-blindness, refer to Hemeralopia o. •pri DEMA. (from oiStu, to swell.) The vX-i ancients understood, by this term, all kinds of tumours ; but it is now restricted to a swelling, arising from the effusion of a serous fluid in the cellular substance of a part; the affection, when more extensive, and accompanied with a general dropsical tendency, becoming a medical case, and receiving the name of anasarca. An cedema- tous part is usually cold, and of a pale colour; and, as it is little, or not at all elastic,it pits,as surgeons express themselves, or, in other words it retains, for some time, the mark of the finger, after being bandied, or pressed. (Edematous swellings are often connected with constitutional causes. In many cases, however, they seem to be en- tirely local Affections, arising from such causes as only act upon the parts, in which the swelling is situated. Thus we observe, that after violent sprains of the wrist, or ankle-joint, the hands and feet often become (edematous ; and limbs are frequently affect- ed with oedema, in consequence of the re- turn of blood through the veins being ob- structed by the pressure of tumours on them, or that of splints, bandages, be. Pregnant women are known to be particularly subject to oedema ofthe legs, owing to the pressure of the gravid uterus on the iliac veins Per- sons who have been confined in bed, with fractured thighs, or legs, generally have more or less oedema in their feet and ankles, on first getting up again ; and the affection in these cases is probably quite dependent on loss of tone in the vessels of the limb. In the treatment of oedema, great attention must always be paid to the nature of the cause, in order to determine whether the disease originates from a mere local, or a general constitutional affection. When it depends on the pressure of a tumour on the veins, as we often see happen iu cases of aneurisms, the effect cannot be got rid of till the cause is removed ; and the aneurii mal swelling must be lessened, before the (edematous one can admit of the same be- neficial change. When oedema is the effect of vascular weakness in a limb, in conse quence of sprains, contusions, be. the best means of relief is to support the parts affect- ed, with a laced stocking or a flannel roller, while they are also to be rubbed with lini- ments, and bathed with cold spring water, till they have perfectly recovered their lone. With regard to the oedema, attendant on the advanced stage of pregnancy, a com- plete cure cannot be expected till after deli- very. The affection is generally more con- siderable in the afternoon than the morning, owing to the different effects of an erect and a recumbent position. Some relief may be obtained by the patient's keeping as much as possible in a horizontal posture ; and, when much inconvenience and pain are felt, the parts may be fomented with any aromatic or spirituous application. Frequently, oedema is one of the symp- toms of suppuration, and, when the collec- tion of matter is very deeply situated, some- times leads to its discovery, as is exem- plified in cases of empyema. There is a species of oedema, accompanied with a degree of heat, pain, be. in the part, and which, in short, seems combined with phlegmon. In this case, cold evaporating lotions, the application of leeches, and tbe exhibition of saline purgatives, are proper. An erysipelatous oedema is also met with, in which the treatment should very much re- semble what is explained in the article Erysipelas. (ESOPHAGOTOMY. (from oesophagus and Ttptyce, to cut ) The operation of cutting into the oesophagus, in order to take out of this tube any foreign body which lodges in it, and can neither be extracted through the 2»«> (EsOPlU mouth, nor pushed down iuto the stomach, though its removal is absolutely necessary for the preservation of the patient's life. A substance, above a certain size, lodged in the upper part of the oesophagus, not only obstructs deglutition, but by ils pressure against the trachea, produces the most urgent -symptoms of suffocation. In this circum- stance, if relief cannot be expeditiously af- forded in any other manner, and the situation of the foreign body is denoted by a prominence distinguishable in the neck, cesophagotomy should be practised without delay. How- ever, when the symptoms are pressing, yet unattended with any possibility of feeling the foreign body, either externally or with a probang, desperate as the situation of the patient may be, modern surgeons do not sanction the practice. And this difference from the opinion of the first proposers of cesophagotomy, does not arise so much from any reflections upon the greater difficulty of the operation in this circumstance, as from the consideration of its be ng unlikely to answer the only purpose, which makes its performance at anytime proper, viz. enabling ihe practitioner to extract with reasonable certainty the substance, whose continuance and pressure in the oesophagus are the imme- diate cause of tbe patient's danger. Hence, when the symptoms of suffocation are ex tremely urgent, but the foreign body produ- ces no external prominence in the neck, the Mirgeon should in the first instance perform tracheotomy, so as to obviate the imminent peril arising from the impeded state of respi- ration, and afterward try such measures for the removal of the substance lodged in the oesophagus as experience points out as most likely to prove successful. Though cesopha- gotomy was cursorily mentioned by Verdue in his "Pathologie Chirurgicale," Guattani, formerly a distinguished surgeon at Rome, is entitled to the honour of having published the first valuable observations on the subject. (Mim. de I'Acad. de Chir. T. 3, 4/o.) Guatta- ni proved by experiments, that the operation might be safely performed upon dogs, which recovered after it very well, and he demon- strated on the dead body, that it was equally practicable on tbe human subject. Nay, what is still more to the point, he brought forward two instances, in which the practice had been successfully adopted on living pa- tients. " In May, 1738, Goursauld, a sur- geon at Coussat-Bonneval, in Limousin, was called to a man, in whose oesophagus a bone was lodged, an inch long and half an inch broad. Various ineffectual endeavours were made to force it down into the stomach, and, as il was perceptible on the left side ofthe neck, Goursauld ventured to make an incision for its extraction. The bone was thus easily ta- ken out, no bad symptoms followed anel the wound healed up favourably with the aid of an uniting bandage. For six days the pa- tient was not allowed to swallow any kind of food, but was nourished entirely with clysters. According to Morand, a similar operation was performed, with equal suc- cess, by Roland, surgeon-major of tbe regi- GOIOMY ment of Mailly." (Mem.de I'Acad. de Chir T. 3.) Although the deep situation of the eso- phagus, among the most important parts in the neck, makes cesophagotomy an operalioo of considerable delicacy in the hands even of a skilful surgeon, and one of great danger iu those of a man, deficient in anatomical knowledge, and ignorant of the right way of proceeding, yet the propriety of perform- ing it, under (he circumstances, which have been specified, is universally admitted. When, however, I refer (o (he delicucy and difficulty of Ihe operation, I am meaning a case, in which a deliberate dissection is made down to the oesophagus, without any gui dance from (he projection of (he foreign body within it; a case, iu which my views of the subject lead me lo think, contrarilyJo Guattani, that the experiment would gene- rally be attended with no practical benefit; which is also ihe sentiment ot Baron Boyer For, with respect to opening the oesophagus. w ith the view of tracing a substance in ii, not externally perceptible, and either of taking bold of the same substance wilh forceps, or pushing it down into the stomach with other instruments, introduced through the incision, as suggested by Guattani, the chances of success must be too small to justify a practice, in w hich it is above all things of consequence lo have the guidance afforded by the promi- nence in the throat, as a test of the foreign body being actually lodged in (he oesophagus, and capable of being removed from il by (he proposed operation. Indeed, the uncertainty of being able to reach and extract ibe foreign body, when its precise situation is not indi- cated by any external swelling, appears to me an objection of greater validity, than any consideration either of the increased diffi- culty of cutting into the cesopbagus under these circumstances, or of the usual conse- quence- of such an incision, after it has been accomplished ; because the practicable na- ture of (he operation, and the tendency of wounds of the oesophagus to heal favourably, when not complicated wilh other mischief of loo serious a description, are facts proved beyond the possibility of dispute. In at- tempts at suicide and murder, and in cases of gunshot injury, the oesophagus is some- times wounded, together with other parts in the neck, and yet the patients frequently re- cover; and, when they die, their fate seems to depend rather upon other unfavourable circumstances in iheir cases, than upon the accidental injury of (he guilet. The cures of wounds of the neck, involving tbe latter tube, as well as the tr-echea, are reported by numerous writers, B. Bell, Desault, Bohnius, be. and some have fallen under my owu observation. If i» were necessary to sub- stantiate this point further, I might cite the instance, recorded on the authority of Dr. James Johnson, where a man recovered after the larynx had been completely severed between the thyroid and cricoid cartilages, and one half of the calibre of the oesophagus divided. (See Hennen's Military Surgtry,p- 364, Ed. 2 ) But. sutmosing a wound of the (ESOPHAGUS. 2& oesophagus, abstractedly considered, were more dangerous, than it really is, the ques- tion of the propriety of cesophagotomy would not be materially affected by it, be- cause Ihe operation is never recommended, except as a mailer of necessity, and without which the patient would have no chance of preservation. As the oesophagus does not descend ex- actly in a straight line, between the trachea and vertebrae, bu( inclines rather to (he left side of (he spine, Guattani directs the left side of (he neck (o be preferred for (he per- formance of cesophagotomy. But, Boyer bas justly remarked, that as the operation should never be attempted, unless there be projection of the foreign body, the place for the incision is always to be determined by the situation of the projection, the left side being chosen only when Ibe prominence is either most distinguishable (here, or at all events not less, than on tbe opposite side of the neck. (Traiti des Mai. Chir. T. 7.p. 192.) The parts, which cover the oesophagus, from the middle and external part of the neck to the upper part of the sternum, are the skin, f'l, cellular substance, muscles pro- ceeding from tbe sternum to the larynx, the thyroid gland, the thyroid arteries and veins, the trachea, (he recurrent nerve, be- Gual- tani, wio preferred ihe left side of the neck, recommended the following mode of opera- ting. The patient is to sit on a chair, with his head inclined backward, and steadily sup- ported by an assistant. The skin having been pinched up into a transverse fold, an incision is to be made in the integuments from the upper part of the sternum. The cellular substance, between the sterno-hyoi- deus and sterno-thyroideus muscles and trachea- is next to be divided. With two blunt hooks, (he lips of the wound are to be kept open; and, o.n separating Ibe cellular substance at the side of (he trachea with ihe aid of the finger and a few strokes of the knife, the oesophagus will be seen. The lower part of this lube is then (o be opened, and (he wound in it enlarged with a pair of curved blunt-pointed scissors, a director being employed, if any difficulty arise With a small pair of carved forceps, similar to those used for Ihe extraction of polypi, the foreign body in ly then be removed. According to Guattani, the wound will serve for (he ex- traction of the loreign body, whether this be situated above, or below it, and he asserts, that the opening will even be useful, when the extraneous substance has passed so far down, that it cannot be taken out, as it can now be easily pushed into the stomach. Guattani lays great stress on (he usefulness ol en- deavouring to unite tbe wound, and adverts to his experiments, proving that, in animals, wounds of the oesophagus heal very favoura- bly. If, says he, the vein, which brings buck the blood from the inferior parts of the thyroid gland, and runs into the subcla- vian, happen to be cut, the hemorrhage may be slopped wilh a dossil of lint held upon (he aperture in the vein during the operation, find afterward, if the bleeding continue, l«T, 11. H7 compression, or a ligature, is to be employed. The recurrent nerve, if at all likely to be touched with tbe knife, is to be cautiously drawn a little out of the way with the bluot t enaculum. Guattani also particularly insists ,upon opening the oesophagus as near as pos- sible to the trachea, especially at its upper part, where the artery, which goes from the subclavian to the thyroid gland, sometimes runs. When the foreign body requires an ample opening, and particularly when the thyroid gland is enlarged, Guattani approves of separating this part a little from tbe side of the trachea. (See Mim. de I'Acad. Chir. T. 3, 4fo.) There can be no doubt, that Guattani's di- rections for finding (he oesophagus are very good ; but his chief detect is representing the place for the incUian as being always (he same, whereas it ought to be partly regulated] by (he situation of the foreign body itself. However, his advice io make the incisions close to the trachea appears to me more ju* dicious, than that recently delivered by Boyer, who directs them to be made through the cellular substance between tbe sterno- hyoideus and sterno-thyroideus muscles, and the omo-hyoideus. (see Traiti des Mai. Chir. T. 7, p. 193, 8vo. Paris, 1821,) in which method, he quits the trachea, wliich is the best guide to the cesophagus, and approaches unnecessarily the large blood-vessels of the neck. Yet, I agree with Boyer, respecting the general impro- priety of attempting cesophagotomy, when the situation of the foreign body is not indi- cated by any prominence in the neck, and the prudence of determining the place of the incision in a great measure by such pro- jection. Boyer also cautions the operator to let his incisions always be made in such manner, as to leave unhurt the trachea and recurrent nerve at tbe inner edge of the wound ; the carotid and internal jugular vein at its outer edge ; the superior thyroideal vessels, above ; and the inferior ones, below-. With this view, the cellular substance is to be slowly divided layer by layer, and the blood repeatedly absorbed with a sponge ; but, if any vessel bleed freely, it is to be immediately tied. After the operation, an elastic gum ca-* the-ter should be passed from one of the nos- trils down the pharynx and oesophagus, by which means, the requisite food and medi- cines may be injected into the stomach, without any risk of their passing through the incision, and retarding (he cure. But, a still stronger motive for this practice is the avoidance of (he convulsive action of the muscles in deglutition; a source of very hurtful disturbance to the parts. Before the advantages of this contrivance were duly appreciated, the patient, for the first week, was allowed to swallow scarcely any thing, and was kept alive with broths injected up the rectum. (ESOPHAGUS, Foreign bodies in the. Ttiere are few situations, in which foreign bodies lodge more frequently, than in tbe oesophagus ; a fact, explicable by th* c<*r» 2ao OESOPHAGUS. sideration of the function of (his tube, (he nearness of part of which to the windpipe at the same time accounts for the frequent danger of suffocation, when a substance, above a certain size, is lodged in it. The lodgment often lakes place at the lower part of the pharynx, or beginning of the oeso- phagus, and sometimes just above the dia- phragm ; but very rarely iu the intervening portion of that canal. Foreign bodies, liable to lodge in the oeso- phagus, are not only articles of food, such as pieces of crust, or meat imperfectly chewed, the yolk of an egg, boiled very hard, and nol masticated, a chesnut, or small apple, be.; but also various substances, which are accidentally swallowed either alone, or together with the food, such as pieces of bone, stones, pins, needles, buttons, pieces of money, knives, forks, scissors, spoons, keys, ike. These latter articles, by lodging in the pharynx, or cesophagus, may occasion very bad and fatal symptoms, and, if forced down into the stomach, may pro- duce effects of a nol less serious description. Hence, an immediate attempt should always be made to extract them. For this purpose, the fingers may be employed, and, if they will not reach far enough, a pair of long curved forceps should be used. But, no instrument seems belter calculated for cases, in which the body lodged in the cesophagus is not too wide, than the urelhra-forceps, invented by Mr. Weiss, of the Strand, and used by Sir Astley Cooper for the re- moval of calculi under a certain size, from the bladder. (See Med. Chir. Trans. Vol. 11.) Nooses of wire, and bunches of thread with a multitude of nooses, fastened upon the end of a probang, and a piece of sponge fixed on the extremity of the same instru- ment, or on that of the strong wire stilet of a long elastic gum-catheter,and various olher contrivances have been made wilh the view of extracting different articles from the oeso- phagus. The bunch of thread seems well calculated for catching hold of small sub- stances, like fish-bones, needles, be; and the sponge, when expanded with moisture and withdravvn, will sometimes bring up ar- ticles, which on its introduction, it had passed in its dry and diminished slate. When the stomach is full, the excitement of vomiting bas sometimes answered ; but, if the foreign body be sharp and pointed, (he method is not free from danger, and, instead of relieving (he patient, may put him to great pain, and bring on violent inflammation of the passage, and the most distressing symp- toms. When the substances are not of a very hurtful kind, and cannot be extracted, they must be pushed down into the stomach with a large bougie, or a whalebone probang. fifteen or sixteen inches long, and on the end of which a piece of fine sponge is securely fastened. But such practice is notadviseable, when the foreign bodies have a sharp, point- ed form, so as to be likely to prove a source of at least equal danger and suffering, if placed in contact with the inner surface of the stomach. Experience proves, that hard, angular substances, and pointed bodies, like nails, pins, needles, &< w hich surgeons have not ventured, or not been able, to force down into the stomach, have often made their way after a time to the surface ofthe body, where an abscess has formed, oul of which tliey have been discharged. When very hard, irritnting bodies have either passed of themselves, or been pushed with a probang into the stomach, their ill effects should be counteracted, and their passage through the bowels promoted, with mucilaginous draughts, containing the oleum amygdalarum or oleum ricine. When the substances, lodged in the cesophagus, can neither be extracted, nor pushed down into the stomach, if respiration be not danger- ously obstructed, and liquids can vet be swallowed, the wisest plan is to avoid irrita- ting the passage with the further use of in- struments, and leave the case to nature, that is to say, as far as manual interference is concerned ; for, bleeding, and macilaginous oily draughts, may be in some cases useful. But, when the lodgment of a foreign body in the o esophagus dangerously obstruct re- spiration, and the substance itself can be felt externally, the patient would perish, if some means of facilitating the breathing were not immediately adopted ; and, under these circumstances, perhaps, the most pru- dent plan would be to make an opening in the trachea. (See Bronchotomy.) The sub- sequent treatment, with reference to the foreign body itself might be determined by the circumstances of the case. In this part of surgery, one fact deserves to be particularly remembered, which is, that after a sharp, hard substance has been either ejected, orpropelled into the stomach by nature, or art, the same painful sensations in the throat frequently continue a certain time afterward, which were experienced while the foreign body was actually lodged in the passage. These sensations, however, are only owing to the manner, in which the cesophagus has been irritated, and, conse- quently, would be seriously aggravated by the further unnecessary introduction of pro- bangs, and other instruments. There may be cases, in which the patient would lose his life by suffocation, if a foreign body of considerable size were not taken out of the oesophagus, so as to remove the compression of the trachea. Here, if it could neither be extracted, nor pushed into the stomach by common means, and its situation were indicated by any hardness, or prominence in the neck, an operation would be necessary for its removal. (See CEsopha- gotomy.) A foreign body, not large enough to cause danger of suffocation by pressure on the trachea, may yet bring on fatal symptoms, as is exemplified in a case, which fell under the notice of Guatlani. As a man was throw- ing up a boiled chesnut in the air, and catch- ing it in his mouth, it passed down his thmat, and he was immediately seized with n r'&- culty of 'wallowing, and seal to Uic ho^i'M OESOPHAGUS 291 However, as he breathed and spoke with facility, and had vomited since the accident, which happened when he was tipsy, the story of his having swallo < ed the chesnut was disbelieved. His symptoms grew worse, and he died on the 19th day. GuaUani made an incision in the left side of the neck, below th- larynx and thyroid gland, which was considerably swelled and soon came to a large abscess, formed around the portion of (he cesophagus enclosing the chesnut. When the extraneous body is sharp and pointed, so as to stick in the mucous mem- brane of the passage, and it cannot be removed, nature will sometimes expel it herself, without any dangi rous symptoms being the consequence. The foreign body is gradually loosened by ulceration, and is then either ejected by vomiting, or descends into the stomach, whence it is voided either through the bowels with the fasces or, as is more common, by making its way through some part of the alimentary canal, and approaching (he surface of the body, where an abscess forms, out of which it is discharged. In other instances, foreign bodies, like pins and needles, which cannot be removed, pierce the oesophagus itself, gradually pass completely out of this canal, and afterward travel to remote parts of (he body, without exciting much inconvenience until perhaps, at the end of some years, they come near the surface of the body, in a very remote situa- tion from the throat; and au abscess is pro- duced, in which they are unexpectedly found. However, this transport of sharp-pointed substances from one part of the body to another, which is effected by a process, in which ihe absorbents have a principal share in the wi.rk, is not conducted in every instance with so little disturbance, and, when fore gn bodies of this description come into contai-t with particularorgans, symptoms of a dangerous and fatal kind may be excited. The great art of passing any instrument down the oesophagus, for surgical purposes, consists in putting its extremity at once directly against the posterior part of the pharynx, and keeping it closely against the vertebrae so asloavoidtouching the epiglottis. The know ledge of this circumstance will be found extremely useful in passing probangs and bougies. When elastic gum-catheters are intended to be left in the passage, they are introduced down the pharynx from one of the nostrils, and, being secured, they serve for the conveyance of liquid food and medicines into the stomach with great ad- vantage, in many cases, either where the patient cannot swallow at all, or where the disturbance of swallowing would be attend- ed with considerable harm. When, however, the plan is not to leave the instruments introduced, as Boyer observes, they may be passed through the mouth. (ESOPHAGI'S, Strictures, and other Dis- eases of the. Properly speaking, a difficulty, or impossibility, of swallowing should not be regarded as a disease itself; but only as a symptom of different affections, to which the organs of deglutition are liable, or of other diseases, which affect parts in the vicinity of the pharynx and oesophagus. The object of the present article is not the consideration of all the diseases, which may produce dyspha- gia, as a symptom, but chiefly to notice thfs effect, as deptnding upon spasm, paralysis, or some morbid change of structure affecting the pharynx or oesophagus. "Spasmodic dysphagia, as Baron Boyer bas remarked, principally occurs in nervous in- dividuals, hysterical females, aud hypochon- driacal men. It is sometimes an attendant on fevers; it is declared to be constant in hydro- phobia, and epilepsy, and occasionally pre- sent in particular forms of mania. (Traili des Mai. Chir. T.7,p. 151.) However, with re- spect to hydrophobia, the foregoing assertion should be received witb some qualification, for reasons so fully detailed in another part of this work (see Hydrophobia,) that it is unnecessary here to dwell upon the subject. spasmodic dysphagia is said also to be some- times a consequence of taking cold drink, after a violent fit of anger; of strong im- pressions on the imagination; of worms in the stomach, &c. When the spasm is situated in the pharynx and upper part of the cesophagus, and is considerable, neither solids nor liquids can be swallowed, and tbe patient has great pain and a sense of constriction in his throat. When he tries lo swallow any thing soft, or even fluid, he is seized with acute pain, insuf- ferable nausea, and violent agitation of the whole frame. In this case, the spasm is never restricted to the pharynx and upper portion of the cesophagus, but extends to other organs, the inability of swallowing coming on in the midst of numerous other spasmodic symptoms, exceedingly compli- cated, and sometimes of a very alarming nature. When it is the middle, or lower, part of the cesophagus, which is concerned, as is frequently the casein hysterical women, the food passes through the pharynx aud unaffected portion of the cesophagus with tolerable facility ; but, as soon as it reaches the sea^ of the spasm, it is either stopped, or descends further with great difficulty and effort. Liquids, especially when warm, and swallowed slowly in small quantities at a time, usually pass down with more ease, than solid substances. When the matter to be con- veyed into the stomach reaches the point of obstruction, the generality of patients are attacked with pain extending along the spine between the shoulders, and sometimes shooting to the stomach, which is consider- ably disturbed, aud often discharges its con- tents. In some cases, however, no such pain is experienced, and whatever the pa- tients try to convey into their stomadj-s regurgitates quietly into their mouths. Af- though spasmodic dysphagia is mostly com- plicated with other marks of disorder of the nervous system, it is sometimes unattended with any particular impairment ofthe health. (Boyer, T. 7, p. 152.) As the treatment of spasmodic affectidns ofthe pharynx and exsophagus belongs rathe:* 3t2 (ESOPHAGC-3. to the physician thau tbe surgeon, I shall be very brief on the subject. This removal ef tbe cause of tbe infirmity, that is to say, of tbe particular state of the mind, or con- stitution, giving rise to the spasm, is the principal thing, at which the practitioner should first aim. Thus, Boyer cured an hysterical woman of a difficulty and dread of swallowing solid food by attending her, at her meals twice every day for a month, and gradually convincing her of (he absurdity of ber apprehension of being suffocated by at- tempting to swallow solid aliment. (Vol. cit.p. 154.) Sauvages makes mention of an hysterical female, whose difficulty of swal- lowing was cured by a regimen consisting of regular exercise, cold bathing, and milk- diet. The most successful remedies, how- ever, are said to have been camphor iu large doses, and opium taken in draughts, or pills, or administered in clysters ; blisters and cupping-glasses applied to the nape of the neck, or to the epigastrium. Anodyne embrocations are also stated to have been useful. At the present day, the common idea, that many anomalous affections depend upon disorder of the liver and digestive or- gans, leads to the frequent employment of the compound calomel pill, and decoct. sarsaparilla, with draughts of senna, rhubarb, and gentian pro re nala. Dysphagia may originate from a weak- ened, or paralytic state of the muscular fibres, which enter into the structure of the pharynx and oesophagus. The affection may be either symptomatic, or idiopathic. The first case frequently occurs in febrile dis- eases, and is generally set down by writers, as a very unfavourable omen. Tbe idio- pathic form of the complaint may be complete, or incomplete, and is chiefly seen in persons of advanced age, though occasionally the patients are young and in the prime of life. The causes may be said to be little, or not at all understood, and the only remark, which can be safely made re- specting them, is, that they are usually con- nected with constitutional derangement. With regard to the symptoms of paralysis ofthe oesophagus, when the disorder is com- plete, deglutition is absolutely prevented, and, if the patient tries to swallow, the food lodges in the pharynx, and sometimes produces violent fits of coughing. Some pa- tients eat solid substances with moderate facility; but, find more or less difficulty in taking liquids. Others can swallow hastily a large quantity of fluid at a time, yet, cannot drink slowly and a little at once Morgagni relates an instance of still greater singularity, which was an ability to swallow all kinds of food very well, except the last mouthful, which always remained in the oesophagus until the next repast. (De Sed. et Caus Morb. Epist. 28, art. 14.) In cases of dysphagia from paralysis the patient suffers no pain, nor sense of. choking; if the neck be examined, no hardness nor swelling c an be felt; and a probang descends down the gullet without tbe slightest impediment (Boyer, T7,p 158.) In its duration and termination, dysphagia from paralysis presents considerable variety; the complete paralysis sometimes proves ra- pidly fatal, not however, as I conceive, ou account of the affection of the oesophagus alone, but other complications, and the exhaustion arising from inadequate nutrition. Thus, l ulpius relates an instance, in which a woman died on the seventh day from the commencement of the inability to -« ullow, notwithstanding every endeavoui was made to support her witb nourishment thrown up the rectum, which was the only thing that could be done, as she would nut allow a lube to be passed down the cesophagus. In other cases the patients live a considerable time, and afterward perfectly recover, and this sometimes under tbe disadvantage of having been entirely supported for several weeks with broth-clysters, as we find exemplified in a case recorded by Ramazzini. Certain examples are also reported, in which tht patients had their food forced into the stomach by means of probangs, for years, and either ultimately recovered their power of swallowing, or in this manner prolonged their days, without any cure taking place. (Stalpart van der Wiel, Vol. 2, abs. 28; Willis, Pharm. Rat. Sect. 2, cap. 1, p. 45.) Paralysis of (he cesophagus is to be treated on the same principles, as other paralytic affections; a subjeet, which I shall noi be expected to di-cuss; but. i( is of importance lha( practitioners recollect, in these rases, tho very essential service derived from the use of ebistic gum-catheter-, with which the requisite food and medicines may be in- jected into the stomach. Dysphagia from organic disease, or mor- bid change- of structure, is the most frequent case, and generally Ihe most difficult ol cure. In dissections, Ibe parietes ol the cesO|hnguj are often found considerably thickened, indurated, and scirrhous, or sometimes almost cartilaginous, and even ossified. The parts, where the pharynx terminates in the cesophagus, and where the latter tuhe joins the stomach, are occasionally converted into thick scirrhous rings wilh or without ulceration, exactly in tbe same manner as the pylorus. But, such diseases are not re- stricted lo those parts of tbe cesophagus, but sometimes occupy o(ber poin(s of the pas- sage. However, Ihe oiganic disease, producing a difficulty, or impossibility ol deglutition, is not always silualed in the coats ol (he cesophagus itself; for the |arls, surrounding this canal, are subject to various diseases, which may have (he same effect. Thus, dysphagia may depend upon enlarge- ment of the thyroid gland ; lumours formed between the trachea and cesophagus, or at some other point near tbe latter tube; swell- ing and induration of the thymus gland; aneurism of the aorta; enormous enlarge- ment of the liver ; and diseased lymphatic glands in the vicinity oi that portion of the cesophagus, which is covered by the perito- neum, and tbe largest ot which glands are situated near the fifth dorsal vertebra?, just at tbe point where the cesophagus iuclines.a IESOPHAGUS. 293 little lo the right side to make way for the aorta. (Boyer, T.7,p. 162.) This last author set? down every case of dysphagia, depending upon organic disease oi the oesophagus, as incurable; and witb respect to the cure of other examples, in which that lube is compressed by swellings in its vicinity, as the.-e are almost always beyond ihe power ot medicine and surgery, the prognosis is nearly as unfavourable, as where there isachtinge of structure in the cesophagus itself. There are no unequivocal symptoms, by which a case of dysphagia from enlargement of glands in the vicinity ot the cesopiiagus ean be known from seve- ral other forms of the romplaint Hence,it is difficult io estimate the correctness of certain case-, recorded by Rti)sch (Advers. Anat. Med. Chir. Dec 1,'art. 10, p. 24.) and Haller (Opuscul. Pathol. Obs.78.) where dysphagia, slated to have he en produced by enlarged lymphatic glands, was cured by mercurial frictions, or pills composed of calomefnloes, and camphoi. As Boyer justly rema k-, these accounts ot the nature of the diseases, thus cured, ait-, the more doubtful, inasmuch as Ihe resolution of chr-nie. -wellings ot lymphatic gland -, even \> hen externally situ- ated, is very difficult, aud frequently imprac- ticable, notwithstanding the use of topical applications may here be combined with Ihe Bxhilntiun of internal medicines (T.7,p. 169.) However, dismissing the question, whether the cases really arose Irom tbe pressure ol enlarged lymphatic glands, or nol, Ihe facts ol tbe cures having taken place, under tiie use of mercurial medicines, are of themselves interesting. Several wri- ters consider, that there is a great analogy between certain forms of constriction of the cesophagus, and siricturc-s ofthe urethra, and Mauchart recommended the two diseases to be treated, on the same pi inciples, with bou- gies, and elastic gum-catiieters. BaronBoyer, however, represents this doctrine as com- pletely erroneous, declaring thai the affec- tion ot the cesophagus is of ihe nature of scirrhus, and absolutely incurable. He relates one case, iu which a woman's life was prolonged by the use of an elastic gum- catheter, (hough il proved of no service as a means of permanently dilating Ihe diseased part; and, notwithstanding nourishing li- quids were plentifully injected into the Stomach, tbe patient suffered a good deal from hunger, and died exhausted about three years alter the beginning of Ihe disorder. This cast, however, cannot be received, as a proof of ihe inefficacy of bougies for what is commonly implied by a stricture of the cesophagus, because the nature ofthe disease was not ascertained by an in pection of the cesophagus afler death, and the case might have depended upon some organic disease either of this lube, or the parts in its vicinity not classed by the generality of modern writers with strictures of the passage. The following are some- of Sir Everard Home's sentiments, respecting these last cases. As the cesophagus is required to be wider at one time, and narrower at another, in or- der (o be fitted for conveying the different kinds of food into the stomach, it is nearly under the same circumstances, with respect to the formation of stricture, as the urethra. For obvious reasons, strictures of the ce-o- phagus are much less frequent than those of the urelhra. However, they aie by no means uncommon, und produce symptoms even much more distressing and dangerous, than those, which ordinarily arise irom ana- logous obstructions in ihe passage for the mine. Of course, the mosl remarkable symptom of a stricture iu the oesophagus is the diffi- culty of swallowing, wliich must be greater or less, according as the obstruction is more or less con plele. sometimes no solid food whatever can pass down into the stomach, and fluids can only descend wilh great diffi- culty, and in very small quantities. This is, in some instances, attended wilh considera- ble pain, whi« b extends along tbe lauces to the. bopijagus must then be lar- ger than the bougie employed. But if the bougie stops at the distance of six inches and a bait, or even lower, it must be re- tained there with a uniform pressure for halt a minute, so as to receive on its point an impression of the surface by which it was opposed. If the end of the bougie retains its natural form, or nearly so, and there is a indentation on one side ol it, or all round it, the surgeon may conclude there is a striclure. On tiie other band, should the bougie descend without impediment, as fur as seven inches aid half, and, when w un- drawn, the surface of ils point appear irre- gular, and jagged, the dse*se is an ulcer on the posterior part of the oesophagus. The mode of treatment adopted by Sir E. Home, consists either in passing a com- mon bougie occasionally through the stric- ture, and employing one of a larger size, n. proportion as tbe dilatation ot the obstruc- tion is effected ; or else in introducing an armed bougie at convenient intervals. The views, which I take of the disease, would lead me to prefer giving a full and fair trial to the employment of elastic gum-Crflhe- tn-s. Consul! Practical Observations on the Treatment of Strictures in tht Urethra aud Oesophagus, 3 I ols. Edit. 3, I8n5. Vol. 2, 18tW, and Vol. 3, 1821, by Sir E. Home, Ph.H.Beuttelde Struma (Esophagi; hujusqut coalitu< diffici i acpbolite deglutiHoiis C'uusis: \in Halter's Disp. (hir. 2, 39b,) Tubing. 1742, Mauchart de Struma CEsophagi, Tu- bing. 1742. J. Warner. Cases in Surpery, p. 130, Ed. 4. F. A. J. Zinckema^el, de Clysle- rum Nutrientum Anliquilate, et Usu, (Trilleri Opusc. 1, 499.^ A. later et F. A. Zincker- nagelde Deglulibonis dijficilis et imptditx causis abditis: (Halleri Disp. ad Morb. 1, 577.) E. F. Bulisius de Fame letlvdi ex caliosa oris ventrical angustia. J. M. Ec- cardus. de his qui diu virunt sine alimento, 4to. Kilie Hdsat. 1711. Boyer Traili de Mai. Chir T 7, 8co. Paris, 1821. OLEUM CAMPHOR \TLM ft. Olei oliva*. ibj. Camphoraj "^iv. Misce ut »oba- lur r-amphora. Sometimes employed lor promoting Ihe suppuration of indolent, particularly scrofulous swellings, which are to be rubbed with il once, twice, or thrice a day according to circumstances. OLEUM LINE In surgery, linseed oil is sometimes used as an application to bums, either alone, or mixed wilh an equal quan- tity of tbe liquor calcis. It has also been applied lo cancerous ulcers. OLEUM OBIG ANI. The oil of marjoram is often used for dispersing ganglions: the tumours are to be rubbed with it two or three times a day. OLEUM PALMjE CAMPHOR \TUM. ft. Camphorae ^ij. Olei palmae ft,j The camphor is to be reduced to powder, and the palm oil, being melted, and suffered to be- come almost cold, is to be mixed with it in a mortar. This ..pplication is a mild topical stimulant; and has been used for promoting indolent suppurations, especially those of a scrofulous nature, which take place under the jaw, and are attended with a good deal of chronic induration. OLEUM RICIM. In surgical cases, re- quiring the bowels to be opened with the slightest degree of irritation possible, the oleum ricini is the best and safest medicine. The usual dose is one large table spoonful. which must be repeated every two or three hours, till the desired effect is produced. OLEUM TERh BLNTHINiE. Oil of tur- pentine is employed externally as a stimula- ting liniment and a styptic In the article Liniment may be seen some formula?, ia which turpentine is the most active ingre- dient. It is sometimes exhibited internally, for the cure of gleets OLEUM TKREBI.NTHINATUM. ft. Olei amygdala? ^ss. Olei terebinthinae gutt. xl. Misce. In deafness, occasioned by defective, or diseased action of the glandulae ceruminese, Mr. Maule directs a little of this oil to be dropped into the patient's ear, or applied at the end of a small dossil of cotton. W!"*n a thin secretion takes place, the OPHTHALMY. 29d cure is also promoted by a small blister, which is placed as near the ear as convenient, and kept open w ith the savine cerate. The meatus auditorius externus must also be cleansed every day wilh a lengthened bit of soft cotton, affixed to a probe. (See Phar- macop Chirurnica.) OMPHALOCELE, (from e/r*YX. (from ovt/f, the nail.) A small collection of matter, situated in the anterior chamber of the aqueous humour, and so named from its being shaped like a nail It is of the same nature as Hypopium, to which word I must refer the reader. Maitre-Jean, Mauchart, and several other oculists, imply by the term onyx, a small abscess between the layers of the cornea. OPHTHALMY. (from o so close to the edge of the cornea, that its colour can scarcely be seen. When the surgeon is consulted in a case of this kind, though some inflammation may have com- menced, the prognosis is yet favourable, in regard to the preservation of the eye ; for a gentle opiate will relieve the vomiting when merely a nervous effect, not depend- ing upon the loaded state of tbe gastric organs; bul, if (he case be of this last de- scription, the prima* viae should first be emp- tied. However, when a traumatic inflam- mation is completely established, before the treatment is begun, the eye is generally de- stroyed, as the repeated and violent vomiting cause a great determination of blood to the head and eyes, and increase ofthe inflamma- tion ; an effect which the opiates, given for the relief of the vomiting, also tend to pro- duce Beer has seen two cases in which the eye was pricked with a needle near the insertion of tbe external straight muscle into the scle- rotica ; in both instances, the punctures were so small, that they would scarcely have been found, had not the patients known their situation exactly by the pain, and they were then only perceptible with a magnify- ing glass. The punctures were soon follow- ed by a convulsive rolling of the eyeball, and afterward by trismus, which continued severe in one patient a day and a half, and in another two days, but yielded to large doses of musk and opium given at short intervals, the warm bath, and the applica- tion of warm poultices containing hyos- ciaraus. As chymical injuries of the eye produce an actual loss of substance, they are even more serious than common mechanical lesions. However, chymical injuries of little extent are generally repaired wilh tolerable facility and expedition. Quietude of the organ, and moderating the outward noxious effects by lukewarm mucilaginous applications, either in tbe form of fomenta- tions, or eye waters, are the only requisite measures. If the cornea itself be hurt, as frequently happens when boiling hot fluids strike the eye, a kind of vesicle arises on the injurad part, which becomes more and more white. The vesicle either bursts of itself, or subsides without breaking. In both cases, the production of the conjunc- tiva, of which the cyst of the vesicle is composed, shrivels up, and peels off, a new membrane of a similar nature being regene- rated underneath. Au opaque speck is fre- quently apprehended ; but, says Beer, if the surgeon will merely avoid being too much in a hurry to open the vesicle, and not disturb the work of nature by applying •various remedies to (he eye, there will be no danger of such an occurrence. More extensive chymical injuries of the eye, which at first are not in themselves very severe, frequently become dangerous, in consequence of care nol being taken to prevent the influence of external stimuli. To this class of cases belongs the accidental •sprinkling ofthe eye with boiling fluids, or Vol. 11 :jo strongish mineral acids. And even in these examples, says Beer, the prognosis i- not unfavourable, and a complete recovery may be effected when the treatment is con- ducted according to the directions already given with respect to such accidents in general. White this author approves of cutting away any substance which is dead and partially detached, he strongly cau- tions surgeons not to remove the thin layer of the conjunctiva, nor to puncture any vesicle which may form. When the burning or corrosion is not limited to the conjunctiva of the eyeball, but extends to the lining of one or both eye- lids, Beer recommends covering the injured parts with mucilaginous applications, and mildly astringent ointments, containing tutty, or the white oxide of lead. In these cases, keeping the eye perfectly motionless must be hurtful, as it lends to promote the formation of adhesions, either between the eye and eyelids, (ftymblepharoiij or be- tween the eyelids themselves. (Ankylo- blepharon.) Extensive, deeply penetrating, chymical injuries of the eyeball, Beer describes as being almost always followed by more or less impairment of the functions of the organ, or of some of its particular textures, because such accidents never happen with- out a loss of substance. Thus a part, or the whole, of the cornea may be entirely de- stroyed, as in injuries caused by quicklime ; and, frequently, adhesions between the eye and eyelids, or between the two latter parts, cannot he prevented by any kind of skill. (Beer.) These serious degrees of mischief, as the same author observes, are mostly- occasioned by slaked or unslaked lime, con- centrated mineral acids, fire,&c. Unslaked lime, especially when extensively diffused over the eye by the immediate application of water, not unfrequently produces a sud den destruction ofthe whole of the cornea, which is changed into a grayish, pappy sub- stance, capable of being removed from the subjacent iris with a camel-hair pencil. Such an annihilation of texture, however, is generally restricted to particular points, or the surface of the cornea. Wherever this membrane has been so much decom- posed that a manifest depression is directly perceptible in it when inspected sideways, a snow-white shining speck must be expect- ed to be the consequence. Slaked limo never operates upon the cornea with so much violence, usually causing (as Beer states) only a superficial corrosion, or a coagulation of tbe lymph between the layer.-*, of the cornea. JNor are mineral acid.-. even when concentrated, generally so de- structive to the cornea as qu-cklime; firs,, because, as fluids, they do . ot long remain in contact with the eye; and secondly, be- cause tne immediate mixture of the tears with them weakenstheir operation; w iitreas- it only increases that of unslaked lime- Tho local treatment here consists in carefuih- reinovine every particle of the hurtful sub- stance, afterward dropping frequently into OPHTHALMY the eye lukewarm mucilaginous decoctions or coliyria, or covering the injured place with a mild cerate, and excluding the air and light from the eye. Every endea- vour must also be made to prevent the formation of adhesions between tbe injured surfaces. In very severe burns of the eyeball, of course, all icha of restoring its functions is out of tne question i he violence of the in- jury is (he greater, the more mime rous the. vesicles arc upon the conjunctiva, and the more ihe eyebal.l and tbe iris ure incapable of motion. Here the only indication is to moderate the inflammation, and avert such addition .1 mischief, as might otherwise be produced by it. With this view, the eye should be kept at rest, and excluded from the light and air. According to Beer, the most common injuries of the eye, partaking both of a mechanical and chymical nature, are those caused by mortar, or the accidental touching the eye with hot curling irons. When the mortar contains no particles of quicklime, it often occasions, at particular points of the cornea, very white specks, which Beer describes as being composed of coagulated lymph, and admitting of disper- sion. He even declares, that when the w bole of the cornea is in this state, its trans- parency may be restored by proper treat- ment, as has been frequently exemplified to the gentlemen attending his clinical lectures. (B. 1, p. 234.) The pricking of the eyeball wilh a red-hot needle, and the stinging of it by bees, wasps, and other insects, are also bolh chymical and mechanical injuries. Whether the sting be left in the skin of the eyelid, or in the conjunctiva, or not, a considerable inflammatory swelling immedi- ately takes place; and, if the sting be lodged, ■■■iid not now taken away, the inflamma- tion spreads, and theeye itself is endangered. In two cases, w here the stings of bees were left in the skin of the upper eyelid, Beer has known gangrene arise in the short space of a day and a half, and the patients were saved with great difficulty. The treatment of such cases consists in immediately ex- tracting the sting, if lodged, and applytig folds of linen over the eye, wet with cold water. After noticing the destructive effects of burning substances, the explosion of gun- powder, and fulminating silver, on the eye, (cases in which, when the functions of the organ are annihilated, the only indication is to diminish the subsequent inflammation and its consequences,) Beer inquires, what is the reason why the slightest mechanical, or chymical, injuries of the eye, in an apnai rently healthy subject, are sometimes fol- lowed by an immoderate degree of inflam- mation, and even the loss of ihe organ from huppuration ? It is, says he, an observation made ffy Schmidt, that there are some eyes, which the greatest bunglers may abuse for hours at a time, v. ithout being spoiled, their powerful organization defying all such un- skilful dirturbunce ; while other eyes are U-rc-t with, which the most skilful opera- tors can hardly touch, v. Ithout inducing a destructive degree of inflammation and sup- puration. It was to this peculiar idiosyn- crasy tbat Schmidt applied the term vulnera- bility (Verwundt'Orkeil.) Patients of Ibis nabit are said to possess an exceedingly fine soft skin, with a reddish polish upon it, and their cheeks are not only red, but exhibit a net- work of very minute vessels, which sec in as if injected, such indiv iduals appear as if they were in the-bloom of health ; an,I, says B er, in some respects they are really so. VVueii their spirits are raised by the slightest causes, their complexion is universally red- dened ; but the least fear turns them as pah as a corpse. Their skin is described as being uncommonly irritable, sensiole of every im- pression, and attacked wilh an erysij elatous redness, whenever any fatty s.ibstanee touch- es it. In such habits, the utmost caution is necessary whenever Ihe eyes have been in- jured, and the prognosis should be reserved. And, when an operation is to be done on their eyes, Beer recommends the previous exhibition of opium, and the application of a blister to some part of the skin, at a consi- derable distance from them. As a prophy- lactic measure, he also directs regular fric- tion of the surface of the body. In severe ophthalmies, particularly those which affect the eyeball itself, all mental emotions, anger, joy, be. should be avoided. Hence, no talkative nor quarrelsome per- sons should be suffered to remain with the patient; and noisy child en ought to be kept away from him. The apartment slmuid be ventilated a( least once a day, Without the patient being exposed to any current of wind. All touching of the eye, or rubbing it with the bed-clothes during sleep, must be strictly prohibited. Stimulating, spicy food, spiritu- ous drinks, and great bodily exercise are like- wise to b- forbidden. In the list of things which bave a hurtful effect, Beer also in- cludes all exertions of the lungs, every kind of disturbance, an atmosphere impregnated with tobacco-smoke, be. Having fulfilled the first general indication by removing, if poss ble, every kind of irrita- tion acting upon the eye, the. second general in- die- tion specified by Beeras proper in the first sta-e of ophthalmy, is to be observed, which is to moderate, according to tht degree of in- flammation, the agenty of sev-ral things to the effect of which Ihe organ is naturally subjected. Thus, the inflamed eye should not he exer- cised, even though the eyeball itself may not be immediately inflamed ; and tl.v operation of the light and air should be diminished partly by green silk eye-shades, and partly by vvindow-blinds. Attention to this rule is still more necessary, when the eyeball itself is affected. With respect to the exclu- sion of light, it is to be well remembered, that it is only adviseable, as Dr. Vetch observes, in the very early stage of inflam- mation, the eye becoming more irritable and less manageable, when the access of * moderate degree of light is afterward pre- vented. (Vetch on Diseases ofthe Fye,pA6-> The third general indication, rEcntionf'' OPHTHALMY by Beer, as proper in the first stage of ophthalmy, when the disorder threatens to extend to the whole organ, and to bring on a febrile disturbance of the system, is to counteract tliese effects by covering the eye with folded linen w^t with simple cold water, or vinegar and water; and having recourse to leeches, or when the nature of the case allows, to scarifications. (B. 1, p. 242.) Here, however, it merits particular notice, that, Beer, in expressing a general preference to cold lotions in the first stage of ophthalmy, dtffers from Richter, Scarpa, and Mr. Travers, (Synopsis of Ihe Diseases of the Eye, p. 250,) all of whom, in the painfully acute stage, recommend tepid emollient ap- plications. With regard to leeches, also, the late Mr. Ware objected to their being put on, or very near the e, elids, as they sometimes cause a considerable swelling of these parts, and increase, instead of lessening the irritation. In ordinary cases his method was to apply three on the temple, ah ut an inch and a halt from the uter part of the orbit. Scarpa recommends applying the leecnes to the vicinity of the eyelids, especially about the inner canthus, on Ihe vena angularis, where it joins the frontal, deep orbitar, and transverse vein of the face. Beer prefers nearly the same situation, as that specified by Scarpa, viz.lhe in ner canthus, immediately below the under eyelid ; and he forbids the application of leeches above either canthus, as likely to produce a disagreeable ecchymosis in the cellular membrane ofthe upper eyelid. The number of leeches, and the time, which they should be allowed to suck, he thinks, ought to depend upon the severity of the inflammation. According to Beer, when this mode of bleeding is to be of any service, the patient will experience a considerable abatement of the throbbing pain, tension, be. in the affected eye. Hence, when any of the leeches fall off premalurely, the bleeding from the bites is to be kepi up, with a sponge dipped in warm water, until such relief is felt. In the acute stage, Beer considers the abstraction of blood by means of scarilica tions rarely admissible. (B. 1, p. 243.) Mr. Travers also sets down scarifications of the conjunctiva as mostly objectionable in the acute stage; though highly beneficial in the chronic, where the lining of the eyelids is thickened and over vascular; and a con- siderable discharge of blood may be thus obtained, if the operation be briskly done with a sharp lancet, and the lower fid kept everted, and fomented. The same gentle- man states, that cupping has a decided supe- riority over leeches, but that both are well adapted to relieve local congestion. Yet, he deems these methods too indirect to answer as substitutes for the lancet, where it is de- sirable to make the system " sustain and feel a reduction of power," in which case blood must be taken from a vein, or the temporal artery. (Synopsis, fyc p. 249.) While inflam- mation of the conjunctiva is described by Dr Vetch, as not much affected by bleeding, unless the quantity of Wood taken awav be such as fo occasion syncope, he states, that the abstraction of blood, in quantities pro- portioned to the violence of the symptoms, more especially, by means of cupping and leeches, has for the most part sufficient con- trol over the various states and individual symptoms of sclerotic inflammation. In some obscure cases of what this author terms amaurotic inflammation, he has seen great benefit derived from the application of leeches to the septum nasi, and he represents tbeir being put directly on the conjunctival lining of the eyelids, as being sometimes more advantageous than on (he adjacent integuments the orifices bleeding with great freedom. (On Diseases of the Eye, p. 15.) If some of the above remarks are correct, scarifications are rather too boldly praised by the bite Mr. Ware, as applicable lo the acute stage of ophthalmy. But, supposing the first violence of the attack past, his re- commendation of the practice either in the vascular and turgid state of the lining ofthe eyelids, or in the eversion of the lower ene from a similar cause, seems perfectly unob- jectionable When the upper eyelid was very cedematous, and its thickness prevented the application of proper remedies (o the eye. Mr. Ware also thought a few puncture* near the cilia useful, by causing a discharge of bloody serum, and a quick subsidence of the swelling. And he speaks of the excision of a piece of the excessively tumid lining of each eyelid, in cases of ophthalmy with eversion, as having afforded ,rcatand speedy- relief. (Wart on Ophthalmy fyc p. 39 ) The fourth general indication, enumerated by Beer, is that, which has for its objects a diet and rerimen suited to the state of the case, after it has attained a degree, in which its effects begin to be felt throughout the system. When therefore the plan is to be rigorously practised, the patient's ordinary diet is to be reduced, and he is to be allowed only vegetable food, cooling drinks, water, weak lemonade be. And not merely the eye itself is to be kept at rest, but the whole body. Should the disorder be further advanced, and attended with a great deal of inflamma- tory fever, the observance of the foregoing indications will not suffice for checking the inflammation and preventing suppuration, unless the fifth indicati-n, laid down by Beer, be fulfilled, which is to employ such remedies as operate upon the whole constitution. 1. Purgative and gently aperient medicines, which will empty the bowels well, and lessen the determination of blood to the head and eyes. 2. Clysters, which are useful on (he same principles. 3. The frequent exhibition ofthe nitras potassa;. 4. General bleeding, the efficacy of which will much depend upon the blood being voided in a full stream. Beer se°ms to prefer opening a vein on the foot; but, in Kngland, the most experienced practitioners generally open a vein in the arm, and sometimes the tempbral artery. The blood, as Beer remarks, should be allow- ed to flow until the hard small pulse rises and becomes plainly rofter;. for, otherwise the Mt, OPHTHALMi operation will be completely useless. Also, when in these ca=es, general bleeding is no longer indicated, the employment of leeches will yet be advantageous, and afterward, sca- rifications may be practised, which, at any earlier period, would have aggravated all the inflammatory symptoms. By strict attention to the five above ex- plained indications, either without precipita- tion, or too much delay, the first stage of ophthalmy, even when in its most violent degree, may be certainly checked and re- solved ; and all s tpp-iration avoided, so that the eye may be restored to a perfectly sound state again, provided the patient, previously to the attack, vvas quite healthy, and of course the affection of the eye a genuine idiopathic inflammation. (Beer, B. l,p. 246,247.) Respecting the prognosis and indications in the second stage of ophthalmy in general, and of idiopathic cases in particular, Beer offers many interesting remarks. He observes, that when ophthalmy has reached its second sta?e, which may be known by circum- stances already referred to in the preceding columns, it must be clear, that the above indications are no longer valid, and the ful- filment of them would destroy the eye. In Ihe second stage, every thing which has a tendency to produce further weakness of the eye must be avoided, or suppuration will be the consequence: the first indication, therefore, specified by Beer, is t ■ Id the eye be cautiously exposed according as its tendency will allow, to its wonted stimuli again. 1. By letting fresh, dry, and, if possible, a warmish air, have free access to the organ. 2. By exposing the. eye lo as much light (not of a reflected description) as can be borne, not only without difficulty, but with pleasure, 3. By moderately exercising the organ, especially in the inspection of agreeable diversified objects ; a plan, which is of infi- nite service, when the eyeball itself bas Leen affected. The second indication, proposed by Beer in the second stage of oihthdmy in general, is to apply tonic remedies, particularly those of a volatile kind, to Ihe eye, which are to be dis- continued in the evcnl of suppuration. 1. B -*r prVises the application of well-warmed l.ue-i compresses, which, if necessary, may be sprinked with camphor; or, in urgent cases, he us-s little bags of aromatic herbs a.ni camphor ; a practice, in which I am disposed to think surgeons here will have little or no confidence 2. However, when the eye is too irritable to bear the applica- t. m of bags of aromatic substances, Bi-er s inns the employment of poultices m de of j.-?ad crum and war n herbs, or the pulp of i run. ! a;c»le. But. this experienced auth »r i- ver particular i-i qualifying his a>>p"obati)i .;. mist applications with a e» >;, t,mt t|j.-, st never be allowed to uej ne completely , 'I on the eye, where- by they .vould do more ,.:.-m in a quarter of a i hour, man any good, ,. lich may have be'in attained in many hours by their pre- vi'us.'-v. Hence, Boer employ-' pou''ices only iu cases of necessity. In thw counti;, " when the extreme vascular congestion and excessive sensibility are reduced, and the inflammation tends to become chronic, the use of cold lotions, of a slightly tonic quality, is substituted with great advantage for ablu- tions of warm water. The sulphates of alum and zinc are the best." (Travers, Sy- nopsis, fyc. p. 25-2.) The employment of astringents also agrees with the advice delivered by Richter and Scarpa. Here then we find a point on which Beer differs from the generality of writers ; but, nothing is clearer to me, than that his alarm about the ill effect of cold upon the eye in the second stage of ophthalmy is only the fruit of some theories, which he entertains, and not of impartial experience. 3. When there are small ulcers, or pustules, on the eyeball itself, Beer assures us, that great benefit is derived from dropping between it and the eyelids a tepid solution of the lapis divinus, the composition of which is elsewhere des- cribed (see Lachrymal Organs,) and bathing the eye with the same application, to which a little of the vinous tincture of opium is added. Should this remedy fail in checking the progress of the ulcers, or pustules, Beer recommends the addition of acetate of lead. 4. And, says the same author, when no deci- ded amendment is produced, within twenty- four hours, the suppurating points must be touched once or twice a day, according (o the urgency of the danger, with a camel-bair pencil, dipped either in a watery solution of opium, or the vinous tincture of opium. In the worst cases, he even directs Hoffman's balsam, vitae, naphtha, or the Peruvian balsam to be mixed with the vinous tincture of opium. Bui, Beer observes, that when these reme- dies have been too precipitately employed, and any granulations, or excrescences form, the treatment must be less active, and then these new productions will frequently recede of themselves ; but, if they should not do so, they may be removed with burnt alum, or caustic. (B. I, p. 252.) The third rule, laid down by Beer, in the treatment of the second stage of ophthalmy, cautions the practitioner not to apply the caustic or the knife, to any of the morbid changes, which either originate during the first stage, and continue in the second, or make their first appearance at the period of suppuration, as, for instance, opacities of the cornea, eversion of one or both eyelids, kc. However, as exceptions to this advice, Beer adverts to the treatment of new-growths under the circumstances above specified, and to that of abscesses ofthe eyeball, where the matter is of an unhealthy quality, and so copious as to make an opening adviseable, which practice, h iwever, as a general one, he condemns. Tlie other morbid changes, already alluded to, the practitioner must endeavour to remove simply by proper treat- ment of the second stage. (Beer, B. 1, P- 254.) Beer's fourth rule in the treatment of ^' second stage of ophthalmy in general, f ".'i '*' OPH'iHALMY. -JOD luiopathic ophthalmy in particular, when the suppurative process is extending itself, and threatening to impair the health, is, 1st. To allow the pal ient 3uch food as is both easy of digestion, and of a very nutritious quality, and even a moderate quantity of wine and spirituous drinks, if he his been accustomed to them. 2dly. To direct the patient to keep his eye exposed the greater part of the day, in a fresh, dry, and (if possible) mild air, and take just exercise enough in various ways to produce a slight degree of fatigue. 3dly. When the eye itself is affected with suppura- tion, and the sight is either thereby much impaired, or quite lost, and, of course, the patient very unhappy and depressed, Beer considers it highly beneficial to let his spirits be improved by society. The fifth rule, or. general indication in the second stage, laid down by Beer, refers to the necessity of supporting the constitution, when the suppurative process is attended with a general febrile disturbance. For this purpose, he recommends, 1st. The exhibition of calamus aromaticus, naphtha, and cam phor. 2dly. If they prove ineffectual alone, they are to be joined with other tonics, espe- cially bark. 3dly. The warm bath, which, in consequence of the sympathy between the skin and eyes, is particularly efficacious. 4thly. Rubefacients, applied not far from the eye ; means, which are exceedingly bene- ficial iu the second stage of ophthalmy. (B. I, p. 257.) As an appendix to these general remarks, delivered by Beer, on the general treatment of ophthalmy in its first and second stages, I annex the sentiments of some other writers, as either confirming, or rendering question- able, some of his statements. According to Scarpa, when bleeding and other evacuations have been practised, the next most useful measure is the application of a blister to the nape ofthe neck. He ob- serves, that the skin here and behind the ears, has a stronger sympathy with the eyes, than any other part of the integuments. On the other hand, the late Mr. Ware pre- ferred blistering the temples, and says, " When the leeches have fallen off, and the consequent hemorrhage has ceased, I would advise a blister of the size of half a crown to be applied on the temples, directly over the orifices made by the leeches, and I have found, that the sooner the blister has followed tht bleeding, the more efficacious both have proved." He adds, that when ophthalmy is very violent, and resists common methods, the most beneficial effects are sometimes produced by the application of a blister large enough to cover the whole head. (P. 43,44.) With respect to blisters, another modern writer particularly objects to their being applied near the eye, or on the temples, •*« vyhere they never fail to prove injurious." There is (says he)" but one exception to this, as a general rule; for, it would seem, that blisters applied to the external surface of the palpebral, in cases of purulent ophtbal- min.tenr*-? considerably to dimini-b the nnru-. lency and chenioaia." (Vetch on Diseases of the Eye,p. 17.) In the second stage of acute ophthalmy, the vinous tincture of opium (the tinctura thebaica) has been very extensively used, as a topical application. In common cases, two or three drop- may be insinuated be- tween the eyelids and globe ofthe eye, twice a day ; but, in other instances, attended with more sensibility, once at first will be suffi- cient. The late Mr. Ware, who brought thus application into great repute, found, that in- troducing two, or three drops, of this medi- cine at. the inner canthus, and letting them glide gradually over the eye, by gently drawing down the lower eyelid, proved equally beneficial, and less painful than letting them fall directly upon the eyeball. Immediately the application is made, it usu- ally creates a copious flow of tears, a smart- ingj and a sense of heat in the eyes ; which inconveniences, however, soon cease, and the eyes become clearer, and feel decidedly improved. But, notwithstanding every ex- aggeration, unbiassed surgeons are now fully convinced, that the vinous tincture of opium is a proper application only when the in- flammatory action has been previously di- minished by bloodletting, aperient medi- cines, and blisters, and when the action of the vessels has been weakened by the con- tinuance of the disease. Nor is any doubt entertained, that the late Mr. Ware went much too far, when he recommended the vinous tincture of opium, as a most effectual application in every species and stage of the disorder, from the most mild and recent to the most obstinate and inveterate. (P. 51. Scarpa has seen the necessity of limiting the use of the remedy in question, and has expressly pointed out, that it is useful only when the violence of the pain, and the aversion to light, have abated. Indeed, Mr. Ware himself, a little before sanctioning its employment in all cases, has acknowledged, that, in certain instances, in which the com- plaint is generally recent, the eyes appear shining and glossy, and feel exquisite pain on exposure to the light, no relief at all was obtained. (P. 48, 49.) Mr. Travers has re- marked, that " there are inflammations, which assume a chronic character in their commencement, evidently depending on a state of atony, of vek-y partial extent, void of pain, and scarcely possessing any sign of inflammation, except the congestion of the vessels, or, if any, so feebly marked, as to encourage us to disregard them in the treat- ment. In such cases, a single stimulus will often restore the healthy action at once. The vinous tincture of opium has acquired a nostrum-like importance from its restora- tive operation in such casas ; a virtue, I be- lieve, not proper to it. A drop or two of the zinc, or the lunar caustic solution, or water impregnated with calomel, or a minute portion of the citrine ointment, or any other stimulant, would do as much." (Synopsis. fyc. p. 252.) Whenever the patient can easily bear a moderate degree of light, Scarpa directs all .iig or Hi] coverings to be removed irom the eyes, ex- cept a shade of green, or black silk. A brighter light should be gradually admitted into the chamber every day, so that the eyes may become habituated, as soon as possible, to the open daylight; for, as Scarpa truly states, nothing has a greater tendency to pro- long and increase tht* morbid irritability of the eyes than keeping them unnecessarily long in a dark situation, or covered with compresses and bandages. Dr. Vetch has such a di-like (o the plan of covering the eye, that he never suffers a shade to be worn, conceiving that, in con- junctival inflammation, it always does a great deal of harm by preventing a free exposure ofthe eye ton temperate atmosphere. (On Diseases of the Eye,p 17.) Besides the common remedies for inflam- mation, there are some very powerful mean*, which may be employed for (he re- lief of particular s(a(e- of ophthalmy with great effect. Thu<, as (he litter aulhor bas observed, by means of hv-osoinmtis, bella- donna, and stramonium, (See Belladonna) the important si rue ure of the iris may in- secured from injury, al (he same time that Other measures are adopled for checking (he inflammation. Such medicines may even be applied, as a mechanical force, for de- taching any recent adhesion. (Op. cit.p. 18.) The uses of the argentum nitratum are also very extensive: "the slighest applica- tion of it in substance (says D . Vetch) can often remove the highest degn-e of morbid sensibility to light, and instantaneously re- store quietude to the organ; il cm prevent incipient changes, and obviate advanced ones; and may also be used in solution, as a valuable sedative." The mention of so stimulating and active a substance as Ihe nitrate of silver having a sedative effect may excite surprise ; but the fact is unquestionable, and well illustrated iu ihe treatment of several diseases. (See Cornea and Iris.) As another modern writer correctly slates, it is remarkable thai even the weaker form- of medicated lotions irri- tatp, and one m »r»* than -u.-h as contain opium. The rebel, afforded by anodyne fomentations in gene al,is very v-n-ium. " I have known ibe n (-ays Mr. l'raver-) ob- jected »0 is painfm, a d patient inquire if they migiii not sub-.liiu;e warm water lor the aqueous solution of opium md >nf isnms of poppy and hemlock. Tne- -am- ob-c-va- tion app'ies especially io painful Herpetic' cutaneous affections, and a. utely irritable ulcers. Upon these a solution of opium often acts as :i stimulant, and augments pain, while the lunar caustic solution a- often as- suages it." At Ihe same time, Mr. Travers admits, thai exceptions occur, aud that he has met with case-. '•'• in which no other ap- plication than the aqueous solution of opium could be borne." He has also known the vapour of laudanum afford the most marked relief to the irritability to light accompany ing strumous ophlhal ny. (Synopsis of the Diseases of the Eye, p. 251.) According *■■> Dr. Vetch, it is impossible, in cases of conjunctiva! opht.iaimia, to pus sess an application of greater efficacy, than the undiluted liquor plumbi suhacetati-, for altering the morbid and purulent slate of thai membrane; he al-o describes uico- liana externally employed as a narcotic and astringent, as being of singular service in lessening the pam, and tumelartion. (P. 19.) However, the discordance among the best writer-, about the ■ ffects of favourite local applications, would lead me to enjoin rather attention (o the leading principles of the treatment, than confidence in ihe superior efficacy of any particular drug or composi- tion. As also the local applications should vary in the different stages of purulent opblh-lmy, no single one will always be right. 11 Beer had d liver' d no observa- tions of greater importance, than his con- demnaion of Baes's camphorated lotion, and ins praise ot other stvplic s|j-nul»ting applications, his nm irks would be of little value ; but, as he has pointed >>ui tne differ enl siages of purulent ophthalmia iu u very orrect manner, and adapted his rein-i! e» io these various tales •>( the disease, hi. mlor- m it ion comprehends scientific principles, and becomes peculiarly interesting. The same praise belongs also lo Dr. Vetch'* ob- servations on purileni ophthilmy, who in some points, bo h of the description of the complaint and its treatment, has surpass- ed Beer. Of the different Kinds of Ophthalmy. Beer'» classifican >n is very comp - en-ive. According to tht situations, in which oph- thalmic inflammation first originates, he pro- poses a general division of it into three forms, as sug ested by some of the older writers; viz inflammation of Ihe eyelids, or blepha- rophlhalmitis; inflammation of the parts between the orbit and globe of the eye; and, lastly, inflammation of the eyeball itself, or ophthalmitis. He observes, however, that these distinctions seem (o assign a considera- ble extent to ihe original seat ofthe aff ctiou; for. (he expression, inflammation of the eye- lids, can only denote a case, in which (be disorder begins a( once in all the parts emm- posing (he eyelids. In ihe same way, nflam- mation of the parts between the eyeball and orbit appears (o signifv, that all I hose parts consliu e the original sphere of th* com- plaint ; while inflammation ofthe eyeball seems to denote that the disorder has begun at once in all the textures, of which ibis organ is composed. But, foriun-io-ly, as Beer remarks, the rxleut of (he original seat of genuine idiopathic inflammation of tbe eye is but seldom thus considerabb ; beiag mostly restricied to particular lextures.from which it first spreads further only when neglected, or injudiciously treated. Hence, certain subdivisions of the complaint are necessary; and. accordingly, B*er subdivides inflammation ofthe eyelids, first, into the erysipelatous, or blepharophthalm'dis erysipe- latosa, which commenc- ? in the integuments ol these parts. Secondly, into that, which originates at the edges ol the palpebrae, in the conjunctiva lining these parts, and the uruiHALMi. 311 Meibomian glands, and which Beer denomi- nates glandular inflammation of the eyelids or blephnruphthalmitis glandulosa ; a case, described by writers under an infinite num- ber of names, and often confounded with complaints of a lola'ly dilferent nature. Thirdly, when Ihe effects ol the inflamma- tion are confined to a small portion of the eyelid ii con-tiiuie- (he disease, termed tbe inflammatory stye, or hordeolum, whit h Beer sav - is iai •- y a simple inflammation, but complicated with a Mrrofulou** hxbit ; a pro- position, which,I think, will not receive any credit in England. Fourthly, as (here is one raoie form of inflammation of the eyelids. Bei/i ive-s it I tie name of Ibe erysipelatous swelling of the cornea of the eye, or anchy- lops erysipelatosa, which affects Ihe skin of the inner canthus, immediately over the lachrymal sac. The name, h«*re suggested. expresses precisely the seal of the inflamma- tion, and, as Beer thinks, will tend lo prevent the case from being mistaken for inflamma- tion of Ihe lachrymal sac. Inflammation of the parts in the orbit comprehends, first, in- flammation ofthe lachrymal gland; secondly, inflammation of the lachrymal sac, a disorder, which begins in the lachrymal sac and nasal duct, and generally extends with great ra- pidity over all the excreting parts ol the la- chrymal organs ; and, thirdly, inflammation of the caruncula lachrymalis, or the encanthii inflammatoria. In Ihe same way, inflammations of the eyeball admit of a classification, which is of ihe highe-t practical importance, first, into the erysipelatous inflammation of the sclerotic conjunctiva, the ophthalmitis erysipelatosa, which denotes (hat form of the disorder, which is first entirely confined io the mem- brane connecting together the eyelids and eyeball. Secondly, into inflammation of the outer textures of the eyeball, (he ophthalmitis externa, originating in Ihe cornea.and sclero- tica. Thirdly, into inflammation of the in- nermost textures of the. eyeball, the ophthal- mitis interna, which has two forms highly necessary to be recollected in practice ; for (he inflammation may begin immediately in Ihe retina choroides, (be membrane of vi- treous humour, be. and spread from these textures lo all the rest of the eyeball, being n nned true internal inflammation of the eye- ball, or ophthalmitis interna vera, and thus discriminated from another case, which is originally sealed in the iris, the adjoining corpus ciliare, the lens, and its capsule, and afterward extends from these parts lo the more deeply situated coa(s, and lo (he texture of (he vitreous h iniour. This last form of internal infla million ofthe eyehall is named both by Schmidt and Beer, iritis. The clas- sification then embraces a view of the dif- ferent forms of ophthalmy, as modified by constitutional causes . as the effect of con- tagious aud infectious diseases, measles, small-pox, be; and as a complication of certain cachexia;, like goul, rheumatism, and scurvy. Although 1 have thus given a brief deline- ation «f Beer'-, classification of ophthalmic inflammation;, it is not ray design in the sub- sequent columns, to enter into a full consi- deration of every particular case, above enumerated ; first, because the limits of Ibis work will nol permit me to do so; and se- condly, because some of these enses have been already considered in olher parts of the work. (?ee Lachrymal Organs.) Common Inflammation of the Eyelids. This form of disease is said by Beer lo affect Ihe upper niuchjnore frequently, (nan Ihe lower eyelid, because Ihe former obviously has a larger surface exposed to injuries from without; i.or does (he complaint always spread to the latter. From the margin of Ihe eyelid, a very red, tense, painful swelling arises, attended with heal, throbbing, and a great deal of tenderness, when touched. It gradually extends over the whole eyelid : ,but seems lo be plainly bounded by ihe edge of the orbit. The motion of the eyelw.' is always more or less obstructed, and, at length, when the inflammation has reached its greatest degree, it is completely prevent- ed. Nor is there any difficulty in compre- hending why, when the inflammation has become severe, Ihe eye should be excessively- dry, and every aftempt on the part of the patient to move the eyelid should be produc- tive of considerable pain, and of a sensation, as if some sharp extraneous substances lay under the lid ; for at (his period, the palpe- bral conjunctiva is already severely inflamed, and, consequently, the secretion of mucus from the Meibomian glands is immediately stopped by (he inflammation itself, while that of (lie (ears is interrupted partly by the ex- tension of the inflammation to the sclerotic conjunctiva, and partly by the effect of the sympathetic connexion existing between the conjunctiva of the eyelid, and that of (be eyeball. To (his last cause, viz. sympathy, Beer refers the supervening dryness and shri- velling up of (he lachrymal papilla*, as well as the apparent closure ofthe puncla lachry- malia, and the uneasy dry slate of the edges of the eyelids. Hence, also, the dry- ness of the adjacent nostril, and a very disa- greeable smell of dust obliging the patient to sneeze repeatedly, which act is constantly attended with a great increase of pain in the swelling, a transient shooting of it lo Ihe eye and head, a.id a sensation as if flashes of light were elicited within the eyeball; a kiud of hallucination, technically named photopsia. As the original seat of the in- flammation is already extensive, one may readily understand, says Beer, why the affec- tion in its first stage, particularly when neglec led,or badly treated, should frequently give rise to some febrile disturbance of the system. In the second stage of the case, or that of suppuration, which follows when the inflam- mation is violent and nol soon dispersed, malter forms wilh the annexed train of symptoms. Tbe redness suddenly increases very much, the eyelid becoming of a brown- ish red, and lastly of a purplish red colour. The stvelling becomes more prominent, and present" a conical eminence, either in the 3L2 OPHTHALMY. middle of the eyelid, or close to the outer or inner canthus. The pain is irregular, and of a stinging, burning kind, a throbbing being felt only in tbe deeper part of Ihe tumour. At length, the swelling becomes somewhat softer, and less sensible at its most projecting point. The secretion from Ihe Meibomian and lachrymal glands, which in the first stage of tbe disorder was suppressed, is now quite re-established, but more copiously, than in the healthy state. During sleep, a quantity of mucus accumulates be"ween Ihe edges of the eyes, and glues them together. An ex- traordinary sensation of cold and heaviness is felt all about the eye. Ultimately the most prominent point ot the swelling presents a pale red colour, followed by a yellowish livid tinge. As the abscess is now com- pletely formed, the fluctuation of ihe matter can be plainly felt. (Beer, B. \,p. 269, fyc.) According lo the same author, nothing very particular is known respecting the causes of the preceding form of ophthalmic inflammation, and, with tbe exception of blows, he has not been able to discover the precise circumstances which give rise to it. With regard to the prognosis, if the treat- ment be neglected, or injudicious, the in- flammation may suddenly become so violent, as to produce in weak subjects gangrenous mischief. BuJ, when the case is properly managed in its first stage, the second, or that of suppuration, never ensues; yet, says Beer,the curative measures must be decisive, and valuable lime nol wasted on (rifling means, although due regard must be paid to the constitution. When the inflammation subsides favourably, it le ives no vestiges of it behind, and even the red ess, which is the latest in disappearing, completely goes off in a few days, and the function of the eyelid becomes perfeci again. If gangrene and sloughing take place, the outer coverings of tbe eyelid are destroyed, and the consequences are an incurable eversion of the pari. (See Ectropium) or a hare-eye, (see Lagophthalmus.) . When suppuration happens favourably, the abscess sometimes breaks very well of itself on the upper eyelid; but, according to Beer, this does nol readily occur on Ihe lower one, nor without the formation of sinuses, which sometimes run quite into the orbit. After the abscess has burst, or been opened, the part heals up with great celerity in favour- able constitutions, but slowly in others ; vermilion granulations arise from the bot- tom of the cavity, and a cicatrix follows which is scarcely perceptible. When the abscess is very large, however, and bursts of itself, the upper eyelid continues for some time very much weakened. If the collec- tion of matter be neglected, or wrongly treated,or the subject be. unhealthy,or the disease be aggravated by tbe effects of a damp atmosphere, hurtful food, severe mental trounle, wet poultices, or (oo long confinement of (he malter, Ihen, says Beer, fistula? are apt to be produced, sometimes complicated with necrosis of the bone, the certain effects of which are some perma- nent and mostly incurable disease of the eyelid, and impairment of its functions : 1st. A closure of the lachrymal canals, with a permanent slillicidiurn. 2. A complete obliteration of the same lube-, wilh an in- curable stillicidium- 3. A prolapsus of the upper eyelid, from detention of the skin by the long confinement of the mailer. 4. Inversion of ihe edge of (he eyelid. Irom a shrinking of its curtilage. 5. Eversion of the eyelid, and bare-eye, from loss of -kin. (Beer.) A-, in this species *of inflammation, says the same author, (he organ of sight cannot well be affected, unless (he disorder after- ward extend itself very much, the exclusion of air and light is here but of little use. Linen compresses, well wei with very cold water, or vinegar and water, are to be ap- plied ; and, while the complaint is local, leeches are to be used ; but, if (he constitu- tion be threatened with febrile symptoms, then Beer urges the neces.siu of venesec- (ion, low diet, purgatives, and general antiphlogistic, measures. (JS. \,p. 275.) In the second siage, with the exception of a few points, Beer states, ihal the case is In be treated like any other common abscess, When the matter is situated in tbe middle of the upper eyelid, not far beneath Ihe skin, the abscess may be allowed lo hurst of ilself, especially, if the patient have a great dread of Ihe knife. But, if ihe matter lie near the outer, or inner canthus, it should be let out w ith a lancet as soon as its fluctua- tion is quite distinct, the incision beinq made in die diiei lion ol the fibres of the orbicular muscle. When fistulae, or gan- grene, have already taken place, the treat- ment stiould be like that, which is applicable to the s me kind of mischief in moit other parts ol ihe skin. Erysipelatous Inflammation of the Eyelids usually affects both these parts together, very seldom only tbe upper one, and never the lower alone. When also both are affected, the disorder always presents itself in (he greatest degree in the upper eyelid. A pale,yellowish red,seemingly transparent, shining swelling arises from the edies of the eyelids, and rapidly <*xtends ilself, without any determinate boundary, the faint red colour being gradually lost upon the eyebrow above, and nol unfrequently upon the cheek below. When the infl.med part is gently touched, the redness disappears, but cnly for a moment. Al length, tbe swelling towards (he margins of the eyelids becomes exceed- ingly soft, and feels "like a vesicle that has been raised by a blistering plaster. The pain is inconsiderable, not attended with throbbing,but raiher with a sense of heal and stiffness; w hen the part is slightly touched, (he patient experiences a lancinating sensation in it. lis temperature is not much increased* The secretions from the Meibomian glai.ds, lachrymal gland, and mucous membrane of the nostrils, are much augmented.— In a strong subject, the disorder, il genuine and idiopathic, is not productive ol any constitutional dicturbarme ; but. in bail OPHTHALMY. 313 iiaoils, and weak females and children, it is sometimes attended with fever. However, when the complaint partakes of the phleg- monous character, and is badly treated, the general symptoms are occasionally very se- vere at the change from the first to the second stage, and the case may then termi- nate in a gangrenous kind of suppuration. In irritable, delicate children, says Beer, when the disease spreads over ihe face, tbe case requires (he most skilful treatment for (he prevention of a disastrous- termination. In strong persons, the second stage of this disorder rarely ends iu a manifest suppura- tion : but there is rather an exudation of lymph, which becoming dry, forms very small, delicate, branny scales, in the com- position of which (he desquamated cuticle has also a considerable share. In other instances, vesications of various sizes are formed on the erysipelatous surface, and burst, and discharge a fluid, which is con- verted into yellowish scabs. According lo Beer, the skin of the eye- lids is particularly prone lo erysipelatous in- flammation, which is therefore more easily in- duced in il, than iu the integuments of other parts. Beer considers the sudden effect of a cold blast of air, or of very cold water, upon the skin of the eyelid, while in a state of free perspiration, as the most common cause of its being attacked with erysipelas, parti- cularly in weak subjects. He states, how- ever, that the complaint may be occasioned by the slings of bees, wasps, am! olher insects; accidents, wliich when the stings are not extracted, are liable* lobe followed by a violent and dangerous general inflam- mation of (he eyelid, not unfrequently extending in a perilous degree to the eyeball itself. (B. l,p.2Sl.) Wilh regard to the prognosis, no other case of ophthalmic inflammation so fre- quently subsides without the aid of surgery as this, provided the constitution be heallby and strong; and, when (he complain! is resolved in ils first stage, the vestiges of it afterward are as little as those consequent to common inflammation of the eyelids. The second stage, however well treated, is followed for a long time by a peculiar sen- sibility of the skin to (he impression of cold damp air, and a strong propensity to relapses. If, when the cuticle peels off, a patient of weak constitution sit in a current of damp cold air, or try to wash away the scales and scabs wilh cold water, Beer states, (hat an ottdemntous affeclion of ihe eyelid will be produced, which is often very obstinate, and apt to occasion a temporary inversion of the cilia; (Trichiasis,) or a similar stale of the edge of Ihe eyelid (Entropium.) And, he ohserves, (hat when from neglect, or bad treatment, an erysipelatous inflamma- tion of th<* eyelid terminates in suppuration, the abscess is not like a common one, but the mailer rapidly makes its way out through several openings in (he already partially disorganized skin, and, in general, (his state is followed by ill-conditioned tedious ulce- rations, whcreliy n rood deal of skin is V'u. H. !t. always destroyed. Under these circum- stances, all those consequences may be produced, which have been described as liable to take place from the second, or suppurative stage, of common inflammation of the eyelid. Gangrene and sloughing may even occur, when erysipelas of the eyelids is brought on by the unremoved sting of an insect, and efficient treatment is delayed. The treatment, recommended by Beer in the first stage, consists iu the application of cold water, and he remarks, that exposure of the part for a time lo a cool, moist, but, in other respects, pure atmosphere, will often suffice for the removal of the complaint. When, however, the disorder increases, and assumes a phlegmonous character, ihe direc- tions given for the treatment of blepharoph- thalmitis, are (o be followed. In the second stage of erysipelas of. the eyelids, Beer praises the good effects of a mild, dry air, of an equal temperature, and recommends covering the parts with a light bandage, under which are to be put well warmed linen compresses, which, for weak persons, should be sprinkled with camphor; or he directs the eyelids to be covered wilh bags of aromatic herbs; generally a very favourite plan with Beer, whenever he ob- jects to moist applications. In such indivi- duals, he observes, that the cure is promoted by keeping up the function of the skin with gentle diaphoretic medicines, with which, when the debility is very great, camphor should be joined. Should an abscess form, the same treatment is proper as in the se- cond stage of common inflammation ofthe eyelids, or (what Beer calls) blepharophthal- mitis. Glandular Inflammation of the Eyelids, or the Blepharophthalmilis Glandulosa, as Beer terms it. is considered by this author as the disease, of which all the various cases of pu- rulent ophthalmy are only modifications, which he describes under the names of idio- pathic catarrhal ophthalmy ; idiopathic catar- rhal-rheumatic ophthalmy; and blepharo-blen- norrhcea, or ophthalmo-blennorheea. The two latter terms comprehend the purulent oph- thalmy of infants, the Egyptian ophthalmy, the gonorrhoea! ophthalmy, &,c. Glandular Inflammation of the Eyelids, Beer knew very well was so far a defective term, that it seemed to imply merely an af- fection ofthe Meibomian and mucous glands of those parts, whereas he means to express by this name the kind of inflammation, of which all the cases, usually called in this country purulent ophthalmies, are varieties and modifications, and in which the con- junctiva is also particularly affected. Acute suppurative inflammation ofthe con- juncliva, divisible into the mild and severe forms, as proposed by Mr. Travers, appears, perhaps, a better name (Synopsis, fyc. p. 96, be.) Dr. Vetch, who also prefers the gene- ral term conjunctival inflammation, observes, that from many internal and external causes, the membrane of the conjunctiva is liable to become the seat of inflammation, more especially lo orimiALMV or what C-cr terms a complete blcpharoph- thai nut 11; which he says, only happens in weak subjects, and women and children, wlio^e skin is in a very irritable stale, or when a person of apparently good consti- tution remains under the influence of cir- cumstances wliich tend to augment the in- flammation, as for instance, exposed to the air of a stable, privy, ike. in which event, Beer describes the inflammation of tbe eye- lids as being quite of a peculiar description. As for the prognosis in the second stage, Beer observes, that, if the excoriations at the suppurative period should spreud all over the edges of the eyelids, and compel the patient to keep his eye incessantly shut, a partial adhetion of the eyelids to each other (anchyloblepharon) may be the result. Also, when at either of the periods of the secretion of mucus, or at that of suppura tion, the patient is content with merely sof- tening with warm water the thick matter glueing the eyelids together, so as just to be abie (o open his eye ; and does niyt com- pletely free the eyelashes from the crusts, clusters of the hairs will project inwards, (see Trichiasis) whereby a secondary in- flammation of the conjunctiva of the eye- ball will be excifed, which, Beer says, should be carefully discriminated from a mere extension of the glandular inflamma- tion of the eyelid. Such a trichiasis, be observes, may easily become incurable, when the edge of the eyelid is seriously in- jured by the depth of the excoriations. But, if the suppurative process be restricted chiefly to the canthus, especially the outer one- (which ca3e, according to Beer, is not itiifrequeut in old, defoliated subjects, of a relaxed constitution) and if the excoriations should deeply penetrate tbe commissure of the eyelids this may be completely destroy- ed, and the lower eyelid everted. As the state of the atmosphere, unclean- liness, crowded and close places, &.c. are considered by Beer to be the principal causes of the glandular inflammation of the eye- lids, or simple purulent ophthalmy, one of the most important indications, in the first stage of the disorder, seems to him to be tbe removal of these hurtful circumstances. And, he declares, that, if immediate atten- tion be not paid to such indication, it will be cjuite impossible to prevent a dangerous increase of the disorder. A cool fresh air, and bathing the eye with cold water, or a weak lotion of vinegar and water, Beer represents to be means, usually adequate to stifle this inflammation in its birth. In the second stage, he says, the indication is entirely different. But, also in the beginning of this stage, and even at its second period, namely that of suppuration taking place, the disorder, according to Beer, seems for a short time to be benefited by the employment of cold water, but the consequences are rendered by such treatment a great deal worse ; for a fresh, much more extensive inflammation of the same kind again takes place. At "the first period of the second stage, viz. while the secretion is a pure mucous aud sebaceous malter, Beer says, that it is abso- lutely necessary to employ such external means, as are calculated to promote the ac- tion of the veins and absorbents. For (his purpose, he recommends the following col lyrium : fy. Aq. rosae |iv. Hydrarg. oxymur. gr.j.vel.gr. diinidium.Mucil.sem cydon. 2j. Tinct opii vinos. Qj. Misce. This eyewater is to be used lukewarm from four to six times a day, and the eye afterward care- fully and completely dried. No eye, in this state, he says, will bear more than the pro- portion of one gr. of the oxymuriate of quicksilver, and only seldom more than half a grain. But, as soon as the suppurative period commences, attended with excoriations, gentle astringents, like the liquor plumbi subacetatis, in a solution of ihe lapis divinus (See Lachrymal Organs) should be added to the above lotion, for which they may at length be entirely substituted. And, when the suppurative period has terminated, but a morbid secretion of mucus yet obstinately continues, and threatens to become habitual, recourse should be had, without the least de- lay, to one ef the following eyesalves, a bit of which, about the size of a small pea, Beer directs to be smeared once a day over the edges of the eyelids, f-^. Butyr. rccen- tis insulsi "^ss. Hydrargyri nitrico-oxydi gr. x. Tutia* ptt. gr. vj Misce. This oint- ment, he says, will sometimes answer; but, that it is mostly necessary to use Janin's salve, composed as follows: JV Butyri re- centis insulsi §ss. Hydrargyri prajcipitali albi. gr. xv. «Boli albi 3j. Misce. According to Mr. Travers, the mild acute suppurative inflammation of the conjunctiva is not attended with that excessive swell- ing of the eyelids, that intense pain, nor that profuse secretion, with which the vehe- ment acute form of the disease is character- ized. In the treatment, he directs a solution of alum to be early substituted for emollient fomentations, which he recommends to he freely used during the acute period. Simple purging and abstinence, he says, are gene- rally sufficient to allay the febrile irritation, which is moderate, topical bleedings, and blisters, kept open on the back of tbe neck, are also stated to be of great efficacy " When the pain and irritability to light subside, and the discharge becomes gleety, the conjunctiva pale and flaccid, tonics, es- pecially the extract of bark and the acids, do great good." (Synopsis, fyc. p. 264.) Catarrhal ophthalmy, so called by Beer, is described by him as a species of glandular inflammation of the eyelids, attended with a simultaneous affection of the mucous mem- brane of the nose, trachea, be. brought on by particular states of the weather, and at- tacking so many persons at once, as to ap- pear epidemic. 1 he prognosis and indica- tions are the same as those in common glan dular inflammation of the eyelids, with lb'» exception, that attention must be paid to the affection of other organs, and both at the fii-t and second periods of the 'erond vrni'HALSdV. 31V stage, such remedies -,iven as operate power- fully on Ihe mucous membranes and skin, and, in general, during the second stage, an equal warm temperature, and gentle diapho- retics, with camphor, are highly beneficial. Severe Purulent Ophthalmy.—The Blepha- ro-blenorrhcea, and Ophlhalmo-blenorrheta, of Schmidt and Beer; including (he ophthalmia neonatorum; the Egyptian ophthalmy ; the gonorrheal ophthalmy, fyc, on w hich varie- ties, however, I shall annex to this account some further particulars, as they relate to each of these cases individually, because, though the following history contains an ex- cellent general description of the severe forms of suppurative inflammation of the conjunctiva, it leaves unexplained some of the circumstances on which its varieties de- pend. The vehement acute suppurative inflam- mation of the conjunctiva is described by Mr. Travers as being sudden in its attack ; a feature, in which it particularly differs from the milder cases usually met with in schools. (See Lloyd on Scroj'ula, p. 321.) It is accom- panied with most severe darting pains ; and the upper eyelid is sometimes in a few hours prolonged upon the cheek, owing to the in- filtration and enormous swellingof the tissue, connecting the conjunctiva to the tarsus. (Travers, Synopsis, fyc. p. 265.) According to Beer, the modification of glandular inflammation of the eyelids, here to be considered, consists entirely in (he ra- pid extension of the inflammation and sup- puration, the disorder affecting, ere it is sus- pected, nol only the whole of the conjuncti- va of the eyelid, but also that of the eye- ball, and the sclerotica and cornea. The swelling of the palpebral conjunctiva is de- scribed by Beer as being unusually great; at first, soft, somewhat elastic, smooth, and readily bleeding; but, aflerward, in (he se- cond stage, hard and granulated, or, as ano- ther writer says, it" becomes preternaturally vascular, thickened, and scabrous, or forms fleshy eminences." (Travers, Synopsis, fyc. p. 96.) The first stage is rapidly over. At the first period of the second stage, the se- cretion both of mucus and pus is surprisingly copious. First, the mucus is whitish and thin ; but, as soon as the suppurative pro- cess begins, it becomes yellowish and thick, and when an attempt is made to open the eyelids, it gushes out with such force, and in so large a quantity, as frequently to cover, in an instant, the whole cheek. Sometimes, this mixture of mucus and matter contains light-coloured streaks of blood ; but, in worse cases, these streaks are dark aud brownish, or else a thin ichor is discharged, iu which case, the progress of the disease is so rapid, that the eye can seldom be sa- ved. The swelling of the conjunctiva of the eyelids, especially of that of the upper one, always increases during the first period of suppuration, and, when Ihe discharge is more ichorous, the membrane is more gran- ulated, so that if the eyelid be opened care- lessly, or during the child's crying, fits of pain. ke. the whole t;imelif*d conjunctiva of the upper eyelid ii immediately thrown outward, in the form of ectropium, and it is sometimes difficult, und even impracticable to turn the part inward again, especially. when the conjunctiva is already changed into a hard sarcomatous substance. While the swelling at the inner surface of tbe eye- lids continues to increase, their outer sur- face, particularly that of the upper one, becomes reddened ; but the redness is dark- coloured, inclining to brown, and when the child cries, to blue. In children, the w hole cheek on the affected side is very often swelled, and sometimes the mucous mem- brane of the lachrymal sac and even of the nose, participates in the effects of the dis- order. Sometimes, at first, only one eye is affected, and the other is afterward attack- ed. And, according to Beer, just before the period of suppuration, it is by no means un: common for rather a profuse bleeding to to take place from the eye ; an event, which though it seriously alarm the parents of the child, or an adult patient, is hailed by the experienced surgeon as a favourable omen ; for, in such cases, the suppuration is generally very mild, and nol of a destruc- tive kind, and the swelling of the conjunc- tiva of the eyelids, as well as that of the sclerotic conjunctiva, if already present, soon undergoes a remarkable diminution after such hemorrhage, which often recurs two or three times. When during the first, very short and transient stage, the inflam- mation extends also to the sclerotic con- junctiva, this membrane forms a pale-red, soft, irregular swelling, all round the cor- nea, which at length seems so buried, that at the period of the mucous secretion, its centre can hardly be discerned ; and, when suppuration begins, both mucus and pus are discharged from the conjunctiva of the eyeball in profuse quanfUy, particularly ac- cumulating over the cornea, and not unfre- quently drying into a thick pellicle, when long detained in the eye. Hence, the case: looks as if the whole eyeball, or at least, all tlie cornea, were in a state of complete sup- puration. At length, the tumefied conjunc- tiva of the eyeball becomes sarcomatous, though never in such a degree as that of the eyelids. When the suppurative pcriud cea- ses, aud with it the most urgent danger to the eye, the secretion of mucus alone con- tinues, as at the first period of the second stage, the swelling of the conjunctiva of the eyelids, and of the sclerotic conjuncti- va, when this has also been affected, dimi- nishes, and the disorder ends iu an increased effusion of tears or true epiphora. When the effects of the suppuration upon tbe con- junctiva of the eyeball are more severe, the corneal production of this membrane in the most favourable cases is raised from the sub- jacent cornea, and so opaque,that the eye- sight is lost, or at all events seriously impair- ed, until the transparency returns, which is sometimes late, especially when efficient treatment is not put in practice. Should the suppuration be very deep, the cornea, which always turns whiter and whiter, pre' -318 OPHTHALMY. sent* near the edge oi' the swelling of the conjunctiva an arrangement, similar to that of tbe leaves of an old book, and at length seems converted into a mass of purulent matter, which projects more and more out of the depression in the swelled conjunc- tiva, and then bursts in its centre either quickly and with very violent pain, or slow- ly w ithout any suffering, an oval hole being left, behind which the yet transparent crys talline lens appears, included in its undama- ged capsule. At this period, adults can often see very plainly, and fancy their recovery near at hand, or, at least, all danger over. Already, however, every part of the cornea has been more or less perforated by ulcera- tion, the iris protrudes through all these apertures, so as to form what bas sometimes been named the staphyloma raceraosum. In a very short time, not exceeding a few hours, the capsule of tbe lens is affected, and bursts like the cornea, When it is dis- charged either with, or without, a portion of the vitreous humour. At length, the suppuration subsides, and with it the pro- trusions of the iris, the opening in tbe cornea becoming closed with a brown, or bluish, opaque flat cicatrix. But, if in this destruc- tive form of suppuration, nothing is done for the relief of the disease, the whole eye- ball suppurates, (heeyelids become concave instead of convex, and the fissure between them closes for ever. In adult3 of feeble constitutions, when the case is not properly treated, but particularly in weak children, this excessively violent form of conjuncti- val inflammation and suppuration spreads with such rapidity, that a considerable ge- neral disturbance of the system is occasion- ed. Indeed, according to Mr. Travers, in the common course of this vehement form of conjunctival suppurative ophthalmy, the system sympathizes ; chilliness is succeeded by a hot and dry skin ; and the pulse is frequent and hard. Yet, it is particularly pointed out by the army surgeons, that one peculiarity of the Egyptian purulent oph- thalmy is its being generally attended with little constitutional disturbance. When the above-described annihilation of the eyeball takes place, it always creates violent gene- ral indisposition in unhealthy weak chil- dren, and even leaves adults for along while afterward in an impaired state of health. According Io Beer, who appears to have no idea of infection being concerned, the particular cause of this unfortunate exten- sion of idiopathic glandular inflammation of tbe eyelids, both in infants and adults, frequently depends altogether upon the foul atmosphere, in which they are residing, and hence, says he, the disorder is, as it were, endemic in lying-in and foundling hospitals, where the air is much contaminated by ef- fluvia, from the lochia, the crowding toge- ther of many uncleanly persons, dirty clouts, be The unjustifiable folly of exposing the eyes of new-born infants to every degree of light; a tedious labour, in which the child's head is detained a long while in the vagina; and roughly washing the eyes after birth with a coarse sponge; aro other cijv cumstances, supposed by Beer to be condu- cive to tbe origin of the complaint, in new- born infants. The reality of many of these causes I regard myself with a great deal of doubt; and iisforhisconjecture.thatsprink- ling cold water on the head in baptism, while in a state of perspiration, may pro- duce the complaint, it is too absurd to need any serious refutation. The disorder, he says, is always more rapid and perilous in new-born infants than adults; (B. 1, p. 318,) a remark which does not agree with the statements usually made, if the Egyp- tian ophthalmy, as seen in the army, be comprehended. It is observed by Mi Travers, that the highly contagious nature of the suppurative ophthalmia, whether in the mild, or vehement acute form, is suffi- ciently proved. For one person, affected with this disease above three months old, he thinks at least twenty are attacked under that age. " The mother is the subject of fluur albus, or gonorrhoea, and the discharge is usually perceived about tbe third day.' (Synopsis, fyc. p. 97.) Some further obser- vations on the causes of some of these severe modifications of glandular inflammation of tbe eyelids will be introduced, after the prognosis and treatment have been consi- dered. This will be the more necessary, as the propagation of the disorder by infection is here entirely overlooked. According to Beer, whenever an idiopa- thic inflammation of the glands of the eye- lids attains the severe forms, exhibited in the purulent ophthalmy of infants, the Egyp- tian ophthalmy, and gonorrhceal ophthalmy, tbe prognosis must naturally be unfavoura- ble, and this in a greater degree, the more tbe inflammation and suppuration have ex- tended to the eyeball itself. The cases are still more unpromising, when they happen in poor, half-starved, distressed individuals, whom it is impossible completely to extri- cate from the circumstances, which either cause, or have a pernicious effect upon the disease. Should an im idental ectropiom not be immediately rectified, says Beer, it will continue until the end of tbe second stage, and even frequently longer, so as to require particular treatment. When at Ihe period of suppuration, merely the layer of the conjunctiva, spread over the cornea, is destroyed, the prognosis, in respect to the complete recovery of the eyesight, is fa- vourable, although it takes place but slow- ly. If the effects of the disease at this period should be deeper, yet the cornea not destroyed, only rendered flat and somewhat opaque ; or, if the cornea should be ulcerated only at a very lim- ited point; there will remain in the first case, an opacity of the cornea ; but, in the second, a partial adhesion of the iris to the latter membrane (synechia anterior) is apt to follow, with a more or less extensive ci- catrix on the cornea, covering in a greater or lesser degree the lessened and displaced pupil, and thus diminishing, or preventing vision. When, during the mflamraalion urtiirfALMV ©19 aud suppuration, a considerable part, or the whole of the iris adheres to the cornea, and this is not penetrated by ulceration, the re- sult, in the first case, is a partial, in the se- cond, a complete staphyloma of the cornea, which does not fully develope itself, until towards the decline of the second stage of the ophthalmo-blennorrhoea. If the inflam- mation should spread to the textures of the eyeball itself, so as to produce severe con stitutionat disturbance, the eye wastes away in the midst of the profuse discharge, the eyelids sink inwards, and the fissure between them becomes permanently closed. (Beer, B. 1, p. 319.) Beer notices the opinion ofthe celebrated Schmidt, which was, that the opthalmo- bletinorrhoea, or purulent ophthalmy involv- ing the sclerotic conjunctiva, always has a fixed duration of a mouth, in new-born in- fants, and of six, eight, or twelve weeks, in very weak individuals. Beer acknowledges the correctness of this opinion, only in cases where the surgeon has to deal with a completely formed ophthalmo-blennorrhcea, and not in a more recent case, or one in which the disease is chiefly confined to the inside of the eyelids. (Blepharo-blennor- rhaa.) When tbe disorder is met with in the first period of the second stage, or it is confined to the palpebral conjunctiva and Meibomian glands, and truly idiopathic, Beer asserts, that its course may be restrict- ed by efficient treatment to a few days, as he has often proved in the establishment for foundlings ut Vienna. It is further remarked by Betr, that, in this modification of genuine idiopathic glan- dular inflammation of tbe eyelids, the in- dications have something peculiar in them. If, by chance, the surgeon meet with the disease in its first stage, it will be most bene- fited by the application of folded linen wet with cold water; and sometimes a brisk purge of jalap and calomel, and putting a leech over the lachrymal sac at the inner canthus, will promote the subsidence of this dangerous species of ophthalmy. The case, however, rarely presents itself for me- dical treatment thus early, and, in hospitals, Beer soys, antiphlogistic treatment is, on this account, hardly ever indicated. With some exceptions of importance, the treatment, advised by Beer, for the second stage of these severer forms of purulent ophthalmy, resembles that proposed by him for the second stage of simple glandular in- flammation of the eyelids, or the milder varieties. These more severe kinds of puru- lent inflammation of the eye, implied by blepharo-bleunorrhoea and ophthalmo-blen- norrhcea, he says, should never be viewed and treated merely as local disorders; but that, both in children and adults, internal remedies should be exhibited, particularly volatile tonic medicines. In cases, where the cornea is already attacked by a destruc- tive ulcerative process, manifold experience has convinced him, that bark, combined with naphtha, and the tincture of opium, is the only mea:»s of saving the eye ; but. that if Ihe suppuration be confined to the eye- lids, the decoction of calamus aromati- cus with naphtha and opium will mostly answer. When, on tbe supervention of suppuration, the pain in the eye and neigh- bouring parts is excessively severe, Beer assures us, that friction with a liniment of opium will give great relief. In new-born infants, the maternal milk of right quality will mostly do more good, than internal medicines : but if the case be very urgent, and the child feeble, Beer thinks volatile medicines may sometimes do good. With respect to particularities made ne- cessary in the local treatment by the modified nature of the inflammation, Beer offers the following information. First, in new-born infants, or very young children, the oxymu- muriate of mercury cannot be used without danger, though blunted with mucilage; aud even in adults, it should be employed in these cases with greal circumspection. Se- condly, tbe mucus and purulent matter should not be allowed to remain long under the eyelids, as such lodgment is found to promote the destruction of the layer of the conjunctiva situated on the cornea; but, at the same time, Beer thinks, that leaving any water on the eyes, after cleaning them, and letting it become cold there, will have quite as pernicious an effect. Hence, he is very particular in directing all the mucus and, purulent matter to be wiped away from the eye with a bit of fine sponge moistened with a warm mucilaginous collyrium; but not so wet as to let the fluid drop out of it; or when they are very copious, and in large flakes, he even recommends them to be washed away by means of Anel's syringe ; but, he says, that every part about the eye should be immediately afterward well dried with a warm napkin, and then covered with a warm camphorated compress. Thirdly, during the suppurative period, according to Beer, com- mon tincture of opium, or the vinous tincture is the best local application, the parts being smeared witb it twice a day, by means of a fine camel-hair brush. It is only in a few instances, that a small proportion of the lapsis divinus (see Lachrymal Organs,) mixed with the mucilaginous coilyrium, can be endured. Beer declares, that he has never seen any good produced by Bates's campho- rated lotion, which was so highly praised by the late Mr. Ware. Fourthly, when the suppurative period has terminated, the mu- cous secretion again becomes white and thin, as at the very commencement of the second stage, but it is always more copious ; now is the time, (as in the last stage of simple glandular inflammation ofthe eyelids) when the topical use of mercury, joined with styptics, especially iu the form of an eye- salve, is indicated. Fifthly, if an eversion of the upper eyelid should happen from washing the eye carelessly, or the mere crying of the infant, iu consequence of the thickened granulated state of the palpebral conjunctiva, the position ofthe eyelid must if possible, be immediately rectified; for afterward, this- cannot be done. In order trt 320 ut'HTHVLiVll'. avojd this ectropium, the eyelids should never be opened while the child is crying, or in any way agitated; for, at such periods, the thickened scabrous conjunctiva will sudden ly protrude, and cannot be kept buck. Beer siys, that the eyelid should be replaced in the manner directed by Schmidt. (Ophthal- mol Bibl. 3. B. 2. Stuck, p I4*.».) The surgeon having smeared tiie ends of the thumb and forefinger of each of his hands with fresh butter, is to take hold of the everted cartilage of the eyelid at the outer and inner canthus, draw it slowly a little upwards, and then suddenly downwards. Thus, the thickened conjunctiva, if not too fleshy and granulated, may be quickly reduced, aud the ectropium removed. But, if the swelling of this membrane should be already very considerable, and have begun to be hard and studded with excrescences,thethumbs should* be placed so as to compress rather the middle of tbe eyelid. However, if the ectro- pium cannot be at once removed, it is to be treated, after the termination of the second ktagf* of the purulent ophthalmy, as a sequel of ;his disorder. (See Ectropium.) In the ophthalmo-blennorrntea the altera- tion of the sclerotic conjunctiva is said by Beer to be very different from chemosis ; a remark, which is strictly correct, inasmuch us ordinary cbemosis is not attended with that change in the surface of the sclerotic conjunctiva, which fits it for the secretion of pus. But, if we are to understand by chemosis, a copious effusion of lymph in tbe loose cellular substance between the con- junctiva and the eyeball, this state must be admitted as one of the usual effects of severe purulent ophthalmy. " It is after this morbid condition, which is characteristic of the suppurative ophthal- mia (says Mr. Travers) that the conjunctiv-i forms fungous excr scences, pendulous (laps, or hard callous rolls protruding be- tween the palpebra; and globe, and everting t'le former, or, if not protruding, causing the turning of the lid over against the globe. The tarsal portion takes on from the same cause the hard granulated surface, which keeps up incessant irritalion of the sclerotic conjunctiva,and at length renders the cornea opaque." (Synopsis, fyc. p. 98.) The treatment recommended by Mr. Tra- vers for the vehement acute suppurative inflammation of the conjunctiva consists in a very copious venesection, by which, he snys, the pain is mitigated, if not removed ; the pulse softened ; and the patient sinks into a sound sleep and perspires freely. The high scarlet hue aud bulk of the chemosis are sensibly reduced, and the cornea is brighter. The blood-letting, if necessary, is io be repeated, and the patient briskly purged, every dose of the opening medicine being followed by a tea spoonful of a solu- tion of emetic tartar, so as to keep up a slate of nausea, perspiration, and faintncs.s. When the di-cburge becomes thin, gleety, and more abundant, ihe swelling of the eye- lid sub i''es, the conjunctiva sinks and be- e-ori)'*- :-:i!n und (labby. Vm* prbi and fobrile irritation are pa.->i, and the cornea retains i(c tone and brightness, Mr. Travers considers the case safe, and states, that the prompt exhibition of Ionics, with the use of cooling astringent lotions, will prevent its lapsing into a chronic form. " But if, when the lowering practice has been pushed to the extent of arresting acute inflammation, the patient being at the --tnie time sunk and ex- hausted, the cornea shows a lack lustre and ragged n ess of its whole surface, as if shrunk by immersion in an acid, or a gray patch in Ihe centre, or a line encircling, or half en- circling its base, assuming a similar appear- ance, the portion so marked out will infalli- bly be detached by a rapid slough, unless by a successful rally ofthe patient s powers, we can set up (he adhesive inflammation, so as to preserve in situ that which may remain transparent." (Synopsis, fyc. p. 2ti6.) Here we find some approximation of practice, be- tween Mr. Travers and Professor Beer; but it is almost the only point, in which any re- semblance can be found in their modes of treatment. The granulated, or fungous state of the palpebral conjunctiva, produced by punt lent ophthalmy, sometimes demands parti- cular treatment, after the original disease is subdued. If such state of the eyelid be not rectified, it often keeps up a " gleety dis- charge, irritability to light, drooping of the upper lid, a pricking sensation as of sand in the eye, and a preternaturally irritable and vascular state of the sclerotic conjunctiva; witb these are frequently combined opaci- ties ofthe cornea." (Travers, op. cit. p. 271.) The affection, as conjoined with opaque cornea, is particularly noticed by Dr. Vetch, who de scribes the disease of the palpebral as consisting, at first, in a highly villous state of their membranous lining, which, if not treated by appropriate remedies, gives birth to granulations, which in process of time become more deeply sulcaled, hard, or warty. Along with the villous and fleshy appearance ofthe lining of the eyelids, (hero is a general oozing of purulent malter, which may at any time be squeezed out by press- ing the finger on the part. The diseased structure is highly vascular, and bleeds most profusely when cut. It possesses, as all granulated surfaces do, a very great power of growth or reproduction. Dr. Vetch has seen many cases in which it has been remo- ved with more zeal than discretion, twenty or thirty times successively, without this disposition to reproduction having suffered any diminution. Indeed, be assures us, that tbe operation was very unfavourable to the ultimate recovery ofthe part; " a new sur- face is produced of a bright velvety appear- ance, much less susceptible of cure than the original disease, and which, even if at length healed, does not assume the natural appear- ance of the part, but that of a cicatrized surface," not attended with a return of the transparency of the cornea. It is satisfacto- rily proved, by the observations of Dr. Vetch, that this diseased state of the inner surface of tbe cvelid wa«= not e--'" known! OPHTHAElVrY. 6*2 i tlnases, and other old practitioners, under tbe names of sycosis, trachoma, scabies pal- pebrarum, fee'but that it9 treatment by the actual cautery, excision, and friction, was also recommended by them. The honour of having introduced the preferable mode of cure with escharotics, Dr. Vetch assigns to St. Ives. No substances appear to Dr. Vetch more effectual for this purpose than the sulphate of copper and nitrate of silver. He says, that they should be pointed in the form of a pencil, and fixed in a port-crayon. Tbey are to be applied, not as some have conceived, with the view of producing a slough over the whole surface, but with great delicacy, and in so many points only, as will produce a gradual change in the condition and disposition of the pnrt. As long as any purulency remains, Dr. Vetch stales, that the above applications will be much aided by the daily use of the liquor plumbi subacelatis. When the disease re- sists these remedies, and the surface is hard and warty, he applies very minute quanti- ties of finely levigated powder ol verdigris, or burnt alum, to the everted surface, with a fine camel-hair pencil, but carefully washes them off with a syringe before the eyelid is returned. The caustic potassa, lightly applied to the more prominent parts of the diseased surface, will also answer. (See Vetch on Diseases of the Eye p. 73, fyc.) Mr. Lloyd also gives his testimony in favour of Ihe superiority of the nitrate of ■silver, which he ha« employed in the form if a saturated solution for restoring the healthy state of the inner surface of the ryclid. (On Scrofula, p. 328.) Others, however, still adhere to the practice of ex- cision, which, as-already observed, was fol- lowed by the ancients, and revived of late years in England by Mr. Saunders, who did *.vith scissors whatSir W. Adams and others have subsequently performed with a knife or lancet. Mr. Travers, I may observe, is also one ofthe advocates for the excision of the granulations and hardened excrescences ofthe conjunctiva. If there be a nebula of the cornea, with a plexus of vessels extend- ing to it, these are then divided, near the edge of the cornea, in the manner recom- mended by Scarpa. Mr. Travers afterward implies a solution ofthe sulphate of copper, the liquor plumbi subacetatis, or the vinous Cincture of opium. One remark which he makes tends very much to confirm the gene- ral advantage of the practice inculcated by Dr. Vetch ; for, it is observed, " the appli- cation of the bluestone, or of the lunar caus- tic, is often useful in preventing the regene- ration of the granulations afler their exci- sion." (Synopsis, fyc. p. 272.) My friend, Mr. Lawrence, whose experience in diseases of the eye is very considerable, lately in- formed me, that he finds caustic the sure mode of permanently removing the granu- lated fungous state of the inner surface of the eyelid, and that, when the granulations are cut away, thev arc frequently reprodu- ced ; a fact on which Dr. Vetch has particu- larly insisted VV. U 41 Egyptian Opkthnlmy. One of the best accounts of this disease, as it appeared in the army, is that delivered by Dr. Vetch. Although there can be no doubt that the disorder, in all its general characters, closely corresponds to the severe form of acute suppurative inflammation of the con- junctiva, as described by Beer; yet there- are some peculiarities with which it appears to have been characterized. Thus, one thing noticed in the Egyptian ophthalmy, but not in other purulent ophthalmies, i., that the first appearance of inflammation tt*i? observable in the lining of the lower ei/clid (Peach, in Edinb. Med and Surgical Jourv. for January, 1807. Vetch, on Diseases of tfin Eye, p. 196.) According to the latter wvi ter, the feeling of dirt, or sand, rolling in the eye is a symptom requiring particu!.—•* attention, as its accession is r certain hide* ofthe disease being on the increase. It 1? subject to exacerbations and remissions, the attacks always taking place in the evening, or very early in the morning. The first stage of the disease is said by Dr. Vetch to be characterised by its great and uniform redness, without that pain, tension, or intolerance of light, which accompanies most other forms of ocular inflammation ; and, in particular, that in which the sclerotic coat is affected From the very beginning of the complaint, there is a disposition to puffiness in the cellular texture between the conjunctiva and the globe of the eye, often suddenly swelling out into a state of complete chemosis. and at other times making a more gradual ap- proach to the cornea. Y\ bile effusion is thus taking place upon ^he eye, oedema is likewise going on beneath the integuments ofthe eyelids. This enormous tumefaction of Ihe'eyelids is said to be generally consen- taneous with the complete formation of chemosis; entropium is produced, and the- integuments of the two eyelids meet, lea- ving a deep sulcus between them. When the external swelling begins, the discharge, which was previously moderate, and consist- ed of pus floating in a watery fluid, changes into a continued stream of yellow matter, which, diluted wilh the lachrymal secrp- tion, greatly exceeds in quantity that deri- ved from any gonorrhoea. Although, says Dr. Vetch, the tumefaction may be, at first, farther advanced in one eye than the other, it generally reaches its greatest height in both about the same. The patient now begins, to suffer attacks of excruciating pain in the eye ; a certain indication of the extension ofthe mischief. " An occasional sensation, as if needles were thrust into (ho eye, ac- companied with fulness and throbbing of the temples, often precedes the deeper seat- ed pain." This last is often of an intermit' ting nature, and a period of excruciating torture is succeeded by ar, interval of perfect ease. Sometimes the psin shifts instanta- neously from one eye to the other, and is seldom or never equally severe in both at the same time -. and sometimes, instead of being in the eye, it occurs in a circumscri- bed ",*of of the head, vvbicb the ptt'er.t d*r- -•£2 OPHIHALM\. scribes by raying, he can cover the part ith bis finger. Sooner or later, one of tiiese attacks of pain is terminated by a sen- sation of rupture of the cornea, with a gush of sc.ilding water, succeeded by immediate relief to the eye in which this event has happened, but generally soon followed by an increased violence of the symptoms in the other. *At length the attacks of pain become shorter, and h-s severe, though they do not cease altogether till after the lapse of many weeks, and even mouths. During this stage of the disease, according to Dr. Vetch, Btere is seldom the slightest alteration of the pulse, unless the lancet have been freely employed. The patient's general health is little impaired, his appetite conti- nues natural, but sleep almost totally for- sakes him. As the pain abates, the external tumefac- tion also subsides, and a gaping appearance ofthe eyelids succeeds, their edges, instead of being inverted, now becoming everted. This is what Dr Vetch designates as the third jtuge ofthe disease. After the swelling ofthe second stage has subsided, the eyelids are prevented from returning to their natural sate by the gra- nulated change of the conjunctiva which lines them ; and an eversion of them now occurs in a greater or lesser degree. (Vetch on Diseases of the Eye, p. 196, 202 ) Among other interesting remarks, made by the same author, he states, that there is no reason to warrant the idea, that the ulceration ever proceeds from wilhin outwards. He ob- serves, that, when any large portion of the cornea sloughs, an adventitious and vascu- lar membrane is often produced, which finally forms a staphyloma " In some few cases, (says he) I have seen the lens and its capsule exposed, without any external co- vering whatever, and, for a short time, the patient saw every thing with wonderful ac- curacy; hut, as soon as the capsule gives way, the lens, and more or less of the vitre- ous humour, escape, the eye shrinks, and the cornea contracts into a small horn-co- loured speck." This total destruction of the globe of the eye is said generally to en- sure the other, and renders it less liable to be affected by future attacks of inflamma- tion. A few years ago, an ophthalmy, supposed to be of the same nature as the Egyptian, though milder, like that which has generally been observed in schools, occurred to a great extent in the Royal Military Asylum at Chelsea, and Mr. M'Gregor, the surgeon of that institution, has favoured the public with an excellent description ofthe disease, and some highly interesting facts and reflec- tions upon the subject. In the Military Asylum the symptoms of this species of ophthalmy generally made their appearance in tbe fo'fowing order: "/A considerable degree of itching was first felt in the even- ing: this was succeeded by a sticking toge- ther of the eyelids, principally complained of by th" patient on waking iu the morning. ih" «**--e!i'J» pppea-ed fuller externally than they naturally are ; and on examining; their internal surlace this was found inflamed. The sebaceous glands of the tarsi were con- siderably enlarged, and of a redder colour than usual. The caruncula lachrymalis had a similar appearance. " Ln 24 or 30 hours after the appearance ofthe above-mentioned symptoms, a vi,dd mucous discharge took place from the inter- nal surface of each eyelid, and lodged at the inner canthus, till tbe quantity was suflic ent to be pressed over the cheek by the motions ofthe eye. The vessels of the tunica con- junctiva, covering the eyeball, were distend- ed with red blood, and the tunica conjunc- tiva was generally so thickened, and raised, as to form an elevated border round the transparent cornea. This state was often accompanied with redness ofthe skin round Ihe eye, which sometimes extended to a con- siderable distance, and resembled, in colour and form, very much what takes place in the cow-pox pustule, between the 9th and 12th days after inoculation. " When the purulent discharge was con- siderable, there was a swelling of the ex- ternal eyelids, which often prevented the patient from opening them for several days. The discharge also frequently excoriated Ihe cheeks as it trickled down Exposure to light caused pain. When light was excluded, and the eye kept from motion, pain was sel- dom much complained of "These symptoms, in many, subsided, without much aid from medicine, iu 10, 12, or 14 days, leaving the eye for a considera- ble time in an irritable state. In several, however, the disease continued for a much longer time, and ulceration took place on the internal surface of tha eyelids, and in different parts on tbe eyeball. If one of those small ulcers happened to be situated on the transparent cornea, it generally, on healing, left a white speck, which, however, in the young subjecs under our care, was commonly soon removed. In some few instances, an abacess took place in tbe sub- stance of the eyeball, which, bunting ex- ternally, produced irrecoverable blindness.'' (P. M'Gregor, in Trans, of a Society for Ike Improvement of Med. and Chirurg. Knoultdgt, Vol. 3, p. 38—40.) When the local symptoms bad prevailed two or thres days, some febrile disturbance occurred ; but, except in severe cases, it was scarcely observable. Mr. M'Gregor considered this ophthalmy to be of the same nature as that which ha- nged with such violence in tbe army at dif- ferent periods, since the return of our troops from Egypt in 1800, 1801, and 1802. How- ever, he has found that its conaeqneiicw have not been so injurious to children as to adults; for, out of the great number 01 children that were afflicted with the dicea* at the Military Asylum, only six lost th* sight of both eyes, and twelve the sigM «*• one eye. (0p..eit.p.49.) On the other hand. Dr. Vetoh informs us, that, in tbe second battalion of the 52d regiment, which con- sisted of somewhat more ♦'mn 700 inen ^ UfH'lHALMY #2X ■.uses of ophthalmy were admitted into the hospital between August, 18'>6, and August, 18(t6; and that, " of this number, fifty were dismissed with the loss of both eyes, and forty with that of one." And, as Mr. M'Gre- gor observes, it is a melancholy fact, as ap- pears from tbe returns of ( Iielsea and Kil- matnham Hospitals, that 2317 soldiers were, on the 1st of December, 1810, a burthen upon the public from blindness, in conse- quence of opblhalmy. The cases, in which only one eye was lost, are not here included. The attacks of tbe disease appear to be much more frequent, severe, and obstinate, in hot, sultry weather, than in cold or tem- perate seasons. (P. M-Gregor, op. cit p. 37, 84, fyc.) This gentleman also observed, that the ophthalmy was more severe and protracted in persons having red hair, or a scrofulous habit, than in others. The right eye was more frequently and violently affecled than the left. In females tbe symptoms are greatly aggravated for some days previous to the catamenia; but, on this evacuation taking place, (hey are quickly lessened. Mr. M'Gregor further remarks, that the measles, cow-pox, and mumps, go through their course as regularly in persons affected with this species of ophthalmy, as when no other disease is present ; a circumstance which, with some others, proves that the disorder is entirely local. (P. 64,65.) With respect to the causes of tbe Egyp- tian Purulent Ophthalmy, much difference of opinion has prevailed, and, indeed, there was a time when the disease was regarded by the majority of army surgeons, who alone had opportunities of judging of it, as not being in reality contagious, but dependent upon local epidemic causes; the irritation oj sand; peculiarity of climate, fyc. Tbe late Mr. Ware even doubted the propriety of calling this ophthalmy Egyptian, and he con- tended that a disease precisely similar in its symptoms and progress had been noticed long ago in this and other countries; and that, in Egypt, several varieties of ophthalmy prevail. He preferred calling the disease the Epidemical Purulent Ophthalmy. On the other hand, Sir W. Adams conceives, that it ought rather to be called Asiatic Ophthalmy, as recent investigations prove that it prevails in the greater part of Asia, and was long ago described by Avicenna. (Graefe, Journ. iter Chir 1 B. p. 170.) That there has been long known in this country an infectious species of purulent ophthalmy cannot be doubted. The case, described by many surgeons, as proceeding from the sudden stoppage of gonorrhoea, or the inadvertent application of gonorrhaeal matter to tbe eyes, which disorder will be presently noticed, is certainly an infectious purulent ophthalmy. It is also admitted, that it resembles Egyptian ophthalmy, by tbe intensity and rapidity of its symptoms ; but the latter case is strongly characterized by the quickness with which it causes, espe- cially in adults, opacities or ulcerations of f no cornea: the long continued irritability of the eyes after the subsidence of inflam- mation ; but, more particularly, its very in- fectious nature, by which it spreads to an extent, that has never been observed wilh re- gard to any other species of purulent oph- thalmy. There have been epidemic oph- thalmies of other kinds, which have been known to affect the greater port, of the population of certain districts and towns in England. The celebrated ophthalmy, which happened at Newbury, in Berks some years ago, is an instance, that must be known to every body. But I know of no purulent inflammation of the e\e>, which everspread to a great extent in England, before the return of our troops from E:vpt. The reflections and observations of Mr. M'Gregor, as well as those of Dr. Vetch, and Dr. Edmondstone, I think, leave no doubt of two facts ; first, that this ophthalmy was at all events brought from Er,ypt; and secondly, that it is infectious, but only ca- pable of being communicated from one person lo another by actual contact of the discharge. " If (says Dr. Vetch) any belief were en- tertained by the- officers ofthe British army, during the first expedition to Egypt, that the disease vvas contagious, it was of a nature very vague and indefinile. Combined as its operations necessarily must be iu that coun- try with other exciting causes, there would be more difficulty in the first recognition of the fact. But, the coiitinuam e of the complaint with the troops, after their departure from Ihe country, could scarcely fail to lead to the obvious conclusion of its possessing a power of propagation. Before the disease reached this country, the opinion of its being contagious was adopted by many. Dr. Edmunddone, in the account which lie published of the disease, as it appeared in the regiment, to which he was surgeon, after its return to England, first made the public acquainted with Ihe fact of the disease being communicable. In an account ofthe Egyptian ophthalmia, as it appeared in this country, printed in the early part of 1807, I first establishsd, that the communication ofthe disease was exclusively produced by the appli- cation of the discharge from the eyes of the diseased lo those of the healthy." (Vetch on, Diseases of the Eye, p. 178.) The opinion that tbe disease is ever com- municated from one person to another, through the medium of the atmosphere, is at present nearly abandoned. During the whole time that Dr. Vetch had the manage- ment oft he ophthalmic hospitals, there never was an instance of any medical officer contracting the disease, although exposed to what might be supposed to be the greatest concentration of any contagion that could arise in the worst stage of the complaint. Two orderlies only contracted the disease, and both in consequence of the accidental application of the virus. However, Sir W. Adams maintains, that he has seen many cases which prove, that the disorder, like small-pox, may spread contagiously, without any kind of inoculation. (See Graefe's Journ. B. l.p. 17?'■ ^ Th--* fb? di'fise r-Ry^iV OP-M-i'HA-LMX- partly prop*;-.*^-.! by epidemic causes in certain places, I think as certain and clear, as that there must be a cause for the first commencement of the disorder in situations where infection by contact is out of the question. And, as Dr. Vetch has observed, "from whatever cause inflammation of the coijuncliva m iv originate, when the action is of that nature, or degree of violence as to produce a puriform or purulent discharge ; the discharge, so produced, operates as an animal virus, when applied to the conjunc- tiva of a healthy eye Considering the various modes, by which such a contact must inevitably occur in the usual relations of life, it must be obvious, that wherever ophthalmia prevails, whether it be the effect of local conditions of the soil, or of the at- mosphere, naturally or artificially produced, this contagious effect must sooner or later mix, or unite its operation with that of the more general and original one ; and hence, withoutregard to this propertyof the disease, its occurrence must often remain inexplica- ble, and at variance with the more general cause existing in external circumstances, And further, as the disease, produced "by infection, is of a nature more violent and malignant, than that produced by the impres- sion of atmospheric causes, it will, in every instance of extensively prevailing ophthal- mia, occasion two different forms of disease, "which, as long as (hey are considered as one aad (he s,ime,will produce, according as the one orthe other predominates, very discor dant resulto." (Vetch on Diseases of Ihe Eye, p. 175.) Mr. M'Gregor relates three cases, which prove, that the matter, after ils application, produces its effects in a very short time. I shall only cite (he following example :—On the -21st of October, 1809, about four o'clock, p. m Nurse Flannelly, while syringing the eyes of a boy, let some of Ihe lotion, which had already washed the diseased eyes, pass out of the syringe into her own right eye. She felt little or no smarting at the time; but, towards nine o'clock the same evening, her right eye became red, and somewhat p biful, .-it. J when she awoke next morning, b;- °lids were swelled, there vvas a puru- lern .. ...'.arge, pain, be. (Op. cit, p. bl.) The U Mr. Ware, though he admitted, that the inu-v.i* »n vvas brought into this coun- try from Egypt by tbe troops, conceived that the same disec-* : also sometimes arose from the matter of g njrrboea being applied to the eyes, and that it had been prevalent in thiscou try I e-fon- the reti.rn o; the army frim Egypt. He thought, howt-ver, that t e if<»C[*on Was generally conim icated !>y cw tact. Mr. Ware ob-erves, s ,.e of the wor-t cates of the purulent ophthalmy of children have happened in those whose mothers were mbject lo ui acrimonious dis- cJiaive fro t .,* vagina at ibe ti(;!e ,,f mtu- I'tion. Some erpelual wntchlul ness, which tin* Unrest dose- of opium can- not subdue." (P. 211) Bleeding, however, is Ihe '• sheet anchor," and the only means of preventing Ibe destruction of the cornea, whenever attacks of pain in the eye, or or- bit, denote (he unsubdued state of tbe dis- ease. (P. 212.) When the disease shifts ils violence from one eye lo (he other, and is of long duration, Dr Vetch recommends cup- ping, and the eye to be more carefully clean- ed by the injectioii of tepid water, or any gentle astringent lotion, and afterward wiped dry. When the discharge continues acrid and scalding, he directs blisters to be applied to the nape of the neck, and behind the ears. He wishes it to be distinctly kept in mind, that the time for the employment of bleeding, with Ihe view of saving the eye, is during the first stage, or early part of the second ; and when ulceration of the cornea hns commenced, the case is to be treated on the principles applicable to sclerotic inflam- mation. Wilh regard to the plan of diminishing in- flammatory action by medicines which ex- cite nausea and sickness, in-lead of having recourse lo the lancet, Dr Vetch stales, lhat, in soldiers, it does not answer so well, and in the end proves more debilitating. As soon as the'esternal oedema of the eye- lids subsides, and they begin to be everted, Dr. Vetch begins the cure ofthe granulations and general villosity. by a very light and careful application of Ihe argentum nitratum. The everted portion is then lo be returned, and secured in its place with a compress and bandage. This method is to be repented every time the eye is cleaned, and, in the course of a fortnight, Ihe tendency to ectro- pium will be removed (P. 229.) Assalini found venesection, all emollient npplicalions, and eyewaters, hurtful. He first purged his patients, and then introduced into their eyes a few drops of a solution of the Iapi3 divinus, (see Lachrymal Organs,) lo which was sometimes added a small quan- lily of the acetate of lead. He speaks fa- vourably of leeches, and sometimes he put a small blister on the temple, or behind ihe ears. (See Manuale di Chirurgia ; Milano, 1812.) 6 Perhaps the best mode of putting an im- mediate stop to the Egyptian ophthalmy, when it prevails extensively in a regiment in garrison, or barracks, is to put the men actu- ally affected into a detached hospital, at a considerable distance from the res! of the corps, which should be dispersed as much as possible in separate billets and villages. Purulent ophthalmy is a disease which makes great head only when large numbers of per- sons are either exposed together to the epi- demic causes, which first give birtb to it, or to the causes which occasion tbe disease to be communicated from one individual to another, as when soldiers are crowded to- gether in the same building, using tbe same (n-irclsrid wafer, be. !Vofw•t,^5tflnd.;r»«;t^,, OPHTHALMY. 327 reports of Koui and Larrey prove, that the disease did not spread b> the French army, after the return of uncured soldiers from Egypt to France, though these Were freely mixed witb their comrades in hospitals and barracks the same security did not extend to the British troops lately in Ihe latter coun- try, who at one lime were ihrf atened wilh a very extensive renewal of the Egyptian oph- thalmy among hem, but which was wis ly checked by attention to the principles above specified, and in which Dr. Granl, (he head ofthe medical department of thai army, bad ihe greatest < onfidence. In (he cases under Mr. M'Gregor, local applications were found most advantageous. Dining the inflammatory stage, however, (bis gentleman also had recourse to antiphlo- gistic means, spare diet, bleeding, neutrnl salts, Sic. The topical treatment vvas as fol- lows: Leeches were freely Rnd repeatedly applied near the eye. But while there was much surrounding redness, instead of leeches, which created (oo much irritalion, fomenla- tions, wilh a weak decoction of poppy-heads, und a little brandy, were used. A weak so- lution of acetate of lead, and sulphate of zinc, had mostly a good effect when applied to the eye. Tin- vinous tincture of opium did not answer Ihe expectations entertained of it. But of all the remedies, Ihe ung. hy- drarg. nitrat. was found mosl frequently suc- cessful. It was applied hy means ot a camel- hair pencil, aud at first weakened with twice its quantity of lard. The red precipitate, well levigated, and mixed wilh simple oint- ment, sometimes answered when Ihe ung. by drarg. nitral. failed. Mell levigated verdi- gris, and i quack im dicine, called the golden ointment, i. oved -dso sometimes efficacious. (P. 41—13.) According lo Mr. M'Gregor, blisters behind the ear-, and upon the neck, are useful; but hurtful when put nearer (o the eye. In cases where tbe disease seems to resist antiphlogistic means, and ulceration has commenced on the external surface of tbe cornea, ilii- gentleman approve of dis- charging Ihe aqueous humour by a puncture, as advised hy Mr. Wardrop. When the violence of the inflammation has subsided, Mr. M-Gregur recommends the us<- of Bates's camphorated water, diluted With four, five, or six times ils quantity of water. But the astringent coilyrium, from which he mw most good derived, was a so luli-eii of the nitrate of silver, in the propor- tion of half a grain to every ounce ol dis- tilled water. In some cases, it may be used stronger. Tepid sea-water sometimes proved ser- viceable in removing the relics of (he com- plaint. (P. 56 fyc.) The laie Mr. VVare was in favour of bleed- ing ; but he rarely carried it to the extent which has been done iu ihe army. In weak persons, instead of repealed venesection, he preferred topical bleeding, either from (he vein that passes on (he side of (he nose, or by means of five or six leeches put on Ihe temple. Sometimes he thought it better to rrarify (ho inside of (he lower eyelid with the point of a lancet, carried along parallel to, and very near the margin of (his part He objects to pricking the eyelid in an infi- nite number of places, as very painful, and like-ly to increase (he irritalion. The lancet (he says) never need be applied more than twice, and rarely more than once ; and, per- haps, less pain will be oc:<«sioned by making (he incision wi(h (he edge, radier (han die poinl of the lancet. Afler taking away blood, Mr. Waie says, « iarge blister on the head, or back, is often useful. Anodynes should be given, with occasional purgatives, and an antiphlogistic regimen. (Ware on Purulent Ophthalmy, 1808. p. 26, fyc.) Asa local application, Mr. Ware- preferred the aqua camphorata, which was used exacl- lyin the same way, as will be described in speaking of his method of treating (he puru- lent ophthalmy of children. When Ihe in- flammation was very great, he only put four or five grains, instead of eight, of (he sul- phate of copper lo eight ounces of water. He usually employed Ihe lotion cold, espe- cially in children; but in adults, in whom the general fever and local inflammation were considerable, he was obliged to use it warm. In cases of great pain and swelling, it should be very weak, less often applied, and sometimes only warm water injected. In such circumstances, Mr. VVare also sane- lions fomenting the eye wilh a flannel, or sponge, wel with a hoi decoction of poppy- heads, or mere hot water. When the cor- nea threatens to burrt, this gentleman op- proves of opening il, in order to discharge the aqueous humour, by making an incision in a place where the sear'will not obstruct vision, as first snggesled by Mr. Wardrop. Purulent Ophthalmy oj Infants. Dr. Vetch describes (he exlernal appearances of this case as not materially different from those of Ihe purulent ophthalmy of adults; but, be states, that its nature is considerably modi- fied by the more delicate texture and great- er vascularity of (he parls affec(ed, and the more- intimate connexion, subsisting bt^fu'een the vessels of tbe conjunctiva and those of the sclerotic coat. Hence, he says, the in- flammation is sooner communicated to this coat, and sloughing and ulceration of the cornea occur earlier in infants, than adults. When the oedema ceases, the inner surface of the palpebral becomes sarcomatous, and this diseased surface, when the eyelids arc opened, forms an exterior fleshy circle, be- yond which the relaxed conjunctiva of the eye c omes forward as a second ; and often (he caruncula lachrymalis adds still farther to the valvular appearance, which (he part pre- sents. (On Diseases of the Eye, p. 256— 253.) According (o the late Mr Ware, the prin- cipal difference between the purulent oph- thalmy in infants and that in adults, consists in Ihe different states ofthe tunica conjuncti- va: in the former, notwithstanding Ihe quan- lily of matter confined within (he eyelids is often profuse, the inflammation of (he con- junctiva is rarely considerable, and when- ever (he cornea bcrorae? impaired, it is rather UPIiTHALMY. owing to the lodgment of such matter on it than to inflammation; a statement, which appears to roe very questionable. But, in ihe purulent ophthalmy of adults, the dis- charge is always accompanied with a violent inflammation, and generally wilh a tumefac- tion of the conjunctiva, by which its mem- branous appearance is destroyed, and the cornea is made to seem sunk in the eyeball. (Ware on Epidemic Purulent Ophthalmy, p. '23.) In children, the affection of the eyes is occasionally accompanied witb eruptions on tbe bead, and with marks of a scrofu- lous constitution. (See Ware, p. 138, fyc.) The only inference to be drawn from this fact is, that scrofulous, as well as other chil- dren, are liable to this disorder of their eyes. The following is the treatment recommend- ed by Mr. Ware. If the disease be in its first stage, the temporal arteries are to be opened, or leeches applied to the temples, or neighbourhood of the eyelids, and a blis- ter put on (he nape of the neck and temples. The child should be kept in a cool room, not covered with much clothes, and if no diarrhoea prevail, a little rhubarb or mag- nesia in syrup of violets should be prescribed. A surgeon, however, is seldom called in before the first short inflammatory "tage has ceased, and an immense discharge of matter from ihe eyes bas commenced. Of course, c'says Mr. Ware,) emollient applications mu-t generally not be used. On the contrary, as- tringents and corroborants are immediately indicated, in order to restore to the vessels of the conjunctiva and eyelids Iheir originnl tone, to rectify the villous nnd fungous ap- pearance of the lining of the palpebral, and thus finally to check the morbid secretion of matter. For this purpose Mr. Ware strongly recommends the aqua camphorata of Bates's Dispensatory : Q. Cupri sulphatis, bol. ar- inen. a a "^iv. Camphora;, ^j. M. b f. pulvis, de quo projice ~j. in aquae bullienlis ib'V. amove ah igne, et subsidanl fceces. Mr. Ware, in hi" la(e Remarks on Purulent Oph- 'halrA 1803,observes, that he usually directs the aqua camphoratu as follows: ^. Cupri sulphatis. bul. arrnen.a&gr viij. Camphora gr ij. Misce, et affunde aqua; bullientis Sviij. Cum lotio sil frigida, effundatur limpidus li- quor, et sa:pi=sime injie iatur pnululum inter oculum et palpe-bras. This remedy possesses a very styptic quality ; but, as directed in Bates's Dispensatory, it is much loo slrong for use hefore it is diluted ; and the degree of its dilution must always be determined by ihe peculiar circumstance of each case. Mr. VVare ventures to recommend about one dram of it to be mixed with an ounce of cold clear water, as a medium or standard, to be strengthened or weakened as occasion may require. (P. 143.) The remedy must be ap- plied by means of a small ivory or pewter syringe, the end of which is a blunl-poinled cone. The extremiiy of this instrument is to be placed between the edges of the eye- lids, in such a manner, that the m-d'eated li- quor may be carried over the whole surface of the eye. Thus the matte-i will be entirely washed away, an ; enough ofthe slyptic rue'- dirine left behind t"< in'erriu I and"dimini«h the excessive disc.iarge. According to the quantity of malter, and the rapidity with which it is secreted, the strength of ihe np- plication, and the frequency of repeating it, must be regulated. In mild recent cases, the lotion may be used once or twice a day, and rather weaker than the above proportions; but, in inveterate cases, it is necessary to ap- ply it once or twice every hour, and lo in- crease its styptic power in proportion ; and when the complaint is somewhat relieved, the strength of the lotion may be lessened, and its application be less frequent. " The reasons for a frequent repetilion of the means just mentioned, in b.id cases, are, indeed, of the most urgent nature. Until the conjunctiva is somewhat thinned, and the quantity of the discharge diminished, it is impossible to know in whnt state iheeje is; whether it is more or less injured, totally lost, or capable of any relief, fhe continu- ance or extinction ofthe sight frequently de- pends on (he space of a few hours: nor ran we be relieved/rom the greatest uncertainty in these respects, until the cornea become visible." (Ware. p. 145.) This author condemns the use of emollient poultices, which must have a tendency loin- crease the swelling and relaxation of the con- junctiva. If poultices are preferred, he par- ticularly recommends such as possess a tonic or mild astringent property; as one made of the curds of milk, turned with alum, and an ecjual part of the unguenturn sunbuci, or axungia porcini. This is to be put mi cold, and frequently renewed, without omitting .he use of the injection. (Ware, p. 147.) When the secreted mailer is glutinou?, and makes the eyelids so adherent together, lhat they cannot be opened, after being shut for any lenglh of time, the adhesive matter must be softened wilh a little fresh butter mixed with warm milk, or by means of any othersoft oleaginous liquor, after the poultice is taken off, and before using the lotion. (P. 147.) If fhe eversion of the eyelids only occurs when the child cries, and then goes off, no thing need be done in addition (o (he above means. When, however, (he eversion is con- stant, the injection must be repeated more frequently than in other cases, the eyelids put in Iheir natural position, after its use; and an attendant directed lo hold on them, with his finger, for some length of time, a compress dipped in the diluted aqua campho- rata. (P. 148.) In some cases, when ihe inside of theeye- lid-i has been very much inflamed, the tinc- tura thebaica, insinuated be(weeu (he eye nnd (he eyelids, has been useful. If, alter (he morbid secretion is checked, any part of ihe cornea should be opaque, the unguen-. (um hydrargyri nitrati, melted in a spoon, and applied accurately on the sjteck, wilh a line hair pencil; or Jin'm's ophthalmic oint- ment, lowered and used in the s,une manner, may produce a cure, if ihe opaci y be no' ol loo deep a kind. When the local d;-"»*.'se seems lo be kept up by a had ha'ht, altera- tives should bf* exhibited, pnrtir'ihH-ly the' UPHTHALMt. '429 black sulphuret of mercury, or small dosesof calomel. The treatment, recommended by Dr. Vetch, is asjfollows: if the inflammation has not extended to Ihe conjunctiva of the eye, ils further progress may be checked by re- moving the infant to a healthy atmosphere, and washing (he eye with any mild coilyri- um. Leeches are commended throughout the whole course of (he complaint. On the first accession of the tumefaction, the best effect will often be produced by the applica- tion of a small portion of ointment, composed of lard, or butter 3yj. and x gr. of the red ni- trate of mercury, without any W'X. As the purulency advances, the liquor plumbi suba- cetalis, he says, will be found not less ser- viceable, than in olher instances of purulent ophthalmy. For promoting the separation ef any slough, he recommends a solution of the nitrate of silver; and for curing the re- laxed slate of the conjunctiva, a solution of alum, or of the sulphate of copper. (On Diseases of the Eye, p 260.) The Purulent Ophthalmy arising either from suppression of gonorrhoza or from the inadvertent conveyanca of gonorrhaal matter to the eyes, is said to produce rather a swell- ing of the conjunctiva, than of the eyelids, which is followed by a discharge of a yel- low greenish matter, similar to that of clap, The beat and pain in the eyes are con- siderable ; an aversion lo light prevails, and, in some instances, an appearance of hypopi- on is visible in the anleri r chamber of the aqueous humour. When the complaint pro- ceeds from the second cause, it is described as being less severe, than when it arises from the first. However, by such gentlemen, (Ware, Travers,fyc.) as have seen unequivo- cal instances of purulent ophthalmy excited in the second way, the disease is said io be remarkable for its violence and intensity. The reality of cases of purulent ophthalmy from the application of gonorrhoea I matter to the eyes, seems supported by sm:h a mass of evidence, that I believe Ihe fact must be ad- mitted. Yet, from some statements, lately published by Dr. Vetch, it would appear, thai the frequency of this mode of infection must be very much lessened by the circumstance of the matter taken from the ureihra, not being capable of communicating the dis- ease lo the eyes of the individual, by whom such matter is secreted, though probably capable of doing so to the eyes of another person. In the same way, the urethra cannot be affected by the application of matter taken from the purulent eyes of the individual, on whom the experiment is made. At least, of these circumstances, there is a negat ive proof in some facts recorded by Dr. Vetch. " In the case of a soldier, received in a very ad- vanced stage ofthe Egyptian ophthalmia, in whom destruction of the cornea had to a cer- tain extent taken place, I took occasion lo represent ihe possibility of diverting the dis ease from the eyes to the urethra, by apply- ing the discharge to the lalter surface. Ac- cordingly, some of the matter taken from the V< r Ff 42 eyes, was freely applied fo the orifice of the urethra. No effect followed this trial, wliich was repealed on some olher pa(ien(s, all la- bouring under (he most virulent state of the Egypti n disease, and in all the application was perfectly innocuous. Bul, in another case, where the matter was taken from the eye of one man, labouring under purulent ophthalmia, and applied to the ureihra of an- other, the purulent inflammation of the ure- thra commenced in thirty-six hours after- ward, an I became a very severe attack of gonorrhoea. From the result of these cases, (says Dr. Vetch) I could no longer admit the possibility of infection being conveyed to theeyesfrom 'he gonorrhosal discharge ofthe same person. Some time alter ibis, the im- probability, or rather impossibility of this ef- fect, was rendered decisive by an hospital assi (ant, who conveyed the matter of gonor- rhoea to his eyes, without any affection of the conjunctiva being the consequence." (See Vetch on Diseases of the Eye, p. 242.) Hence, this gentleman is led to refer ibe con- nexion, hetween gonorrhoea and ophthalmia, in the same person, lo peculiarity of consti- tution; but (he theories on which this opi- nion rests, my limits will not allow me to examine If il be actually true, that, in adults, a spe- cies of purulent ophthalmy does originate from the sudden suppression of a gonorrhoea are we to consider the complaint so pro- duced as a metastasis of the disease from the urethra (o the eyes? This ophthalmy does not regularly follow the suppression of gonor- rhoea ; nay, it is even a rare occurrence: also, when il is decidedly known, (ha( the purulent ophthalmy has arisen from the in- fection of gonorrhoea, namely, in those in stances in which the malter has been incau- tiously communicated to the eyes, it appears that such an affection of these organs,so pro- duced, is diff-rent from the one alluded to, inasmuch as it is slower in its progress, and less threatening in its aspect. When the eyes are affected, the disease of the ureihra is not always su-pended. (Vetch on Diseases of the Eye, p. 239.) Hence, there is good reason for supposing that no metastasis lakes place in this species of purulent ophthalmy, supposed to be connected wilh a suppressed gonorrhoea: but, we must be content with inferring that, if it really has such a cause, it originates from a sympathy, prevailing be- tween the urethra and eyes, and, that the difference of irritability, in different people, is the reason, why it is not an invariable consequence of the sudden stoppage of a gonorrhoea. The injection of warm oil, the introduc- tion of a bougie into the urethra, aud the application of cataplasms to the perinamm, with a view of renewing the discharge from the urethra, form the outline of the practice of those who place implicit reliance in the suppression of gonorrhoea being the cause of the complaint. The rarity of the occur- rence; tlie frequency of the sudden cessa- tion of the urethral discharge ; the possibi- lity of an ophthalmy arising, as well at this 33W OPHTHALMY particular moment, iis at any other, totally independent of the other complaint; cannot fail to raise in a discerning mind a degree of doubt concerning the veracity of (he assign- ed cause. Besides, admitting that there is a sympathy between the urethra and eyes, how are we to ascertain whetherthe suppres- sion of gonorrhoea be the cause or the effect of the ophthalmy, supposing that the one ceases and the oilier commences about the same time ? Actuated by such reflections, I am induced to dissuade surgeons from adopt ing any means calculated to renew a dis- charge of matter from the urethra. When the puruleiit ophthalmy, in adult subjects, is decidedly occasioned by the actual contact, and infection of gonorrhoeal matter, applied accidentally to the eyes, no one has recom- mended this unnecessary and improper prac- tice. The first indication in the treatment ofthe disease from either cause, is to oppose the violence of the inflammation, and thus re- sist the destruction ofthe eye and opacity of the cornea. A copious quantity of blood should be taken away both topically and ge- ne ally ; mild laxatives should be exhibited, and a blister applied to the nape of the neck, or temples. The eyes ought to be often fo- mented with a decoction of white p*>ppy- heads, and warm milk repeatedly injected beneath the eyelids. To prevent the palpe- bral from becoming agglutinated together, during sleep, the spermaceti cerate should be smeared on the margins of the tarsi every night. When the heat and pain in the eyes, and febrile symptoms have subsided; when an abundant discharge of pus has commenced; all topical emollients are to be relinquished, and a coilyrium of Aq. rosa* ?x. containing Hydrarg oxy. mur. gr. j. used in their place. Scarpa states, that in tbe ophthalmia, origi- nating from the inadvertent communication of the matter of gonorrhoea to the eyes, ap- plications, in the form of ointment, such as the ung. hydrarg. and Janin's salve, to which might be added the ung. hyd. nitrat. avail more, than fluid remedies. Inflammation of the Eyeball in general. From cases in wliich the eyelids are at first chiefly affected, 1 pass to the consideration of inflammation, as commencing iu the eye- ball itself. As Beer remarks, fortunately it is only very seldom, that the w hole of the organ is at once attacked with genuine idio- pathic inflammation, without any part of its texture being spared. Although this kind of ophthalmy is far more frequent than com- mon inflammation of the orbit, it is much more rare than the same disorder of the eye- lids. For the most part, healthy inflamma- tion ofthe eyeball has a limited point of ori- gin, from which it spreads, sometimes quick- ly, sometimes slowly over the whole organ. During an exceedingly violent, tense, throb- bing pain, affecting not only the eye itself, but extending to all the surrounding parts, the bottom ofthe orbit-and within the head, the white of the eye becomes suffused with an uniform redness, which, on attentive e3 animation, is found to be seated not only in tbe conjunctiva of the eyeball, but also in fhe sclerotica, and to exhibit at first a very fine vascular network, wliich, as the redness grows more intense, assumes the appearance of scarlet cloth, forming all round the cor- nea an uniform circular prominent fold, which has a very firm feel, and is so tender. that when touched in the gentlest manner, the patient cries out wilh agony. The cir- cumference of the cornea continues to be more and more covered by this increasing swelling of the conjunctiva, until at length only a portion of its centre remains visible. At the same time, the pupil is very much contracted ; the iris motionless ; and though vision is nearly or entirely lost, the patient is seriously disturbed by fiery appearances before the eye. When the iris is naturally gray, or blue, it turns greenish, and when brown, or black, it becomes reddish. Every movement of the eyeball and upper eyelid is suspended, and the orbit feels to the pa- tient, as if it were too small, which, Beer says, is in reality the case, because the whole of the eyeball, and not merely the conjunctiva, is enlarged, so as to project like a lump of raw flesh further and further between the edges ofthe palpebra*, and com- pletely fill every part of the orbit. While the eyeball enlarges, the cornea always loses its transparency, and the inflammation spreads to the eyelids, the lower one at last becoming everted by the excessive and firm tumefaction of the parts behind it, and the upper one presenting the most unequivocal marks of phlegmonous in- flammation. The secretion of tears and mucus is now entirely suppressed, and of course, the eye preternaturally dry. -Vt the very commencement of this violent form of ophthalmy, the constitution is disturbed by a severe attack of inflam- matory fever, and irritable patients are not unfrequently seized with delirium.— Hero, says Beer, terminates the first stage of this very dangerous disorder. When tbe disease is left to itself, suppura- tion comes on, attended with fever and constant shiverings ; the swelling of tbe scle- rotic conjunctiva undergoes a remarkable increase, and assumes a dark red colour, at the same time that it becomes softer. The pain becomes irregular, throbbing, and, when ihe eye or eyelids are touched, of a lancinating description. As a morbid secre- tion now begins to take place from the Mei- bomian glands, the swelled conjunctiva has a more moist appearance. The upper eyelid has a purple hue, aud, on account of the con- tinually increasing size of the eyeball, is pushed further and further outward. The portion of Ihe cornea, still discernible in the middle of Ihe protuberant conjunctiva, ac- quire; a snowy whiteness, which afterward changes to yellow. 1 he patient feels an op- pressive sense of heaviness in the orbit, and a disagreeable kind of coldness ail round the eye. At leugth the throbbing and ten- ttVHTHALMY. 33 i i>ion are so agonizing, that the patient often expresses a wish to have the eyeball extir- pated. If no effectual treatment be adopted, the eye now bursts, and a mixture of matter and blood, together with the scarcely per- ceptible remains of the lens and vitreous humour, is discharged with considerable force to some distance in font of the pa- tient ; an occurrence sometimes termed rhexis, or rhegma oculi. From this moment, the pain all at once subsides into a very mo- derate feel of burning in the eye ; and sup- puration goes on, until all the textures of the organ are annihilated, the orbit has an emp- ty appearance, aud die closed eyelids sink into a concavity. Thus ends, as Beer ob- serves, the second stage, after much tedious and general indisposition. But, he remarks, that the course ofthe case is epiile different, when it has been wrongly treated in its first stage with stimulants, or exposed to the ill effects of tobacco smoke, the drinking of spirits, improper diet, immoderate exercise, be.; for, under the operation of these unfa- vourable circumstances, the second stage may commence wilh dreadful gangrenous mischief, every vestige of the organization of the eye disappearing, and the parts at length sphacelating, while large abscesses form around, and, unless efficient medical aid be promptly given, the patient loses his life. With respect to the causes of such an at- tack of the whole eyeball at once by com- mon inflammation in a healthy subject, they must be of an exceedingly violent descrip- tion, such as injuries produced by gunpow- der, burns, and lesions either of a mechani- cal kind, or acting both chymically and me- chanically together, a subject already fully treated of in the foregoing columns. The following are the observations which Beer delivers on the prognosis: While, in the first stage of this dangerous form of oph- thalmy, the eyesight yet remains, and the eyeball itself is not enlarged, if ihe patient can be properly taken care of, some hope may be entertained of dispersing the inflam- mation so favourably, that, with the excep- tion of a weakness of sight, of longer or shorter continuance, no ill effects will be left. It is manifest, however, that under these circumstances, the surgeon should not be too bold in promising a perfect cure; for, the very commencement of such an inflam- mation of the whole eyeball, even when the disorder is purely idiopathic, is unavoidably attended with some risk, not only of perma- nent blindness, but of the eye itself being destroyed in the most painful manner; and, when things turn out rather better, a tolerably favourable termination of the case is uncommon. But, as soon as the power of seeing is quite lost, the pupil nearly closed, and the eyeball prodigiously swelled, it will be fortunate, if the inflammation can be resolved, so as to preserve tbe shape of the organ; for the restoration of the eye- sight is entirely out of the question. But, besides the irremediable loss of vision, the disorder under these circumstances always produces a greater or lesser closure of the pupil, which, however, has no share in caus- ing the blindness. In the second stage ofthe case, of course, the hope of restoring vision is quite past, and if the eyeball itself, and not merely the conjunctiva, has been considerably swelled in the first stage of the case, the chance of preserving the natural shape of the organ extremely unpromising. But, w hen the eye bursts, the latter desideratum is impossible. If tue first stage should have been so violent as to have induced gangrene, the practition- er will have enough to do in preventing sphacelus, and death, the danger of which is considerable, on account of the intimate connexion between the eye and parts in the orbit, and the brain and its membranes. In the first slage, antiphlogistic treatment, in the general sense eif the expression, is indicated, and the case is not to be re- garded merely as a local disorder. Howe- ver, with respect lo topical bleedings, the surgeon, says Beer, should be more active, than in other examples of ophthalmy, and, after copious venesection and the use of leeches have produced some relief, the pro- tuberant conjunctiva, round the cornea, should be deeply scarified w ith a lancet. If, in the first stage, delirium come on. as it sometimes does during the violence of the inflammatory fever, Beer directs one of the external jugular veins to be opened : or blood might be taken from the temporal artery. In the second stage of the case, when the re-establisbmeut of vision is quite im- impossible, and the objects are to endeavour to keep the eye of a good shape, and quick- ly lessen the suppuration, warm emollient poultices, aud particularly those made of apples, are the applications, on which Beer beatows his praises. This topical treatment is to be assisted with internal means, as ex- plained iu the preceding pages, because the disorder is attended with a general disturb- ance of the constitution. When matter is fully formed, and its fluctuation can be dis- tinctly felt, Beer approves of opening the abscess with a lancet; for, it is only by this means, that the annihilation of the eyeball can be prevented. If the eye has already burst, the preservation of its form is no lon- ger possible, and, according to Beer, both the topical and general treatment should be partly of a tonic description. When gan- grenous mischief has occurred, the practice ought to conform to the principles explain- ed in the article Mortification. Exlernal Ophthalmy. Inflammation of the Outer Coats of the Eye. Ophthalmitis Externa Idiopnthica, of Beer. The modifications of this common species of ophthalmy, as the latter author observes, have a variety of names applied to them, as ophthalmia levis, ophthalmiaangularis,taraxis, and sometimes chemosis, and ophthalmia sicca. Together with a preternatural dryness of the eye, and a sensation, as if the eyeball were compress- ed on every side, the white of the eye be- comes covered witb a general redne?=. 0PH1HALMV. u hich, though it affect both die sclerotica and the conjunctiva, will be found on attentive examination to be much more considerable in the former, than the latter membrane, in which only a delicate plexus of blood-ves- sels is at first percepiblc. The motions ofthe eye and eyelids are not absolutely prevent- ed ; yet, the patient never moves these parts except when he is actually obliged to do so, as every motion of them, if not actually painful, occasions a good deal of annoy- ance. Though the cornea cannot be said to become opaque, its clearness is always much diminished, and this change is the greater, the redder the white of the eye ap- pears. These effects, which occur almost simultaneously, are followed by pain, which increases every moment, at first extending over the whole eyeball, and then to the sur- rounding parts, and to the top of the head. As the pain grows more severe, every move- ment of the eyeball and palpebral becomes more distressing, the dryness'of the eye greater, and the redness of the sclerotic conjunctiva augments, either more slowly, or quickly, according to the degree of in- flammation until the network of blood-ves- sels, which was at first distinguishable, en- tirely disappears, and the conjunctiva looks like a piece of red cloth, epiite concealing the sclerotica, and forming round the coi- nca a very painful, firm, uniform circular projection. Thus, the cornea seems as if it lay in a depression, with its margin partly covered by Ibis inflammatory swelling of the conjunctiva. At the period, when the protuberance of the latter membrane takes place, the cornea itself always becomes less and less clear, and of a reddish gray colour, so that neither the iris nor tbe pupil can be any longer distinguished, and the power of vision is reduced to a faint perception of light. The pain, which was that of heavi- ness and tension, now becomes of a throb- bing description, and the eyelids, which now begin to participate in the effects of the inflammation, are no longer capable of covering properly the swelled conjunctiva. The eyeball and eyelids are perfectly mo- tionless ; and, if an attempt be made by the patient to move them, tbe efforts of the muscles may be perceived, but still no movement of the parts intended is perform- ed. The orbit feels as if it were too small for the eye, and tbe constitution suffers a severe attack of inflammatory fever. Thus, says Beer, does the first stage of this form of ophthalmy gradually rise to its highest degree, to which he applies the name of true chemosis. However, it is observed, that idiopathic external ophthalmy does not always be- come so violent, as for instance, when the complaint has been excited merely by the lodgment of some small foreign body under the eyelids ; for though in such a case ihe conjunctiva and sclerotica are both redden- ed together, yet even when no aid is afford- ed, if no other sources of greater irritation are present, the redness does not readily increase So as quite to conceal the sclero- tica, or to he attended with an inflamma- tory swelling all around the cornea. This milder form of external ophthalmy has sometimes received the name of laraxis. It is the mild acute ophthalmy of Scarpa, cha- racterized, as this author says, by redness of the conjunctiva and lining of the eyelids, an unnatural sensation of heat in the eyes, uneasiness, itching, and shooting pains, as if sand were lodged between the eye and eye- lids. At the place where tire pain seems most severe, Scarpa remarks, that some blood-vessels appear more prominent and turgid than other vessels of the same class. The patieut keeps bis eyelids closed ; for ho feels a weariness and restraint in opening them, and by this means he also moderates the action of the light, to which he cannot expose himself, without increasing the burn- ing sensation, lancinating pain, and effusion of tears. If the constitution be irritable the pulse will be a little accelerated, parti! cularly towards the evening . the skin dry; and sometimes slight shiverings, and nausea and sickness take place. According lo Scarpa, mild acute ophthal- my is often (he consequence of a cold, in which the eyes, as well as the pituitary ca- vities, fauces, and trachea, are affected. It is not unfrequently occasioned by change of weather, sudden transitions from beat to cold, the prevalence of easterly winds, jour- neys through damp unhealthy, sandy coun- tries, in the hot season of the year, exposure of the eyes to the vivid rays of the sun, draughts of cold aii, dust, be. Hence, it does not seem extraordinary, that it should often make its appearance as an epidemic, and afflict persons of every age and sex. As additions to the list of remote causes, authors enumerate the suppression of some habitual evacuation, as bleedings from the nose, or piles, the menses, be. a disordered slate of the prima; viae, worms, denlition.&c. Between Beer and some late writers, there is either one point of difference in their de- scriptions of external ophthalmy, or else they mean different cases ; for while Beer represents the redness as affecting the scle- rotica at first more than the conjunctiva, other writers describe the affection ofthe scle- rotica as generally secondary, when it hap- pens at all ; for according to modern obser- vations, it is not unavoidably either an at- tendant upon, or an effect of simple inflam- mation of the conjunctiva. As the second stage of external ophthal- my comes on, the symptoms vary, accord- ing to the degree of the complaint in its first stage ; but when what Beer calls a true chemosis is produced, the following are de- scribed by him as the usual appearances. The circular prominent fold ofthe conjunc- tiva round the cornea, becomes of a dark red colour, and the swelling increases, but it becomes softer and less painful. The hardly visible portion of the cornea, situated in the depression formed by the circular protuberance of the conjunctiva, seems at first perfectly white, and afterward yellow- ish, being the «eat of more or lc=s purulent OPH'iHALMY. 333 nfatter. though the swelled conjunctiva is every where moistened with a thin whi- tish mucus, this secretion, says I> er, is never so copious as to run over the t- cc, as in the case of ophthalmo-blennorrhoea. In this stage, the lower eyelid is turned some- what outwards, in coiisecpience of its lining becoming more swelled. While suppura- tion is taking place iu the conn a, attended with the febrile symptoms which usually ac- company the formation of acu e abscesses, little collections of matter sometimes occur at different points of the conjunctiva, and after they have burst, a probe may easily be passed rather deeply into them, without ony particular pain. (Beer, B. l,p.A12.) The suppuration continually advancing, the swellingof the conjunctiva, and of the whole eyeball now diminishes, the effects of the inflammation penetrate deeply into the or- gan, and the structure of the eye is so alter- ed as not to be cognizable, the part shrivel- ling up, as Beer says, into a motionless, whitish mass. However, according to this author, these deep effects of suppuration are sometimes produced only in a certain part of the eyeball, especially when the chemosis is the coiisecpience of an external injury, and in this circumstance, the rest of the circumference ot the globe of the eye exhibits its natural organization, while in the part above alluded (o, there is a funnel- like depression, attended with a considera- ble diminution in the size ofthe organ. But, says Beer, when an idiopathic exter- nal inflammation of the eye has only altain- cd the milder degree, expressed by the term taruxis ; as, for instance, when the com- plaint is principally ow ing to (he lodgment of some mechanically, or chyniically irrita- ting substance under the eyelids . the red- ness of the conjunctiva and sclerotica un- dergoes a remarkable increase on the ac- cession of the second stage; the first of these membranes becomes somewhat swell- ed ; the pain is lancinating and irregular; and the secretion of tears unusually pro- fuse ; but at the point when the extraneous substance lodges, an open superficial sup- puration occurs, and according to Beer, tiie case both in the first aud second slage, is generally accompanied with no febrile symptoms. In the first stage, Beer represents the prognosis as very favourable, provided the disorder does not exceed thai decree, to which the name of tar ax >s is applied; for with tiie aid of proper treatment, the in- flammation when of a healthy kind, may be soon so favourably removed, as not lo leave a vestige of it behind. If the cause of the disorder be not greater than a moderate injury or wound of (he eye, any traces of the lesion, which are perhaps still remain- ing, will disappear as soon as the inflamma- tion subsides. On (he other hand, when this kind of ophthalmy presents itself in the form of true chemosir, the prognosis is serious, and must he made wilh great re- serve, especially when (he patient is of a weak irritable constitution, a child, very stubborn and unmanageable, or incapable ot following strictly the advice which he receives from his medical attendant; for, under tliese circumstances, it will not be in the power of the latter to prevent the com- plaint from advancing unremittingly to its second stage, in which event the ill conse- quences of suppuration will be incalculable. But if these unfavourable conditions are not present, though the genuine idiopathic che- mosis may really have attained a violent, and almost its highest degree in the first stage, not only the eye may be saved by prompt and judicious treatment, bat also the eyesight; nor will the result be differ- ent, even when the co-nea continues for some time deprived of its transparency, and the power of vision impaired by a slight varicose affection of its conjunctival cover- ing. These effects, says Beer at length completely disappear, less in consequence of the aid of meilicine, than of a proper regim n, the uninterrupted eujoymen of a fresh, dry air, &c. The prognosis in the second stage, is un- der very different circumstances ; for, aph haliny presents itself in its first stage in (he form of true chemosis, (he prognosis in (he second stage is very unfa- vourable ; for when the cornea is generally pervaded by suppuration, the eyesight, and, iu some degree, the- form of the eyeball, arc tor ever lost, and it will be lucky, if the case can be bron.ht to a conclusion with the mere destructi u of the cornea. But when tbe uiattei points at once in several places ofthe conjunctiva, round the cornea, ab idea of preserving the shape of the ey-e sufficiently tor the application of an artifi- cial eye is out of the question, and the sur- geon w ill be very successful, if he can now c; <*i k iu moderate time the suppuration, mi ich continues w ith a good deal of gene- ral indisposition. An extraordinary relaxa- tion of the conjunctiva of the lower eyelid, 334 OPHTHALMY and a consequent ectropium, are the least disastrous effects ofthe absee>se« ofthe eye thus produced. Lastly, Beer remarks, that when chemosis is in the second stage, that is lo say, attended with suppuration of the eye, it rarely happens, under the most fa- vourable circumstances that the eyesight and shape of the organ can be preserved entirely free from permanent injury. (B. 1, p. 418.) Lei us next consider the treatment of idio- pathic external ophthalmy iu its modifica- tions of simple inflammation of tbe con- junctiva, mild acute ophthalmy, or taraxis, and severe acute opnthalmy, with che- mosis. According to Mr. Travers, simple inflam- mation of the conjunctiva unconnected with injury ofthe eye, and neither depend- ing upon any established disorder of Ihe system, nor modified by a scrofulous dia- thesis, may be easily and speedily reduced, even in its mosl acute form, by bleeding and some brisk doses of purgative "medicine. (Synopsis ofthe Discaes of the Eye, p. 247.) For the relief of mild acute ophthalmy, Scarpa recommends low diet, gentle purging with small repeated doses of aiitimoniiim tartarizatum, the removal of any extraneous body lodged under tbe eyelid, and frequently washing the eye with a warm decoction of mallow leaves, and covering it with a very soft emollient poultice, included in a fine little muslin bag. Mr Travers also expr-sses his decided preference to a tepid application in the painfully acute stage <>f inflammation, and considers simple warm water generally better than medicated lotions, like the aque- ous solution of opium, or infusions of poppy and hemlock. When the disease presents itself in its first stage, in the mild form of taraxis, says Beer, it usually runs its course, quite uncomplica- ted with any general indisposition, and may be cured by moderate antiphlogistic treat- ment, in which, indeed, since the eyeball it- self is affected, particular attention must be paid to lessening the action ofthe light and air upon the organ. But when a true che mosis is present, every antiphlogistic means must be promptly and rigorously put in practice, internal as well as external reme- dies being employed, and besides common measures, the conjunctiva, round the cor nea, is to be scarified ; a proceeding never necessary in the case of taraxis. Such sca- rifications, Beer observes, have a wonderful effect when practised at the proper period, aft r veues' a ion and topical bleeding with leeches have been fully put in execution, and when the cuts are made de* p. so as to produce immediately a copious discharge of blood. " By means of such scarifica- tions (says he)'I have seen the inflam- mation and all its threatening effects re- cede, as it were, before my face, when no material relief could be effected by other measures." (B. I, p 419.) According to the late Mr. Ware, there cannot be, in chemosis, an easier or more effectual remedy than a?ther. A few drops are to be poured into the palm of the hand, and diffused over it, which may be inime- diately done by pressing the other band against it The hand is then to be applied to the eye, and kept so close to it that the spirit, as it evaporates, may insinuate itself into the part affected, and act on Ihe extra- vasated blood, so as to disperse it. In a few instances of chemosis, in which the swelling and inflammation have been considerable, this gentleman found the following applica- tion of singular service : l\. lnteriorum fo- liorum recentiutii Lactuca? Sissilis ?iij. Coque cum aq. pur. "^ss. in balneo maria*. pro semihora ; tunc exprimalur succus, et applicetur paululum ad oculos et ad palpe- bral saepe indie. (Ware, p. 54) As these applications are not noticed bv the genera- lity of modern writers, I infer, that the supe- rior efficacy imputed to them by the late Mr. Ware, is not such as to obtain the con- fidence of all other ophthalmic practitioners. General and local bleeding, and, if chemo- sis be present, scarificat ons having been put in practice, (he treatment is to be continued by administering purgatives of tbe mildest description, and, after their operation, apply- ing blisters, according to the directions given in a preceding part of this article. In the firsl stage of severe acute ophthalmy, Scarpa considers topical emollient applica- tions to the eye most beneficial, such as mallows boiled in new milk; bread and milk poultices ; or the soft pulp of a baked apple ; all included in fine little muslin bags. Remedies of this description should be re- newetat least every two hours. The pa- tient should be directed to observe perfect quietude, and to lie with his head in au elevated position. To keep the eyelids from adhering together in the night-time, the spermaceti cerate is proper. When ophthalmy is accompanied with a violent pain in the head, the late Mr. VVare recom- mended a strong decoction of poppy-heads to be applied as a fomentation. (P. 51.) Under the preceding plan of treatment, the first stage of severe ophthalmy com- monly abates in about a week. The burning heat and darting pains in the eyes, and the febrile disturbance of the constitution sub- side. The patient is comparatively easy, and regains his appetite. The eyes become moist again, and can now be opened without experiencing vast irritation from a moderate light. In this state, notwithstanding they may continue red, and tbe conjunctiva swelled, all evacuations are to be left off, as well as the use of topical emollients, for which latter astringent, corroborant collyria are to be substituted. Suaipa recommends the following application : fy. Zinci sul- phatis gr vj. Aqua* distillate ||vj. Mucil. sem. cydon. mali ^j. Spiritus vini cam- phor guttas paucas. Misce et cola. This coilyrium may be injected with a syringe, between the eye and eyelids, once every two hours; or the eye may be bathed in it by means of an eye-cup. Such persons as cannot bear cold applications to the eye, must have the same kind of coilyrium a little OPHTHALMY 333 warmed; but as soon as the irritability is lessened, it may be used cold. Scarpa then speaks of the good effects produced in the second stage of ophthalmy by the application to the eye of two or three drops of the vinous tincture of opium, once or twice a day ; a subject already consider- ed in the foregoing columns. The utility of letting the eye be habituated to the light, as soon as it can bear it, is next strongly commended; a rule of great importance, but on which 1 need not here dwell, be- cause it has been already insisted upon in thcigeneral observations. When idiopathic exlernal ophthalmy has terminated in suppurations of little extent, Beer speaks highly of the benefit derived from a solution of the lapis divinus, (see Lachrymal Organs) containing the liquor plumbi subacetatis, or from smearing the suppurating points with a little laudanum. In worse cases, Beer stales, thaf, when such local treatment is combined wilh tbe inter- nal exhibition of bark and naphtha, and a diet and regimen conducive to the support of the system, its efficacy is very great. And here, says he, it is worth observing, that while the solution of the lapis divinis is of great service in the second stage of true chemosis, it is more or less detrimental in the kind of chemosis which accompanies purulent ophthalmy, especially if not blend- ed with mucilage, and, even when thus qua- lified, it cannot be endured by weak and irritable subjects, affected with the latter complaint; a fact not observed in other in- stances of chemosis. (B. 1, p. 420.) To Mr. Ware's use of aether in chemosis, 1 have already adverted. When pustules, or abscesses in the swell- ed conjunctiva point round the cornea, a free outlet to the matter must he immedi- ately made in each of them with a lancet; for, if this be not done, as Beer observes, the matter will spread extensively, and the eyeball be in danger of being destroyed. For an account ofthe method of treating the eversion ofthe lower eyelid, sometimes re- maining as a consequence of the disorder, see Ectropium. Inflammation of the Sclerotica. Sclerotitis. —The modern attempts to class ophthal- mies, according to the texture of the eye first or chiefly affected, promises, I think, to lead to clearer views of the subject, and sounder practice. One circumstance, par- ticularly adverted to, both by Dr. Vetch and Mr. Travers, in inflammation ofthe sclero- tica, is the appearance of a vascular zone at the margin of the cornea. By the latter gentleman, this effect is ascribed to the par- ticular distribution of the vessels. " Branches f omthe straight vessels ofthe conjunctiva, pmetrate the sclerotica obliquely towards the margin of the cornea, and the long ci- liary vessels pass in sulci of this membrane to the plexus ciliaris at the root of the iris. At the interior border of the sclerotica, where the annulus ciliaris is adhering closely to this tunic, the ciliary communicate with the muscular branches, an J being in deep- seated inflammation fully injected with red blood, the condensation of colour gives the well-known and remarkable appearance of a vascular zone at the margin ofthe cornea." (Synopsis, fyc. p. 126.) According to Dr. Vetch, only a few interspersed trunks are posteriorly observed, " w bich do not affect the natural appearance of tbe intermediate space, but these, diverging as they come forwards, produce a zone more or less com- plete, of minute hair-like vessels, distin- guished by their rectilinear direction, and their uniform concentration towards the margin of the cornea ; their colour advances with the progres-of the disease, from that of a delicate pink, or damask rose, to a deeper hue, and imparting a faint blush to the part immediately surrounding it." (On Diseases of the Eye, p 27.) There appears, however, to be a good deal of variety in the symptoms of sclerotitis ; for rheumatic in- flammation of the eye, described by Pro- fessor Beer and Mr. Wardrop, as particularly affecting the sclerotica in common with other fibrous membranes, is not noticed by these authors as characterized by the red zone round the edge of the cornea. Indeed, instead ol there being posteriorly only a few interspersed trunks, Mr. Wardrop states, " that (in rheumatic ophthalmy) the blood- vessels are generalK equally numerous over the whole white of die eyet passing forwards in nearly strai.ht lines from the posterior part of the eyeball, and advancing close to the cornea; but neither passing over it nor leaving the pah circle around it, which is so striking when either the choroid coat or iris is inflamed. If the vessels be closely exami- ned, the general redness will be found pro- duced more from numerous small ramifica- tions than a few large trunks." (Med. Chir. Trans. Vol. 10, p. 3.) However, as if there must be no harmony.on this subject, Beer describes the blood vessels, in rheumatic ophthalmy, not as being equally numerous over the whole white ofthe eye, but as be- ing in some places collected in larger numbers or clusters, and he differs again from Mr. Wardrop, in describing the redness as coming on with considerable intolerance of light, (Libre von den Angenkr. II. 1, p. 397 — i98,) while the lalter author distinctly mentions, that " the eye does not seem to suffer from exposure to light." (Med. Chir. Trans. Vol. 10, p. 6.) I can only reconcile these accounts by concluding, that sclero- tic inflammation, like that of other textures of the eye, has stages and modifications which account for these seeming contradic- tions. And, with respect to the vascular zone round the edge ofthe cornea, it would appear, at all events, to belong lo iritis, as well assclerotic inflammation. The vessels of the sclerotic coat are observed by Dr. Vetch to follow the motion ofthe eye, and he says, that they may, by this circumstance, be distinguished from those of the conjunc- tiva, " the vessels of the latter, independent of their darker colour, their more lorfuous form, and varying size, have likew ise a more: longitudinal direction- and as (hey proe-<*c.t S36 'HI1HALMV- > from the angles ol the orbit, they form radii of a larger circle. The distinction between the inflamed vessels of the conjunctiva nnd the sclerotica, (says Dr. Vetch) I consider to be, therefore, obvious ; but, that any dif- ference can be obserred in the arrangement or appearance of the i essels oj' the la ter, suffi- ciently distinct lo indicate Ihe peculiarity of the exciting cause, or specific nature of Ihe case, is more than I have been a le to perceive. Ihe general character, as it arises out of tbe structure ofthe part, will be found the same, whether the cause be gout, rheumatism, or syphilis. The vessels, such as I have de- scribed them, will always be most observa- ble on the upper portion of the eye, as it is in that place that the inflammation is most intense, except when its locality is affected by any external exciting cause, in which case it will be greatest near the injured part." (On Diseases of t'ic Eye, p. 29.) While Dr. Vetch describes Ibe vessels of the conjunctiva as exhibiting in sclerotic inflammationadarkercoloiirthdii that of the vessels of the sclerotic coat itself, Mr. Tra- vers represents the vessels of the latter mem- brane, which pursue a straight course to the margin of the cornea, as having a somewhat darker hue than the areolar vessels upon the loose portion of the conjunctiva. It should be mentioned, however, that by sclerotic inflammation Dr. Vetch signi- fies inflammation of the eye itself, as con- trasted wilh conjunctival inflammation; but, how far this will account for the differ- ences, above pointed out, between his des- cription and that of Mr. Travers, I am not prepared to say. According to Mr. Travers, ordinary inflammation of the sclerotica is secondary, that is to say, this membrane is usually affected only as intermediate to the conjunctiva and the other tunics. How- ever, he has occasionally observed, in a re- cent ophthalmia, a turgescence of the ves- sels, which pursue a straight course to the • ornea, unaccompanied with any affection of fhe iris, and so slight a vascularity of the loose conjunctiva, that he vvas disposed to regard the case as a primary sclerotitis. The inflammation he says, is not acute, and the motions of the eyeball are painful. It sometimes accompanies, and sometimes fol- lows rheumatic inflammation. If continued, it presents the vascular zone and a pupil contracted, or drawn a little, to one side. It is often seen in company with eruptions, or sorethroat, of a pseudo-syphilitic cha- racter, or is secondary (o gonorrhoea. ( Tra- cers, Synopsis, fyc.p.'l23) The practice/ recommended by this gen- tleman, is as follows: obtuse pain in (be eyeball, he says, maybe materially relieved byblood-!eiting,i completely closed, that the iris seems as it it had no aperture whatever. Bi;t long before this pcrlect closure of the pupil has It-ken place, (he power e f sCtj„g js r-mircly OPHTHALMY. 337 gone, (hough alter the faculty of perceiving tbe external light is eiimguished, fiery ap- pearances, which trouble the patient serious- ly, are seen al each pulsation of Ihe blood- vessels within the eye. As the developemenl of these symptoms is going on, the* iri*- evi dentt) loses its natural colour, becoming, as Beer says, greenish, when it was gray, or blue ; and eddish, when ils was b own, or black. Iu consequence of Ihe iri- swelling, and projecting towards the cornea, ihe ante rior chamber becomes considerably diminish ed. Immediately ihe least mark of the swell- ing of Ibe iris is se. n,together with a mode- rate degree of contraction of the pupil, the whole sclerotica assumes a pink-red colour ; n plexus of innumerable blood-vessels is seen in the conjunctiva ; und the cornea loses a good deal of its natural brilliancy, without being actually opaque. The latter symptoms of (his form of ophihal ny are at ended with manifest general indisposition, and intolera- ble headai h. Sometimes in the first stage of Ihe case, (he pupil, though much lessened, is not absolutely closed, bul thickish and if oxamined with n magnifying glass, it has a red ish-gray appearance, and the power of vision, notwithstanding (he continuance of the aperture, is quite lost. (Beer.) Symptoms in the second stage. According to ihc- same author, while the eye is suffering very irregular throbbing pain, attended wilh a sensation of heaviness and cold in the eye, an increase of ttie redness of the conjuncti- va, severe constitutional disturbance, and constant shivering, there is suddenly formed al the bottom of the anterior chamber a col- lection of matter which above presents a horizontal line, but on every inclination of the nead sideways, changes its position. This matter continues to accumulate more and more, until it not only teaches the pupil, bul Alls ih< whole of the anterior chamber, con- stituting the case termed Hypo/ium. If Ihe disease be left to itselt, says oeer, the mailer collects in such quantity, that Ihe cornea ia rendered more prominent, and afterward conical, very like an abscess, ultimately bursting during an aggravated attack of pain, when the eye shrinks, and (he sufferings gra- dually cease. This kind of hy,.opium Beer names true, in order (o distinguish it from the case, in which tbe matter passes into the anterior chamber out of an abscess in the corn-a, and which he terms a false hypopi- um. When, at the end of Ihe first stage, the pupil is not entirely closed, one may discern in the second stage, at the period of matter presenting itself at the bottom of the anterior chamber, (though not easily with the unas- sisted eye) whitish filaments, extending from (he edge of that opening towards its centre, produced by the coagulable lymph effused in the aqueous humour, the secretion of which was interrupted io the first stage, but now commences again. And, continues Beer, one may perceive, with a good magnifying glass, a very delicate cobweb-like mem- brane, which, when tbe matter collected lies over the pupil, and remains for a good while uuabsorbed, at length becomes quite yet- Vol. II. 43 low, the matter being really encysted by it in the form of a small lump, which remains iu (he pupil, nd partly projects into the ante- rior chamber, forming the case, w hich Beer denominates .1 spurious purulent cataract, to which the edge of die iris is -0 closely adhe- rent, that sooner than <> separation could be effected, the whole of the iri-* would be torn in piur ofthe iris undergoes h material altera- tion, first ai ils lesser circle, which grows much darker, and afterward at ils greater circle, which (urns greenish, wdien it was gray or blue, but reddish when il was brown or black. At the same lime, the margin of the pupil becomes indi-tinct, and appears not so ♦sharp as natural. As soon as the greater ring of the iris has undergone a considerable change of colour, this membrane becomes evidently swelled, and pojects towards the cornea, so ih it ihe anterior chamber is very much lessened. As early a the period when the contraction of the pupil, and (he immo- bility of the iris, aie observable, a serious di- minution of ihe power of vision occurs ; be- cause, in all cases, tbe inflammation extends more or less over ihe anterior layer of tbe crystalline capsule, and afler>vard, whei, the case is somew hal m ne advanced, says Beer, one may perceive quite plainly, wilh (he Unassisted eye, those effects of iiiflmim 'tion on the capsule, which have been so excel- lenUf described by Professor Waif her. (Ah. handl. aus detn Gtbieth* der Practuchcn Me- dian, 1 B. Landshut, 1810.) In proportion as the inflammation makes progress, the pain grows more severe and extensive, and to- wards the end of the first stage, it shouts par- ticularly up to the lop of ihe head; a rir- cuinttanee strikingly proved whenever any thing like slight pressure aggravates the pain in the eye. The redness percep ible in (he eye during the whole of tbe first stage is in- considerable, and seems to be not at all pro- portioned to (he violence and danger of the inflammation ; for the sclerotica is only of a rose-red colour, and even this pale redness fades (owards the circumference of tbe eye- ball. (B. \,p 434.) According to Beer, idiopathic iritis is al- ways, attended with a corresponding general disturbance of the system; but a good deal depends upon whether the inflammation sp.eads immediately to tbe deeper textures of the eye. or to its outer coots, or in both directions at once. In the first case, the constitutional indisposition is always more severe, and the danger of the disease in- creases every moment; in the second in- staiice,the augmentation of the general symp- toms is less striking; but in the third, the inflammation, and the corresponding febrile symptons soon rise to such a pitch that the possibility of preserving the eyesight be- comes very doubtful. The continued ope- ration of hidden exciting causes, neglect, nnd erroneous management of the diseass, also produce considerable differences; and, as Beer observes, it not unfrequently hap- pens that a genuine idiopathic iritis, which does not appear at first very dangerous, nor rapid in its progress, will suddenly change, under the unfortunate concurrence of the circumstances, above alluded to, into a com- plete inflammation of Ihe whole eyeball, de- stroying the organ in a few days, unless tbe most efficient treatment be speedily adopted. In the second stage, says Beer, in conjunc- tion wilh a corresponding still more mani- fest general indisposition, the pain in the eyp grows very irregular ; luminous appear- ances flash within the organ, aud seriously annoy the patient, especially in the dark, while the power of seeing the exlernal light undergoes a great decrease: the rednesj, even in the conjunctiva, increases ; and Ibe, pupil, which hitherto has been perfectly cir- cular, becomes more or less angular. At Ihese angles, something of a lighl grayish co- lour may be seen projecting behind the pu- pillary edge of ihe iris, and on examination with a glass, plainly appears to be a very de- licate layer of coagulating lymph, by which, first Ihe lesser ring of the uvea, and (if pro- per treatment be not expeditiously employ- ed) also its greater ring, are soon rendered adherent to the anterior portion «»f 'he cap- sule of (he lens, (synechia posterior,) which membrane, as the disease advances, becomes more and, more deprived of its transparen- cy. Under these circumstances, it is evident, that 'he power of vision mus( daily decline, and that if this process of (he effusion of lymph anr1 Itsorg-iriiz'-r'- n !«•» no! rcsijledby OPHTHALMY. 31» powerful measures, tbe patient will soon be left just capable of faintly distinguishing tbe light. While (be above-described changes are taking place belween (be uvea and ante- terior position of the capsule, very peculiar effects are occurring in (he anterior cham- ber; for, as the iris continues to project fur- ther towards the cornea, the latter mem- brane grows less and less transparent, and tbe iris seems as if concealed in a mist, al Ibe same time that a small, yellowish, red, round prominence is formed at one or more places together,generally between (he great- er and lesser rings of tbe iris, and proves af- terward (o be a small abscess, which ulti- mately bursting, pours its contents into the anterior chamber, and thus occasions a true Hypopium. For several days, the flakes of tbe burst little cyst, still connected with the iris, may be seen floating in the aqueous hu- mour, until they gradually disappear. When there is not merely one, but several of these little abscesses, says Beer, Ihe greater part of Ihe anterior chamber may be filled with matter, so that little more of the iris can be distinguished. In weak subjects, at Ibis pe- riod ot suppuration, blood may not unfre- quently be perceived in the chamber of Ihe eye ; u circumstance regarded by Be er as a very unfavourable omen, n respect to the recovery of sight, as in such cases, portions of blood and matte: are ■ pt to lie iu the pos- terior chamber entangled in tbe lymph. Ac- cording to the same author, ihe malter in the anterior chamber is at Inst absorbed ; (he pupil, if it has been concealed, can again be seen, bul ii appears angular and very turbid ; and in consequence ol ihe layer of lymph in the posterior chamber, the eyesight is ex- ceedingly diminished, or even reduced to tbe mere power ol knowing light from dark- ness. Sin b, says Beei, is the course of the second stage ot idiopathic iritis, when (he inflammation has nol extended lar beyond its proper locu-, and has been principally con- fined io ibe iris, corpus ciliare, the lens and its capsule, and the anterior part of the scle- rotica. But if il should spread more deeply to Ibe vitreous humour, the retina, ihe mem- braua Ruyschiana, and Ihe cboroides, symp- toms oi internal opmth :lmy (siricd} sot-ail- ed) then occur wth great vehemence in Ihe fiist stage, and at the termination of Ihe se- cond, the eyesight is for ever certainly de- stroyed in such a degree, (bat not the leasi perception of light remains; and even ii (he patient should think that he can distinguish it, the feel is only a deception ; a develope* ment of light within Ihe eye itself; of which ibe surgeon may easily assuie himself by placing the patient with his back towards tbe light, and asking him to poini out where it is; or by putting him directly opposite a window, and moving the hand slowly along before his eyes; of which proceedin. the patient w ill be cpiite unconscious. The ef- fects till in Ibi eye after such an inn-, and indicating its unsehirvous extension, an so cbarac tenstie-, that, on the fir-i inspection of tbe eye, no surgeon can entertain a doubt of ■ha deeper tenures of the eye having been involved, in the infl.vmmation. But when idiopathic irilis extends rather to the exter- nal, (ban the deep textures of the eye, the swelled iri*, a? early as the end of the first stage, approaches so near the cornea, which grows less and less clear, (hal (hey seem as it they were adherent, ere (he second «tage has commenced. And, indeed, on the ac- cession of this stage, they actually adhere together at every point, either directly, or with the intervention of a mass of coagula- ting lymph. In Ihe first event, at (he end of the second stage, the cornea forms a co- nical protuberance, and a total staphyloma arises ; (see Staphyloma;) but in (he second, the cornea is said no( to undergo this change. On ihc contrary, it becomes rather flat, and on account ofthe layer of organized lymph, which fill- up the space between the corner* and iris, btlle of the litter membrane can be discerned, and what can be seen, appears lo have ils organization entirely subverted. When idiopathic iritis in its first singe ex- tends its effeds direclly over the whole, eye- ball, ihe eye becomes nearly or quite de- stroyed in the same manner as in cases of vi- olent acute ophthalmy. The causes which give rise to idiopathic irilis, mn-t always he such as operate d'nect- ly upon Ihe iris; and, hence, the disorder is usually a consequence of injurips and wounds ot the eye, produced by accident, or in operations. And, says Beer, although rheumatic inflammation oi the eye, when neglected, or wrongly treated, may ai length aff-ct the iris, and adjacent textures, yet such an irilis is but n secondary effect, deri- ved from the pre-existing rheumatic oph- thalmy. All injuries in which the weapon, or instrument, has more or less pre-sed against, flushed, ii i il»t< d,or violeni ly brui-ed, or torn, ihe iris itsi-h, and all largish wouids of the cornea, are lo be accounted 1he prin- cipal exciting causes ot idiopathic irilis. Hence, extra-'ion ol ihe cataract is not un- frequently followed by this in flammation, when th' flap of the cornea is kept too long op> ned, a d the iris is hurt wilh any blunt instrument ; when the incision in the cor- nea is loo small, and a hard ca aract pushes tbe iris belween Ihe lips of the wound, and is slowly pressed out of the eye ; when many pieces of the cataract break off. X'S, nnd opei aiions for artificial pup 1. Nor, as Beer observes, is it at all surprisiiii. that irili- shouhi follow thesi las' ope-mienis.. as the singeon has often to in. eldle n i h an iris tha* has been dready \ioi.nily nfl ned. Prognosis ir. the first stage. Venous : s the disord i aiu ay s i.-; ii, , i,j- Hydrargyri nitrico-oxydi rabri gr. vj. Extract opii gr. viij. M Beer also states that rubbing a little mercurial ointment, with uhiib some opium is blend- ed, once a day into the eyebrow, will great- ly promote tbe removal of the lymph effu- sed in the posterior chamber. (B. 1, p. 450.) Excellent as Beer's description of idiopa- thic iritis certainly is, tbere are some im- perfections in his method of treatment. 1st, It does not appear to me, tbat he insists suf- ficiently upon the necessity of taking away a Very large-quantity of blood at the com- mencement of the rase, and of repeating the general and topical bleeding, until tbe circulation is duly lowered, and the violence of tbe inflammation checked. 2dly, Though his recommendation of rigorous antiphlo- gistic treatment implies the approbation both of bleeding and cathartics, be says nothing of the use of moderate doses of tartaiized antimony, in weakening the pulse ; a practice highly praised by the late Mr. Saunders. (On some Practical Points relating to Diseases of the Eye, p. 26, Svo. Lond. 1811.1 3dly, If mercury has the pow- er of arresting acute inflammation of tbe iris, " both prior to, and after, the effusion of ad- hesive matter," and of rapidly removing, "by an excitement of tbe absorbing system, peculiar to itself, the newly-effused mat- ter, (Travers, Synopsis, fyc. p. 291,) then Beer must delay too long the employment: of this powerful medicine, since he does not commence its use until the close of the second stage, when he has found, that the absorption of the effused lymph cannot be effected by other means. 4tnly, Beer en- tirely overlooks the important utility of bel- ladonna and hyosciamus in producing a dilatation ofthe pupil, whereby adhesions of the iris to tbe capsule of the lens, or to the cornea itself, may frequently be prevented, or their ill effects considerably lessened. Belladonna, (says Mr. Saunders,) " if properly applied to the eye, during the ad- hesive process of inflammation, will cause the inner margin of the iris to expand, and recede from the axis of the pupil, and will thus overcome the restraiut arising trora the agglutination of lymph, by elongating tbe organized bands, which connect the iris and capsule, if tbey have not been of long duration. Thus, the adhesions are drawn out to a degree of tenuity, and consequently transparency, and a considerable quantity of light is admitted. If the effect of the inflammation bas been slight, the adhesions will be trivial, and the pupil only slightly irregular. The iris will retain a certain power of action, and vision will be very little injured. In general, the pupil is misshapen, and tbe iris perfectly fixed; but, if the aperture be of sufficient size, and the capsule not rendered too opaque, the patient will enjoy a very useful degree of sight." (Saunders, p. 32.) Respecting belladonna, it is observed by Langenbeck, that, as all applications directly to the inflamed eye itself are frequently hurtful, and render it still more painful and irritable, it is a good plan to let the extract of belladonna be smeared upon tbe eyebrow, instead of putting a solution ot it immediately in contact with the conjunctiva. (Neue Bibl. B. 2, p. 236.) The same author expresses his attachment to Beer's method of rubbing mercurial ointment with opium into the eyebrows; and, after dwelling, with due force, on tbe necessity of copious and re- peated bleedings, leeches, evacuations, be. be cautions practitioners not to be led into the supposition, that the efficacy of bella- Jk OPHTHALMY donna will supersede the occasion for taking away blood. He even declares, that, during the first vehemence of the inflammation, the application is quite inefficient, and that it frequently will not succeed in producing a dilatation of the pupil, before bleeding has been practised. " If, (says Langenbeck,) bleeding is to be useful in iritis, it must be copious, and often repeated." Specific Cases oj Iritis. The foregoing ob servations refer to idiopathic iritis, or in- flammation of the iris uncomplicated with any specific disease. But there is an iritis, which " appears in company witb rheuma- tism of the chronic form ; sometimes with gout; with the constitutional signs of the lues venerea; and during, or following, the action of mercury upon tbe system." (Tra- vers, Surgical Essays, Part 1, p. 59.) Mr. Hunter entertained doubts, whether any inflammations of the eyes are syphilitic, and he appears to found bis opinion upon two circumstances ; one is, that, if such cases be venereal, the disease is very diffe- rent from what it is when it attacks other parts, and is attended with more pain than venereal inflammation, arising from an af- fection of the constitution : the second is, that be never saw these cases, attended with snch ulceration, as occurs when the com- plaint invades the mouth,throat, and tongue. (Hunter on the Venereal Disease, p. 324.) On tbe other hand, the generality of modern surgeons believe in the reality of venereal ophthalmy, though their accounts of the symptoms and appearances of the com- plaint are in some respects discordant. Scarpa says, the venereal ophthalmy is pe- culiar in not discovering manifest signs of inflammation, stealing on clandestinely, without much uneasiness. It afterward re- laxes tbe vessels of the conjunctiva and lining of tbe palpebral, and changes tbe se- cretion of Meibomius's glands. In time it causes ulceration of the margins of tbe eye- lids ; the ciliae fall off, and the cornea grows opaque. In the worst stage it excites itch- ing in the eyes, which is exasperated at night, and abates in violence towards morn- ing, as do almost all the effects of syphilis. ft never attains tbe state of chemosis. With the exception of the venereal oph- thalmy, in tbe form of iritis, 1 cannot dis- cover, that any thing very certain has yet been made out. By this observation, bow- ever, it is not meant to assert, that cases, corresponding to Scarpa's description, do not present themselves, and may not be relieved ny bis method of treatment; but, that their venereal character is not fairly proved. In examples, like those described by Scarpa, the decoct, sarsap. the oxymuriate of mercury ; mezereon; guaiacum ; and even mercurial frictions, may be employed, with leeches and blisters. Scarpa particu- larly recommends a coilyrium, made with the oxymuriate of mercury. When the eyelids are ulcerated, the unguenturn hy- drargyri niti at ri, weakened at first with twice or thrice its quantity of tbe unguenturn ce- :*re*.*rn. i? the be-^Mopical applicdip-i. The iris is now supposed to be more li;,. ble than any other pait of the eye, to vene- real inflammation. (Itardrop's Essays on the Morbid Anat. of the Eye, Vol 2, p. 36.) The case is mentioned by Mr. Saunders, w ho recommends the vigorous exhibition of mercury, and the use of belladonna. Its symptoms and treatment, however, have been more particularly detailed by Beer. (Lehre von den Augenkr. B. 1, p. 663.) As this ense, and some other specific forms of iritis, are described in the first vol. of tbe last edition of the First Lines of Surgery, I need here only refer the reader to that volume, and to a few works containing ad- ditional information on iritis in general; as Sounder's Treatise on some Practical Points, relating to Diseases of the Eye. p.21,8co. 1811; and particularly the latter editions, in ichich the utility of mercurials is noticed. Beer's Lehre von den Augenkr. B. 1, Hvq, Wien. 1813. In the article Hypopium, I have referred to an early case, in which the quick exhibi- tion of mercury and its good effects were exemplified in Germany. But whatever claims the continental surgeons may have respecting the first administration of mer- cury in iritis, 1 believe it a justice due to Dr. Farre and Mr. Travers to state, that these gentlemen have undoubtedly given not only the best practical directions on tbe subject, but laid the greatest stress upon the neces- sity of the practice, establishing the efficacy of mercury, as a means as well of rtsisting the effusion of lymph in the eye, as of exci- ting the absorption of it, after it has been effused. (See Travers, in Surgical Essays, Part 1.) Consult also J. Vetch, A Practical Treatise on the Diseases of the Eye, p. S8,$-c. 8vo. Lond. 1820. Welter's Manual of tht Diseases of the Human Eye, Trans, by M aqueous humour is discharged, and the eye- ball collapses, when all pain ceases; or abscesses may form within the posterior chamber, and burst through the sclerotic coat. (Wardrop, in Med. Chir. Trans Vol. 10.) Beer describes small watery vesicles as forming on the cornea, or white of the eye, and changing during severe pains into small ulcers, which occasion an appearance, as if a small piece were torn out of the sur- face of the cornea. He adds, that they seldom leave scars behind ; but generally little pits, which are soon filled up in healthy subjects. (See Weller on Diseases of the Eye, Vol. 2, p. 217 ) The causes of rheumatic ophthalmy, enu- merated by writers, are change of weather, variation of temperature, exposure to damp, a cold current of air directly striking the eye, and a constitution disposed to rheuma- tism. Mr. Wardrop states, that both sexes are equally subject to tbe disease ; but that he has observed it most frequently in adults, aud persons of rather advanced age. Only one eye is usually affected ; and when the second is attacked, the disease is almost always less severe in it, than that which is first inflamed. According to Mr. Wardrop, rheumatic ophthalmy resembles syphilitic more than any other kind of inflammation of the eye. But, be notices, that, in rheumatic ophthalmy, Ihf proper vessels of the sclerotic coat are enlarged, which is the cause of the redness being generally diffused over the whole albuginea, whereas in syphilitic inflammation, U is the anterior ciliary arteries, passing along the sclerotica on their way to the iris, which are chiefly affecled; and hence the pale ring, which is always observed between the cor- nea and the enlarged vessels. Mr. Wardrop further explains, that though these diseases resemble each other in tbe pains round the orbit, and their evening exacerbation, pa- tients, with syphilitic ophthalmy always have the constitutional symptoms of syphilis. When the disease has made much progress, and the symptoms have not yielded to other remedies, Mr. Wardrop recommends the evacuation of tbe aqueous humour, as a prac- tice, fr'-m which the most beneficial effects may be expected. After the operation, fo- mentations are the only necessary applica- tions ; but, if the eye continue long irritable, the vinous tincture of opium is to be used. Mr. Wardrop enjoins attention to the state of the biliary organs in every stage of the disease, and speaks highly ofthe sudden relief sometimes afforded by an emetic, care being taken to empty the bowels afterward with calomel and rhubarb, or other purgatives. If the functions of the skin were suddenly interrupted by a chill just before the attack, this author prescribes a couple of grains of antimonial powder, alone, or combined with opium, to be taken every four or six hours. Little advantage, ne says, is derived from local bleeding, and where venesection may become necessary, on account of the com- plaint resisting other means, it ir to be nra< tisH vvith moderation -44 ©PHTHALMY. In the early siage, Mr. Wardrop has found, that the pain in the eye and eVebrow are sometimes much alleviated by a fomentation °with the decoction of poppy-heads. He also praises blisters to the nape of tbe neck, or behind the ear; but, disapproves of their being put near the eye itself. The vinous tincture of opium, he says, is the only local application which he has ever seen deci- dedly beneficial; but, its use is to be deferred, till a late stage of the inflammation, when all febrile symptoms have been subdued. " After the prima? viae have been well evacuated, the tongue may still remain very white, and the pulse quicker than natural." In this state, small doses of bark, either alone, or witb the mineral acids, will be most serviceable. (Wardrop in Med. Chir. Trans. Vol. 10.) The outlines of Beer's practice may be given very briefly: iu the first stage, he applies a leecb to the inner canthus, and covers the eye with a cold poultice, with a small proportion of vinegar in the water, with which it is made Diaphoretics are also prescribed. In the second stage guaiacum, camphor, arnica, anfnnonials, blisters to the neck, or behind (be cars, frictions with opium over the eyebrows, and covering the eyes witb bags of aromatic herbs and cam- phor, are the means of the relief. When abrasions, or ulcerations exist on the con- junctiva, sclerotica, or cornea, a coilyrium of the lapis divinus, with a large addition of the vinous tincture of opium,is commended; or if the ulcers are large, and on the cornea itself, they may be touched with the latter tincture by means of a camel-hair pencil. After each use of the coilyrium, Beer covers the eye again witb the bags of aromatic herbs and c.itnphor. (See Welter on Diseases ofthe Eye, Vol. 2, p. 218.) Respecting tbe last application, I have already expressed my belief, that it is one which is not likely to obtain credit among English surgeons. Scrofulous Ophthalmy. According to Mr. Travers, tbe inflammation of the conjunctiva, termed strumous, when it has not proceeded to a change of texture, is not marked by any prominent local character." The vascularity is inconsiderable. This inflammation some- times accompanies pustule of the sclerotic conjunctiva, in which case, the vascularity is diffused, instead of being partial, as in pure pustular inflammation, and tbe intole- rance of light, characteristic of the strumous inflammation, is present in a greater or lesser degree. It accompanies also the morbid secretion of the lids, when the eyeball becomes affected by tbe acuteness and dura- tion of that disease, and the pustule on the cornea, especially tbe variolous pustule. In its simplest form, it is almost peculiar to young children, stationary, marked by a very slight redness of the sclerotic conjunc- tiva, and the greatest possible degree of intolerance (of light") Tbe same author attributes the disease to a morbid sympathy of the retina with the secreting surfaces of the prima; viae and skin. The following is die treatment, proposed by Mr. Travers for ■■v-h f'-' i <•*•■■-' i»':-.'folo"? oph*!;?''*.-"*^ : I. Strumous inflammation, without change of texture, vascularity more or less, intole- rance (of light) excessive. Calomel and opium, at night; emetic tartar to continued nausea; gentle alvine evacuants ; diaphoretic drinks; large open blister on the nape of the neck; leeches; tepid bath ; tepid or cold water washes, as most agreeable; vapour of opium ; larze bonnet shade ; no Imiidages ; spacious airy apartments ; and light bed-clothing. 2. With recent diffused opacity of the corneal conjunctiva, and vessels raised upon and over- shooting the corneal margin. Calomel and opium to slight ptyalism ; purgatives on alternate days ; leeches; blisters alternated behind the ears and on the nape of the neck and temples. As tbe acute stage passes off, repeated circular sections of the vessels on tbe sclerotica, near the margin of the cornea. 3. With herpetic ulcers of the cornea The same ; blisters on the temples; as the in- flammation yields, solut. argent, uitrat.; via. opii', solut cupr. sulph. *. dilute reinc lotion. 4. With pustules. If partial, weak sine, or alum lotion ; ung. hydrarg uitrat.; occa- sional brisk purgatives; infusion of roses with additional acids ; tonic bitters ; colum- ba ; gentian, be. blisters behind the ears, repeated if necessary ; if tbe vascularity is diffused by the multiplication of pustules, or the duration of inflammation, with irrita- bility to light, treatment as in strumous in- flammation without breach. Ung. sub-acat. plumbi. 6. Wilh inflammation of the follicles and puriform discharge. Active measures at first, but not long continued. Blisters; when be- coming chronic, with thickened lids, scarifi- cations ; zinc, alum, or copper wash, dilute; ung. hydr. uitrat.; hydr. nitr. oxid.; sub- .cet. cupri ; tonics and sedatives; if obstinate, issue or seton. 6. Convalescent state. Infusion of roses ; cas- carilla ; columha ; decoction of bark ; with dilute sulphuric, or nitric acid ; steel, rhu- barb, and soda ; or magnesia, as aperients; tonic collyria and gently stimulant oint- ments; nutritive diet; country air; shower, or sea-bath, in the warm months. (Travers's Synopsis, fyc. p. 92—2fi0, fyc. When I look at the discordant accounts of what are called scrofulous affections of the eye, and the difference of practice laid down by different writers, I leave the subject witb an impression, that the terms scrofu- lous and strumous are here employed as much at random as in any other cases, which can be specified. Indeed, tbe attempt to recon- cile the various statements and descriptions of scrofulous ophthalmy, would puzzle the most able man in the profession : and it is with this belief, that I avoid contrasting tbe sentiments of Beer, Weller, Lloyd, and other modern writers with those already de- livered. (See particularly Beer's lehre ran den Augenkr. B. 1, p. 688; fyc.; Wellei's Manual of the Diseases of the Eye, Vol. 2, p. 266, fyc.; and Lloyd on Scrofula, P- 312, fyc.) Tbe following observations explain the ^racij-ce of Scarpa, and tbe late Mr. Ware- . OPHTHALMV. 346 No specific being known for scrofula, the treatment, in this instance, rather con- sists in preventing the aggravation, than in attempting the radical cure of the complaint. Every thing debilitating is hurtful, as all evacuations; indigestible food; intense study; a sedentary life ; damp marshy habitations ; uncleanliness ; frequent transitions from heat to cold. On the other hand, observing to regulate the action of the bowels with the mildest laxatives; and the administration of bark, cither alone or conjoined with the tinct.guaiaciammoniata,do good. Alterative medicines, and especially aithiops mineralis, from gr. ss. to gr. xx. in the day, taken for a few weeks uninterruptedly ; liquor calcis, in broth or gruel, at first, in the dose of -|iij. at breakfast, and afterward the same quan- tity, twice daily for a few months ; together witb tbe uniform observance of a good regi- men ; may tend much to abbreviate the du- ration of this obstinate species of the dis- ease. (Scarpa.) Mr. Ware found, that the addition of xx to xxx gr. of the potassae sulphas to each dose of bark, suffices to keep the bowels in a re- gular state, when there is a teudency to cos- tiveness. In some cases, in which there was little appearance of inflammation, this gentleman found the eyelids so relaxed, and the eyes so irritable, that children would not open their eyes, even in the darkest room. In some of these relaxed cases, very benefi- cial effects were produced by administering internally small doses of opium, night and morning, to abate the irritability. Sea-bath- ing is always serviceable iu scrofulous oph- thalmy, and, probably the mere residence on tbe seacoast, aud the respiration of the sea- air, may bring about some of those advan- tages, which nave been exclusively attri- buted to bathing. Friction of the body with a fresh brush or flannel, should be employed morning and evening. With regard to topical applications, those of a soft relaxing kind prove injurious, as also retirement in dark situations. Slightly astringent collyria ; the ung. tutiae, and the ung. hyd. nitrat. are proper when there are excoriations upon the eyelids, and when, from their occasional adhesion lo each other, there is reason to suspect, that the sebaceous glands secrete an acrimonious fluid. Mr. Ware also found that one drop of the thebaic tincture, dropped into the eye, once or twice in the course of the day, contributed greatly, both to abate the irritability and lo increase the strength of tbe relaxed vessels (On Scrofulous Ophthalmy, p. 26.) The same gentleman occasionally mixed old verjuice with cold spVing-water, at first, in the pro- portion of one part of the former to six of the latter, aftd sometimes increased the quantity of verjuice, until its quantity equal- led that of the water. All coverings should be removed from the eyes, except a shade of green silk, and patients should be gradually habituated to a stronger light. Good air and exercise always tend to im- prove scrofulous constitutions, and 'bus1, Tor. It 41 indirectly, the disease under consideration. Scrofula often disappears spontaneously, as children approach the adult state, and, if we only have it in our power to check its progress in the early stage of life, it seems to wear itself out afterward, and whatever local effects it may have produced, often disappear Chronic Ophthalmy. Unfavourable pecu- liarities are met with in practice, which prevent the complete cure of the second stage of acute ophthalmy, or that connected with a weak vascular action in the part affected ; whence the protracted disease becomes purely chronic, and threatens the slow destruction of the eye. These peculiarities may be chiefly re- ferred to three causes: 1. To an increased irritability continuing in the eye after the cessation of acute inflammation. 2. To some other existing affection of the eye, or neighbouring parts, of which the chronic ophthalmy is only an effect. 3. To consti- tutional disease. 1. That chronic ophthalmy may depend upon a morbid irritability of the eye is evinced, not only from its resisting topical astringents and corroborants, to which the disease from simple relaxation and weakness yields, but from its being exasperated by them, and even by cold water. The patient complains of a sense of weight in the upper eyelid, and restraint in opening it; the con- junctiva has a yellowish cast, and when exposed to the damp cold air, or a brilliant light, or when the patient studies by candlelight, its vessels become injected and turgid with blood. If, in combination with such symptoms, the habit of body be weak and irritable ; subject to spasms; hypochondriasis, be then, it is manifest, that the chronic ophthalmy is connected with a general impairment of the nervous system. 2 Besides extraneous bodies, lodged be- tween the palpebrae and eyeball, the inver- sion of the cilia? and hairs, growing from the caruncula lachrymalis ; ulcers of the cornea; prolapsus of the iris; herpetic ulcerations of the margins of the eyelids; a morbid secretion from the Meibomian glands; a diseased enlargement of tbe cor- nea, or of the whole globe of the eye, be may occasion and maintain chronic ophthal- my.—It is only my part here to mention such remoteleauses ; for, the particular treatment of them is described in other articles. (See Cornea, Ulcers of; Iris, Prolapsus of; Lippi- tudo ; Staphyloma; Hydrophlhalmy; Tri* chiasis, fyc.) 3. The cure of tbe second stage of acute ophthalmy may be retarded by the preva- lence of scrofula in the system ; or by the small-pox affecting the eyes. According to Scarpa, chronic ophthalmy is also sometimes a consequence of lues venerea ; but I know- nothing certain on this subject, in addition to what bas been stated in the foregoing columns. When chronic ophthalmy depends upon 346 OPHTI preternatural irritability, the internal exhi- bition of bark with valerian is proper; animal food of easy digestion ; gelatinous and farinaceous broths; wine in moderation; gentle exercise; living in salubrious and mild situations ; are all severally productive of benefit. Externally, the applications should be of a sedative and corroborant kind ; such as aromatic spirituous vapours (from the spiritus ammon. comp.) applied to the eye through a funnel, for half an hour, three or (bur times a day ; and the eyelids and eye- brows may also be rubbed with the linimen- nim camphorae. Patients, both during the treatment and after the cure, must refrain from straining the eye, and, immediately the least uneasi- ness is felt, must desist from exercising it. When they write or read, it should con- stantly be in a steady, uniform light, and too little, as well as too much exercise of the organ, aggravates the disease. Having once begun to wear spectacles, tbey should never study orsurvey minute objects without them. (Scarpa.) Intermittent Ophthalmy. It is the charac- ter of certain forms of ophthalmy, like tbe rheumatic and venereal, to be liable to [ieriodical exacerbations; but I am not certain that there are any cases specifically claiming the name of intermittent ophthalmy. The late Mr. \\ are, however, has noticed some examples, which intermitted, or at hast, remitted at slated periods. In these, he did not find bark so useful, as in scrofu- lous ophthalmy ; but be had seen the most beneficial effects produced by the oxymu- riate of mercury, sometimes joined with the compound decoction of sarsaparilla. (See Ware on Intermittent Ophthalmy.) Variolous Ophthalmy. As the small pox inoculation has at present almost generally been abandoned by the faculty in favour of the vaccine disease, there seems less occasion now for detailing circumstantially a very obstinate species of ophthalmy, induced by the former complaint. When the small-pox eruption is very abundant in the face, it causes a considerable swelling of this part of the body ; the eyelids become tumefied, the eyes redden, and there ensues a dis- charge of a very thick adhesive matter, which agglutinates the palpebra* together ; so that if no steps betaken, the eyes will continue closed for several days in succes- sion. The matter, confined between the eyelids and gfobe of the eye, being per- haps of an irritating quality, and injurious fropi the pressure il occasions on the sur- rounding parts, seems capable of exciting ulceration of the cornea, and even of irre- mediably destroying vision. When the pustules of the small-pox in other parts of ihe body have suppurated, they cicatrize ; but those, which happen within tbe margin of the cartilage of the eyelids, are prevented from healing by the diseased secretion, which is then made from the Meibomian glands, aud such ulcers result, as will some- dines l-^st for scvfivil * ear.-* ;ui J <;ven during ALM"\ life, if unremedied by art. {St. Yves sur Us Mai. des Yeux, p. 216, Edit. 12mo.) After the employment of the antiphlogistic treat- ment, should tho disease, when treated with topical astringents and corroborants, yet baffle the efforts of the surgeon, setons in tbe nape of tbe neck, kept open for a long while, prove one of the most useful reme- dies. Scarpa bas experienced much advan- tage from giving every morning and evening, to a child, ten years old, a pill, containing one grain of calomel, one grain of the sulpb. aur. antim. and four grains of cicuta io powder. It is obvious, that so potent an alterative, if ever serviceable in this case, will soon evince its efficacy ; nor would it be justifiable to sport with tbe patient's constitution by continuing its use beyond a certain period, unless sanctioned by evideut signs of its salutary effects on the disease of the eyes. When great irritability prevails, a mixture of three drams of the vinum antirnoniale, and one dram of the tinctura thebaic*, given in doses of five or six drops, in any convenient vehicle, and at the same time, applying externally the vapours of the spiri- tus ammon. comp. to the eye, constitute an excellent plan of treatment. In othei cases, saturnine collyria, with a little camphorated spirit of wine, or white wine, in which a little sugar is dissolved; tinct. thebaica; Jauin's ointment, be. avail most. This treatment is also applicable to the chronic ophthalmy from measles. When inveterate ulcers remain upon Ihe edges of the palpebral, the disease may then be regarded as the psorophthulmy, described by Mr. Ware, and will demand the same method of cure. (See Psorophlhalmy.} Operation of discharging the aqueous hu- mour. To this practice, some allusion has been already made in tbe preceding co- lumns ; and as the proposal is iutended to apply to several forms of inflammation of the eye, 1 have not given auy particular account of it in treating of the various cases. Mr. Wardrop remarked, that if the eye of a sheep, or ox, be squeezed in the hand, tlie whole cornea instantly becomes cloudy, and wheneverthe pressure is removed, this niein- brane regains its transparency. Fromthisca- rious phenomenon in the dead eye, it was evi- dent that, in the living body, the transparen- cy of the cornea might vary according to tbe degree of its distention ; and tnat, ib cases of opacity ofthe cornea, accompanied with fulness of the eyeball, its transparency might be restored by the evacuation of theaque ous humour. The cornea is little sensible, and, as every body knows, its wounds arc free from danger. Mr. Wardrop soon met with a case, favourable fotrj. making the experiment; the cornea was milky and opaque, and the eyeball distended and pro- minent, attended with acute inflammatory symptoms. The aqueous humour was dis- charged by a small incision,and the operation produced not only a removal of the clottdwaw i*f the cornea, hut an abatement of the UPti'fflAI.MV 347 pain, ami a sudden check to nil the inflamma- by the use of certain, mercurial preparations, tory symptoms. From the successof this case, 4/o. Lond. 1770. James Ware, Chir. Ob- Mr. Wardrop was led to perform the opera- serrations relative to the Eye, 2 Vols. 8vo. lion on others, not only with a view of Lond. 1805. Richter, Anfangsgr. der Wun- diminisbing the opacity of the cornea, but darzn. B. 3 G. Peach and J Wardrop in also of alleviating the inflammation. Four Edinb. Med. Surg. Journ. for January, 1807. interesting cases are related by this gentle- Also J. Wardrop, in Med. Chir. Trans. man, very much in favour of the practice, Vols. 4 and 10; and Essays on the Morbid when the eye is severely inflamed, attended Anatomy of the Eye, 2 Vols. 8vo. 1808— with fulness of the organ, a cloudy state of 1818. John Vetch, An Account of the Oph- the cornea, and a turbidness of the aqueous tlialmia, which has appeartd in England since humour. Mr. Wardrop also advises'he ope- the return ofthe British Army from Egypt, ration, whenever there is Ihe smallest quan- 8«*. Lond. 1807. Also Obs. relative to the tity of pas in the anterior chamber, ac- Treatment by Sir Wm. Adams of the Oph- companted with violent symptoms of inflam- thalmic Cases of tbe Army, 8vo. Lond. 1818. mation. He thinks, that the great and im- Ldter on the Ophthalmic Institution for the mediate relief, Which the method affords, is Cure of Chelsea Pensioners, 4lo. Lond. 1819. imputable to the sudden removal of tension; And A Practical Treatise on the Diseases oj' and he performs the operation with a small the Eye, 8vo. Lond. 1820. W. Thomas, Obs. knife, such as is used for extracting the on the Egyptian Ophthalmia, and Ophthalmia cataract. The instrument is to be oiled, and Purulent a, Svo. Lond. 1805. P. Assalini on introduced so as to make a wound of its the Plague, Dysentery, and Ophthalmy oj' own breadth, at the usual place of making E*ypt, fyc. Transl. by A. Neale, Lond. 1804. an incision in the extraction of the cataract. Also Manuale di Chirurgia, 8vo. Milano, By taming- the blade a little on its axis, the 1812. F. Vasani Sloria dal' Ollalmia con- aqueous humour flows out. (See Edinb. tagiosa dello Spedale Mililare d'Ancona, Svo. Med. and Surg. Journal. Jan. 1807; also In Verona, 1816 Also Risposta h cio che la Med. Chir. Tram. Vol. 4.) The late Mr. riguarda nei Cenni del Dr. Omodei sull Ware approved of Mr. Wardrop's operation Oltalmia d'Egitto et sulla sua propagazione in in the epidemic, purulent, or Egyptian oph- Italia, 12mo In Verona, 1818. T. F Baits. thulmi), When, notwithstanding general eva- de Ophthalmia Catarrhali Bellica, 4to. Hei- cuations. topical bleeding, mildly astringent delb. 1816. Arthur Edmonslone, A Treatise on lotions, and a strict antiphlogistic regimen, the Varieties and Consequences of Ophthalmiaj the symptoms still continue, and especially, with a preliminary inquiry into its conta- ct the cornea begin to lose its transparency, giou- nature, 8vo. Edinb. 1806. De Wenzel, and a white rim appear round its circumfcr- Manuel de l'Oculiste,2 T Svo. Paris, 1808. ence. Mr. Ware did not Object to using a C. Farrell, On Ophthalmia and its conse- small knife, of the kind employed in extract- quences,Svo. Lond. 1811. On the Utility of ing the cataract; but preferred a lancet, or Blisters in the Ophthalmia of Infants, in Ed. a sharp-pointed couching needle, with a Med. Surg. Journ. No. 58, p. 156. R. C. blade somewhat wider than usual, and a Graefe, Journ. der Chir. B. 1. Also Re- groove in its middle. The instrument, he pertorium augenarzlicher Heiformeln, Svo advises, to be introduced about one-tenth of Berlin, '817. G. Benedict, De Morbis Oculi an inch before the connexion of the cornea Humani Inflammatoriis, 4lo. Lips. 1811. with the sclerotica, and pushed gently on, J. C. Saunders on Some Practical Points re- parallel to the plane of the iris, until the aque- lating to Diseases of the Eye, edited by Dr. ova humour makes its escape. (Ware on the Farre, Lond. 1811, or rather the later editions Purulent Ophthalmy, p. 41, 1808.) As alrea- Karl Him ly Ophthabnologische Beobachtun- dy explained, Mr. Wardrop also recommends gen, fyc. 12mo. Bremen, 1801. Also his Ein- thispracticeincertabistatesofrheumaticoph- leitung in die Augenheilkunde, 12mo. Jena, thalmy. Consult Avicenna, Canon L. 3, Fen. 1806, and his Bibliothek fur Ophthalmologic, 9, Trad. 1, cup. Q. Mattre-Jan, Traile des Mai. fyc. 12mo. Hannov. 1816 F. J. Wallroth, de I'tEil, \2mo Paris. 1722. St. Yves, Traili Syntagma de Ophthalmologia Velerum, 8vo. des Mai. des Yeux, p 176, fyc. Janin, Mem. Halee, 1818. C. J. M. Langenbeck in Bibl. surl'(Eil,fye.SVo.Paris,1772. L.F.Gendron, and Neue Bibl. fur die Chirurgie, in various Traili des Mai. des Yeux. 2 T. 12mo. Paris, places. Ant. Scarpa, sutle Principali Malattic 1770. C. F. Ileuss, Dissertationes Med. Selects degli Occhi; Venez. Ediz. bta.: or the Transl. Tubingenses Oculi Humani Affedus Medico- by Mr. Briggs 2d Ed. Roux, Voyage fait en chirurgice consederalas sistentes, 3 Vols. 8vo. Anglcterre en 1814, ou Parallele de la Chirur- Tub. 1783. Trnka de Krzowits, Hist Ophthal- gie Angloise avec la Chirurgie Francoise, p. mia omnisceviobservatamedicacontincns,8vB. 37, fyc P. M'Gregor in Trans of a Society Vindob. 178*. G.Power, Attempt to investigate for the Improvement of Med and Chirurgical the causes of the Egyptian Ophthalmy; with Knowledge, Vol. 3, p. 30. fyc. Larrey, Me- obs. on its nature and cure, Svo. Lond. 1803. H. moires de Chir Militaire, T. l,p. 202, fyc. ./. Read, An Essay on Ophthalmia, Svo. Portsea, A. Schmidt, uber Nachstaar und Iritis, 4to. 1^06-7. J. B Sernetf, Treatise on Local In- Wien. 1801. G. J. Beer, Lehre von dem Jtdmmation, more particularly applied to Dis- Augenkrankheiten, 2 B. Svo. Wien. 1813— eases of the Eye, fyc. Svo. Lond. 1809 J. P. 1817. C. H. Welter, A Manual of the Dis- Marat, An Inquiry into the Nature. Cause, eases of the Human Eye, Transl. with Notes nnd Cure of a singular Disease of the Eyes, by G C Montealh, 2 Vols Svo. Qlasg. 1821. Hitherto ■unknown, and yet common, produced B. Travers on Iritis, in Surgical E$$ctys, 34s> 'i.Vl'KOS Ut<"Y»MA. Part 1. Also a synopsis of the Diseases of the Human Eye, Svo. Lond. 1820. Eusebius A. Lloyd on ScroJ'ulous and Purulent Oph- thalmia, in a Treatise on Scrofula, tsro. Lond. 1821. OSCHEOCELE, (from o^sen, the scro- tum, and kjikh, a tumour.) A hernia which has descended into the scrotum. "OSTEOSARCOMA, or Osteosarcosis. (from otrrtcv, a bone, and a-atf, flesh.) This term signifies the change of a bone into a substance, ofthe consistence of flesh. Bones are sometimes converted into a soft, lardy, homogeneous substance, resembling a can- cerous gland,and it is this affection, to which Boyer thinks, that the appellation ought to be confined. Callisen seems also to regard tbe osteosar- cosis as a disorder by which the texture of the bones is converted into a fleshy or fatty substance, accompanied .with a tendency to carcinoma. (System. Chirurgim Hodiernal, p. 204. Vol. 2. Edit. 1800.) We are to un- derstand by osteosarcoma, says Boyer, an alteration of the osseous structure, in which, after more or less distention, the substance of the bone degenerates, and is transformed into a diversified mass, but, more or less analogous to that cancer of the soft parts; while the local and general symptoms still more strikingly resemble those of the lat- ter disease. (See Traite des Mai. Chir. T. 3, p. 587.) According to this writer, all the bones are liable to such a disease ; but. it has been more frequently observed in the bones of the face, those of the base of the skull, the long bones of the limbs, particularly the ossa innominata, which are perhaps oftener affected than any other bones of the body. (Op. cit.p. 588.) Foreign surgeons do not appear to enter- tain precisely the same ideas respecting cancer, which prevail in England : at least, they apply the term to many complaints in which there are no vestiges of a carcinoma- tous structure, and numerous diseases of an incurable nature receive abroad very indis- criminately the name of cancer. Thus, the French surgeons have not yet distinguish- ed the strongly-marked differences between carcinoma and fungus haematodes. (See Roux, ParalUle de la chir. Angloise, fyc.; and the article Fungus Hamalodes.) Fungous diseases in the antrum expand the bones of tbe face, make their way out, and present a frightful specimen of disease. This change of the bones, though known to have nothing to do with cancer, (see An- trum,) is considered by Boyer as a kind of osteosarcoma, proceeding from carcinoma- tous mischief in the neighbouring soft parts ; and this he adduces as an example of his first species of osteosarcoma, or that arising in consequence of previous disease in other parts. In the second species, the disorder commences in the bones, and the soft parts ara secondarily affected. In all cases, osteosarcoma comes on with deeply-seated pain, which sometimes lasts a considerable time before any swelling is manifest. Some- times the pain becomes more and more afflicting, and of the lancinating kind, im- pairing the health even before there is any change in the form of the limb. At length, the swelling takes place, occupying the whole circumference of the member. Its nature and situation are in some measure indicated by its hardness and depth. It is unequal and tuberculated, as it were. Pres- sure does not lessen its size, nor make tbe pain worse. The soft parts are still in their natural state. The tumour, however, grows more or less rapidly, and the lancinating pains become more severe. In time, the soft parts themselves inflame, and become painful. Sometimes, the skin ulcerates, and, in this very uncommon case, the sore pre- sents a cancerous appearance. Hectic symptoms are induced, the patient gradually loses his strength, and, at length, falls a vie tim to the disease. The alteration, which the structure of the bones undergoes in the osteosarcoma, (says Boyer) deserves great attention. Most frequently, when the disease has made con- siderable progress, and tbe tumour has exist- ed a long while, the bony texture has disap- peared more or less completely ; in lieu of it, an homogeneous grayish,yellowish, lard- like substance is found, the surface of a slice of which is smooth, much like that of a very hard white of egg, or old cheese, the consistence varying from that of cartiluge to that of very thick bouillie. The sur- rounding soft parts, which have participated in the disease of the bones are converted into a similar matter; muscles tendons, periosteum, ligaments, vessels, cellular sub- stance, all are confounded in the same homogeneous mass, and have undergone the same degeneration. > In some examples, the disease is less ad- vanced : portions of the bone are then met with whose texture and consistence are nearly natural, and which are merely some- what enlarged. But in proceeding towards the centre of the disease, the substance of the bone is found softened, and its consist- ence less than that of cartilage, still mani- festly retaining, however, a fibrous texture; while more deeply, it is converted into a lard-like substance, resembling (says Boyer) that of parts affected with carcinoma. In these tumours, cysts are often found, some- times containing a fetid ichor,—some- times a matter like clear bouillie; and, in certain cases, a quantity of semi-transpa- rent, tremulous, gelatinous matter is found in the middle of the lard-like substance. Boyer records an instance, in which nearly the whole humerus was changed into a gelatinous mass. (See Lecons sur les Mai. des Os, T. l,Chap. 22.) The prognosis of this disease must always be unfavourable ; for, it is equally incurable, and disposed to bring on fatal consequences, whether Boyer's opinion, concerning its being cancer of the bones, be true or not. This author notices, that, even after ampu- tation, the complaint almost always recurs. (P. 591.) The only chance of relief, how- PAT, PAR 149 ever, obviously depends upon tha possibility tind success of the operation. In the Traiti des Mai. Chir. T. 3, p. 694—605, Boyer re- cords two cases of osteosarcoma ; one of the thigh ; the other, of the os iunominatum The first patient was saved by amputation. Some further particulars relative to osteo- sarcoma may be found in Boyer, Traili. des Maladies Chir, T.3; Halter's El>ment. Phy- siol. T. 8, p. 2, pag. 5; S. A. Kulmus, Diss de Exostosi Slealomaiode Clavicular; Gcdan. 1732; S. F Hnndertmark, Diss, sistens Os- teosteatomalis Casum rariorem ; Lips. 1752 ; S. G. Hermann, Diss, de Osteosteaiomute, Lips. 1767: S. C. Plenck, de Osieosarcosi: Tub. 1781. fyc. B. 1LSIS retention of urine. Effused biood may also require an opening to be made into the chest; and »o may confined air in the instance of emphysema. TAPPING, OR PARACENTESIS ABDOMINIS. When the swelling extends equally over the whole abdomen, the fluid is usually diffu- sed amongall the viscera,and is only circum- scribed by the boundaries of the peritonae- um. The water is. occasionally included in different cysts, which are generally formed in one of the ovaries ; and in ihis case, the tumour which is produced, is not so uniform, the fluctuation is not so dis ine! as in the former instance, at least this is the case while the disease has not made very great progress. The difference, also, in the con- sistence of the fluid, may render the- fluctua- tion more or less difficult of detection. When the water is contained in different cysls, it is frequently thick and gelatinous ; but when it is uniformly diffu>ed all over the cavity of the peritonseum, it is generally thinner, and even quite limpid. Sometimes a considerable number of hydatids are found floating in the fluid, discharged in cases of ascites. Whatever may be the efficacy of digitalis, mercury, diuretics, and other evacuants in ascites, they are rarely of any service in cases of local and encysted dropsies. When such swellings continue to enlarge, notwith- standing the adoption of a few measures which will presently be suggested, (be soon- er tbe fluid is evacuated the better. It is also well known, that all efforts lo produce a radical cure even of dropsies, which are not encysted, too frequently fail. I am decidedly of opinion, however, witb Dr Fothergill, that phy-icians would meet with much more success iu tbe treatment of asci- tes, if ihey were io recommend paracentesis to be done sooner than they generally do. This operation is, for the most part, much too long delayed ; and during a long space, tbe bowels are continually suffering more and more, from the effect of the large quantity of fluid which oppresses them. What ought to render the practice of early tapping more entitled to approbation is, that the operat;on, when done in the situation which will be presently advised, is perfectly free from danger, attended with very little pain, and need not interrupt the further trial of such medicines as tbe physician may ptace confidence in. Paracentesis only be- comes a serious measure when the disease has existed for a great lenglh of lime, and the patient has been much weakened by it. Indeed there seems much reason to suspect that tbe operation should be done as soon as tbe tension of the abdomen, and the fluctuation, leave no doubt concerning the nature of the malady; especially when the first trials which have been made of internal remedies, seem to promise no success. Dr. Fothergill has demonstrated by facts the ad- vantages of this method. Oil the commence- ment of ao ascites- this celebrated practi- tioner advises tha trial of diuretics and oilier evacuants. He then adds, that " if by a reasonable perseverance in this course, no considerable benefit accrues ; if the viscera do not evidently appear to be obstructed, and unfit for the purposes of life; if the complaints have not been brought on by a long habitual train of intemperance, and from which there seems little hope of re- claiming the patient; i; the strength and time of life are not altogether against us ; I desist from medicine, except of the cordial kind; and let the disease proceed til! the operation becomes safely practicable. When this is done by the moderate use of the warm diuretics, chalybeate*, and bitters,also tbe preparations of squills, in doses below that point al which the stomach would be affecled, I endeavour to |>re*ve nt the abdomen from filling again." (Med. Obs. and Inq. Vol. 4. p. 112.) The same author remarks, with regard to encyst- ed dropsies, that tapping sometimes effects a radical cure. The operation should not only be per- formed in as early a stage of (he disease as is compatible with the safety of the parts within the abdomen, it should also he repeal- ed as soon as the quantity of fluid accumu- lated again is sufficient to make tbe puncture practicable without danger. Desault used to tap dropsical patients once a week*, and in many cases, after he had performed tbe operation two or three times, the disease was stopped. The great number of times that (ha ope- ration has been repeated in some individu- als is surprising; for instance, twenty-nine times (Schmucker, Wahrnehmungin,2 B. f. 102;) forty-one times (Med. Communita- lions, Vol.2;) fifty-two times (Schmucker, Vol. cit. p. 187;) sixty-five times (Mead;) one hundred time- (Callisen, Syst. Chir. Ho- diernal, Vol. 2. p. 55;) one hundred and fifty-five times (Phil. Trans. Vol. 69;) and if it be possible to credit Bezard, even six hundred and sixty-five times upon one wo- man in tbe course of thirteen years. _ When (he patient died, the peritoneum was found (o be three lines in thickness. The omen- tum, mesentery, and even tbe liver, pall- bladder, spleen, pancrea*?, kidneys, and blad- der, had almost disappeared, a scirrhous mass containing pus occupying their place towards Ihe right side. (See Bulletin de la Soeiiti Midicale d'Emulation, No. 12, Dec.lSlb.) Whenever a considerable quantity of fluid is suddenly let out of the abdomen by tap- ping, the quick removal of the pressure of the water off the large blood-vessels and viscera, may produce swooning, convulsions, and even sudden death These consequen- ces b*d the ancients to consider paracentesis as a very dangerous operation, and when (hey ventured to perform it, they only let out the water gradually, and at intervals. Dr. Mead, afler considering what might occasion the bad symptoms resulting froa too sulden an evacuation of a larga quanti- ty of fluid from the abdomen, was led to try what effect external pressure would have in preventing such consequences. This pracfi- PARACENiEbiS. 3oi tioner thought that in this way be might keep up the same degree of pressure which the fluid made on tbe viscera. The success at- tending some trials of this plan, fully justi- fied the opinion Dr Mead had conceived ; for when tbe compression is carefully made, the whole of tbe water contained in the nb- domeu of a dropsical patient, may be safely discharged as quickly as the surgeon chooses. For Ibis purpose, however,(be whole, abdo- men must be equally compressed, tbe pres- sure increased in proportion as the evacua- tion lakes place, and kept up in tbe same degree for several days afterward. In St. Bartholomew's Hospital, while (he water is flowing out, tbe necessary degree ot pressure is usually made with a sbeet, which is put round the abdomen. Two assistants, who hold tbe ends of tbe sheet, gradually tighten it, in proportion as the fluid is discharged. Immediately after the operation, some folded flannel sprinkled with spirit of wine, is laid over tbe whole anterior part of the belly, and covered with a broad linen roller, applied wilh due tightness round tbe body. Dr Monro invented a particular kind of belt (or the purpose; but though it may be well adapled to Ihe object in view, it is, perhaps, unnecessary, as Ihe above method seems to answer every end. Tiie instrument used for tapping the abdo- men, is called a Irocar. (See Trocar.) Of this instrument there are several varie- ties ; but Richter and many other experien- ced surgeons, give a decided preference to the common trocar. Mosl ofthe modern al- terations which have, been made in the construction of trocars, have only tended, says Richter, to render the employment of these instruments more difficult. There is no reason for ihe ordinary objection, that the common trocar cannot be introduced vvilhoul considerable force. If the part into which it is about to be passed, be made tense, very little force will be necessary, especially if care be taken to rotate the in- ttiumenl gently, as well as push it forward. Hence all the inventions which have origi- nated from this supposed imperfection, are represented by Richter to be entirely useless. He condemns the trocar wilh a double-edged point, as a bad instrument. The proposal of Mr. Cline to make a puncture with a lancet first, and then lo introduce into the opening a blunt-pointed trocar, is alleged to be su- perfluous. JNay—these innovations are de- clared lo be worse than useless. A cutting instrument is liable to injure blood-vessels, F.nd bring on a weakening degree of hemor- rhage ; and it is said, (hat the wound thus made does not heal so readily as that made with a common trocar. That sharp-edged instruments are attended with the income nienceof being apt to wound enlarged veins. and produce au unpleasant degree of hemor- rhage, is a truth of which I have myself rm-t wilh a convincing example. A female who had a strong aversion to being lapped wilh a trocar, prevailed upon me to make the open- iug wilh a lancet. The puncture was made in die 'ittea alba, about three inches below the navel. A stream of dark-coloured ve- nous blood continued to run from the wound. tbe whole lime the water was flowing out of the cannula, and did not cease until a com- press was applied. The quantity of blood lost could nol be less than a pint, or a pint and a half. In many cases the loss of so much blood would prove fatal to dropsical patients, and is what one must always feel anxious to avoid. The most convenient position for tbe ope- ration, is certainly when die patient is sitting in an arm-chair. However, weakness aud other circumstances frequently make it ne- cessary to operate on tbe patient as he lies in bed. Until of late, the place in which surgeons used to puncture tbe abdomen, in cases of ascites, was the centre of a line drawn from the navel to the anterior superior spi- nous process of the ilium, and on ibe left side, which vvas preferred in consequence of the liver nol being there. The place for the puncture was usually marked wilh ink, and was supposed to be always situaied jusl over a part of the linea semilunaris, where'here is no fleshy substance, nor any large blood- vessel, exposed to injury. This calculation, however, wiis made without considering that, in dropsy, the parietes ol the abdomen do not yield equally in every situation. On the contrary, it is know n, thai the front is always mine distended than the lateral parts, and that tbe recti muscles, in particular, are sometimes very much w idened. In conse- 3uence of these alterations induced by Ibe isease, no dependence can be put on any measurement, made wilh the view of ascer- taining the piecim situation <>l the linea semilunaris. The surgeon who trusts to his being able lo introduce (he trocar cxncdy in this place, from any calculation of the above kind, will frequently wound a great thickness of muscle, instead of a part where tbe abdo- minal parietes are thinnest. Bul a still stronger objection is lo be urged against the practice of attempting to tap in Ihe linea semilunaris. Men well acquainted wilh anatomy, have frequently been deceived in Iheir reckoning, and instead of hilling the intended line wilh (heir Iroceirs, tbey have introduced these instruments through the recta- muscle, and wounded the epigastric artery. Patients have died from this error, with large extravasations of blood in the cavity of Ihe peritonaeum. n a dropsical perron, who has be en tapped, it is to be ob- served also, that on effusion of blood in the abdomen will of course more readily take place, io consequence ol the parts not being i<, the Mfflr close, compact slate, in which Ihe y are in the healthy condition. Let ever) prudent practitioner, therefore, henceforth abandon the plan of tapping in the linea semilunaris, and he may the more easily make up his mind to do so, as there is another place where the operation may be done with the utmost facility aud safety. The linea alba is now commonly preferred by the best surgeons; because, here no niuscnt-r (i'tcs need 1*0 wounded, *':e nlare a&i I'ARALL.NTEfelb. can be hit with certainty, and no large blood-vessel can be injured. About the middle point, between the navel nnd pubes, is as good a situation for making the punc- ture as can possibly be chosen. The sur- geon should introduce the trocar in a steady, firm manner, never in an incautious, sud den way, lest parts contained in tbe perito- naeum should be rashly wounded. For the same reason, immediately the point of tbe trocar has entered the abdomen, a thing always known at once by the sudden ces- sation of resistance to its passing inward, it should be introduced no further, and its office of making a passage for the cannula is already accomplished. The surgeon, con- sequently, is now to take hold of the cannula witb the thumb and index finger of his left hand, and gently insinuate it further into the cavity of the peritonamm, while with his right hand he is to w ithdraw the stilette. The fluid now gushes out, and regularly as it escapes, the sheet which is round the pa- tient's body is to be tightened. All the wa- ter having been evacuated, a piece of flan- nel and a roller are to be immediately ap- plied, as above explained, a piece of lint and soap-plaster having been previously applied to the wound. It is not uncommon for the water suddenly to stop, long before the full quantity is dis- charged. Sometimes this happens from a piece of intestine, or omentum, obstructing the cannula. This kind of stoppage may be removed by just introducing a probe or di- rector, and holding the portion of bowel back. When the water is very viscid, the only thing we can do is to introduce a large Irocar, if doing so should promise to facili- tate the evacuation. Also, when hydatids obstruct the cannula, a larger instrument might allow them to escape. In encysted dropsies, the practitioner, of course, can only let the fluid out of those cavities w hich he can safely puncture. When a dropsy of the ovary is very large, it also admits of being tapped in the linea alba; but, in this particular rase, it is gene- rally best to make the puncture where the swelling is most prominent. In this disease, the ovary is either converted into one large cavity, filled with fluid, or else it contains several distinct cells. The contents are sometimes exceedingly viscid. In the early -■tages of the case, the tumour is situated towards one side of the abdomen, and seems to ascend out of the pelvis. This kind of progress at once distinguishes the disease from a common ascites, which is attended, from the first, with an equal, gradual, uni- versal swelling of the abdomen. The cyst ofthe ovary, when it has attained a larje '•ize, generally adheres, in different places, to the inner surface ofthe peritonaeum, and, in this state, the whole abdomen often cems uniformly swollen, in consequence of the immense magnitude of the disease. (Sea. G. D. Motz, de Struclurd, Usu, d Morbis Ota- riorum, 4lo. Jcii/e, 1788.) The impairment of the health, urifoig from the pressure of fhe vis irera. and bite mint ion "! ''" -'!• fo-;<- (ions, and the g.eat difficulty of urtathing produced by the pressure on the diaphragm, make it necessary to let out the fluid, and paracentesis must be done in the way alrea- dy related. The disease is often attended with an almost total stoppage of the secre lion of urine. Sometimes the urine is duly secreted, but a retention occurs, so that the use! of the catheter becomes indispensable. Tapping, however, can only be regarded a- a palliative measure; the water collects again, the same grievances recur, and tbe operation must be repeated. While an ova- rial dropsy is recent, and even after it has been tapped, some attempts may be made to effect a radical cure. Blistering the sin- face of the abdomen, keeping up a discharge with the savine cerate, and applying a tight roller, have been known to do good. In France, the celebrated Le Dran laid open the cysts of ovarial dropsies. His patient; did not die ofthe consequent inflammation. and the dropsy, indeed, was cured; but there remained either a sarcomatous en Iargement ofthe ovary, which continued to increase till death, or else incurable fistula*, leading into the cyst, were the consequen- ces. The large size of a wound necessary for this purpose, the danger of inducing in- flammation in so extensive a surface as the cyst of a large ovarial dropsy, and the events of Le Dran s cases, are circumstances, on the whole, which ought to keep the prac- tice from ever being revived. A still more absurd plan has been attempt- ed, viz. to cure the disease by injections, like hydroceles. I formerly saw two case- in which port wine and water vvere inject- ed, by the late Mr. Ramsden of St Bartho- lomew's Hospital; one patient died very soon afterward of the inflammation, and the other perished more lingeringly from the same cause. Setons have been tried with- out success. Sometimes, though very seldom, the opr- ration of paracentesis is necessary forgiving vent to collections of air in the abdomen Air, when confined in this manner, i3 gene- rally contained in the bowels, which it in- flates to an enormous size. Instances, how- ever, are related of quantities of air being confined between the peritonamm and intes- tines : but, in some of these cases, it is said that the air was known to have escaped through a small hole in some part of the in- testinal caual, and it is probable, that all the other examples were of the same kind. This disease is named tympuvites. and may ren- der making an opening into the abdomen necessary. Notwithstanding authors gene- rally recommend a small trocar for the pur- pose, there can be no doubt that dividing the skin, and making a yautions puncture with a lancet through the linea alba and peritoneum, would be a preferable mode ot proceeding. The abdomen must also be compressed with a sheet while the air is escaping, and afterward wilh a roller, just as if the case were an ascites, h've-n when the air is contained in th<" bowels, if it should be enormous in epp>ii'-:v M-on, notwithstanding his great opportu- nities, ever saw a really venereal wart. For many years past 1 have never seen any ex- crescences of this kind in St. Bartholomew's hospital, which truly required mercury for their cure, or which, when cured without it, were followed by any inconvenience. If my memory does not fail me, Mr. Aberne- thy also disbelieves in the doctrine of vene-. real warts. Foul, spreading, sloughy ulcers of the penis, should be discriminated from cancer. It is worthy of attention that almost all the inscs of cancer of the penis recorded by Mr. Hey were attended with a congenital phymosis. The same complication also ex- isted iu another example, in which Boyer performed amputation of the penis in la Charite, on account of a cancerous affection of the part. In the only two opportunities of doing this operation, which M.Roux has bad, the cases were likewise accompanied with a uaturi.1 phymosis. Hence^ this au- PHR llior considers such a state of the prepuci- as particularly conducive to cancer of the penis, and earnestly enjoins surgeons to re- commend their patients to have the first inconvenience rectified, so that no risk of the other more serious affection may be en- countered. (See Parallile de la Chirurgie Angloise, fyc. p. 306, 307.) In two out of three cases which vvere reported to be can- cerous, and for which amputation was done under my notice, it did not appear that auy degree of phymosis existed. (See Pearson on Cancerous Complaints. Hey's Practical Observations in Surgery. Roux, Voyage fait en Anglelerre en 1814, ou Parallile dc la Chir. Angloise, fyc. p. 306.) PERINEUM, FISTUL.r. OF. (See Fistula in Perinao.) PE'RMO. (from a?i/>£, tbe pharynx, and rtfAvm, to cut.) See fEsopha- golomy. v PHARYNGO'TOMUS. (from **.t}>y%, the throat, and , an incision.) An instru- ment for scarifying the tonsils, and for open- ing abscesses about the fauces. It was in- vented by Petit, and is nothing more than a sort of lancet which is enclosed in a sheath. By means of a spring the point is capable of darting out to a determinate extent, so as to make the necessary wound, without risk of injuring other parts. PHLEBOTOMY, (from , to inflame., An inflammation. A flushing. PHRENITTS. (from p*jev«**, the diaphragm, supposed by the ancients to be the seat ol the mind.) An inflammation of the brain, Phrensy. Inflammation of the brain is a frequent consequence of injuries of the head. The symptoms are an increased and disordered state of the sensibility of the whole nervous system ; the retina cannot bear the usual stimulus of light; the pupils are contracted ; the pulse is frequent and small; the eye- are red and turgid, and the iris sometimes actually inflamed, (Wardrop, Essays on the Morbid Anat. of the Eye, Vol. 2,) the coun- tenance is flushed, and the patient is res'. I'HYMOSIS 3i7 less, mutters incoherently, and grows wild and delirious. Phrcnitis is treated on the antiphlogistic plan. Copious bleedings and other evacua- tions, are highly proper. Some of the blood should be taken from the temporal arteries. The skin ought to be kept moist with anti- monials, and a counter-irritation should be excited on the scalp by blisters. PHY .MA. (from t, yet it is removeable without pain, he- morrhage, or hazard <>f any kind ; the se- cond of which circumstances Mr. Pott can with strict truth affirm, he never yet met with when the disease was at all fit for the operation. Of the benign kind of polypus, fit for ex- traction, there are (says Mr. Polt) two sorts, whose principal difference from each other consists in their different origin or attach- ment. That which is most freely moveable within the nostril, upon forcible respiration ; which has been found to be most liable to chance of size, at different times andseasons; which has increased the most in the same space of time ; which seems most limpid, and most freely yields lymph upon pressure, has its origin most commonly by a stalk or kind of peduncle, which is very small, com- pared with the size of the polypus. The other which, although plainly moveable, is much less so than (he one just mentioned, which has been less liable to alteration from air and seasons ; and which has been rather slow in arriving at a very troublesome size, is most frequently an elongation of the membrane covering one of the ossa spon- giosa. These latter may be extracted with no kind of hazard, and with very little pain, and hemorrhage : hut tlie former require 36^ P'Ji.li'Lb Ibe least i.oii.e. and mostly come away en- tire ; while the others often break, come away piecemeal, and stand in need of the repeated use of (he forceps. (Poll, on the Polypus of the Nose.) Mr. John Bull criticises the distinctions drawn by the preceding writer, and he says, (hat a polypus is never mild, and never ma- lignant ; lime, and the natural growth of the tumour, and the pressure it occasions within the soft and bony cells of tbe nostrils and jaws, must bring every poly pus (o one iuva- ri :Je form, iu ils last and fatal stage. Po- lypus, says Mr. John Bell, is indeed a dre.id- ful disease ; bul it becomes so by a slow progression, and advances by gradations easily characterized. Every polypus in ils early stage, is, according lo this writer, a small moveable tumour, attended wilh a sneezing and watering of the eyes ; swelling in moist weather; descending with the breath ; but easily repressed wilh the point of the finger. Il is void of pain, and not at all alarming ; it may also be easily extracted, so as to clear for a time the passage for the breath. Yet this tittle tumour, simple as il may appear, is the germ of a very fatal aud loathsome disease, and this easy extraction often the very cause of its appearing in its most malignant form. The more easily it is extracted, (says Mr. J. Bell,) the more easily does it return ; and whether carelesslv ex- tracted, or altogether neglected, it sfion re- turns. But when it does returilp^it has not really changed its nature ; it has not ceased to be in it-elf mild, it is then to be feared, not from its malignity, bul from its pressure among the delicate cells and membranes of the nose. It soon fills die nostrils, obstructs the breathing, and causes indescribable anx- ieties. The tears are obs(ruc(ed, and tbe eyes become watery from die pressure on the lachrymal sac ; the hearing is in like niiinner injured, by (he pro-sure of the tu- mour H^ainst the moirih of (he eustachian lube ; the voice is changed, and its resonance and tone entirely lost, by die sound no lon- ger paving through the cells of (he nose and lace. The swallowing is in some de- gree affected by the soft palate beins depress- ed by ihe tumour. The pains arising from such slow and irresistible pressure are un- ceasing. From the same pressure the bones become carious, and (he cells of die face and nose are destroyed by (he slow growth of the swelling. It is not long before the tu- mour begins to project from the nostril in front, and over (be arch of the palate be- hind. One noslril becomes widened and thickened ; the nose is turned towards (he opposite side of die face, and the whole countenance seems distorted. 'Ihe root of Ihc im;-c swells, ami becomes puff-, Ihe fea- tures tumid and flabby, the face yellow, and (he pails round the eye livid. The patient is aiici-K-d with hfMdach;. which seem to i end (he bone" asunder, and wilh perpetual '-•'upor, nnd drying. The bones are now ab ■oihed, nnd Ihe membranes ulcerate ; a foul and fetid mailer, blackened wilh bfood, it discharged from (ho nostrils, ami excoriates them. The blood-vessels next give way, anil sudden impetuous hemorrhages weaken the patient ; the teeth full from Ibe sockets, and through the emply sockets a foul and fetid matter issues from the annum. i\ow the disease verges lo its conclusion The patient has terrible nights, and experi- ences e. sense of suffocation. The repealed loss of blood tenders him so weak that he cannot quit bis bed for several days together; and when he does get up, he is (to use Mr. Bell's words) pale as a spectre, his lips co- lourless, and his face like wax, yellow, and transparent. He now suffers intolerable pain, while bis saliva is continually dribbling from his mouth, and a felid di-charge Irom his nose*. In this stale, he survives a few weeks ; during Ihe last days of his illness, lying in a state of perpetual stupor, and dy- ing lethargic. Mr. J. Ball afterward ob- serves, dial " if horrid symptoms could es- tablish Ihe fact of malignity, there is nol to be lound in all nosology a more malignant di-ease than this : but aneurism, though it destroys the (high hone, tbe sternum, or cra- nium, is not accounted malignant ; neither is polypus malignant, though it destroys (he ce ils of tht* face, and penetrates even through Ihe ethmoid hone to the brain. These consequences re-ult merely from pressure." (John Bell's Principles oj' Surge- ry, Vol. 3, Part l,p 90—92.) In April. 1817, ibe-re was a boy in St. Bar- tholomew's H .-.pilal, only twelve year* old, who hud just fallen a victim lo Ihe ravages of the largest and mosl disfiguring disease within the* nose which I have ever had an opportunity of beholding. The tumour be- fore death had expanded the upper part ot (he nose lo an enormous size, while below (he left nostril was immensely enlarged. The distance be* ween the eyes was extraor- dinary, being more than four inches. The left eye was affected vv it ii amaurosis, biouglit on by the pressure ot ihe swelling ; Ihe right n-l'iined (o the last the faculty of seeing- The tumour nearly covered the mouth, sn that food could only be introduced wilh a spoon, and an exaiiiiimlion of the stale of Hie palate was impovible. About a fortnight before death, (he leg became paralytic, and during the iust week of (he boy's existence, an incontinence of Ihe mine and feces pre- vailed, tin examination of the head afler uealb, a good deal of (he tumour was found io be ot a cartilaginous consistence, and, what was most remarkable, a portion ol it. which was as large us an orange, extended uirhiri Ihe cranium, where il had annihila- ted the .interior lobe of the left hemisphere of die brain. Y«*(, nolw iihstanding litis ef- fect, die boy was not comatose, nor insensi- ble, till a few hours before his decease. All the mii rounding bones had been more or less ai>m>ibed, and ihe place (mm which the ex- crescence* first grew could not be determined. Ihe ceb-biaied Pmb.-ssoi Uicbler has de- nied the validity of ihu ni jti-lions uigcd by Poll against aiiriii) (ing to relieve the pa- (ifiit : :.cither the malignant nature of a po- ', tin», ilh MiJIiesion-, iiiiifiovt-ableribss, ultt- POLYPUS. 363 ratious, nor disposition to hemorrhage, Sic. are, according to Richter, any apology for leaving Ihe disease to itself. (See An- fangsgr. der Wundarzn. B. 1, cap. 21.) Mr. J. Bell refutes the common notions, that polypi may be caused by picking the nose, blowing il too forcibly, colds, and local injuries. He asserts, (hat a polypus is not in gem ral a local, solitary tumour: he bas only found il so in three or four instances. Both nostrils are usually affected. He states, that no finger can reach that part ofthe nos- tril where the root of Ihe swelling is situated, as it is deep and high iu the nostrils, towards the throal, and near tbe opening of the eus tacbian tube. The finger cannot be intro- duced further than (he cartilaginous win;: of the nose extends, and can hardly touch the anterior point of the lower spongy bone. The anterior and posterior chambers of the nostril are separated Irom each olher by a narrow slit, which ihe finger can never pass, and iv hich is divided, in consequence of tbe projection ot the lower spongy hone, into two openings, one above, the other below. Through these die heads ot the polypus pro- ject. These tangible parts of ihe tumour, iiowever.are very distantfrom itsrool, which is in the highest and narrowest part of the nostril. (Seep. 103, li>4.) Mr. J. Bell also says, that three or four polypi are often crowded together in one nostril, while more are formed, or forming, in the other. He dwells upon the difficulty and imprac- ticableness of tying the root of a polypus; and explains, in all attempts lo extirpate such tumours, the surgeon's aim should be to reach a point nearly under the socket of the eye, in the deepest and highest part of the nostrils, and that instruments can only do good when introduced beyond tbe narrow cleft,formed by Ihe projection oi (he spongy bone. (/>. 108.) S Though Mr. John Bell i*probably right in his opinion, dial polypi do nol proceed from the several circumstances which have been above noticed, yet ihey are, in mosl instan- ces, diseases of an entirely local nature. Certainly, in general, it is very difficult to describe what is the cause of a nasal polypus. Frequently the patient is, in other respects, perfectly well; and after the removal ot Ihe tumour, no new one makes its appearance. In this circumstance, it must originate from a local cause, (hough it is generally difficull to define whal (he nature of this is. Some- times several catarrhal symptoms precede the polypus, and, perhaps, constitute • its cause. It is possible, they may only be an effect of Ihe same cause which gives bir h to Ihe tumour; but, no doubt, they are some- limes the effeel ot the polypus itself. Some- times, perhaps, a faulty stale of the con-dtu tion really contributes to ihe disease ; lor se- veral polypi frequently, grow in both nostrils, nnd even in other situations at the same time; are reproduced immediately after their removal ; and the patient often has an unhealthy appearance. Notwithstanding it lias been asserted, (hat a solution of the mu riateot ammonia, frequently injected into the nose, sometimes disperses polypi, fhe ef- ficacy of the remedy remains unestablished by experience ; as, indeed, the very nature of the disease might lead one lo anticipate. An operation affords the only rational chance of a cure. There are four modes of extirpating a na- sal polypus: viz. extracting it with forceps ; lying it with a ligature ; cutting it out; and destroying it with caustic. Extraction is the most common and pro- per method. It is performed wilh the ordi- nary polypus forceps, (he blades of which have holes in (hem, and are internally ra- ther rotiih, in order that they may take hold of the tumour more firmly, and not easily slip off it. The front edge of each blade must not be loo thin and sharp, lest, with its fellow, it should pinch off a portion of the polypus. The blades must necessarily have a certain breadth: for when they are (oo small, ihey cannot properly take hold of and twist (he tumour. When (he handles are rather long, (he instrument may be more fn inly closed, and more conveniently twisted. However, (he forceps is not applicable (o all cases. The anterior part of the polypus, lying in the nostril, distending, and totally obstructing it, is sometimes quite hard, and when the forceps is introduc-ed, it presses the blades in such a manner, from each olher, as il lies between them, (hat (he instrument cannot be introduced sufficiently far to lake hold of the tumour at a proper depth. If introduced to a proper distance, it cannot be closed. In such a case, says Richter, one might, perhaps, advantageously make use of a pair of forceps, the pieces of wliich may be separately introduced, and then fastened together again at Ihe joint, and the blades of which diverge from each other behind (he joint, and touch again al (heir extremides. The anterior indurated portion of the poly- pus lies in the interspace, and doe3 not pre- vent the closure of (he instrument. It is generally deemed of importance to lake bold of the polypus with Ihe forceps close (o itsroo(; and, indeed, when this rule is observed, the whole of the polypus, to- gether with its root, is commonly extracted, and there is less reason to apprehend he- morrhage, which is naturally more profuse when the polypus is broken at the thick, mid- dle portion of ils body. It is also a rule fre- quently easy of observance, especially when (he polypus is not loo large. But in many instances (he (umour is so large, and Ihe nos- tril so compleiely occupied by it, that it is impracticable lo get hold of its root. In this circumstance it is often ahogedier impossi- ble to discover even where the root lies. Here we must be content to take hold of Ihe polypus as high as possible. The conse- quences are of two kinds. The tumour sometimes gives way at itsrool, (hough it be only taken hold of a' ils anterior part ; and, in olher cases, breaks where il is grasped, a portion being left behind, and a profuse he- morrhage en^uhii. This i3, however, void of danger, if Ihe surgeon does not waste time in endeavouring to suppress th effi" 3« POLYPI t* sion of blood ; but imuieuiiaioly introduces the forceps again, grasps the remnant piece, and evtrucls il. The most iniallibte method of diminishing the bleeding, is lo extract what remains behind at its root In this way, a large polypus is frecpienlly extracted, piece- meal, wilhout any particular loss of blood. After the polypus has been propelled as far forward, into the nostrils, as it can be by blowing strongly through die nose, its ante- rior part is to be (aken hold of by a smnll pair of common forceps, held iu the left hand ; and is to be drawn gradually and slowly out, to make room for the introduc- tion of the polypus-forceps into the nostril. The more slowly we proceed in this ma- ncjeuvre, the more the polypus is elongated, tbe narrower il becomes, the greater is the space in the nostril tor ihe introduction ot tbe polynus-forceps, and (he higher can (his instrument grasp (he tumour. Alter it has taken hold of the polypus as high as possi- ble, it is to be twisted slowly round, and. at the same time, pulled outward, till the lu- mour breaks. It is a very important maxim, rather to twist the instrument tliiui to pull it, and thus rather to writhe the polypus off than to drag il out. The longer and more slowly the polypus-forceps is twisted, the more the part where the excrescence separates is bruised, Ibe less is the danger of hemor- rhage, and the more eeitniuly does the tu- mour break at its thinnest part, or root. "When (he extraction is done with violence and celerity, only a piece is usually broughl away, and we run hazard of occasioning a copious bleeding. As soon as the polypus has given way, the surgeon is to examine whether any part re- mains behind. Whe-n the polypus is very narrow at the place where if has been brok'-n, and the patient can breathe through the > ose freely, there is reason lo presume thai the polypus has given way at its root, and that none continues behind. Tbe finger, if it can be introduced, procures the mosl certain information ; or the probe, when this, for want of room, cannot be employed The ancients proposed several means for the ex- tirpation of Ihe remaining piece of polypus ; but tbey are, for Ihe most part, objectiona- ble. Il is best lo introduce tbe forceps again, under the guidance of the finger, or probe, and thus pinch, and twisl off, the part con- tinuing behind. Hemorrhage invariably succeeds the ope- ration ; and by many writers bas been re- presented as exceedingly perilous and alarm- ing. But it is not constantly so, and in some cases is quite insignificant. Frequently, however, it is really serious ; and as the sur- geon can never know beforehand (o what extent it will happen, he is always to lucni-h himself, before the operation, wilh the most effectual means tor ils suppression. Ihe danger of hemorrhage may always be less- ened, as was before mentioned, by slowly twisting the polypus at its root, in preference to pulling it directly out. Wheu only a por- tion of the tumour has been extracted, the ?'irvst mode of slopping .he effusion of blood is io extract the remaining pml without de lay. \"\ hen the polypus has given way at its root, if there should be profuse bleeding, we may first try ice-cold water and strong brandy", which may either be sucked or in- jected into the nose. This single remedy proves effectual in numerous instances. If the hemorrhage should still prevail, it may always be checked with certainty, how co- pious soever it may be, in die following man- ner. Roll a considerable piece of lint, as fast as possible, round the extremity of a probe; wet it completely through with a strong solution of the sulphate of zinc; in- troduce it into the nostril, and press it as strongly as possible against Ihe part whence Ihe blood issues. When ihe nostril is very much dilated, the fingers may be used lor this purpose with more advantage than (lie probe. The point from which the blood ii effused, may eadly be ascertained, by press- ing tbe finger on various points. As soon as the blood ceases lo flow, we may conclude that (he finger is on ihe situation of ihe he- morrhage. This method is so efficacious, (hat then- is seldom occasion for any other. When (he bleeding point lies deeply in (he nostril, it might be difficult to reach it with the finger. At all events, we may then em- ploy a plan which ha3 been strongly praised in urgent cases. A piece of catgut may be introduced into Ihc nostril, and by means of a pair of for- ceps, be brought out of the mouth. A roll of lint is then to be attached lo it, and dram through the mouth into the nose ; thus the posterior aperture of the nostril may be stopped up. Then the nostril in front is to be tilled with a sufficient quantity of lint. moistened in Ihe solution of zincuin vitrio- latum. Tbe objections to extracting some polypi, says Richier, have been much exaggerated. When the polypus is so large, that its root cannot be got at, its anterior part is to be taken hold of, and the tumour extracted piecemeal. It has already been noticed, that this practice is free from danger. Ex- perience does not prove, that the polypus, which often bleeds profusely, is apt to occasion a violent hemorrhage in the opera- tion ; and even if it should do so, powerful measures may be adopted for the stoppage of the bleeding. The malignity and ulcera- tions attending a polypus, are no objections to the operation ; but are rather motives wr- its being promptly performed, as delay must occasion more manifest and urgent danger. If the polypus should be here and there adherent to the membrane investing the nostrils, it is proper to separate it before the operation. . This object cannot be accom- plished by straight inflexible instrument, such as have been invented by various surgeons. It may be very conveniently done, according to Richter, with thin, long, flat pieces of tortoise-shell, introduced a* deeply as possible into the nostril, on every side of the polypus. As it can seldom be known with certainty, a priori, that ad- hesions are not present, it is proper whene- POLYFUb oO-'j ver the tumour is large, to introduce these instruments before the operation Sometimes, the greatest part of the polypus extends backward, hanging down behind the palatum mollt-, towards ihe pharynx. If there should be but little of the polypus visible in the nostril, its extraction must be performed backward, in die throat, ibis is usually done with a pair of curved polypus forceps, which is to be iutrodu< ed through the mouth, in order to seize aud tear off the tumour as high as possible above the soft palate. Care must be taken not to irritate the root of the tongue, or else a'vomiting is produced, which disturbs the operation. When the polypus cannot be properly taken hold of, we may, according lo the advice of some surgeons, divide the soft palate. But this is very rarely necessary. As, by this mode, the polypus is not twisted, but pulled away, the hemorrhage is, in general, raihe.-r copious. If a fragment of the tumour should remain behind, it may commonly be extract- ed through the nose. Some recommend, for the extraction of polypi in the throat, a ring, consisting of two semicircular portions, with a kind ot groove externally, which are capable of being opened and snut, by being fixed on the ends of an instrument constructed like forceps. A ligature is to be placed round the ring, and its end is to be brought to the handle of the instrument, and held with it in the hand. The instrument is to be intro- duced into the mouth, under the polypus, and expanded as much as the size of the tumour requires. Its ring is then to be carried upward, over the polypus, so as to embrace it; and afterword is to be shut, whereby the noose, after being carried up- ward, is disengaged from the ring. The noose is to be pushed as high as possible over the tumour, by means of forceps, and the extremity of the packthread is then to be drawn, so as to apply the noose tightly rouud the polypus. VVheii this is done, the ring of the instrument is to be turned round firmly closed, and placed in front of the polypus, on the noose, in such a way, that the packthread is to lie between two little pegs, made for the purpose, at the ends of the ring. On drawing the packthread firmly, und pressing (he instrument at the same time downward, so as lo make it act like a lever, the polypus in general easily breaks. Another peg projects in tbe direction of the ring, so as lo prevent the ligature from in- sinuating itself within tbe circle. (see Thedeu's liemerk. Part 2. and Plate 6. fig. 1. in Richter's Anjdngsgr.) The employment of this instrument, however, is attended, says Richter, with va^,.j difficulties, and little advantage. Po- lypi in the throat are most conveniently extracted by the ordinary straight polypus forceps, with wliich they may be seized, and gradually draw n out through the mouth. The tumour generally allows itscll to be drawn out without trouble, and the inclina- tion to vomit, which at this moment occurs, ><'-<■> contributes in propid it emtward. When it is so stretched, that it cannot be drawn out further, without considerable force, a spatula is to be introduced into Ihe mouth, and (o be carried as high as possible behind (he polypus, in order to press it downward. toward the root of the tongue. When tb<: tumour is at the same time forcibly pulled outu ard by the forceps, it usually gives way. U hen the | olypus is situated partly iu the throat and partly in tbe nostril, ihou.h it admits of being extr cted, iu the same way, through the mouth, yet its anterior part often continues attached, and must afterward be saparately removed through the nostril. It is also frequently adviseable to twist off the anterior portion of the polypus first, by which the mass in the throat is often ren- dered so loose, that it can be easily extract- ed. Whenever ,t is conjectured, that the polypus will come away in two pieces, it is always preferable first to extract the part in die nostril, and afterward that iu the throat: because tlie separation of the last is con- stantly productive of more .deeding, than th- removal of the first. sometimes, the following plan succeeds in detaching tho whole polypus ,-A once. Both the part in the nostril, and that in the throat, are to be firmly take hold of >\ ith the for »ns, and drawn at first go.If a.i ■ then me; e f. cibly, backward a. ci fi.rward. By such repealed movements, the root is not unfrequently broken, and the whole polypus brought away from the mouth. Frequently the polypus grows again. Po- licy requires that the patient should be apprized of this beforehand. Some ofthe root remaining behind, may often be a cause of the relapse. Hence the surgeon should examine can-fully, after the operation, the part at which the root of the polypus was situated, and separate, and twist off, m«a diligently, with (he forceps, any fragments that may still continue attached. Ihe re- currence of the disease, however, may arise from other causes. Ihe tumour is occasional- ly reproduced, after it bas been extracU i in the most complete manner; and doubt- less, this circumstance is sometimes owing to the continued agency of constitutional causes, which so often remain undiscovered and unremoved Sometimes, also, the re- currence of the disease is owing to a local morbid affection ol the Schneiderian mem- brane, or of the bones situated beneath the root of the polypus. Kidder, iu this case, approves of the cautery ; but few English surgeons will coincide with him. The po- lypus, sometimes observed subsequently to the operation, is frequently not, in fact, a a new substance, but only a part of the original tumour, not previously noticed by the surgeon. Some,inns it occurs, that a smaller and larger polypus are found in the nose al the same time The larger one is extracted,-while the other remains undisco- vered ; and when it has increased in magni- tude, it is apt to be mistaken for a repro- duction of (he one previously extirpated. (See Richter's Anfangsgr. der Wundarzn, B. 1 Kap. 21.> 366 POLYPI^. Ligature. As the extraction of the poly- pus is invariably attended with hemorrhage, which is sometimes profuse, another more modern method of cure has been proposed as more convenient and secure. This con- sists in tying the root of the tumour with a ligature, by which the polypus is thrown into the slate of intlatnmation, suppuration, and sphacelus; and ai length becomes de- tached Many instruments have been in- vented for applying the ligature; bul Levret's double, cannula seems to be the best. Through this, a silver wire is to be introdu- ced, so as to form a noose at the upper end of the instrument, proportioned in size to the anterior part of the tumour, situated iu the nostril. ihe two ends of the wire are to hang out of the two lower apertures of the double cannula ; and one of them is to be fastened to a small ring on its own side of the instrument. The other is to remain loose. The wire must be made of the purest silver, and ought to be as flexible as possible, that it may not readily break It mu-t also not he too thin lest it should cut through the root of the polypus. The can- nula is to be somew hat less than five inches l.» ig By the assistance of this cannula, Ihe noose is to be introduced into the nose, and put round the polypus. But as the cannula, which is usually constructed of silver, is straight and inflexible, while the inner surface of the nostril is preternaturally arche l, especially when much distended by tbe polypus, it is easy to discern that its introduction must be intended with consi- derable difficulty, in fact, it can seldom be introduced as deeply as the root of the polypus. There are two ways of avoiding this obstacle. The cannula may either be passed under the polypus, over the ossa palati, which present a tolerably straight surface, or it must be curved a little. Per- haps, a tortoise-shell cannula, says Richter, might be convenient. , The noose is to be applied in the follow- ing manner. The polypus is to be taken hold of with the forceps, and drawn a little out of the nose. The noose is then to be carried over the forceps and polypus, into the nostril. In order to carry it as high as possible, it is necessary not to push the can- nula straight forwards into the nose, but to move it from one side of the polypus to the other. The more deeply the instrument bas entered the nose, the more of the loose end of the wire must be drawn out of the lower aperture of the cannula, so as to contract the noose, which otherwise might stop in the nostril, and not be carried suffi- ciently high. The elasticity of the silver wire tends to assist in raising it over the p ' pus, and hence, it is more easy of appli- c .lion than a more flaccid kind of a igature, Vv titii there is cause to conclude, tint the polypus is complicated with adhesions, they must be previously broken, in the way "already mentioned. As soon as the noose has been introduced a* deeply as po=-iM°. ti>«> loo«=e extremity of the wire is to be drawn out of the lovur aperlure of the cannula, and rolled round the ring on that side of the instrument. Thus the root of the polypus suffers con- striction The wire must not be pulled too forcibly, nor yet too feebly. In tbe first «ircumstanre, it readily cuts through the root of the polypus: in the second, great tumefaction of the excrescence, and many inconveniences arise, which a tenser state of the wire prevents. As the noose gradually makes a furrow where it surrounds the polypus, it g'rows slack after a short time, and no longer constricts the tumour. One end of the wire, therefore, is to be daily unfastened, and drawn more tightly. The more tense it is kept, (he sooner the separa- tion of the polypus is brought about. Hence, when it is particularly indicated (o produce a speedy attachment of the polypus, the wire should be tightened, at least, once a day. In this mannner the cannula is to remain in the nose until the noose is detached, to- gether with the polypus. There is another method of tying the tumour, without leav- ing the cannula in the nose. After the noose has been introduced as far as possible into the nostril, the two ends of the wire are to be twisted round the two rings, and the cannula is to be turned round a couple of times. The wire is then to be unfastened from the rings, and the cannula withdrawn. In this way the noose is made to embrace the pol. pus, round which it remains fastly applied. Whenever it is wished to produce a greater constriction, the cannula may be again introduced into the nose, the ends of the wire fastened lo the rings, and the in- strument turned round again ; after which it is to be taken away, as before. As the cannula, when it continues long in the nose, may occasion pain, and other inconveni- ences, Ihe last method seems preferable to the former. However, introducing and withdrawing the cannula every day, as Kichter adds, may, perhaps, be equally trou- blesome and painful. The cannula for this purpose being necessarily straight, is by no means handy. One might, at all events, make use of a single cannula, the upper opening of which is divided by a bridge; this could be much more conveniently twist- ed than a double one. Although the ligature has been very much praised by some of the moderns, it is »t- tended with so many difficulties, that in the majority of cases, the forceps is infinitely preferable. Hemorrhage is the only incon- venience, for which extraction is abandon- ed for the employment of the ligature. But this, as was before stated, is much less dan- gerous than is represented. The inconve- niences of the ligature are far more serious, and numerous. The cure by the ligature is al- ways accomplished with much less expedi- tion than by extraction. When the polypus is of such a size as to occupy the whole ofthe nostril, it is generally impracticable to in- troduce the* noose fo a sufficient depth roLvPb-s 367 The figure ol tlie polypus renders it almost impossible to tie its root; for commonly the lumour expands very much before and behind, and the wire must be brought over the posterior part of the polypus, ere it can be applied to its root. In general, also, the noose only includes Ihe front part of the polypus, while the root, and back portion remain untied, and consequently do not become detached.—It is, indeed, asserted, that the ligature, when only applied to the front part of the polypus, is capable of bring- ing about inflammation, suppuration, and a detachment of the whole of the tumour. This may sometimes be the case; bul ana- logous instances prove, that it is undoubted- ly not constantly so. The ligature seldom accomplishes an entire destruction of tbe disease, and there is usually reason to appre- hend its recurrence. If the polypus be very large, and the whole nostril occupied, it is frequently utterly impossible to introduce the wire; and when this is done, the front of the tumour alone can be tied. The polypus nasi is commonly highly sen- sible, and consequendy,tying it proves very painful. As soon as the noose is drawn tight, not only the poly pus inflames, but the whole extent of the Schneiderian mem- brane. The pain and inflammation often extend even to parts at some distance, such as the throat, eyes, be. occasioning acute fever, which requires the strict observance of fow diet, the exhibition of cooling physic, and the evacuation of blood Hence, it is adviseable in many cases, to prepare pa- tients for this treatment, by diet and medi- cines. When the polypus is tied, it swells very much, and all the complaints which it pre- viously caused are exasperated. But, in particular, the part situated in the throat, sometimes obstructs deglutition and respi- ration, in such a degree, that prompt re- lief becomes necessary ; and one of the best plans for affording it, is to make a few punctures in the tumour. These excite a bleeding, that very speedily lessens the swelling, but is sometimes difficult to check. Hemorrhage from a part of the polypus that is tied, is mosl effectually slopped by twisting (he wire so tight, that it closes the arteries distributed to it. The wire sometimes breaks off close to (he lower aperture of the cannula, in con- sequence of being twisted so much and thus the progress of the cure is interrupted. A new wire may be introduced ; but it is difficult to apply it exactly in the situation of the other. A fresh place is commonly lied, which is almost the: same thing as com- mencing the cure anew. It is better lo prevent this interruption of the treatment, hy employing very flexible wire, made of the purest silver ; and by not twisting and untwisting regularly the same extremity of it, but sometimes one and sometimes die other. A strong piece of catgut might be a very good substitute for silver wire. Immediately (he polypus is tied, it swells. Inflames, and becomes painful : in a f'-w days, \i becomes shrunk, tree from pain, and sphacelated. The fetid discharge now occasions considerable inconvenience to the patient, and ought to be washed away by repeated injections. Towards the ter- mination of the case, the surgeon ought to take bold of the polypus wilh the forceps, to try whether any of it is loose. When the polypus is extracted, one may inject si solution of alum, lor a day or two after- ward, in order to dimmish ihe effect of the irritating discharge on the Schneiderian membrane, and the suppuration in the situa- tion of (he ligature, as it is sometimes pro- fuse, and of long duration. Though one might also tie polypous tumours in the throat; and, indeed, tbe introduction of the cannula through the mouth, and the application of the noose, would be attended with no great difficulty; and, though tbe treatment might be rendered more tolerable to the patient, by withdraw- ing the cannulaafter twisting the wire ; yet, the swelling of the tied portion ofthe tumour would, probably, create immense inconve- nience. In this case, therefore, extraction usually merits the preference, and the liga- ture is only fit to be practised in the throat, when the polypus is very small, or there is some especial cause forbidding extraction. When deglutition and respiration are impe- ded by the swelling of the tied portion of the polypus in Ihe throat, the swollen part must be scarified by means of the pharyngo tomus. so as lo excite a bleeding, and thereby produce a diminution of the"swell- ing. The noose is to be frequently and strongly tightened, in order to accelerate the detachment of the polypus, and shorten the inconveniences. W hen the excrescence has not only descended towards the pha- rynx, but also into the nostril, its front por- tion is to be tied first. The result of this may be, such au inflammation and suppura- tion of the whole polypus, that, after the separation of its anterior portion, tbe pos- terior one may also become detached, or at least easy of removal. Caustics. The cautery, formerly recom- mended for tlu cure of Ihe polypus nasi, is now almost entirely rejected, and. indeed, in the manner it was customary to use it, litlie good could be done. It was applied to Ihe unterior surlace of the lumour in the nostril, and its employment was repeated every time the slough separated. Its opera- tion could naturally be but of small extent, as it only came into contact with a trivial portion of the polypus. Its irritation aug- mented the determination of blood to the excrescence, and accelerated its growth: while as much of the the tumour was repro- duced, ere the slough separated, as wa- dm<= deslroyed: and the design of completely extirpating the disease, in this way, seldom or never proved successful.' However, say- Richter, there is one particular example,. wiic-ic the cautery is the only means from which relief can be derived ; and, used in a certain way. it always fpeedily produce^ Ihe desired effect. POLY ITS. There arc some nasal polypi, much dis- posed to profuse bleediug. Touching them in the gentlest manner, and every trivial con- cussion of the body, give rise to hemorrhage. The patient is exceedingly debilitated by re- peated loss of blood ; his countenance is pallid; his feet swollen; be is affected with hectic fever; andfaintswheneverthereisany considerable bleeding. Doubtless, extrac- tion,in this case, isa very precarious method, as the patient is so c'neumstanced, tha; *v oop-ous effusion ol blood must be 'u-Jilv p* rilous. Sometimes the polypus is, t the same time, so large, and the nostril so com- pletely occupied and distended, that it is impossible to apply a ligature. -such is the rase, to which alone the cautery promises assistance. (Rich er.) In employing the cautery, (says the latter author,) the object is not to effect, by its direct agency, a gradual destruction of the polypus ; but toexcite such an inflammation, and suppuration, ofthe whole of il, as shall lead to this event. To fulfil this purpose, a common trocar, three inches long, may be used. Ihc* cannula ought to be two inches shorter than the trocar, whereby the latter m lso occasionally form in the vagina, some of which have a broad basis, and others a thin pedicle. Tlie last merit the appellation of polypi. Their ex- istence is easily ascertained by the touch. By making pres-ure on the bladder and rec- tum, they occasion several impediments to the evacuation ol the urine and feces. They may be conveniently tied, by means of ihe double cannula. Should the polypus be situated at the lower part of Ihe vagina the cannulas would not be required. The liga- ture might be applied With the hand, and the tumour cut off below the conslrict«d part. There is still another kind of tumour in •he vagina, to be classed in the rank of po- lypi. It resembles, in many points, the po- lypus of the mucous membrane of the nostril, consisting altogether of the membranous lining of the vagina which, at the part affecled, becomes relaxed, thickened, and elongated; hence the tumour mi^bt be more properly termed aprolapsusofiJie membranous lining of the vagina, than a polypus. When *■ it resists the efficacy of astringent and corro- borant injections, it may be tied, or what is better, cut off. A polypus in the oesophagus renders de- glutition difficult ; and when of large size, puts an entire slop to it. When an inclina- tion to vomit is excited by irritating the throat with the finger, or a feather, the poly- pus, if situated towards the upper part of the tube, ascends into the mouth, so as lo become visible. But ns it impedes respiration during its residence in the meutb, the patient is soon necessitated, as it were, to swallow it again. When the polypus is .situated far down the oesophagus, of course it cannot be brought into Ihe mouth, and is very difficult to detect. The difficulty of swallowing, its only symptom, may result from other causes. In this case it is also incurable ; for it is impossible to take hold of it with instru- ments. An operation can only be practi- sed, when the polypus is situated in the upper part of the oesophagus. The tumour cannot be extracted ; and the tying of il is difficult. Polypi in the rectum may be lied with the aid of the cannulae. Excrescences in the meatus auditorius externum, resembling po- lypi, have been successfully extirpated by extraction, or rather by twisting them off. For many of the foregoing remarks, I am indebted to Richter, who has very ably treated of polypi in his Ansfangsg. der Wun- darzn. B. 1, Kap. 21. See also J. B. de Lamsweerde, Historia Naturalis Malorum Uteri, 12mo. Lugd. 1700. P. G. Schacher, Programme dt Polypis, Lips. 1721. C. F. TOR halt schmid, De Mola scirrhosu in ultra inverso extirpata, Jena, 1754. C. Schunck, De polypo post febrem Epidemicum ex utero egresso. Wittemb. 1739. A. Levret. Obs. sur la Cure radicale de plusiturs Polypes de la Malricc, de la Gorge, et du Nez. 8vo. Paris, 1749. M. G. Herbiniaux, Traili sur divers Accouchemens latwrieux, el sur les polypes dc la Malrice, fyc. 2 Tom. Svo. Bruzellts, 1782—1794. E. Grainger, Medical and Sur- gical Remarks, including a description of a simple and effectual method of removing polypi from the uterus, fyc. Svo. Lond 1815. Dcwuan's Plates of a Polypus with an In- version ofthe Uterus, and of a Polypus oj the Uterus, fol. 1801. F.A. Waller, Annotation et Academica 4to Berol. 1786. W. Newnham, An Essay mi the S./mploms, fyc. of Inversio Uteri, with a History of the successful Extir- pation of that Organ, 8vo. Lond. 1818. Pott's Remarks on the Polypus of the Nose. Whale- ly's Two Cases of extramdinary Polypi, Svo. Lond. 1805. John Bell's Principles of Sur- gery, Vol. 3, Part 1. Encyclopidie Mitho- dique, Art. Polype. J. G. Huase, De Narium Morbis Comment. Lips. 1794—1797. Lassus, Pathologi. Chir. T. 1, p. 528—538, fyc. Edit. 1809. Callisen's Systema Chirurgie Hodier- nal. Vol. 2, p. 169, fyc. J. L. Deschamps, Traiti des Maladies des Fosses Nnsales, et de leur Sinus, Svo. Paris, 18t>4. Nauche. des Mai. de I'Uterus, Svo. Paris, 1816. S. Schmeider, Schediasma de Polypo CEsophagi vermiformi rarissimo, fyc. Delitii, 1717. See Halleri Disp. Morb. 7, 595. POKKIGO. TL\EA CAPITIS, (called also Ringworm of the Scalp, Scald-head, fyc.) is, according to Dr. Bateman's excellent account of (he subject, a contagious disease, principally characterized by an eruplion of of (be pustules denominated/cm and achores. The achor is defined to be a small acumina- ted pustule, containing a straw-coloured matter, which has the appearance and nearly (ho consistence of honey, and is succeeded t by a thin brown or yellowish scab. The favus is larger, flatter, and not auimiuated, and contains a more viscid matter; its base, which is often irregular, is slightly inflamed ; and it is succeeded by a yellow, semi- transparent, aud sometimes cellulhr scab) like a honey-comb ; wln-nce it has obtained its name. (See Bateman's Synopsis oj Cutaneous Diseases, p. xxiv. and 159, Edit. 3) 1 his intelligent physician has noticed six species of Porrigo, of which my limits will allow me to give only a very abridged de- scription. 1. The Porrigo larvalis, or crusta laclea of authors, begins wilh an eruption of numerous minute whitish achores, upon a red surface. These pustules soon break, and discharge a viscid fluid, which concretes into thin yel- lowish or greenish scabs. Tbe disease in- creases in extent, and the scabs become thicker and larger, until the forehead and cheeks, even Ihe whole face, excepting (be eyelids and nose, become enveloped, as it were, in a mask, whence the epithet larvalis. Small paiches of the disease sometimes PORRIGO. *iT3 appear about the neok and breast, and on the extremities; and the ears and scalp are usually affected in the progress of the case. The infant suffers more or less from the itching and irritation. When ihe discharge is copious and a< rid, Dr. Bateman recom- mends the part to be washed two or three times a day with tepid milk and water, and the application of the unguenturn zinci alone, or mixed with the saturnine cerate. The latter, he says, will be useful for die relief of the excoriation left after the cessation of the discharge. Small doses of the submu- riate ol mercury , either alone, i r in combi- nation with a testaceous powder, will also expedite the cure. If ihe bowels are very irritable, the hydrarg) rus cum crela, or tbe cinereous oxide, may be exhibited instead of the calomel. When the health is good, soda, precipitated sulphur, and the testacea, will lessen the local inflammation and dis- cbarge. When the irritation is removed, and Ihe crusts are dry and falling off, (lie unguenturn hydrarg. nilrat. much diluted, may be used. and the decoction ot bark, or tbe vinum fern prescribed. 2. Porrigo furfurons begins with an erup- tion ol small achores.- The excoriation is slight, and tbe discharge, which is nol abundant, soon concretes and falls off in innumerable thin laminated scabs. At irre- gular periods fresh pustules arise, and follow the course of the preceding. The com- plaint is confined to the scalp, which is affected with itching and soreness; and the hair, which partly falls off, becomes thin, less strong, and sometimes of a lighter colour than natural. This species of porrigo occurs principally in adults, aud it is sometimes attended wilh swelling of the glands in ihe neck. Dr. Bateman observes, that the treatment requires the hair to be closely cut off the scalp. The branny scabs are then lo be gently washed away with some mild soap and water twice a day; and an oil silk cap should be worn. In the beginning, when the surface is moist, tender, and inflnmed, the zinc ointment, or one made with 3'j- of the cocculus indicus and ?j. of lard. After- ward, when the scalp is dry and free from irritalion, it may bt washed with common soft soap and water; e>r with a mixture of equal parts of soft roup and unguenturn suiphuris. Then the unguenturn hydrargyri nitrati, the ung. hydrarg. nitrico oxydi, the tar and sulphur oint ments, or the ung. acidi nitrosi of the Edinb Pharm. may be employ- ed. These last stimulant applications, however, must be led off, if the inflammation and discharge return. 3. Porrigo lupinosa is characterized, ac- cording (o Dr. B iieman, by dry, circular, yellowish while scabs, set deeply iu the skin, with elevated ede,e-, and a central depression, and somewhat resembling, on the whole, the seeds of lupines. These scabs Bre formed upon the separate cluslers of achores, and attain on the scalp (he size of a sixpence ; but when on tbe extremities, they are not more than two lines in diame- ter. In the treatment of the porrigo lupinosa Ihe scabs are first to be gently washed off wilh some soap and water, and the scalp is to be shaved, if it be the part affected. When ihe scabs are difficult of removal, tbe liquor potassae, or a weak lotion of muriatic acid may be u*ed for loo-ening them. Then the ointment of cocculus indicus is to be applied lo the red cuticle, and afterward any of Ihe more stimulant ointments above enu- merated 4. Porrigo Scutulata, or ringworm of the Scalp, as Dr Bateman has observed, makes its appearance in separate patches, of an irregular circular shape, upon the scalp, forehead, and neck. It commences with clustersof small,light-yellow pustules, which soon break, and form thin scabs, which, if neglected, become thick and hard. If the scabs are removed, however, the surface un- derneath is left red and shining, but studded with slightly elevated points or pustules. When the disorder is neglected, the patches become confluent, and the whole head affected Wher the disease is situated, the hair becomes tighter in its colour, it falls off, and its roots are destroyed. The porrigo scutulata generally occurs in children three or four years old and upwards, and fre- quently proves exceedingly obstinate. Ac- cording to Dr. Bateman, it seems to origi- nate spontaneously in children of feeble and flabby habit, and who are ill fed, uncleanly, and not sufficiently exercised ; but he thinks that it is chiefly propagated by contagion, i.e. by the actual conveyance of the matter from the diseased to the healthy, as may happen in the frequent contact of the heads of children, the use of the same towels, combs, caps, and hats. While the patches are inflamed and irrita- ble, it is necessary to limit the local appli- cations to washing the parts with warm wa- ter. Even shaving the scalp, which must be repeated at intervals ofeightorten days, produces a temporary irritation. Nothing but a light linen cap is now to be worn, and it must be often changed. The disease afterward forms dry scabs, and becomes for a time less irritable ; but a fresh eruption of achores soon follows, and the inflammation and redness return. In the inflamed states, Dr. Bateman recom- mends the use of ointments, made either with the cocculus indicus. submuriate of mercury, oxide of zinc, superacetate of lead, opium, or tobacco ; or else the infusion of poppy-heads, or tobacco. Where there is an acrimonious discharge, Dr. Bateman pre- scribes the zinc, or saturnine ointments, the ung. hydrarg. praecip. calomel ointment, oi a lotion of lime-water and calomel. In the less irritable stages, the ung. hy- drarg. praecip. the ung. hydrarg. nitrico- oxydi, and especially the ung. hydrarg. nitrat. are often effectual remedies. So are the ointments of sulphur, tar, hellebore, and turpentine, and lotions of the sulphates of zinc and copper, the osy muriate of mercury. 374 POR I have often seen a solution of 3j of the sulphuret of potassa in a pint of lime-water, succeed when most other applications had failed. In the very dry and inert state of the patches, Dr. Bateman bas seen the dis- ease removed by a lotion, containing from three to six grains of the nitrate of silver in an ounce of distilled water. The applica- tion of the diluted mineral acids, or of a blister, bas also been known to put a perma- nent stoppage to the morbid action. In general, no local application agrees well, if long continued, and it is necessary to have several, which must be alternately employed. The cure may often be expedited by cin- chona, chalybeate, and alterative medi- cines ; and attention must be paid to the patient's diet, exercise, be. 5. Porrigo decalvans consists in bald patches, surrounded by hair which is as thick as usual. It is not known whether any eruption of minute achores actually precedes the detachment of tbe hair. Dr. Bateman remarks, that if the scalp is regularly shaved, and some stimulating liniment be applied to it, this obstinate affection may at length be overcome, and tbe hair will regain its usual strength and colour. Two drams of oil of mace, in three or four ounces of alcohol, are said to make an excellent liniment. 6. Porrigo favosa consists of an irruption ofthe large, soft, straw-coloured flattened pustules, denominated favi, which may occur on any part of tbe body ; but most commonly spread from the scalp, especially behind the ears, to the face, or from the lips and chin to the scalp. Tbey are attended witb considerable itching, and are most fre- quently seen in children from six months to fouryears of age, though adults are also often affected. The pustules pour out a viscid matter, which concretes into greenish or yellowish semi-transparent scabs. When the hair and moist scabs are matted together, pediculi are often generated in great num- bers, and aggravate the itching and irrita- tion. If tbe disease be allowed to increase, the scabs are thickened into irregular masses, not unlike honey-comb; and considerable ulcerations sometimes form,especially when the heel and toes, or other parts of the lower extremities, are affected. The ulcerating blotches are generally soon followed by irri- tation and swelling of the lymphatic glands, which sometimes slowly suppurate. The contact of the discbarge inoculates the dis- ease ; thus, in young children, the breast is inoculated by the chin ; and the arm and breast of the nurse may be infected in the same way; though adults do not take the complaint so quickly as children. The porrigo favosa requires the same alteratives, internally, as the porrigo larva- lis. The diet should consist of milk, pud- dings, and a little plain animal food. When the habit is bad, and the glands swelled, bark, chalybeates, and a solution of tbe mu- riate of barytes, are proper. As local applications, Dr. Bateman pre- PRE lers the unguenturn -zinci, or tbe uug. hy drarg. prsecip. mixed with this or the satur- nine ointment, especially when the discharge is copious. He also speaks favourably of the ung. hydrarg. nitrat. tbe strength of which is to be diminished by an addition of simple cerate, according to the degree of irritation present. For tbe preceding particulars I am indebt- ed to Dr. Bateman's valuable Synopsis of Cutaneous Diseases, where the reader, de- sirous of additional information respecting porrigo, will be amply gratified. POTASS \ARSENICATA. Kali Arstni- catum. Arsenias Kali. \\- Oxydi albi arseni- ci, potassa? nitratis sing. Zj Crucibulo im- plo igne candenti injice nitrum, et liquefacto adde gradatim arsenicum in frustulis donee vapores nitrosi oriri cessaverint. Solve ma- teriam in aquae distil lata* fb'V. et post ido- neam evaporationem sepone ut fiant crys- talli. These crystals may be given in the dose of one-tenth of a grain, thrice a day. (Pharm. Sancti Barthol. 1799.) Justmnotid strongly recommended the internal exhibi- tion of arsenic in cases of cancer. (See Cancer.) POTASS^ CARBONAS. Two drams of this medicine have been given, as a lithon- triptic, at St Bartholomew's Hospital, in a pint of distilled water, twice a day. POTASSA FUSA. Caustic Potash. This is one of the most useful caustics for de- stroying fungi, making issues in cases of diseased vertebra?, white swellings, be.; and it is recommended to be used in a par- ticular manner, by Mr. Whately, for the cure of strictures in the urethra. When surgeons prefer opening buboes, or any other ab- scesses, with caustic, the caustic potassa is very commonly employed. When surgeons used to cure hydroceles, by destroying a part of the scrotum and tunica vaginalis with caustic, the potassa fusa, either alone or mixed with quicklime, was made use of. (See Vertebral, Urethra, Strictures of, fyc.) POTASSA SULPHURETUM. Sulphu- ret of Potash, Liver of Sulphur. Two drams, dissolved in a pint of lime or distilled water, make an excellent lotion for the cure of porrigo. Many other cutaneous affections yield also to the same remedy. When arse- nic has been swallowed as a poison, twenty grains of the sulphate of zinc may be given as an emetic of the quickest operation ; and, after keeping up the vomiting by drinking warm water, and, what is better, sweet oil, some authors recommend making the pa- tient drink as much as possible of a solution of the sulphuret of potash. PREGNAiNCY is set down by some wri- ters as preventive of the union of broken bones ; but many exceptions to the remark present themselves in practice ; for I have attended myself a female, six months gone with child, who broke both bones of her leg, yet they grew together again in tbe usual time. (See Fractures.) Pregnant wo- men also frequently bear operations much better than might be expected. Thus M. Nirod has recently published a •»ucce*"f«d PROSTATE GLAND. 37<> amputation of the left leg during pregnancy, in a case where the right tendo Achillis was also ruptured. Both the wound, and the broken tendon, united very well. (See Annuaire Mid. Chir. des Hdpitaux de Paris, p. 509 4lo. Paris, 1819.) PROBANG A long slender bit of whale- bone, with a bit of sponge at its extremity, intended for the examination of the oesopha- gus, or tbe removal of obstructions in it. PROCIDENTIA. Prolapsus. A falling down of any part. (See Anus, Prolapsus of. Uterus, Prolapsus of, fyc.) •PROSTATE GLAND, DISEASES OF. It is an observation, made by Mr. Hunter, that the use of this gland is not sufficiently known to enable us to judge of the bad con- sequences of its diseased state, abstracted from swelling. Its situation (says he) is such, that the bad effects of its being swelled must be evident, as it may be said to make a part of ihe canal of the urethra, and there- fore, when it is so diseased that its shape and size are altered, it must obstruct the passage ofthe urine. (On the Venereal Disease, p. 169.) A swelling of the prostate gland, however, may be of very different kinds : thus it may depend either upon common inflammation ofthe part, abscesses, calculi formed within its substance, a varicose en- largement of its vessels, or a scirrhous chro- nic induration. (See QZuvres Chir. de De- sault par Bichat, T. 3, p. 220.) Modern anatomists describe the prostate gland as not being itself a very sensible part, and hence it is more subject to chronic than acute disease, to which, however, it is also liable. We have the authority of Desault, Hunter, and Dr. Baillie, for setting it down as subject to scrofula. The latter physician, after staling that he has seen a common abscess situated in it, adds, that it is also subject to scrofulous disease, as, on cutting into it, he bas met with tbe same white curdy matter which is formed in a scrofu- lous absorbent gland ; he has likewise forced out of its duct scrofulous pus. (Morbid Anatomy, fyc.) Mr. Lloyd states, that he bas also met with fleshy enlargements of the gland, in the substance of which several small ab- scesses were formed, containing " a com- plete scrofulous matter." He has also known enormous enlargements of this gland hap- pen in young men who were labouring, at the same time, under other scrofulous dis- ease. Other instances of supposed scrofu- lous swellings of the same part in young patients are likewise cited by this author, one of which is particularly remarkable, as in it the gland was found after death to be of the size of a child's head, though its na- tural consistence was not much changed. (On the Nature and Treatment of Scrofula, p. 107 ) Other chronic, or as they are more often called, scirrhous enlargements of the prostate gland, rarely occur io subjects un- der the age of fifty. To these cases I shall presently return. Like every other part of the body, the prostate gland i*? sometimes, but not often, the seat of common phlegmonous inflamma- tion Mr. Wilson has known two or three instances of this kind take place soon after puberty; one case was from a fall; the others arose witbout any assignable cause, (On the Male Urinary and Genital Organs, p. 327.) There is also a phlegmonous swell- ing of the prostate gland, sometimes an effect of strictures, as will be presently no- ticed. As Desault observes, the retention of urine, arising from such a cause, comes on very suddenly and rapidly increases. The patient at first complains of a sense of heat and weight about the perinaeum ; and, soon afterward, of a continual throbbing pain about the neck of the bladder. The paiu is severely increased when the patient goes to stool; and there is tenesmus, and trequent inclination to make water. How- ever, according to Mr. Wilson, the desire to evacuate the urine is here less constant than in cases where the inner membrane of the bladder is inflamed. (Vol. cit.p. 327.) The patient feels also as if a large mas3 of excre- ment filled the extremity of the rectum, and were ready to come out. If a finger be in- troduced within the rectum, the swelling of the gland is plainly distinguishable; and, according to J. L. Petit, the projection of the prostate gland in the bowel makes a corresponding hollow groove along the concave side of the excrement, as may be noticed, when what is voided is hard. How- ever, Bichat conceives, that such an appear- ance must generally be obliterated as the excrement is passing through the sphincter. When the patient attempts to make water, it is a long while before the first drops come out, and as straining has the effect of pro- pelling the swelled prostate more against the neck of the bladder, it only increases the difficulty, and no urine will come out until such efforts are discontinued. The more violent the inflammation is, the smaller is the stream of urine, and the more acute the pain felt during its expulsion. Accord- ing to Desault, it is likewise particularly re- markable in such cases, (hat if an attempt be made to introduce a catheter, the instru- ment passes without the least resistance as far as ihe prostate gland, where it stops, and causes great pain. The pulse is hard and frequent; and the patient is exceedingly thirsty and feverish. Desault considered the retention of urine in cases of this kind, and, indeed, in all enlargements of the prostate gland, or other obstruction of the urethra, as generally more dangerous than other retentions, merely depending upon weakness of the bladder, where there is little risk of this organ giving way. When the urethra is free from obstruction, the urine, after distending the bladder in a cer- tain degree, generally oozes through that canal, and the patient may live in this con- dition for years without any alarming symp- toms But the case is differeni when the retention of urine depends upon any stop- page or stricture in the urethra. TheTurine does not then partially escape, but stagnate? in the bladder; the distention increase* , PROSTATE GLAND and if speedy relief be not afforded, a peril- ous extravasation follows. The danger, however, of such a retention of urine de- pends very much upon the extent and seve- rity of the inflammation. However, this -statement will not apply to the chronic scirrhous enlargement of the prostate, be- cause, as will be presently explained, in this affection some of the urine begins to drib ble away after the bladder has become dis- tended in a certain degree. In cases of phlegmonous inflammation of the prostate gland, antiphlogistic treatment is indicated ; especially venesection, leeches to the perinaeum and near the anus, the warm bath, emollient clysters, poultices, and fomentations, and a low regimen. How- ever, as Desault admits, the efficacy of these means is often too slow, and the symp- toms too urgent, to allow the surgeon to wait for the urine to flow of itself. Fre- quently, also, the distention has so weaken- ed the bladder, that this organ cannot expel its contents; in which event the catheter must be used, though the diminished dia- meter and altered course of the prostatic portion of the urethra sometimes renders its introduction difficult, and always very pain- ful. The practical observations respecting the best kind of catheters, and the mode of introducing them in cases of swelled pros- tate gland, will be more conveniently intro- duced when the chronic enlargement of this part is considered. (See also Catheter and Urine, Retention of) In every instance of retention of urine from acute inflammation about the neck of the bladder, whether tbe case be an abscess forming near the anus, or a phlegmonous inflammation of the pros- tate gland, or other adjacent part, it has always appeared to me that antiphlogistic and anodyne remedies should first be fairly tried, and the catheter, which always in- creases the pain and irritation, only used where such means do not afford relief with sufficient expedition. When a catheter has been introduced, ought it to be left in the bladder, or with- drawn, after the discharge of the urine ? Its presence no doubt will increase the irri- tation about the neck of the bladder; but on the other hand, if it be taken out, the surgeon may not be able to introduce it again. No general precept, says Desault, can be laid down on this point The course which tbe practitioner will pursue, must depend upon the difficulty he has experien- ced in getting the instrument into the blad- der, and upon the confidence which he may have in his own skill, and which must be founded upon constant success in analogous instances. According to Desault, when an abscess follows inflammation of the prostate, the body ofthe gland itself does not suppurate, but only the surrounding parts, and the cel- lular substance, which connects its lobes together. This, at least, vvas what was ob- served in examining several dead subjects, who were publicly opened in the amphi- theatre ofthe H"" the same subject, in which they were mon in the decline of life; one circum- unusually large, that it appeared to be a stance in which it differs from scrofulous gland of that kind. It could not, however, diseases of the same part, which are well be satisfactorily separated from tbe prostate known to happen chiefly in youngish persons, gland, nor could any distinct duct be found It is observed by Mr. Hunter, that when Uie leading into the bladder. prostate gland swells, "it does not lessen " A similar examination was made of this the surface of the urethra at the part, like a part in five different subjects. The appear- stricture ; on the contrary, it rather in- ance was not exactly the same in any two creases it'; but the sides of the canal are of them. In one, there was no apparent glan- compressed together, producing an obstruction dular substance, but a mass of condensed cel- to the passage ofthe urine, which irritates the Mar membrane: this, however, on being bladder, and brings on all the symptoms in cut into, differed from the surrounding fat. that viscus, usually arising from a stricture, In another there was a lobe, blended late- or stone. From the situation of the gland, rally with the sides of the prostate gland. which is principally on the two sides of the These facts (says Sir Edward Home) are canal, and but little, if at all, on the fore- mentioned in proof of its not being always part, as also very little on the posterior side, of the same size, or having exactly the same it can only swell laterally,whereby it presses appearance." • the two side? of the canal together, and, at This is found also fo *e the caie wilh Vol. II. 18 378 PROSTATE GLAMX Cowper's glauds : they are sometimes large and distinct; in other subjects, they are scarcely to be detected ; and, in others again, are in all the intermediate states. The most distinct and natural appearance of this part was in a healthy subject, twenty-five years of age, of which the following is an account. On turning off the vasa deferentia and vesicular; seminales, exactly in the middle of the sulcus, between the two lateral portions of the prostate gland, there w7as a rounded promiuent body, the base of which adhered to the coats of the bladder. It vvas imbedded, not only between the vasa deferentia and the bladder, hut also, in some measure, between the lateral portions of the prostate gland and the bladder, since they were in part spread over it, so as to prevent its circumference from being seen, and they adhered so closely as to require dissection to remove them ; nor could this be done, beyond a certain extent, after which the same substance was continued from one to the other. This proved it to oe a lobe of the prostate gland; its middle had a rounded form, united to the gland at the base next the bladder, but rendered a separate lobe by two fissures on its opposite surface. Its ducts passed directly through the coats of the bladder, on which it lay, nnd opened immediately behind the verumontanum. By means of this lobe, a circular aperture is formed in the prostate gland, which gives passage to the vasa deferentia. " Previous to this investigation (says Sir Everard) it was not known to me, that any distinct portion of the prostate gland was situated between the vasa deferentia and the bladder." (On Diseases of the Prostate Gland, p. 9,Svo. Lond. 3811.) Notwithstanding this explanation, lo the correctness of which most English anatomists have acceded, it is worthy of no- tice, that Langenbeck, the present distin- guished Professor of Anatomy and Surgery at Goitingen, in a review of Sir Everard's account, declares, that he has never, in the natural state of the parts, found the middle lobe, as it is called, which he considers as a partial induration, rising up in the shape of a lobe. (Neue Bibl. B. 1, p. 360, 12mo. Hanover, 1818.) This dissent would seem extraordinary, if it were not possible lo suppose, that it may proceed, not from all the subjects at Gottingen differing from Londoners in being destitute of, what Sir Everard Home has named, the middle loot ofthe prostate gland, but from Langenbeck's not having traced in the healthy state of the gland, any portion which he thought deserving of that name. But though differences of opinion may be entertained about the name, none I presume can remain about the thing itself, which appears to have been long ago mentioned, though not perfectly described, by Morgagni. (Adversa- ria Anat. 4, Animad. 15.) The paper by Mr. C. Bell, illustrating how far our predecessors had a knowledge of this portion of the ^land, seems to me one of his best produc- lion's : and it is therefore; witb pleasure that I refer to it. (See An Account of the Muscle* of the Ureters in Med. Chir. Trans. Vol. 3, p. 171, fyc.) However, as this author impartially acknowledges, it is not because a fact was anciently known, or perhaps only cursorily noticed, that there may not be great merit in reviving the recollection, or perfecting the description of it; and as far as I can learn, none of the anatomical teachers in this cit-y, previously to Sir Everard's paper, particularly adverted, in the healthy original state of the prostate gland, to the structure, which he has pointed out, by whatever name it be distinguished. According to Sir Everard Home, this lobe, in the earlier periods of life, when the body of the gland is in a sound state, is small; nor does it appear to become enlarged, even when the body and the lateral lobes have been considerably increased in size ; but, in subjects of advanced age, this part, as well as the rest of the gland, is usually found somewhat enlarged, even in cases where no disease has been suspected during life. (P. 17.) When the middle lobe begins to enlarge, it presses inwards towards the cavity of the bladder, putting the internal membrane upon the stretch, and communi- cating to it by immediate contact the in- flammation, which occasioned its own enlargement. Hence, pain in making water, particularly after the last drops are voided, and a desire and straining to discharge more, after the bladder is empty. As this organ cannot now retain much urine, the desire-to make water becomes frequent, and there is commonly more or less constitutional disturbance, or sympto- matic fever. According to Sir Everard Home, in proportion as the middle lobe increases in size, it projects into the cavity of the bladder in the form of a nipple ; but after a further augmentation, it loses the nipple-like appearance, becomes broader, and forms a transverse fold by pushing for- ward, and stretching, the membrane, con- necting it to the lateral lobes, " As the tu- mour, and the transverse fold, are situated im- mediately behind the orifice oftheurelkra, they are pushed jorwards before the urine in every attempt that is made to void it, acting like a valve, and closing up Ihe opening, till the cavi- ty of the bladder is very much distended, when the anterior part of the bladder being pushed forward, and the lumour being drawn back, in consequence of the membrane of the poste- rior part ofthe bladder being put on the stretch, the valve is opened, so that a certain quantity of water is allowed lo escape, but the blad- der is not completely emptied. (P- 19) Sir Everard Home afterward explains, that, as the tumour enlarges, the quantity voided at each time becomes smaller, and that which is retained is increased, until at length, the disease becomes so much aggra- vated, that there is a complete retention of urine. The body of the gland, and the late- ral lobes, though less disturbed than the middle lobe by the patient's repeated ef- forts to void the urine, become more or less enlarged : hut it is remarked, that they do PROSTATE not preserve either their natural, or any regular, proportion, to the middle lobe, nor do they always swell equally together, the left in some instances becoming much larger than the right. (P. 22.) When Sir Everard Home published his first vol. on diseases of the prostate gland, he had seen only the left lobe form the greatest projection within the bladder ; but, in his second vol. published in 1818, there is an engraving, representing the right lobe thus altered ; and he mentions two instances, in which a similar enlarge- ment of the same lobe had taken place. Mr. Wilson has also more than once met with this greater swelling of the right lobe. (On the Male Urinary and Genital Organs, p. 336.) The recollection of these facts will often enable the practitioner to incline the beak of a catheter in the direction by which it may be conducted into the bladder, and thus, as Sir Everard Home has remarked, the surgeon, after trying gently on the left side, and not succeeding, is not to perse- vere in that direction, but try whether the passage will offer less resistance on the op- posite side. The diseased state of the body of the prostate gland, and of the lateral lobes, here alluded to by Sir Everard Home, he says, is very different from that, which is met with in the earlier periods of life, in conse- quence of strictures of the urethra, and which subsides when the obstruction in that canal is removed. This enlargement of the prostate gland from strictures, he observes, may not be unaptly compared to the swell- ing of the testicle in gonorrhoea, a case of accidental inflammation in a healthy tes- ticle ; while the other disease of the pros- tate is analogous to the more permanent disease of the latter organ. This author adverts, however, to a few instances, in which the enlargement of the body of the prostate gland from strictures, in persons 50 years of age, did not subside immediate- ly the latter affection was cured, a common bougie stopping at the neck of the bladder, although a catheter, which had a regular curve, readily passed. According to Sir Everard Home, as in such cases, the patients were able to empty their bladders, it is evi- dent, that there could be no enlargement of the middle lobe. In cases like these, no symptom of importance is produced, and, whether the swelling of the prostate readily subsides, or not, is of no consequence ; though, if the stricture do not return, it will always ultimately diminish. (On Diseases of the Prostate Gland, Vol. 1, p. 24.) In ^ patients under 50 years of age, Sir Everard Home has rarely found the middle lobe so swelled as to produce retention of the urine, or an inability to empty the bladder, not- withstanding the rest ofthe gland might be much enlarged. (P 23.) When the middle, and one of the lateral lobes, project consi- derably into the bladder together, their sur- face i sometimes excoriated, and has an ulcerated appearance. Under such circum- stances, the pain, after voiding the last drops of urine, is said to be very severe. GLAND. 37* and attended with spasmodic affections of the neck of the bladder, of the most dis- tressing kind. According to Sir Everard Home, another effect of a similar enlargement of the pros- tate gland is to render its secretion extreme- ly viscid and very abundant. A question might arise about the real source of this ropy mucus, and some might infer, that it was secreted by the bladder; but that it comes entirely from the inflamed prostate; gland is proved, says this gentleman, by its having been found in one instance with one extremity floating in the bladder in the dead body, while the other extremity appeared divided into small filaments, terminating in the orifices of the excretory ducts of the gland at the verumontanum. The quantity of secretion is observed to depend more upon the degree of irritation, than the actual enlargement of the gland, and, as this in- creased secretion happens in cases of swell- ing of this part from strictures, where the body and lateral lobes are alone affected, it is inferred, that the disease of the middle lobe only contributes to this effect by keep- ing up a straining, and disturbance of every part of the gland. (P. 32.) The internal membrane of the bladder inflames, and be- comes extremely irritable, so that, even when the quantity of urine is small, there is a great deal of straining. When the size and form of the tumour are such as to allow the greater part of the urine to pass, though with great effort, Sir Everard states, that the symptoms may continue nearly the same for months ; liable, however, to occasional aggravations from slight causes, and becom- ing more or less relieved, when these rue removed. Nay, he observes, that the symp- toms may even lessen, although the disease is not at all diminished ; a circumstance,. which is ascribed to the muscular coats of the bladder having acquired greater strength, and the internal membrane having lost, from habit, the sensibility, which it possessed in the earlier stage. (P. 34.) He further explains, that, in this disease, when the inside of the bladder is inflamed, fila- mentous portions of coagulating lymph are thrown off from it, which, when the in- flammation increases, subside in the urine evacuated, looking not unlike white hair- powder ; and, when the irritation is very violent, perfectly formed pus is met with in the urine. (P. 35.) After the inflam- mation subsides, the bladder becomes again capable of retaining a larger quan- tity of urine, though its power of com- pletely emptying itself is still further dimi- nished. According to Mr. Wilson, the symptoms, which generally attend au enlarged prostate gland, are similar to those of an irritable bladder :—constant, heavy, dull pain in the gland, and sometimes sharp lancinating pains, darting from it to the urethra, and occasionally to the bladder and ureters. Frequent calls to void the urine, which is passed with difficulty, only a small quantity being discharsed at a time, as more or less 3«0 PROSTATE GLANDS. always remains behind in the bladder. A complete retention of urine may be produ- ced, so that not one drop will pass, although much straining is used. Great difficulty in expelling the feces, and after each evacua- tion, a feeling is still experienced, as if the gut were not yet emptied. During the ef- forts to expel the urine and feces, a quantity of the mucous secretion of the prostate gland is not unfrequently forced out. Most of these symptoms, as Mr. Wilson observes, are similar to those produced by stone, and, therefore, when they occur, the gland •should be examined by the rectum, and, if it be not found diseased, a sound should be introduced into the bladder. (On the Male Urinary and Genital Organs, p. 339.) The particular differences,between the symptoms of stone, and those arising from disease of the prostate gland, are explained in the ar- ticle Lithotomy. Mr. Hunter first pointed out a fact, which the practical surgeon should never forget, viz. that the swelling of what is now called the middle lobe of the prostate gland, often raises the sound over u small stone in the bladder, and prevents it from being felt. (On the Venereal Disease, p. 170.) Hunter also first noticed another circumstance well de- serving recollection, viz. that an enlarge- ment of the same part may account for the disappearance of all the symptoms of stone in patients who have already suffered greatly from them, as the swelling prevents the cal- culi from falling down upon, and irritating the neck of the bladder. These truths are exemplified by cases which are highly inte- resting. It appears also probable, from the observations of Sir Everard Home, that an enlargement of the middle lobe conduces to the formation and lodgment of calculi in the bladder, partly by preventing the evacua- tion of small ones through the urethra, and partly by hindering the bladder from com- pletely discharging its contents. (Vol. 1, p. 40.) Lastly, it is explained, that in disease of the prostate gland, patients secrete less urine than natural, and that death is some- times produced by the retention of urine BUppressing such secretion altogether. In cases of enlargement of the middle lobe, one symptom, on which Sir Everard Home lays great stress, is hemorrhage produced by riding on horseback. (Vol. 2, p. 27.) In- flammation and even ulceration ofthe mem- brane covering the middle lobe, he says, are more frequent than he was at first aware of, and are produced by the rough introduction of instruments. Hence, the burning heat at the neck ofthe bladder, the great pain and dis- tress attending tbe passage and the continu- ance of an instrument, the occasional neces- sity of taking it out, and the duration of the pain for some time afterward. (Vol. cit. p. 29.) ' ' According to Mr. Wilson, in a case of What is named scirrhous prostate gland, the enlargement at first takes place slowly, at- tended with pain, and no particular altera- tion of the structure is apparent in (be gland, When examined in this stage after death, nor is any change discoverable when the part is felt from the rectum in the living patient. As the disease proceeds, the structure of the whole gland changes, end the part enlarges, sometimes regularly so as to preserve ils shape, to the size of a moderate orange ; sometimes very irregularly, projecting in « lobulated manner. When die gland in Uiii stale is cut into, its substance feels firm, Ihe cut surface is of a whitish brown colour, and the membranous septa, extending through it in various directions, are often very strongly marked. In general, before (he urethra anil bladder are opened, the gland appears most enlarged laterally. It also swells backwards towards the rectum, producing that appear ance of the excrement particularly noticed by J. L. Petit, and already mentioned in speaking of common inflammation of the gland. Mr. Wilson further states, that its an- terior part is generally least enlarged, he cause its connexion with the pubes prevents it from passing far forward. However, this gentleman bas seen some instances, in which the enlargement above, or in front of the urethra, was considerable. The extent of (he lateral and posterior swelling may be readily felt wilh die finger, introduced with- in the rectum. That these very irregular windings in the prostatic portion of the ure- thra are frequently occasioned by the dij- ease, is also confirmed by Mr. Wilson's ex- perience, and numerous preparations in the Museum of the College of Surgeons. " In the progress of the enlargement, the two sides do not always swell equally ; one of- ten enlarges most, and often swells more in one particular part than another. This pro- duces a lateral bend, or obliquity in the passage, which will of course increase the difficulty of passing tbe urine, and of intro- ducing tbe catheter. 1 have seen from the irregularity of tbe lateral swelling, (lie passage through the gland bend in suc- cession to both sides." (J. Wilson on the Male Urinary and Genital Organs, p. 33-2, 335.) As every considerable enlargement of Ihe prostate gland is attended with great difficul- ty of voiding the urine, the muscular coat of the bladder always becomes more or less thickened, in consequence of the efforts which it is obliged to make. In relation to the third, or middle lobe, it is to be observed, that from some dissections made by Mr. Sbaw, it woifid appear, that in many cases the enlarged portion of tbe pros- tate, projecting into tbe bladder, is not ibe third lobe, but a part of the gland situated more forwards. (See Bell's Surgical Obs. Vol. l,p.223,fyc.) According to Sir Everard Home, a stric- ture may be distinguished from an enlarge- ment of the prostate gland, by the following circumstances : the distance of the obstruc- tion from the external orifice is to be deter- mined by passing a soft bougie, which is to be left in the canal for a minute, so as to re- ceive an impression from the obstruction. If tbe bougie does not pass further than se- ven inches, and the end is marked by an ori- PROSTATE GLAND. 381 face of a circular form, (ii is immaterial as to the size of the orifice,) the disease is cer- tainly a stricture ; but if it passes further on, and the end is blunted, a disease in the prostate gland is to be suspected. This in general may be ascertained by the possi- bility of passing into Ihe bladder a flexible gum-catheter with a stilet, very much curved, which in most cases of enlargement of Ibe gland may be accomplished. On the subject of the causes of a scirrhous enlargement of Ihe prostate gland, it ap- pears to me, that little certain is known, ex- cepting that il is a disease seldom met with under the age of fifty. Desault suspected, (hat il was sometimes venereal, and common in individuals who had repeatedly had go- norrhoea. (Traili des Mai. Chir. T. 3, p. 238.) I believe neither of these sentiments is entertained by the best surgeons of the present day. According to Sir Everard Home, it is a rare occurrence for a man to arrive at 80 years of age, wilhout suffering more or less under disease of this part. " The more common causes (says he) of in- flammation of the prostate gland, are full living of every kind, inebriety, indulgence lo excess wilh women, a confined state of Ihe bowels, and exposure to the effects of cold ; indeed, whatever increases the circu- lation of the blood in these parts (the geni- tals I suppose) beyond the healthy standard, may become a cause of inflammation in this gland, the blood-vessels of which lose Iheir tone in the latter periods of life." (On Dis- eases of the Prostate Gland, Vol. 1, p. IS, 19.) If we are to credit another statement, the disease occurs most frequently either in persons who have not used Ihe genital or- gans so much as nature intended, or in others who have led a life of excess. (Wilson on Ihe Urinary and Genital Organs, p. 332.) It seems to me better to confess, that the etio- logy of this complaint is unknown. Nor are we rendered much wiser by conjectures Bbout the effects of horse exercise, or those of a retarded venous circulation in old sub- jects, in creating a tendency to the disease. f have known several persons afflicted, who had led very sedentary lives. I am afraid, that the observation formerly made by Mr. Hunter still continues true, which is, that a certain cure for the scirrhous enlargement of the prostate gland is not yet discovered. But though such is the fact, surgery is undoubtedly capable of affording a great deal of relief, so as to lengthen the patient's days, and render them much more comfortable. This is accomplished princi- pally by anodyne medicines, and drawing off tbe patient's water, when he cannot void it himself either at all, or but imperfectly, and wilh considerable straining and suffering. As a temporary relief from pain, and also as a means of removing spasm, opiate clysters should be administered once or twice a day. (Hunter, p. 174.) Scrofulous enlargements of the prostate gland, occurring iu younger subjects, are probably more under the con- trol of judicious treatment. Thus, Mr. Hun- ter informs us, that in several cases be bad seen hemlock of service. " It was given upon a supposition of a scrofulous habit. On the same principle, (he adds,) I have re- commended sea-bathing; and have seen considerable advantages from it, nnd in two cases, a cure of some standing." In one case, burnt sponge had reduced the swelling ; and in another the same effect was produced, and the irritability of the bladder lessened, by means of a seton in the perinaeum. Af- ter the healing of the seton, however, the symptoms returned, and on a trial of the plan again,the former good effects were not experienced from it. Some time ago, I at- tended a gentleman under Mr. Lawrence, who was trying the effect of an issue in the same situation ; but I am not at present ac- quainted with the result. In these cases, the pilulae hydrargyri cum conio (see Pilulai) have been very commonly prescribed, as on eligible alterative. Sir Everard Home men- tions an instance, in which suppositories of opium and hemlock, passed up the funda- ment, and allowed to dissolve there, gave more relief than any other plan, not only lessening the irritalion, but producing a di- minution of the projection of the gland. In the first stage of the enlargement of the middle lobe, when there is no absolute ob- struction to the passage of the urine, Sir Everard recommends bleeding from the loins, opiate clysters, and the pulv. ipecac. comp. (On Diseases of the Prostate Gland, Vol. 1, p. 70.) The tepid bath, the use of which he formerly advised, he now con- demns as a practice " as little applicable to this disease, as putting Ihe head in warm wa- ter would be to remove the symptoms of apoplexy ; if any applicalions are to be made to the parts, they should be such as produce cold." (Vol. 2, p. S3.) In this stage, We observes, that catheters and bougies should on no account be introduced, more especial- ly those ofthe metallic kind,since ihey pro- duce a degree of disturbance which the parts are not in a state to bear, and if unskilfully employed, they will increase Ihe swelling, and bring on a complete retention of urine. Sir Everard is an advocate for keeping the bowels open, for which purpose he prefers the infusion and tincture of senna, with the tartrate of potash. (Vol. 2, p. 84.) If, in defiance of these means, the patient becomes unable to make any water, or, although able to pass a few ounces, is every hour obliged to make the attempt, and after much strain- ing, discharges only the same quantity, Sir Everard directs a flexible gum-catheterJft wilhout a stilet, to be passed into the blad- der, in the gentlest manner possible. This instrument is to be kept introduced wilh the catheter bracelet, or retainer, made and sold by Mr. Weiss of the Strand, and the water drawn off at regular intervals, not only till the first symptoms go off, but till the bladder retain (he urine for the usual length of time, and what is voided has tbe appearance of heathly urine. If, when the catheter is with- drawn, the patient should not be able to empty his bladder, it must be re-introduced, and after sis or seven days, taken out again 3S2 PRO PSO When the disease is somewhat more ad- vanced, and the patient cannot keep himself quiet, the above practice of course cannot be adopted, and it becomes necessary to pass the catheter three or four times a day. But even under such circumstances, when irri- tation is brought on by accidental circum- stances, SirEverard recommends keeping the instrument in the bladder until the attack bas subsided. (Vol. 2,p. 92, 96.) This gen- tleman finds that, for cases of diseased pros- tate gland, common flexible gum-catheters, originally made straight,are disadvantageous, as it is a long while before they can be made to keep a permanent curved form. " When (says he) the curvature of the catheler is no part of its original formation, although it may have been produced by being long kept in a curved state, yet, when allowed lo remain in the bladder, it gradually returns to its straight form by being moistened, and when it has acquired it, the point is no longer kept di- rected upwards in the cavity of Ihe bladder, hut is constantly pressing against the pos- terior coats, pushing itself out of Ihe urethra, and the irritation it gives the muscular coat of tbe bladder, will often be the means of its being expelled by a spasm with consider- able violence." (On Discuses of the Pros- tate Gland, Vol. 2, Chap, b.) Sir Everard further informs us, that Mr. Weiss, No. 33, in the Strand, has -it length succeeded in making flexible gum-catheters, originally curved, so that they always retain Iheir shape. Their polish is great, and tbey can be had of any size : they arc also made particular- ly strong, a quality necessary to secure them from being broken in vioient attacks of spasm. Sir Everard states, that he has kept them fifteen days in the bladder, wmiout iheir being spoiled by tbe urine, or mucus; whereas, common French and Eng- lish catheters become in a shorter period so rough as to be unfit for further use. Metal catheters, he asserts, should never le em- ployed but in cases of necessity, w",u forward into the anterior chamber, while others he leaves in the opening of the iris, where ihey at first serve as a plug, hindering union by Ibe first intention, (P. 38.) and are after- ward absorbed. For an account of this gentleman's particular methods in all the va- rious complications of these cases, tbe reader mu-t consult his publications, where many successful examples of tbe operation are re- corded. That Cheselden's method ought not to be entirely rejected, there can now lie no doubt. Like all other modes of forming an artificial pupil, it certainly does not merit exclusive preference. Besides the authority of Sir W. Adams, we have the testimony of Mr. Ware, to prove that Cheselden's operation fre- quently succeeds. This gentleman inform-] PUPIL 391 us, that wuen the pupil has become closed, after an unsuccessful operation of extracting the cataract, he has iu several instances made a new pupil agreeably to Cheselden's mode of performing the operation, with the most perfect and striking success. " The fibres of the iris retracted as soon as they weie divided, and left the pupil very nearly of its natural size. Its shape was nol quite round ; but the sight was immediately re- stored, and lo so great a degree, as to enable the patient, by the help of suitable convex glasses, to see distinctly both near and distant objects, neither pain nor inflammation being consequent lo the operation." Where there is a prolapsus of the iris, through a breach of ihe cornea, involving morator less of the pupillary margin, Mr. Tray-^JI considers Cheselden's method Ihe most applicable; "viz. the transverse divi- sion of the stretched fibres of the iris, and which, if the section be made in front of the membrane, i. e. from before backwards, admits of no improvement. The edges of tbe section instantly recede and form an excel- lent pupil." However, be afterward adds, "that a partial adhesion of the pupillary margin may be combined with a healthy lens In this case, the removal of the free border of the pupil, drawn by means of for- ceps, through au incision in the cornea, will be preferable, on account of preserving Ihe transparency ofthe lens." (Synopsis of ihe Diseases ofthe Eye, p. 343.) In a modern work, Professor Maunoir of Geneva, bas published a very successful case, in which an artificial pupil was formed, and a caseous cataract extracted. " I ope- rated, (says M. Maunoir) on the right eye in the following manner. The patient being seated on a chair, and having the head in- clined upon a cushion, I placed myself be- hind him, and with Ihe lore-finger of the left hand, confining the upper eyelid, whilst an nsaislant depressed die low er, I made wilh the right hand a semicircular incision in the lower and exlernal part of Ihe cornea This incision occupied a full third ofthe circumference of the membrane. On reopening the eye, die iris was seen projecting a little from the wound in the cornea. I replaced it with the blunt point of my scissors. Introducing the two blades closed into the* anterior chamber, and then opening them, I caused the pointed blade to penetrate the iris, leaving the blunt blade between that membrane and the cor- nea ; then closing the scissors, a perpendicu- lar incision of the iris re-ulted, describing a little more than half the i-lmrd of an arc of (wo fifths of the circumference of the iris, traced on the side of the temple. The first in- cision not having occasioned the formation of a pupil ofthe necessary rize, I introduced the scissors into the iris a second time a little obliquely; and immediately the pupil appeared of a satisfactory form and size, but exhibiting tbe crystalline entirely opaque. 'The second stroke of the scissors had divided the capsula: I iherefore introduced a small curelte, in order to endeavour to destroy what adhered of the crystalline fo die shrunk and contracted circumference of the old pupil. This attempt did not succeed. Lastly, I effected the passage of a portion of the opaque lens, by means of a slight pressure with a large scoop, exercised on the lower part of the globe of die eye. The crystal- line, which was of a cheesy consistence, came out wilh ihe greatest ease, and though it was not entirely removed, yet a sufficient quantily w.>s discharged lo leave the artifi- cial pupil of a most perfect black. This new pupil was on the side of the temple ; and at Ihe exterior and lower pari of the iris." (See Med. Chir. Trans. Vol. 7, p. 305, etseq.) In this communication are also I wo other cases, in which Professor Maunoir operated with success, though complicated with cataracts, and adhesion- of the lens to the iris. In some remarks annexed by Pro- fessor Scarpa to the preceding account, the latter expresses his opinion, that it is nol ne- cessary to be scrupulous, whether die crys- talline be partly or entirely opaque, whene- ver the capsule is opaque, and adheres (o the iris, behind ihe edge of the* interior and en- closed pupil. " Li thi- case only one reme- dy can be pointed out, namely, the removal of the opaque adherent capsule, and conse- quently of the crystalline whether it be transparent or opaque. In die second place, (says 8-arpa) I think there is no reason to doubt, that in similar cases, it is adviseable to make an incision upon the iris, propor- tioned to die size of the body to be extract- ed, rather than to make it small, which obliges Ihe operator to divide the crystalline and the capsule, with tbe intention of ex- tracting a part, and of abandoning the rest to Ihe powers of absorption. Thirdly: 1 would establish as a fundamental principle. in similar cases, that afler the complete ex- traction of Ihe crystalline, with ils opaque cap.-ule, by means of the least possible in- troduction of the instruments, the artificial pupil ought not lo be too near the incision in the cornea, and consequently not loo near the cicatrix occasioned by it." (P. 317.) Scarpa then recommends a particular method of operating, in cuses where there are cataracts: after having made, iu the man- ner-of Wenzel,atransverse incision in Ihe iris, and in the cornea, he would introduce Mau- noir's scissors, blunted at both points, into the anteriorchamberof the aqueous humour, and make an incision in the iris, diverging from the cut made with the knife. The aper- ture thus made, Scarpa thinks would be large enough to allow easy egress to tbe opaque lens. Among other late opinions professed by ibis distinguished surgeon, we find the fol- lowing ; that no instrument is so proper as the scissors for making an incision in the iris ; that when tbe case is not complicated by cataract, a very small wound iu the cor- nea is sufficient; that the formation of a IrianguUr edge in the iris, by means of a double incision witb the scissors, is the most easy and least painful of all the methods hitherto proposed for obtaining a permanent artificial pupil; and lastly- that snots of the 392 PUPIL. cornea present no obstacle, because it is possible to produce the artificial pupil op- posite the transparent pan of ibai mem- brane (Med. Chir. Trans. Vol. 7, p. 320,321.) A- 1 liave already noticed, Ihe contraction of the natural pupil is someiim s occasioned by the iris being stretched towards some point of the cornea, to wliich il is adherent. This state, as Scarpa observes, is most fre- quently accompanied with partial opacity of the cornea, around the adhesion, or prolap- sus of tbe iris, as well as with opacity of the leus and its capsule. At other times, however, these internal pans preserve their natural transparency, notwithstand- ing the deviation of ihe natural pupil. In Ihe latter case the pupil, though removed from its situation, is not in reality obliterated, but merely very much contracted, and inca- pable ot admitting the quantity of light ne- cessary for vision, especialh it the opposite part of tbe cornea be slightly opaque In such an example, Scarpa recommends making a small iuci-ion in the cornea at the most commodious part, when w ith M.uinoii 's scissors closed, and const-ucled wilh little buttons at the ends of both the blade s. an endeavour is to be made to break ihe adhe- sion existing between tne iris and the cornea. If ihis can be effected, the natural pupil ge- ne: ally recovers it- former situation and size ; but if the a-J.n-sion be very firm, Scar- pa introduces one of the blades within the contracted pupil, behind die posterior surface of the iris, until the olher blade has reached die confine? ofthe cornea with the sclerotica. The iris is then to be divided in ihelorm ofthe letter V, without at all injuring the capsule orlen-, both ol which are transparent. (On the Principal Diseases of the Eyes, p. 384. Ed. 2 Transl. by brings.) When, alter ex- traction ol 'lie cnaract, the pupii has been dragged down m his manner by adhesion to the lower third ot Ihe cornea the upper two-'hirds ol which are Iran-parent, Dr Montealh. of Gasgow, has succeeded five times in forming an aitifiVial pupil,and resto- ring vision by making a small opening in the upper and outer part oft he edge ot the cornea, capable of admitting Maunou-'s eyr—tis-ors, with which itie overstretched fibres of the iris are to be cut across by one simple inci- sion, three lines in length. The cut edges instantly recede, and leave an oval pupil of sufficient size. (See Welter's Manual Vol. 2, p. 70.) In ihe. cases above specified by ^Scarpa, Sir Win. Adams, instead of per- forming corotomia, endeavours to separate the iris from the cornea, and then to aller tbe position of the pupil by drawing it to- wards that part of the cornea which has remained transparent. For this purpose he punctures the cornea about one line in front of the iris, separates the adhesion, and then makes the disengaged portion ol the iris pro- trude through the puncture, and leaves it there, even using ihe forceps, if necessary, for drawing it out as far as is deemed neces- sary for its being securely fixed. This method is disappr >ved of by Scarpa, hecau-e a se- cond prolapsus of the ins iu the same eye appears to him a very serious disease, and rather calculated to increase the opacity of Ihe cornea, and augment the contraction of the pupil, than afford relief. According to Beer, the excision of a por- tion of die iris, coreclomia is particularly in dicated in all cases in which there is a sound tr nsparent leijs, as in many examples of synechia anterior, concealment of ihe natural pupil hy a central opacity of the cornea, Aic Beer admits, however, as an exception, the instances in wliich the trans- parent portion ot ibe cornea is so small,that no opening can be* made iu it with the knife, large enough to permit die iris lo be taken hold of »v ith a small hook or forceps, and a piece of it cut out above the ciliary pro- cesses. (B. 2, p. 200.) Tbe reason here given, does not appear lo myself very strong, because, it may be asked, why not aegpire more room by cutting a portion of* the opaque part of the cornea ? Weller assigns a belter reason against coreclomia, viz. w hen he refers to the risk of a sufficient piece of tbe cornea not being lefl transparent, opposite the new pupil, alter the cicatrization ot thai membrane. (Vol. 2, p. 65.) Beer further stales, that coreclomia may be per- formed, in cases of atresia iridis consequent lo ihe operation of extracting Ihe cataract, when the surgeon is certain lhal no coagu- lating lymph, effused during ihe previous in- flammation, in tne posterior chamber, reaches above Ihe lesser circle of the uvea, or is con- joined with opacity of Ihe remaining capsule oi the bus. The first state may be learned trom tue singular colour a .d form of (he greater ring of the iris; Ihe second, from Hie very indistinct manner in which the patient is -eniible of the .lifferent degrees of light. (Be^r. B. 2, p. 200.) I he excision of a piece of the iris, says Beer, requires the preliminary formation of a 11 q', in the cornea, one line in length, with the caluraci knife, and as close as possible to Ihe sclerotica, so that no subsequent opaque cicatrix may interfere with Ihe suc- cess of the operation. The second part of Hie business, viz. die excision of a piece of the iris, must be done iu three ways,accord- ing to circumstances. 1-t. The iris may be nowhere preternaturally adherent lo tbe cor- nea, in which case, after an opening has been made in the latter membrane, tbe iris is pro- pelled out betw.en the edges of ihe wound by the aqueous humour, yet left in the pos- terior chamber, w hich opportunity the sur- geon must immediately -ivail himself of for taking hold of (he projecting piece of the iris with a very fine hook, and cutting it off w ijh Daviel's scissors. Tiie remainder ofthe i ' is instanily retracted behind Ihe cornea, and a well-formed pupil is immediately seen. 2. Only the part of the ed-re of the pupil may remain not adherent lo and drawn towards the cornea, where it is intended to form the artifiii d pupil ; a slate best ascertained by a lateral inspection of the eye. In this case, af er opening the cornea, Beer says, the ope- raior is directly to introduce a small hook between ihe iris and cornea, so as not to in- jure either of t iese parts wilh its point, and he is then, wilb the instrument directed PttWt 393 ibiiquely, to get hold of the pupillary edge of the iris, and while the iris is drawn out between the edges of the incision, the pro- jecting piece is lo be rut off witb Daviel's scissors. Thus the natural pupil is to be ex- tended behind (he transparent pari of the cornea, towards the edge of this membrane. 3. Tbe pupillary edge of the iris may be ad- herent to (he cornea exactly in the situation where the artificial pupil is to be formed: in this case, Beer directs the iris to be taken hold of at ils greater circle with the hook, or, (if this should tear its way out) with a pair of fine-pointed forceps witb teeth, drawn out between the edges of the wound, and the point of the cone, thus produced, cut off somewhat within tbe edges of Ihe wound, as drawing the iris further out might tear it, and have a prejudicial effect. In all these cases, says Beer, the undiseased lens nnd its cap- sule will nol be injured, if the patieid keep tolerably steady, and the operator have al- ready acquired dexterity in the extraction of the cataract. The operation being finished, the subsequent treatment is like tbat gene- rally adopted after the extraction ofthe ca- taract. (See Cataract.) When corectomia is to be performed for a closure of the pupil, consequent to extraction of the cataract, Beer particularly recommends tlie forceps to be used, though he adds, that such opera- tion is applicable only when the remaining capsule has not been spoiled by the trauma- tic inflammation, and (he quantity of lymph in the posterior chamber is not so great as to reach above the lesser circle of the uvea. The only other species of corectomia, which I deem it necessary to notice in this Dictionary, is what was proposed in the year 1811, by the late Mr. Gibson of Man- chester. It is described as follows: " The first step of the operation is to secure the eyelids, as in the operation for extracting a cataract. A puncture is then to be made in the cornea, with a broad cornea knife, with- in a line of the sclerotica, lo the extent of about three lines. All pressure is now to be removed from the eyeball, and the cornea knife gently withdrawn. The consequence of this is, that a portion of the aqueous hu- mour escapes, and the iris falls into contact with the opening in the cornea, and closes it like a valve. A slight pressure must now be made upon the superior and nasal part of the eyeball, with the fore and middle finger ofthe left-hand, till at length, by an occasional and gentle increase of the pres- sure, or by varying its direction- the iris gra- dually protrudes, so as to present a bag of the size of a large pin's head. This protru- ded portion must be cut off with a pair of fine curved scissors, and all pressure at the same time removed : the iris will then re- cede within the eye, and the portion which has been removed will leave an artificial pupil more or less circular." (Gibson's Practical Observ. on the Formation of an Artificial Pupil, fyc. London, 1811.) Such was this surgeon's mode of operating, wheu the closure of the pupil was attended with oentral opacity of the cornea, uncombined Voc II. 50 with adhesions. The effect of a slight ad- hesion of the inner border of the iris to the cornea, will be to prevent the protrusion of the first of these membranes through the puncture in the cornea, which protrusion sa much facilitates the operation. In this case, a portion which does not adhere, must be drawn out with a small hook, and then re- moved. Sometimes the adhesion may be separated at the time of making the punc- ture, and then the iris will protrude. When the whole, or greater part of the inner bor- der of the iris is involved in adhesions to the cornea, these must be separated witb the cornea knife after making the puncture, and the iris may then either be drawn out with tbe hook, or a portion of it be removed by- means of very minute scissors. In every case, however, the removal of a portion is essential to success. When a cataract is known to exist, which it cannot often be, Mr. Gibson recommends it to be depressed, or broken to pieces with a needle, before making the artificial pupil; and, when the whole cornea is transparent, he advises forming a flap in the centre of the iris with the cornea knife, and then cutting such flap off with the iris scissors. (Gibson, Op. cit) Corrdialysis, or the mode of formiug an artificial pupil by detaching a portion ofthe iris from the ciliary ligament, is said to have been devised by Ad. Schmidt and Scarpa about the same time, and has been variously modified by Resinger, Langenbeck, Himly, Graefe, and others. (Weller on Diseases of the Eye, Vol. 2, p. 65.) According to Beer, this plan of operating is indicated, first only when the coagulating lymph, effused in the posterior chamber after the extraction of the cataract or reclination, (see this word) reaches from above the lesser circle of the uvea towards the ciliary processes; a cir- cumstance which may be known by the considerable change of colour in the greater circle ofthe iris, and by the indistinct man- ner in which the patient perceives the light. Secondly, when the uvea is every where adherent to a secondary capsular cataract, or capsulo-lenticular cataract, or the closure of the pupil has been occasioned by a puru- lent or bloody cataract. Whenever the attempt is made in these last cases, however, the patient should be capable, as he some- times is, of plainly discerning the light. Lastly, coredialysis is sanctioned by Beer when the cornea is every where incurably opaque, excepting so small a part of it, that it could not be well opened for the excision of a portion of the iris. (B 2, p. 203.) The feeble union of the iris with the cili- ary ligament, and, consequently, the greater facility of detaching its edge from that liga- ment with which it is connected than of lacerating its body, induced Scarpa to try a new method of forming an artificial pupil, when the natural one has become too much contracted, or quite obliterated, after the extraction or depression of the cataract. His method of operating consists in detach- ing- hy means of a couching needle, a cer- •95*4 PUPIL tain eitent of the circumference of the iris from the ciliary ligament, without making a section of the cornea. The attempt -met with success. The patient being seated and supported, as if he were about to have tbe operation" for the cataract performed, a straight slender couching needle is to be introduced through the sclerotica, at the external angle of the eye, about two lines from the union of this membrane with the cornea; and its point is to be pushed as far as the upper and inner edge of the iris; in other words, as far as that side of tbe iris which is nearest the nose. The needle** advances nearly to the ciliary ligament, and the surgeon perforates the internal edge of tbe iris, at its upper part, so that the point of the instrument scarcely appears in the anterior chamber, because that part of it being very narrow, the point oXthe instrument, however little it advance beyond the iris, would enter the substance of the cornea. The moment the needle appears in the anterior chamber, the instru- ment must be pressed on the iris from above downward, and from the internal towards the external angle, so as to bring it in a pa- rallel line to the anterior surface of the iris, for the purpose of detaching a portion of the edge of this membrane from the ciliary ligament This separation being effected, the operator must depress the point of the needle, in order to apply it to the inferior angle of the slit that he has begun to make. Then the aperture may be enlarged at plea- sure by pushing the iris towards the temple, and withdrawing the needle from before backward, parallel to the anterior surface of the iris and the greatest axis ofthe eye. If, when this detachment has been accom- plished, no opaque body appear at the bot- tom of the eye, the needle is to be with- drawn altogether. If any portion of opaque capsule, left behind after the depression or extraction of the cataract, should afterward advance, and present itself in the vicinity of the new pupil, tbe little opaque membrane must be reduced to fragments, and pushed through the artificial opening into the ante- rior chamber, where, Scarpa says, tbey will in time be dissolved and absorbed. This separation of the iris from the ciliary ligament invariably occasions an extravasa- tion of blood, which always renders the aqueous humour more or less turbid ; but the turbidness is afterward absorbed, and the eye recovers its original transparency. The patient, says Scarpa, complains, du- ring the operation, of a vast deal more suf- fering than at the time when he undergoes the extraction or depression of a cataract. H cannot be otherwise; for, in detaching a part of the edge of the iris from the ciliary ligament, some filaments of the ciliary nerves, which proceed to be distributed to the iris, must at least be dragged or lacera- ted. However, on the whole, the symptoms consequent to this operation, have neither been obstinate nor fatal in the two cases which Scarpa has seen. From some expe- riments made on the dead subject, Scarpa thinks tbe curved needle, -which he use; for the depression of the cataract, would also be better than the straight one, for making an artificial pupil. (Scarpa tulle Malathe degli Occhi, Capo 16.) The celebrated Ad. Schmidt performed coredialysis with a lancet-pointed curved needle, which was introduced through tbe sclerotica into tbe posterior chamber, with its concavity towards the uvea. Its point is to pass as far as the portion of the ciliary ligament, where it is designed to make the artificial pupil. The iris is then to be pier- ced from behind forwards, about the fourth part of a line from the ciliary ligament, from which it is to be separated, the surgeon taking care at the moment to catch well bold of tbe iris witb the point of the instru- ment, which is then to be withdrawn a little from the eye. If the new pupil should not be now large enough, the iris is to be again hooked with the needle, near the ciliary ligament, and the opening enlarged at its upper or lower angle, as may appear most advantageous. This plan is said to be ad- viseable when tbe whole cornea is opaque excepting a small spot. When, however, the diseased state ofthe cornea does not forbid it, Beer and Schmidt very properly recommend the needle to be introduced into the anterior chamber, and the iris thus separated from the ciliary liga- ment ; a plan which, as Weller observei, has proved more successful than the prece- ding method. In both modes, the lens will be pushed away from the new pupil by the movement of the needle, so tbat whether it be opaque already, or become so afterward, vision will not be obstructed by it. (See Beer's Lehre, fyc. B. 2, p. 204—206, and Welter's Manual, Transl. by Dr. Monteath, Vol. 2, p. 66, fyc.) With the view of removing all risk of the new opening becoming closed again, Rei- singer forms an artificial pupil, by making a small incision in the cornea, and introducing a minute double hook, which opens and shuts like a pair of forceps. After passing the hook closed into the anterior chamber, as far as the greater circle of the iris, he turns the points of both the small hooks towards this membrane, then opens tbe in- strument a little, and books bold ofthe hi*, which is to be separated from the ciliary ligament, when the instrument is to be shut again, and the part of the iris taken hold of drawn a little through the opening of the cornea, where it adheres, and cannot re- cede again towards the ciliary ligament. (See Darstellung eines neuen Virfahrens die Masldarmfistel zu unterbinden, und einer leichten und sichern methode kunstlichc P«- pillen zu bilden. 12mo. Augsburg, 1816.) Under certain circumstances, however, as there may be difficulty in drawing the iris through the cornea, or apprehensions may be entertained of the opacity of the cornea being increased by the protrusion and ad- hesion of the iris (the great consideration unquestionably against this method,) Reisia- erer approves of obviating the chanced tbe PUPIL 3W new opening heing closed again, by remo ving a part of the iris, after its detachment from the ciliary ligament; a combination of coredialysiswith coreclomia, in the technical language of modern ophthalmology. Were I a patient, and coredialysis were deemed most applicable to the circumstances of my case, 1 should dispense with any excision of the iris, preferring the chance of the new opening being permanent, to the dangers of too complicated and protracted an opera- tion. Langenbeck is the inventor of an instru- ment for the formation of an artificial pupil: it is a silver tube, to one end of which is attached a very small gold one, containing a minute hook, capable of being moved back- wards or forwards, lo the extent of only two lines, by means of a spring in the silver tube. The fo lowing is the account of Lan- genbeck's method, as extracted by Mr Gu- thrie from his writings. " A very small opening is to be made in the cornea, in or- der tbat the iris, when brought out, may not recede. The hook, enclosed in the golden tubp, (to prevent its bending from itstenuity) is to be directed to the spot where the iris is to be laid hold of. The hook is then to be pushed out by the spring to the extent of one line, which will be sufficient to enable it to penetrate the iris As soon as tbe hook is affixed, it is to be allowed to recede to its usual place in the golden tube, drawing with it tbe iris, which will be caught between it and the end of the tube, something in the manner of a pair of forceps. As soon as the book begins to recede, a small black spot will be seen at the edge of the iris from its incipient separation, and care should be taken to insert the hook at, or even under the edge of the sclerotica, and as near as possible to the ciliary processes. Tbe hook must recede gradually, the finger being kept steadily on, and moved slowly with the knob regulating the spring in the silver tube. As the chan< e of tearing off a part of the iris is proportionate to the distance it has to be drawn out, the opening is to be made, as near as possible, to the spot where the separation is to be effected, taking care that the pupil shall be large enough, so that the prolapsed iris and subsequent opacity of rife cornea cannot obstruct the entrance of the rays of light. The great advantage of this instrument, in Langenbeck's opinion, is, that the separation is effected, by means of the spring, more gently and gradually than by the finger alone, so that if a commence- ment ofthe separation be effected, the com- pletion of it is certain, without any risk of tearing the iris. As soon as the hook has receded to the golden tube, carrying with it the iris, the whole instrument is to be gently withdrawn, moving it slowly up a*id down, in order to loosen the upper and lower attachment ofthe iris ; for Ihis mem- brane may be torn, if there has been much previous inflammation, or if direct force be employed in withdrawing it. The instru- ment always keeps its bold as firmly as the v>»st forceps, and with much more n<\art< tage, for it occupies less space, and enables the operator to make the incision in the cornea small, on which the correct strangu- lation ofthe iris depends. In all his opera- tions, the capsule of the lens has never been injured by this instrument, which he consi- ders another advantage, and, he conceives, that it may be used through the sclerotica, without rendering the lens opaque, as by the methods of Scarpa and Schmidt." (The latter author, however, as I have explained in this article, did not operate through the sclerotica, when the lens was transparent.) When the cornea is transparent only at its outer edge, Langenbeck sometimes performs excision; but, when this membrane is opaque opposite the natural pupil, he opens the cornea near the edge of the sclerotica, and, if the iris will not protrude, he takes hold of ils pupillary edge with the hook, and draws it between the lips of the wound, where he leaves it strangulated. (See G. F. Guthrie on Artificial Pupil, p. 63, fyc. Svo. Lond. 1819; also Langenbeck's Neue Bibl. 1 B. p. 1,454, and 676, 8vo. Hanover, 1817— 19, and 2 B. p. 13 and 106, where be an- swers some objections made to his instru- ment by Schlagintweit.) Doubtless, one cause of the failure of many operations for artificial pupil is one to which Mr. Guthrie has adverted, viz. the omission to keep down the subsequent inflammation of the iris and adjacent textures by the timely em- ployment of the lancet, and other antiphlo- gistic measures. On this subject, however, I need not here dwell, as the proper treat- ment is already described in that part ofthe article Ophthalmy which refers to idiopathic- iritis. As it is impossible for me to allot further room al present to the consideration of nil the numerous modes of forming artificial pupils, I shall conclude with a list of works, in which further information may befound. Cheselden in Phil. Trans, for 1735, p. 451,' fyc. Sharp's Operations, Chap. 29. Janin Mfm.sur I'CEil. Richter von der Verschlos- scnen Pupille in Anfangsgr. der Wundarzn. B. 3. Gott. 1795. Scarpa, suite Malattie degli Occhi, cap. 16; or the English 2'ransl. by Mr. Briggs, Ed. 2. Gibson's Practical Observa- tions on the Formation of an Artificial Pupil, fyc. Svo Lond. 1811; ex work of considerable merit. Wenzel on the Cataract. Sir W. Adams, Practical Observations on Ectropium, and on the modes of forming an Artificial Pupil, fyc. Svo. Lond. 1812 ; also on Artificial Pupil, Svo. Lond. 1819. Roux, Parallile de la Chirurgie Angloise fye. p. 283, fyc. 8ro. Paris, 1815. Maunoir and Scarpa in Med. Chir. Trans. Vol. 7, p. 301, fyc. G. J. Beer Ansicht der Staphyloma tosen Metamorphosen des .--'uges, una der kunstlichen Pupillenbildung, Wien 1815; and Lehre ron den Augenkr. B. 2] Wien, 1817. P. Assaliui. Ricerche sulfa Pupille Artificiali; in Mi'ctnO, 1811. 77?,V author practises the detachment of the iris from the ciliary ligament wilh a particular kind of forceps. He must have an early claim to the invention, as he began the method in 17*6 Jules Cloquet. Mhn sur la M""- 3s»* KANTLA hranc Pupillaire. Paris, 1818. Maunoir sur r Organization de I' Iris, Svo. Paris, 1812. Benedict, De Pupillee Artifieialis Confurma- tione. Lips. 1810. R. Mu'er, Practical Obser- vations on Various Novel Modes of Operating on Cataract, and of forming an Artificial \Pup:i,8ro. Wisbeach 1811. G. F. D. Evens, Practical Observations oi Cataract and < losed Pupil, fyc. 8vo. Lond. 1816. Ch. Jnngken, Das Coreoncion, tin Btitrag zur Knnlsiidien Pupillenldldung. 12mo. Berlin, 1817. G. Wagner, CommentatiodeCoromorphosi, sist ens brtvem method, ad Pupilla artific. amforma- tionem,novique ad Tridodialysin ivstrumenti descriptionem, cum tab. an. Svo. Brunswig. 1818. Schmidt and Himty Ophthal. Bibl. B. 2 and 3. Flajani Collezione di Osservazioni, T. 4, Svo. Roma, 1801. Ryan, in Dublin Hos- pital Reports, 1818. Qjuadri Annotazioni Pra- tiche sulle Malattie degli Occhi, 4to. InNea- poll, 1818. Langenbeck Neue Bibl. far die •TAiV. B lo(2, 12»w. Gott. 1817—1819, Reisinger Darstellung, fyc. eintr leiehttn, fyf. Mtthode Kunslliche Pupillen bu bilden. 12m*. Augsb 1816. Schlagintwcil, Ueber den gcgen- wfirtigen Zustand der Kuntslichen, pupillen- bildung in Deutschland, 8vo. Munich, 1818. Donegana, Raxjouamenlo sulla Pupille Arti- ficiali; Milano, 1809: this work suggests the method of opening the sclerotica, under cer- tain circumstances, for the purpose of dividing the iris from behind forwards. G.F. Guthrie on the Operations for the Formation of an Ar- tificial Pupil, Svo. Lond 1819 ; a work, con- taining a description of nearly every method hitherto suggested, accompanied with remarks. B. Travers, Synopsis of the Diseases of the Eye, p. 334, fyc. 8vo. Lond. 1820. C. H Welter, A Manual of the Diseases of the Hu- man Eye ; transl. oy Dr. Monteath, Vol. 2, p. 55, fyc. 8vo. Glasgow, 1821. PUS. (from -over, matter.) The fluid, formed by the process of suppuration. (See Suppuration.) R. RACHITIS, (from -ja*-*?, the spine of the back, because the disease was once supposed to depend on disease of the spinal marrow.) The rickets. See this word. RANULA. (dim. of rana, a frog.) A whimsical name applied to a tumour under the tongue, arising from an accumulation of saliva aud mucus, in the ducts of tbe sub- lingual gland. The term has either been derived from an imaginary resemblance of the swelling to a frog, or from the disease making the patient, as it were, croak when he attempts to articulate. Such writers as have treated of this disease, before it was known that the parts affected by it were destined for the secretion ofthe saliva, could have no accurate notions of its true nature. Celsus is supposed to have alluded to the ranula, in the fifth section of bis seventh book, where, after treating of the diseases of the tongue, ne continues with the follow- ing passage: sub lingua quoque interdum ali- quidabcedit,quod fere consistit in tunica, dolo- resque magnos movet. The latter circum- stance, however, renders it probable, tbat some other affection was signified, as a ranula Is rather attended with a sense of restraint, than of pain. Fabricius ab Aquapendente considered ranula as an encysted tumour of tbe meliceris kind. Dionis is of a similar opinion. Munick, better acquainted with the modern discoveries of anatomy, does not mistake the nature of the present dis- ease ; and he expressly says, that the affec- tion originates from a thick saliva, which, not being able to pass out of the salivary lucts, accumulates under the tongue, so as o cause a swelling in that situation. Far rom adopting the opinion of Munick, Heis- ter fell back to that of Fabricius, and borrows every thing from this author.— lastly, De La Faye, in his notes on Dionis, fcas taken up Munick's sentiments; he says, that " there are two sorts of ranula;; some which are round, and situated beneath the tongue, seem only to be produced by a dilatation of the excretory duct of the sublingual gland ; the others are longer than they are round ; are situated at the side of the tongue, and are formed by a di- latation of the excretory duct of the inferior maxillary gland. The fluid, which fills such tumours, is the saliva, which gradually ac- cumulates in them, in consequence of its viscidity and the atony of the duct. Ranula is said to be frequently met with in persons who move their tongue a great deal, and in those who sing. The fluid in the tumour is precisely like white of egg; but it is thicker after having remained a long while in the swelling, aqd it is occasionally of a calcareous, and even stony nature. Ranula does not proceed from an inspissa- tion of the saliva, as De la Faye supposed, but from an obliteration of the duct, or ori- fices of this tube. The colleclion often produces a tumour of very large size ; but the swelling generally bursts when it has at- tained tbe dimensions of a walnut, and then leaves an ulcer, which cannot be healed while the real cause of the disorder remains unknown. Mr. B. Bell mentions his having seen an ulcer of this kind treated with tbe utmost care for several months ; various detergent and corrosive applications had been employ- ed ; and even a mercurial course ; but all in vain. At length, the true cause of the disease having been ascertained, a cure was accomplished in a few days, by removing a piece of calcareous matter, wbicb, by ob- structing the ducts, had first caused a swell- ing, and then ulceration. The opening, when made with a lancet, and not of sufficient size, frequently closes up again. In this case the swelling rean RANULA 397 pears some time afterward. The ancients made the same remark; and hence Pare preferred the actual cautery to the lancet. Dionis also mentions having seen ranulae, which recurred in consequence of a mere opening having been made with a lancet, and he recommends, for the prevention of this inconvenience, the application of a mixture of honey of roses, and vitriolic acid to tbe inside of the cyst, so as to destroy it. As Louis remarks, all authors seem to regret that the situation of the tumour should prevent tbe sac from being totally dissected out. The success, which Fabricius ab Aquapendente experienced, when he merely opened the tumour its whole length, did not free him from this prejudice ; and Heis- ter says, he should prefer extirpation, if the nature of the adjacent parts, liable to be wounded, were not a formidable objection. But if this pretended cyst, this pouch, is nothing else than the gland itself, or its duct, dilated by tbe retention of the saliva, it should not be irritated. Whenever a suffi- cient opening is made, no relapse takes place. Munick particularly advises such an incision, and Rossius mentions the small- ness of the opening, among the defects in the treatment, and its being a cause of the disease returning. However, he also re- commends destroying the sac ; but specifies for the purpose only astringent drying ap- plications, which act in a less powerful m inner. In a ranula of moderate size, there is nothing like a cyst absolutely requiring ex- tirpation. It is generally enough to lay the cavity open, and cut off the edges of the incision, when they will not otherwise unite. M. Louis always observed tbat the radical cure depended on a fistulous aperture, through which the saliva continued to flow ; and that, when this opening was situated behind the lower incisor teeth, a very an- noying ejaculation of tbe saliva took place, in certain motions of the tongue. The cure cannot be complete unless this inconve- nience be obviated. For this purpose, such an opening for tbe saliva must be made, as will not close. The ranula, when of long standing, is sometimes so large as absolutely to binder a person from articulating. Le Clerc has recorded a case, in which the root of the swelling extended under the tongue ; the tumour filled the whole mouth; the promi- nence which it formed outwardly was as large as a duck's egg; and the disease, in its progress, had made the teeth of both jaws {iroject outward. At some parts of its sur- ace, a fluctuation vvas perceptible ; other places were exceedingly hard. The patient, who could scarcely breathe, demanded as- sistance ; and a puncture was made in the softest part of the outside of the swelling. A thick yellowish fluid issued out of the ranula. The opening was enlarged with a knife, and about a pint of gritty inodorous matter was extracted. There was no he- morrhage from the cut; and no sooner had •he contents of the swelling been let out, than the patient began to articulate, which he had not been able to do for a long while. The sides of the tumour being so prodigious- ly distended, Le Clerc thought proper to destroy the inside of the cavity with a tent dipped in a mercurial solution. The cure was completed in a month, and the tongue gradually regained its original size, a part of which it had lost. But, as M. Louis observes, fortunate as the termination of this case was, it must not be indiscriminately set down, that destroy- ing the cyst, or even opening the tumour, is always requisite. A more simple method will sometimes succeed. In a particular case, which this gentleman has related, a sinuosity, which divided the swelling into a right and left portion, made him suspect that it consisted of two sacs, in contact with each other. On each side, in front, and in tbe same line, there was a point, which was Ihe orifice of the salivary duct, somewhat dilated, and blocked up with a viscid matter. Having very easily passed a small probe into the orifices, a matter similar to white of egg, made its escape. A small leaden probe was passed into each opening, and two days afterward, the sacs were emptied again, and two pieces of lead, somewhat larger, introduced. The man was advised to take out the pieces of lead every morning, empty the swelling, and then replace them In a fortnight, the openings having been kept continually dilated, had no tendency to close ; the saliva did not accumulate, and the ranulae never appeared again. In certain cases, (he above means are quite inadequate, and tbe tnmour must be totally extirpated. Boinet has related to (he French academy, a case in which (he swelling not only filled the whole mouth, but one half of (he (umour projected cut, and a cure could only be accomplished in the latter manner. The two upper incisor teeth on the left side, were lodged in a depression observable there; and the canine tooth, of the same side, forced outward by the mass of the disease, had pierced the lip near its commis- sure. A fluid resembling mucus, flowed from a narrow aperture at the lower part of the swelling. The tongue could not be seen, so much was it pushed backward, and for some time, the patient had only subsisted on liquid food, which be was first obliged to convey to the back of the throat with some mechanical contrivance. Tbe four incisor teeth, two canine, and first grinders of the lower jaw, had been pushed out of their sockets, by the pressure of the swelling. The patient's aspect was alarming, and he was threatened with suffocation. Extirpa- tion was deemed necessary, and it was per- formed with all (he caution which the situa- tion of the tumour demanded. The large cavity thus occasioned was filled with lint. The lower jaw being diseased, Boinet scra- ped some of its surface off, and covered tbe places with lint, either dry or dipped in spirit of wine. Some exfoliations followed, and the fungous granulations which grew were re- pressed with proper applications. In th-*ee 39b KEt/iUM. months, the parts were healed in so regular a manner, that tbe motion of the tongue was not in the least obstructed, and no change continued, except the alteration of Ihe voice, occasioned by the loss ot leetb. This case is very interesting and proves how much may be boped for in difficult rases, from prudent and judicious measures. (Se e Ency- clopidie Mithodique,Art. Grenouillette. Mim. de I'Acad. de Chirurgie, T. 3, Sabatier. Mi- decine Opiraloire, T. 2, p. 19, fyc. Ed. 2. Callisen, Systema Chirurgia Hodiernal, Vol. 2, p. 108, fye. Hafnim, 1800. Lassus, Pa- thologie Chir. T. 1, p. 402, fyc. 8ro Paris, 1809. Richter, Anfangsgr. der Wundarzn. B. 4, Kap. 1, Go'tingen, 1800. J J. Stahl, et J. F. E. de Schoenerbcn de Ranula, sub lin- gud, speciali cum casu, Erford. 1734.) RECLINATION. A term much employ- ed abroad, to denote the operation of turn- ing a cataract, so as to change the position of its anterior and posterior surfaces. (See Cataract.) RECTUM. Many cases in which this bowel is more or less concerned, are treated of elsewhere in (his Dictionary, and Iherefore it will only be necessary for me here to re- fer to them, and then notice some diseases of Ihe part, which are not considered in other articles. For an account of piles, he- morrhoidal excrescein e, and olher tumours of the rectum, see Hemorrhoids; and for tbat of prolapsus ani, fi-tula in ano, and im- perforate anus, see Anus. Under the bead of Alvine Concretions, 1 have noticed the dan- gerous obstruction of this bowel by masses of indurated matter. In the article Lythoto- my, the mode ot cutting through ihe rectum into the bladder, for the purpose of extract- ing a calculus irom Ihe latter organ, i- ex- plained ; and if the reader refer to Bladder, he will there find a description of tbe memod of tapping it from the rectum. Scirrhus, or stricture of the rectum, some- limes called the scirrho-contracted rectum, and sometimes cancer, especially when the case is inveterate and in a state of ulcera- tion, is a disease which has received much elucidation from the writings of Desault, Sir Everard Home, Dr. Sherwin, and Mr. Cope- land. In the various descriptions given of the complaint by these and olher writers, one great point of difference is remarkable, viz. that some of them represent the case as always of an incurable nature, while others consider it as admitting of relief, at least when it has not made considerable progress, and the parts are free from ulceration. Ac- cording to Desault, scirrhus of the rectum is not uncommon at au advanced period of life, and tbe disease is said to afflict women more frequently than men, as from a table kept at the Hotel Dieu, it appeared that ten cases out ol eleven occurred in females. If it were not for the fact, that Desault some- times effected a cure of tbe disease in its early stage, 1 should venture to conclude, that his observations apply entirely (o (be true scirrhus, or cancer of the rectum, which I believe rarely or never occurs in young oatien's. btit a« Dessiilt states, is not ypry unfrequent in elderly persons. My friend, Mr. Copeland, in his practical remarks, does not confine himself to really scirrhus and cancerous affections, but comprehends stric- tures of the rectum from a variety of causes; and this accounts for his statement, thai (he disease " attacks people of almost all agts ; but is most common about the middle age." However, he agrees with Dsaul,, dial wo- men are more frequently affected (hun men. He admits that it is sometimes cancerous, (bough not so often as is generally imagined, Ihe mere induration not being an unequivocal proof of it. When (he disease is really can- cer, it is usually attended with more severe pain, darting through the pelvis to the blad- der and ihe groin. The countenance is of a sallo-v leaden cist. {Copeland on the prin- cipal Diseases of the Rectum and Aims, p IS —17. Sometimes the disease extends over a considerable length of the gut, but is gene- rally more circumscribed. The coats of Ihe bowel become much thicker and harder than natural. Tbe muscular is subdivided by membranous sepia, and (he internal coat is sometimes formed info hard, irregular folds. The surface of the inner membrane is occa- sionally ulcerated, so as to form a cancerous disease. Every vestige of the natural struc- ture is sometimes lost, and the gut is changed into a gristly substance. The cavity of ibe bowel is always rendered narrow at the scir- rhous part, and is sometimes almost oblitera- ted. When Ihe passage through Ihe gut is very much obstructed, the bowel is always a good deal enlarged jusl above the stoppage or stricture, from the accumulation ol tbe feces there. As the disease advance-, adhe- sions form between tbe rectum and adjacent parts, and ulcerations produce communica- tions between them. As the disease at first is not very painful, it is usually not much noticed till somewhat advanced. The patient is habitually cos- tive, and usually voids his stools witb a little difficulty. In time, a good deal of pain is felt in the part affected, especially at stool, after which some relief is experienced. "As the gu( continues to decrease in diameter (says Mr. Copeland,) the efforts to expel the feces become more violent, and the conse- quent progress of the disease more rapid. The stools, which have been long evacuated with difficulty, become contracled in size, appearing like earth-worms in their form, or small pellets;" and if th- finger be intro- duced into the rectum, " Ihe gut will be found either obstructed wilh small tubercles, or intersected wilh membranous filaments; or else lh»* introduction of ibe finger will be opposed by a hard ring of a cartilaginous feel, composed of the diseased inner mem- brane of the intestines." These states, as Mr Copeland observes, are very different from the regular tumour on the anterior part of tbe* rectum, occasioned by an en- largement of tbe prostate gland ; a ease apt lo be suspected. " As the disease advan- ces (says ihe same author.) tbe feces become more fluid, and (here is ;: thin saneon0 di' RECTUM 399 charge from the anus, accompanied with tenesmus." According to Desault, pus and blood may sometimes be noticed with the excrement, particularly when the disease bas advanced lo the ulcerated slate. The patient at length becomes sallow, frequent eructations of air from the bowels, as Mr. Copeland observes, forment Ihe patient, and render his life miserable- ; the constitution suffers, and dissolution follows. Severe tenesmus attends the whole course of the disease. (OZuvrcs Chir. par Bickal, T. 2.) Sometimes a small fistulous orifice at the verge of the anus communicates with the inferior portion of the diseased part. Such a fistula, in a case recorded by Sir Everard Home, was half an inch in length. (Obs. on Cancer, p. 133.) Desault has often seen tbe disease form a communication between the rectum and vagina, and the feces passed through the latter part. In the latter stage of the afflic- tion, the rectum, bladder, vagina, uterus, and adjacent parts, are all involved in one common ulceration. When the disease has attained the ulcera- ted state, it is probably always incurable. Palliatives can only now be resorted to, such as anodyne and emollient glysters, the warm bath, &c. with the exhibition of me- dicines like opium, cicuta, uva ursi, be. Claudinus applied his remedies to the inside of the bowel, by means of tents, and did not employ the latter as a mode of curing the disease when less advanced. Valsalva in- troduced a cannula, pierced with numerous holes, and then made bis patient get into a hath, so as to let tbe fluid enter the intestine. Numerous practitioners, among whom is Morgagni, made mercurials the base of their treatment, from a supposition that the com- plaint was of venereal origin. I believe tbe latter opinion is at present entirely abandon- ed by all tbe most judicious surgeons in England, and this, whether mercury ever prove useful or not. When the disease is not .attended with ulceration, the contraction and thicken- ing of the gut may be diminished by in- troducing bougies, keeping them for a certain time, every day, so introduced, and increasing their size gradually. The pressure of these instruments seems to lessen the disease, and stop its progress; a proof that its nature differs from that of a common malignant scirrhus. Desault used to employ long tents made of lint, smeared with cerate, and passed into the bowel by means of a probe with a forked end. Their size was gradually increased, so as to keep up the compression, to which, it was con- ceived, all the good was owing. Their length vas also augmented by degrees. At first, fresh ones were introduced twice a day. When any hardnesses were situated oo the outside of the anus, Desault cured them on the same principle, viz. by making pressure on them with compresses aud a bandage. In this manner he effected the t ure of a scirrho-contracled rectum. The patient was taueht to pass occasionally the tents, without assistance, in order to pre- vent a relapse. Instead of tents, modern surgeons employ bougies for the dilatation of strictures iu the rectum. When from habitual costiveness, the altered figure of the stools, and other circumstances, there is reason to suspect organic obstruction to the passage of the feces, and this suspicion is confirmed by an examination of the rectum with the finger, "the fiist object of the surgeon (says Mr. Copeland) should be an enlargement of the obstructed part, by the introduction of a bougie. This should be of such a size as to pass, when well lubricated with oil, without much difficulty or pain. Sometimes, when the disease has been of long continuance, it will be necessary to begin even with a large- sized urethra bougie, or one of the same size as those which are made for a stricture of the cesophagus, and of a length that is likely to pass beyond the end of the stric- ture, that is, about six, or seven, or eight inches. But I think it of consequence to use a bougie, at first, which is rather too small than too large." (P. 29.) When it bas remained for half an hour, or more, it is to be removed, and passed again the next day, the same sized bougie being continued for several days. In the introduction of tbe bougie, Mr. Copeland cautions the practi- tioner not to mistake tbe projection of the sacrum for a stricture of the gut; a mistake which, he says, has often been made, and, as I believe, too often wilfully, and from motives of imposition. Mr. Copeland fur- ther advises the bowels to be kept constantly lax, by the use of castor oil, or electuary of senna, during tbe whole of the treatment. (P. 30.) Whatever be the nature of the stricture, whether it be that kind in which the rectum is obstructed by tubercles, by membranous filaments intersecting its canal, (which two species, Mr. Copeland says, are the most easily relieved) or whether it be the indurated stricture, from a thickening of the coats of the intestine, this local treat- ment is equally necessary. The plan is to be persisted in until a full-sized bougie will readily pass, and even after all symptoms have disappeared, it is recommended to in- troduce the bougie, and withdraw it again once every two or three days, for some time, in order to prevent a relapse. The in- durated annular stricture, which long resists the bougie, Mr. Copeland sometimes divides with a probe-pointed curved bistoury on the side which is contiguous to the os sacrum ; and he has frequently seen the late Mr. Ford perform the same operation. (P. 34.) When the disease is either combined with venereal symptoms, or there is any reason for sus- pecting it to be itself " the solitary symp- tom" of lues. Mr. Copeland joins Desault in recommending a trial of the effect of mercury, in conjunction with bougies. (P. 44.) The formation of abscesses, he re- marks, is very frequent in the advanced stages of the disease, and he has often seen the common operation for fistula done under such circumstance's without?ucce«s. f P.35.1 -*>;0 RICKElc: When any stoppage oi urine occurs in tbe advanced stage ofthe disease, Mr. Cope- land advises surgeons not to use the catheter hastily. (P. 39.) And, in the event of great pain and irritation in the rectum, he has seen the greatest benefit derived from the local application of opium either in a glys- ter, or by the introduction of one or two grains of the medicine within the anus. He also speaks favourably of the effects of the Warm bath, and fomentations, in giving temporary relief; and he has also exhibited in these cases the pil extracti conii cum hydrarg. submur. witb considerable advan- tage. A fatal case of mortification of the rec- tum is detailed by Larrey. (Parisian Chi- rurgical Journal, Vol. 2, p. 398, fyc. See J L. Petit, OHuvres Posthum T. -2. Dr. Sher- win on the schirrho-contracted rectum, in Mem. of the London Medical Society, Vol. 2. Sir Everard Home, Obs. on Cancer, p. 129, fyc. Svo. Lond. 1805. L. F. J. Duchadoz, De Proclostenia, seu de Morbosis Intestini Recti Angustiis, Monsp. 1771. C. G. Siebold, De Morbis Intestini Recti Baillie's Morbid Anato- my, p. 1116. OZuvres Chir. de Desault par Bichat, T. 2, p. 422. Observations on the principal Diseases of the Rectum, fyc. by T. Copeland, 1814. W White, Observations on the Contracted Intestinum Rectum, 8vo. Bath, 1812.) RESOLUTION, (from resolvo.) The subsidence of inflammation without any abscess, ulceration, mortification, &.c. Also the dispersion of swellings, indurations, ike. RETENTION OF URINE. See Urine, Retention of. RETROVERSIO UTERI. A turning back- ward of the womb. See Uterus, Retrover- sion of. RICKETS. (Rachitis.) Is mostly met with in young children ; seldom in adults. Mo- rand, however, (Acad, des Sciences, 1763.) mentions an instance, in which an adult became affected. The disease it is said, may even take place in the foetus in utero ; but the most common period of its com- mencement is in children, between the ages of seven or eight months, and two years. Hence, as Mr. Wilson observes, its origin has frequently been imputed to the effects of dentition. He adds, that he has often known it to make its appearance after this time, and that it not unfrequently attacks fhe spine a little while .before puberty, and may do so even later. (On the Struc- ture and Physiology of the Skeleton, fyc. p. 162.) Pinel has given a description of the skeleton of a rickety foetus. (Fourcroy's Journal.) The disease seems to consist of a want of due firmness in the bones, in con- sequence of a deficiency in the phosphate of lime in their structure. The causes of the affection are involved in great obscurity. Authors have referred them to scrofula, scurvy, lues venerea, difficult dentition, be.; and Richerand still firmly believes, that rachitis is only one of the effects of scrofula in its worst forms. (Nosogrmphie Chir. T. 3, p. MS, EJl' 4.) But these are merely conjectures, which will not bear a rigorou* investigation. Professor Boyer, in particu- lar, has well exposed their invalidity. Traiti des Mai. Chir.T 3, p. 611.) Rickety subjects are often at the same time scrofulous; and this is, probably, the only reason for scrofula being accounted a cause of the other affection. The particu- lar appearances of rickety children we need not detail, as every one is familiarly acquainted with them : such children are usually of a bad, weak constitution, and their limbs and bones become bent in direc- tions determined by the action of the mus- cles, and the weight and pressure which they have to sustain*. When the affection is very general, tbe spine becomes shorter, and is curved in various directions; the breast becomes deformed not only in con- sequence of the curvature of the spine, but by the depression of the ribs, and projection of the sternum. The bones of the pelvis fal^inwards, and the os pubis generally ap- proaches the sacrum. The latter circum- stance is one of the causes of difficult parturition. The clavicles become more bent and prominent forward ; the os humeri is distorted outward ; the lower ends of the radius and ulna are twisted in the same direction ; the thighs are curved forwards or outwards; the knees fall inwards; tbe spine and front surface of the tibia become convex; and the feet are thrown out- wards. According to the observations of Mr. Stanley, when the tibia and fibula become curved, they sometimes " acquire increased breadth in the direction of the curve, losing a proportionate degree of thickness in the opposite direction. Hence the bones be- come, as it were, newly modelled, passing from the cylindrical into the flattened form. This would seem to be designed for the pur- pose of enabling them to support more efficiently the weight of the body, since by this alteration tbey acquire increased breadth and power of resistance in that direction, where the greatest strength is required. I have never noticed (says Mr. Stanley) any expansion in the articular ends of rickety bones, as is mentioned by some authors. I should therefore feel inclined to believe, that there has existed only the appearance of such a phenomenon, the ends of the bones having appeared swollen, in conse- quence of the emaciation of the surround- ing soft parts. (See Med. Chir. Trans. Vol. 7, p. 402—405.) When tbe thoracic viscera are considera- bly oppressed by the alteration in the figure of the chest, produced by rickets, the dis- ease may bring on fatal consequences. Boyer has thus described tbe appearances of rickety bones: They are lighter than natural, and of a red, or brown colour. They are penetrated by many enlarged blood-vessels, being porous, and, as it were, spongy, soft, and compressible. They are moistened by a kind of sanies, which may be pressed out of their texture, as out of a sponge, or rather a macerated hide after i' RICKETS. lo i has been tanned. The walls of tbe medullary cylinder*of the great bones of the extremi- ties are very thin, while the bones of the skull are considerably increased in thickness, and become spongy and reticular. All the af- fected bones, especially the long ones, ac- quire a remarkable suppleness; but if they are bent beyond a certain point they break, be. Instead of being filled with medulla, the medullary cavity of the long bones con- tains only a reddish serum, totally devoid of the fat oily nature of the other seeretion in the natural state, t See Boyer, Traiti des Maladies Chir. T. S, p. 619.) The consis- tence of several rickety bones, examined by Mr. Stanley, was nearly that of common cartilage. They presented throughout an areolaled texture, and the cells were in some parts large, and contained a brownish gela- tinous substance. I his gentleman did not find the periosteum thickened, as Bichat has described it. (Analumie Generate, T. 3.) The investigations of Mr. Stanley have also discovered, that, in the process by which rickety bones acquire strength and solidity, there is always an undeviating regularity in the situation, extent, and direction of the deposited earthy matter. "Thus it is obvi- ous (says this gentleman) that, in the curved bone, the part where there is the greatest need of strength, to prevent its further yielding, is in the middle of its concavity, or in other words, in the line of its interior curve; and it is just in this situation, that strength and compactness will be first im- parted to the bone by the deposition of phos- phate of lime. It will be further found, that the greatest resistance being wanted at this part, the walls are accordingly rendered thicker here than elsewhere, and the degree to which this excess in thickness is carried, bears an exact ratio to the degree of curva- ture, which the bone has undergone." Mr. Stanley's observations also prove, that the bony fibres are arranged obliquely across the axis of the bone, in a direction calcula- ted to augment its strength. Lastly, we learn from the same authority, that if a long bone, like the tibia, be very much bent, while it has to support a great superincum- bent weight, the deposition of the bony mat- ter may not be confined to the thickening of the walls of the concave side, but may extend across the medullary cavity, render- ing the bone here perfectly solid, and there- by greatly strengthened. (See Obs. on the Condition of the Bones in Rickets, fyr. by E. Stanley, in Medico-Chir. Trans. Vol. 7, p. 404, et seq.) We learn from Mr. Wilson, that for many years past, he has also exhibited in his lec- tures preparations, illustrating the fact of the abundant deposition of osseous matter, " when the bones begin to recover from the disease, at the part where it is most wanted, viz. on the inner part of the concave surface of their curve." (On the Skeleton, fyc. p. 167.) Many very rickety and deformed infants improve as (hey grow up, and acquire strength. The deformity of theirlimbss- on- taneonsly diminishes, and the bones gain a proper degree of firmness, a due quantity of the phosphate of lime being deposited in their texture. It is a question, whether the restoration of the proper figure of the bones can be pro- moted by the constant pressure of bandages, and mechanical contrivances, sold in the shops. Some authors contend, that in very young children machines are useless, as the confinement and inactivity of the muscles, necessarily occasioned hy such contrivances, must increase the general debility, and con- sequently the disease. Notwithstanding the praises which have been bestowed on those mechanical means by their inventors, and even by respectable authors, says Boyer, they are not now used by any enlightened judicious practitioners, it being generally agreed, that it is best to leave to nature alone, aided by good medi- cal treatment, the duty of rectifying bones deformed by the rickets. (Traiti des Mai. Chir. T. 3 p. 627.) Delpech expresses him- self still more strongly against the employ- ment of machinery. (See Pricis Elimen- tairc des Maladies Chir. T. 3, p. 740, fyc.) However, these opinions against mechani- cal contrivances for the improvement of rickety bones, are not meant to apply to ma- chines for rectifying distortions of the foot. In such cases, the malformation does not de- pend on constitutional causes, and mechani- cal means will do whatever is possible. No medicine is known, which possesses any direct efhcacy in cases of rickets. To- nics are indicated, and should be employed. The state of the bowels must in particular be attended to. Tbe disease appearing to consist in a deficiency of lime in the bones, proposals have been made to exhibit inter- nally the phosphate of lime ; but this chy- mical project has had no success. (Set Bon- homme's Memoir on Rachitis, in Duncan's Annals for 1797. Several circumstances considered by Mr. Wilson, tend to prove, that this scheme could present no chance of benefit, because there is no proof of a deficiency of lime in the system, though the arteries of the bones do not deposit it in the natural degree. (See Wilson on the Skeleton, fyc. p. 163, fyc.) More good is generally effected by keep- ing children in healthy situations, and in a salubrious air, than by any medicines what- ever. Light, wholesome, nutritious, easily digestible food; cold bathing; good nur- sing; regular gentle exercise ; or airings in a carriage; the use of the flesh-brush, be. are also highly serviceable. The constitu- tional treatment of rickets belongs more properly to the physician than the surgeon ; and it is not necessary to introduce more of the subject into a Dictionary expressly al- lotted to surgery. See the article Mollifies Ossium, and con- sult particularly Buchnerde Racliitide perfec- ta et imperfecta Disput. Argent. 1754. Glis- son, de Rachitide, sive, morbo puerili. Ludg. Batav. 1671. Bonhomme's Mem. on Rachitis, in Duncan's Medical Annals far 1797 Rich' in-: SAR SAR' rand, Nosograpliie Chir. T. 3, p. 142. fyc. Edit. 4. Leveilte, in Mem. de Physiologic et de Chirurgie par Scarpa, fyc. Boyer, Traiti des Maladies Chir. T. 3, p. 607, fye. Stan- ley's Obs. in Med. Chir. Trans. Vol. 7,p. 404. Delpech Pricis Elimentaire des Maladies Chir. T. 3, p. 739, fyc. Trnka de Krzowitz, Hisloria Rachilidis, 8vo Vindob. 1787. R. Hamilton. Remarks on Scrofulous Affections, k-c. 8vo. Lond. 1791. A. Portal, Obs. sur la Nature et sur le Traitement du Rachitistnc, ou des Courbures de la coloimt Vertibraie tt de celles des Extremitis, Svo. Paris, 1797. And particularly, Lectures on the Structure and Physiology of Ihe Skeleton, Diseases of Bones, fyc. by James Wilson, p. 159, fyc. Svo Lond. 1820. RINGWOKM. See Herpes. RUPTURE. A protrusion of th* abdomi- nal viscera. See Hernia. S. •^"MCINA. i said to be named from the Sa- >5 bines, whose priests used it in their re- ligious ceremonies.) Savine. The use of the leaves of this plant, in forming the active ingredient in the ointment commonly pre- ferred for keeping open blisters, has been explained in the article Blisters. The other chief surgical use of savine, is as a stimula- ting application for destroying warts, and other excrescences. For the latter purpose, it is generally powdered, and mixed with an equal proportion of subacetate of copper. The same powder is also sometimes employ- ed by surgeons for maintaining the hollows into which peas are inserted in issues. The best plan is, first lo wet Ihe peas, then roll them in the powder, and put them in this slate on (he issue. But when the whole sur- face of the issue has risen high, above the level of the skin, the powder must be sprin- kled all over the sore, so as to produce an absorption of the high granulations.—Indeed, even in this manner, a good cavity often cannot be obtained ; and it becomes neces- sary to destroy the surface of the issue, by rubbing it with caustic potassa, or potassa rum calce. SACCHARUM SATURNI. Sugar of Lead. Cerussa Acetuta. Acetate of Lead. This is very extensively used in surgery, chiefly as a local application to inflamed parts, nnd in the form of a lotion. See In- flammation, Coilyrium, Lolio, Gonorrhoea, Ophthalmy, and numerous other articles of Ibis Dictionary, for an explanation of Ihe uses of acetate of lead. SAL-AMMONIAC. Ammonia Muriata. Muriate of Ammonia. Employed a good deal by surgeons, as an ingedient in discu- tient lotions. See Lotio Ammon. Mur. SALIVARY FISTL'LJE. See Parotid Duct. :■* ANTES. (Latin.) A thin, serous, fetid matter, discharged from fistulae, unhealthy sores, be. It is sometimes tinged wilh blood SAPO TEREKlNTI-IINiE. (Starkey's Soap.) ]\.. Potassa* Subcarhoriatis calidi, |j. Olei Terebinth, gnj.— Ihe oil of tur- pentine is gradually blended with tbe hot subcarbonate of potassa in a heated mortar. Indolent swellings were formerly rubbed with this application, and, perhaps, some chronic affections of (he joinls might still be benefiit.-'d by it. -•VRCOCE'LE (from «-*£. flesh : and j-j-xd, a tumour.) A fleshy enlargement of tbe teslicle. See Testicle, Diseases of.) SARCO'MA, or Sarcbsis. (from According to Mr. White, struma prevails more extensively in temperate latitudes, than in very hot or very cold climates. It is also more frequent in some parts of Eu rope than others ; and in this country it has been found to be most general in the coun- ties of Suffolk and Lancashire. At all pe- riods, it seems to have been a very common complaint in this island. From history, we learn, that it was denominated the king's evil in the time pf Edward the Confessor, who is supposed to have been the first that attempted to cure it by the royal touch. From a register kept in the royal chapel, we find that Charles the Second touched 92,107 persons, in a certain number of years ; and this equally bigoted and useless practice was not discontinued till a recent period, when kings were found to be, as well as their poorest subjects, totally desti- tute of all supernatural power. Scrofula is not communicable from one person to another; neither can it be con- veyed into the system by inoculation. The opinion also that scrofulous nurses may in- fect children, seems quite destitute of foun- dation. (See While, p 56, 57.) Pinel and Alibert have purposely kept scrofulous and healthy children together in the same ward, without any of the latter receiving the complaint. Hebreard could not communicate the disease to dogs by ino- culation. And G.T. Kortum, whose valua- ble work contains every thing known about scrofula at the period when it vvas written, tried in vain to impart the distemper to a child, by rubbing its neck every day with the pus discharged from scrofulous ulcers. Lepelletior, desirous of ascertaining the correctness of such experiments, has of late repeated them: he has made guinea pigs swallow scrofulous matter, and he has in- jected it into the veins, and applied it to wounds; butin no instance was there even a temporary appearance of the disease be- ing communicated. The same author also mixed scrofulous with vaccine matter, and inoculated with it ; yet he never found the vaccine vesicle, thus produced, deviate in the least from its regular course. Lastly, Lepelletier inoculated himseli with pus. dis- charged from scrofulous sores, as well as with the serum, collected under the cuticle of a strumous patient after the application of a blister ; but he has remained free from every scrofulous ailment. (See Did des Sciences Med. T. 50. p. 294.) Our country- man, Mr. Goodlad, inocuh.ted himself seve- ral tines with the discharge from scrofulous sores and abscesses, and the result vvas, that the disease could n< t be thus transmitted. (On the Diseases of the Vessels and Glands of the Absorbent System,p. 113) 1 nc - arts w hich re mosl frequently affect- ed by scrofula, next to the lymphatic glands, and perhaps the skin, are the spocgy beads of the bone-, and the joints. The form which tbe disease assumes in the latter pans, is particularly described in the article Joints. The disorder of the spine, attended wilh a paralytic affection of die lower extremities, is no doubt verv frequently of scrofulous ori- gin. (See Vertebral.) Tbe spina bifida is a congenital disease, which is found lo occur most frequently in children whose parents are scrofulous. (Thomson'sLectures,p. 133.) Tbe abscess, which forms in Ibe cellular sub- stance, belween the peritoneum a; d psoas muscle, is ofien regarded as a strumous dis- ease ; and when tbe contents ot the abscess are found to contain flakes of a curdy mat- ter, somewhat rese milling white of-egg, a substance peculiar lo scrofulous abscesses, no one can doubt that Ihe complaint is con- nected with this constitutional affection. (See Lumbar Abscess.) The chronic enlarge- ment ol ihe thyroid gland, is sometimes con- sidered as srrofulous ; but though patients, wilh this affliction, very often have, at the same time, other complaint", w b'cb are une- quivocally strumous, though the enlargement of the thyroid gland most frequently com- mences at an early period of life, like scro- fulous diseases, and though, like them, it is sometimes benefited by the carbonate of soda, ihe opinion, I think, is rather on Ihe de- cline. (See Bronrhocele.) Scrofula also frequently makes its appearance in tbe form ot impeded suppurations in variou- parts of the body ; the contents ot such abscesses be ing a curdy kiud ot matter, and the skin covering them having an unheally red ap- pearance, and a thickened doughy feel. The mesenteric glands are oflefi found univer- sally disc ased and enlarged in scrofulous sub- jects ; ai.d as all nutriment bas to pass through these parts, before it can arrive in the circulation, we cannot be surprised at the many ill effects which must be produced on Ihe system, when such glands are thus diseased However, as I have already hint- 400 aCKO ed, doubts arc entertained by Dr. Henning, whether enlarged mesenteric glands are de- cidedly scrofulous ; but if his sentiment be incorrect, I fear he has been led to adopt it by nis particular theory, which limits the ori- gin of scrofula to the superficial absorbent glands. Scrofula frequently makes its attack on Ihe testicle. (See Testicle, Diseases of.) The female breast is also suhjeci to scrofu- lous tumours and abscesses Dr. Thomson believes, (hat more or less local inflammation occurs in every form and stage of scrofulous diseases. He observes, that the swellings are very often from the first attended wilh a sensible increase of heat and redness, and that the pain, though sel- dom acute, ii always present in a greater or Jess degree. Pressure on scrofulous swell- ings never fails to create pain ; and tbe tem- perature of the skin covering them, is usu- ally two or three degrees higher thmi that of the contiguous parts. (Lectures, fyc. p. 131.) Scrofulous inflammation (as Mr John Burns observes,) is marked by a soft swell- ing of tbe affecled part, which very fre- quently is one of the lymphatic glands. The covering, or coat of the gland, be- comes slightly thickened, and its substance more porous and doughy. The swelling increases, and the doughy feel changes by degrees into that of elasticity, or fluctuation, and a firm, circumscribed, hardened margin, can be felt round the base of the tumour. The skin is slightly red. If, at this time, an incision, or puncture, be made, either no matter, or very little is evacuated, the lips of the wound inflame and open, displaying a sloughy-looking substance within ; and, betwixt this and the skin, a probe can often be introduced for some way all round If, however, the disease should have advanced further, then there is very little elasticity in the tumour; it is quite soft, rather flaccid, and fluctuates freely ; the skin becomes of a light purple colour, and small veins may be seen ramifying on its surface. Some time after these appearances, the skin be- comes thinner at one particular part, and here it is also generally rendered of a darker colour. It afterward bursts, and discharges a thin fluid, like whey, mixed with a curdy matter, or thick white flocculi. The red- ness ofthe skin still continues; but the aperture enlarges as tbe tumour subsides, and thus a scrofulous ulcer is produced. The margins of this kind of sore are gene- rally smooth, obtuse, and overlap the ul- cer ; they are of a purpio colour, and rather hard and tumid. The surface of the sore is of a light red colour; the gra- nulations are flabby and indistinct, and the aspect is of a peculiar kind, which, says Mr. Burns, cannot be described. The discbarge is thin, slightly ropy, and copious, with curdy flakes. The pain is inconsidera- ble. When this ulcer has continued for some time, it either begins slowly to cica- trize, or as more frequently happens, the discbarge diminislies and becomes thicker. An elevated scab is next formed, of p dirty bTLA. white, or yellowish colour. This continue,- on fhe part a good while ; and when it falls off, leaves the place covered with a smooth purple cicatrix. Mr. Burns adds, that the preceding description corresponds to the mild scrofula,^ or tbe struma mansueta of the old writers This gentleman next re- marks, that occasionally, especially if a bone be diseased below the ulcer, the sore has a more fiery appearance, the surface ia dark-coloured, the margins soft, elevated, and inflamed, and sometimes retorted. The discharge is watery, (he pain very consider- able, aud the surrounding skin inflamed. This has been called the struma maligna. Such overacting scrofulous sores are most frequently met with over the smallerjoinls, particularly those of the toes. (Burns.) Sometimes a scrofulous abscess, after it has burst, forms a sinus ; the mouth of which ulcerates,and assumes the specific scrofulous appearance, while the track of the sinus still continues to emit a discharge. Mr. Burns also remarks, that scrofulous swellings are often disposed to subside in winter, and recur on tbe approach of summer; but, he adds, that this is not an invariable law. The glandular enlargements are very apt to become smaller, in a short time, in one place, while other glandular swellings origi- nate wdth equal suddenness, somewhere in the vicinity of the former ones. Ulcers, also, very often heal upon the appearance of the disease in other parts. (See Disser- tations on Inflammation, Vol 2, 1800.) The glandular swellings, which occur in syphilis, says Dr. Thomson, are of a more acute character, than those which proceed from scrofula. They arise from the absorp- tion of a specific poison ; and they do not, like those of scrofula, admit of a spontanc- ouscure. Chronicswellingsofthelympbatic absorbent glands occur also in carcinoma; but these manifest little or no disposition to suppuration ; they succeed most frequently (o carcinomatous indurations, or ulcers ex- isting in the neighbourhood of the glands affected ; and tbey are accompanied in their progress and growth by a peculiar lancina- ting pain. (See Thomson on Inflammation, p. 135.) Witb regard to the proximate cause of scrofula, medical men may be said to re- main, even at the present day, in entire ig- norance of it. After the ridiculous theory, referring scrofula to certain humours in the constitution, or chymical changes in the blood, had been exploded, the opinion gra- dually arose, that it was a disease of the lymphatic system ; and indeed, tbat the ab- sorbent glands are often visibly the seat ol its attack, when no changes are distinguish- able in other textures, is a fact, that admits of no dispute. I believe, at the same time, that whoever supposes scrofula to be ex- clusively confined to the lymphatic system, must have a very imperfect conception of what is really the case. On the contrary, I fully participate in the sentiments of Pro- fessor 1 homson, already adduced upon this point, and in tbe belief of another modern 5CR0FI LA 407 writer, thai strumous complaints " are not to be considered as dependent on disease of any particular system, as the lymphatic." (Lloyd, p. 10.) Such writers as have fixed upon the absorbent vessels, as the particular seat of scrofula, can throw no useful light upon its origin, by following up the theory, whether they imagine the cause to be ob- struction of the vessels and glands; or take up the wild speculation of Cabani, that in scrofula, the mouths of the lymphatics are in a state of increased activity, while the vessels themselves are in a state of atony; or the doctrine of Soemmerring, that scro- fula depends upon a passive relaxation and dilatation of the absorbents ; or the hypo- thesis of Girtanner, that these vessels are in a state of increased irritability. The idea of obstruction being the cause, has of late years been much on the decline ; and that the convolutions of lymphatic vessels, forming tbe glands, are quite pervious, and may readily be injected, even when diseased, is a fact, first demonstrated by Soemmerring, which must weigh heavily against this opi- nion. Of the exciting causes, very little is also known. Mr. John Hunter remarks, tbat <■' in this country, the tendency to scro- fula arises from the climate, which is in many a predisposing cause, and only re- quires some derangement to become an im- mediate cause, and produce the whole dis- ease." (Treatise on the Venereal Disease, p. 26.) The disease is remarked to be most common in females; in cold, damp, marshy countries, and in all places near high moun- tains, where the temperature is subject to great vicissitudes. " Nous voyons presque toujours, (says Alibert) que les tumeurs et les ulceres se rouvrent au printemps pour se former ensuite vers la canicule." (Nosol. Naturelle, p. 449.) In fhe work quoted the last but one, Mr. Hunter takes notice of slight fevers, colds, small-pox, and measles, exciting scrofulous diseases. He observes, that in particular countries, and in young people, there will sometimes be a predisposition to scrofula; and that, in such subjects, buboes will more readily become scrofulous. (P. 27.) In short, it was one of Mr. Hunter's opinions, and probably a most correct one, that the venereal disease is capable of calling into action such susceptibilities as are remarkably strong, and peculiar to certain constitutions and countries ; and that, as scrofula is pre- dominant in this country, some effects of other diseases may partake of a scrofulous nature. (P. 96.) Mr. Hunter, speaking of venereal buboes, mentions his having long suspected a mixed case, and adds, " I am now certain that such exists. 1 have seen cases, where the venereal matter, like a cold, or fever, has only irrilated the glands lo disease, producing in them scrofula, to which they were predisposed. In such ca- ses, tbe swellings commonly arise slowly, give but little pain, and seem to be rather hastened in their progress, if mercury is given to destroy the venereal disposition. ^"•"c* come to suppuration, while under this resolving course ; and others, which probably had a venereal taint at first, be- come so indolent, that mercury has no ef- fect upon them ; and in the end, they get well of themselves, or by other means." (P. 269.) For such buboes, Mr. Hunter used to recommend sea-bathing; and, in case of suppuration, poultices made of sea- water. In the words of a well-informed Profes- sor, scrofula readily forms an alliance with almost every morbid affection, occurring either from external injury, or from internal disease ; it modifies the appearance of other diseases, and seems to convert them gradu- ally into its own nature. Indeed, there arc few of the local inflammatory affections, which occur in this country, in which the symptoms and effects of these affections, and ihe operation of the food and remedies employed for their cure, are not more cr less modified by the degree of scrofulous diathesis, which prevails in the constitution of those who are affected by them. The scrofulous diathesis, wherever it exists, usu- ally gives more or less of a chronic charac- ter to local inflammatory affections. (Thom- son's Lectures, p. 131.) It has been the fashion of late years to ascribe the origin of a vast number of dis- eases to disorder of the digestive organs; little trouble being generally taken to con- sider with any impartiality, whether the de- rangement of those organs may not be rather the common effect, than the common cause, of so many various diseases. Nume- rous circumstances tend to perpetuate the delusion, into which young practitioners are falling upon this topic. They see various diseases, attended with dyspepsia, flatulence, loss of appetite, costiveness, and a torpid state of the bowels; they observe that such diseases and the latter complaints of the alimentary canal, generally diminish toge- ther ; lhat, when the functions of the sto- mach and bowels are deranged, any other diseases, which the patient may be labouring under, either grow worse, or are retarded in their amendment; and, lastly, the treat- ment, to which the theory leads, improves the health, by rectifying the state of the alimentary canal, and the sore, tumour, or other complaint, in the end, with the addi- tional aid of time, nature, and'otber favour- able circumstances, gets well. But, how- ever simple, safe, and beneficial the prac- tice may be, and plain as the facts are which lead to it, there is no proof, that the other disease was truly a consequence of the disorder of the digestive organs. The latter symptom. 1 believe, is very frequently an effect mistaken for a cause, and perhaps, always so, in relation to scrofula. Besides, if it were to be assumed, (as indeed it actu- ally is) tiiat, in scrofula " there always is more or less disorder of the digestive or- gans, and primarily of no other important function," I do not see that we advance one step nearer the truth ; because as tbe same cause is generally assigued, by gentlemen attached io this theory, for a vast ntimHfr 408 rsCKtil-'Ll, V of other cases, we still remain in the dark, as to the circumstances, which make so many complaints of different kinds spring from one and the same cause. These cir- cumstances, though buried in silence, are still the mystery—still the secret which is desired ; and, if it be answered, that the ef- fect will only happen in particular constitu- tions, then we are brought back at once to the point from wliich we first started, viz. that scrofula is a disease depending upon some unknown peculiarity of constitution, congenital or acquired, and capable of be- ing excited into action by various causes, as climate, mode of living, be. However, lest 1 may not have attached sufficient im- portance to the doctrine of gastric disorder being the cause of scrofula, I feel pleasure in referring, for the arguments in its support, to the writings of Mr. Abernethy, Dr Car- michael, and Mr. Lloyd, whose sentiments appear highly commendable, as far as they tend to teach surgeons rather to place con- fidence in means calculated to improve the health in general, as the most likely mode of benefiting the scrofulous patients, than to encourage foolish dreams about new spe- cifies for the distemper. Thus far, I can follow these gentlemen safely ; but no far- ther, except as a sceptic. However, per- haps none of the believers in the effect of disorder of the digestive organs mean to say, that such disorder is any thing more than one of the many exciting causes of scrofula ; and with Ibis qualification, tbeir theory may, or may not, be correct. It is the doctrine of Alibert, and indeed of near- ly all writers: " ce sont, les vices de la puissance digestive, qui preparent de loin les scrophules. Rien n' influe davantage sur leur developpement que la mauvaise qualite des alimens, be." (Nosol. Naturelle, p. 449.) " Ajoutez a cet cause le sejour dans les habitations malsaines." But, every explanation, evert of exciting causes, re- mains unsatisfactory, as long as we find children living in the same air, under the same roof, and feeding and sleeping toge- ther, and clothed also exactly alike, yet, only one or two of them become scrofulous, while all the rest continue perfectly free from tbe disease. Here, then, we are again compelled to return to predisposition, con- stitution, diathesis, and a congenital tenden- cy to the complaint as a solution of the dif- ficulty. In short, then, respecting the eti- ology of scrofula, little is known, except that certain constitutions probably have a congenital disposition to the disease ; that such disposition may probably be increased, or diminished, by tne operation of climate, mode of life, age, be.; and that irritations of a thousand kin s nay excite the disease into action, when the system is predisposed to it, by inexplicable causes. That climate has great influence cannot be doubted, when it is reflected, that the inhabitants of certain countries, in which the temperature is invariably warm, never suffer from scro- fula There can also be no doubt that, wilh age, the disposition to scrofula diminishes, ^ for, cbildreu much afflicted While young, frequently get quite well when they ap- proach the adult state ; and, if a person has remained perfectly free from any mark of a scrofulous constituUon till the age of twenty-five, he may be considered as near- ly out of all danger of the disease. TaEATMENT OF SCROFULA. " For (he cure of scrofula, (says the celc brated Cullen,) we have not yet learned any practice that is certainly, or even generally successful. The remedy which seemstobethe most successful, aud which our practitioners especially trust to, or employ, is the use of mineral waters But, (adds this eminent physician,) in very many instances of the use of these writers, I have not been well satisfied, that they had shortened the duration of the disease more than had often happened when no such remedy had been employed. With regard to the choice of the mineral waters most fit for the purpose, (says Cullen,) 1 can- not with any confidence give an opinion. Almost all kinds of mineral waters, whether chalybeate, sulphureous, or saline, have been employed for the cure of scrofula, and seem- ingly, with equal success and reputation; a circumstance, which leads me to think, that if they are ever successful, it is the element- ary water.thatis the chief part of the remedy. Of late, sea-water has been especially re- commended, and employed ; but, after nu- merous trials, I cannot yet discover its superior efficacy." (First Lines of Physic, Vol. 4.) On the subject of mineral waters, Dr. Thomson very properly remarks, that they are now usually employed as pur- gative and tonic remedies, and not as speci- fics. In employing them it is often difficult to distinguish between the effects, wliich they in reality produce, and those which are to be attributed to the slow operation of time, the season of the year, change of situation, alteration in the mode of life, or exercise in Ihe open air. (Lectures on In- flammation, fyc. p. 195.) In scrofulous diseases, Dr Fordyce had a high opinion of bark; and he endeavoured to prove, that, in cases of tumefied glands, at- tended with a feeble habit, and a weak cir- culation, it is a most efficacious medicine, and acts as a resolvent and discutient. He also brings forward a case,in support of bark j being a means of cure for the ophthalmia strumosa. (See Med. Obs. andlnq. Vol. l,p. 184.) Dr Fothergill, in the same work, p. 303, writes in favour of the good effects of bark in similar cases ; small doses of ca- lomel bei ig sometimes given with it. Dr. Cullen considered the efficacy of bark in scrofula very dubious and trivial. KFird Lines, fyc. Vol. 4.) According to Mr. Burns, bark has been frequently found useful in the cure of scro- fulous inflammation, but more often of ulce- ration, than tumefaction of the glands. But, says he, it does not appear to possess, by any means, that certain power of ciiringscrofulottc SCROFULA ■lli*H affections, which is attributed to it by Dr. Fothergill and several other authors. He observes, that we are not to suppose it will infallibly cure scrofulous inflammation, or ulceration of parts, which, even when af- fected with simple inflammation, are very difficult of cure. If it be difficult to cure a simple inflammation, or ulceration, of a tendon, cartilage, or bone, we must not be disappointed if even a specific remedy for scrofula, (were such ever discovered) should prove ineffectual in procuring a speedy re- storation to health. Mr. Burns contends, that bark is often ineffectual, because impro- perly administered. Given in small quan- tities, once or twice a day, it may prove a stomachic, and increase, like olher tonic bitters, the power of the stomach, or the functions dependent on it; but, in order to obtain the benefits of the specific action of bark, be maintains, that it should be given, in large quantities, for several weeks, with a good diet, air, and proper exercise.— Disser- tations on Inflammation, Vol. 2, p. 371.) Dr. Thomson does not believe, that bark, or iron, bas any specific virtue in curing scrofula ; but, he admits, that either of these medi- cines may sometimes prove useful in proving the tone ofthe digestive organs, when given after, or occasionally along with, a course of purgative mineral waters. (Lectures, p. 197.) As far as I can judge, Mr. White has with much reason recommended paying attention to such circumstances as may have effect in preventing the disease, viz. air, cleanliness, exercise, and diet. He mentions cold-bath- ing among the preventives of struma, and speaks of sea-bathing as being the best. He advises attention also (o be paid to the manner of clothing children, keeping them more covered in winter than summer. Mr. White thought, that allowing children to sleep a great deal was prejudicial; but this seems to me only conjecture. In noticing tbe treatment of the disease, Mr. White states, that " tbe general idea of the struma is, that it is a disease of debility ; and therefore, the great object is, to invigo- rate the habit by every possible means ; the chief of which are tonic medicines, and sea- bathing. Some are of opinion., that in the case of young patients, this should be con- tinued, during the summer months, every year, to tbe age of fourteen or sixteen. Many recommend it, not only in the sum- mer, but throughout the year; whilst others are for administering alteratives, principally tbe alkaline salts, with or without anti- monials, and tbe different tonics, during the winter; and the sea-wnter and sea-bathing, or cold-bathing, during tbe summer, for a conti- nuance of two or three years from the com- mencement of the disease ; with this general observation, that they will outgrow the com- plaint." Mr. White adds, that the chief exter- nal means are fomentations of sea-water, and cataplasms, made with the same. Witb re- spect to regimen, some recommend a milk and vegetable diet; others animal food and fermented liquors Vol. II 52 Mr. While maintains, that the preceding plans of treatment are not, in general, effi- cacious, though, in some instances, the*y may prove useful. " In early affections of the lymphatic glands, (says this gentleman,) and from the want of a pure air, and proper exercise, where children are delicate and irritable, a change of situation to the sea- side, together with bathing, when they have acquired some strength, must be exceeding- ly proper ; and, in gross plethoric subjects, who have diseased lymphatics, from impro- per feeding, and want of necessary exercise, a journey to tbe sea-coast may be very use- ful, particularly if the salt-water is drank often, and in a sufficient quantity to become purgative. This, with the novelty of their situation, which may naturally produce an increase of exercise, might answer every expectation; but these are the kind of cases that, with a very little attention, are easily cured. (White on the Struma, Edit.3,p. 104.) The conclusion, to which Mr. White's re- marks upon this part of the subject tend, is, that sea-bathing only deserves praise, as a preventive, and in the early stages of the disease. He particularly condemns cold-bath- ing, for poor, weakly, debilitated children, whose thin visage, enlarged belly, and fre- quent tickling cough, sufficiently indicate diseased viscera ; such do not recover their natural warmth, after cold-bathing, forhours, and their subsequent headach, livid lips, and pale countenance, are sufficient marks of its impropriety. (P. 107.) Dr. Cullen entertained a very favourable opinion of cold-bathing, since he affirms, that he had seen scrofulous diseases more benefited by it, than any other remedy. (First Lines of Physic, Vol. 4.) " Cold-bathing, especially cold sea-bath- ing (says Mr. Russell) is a remedy universally employed in scrofula, and I believe with great advantage in many cases ; for it not only appears to improve the patient's gene- ral health and strength, but likewise to pro- mote the tumescence of enlarged glands, and the resolution of indolent swellings in die joints, even after tbey have attained a considerable size, and have existed for a great length of time. But, in order that cold-bathing may be practised with safety and advantage, the constitution must have vigour to sustain the shock of immersion without inconvenience. If the immersion be succeeded by a general glow over the surface of the body, and the patient feels cheerful, and has a keen appetite, we may conclude that the cold bath agrees with him ; but if he shivers on coming out of the water, con- tinues chill, and becomes drowsy, we may be assured that tbe practice of cold-bathing does no good, and had better be omitted. " In estimating the comparative merit of cold-bathing and warm-bathing, in the cure of scrofulous complaints, my own experience, together with the result of different conver- sations on the subject with some of the most judicious practitioners of ray acquaintance, would lead me to bestow much more com- mendation on the effects of warm-bathing. I 41" SCROFULA. should not even be inclined to circumscribe the practice to cases of emaciation and de- bility* since from observation, I am fully satisfied with regard to the beneficial effects of tbe warm bath to patients of plethoric constitutions, who were much affected with those swelled scrofulous glands. Several of instances occurred in young women, about the prime of life, who were in all res- pects healthy and vigorous, abating the swellings of the glands, ancTthose symptoms of distress which were connected with ful- ness of blood. " The sensation of the warm bath is ex- ceedingly grateful to most patients, and tbe practice is universally safe. It may be em- ployed at all seasons of the year, and in all weather, without danger or inconvenience ; the risk of suffering from exposure to cold, immediately after immersibn in the warm hath, having been much magnified by preju- dice. There is not even any good reason to believe in the existence of such a risk. The precautions, however, which are employed to avert it, are perfectly innocent; aud pro- vided they do not impose any unnecessary and incommoding restraints upon the prac- tice, may be encouraged, sofar as to relieve tbe patient's mind from uneasiness and groundless apprehensions. "It requires many weeks, and sometimes several months, to ascertain the full effects of warm-bathing in relieving scrofulous com- plaints ; but, as the practice is not attended with any inconvenience, nor followed by any bad consequence, there can be no rea- son to intermit the course, till the trial is completely satisfactory ; and I am convin- ced, that the practice of warm-bathing, in cases of scrofula, will be more universally adopted, after the knowledge of its benefi- cial effects is more widely diffused." (See Russell's Treatise on Scrofula.) * Nothing can be more satisfactory (says Professor Thomson,) than the evidence which is on record, of the efficacy of the muriate of soda, as it exists in sea-water. In reading this, one only wonders how so effi- cacious aremedy should ever have fallen into neglect. (P. 196.) In a subsequent passage, however, the same gentleman evinces only a limited confidence in this means of relief. " Local sea-bathing, both cold and warm, has often appeared to be of use in procuring the resolution of scrofulous swellings. The temperature of the bath must always be varied according to circumstances, according to the season of the year, the strength and habits of the patient, and the particular effect, which the bath seems to produce. I» is at all times difficult to distinguish between the effects immediately arising from tbe ap- plication of salt water to the body, and those which arise from the-increased warmth of temperature in tbe bathing seasons of the year; from the exercise which patients goiug to sea-bathing generally take in the open air; from the change of situation and • amusements; and, among the poorer classes, from the more nourishing diet and exemption irom labour,, in which they are usually per- mitted to indulge, during their residing -,,. sea-batbing (quarters. It is not improbable, that those living on the sea-coast, who become affected with scrofula, would for similar reasons, derive equal benefit by going from the sea-coast to reside for a time in the interior of the country." (See Thom- son! Lectures, fy-c. p. 203, 204.) A still later writer declares his belief, that cold sea-bathing has no specific power over the disease. (Lloyd on Scrofula, p. 43.*) Yet the plain surgeon, in search of practical truths, will not eare whether any plan has a specific power or not over a complaint, if that disorder is sometimes relieved by it. And, that this is the fact is admitted by Mr. Lloyd, when he says, " cold sea-bathing, bowever,is certainly useful when judiciously applied; &c. &c." (P. 44.) With regard to electricity, Mr. White .thinks it useful, when from length of time the enlarged glands have acquired a degree of hardness and insensibility. Mr. JVhite, after enjoining attention to air, exercise, and diet, as promotive of a recovery, as well as a preventive of the disease, proceeds to explain his own prac- tice. The internal cases, which properly belong to the physician, we shall dismiss from consideration. The first external symptoms, such as swellings of tbe lips, side of the face, and of glands under the chin, and round tbe neck ; also other symp- toms, usually considered as strumous, via. roughness of the skin, eruptions on the back of the hand, and different parts of the body, redness, and swelling of the eyelids, and eyes; are accompanied, according to Mr. White's conceptions, with an inflammatory diathesis, though seldom such a one as to require bleeding. Calomel is the medicine, which this gentleman recommends for the removal of the foregoing complaints. It is not to be given in such quantities, as to render it a powerful evacuant, either by the intestines, or any other way; but, in small doses, at bedtime. Thus, says Mr. White, " it remains longer in tbe intestinal canal, a greater quantity is taken into tbe habit, and the patient is less susceptible of cold, than when taken in the daytime. The first, and, perhaps, the second dose may prove purgative, which is, in general, a salutary effect; but, afterward, the same quantity will seldom do. more, than is sufficient to keep the body open ; and should it fail of answering that purpose, I have usually re- commended some gentle purgative, every third or fourth morning, according to cir- cumstances. If there should be a prevail- ing acidity, a few grains of the sal soda, magnesia, or some testaceous powder, may be added to the medicine. By this simple method (continues Mr. White) most of the symptoms before mentioned will, in'a short time, disappear ; but if the tumours should continue hard, and retain their figure, with- out dividing into smaller ones, we may de- rive some benefit from external applications, particularly the steam of warm water. I have used a variety of medicinal herbs with SCROFULA. 41 i :uccess, but am inclined to believe, that the advantage was principally derived from the warm water, be. At other times, I have stimulated the part affected with elec- tricity, insulating the patient, and drawing sparks from the tumour, until a slight de- gree of inflammation was excited. After the application of the steam, pi- the use of the electrical machine, I have sometimes rubbed a little of. the unguenturn mercuriale into the tumour, and neighbouring parts, or applied the emplastrum saponaceum, or mercuriale cum ammoniaco, over the swelj- ing, or a liniment with camphor, ol. oliva- rum, and sp. terebinth." Mr. White adds, that in such cases, if the tumours should suppurate, and hurst, the parts will, in most instances, heal without much trouble. For eruptions on the head, he recommends ap- plying the ung. saturn. album camphoratum, or the cerat. alb. cum hydrarg. prrecip. alb. For the roughness of the skin, which is ge- nerally followed by eruptions, he also ad- vises the aqua-vegeto-mineralis, aqua calcis, solutions of sal. tartar, or of the hydrarg. mur. as outward*applications. "This last (says Mr While) will seldom fail to check the progress of the complaint, and dry the softl*; and in the quantity often or twelve grains, to a quart of warm water, the use of it will not be productive of any pain. If the eruption should ulcerate, and require any unctuous application, to prevent the adhesion of the linen, the ointment before- mentioned may be applied ; the best re- medy wuTbe warm-bathing, and when prac- ticable, the sea-water claims a preference." (P. 114.) The author next mentions his having occasionally recommended the vi- num antimoniale, tartarum emeticum, de- coctum Lusitanicum, decoctum lignorum, or sarsaparilla; ; and that he sometimes found advantage derived from artificial drains. We need not detail this gentleman's mode of treating affections of the eyelids, as notice is taken of scrofulous diseases of the eye and eyelids, in the articles Ophthal- my and Psorophthalmy. For the cure of indurations in the breast, remaining after mammary abscesses, Mr. White speaks very highly of the effects of the steam of warm water; and cautions us against indiscriminately employing calomel, which will often affect the mother little, but the child violently. Mr. White mentions his employing a small tin machine, large enough to hold a pint and a half, or two pints of boiling water. From the top pro- ceeded a narrow tube, ten, or twelve inches long, through which the steam passed. Near its end, which was moveable and curved, was a joint, for the greater conve- nience of directing the steam to the diseased parts. The water was easily kept boiling, by means of a lamp under the machine. Mr. White says, that the steam should be employed twice, or thrice a day, and a piece of flannel, or skin, afterward applied. The body should also be kept open. In obsti- nate, neglected cases, mercurial prepara- tions, according to Mr. White, must likewise be'given, and, if they affect the child much, sucking should be suspended. (P. 117,118.) Mr. White speaks largely of the treatment of cases, in which the mesenteric glands are diseased ; but, this subject strictly be- longs to the physician. When, in these in- stances, the glands of the neck, or other parts of the body, tend to a state of suppu- ration, it is very sl&wly, the skia appearing uniformly thin, and of a deep red colour, and the tumour seeming flaccid. In such cases, Mr. White recommends the use ofthe laucet or caustic ; for if nt) artificial open- ing is made, it will be a long time before the skin gives way; and when it does, the aperture will not only be very small, but. often unfavourable in its situation. Mr. White adds, that the contents will often be more like mucus than pus, or like a mixture of both; and the discharge will continue for a great length of time, if no remedy is ap- plied. This gentleman mentions his having found a solution of gum myrrhae in aqua calcis, used as a lotion, and the ceratum saponaceum, or some similar outward ap- plication, the best method of treating this symptom. We need not describe Mr. White's prac- tice in the treatment of scrofulous joints, as the subject is fully considered in the article Joints. It appears, however, that he con- firms the efficacy of stimulating applications, and pressure with bandages, when the fin- gers and toes are affected with strumous disease. (P. 143.) Whoever compares the practice of Mr. White in administering calomel, occasional purgatives, tbe decoctum Lusitanicum sar- saparilla, &.c. with the blue-pill, sarsaparilla, and laxative treatment of the present day, will perceive no very material difference between them, especially when the stress, which Mr. White laid upon attention to diet, clothing, Sic. is taken into the account. Mr. Lloyd, who has detailed Mr. Abernethy's practice in scrofula, lays it down as an ax- iom, that " the disease is only to be cured by avoiding all sources of irritation, and re- storing the natural and healthy functions of the digestive organs." (P. 48.) By sources of irritation, Mr. Lloyd means exciting causes ; the advice is therefore excellent, as- far as it can be followed, or such causes are decidedly known. The restoration of the functions of the digestive organs is also a thing worth aiming at, and the only dif- ference in my views from those of Mr. Lloyd is, that as I look upon the disorder ofthe digestive organs to be in general only a complication, or effect of the scrofulous disease, ulcer, abscess, diseased joint, occasional purgative, it is undoubtedly a good medicine for strumous patients. Mer- cury was much disapproved of by the celebrated Cullen, as a medicine for scrofu- la. As a distinguished Professor observes : '• From the great apparent similarity of the symptoms, progress, aud seats of scrofula, to those of syphilis, and from the well- known effects of mercury in curing syphilis, it need not seem strange, that medical men should have been a little obstinate in their attempts to obtain benefit from the use of mercury iu scrofula. These expectations are in general abandoned, and mercury is now given for tbe cure of scrofula as a purgative only. A long-continued, or im- properly-administered course of this medi- cine, bas often been known to aggravate all tbe symptoms of scrofula; and, in many instances, to excite these symptoms in persons, in whom they did not previously exist." (See Thomson's Lectures on Inflam- mation, p. 194, 195.) Mr. Burns thinks the nitrous acid bas some effect in promoting the suppuration of scrofulous glands aud tumours, and disposing ulcers to heal. He says, two or three drams may be given every day, for a fortnight; but if in this time it should do no good, its employment ought to be discontinued. The mineral acids, diluted with water, (says Pro- fessor Thomson,) are often used with views similar to those, which guide us in tbe em- ployment of tonic remedies. Their medici- nal powers appear to be nearly the same ; but the nitric acid bas of late been preferred, particularly in the scrofulous affections, which are sometimes induced by the action of mercury. (Lectures, fyc. p. 197.) The pills containing carbonate of soda, (see Puulai,) and the different soda waters, sold at the shops, have repute, for their good effects on scrofulous constitutions and dis- eases. A spirituous infusion of gentian, into six ounces of which are put thirty-six grains, of tbe carbonate of soda, or tbe same quan- tity of the carbonate of ammonia, is a medicine highly spoken of by Richerand for scrofulous cases. (Nosogr. Lhir. T. \,p. 184, Ed. 4.) Potassa in large doses, with mercurial frictions, is the practice lately extolled by Mr. Farr; but it appears to me, that mer- cury and potassa had been repeatedly tried, long before this author delivered bis senti- ments to tbe public ; and that such practice cannot be entitled to be called a method. for the eradication of the disease. (See Farr on Scrofula, 8vo. Lond. 1820.) According to Mr. Bums, eight or ten drops of hydrosulphuret of ammonia, given thrice a day, are useful in irritable strumous ulcers. The breathing of oxygen gas has 6een proposed ; but of this plan I know nothing from experience, and, as it now makes less noise in the world than formerly, I conclude that either ils usefulness has been exaggerated, or the difficulty of the practice is too great to allow of its extensive adop- tion. The sentiments of Dr. Cullen are decided- ly against antimony. Ai a modern writer observes, no great dependence seems ever to have been placed in the use of diaphoretic medicines for the cure of scrofula. The different preparations of antimony, indeed, have been occasionally administered ; but chiefly in cutaneous affections, supposed to be of a scrofulous nature. Guaiacum, sar- saparilla, sassafras, and mezereon, singly, and in combination, have all been supposed to be useful in the cure of scrofula; but they are now seldom given with this view, except in cases of scrofula combined with syphilis, or excited by the too free and injudicious use of mercury. (Thomson's Lectures, fyc. p. 199.) With respect to Alibert's practice, among the vegetable bitters, he prefers tbe hop, burdock, gentian, and bark. He seems to have no confidence in specifics, like hem- lock, belladonna, aconitum, be. Neither does he express himself favourably of alka- line medicines, the muriate of ammonia, and the muriate of barytes. However, he praises the good effects of steel medicines on enlarged glands. He affirms, that he has seen most good derived from external means; aromatic fumigations in an apparatus prepa- red by the chymist Darcet. What he calls scrofulous eruptions, he covers with a strong solution of the nitrate of silver. Swelled glands he rubs with the antimonial ointment. He commends also change of air, and the avoidance of low damp places ; and speaks favourably of sea-bathing, sen voyages, sulphureous mineral waters, and particularly of the good effects derived from the solar warmth. (See Nosol. Nat. p. 449.) The focal treatment, preferred by Mr. White, has beeu already described. I hava only a few words to add concerning this part of the subject. Dr. Cullen states, that, in his practice, he had very little success in discussing incipient scrofulous tumours bv topical applications ; and that a solution of the saccharum saturni, though sometimes useful, more frequently failed. Dr. Cullen found the aqua ammoniac acet. not more successful. " Fomentations of every kind (says he) have been frequently found to do harm ; and poultices seem only to hurry on a suppuration. I am doubtful if this last be ever practised with advantage; for scro- fulous tumours sometimes spontaneously disappear, but never after any degree of inflammation has come upon them; and therefore, poultices, which commonly in- duce inflammation, prevent that discussion of tumours, which might otherwise have happened." Even when scrofulous tumours have advanced towards suppuration, Dr. Cullen thought, that hastening the sponta- neous opening, or making one with a lancet, was hurtful. With respect to ulcers, Dr. Cullen re marks, that escharotic preparations, ofeither mercury, or copper, have been sometimes useful in bringing on a proper suppuration, and thereby disposing the ulcers to heal; but they have seldom succeeded, and more. commonly, they have caused the ulcer * ■ 4H . ^CROFLLA spread more. The escharotic, from which Cullen saw most benefit result, is burnt alum, mixed with some mild ointment. But this celebrated writer gives the prefer- ence to keeping the sores continually co- vered with linen wet with cold water in the daytime, and some ointment or plaster at night. Cullen says, that he usually found sea-water too irritating, and no mineral water better than common water. (First Lines of the Pract. of Physic, Vol. 4.) Formerly, the extirpation of scrofulous tumours was advised; but this method is now considered as being, for the most part, injudicious and unnecessary, with tbe ex- ception of diseased joints, and a few other parts, which frequently require being am- putated for the sake of saving the patient's life. Certainly, no particular danger (gene- rally speaking) would attend cutting out scrofulous glands and tumours; the objec- tions to the plan are founded on the pain of the operation; on the number of such glands frequently diseased ; on their otten subsiding, either spontaneously, or by surgi- cal treatment; on the operation doing no good to the general affection of the system, be. When, however, a scrolulous testicle, breast, or joint, seriously impairs the healtn, and endangers lite, the very existence of the patient demands tne immediate, removal of the diseased part. Wiseman relates, that he was in the habit of cutting out scrolulous glands and tumours with great success ; but for reasons already alleged, most of the modems think such operations in general at least unnecessary. Caustics have been employed for the same purpose, instead of the knife ; but, us they effect the object in view less certainly, more painfully and tediously, and cause extensive ulcers, they are disused by all the best surgeons of the present day. Some authors have advised making issues, and keeping them open, iu order to prtvent any ill effects from healing scrofulous ulcers. Issues are certainly quite unnecessary for any purpose of this kind ; but they are emi- nently useful as a part of the local treatment ot scrolulous joints and abscesses, as we have more particularly explained in the ar- ticles Johns, Lumbar Abscess, and Vertebral. Mr. Burns notices, (hat issues have hither- to been chiefly used in diseases of the bones and joints; but he adds, that it is reasonable to suppose, that they ought likewise to be use- ful in the cure of enlargements of the glands and other scrofulous tumours, if inserted in the.immediate vicinity of the part. The only objection to their use is the scar which they leave, and which, in certain situations one would particularly wish to avoid. When the tumour is thickly covered with the in- teguments, the issue may be made directly over it, and kept open with the savine oint- ment. In other cases, a small pea issue or seton may be inserted by the side of the tumour. This method would be*objection- able, for scrofulous glands in the neck, in consequence 0f the scar; but it might be employed whence minima i= disea«rd. • (Dissertations on Inflammation, Vol. 2.) The late Mr. Crowther used to apply blisters to scrofulous swellings, and maintain a dis- cbarge from the part. And a more modern practice is that of producing! irritation of the integuments, covering tumours and abscesses, by means of the tartar emetic ointment. (Alibert Nosol. Naturelle, p. 449; Goodlad on Diseases ofthe Absorbents, p. 162, fyc) Preparations of lead; cloths dipped in cold water, sea-water, or weak vegetable acids ; aether ; sea-salt mixed with bile; the linimentum camphorae; a mixture of aether and the linimentum opiatum; and hemlock poultices ; form a long list of applications, which have been employed for scrofulous tumours. According to Mr. Burns, moderate pres- sure, by means of adhesive plaster, con- joined with the application of cold water, is one of the best plans of treating mild scrofulous ulcers, when their situation ad- mits of it. In other cases, he recommends applying a powder, five parts of wliich consist of cerussa acetata, and the sixth of burnt alum. A piece of dry lint is next to be applied, and a compress, with such pres- sure as can be used. Benefit occasionally results from dipping the compress in cold water. The ceratum e lapid. calamin. is a good common dressing, when it is wished not to interfere much with the progress of the ulcer. The ung. hydrarg. nitrat. rub. and the ung. hydrarg. nitrat. are the best stimu- lating ointments. Poultices of bread and sea-water; solutions of alum, cuprum vi- triolatum, and the hydrarg. mur.; solutions of the nitrates of copper, bismuth, and silver; the recent leaves ofthe wood-sorrel bruised ; lint dipped in lemon-juice, or vinegar and water ; are among the applica- tions to common scrofulous ulcers. For irritable sores, diluted hydrosulphuret of ammonia; ointments containing opium ; carrot and hemlock poultices ; a solution of opium; and carbonic acid gas; are com- monly recommended. The followingare Mr. Russell's sentiments respecting the treatment of scrofulous ul- cers : '* Scrofulous complaints in general do not agree well with stimulant applications. In the treatment of scrofulous ulcers, under tbe ordinary circumstances of complaint, the simplest and mildest dressings answer best. When the patients are using a course of sea-bathing, it is usual to wash the sores with sea-water, over and above the momen- tary application of the sea-water during the immersion of the whole body. Cold spring- water is likewise a favourite application with many practitioners; and from much obser- vation, it appears that the operation of cold is well suited to counteract the state of in- flammation, which accompanies scrofulous sores. Preparations of lead are, upon the whole, very convenient and useful applica- cations, provided the solutions be used in a state of sufficient dilution to prevent irrita- tion. Liquid application? are applied by SCROFULA. 4iu means of wet linen, which is renewed whenever it dries, so that the surface of the sore may be kept constantly moist when un- der this course of management. Upon the same principle, simple ointment and Gou- lard's cerate, furnish the* best dressing in ordinary cases. " Scrofulous congestions, of a solid na- ture, in the more external parts of the body, are little adapted to the practice of local bleeding, unless they be attended with symptoms of inflammation ; but as some degree of inflammation is, in general, pre- sent during the incipient stage, it mayr be prudent to employ local bleeding iu modera- tion at the commencement of the attack, although there may be no indication to per- sist in the practice, after the complaint has advanced farther in its progress. If, how- ever, these congestions are more of aijgindo- lent nature, unaccompanied with heat or* pain, there is no benefit to be expected from the local detraction of blood; warm fo- mentations, together with the use of stimu- lants, and a repetition of blisters, are the most serviceable class of remedies: such cases, too, are the best adapted to the use of friction as a discutient. Friction, indeed, has long been employed for this purpose ; but, of late.years, it has been introduced to an extent, and with an effect^far beyond the experience of all former practice. As yet it has been circumscribed to the prac- tice of a very few individuals, with whom it is said to have performed very great cures ; and if, upon the test of more extensive ex- perience, it is found to answer its present nigh character, I shall consider the use of repeated frictions to be one ofthe most valu- able improvements which has been introdu- ced into practice in modern times. The safety and simplicity of the practice recom- mend it very strongly to favour, though I am afraid they are the very circumstances which retard its adoption by the public in general. I only regret that I do not feel myself entitled to give a decided opinion upon the subject from my own experience, though I have known some instances of successful cures; but the reports of success are so numerous and so well supported, that I am inclined to think very favourably of the practice. " There is no substance interposed be- tween the surface of the swelling and the band of the person who administers Ihe fric- tion, excepting a little flour, to prevent the abrasion ofthe skin. The friction is applied regularly two or three hours every day. with great celerity, the hand being made to move to and fro one hundred and twenty times in a minute, and the course may require to be continued, without interruption, for some months." (See Russell on Scrofula.) I shall not enlarge upon this endless sub ject, which still stands in need of elucida- tion as much as any disease that can be in- stanced. The scrofulous affections of the joints are explained in Joints; Bronehocele; Lumbar Abscess; Spina bifida; and Vertebral, are other articles, containing matter con- nected with the preceding observation's. The reader may consult Wiseman's Chi- rurgical Treatises. J. Brown, Adenochoira- delogia, or an anatomick chirurgical Treatise of Glandules and Strumals, or King's Evil Swellings, together with, the Royal Gift of Healing, or Cure thereof by contact, or impo* sition of hands, fy-c. Svo. Lond. 1684. Wm. Clowes, A right frutefull and approved Trea- tise, for the Artificial Cure of the Struma, or Evil, cured by Kings and Queens of England, 4/o. Lond. 1602. Cullen's First Lines of the Practice of Physic, Vol. 4. Feme on the King's Evil. Cheyne on the King's Evil. R. Russell, A Dissertation on the Use of Sea- Water in the Diseases ofthe Glands, fyc. 8vo. Lond. 1769. B. Bell's Surgery, Vol. 5. B. Bell on Ulcers. Tumor Strumosus Colli post vomitorium imminulus. 8vo. (Weikard, Collect. 88.) Kirkland s Medical Surgery, Vol. 2. J. Morley, Essay on the Nature and Cure of Scrofulous Disorders, fyc. New Ed. Svo. Lond. 1778. While on the Strunta, Edit. 2, 1794. P. Lalonelle, Traiti des Scrophules,fyc. Paris, 1780. A. G. Kortum's Comment, de Vilio Scrophuloso, in 2 Vol. 4to. Lemgovim, 1789. R. Hamilton, Observations on Scrofu- lous Affeclion, fyc. 8vo. Lond. 1791. London Med. Obs and Inq. Vol. 1. S. T. Soemmer ring, De Morbis Vasorum Absorbenlium Cor- poris Humani. Svo. Traj. 1795. C. IV. Hufeland, Ueber die Natur, fyc. der Skrophel- krankheil. 8vo. Jena. 1795. Dissertations on Inflammation, by John Burns, Vol. 2. M. Underwood, Treatise upon Ulcers, fyc. wilh Hints on a Successful Method of treating some. Scrofulous Tumours, fyc Svo. Lond. 178b. Crowth'er's Obs. on the Disease of the Joints, commonly called White Swelling; with re- marks on Caries, Necrosis, and Scrofulous Abscesses, fyc. Edit. 2, 1808. A Treatise on Scrofula, by'James Russell, Svo. Edinburgh, 1808. Lectures on Inflammation, by John Thomson, M. D. p. 130, et seq. p 155—191, fyc. Edinb. 1813. This work contains as good and as rational an account of the subject as any book which I have examined. Wm. Good- lad, A Practical Essay on the Diseases of the. Vessels and Glands of the Absorbent System. 8vo. Lond. 1814. G. Henning, A Critical Inquiry into lite Pathology of Scrofula, 8i;o, Lond. 1815. Richerand, Nosographie Chir} T. 1, p. 165, el seq. Edit. 4. Delpech, Pricis Elimenlaire des Maladies, Chir. T. 3, p. 617, fyc. Paris, 1816. Lassus, Pathologie Chir. T. 2, p. 383, fyc. Edit. 1809. Callisen, Sys- lema Chirurgix Hoduma., Vol. 2, p. 113, Hafnuz, ,1800.. Boyer, Traiti des Maladies Cliir. f% p. 414,,fyc. Paris, 1814. Ch. Brown, Treatise on Scrofulous Diseases, show- ing tlie good Effects of factitious Airs. Sro. Lond. 1798. Baume, Traiti sur le vice Scro- phuleux, 8vo. Paris, 1808. J. Brandish, Obs. on the use of caustic alkali in Scrofula, and other chronic Diseases, Svo. Lond. 1811. C. Armstrong, .Essay on Scrofula, in which an. account of the Effects of the Carbonas Ammo- nia is submitted lo the Profession, 8vo. Lond. 1812. W. Lambe, Inquiry into the origin,fyc. of Constitutional Disorders, particularly Scro- •Ho oLK<*>lt'M fula,Consmiptio7i,Cancer, -ye. 810. Lond.1805. Also Additional Reports on the Effects of a peculiar Regimen in cases of Cancer, Scrofu- la, fyc. 8vo. Lond. 1815. ii. Carmichael, Essay on the Nature and Cure of Scrofula, and a demonstration of ils origin from Disor- der of Digestive Organs, Sro. Dubl. J. Rab- ben, Dc Praicipuis Causis Mail Scrofulosi ejusque Remediis efficacissimis commeutatio, 12mo. Goth. 1817. Alibert, Nosologic Natu- relle, p. 448, fol. Paris, 1820. Did des Sciences Med. T. 50, art. Scrofules, 8vo. Paris, 1820. E. A. Lloyd on the Nature and Treat- ment of Scrofula, Svo Lond. 1821. SCROTOCE'LE. (from scrotum, and m\», a tumour.) A rupture or hernia in the scrotum. SCROTUM, CANCER OF. (Chimney- sweeper's Cancer. The soot-wart.) Mr. Pott gives the following account of this peculiar disorder. " It is a disease which always makes its first attack on, and its first appearance in, the inferior part of the scrotum ; where it firoduces a superficial painful, ragged, il I— ooking sore, with hard and rising edges; the trade call it the soot-wart. I never saw it under the age of puberty, which is, I sup- pose, one reason why it is generally (aken, both by patient and surgeon, for venereal, and being treated with mercurials, is thereby soon and much exasperated: in no great length of time, it pervades the skin, dartos, and membranes of the scrotum, and seizes the testicle, which it enlarges, hardens, and renders truly and thoroughly distempered; from whence it makes its way up the sper- matic process into the abdomen, most fre- quently indurating and spoiling the inguinal glands: when arrived within the abdomen, it affects some of the viscera, and then very soon becomes painfully destructive. " Other people, besides chimney-sweep- ers, (says Pott) have cancers of the same part; and so have others, besides lead- workers, the Poictou colic, and the conse- quent paralysis : but it is nevertheless a dis- ease to which tbey are peculiarly liable ; and so are chimney-sweepers to the cancer of the scrotum and testicles. " If there be any chance of putting a stop to, or preventing this mischief, it must be by tbe immediate removal of tbe part affect- ed ; I mean tbat part of tbe scrotum where the sore is ; for if it be suffered to remain until the virus has seized the testicle, it is generally too late even for castration. I have many times made the experiment; but though the soros, after such operation, have, in some instances, healed kindly, and the patients have gone from tbe hospital seem- ingly well, yet, in the space of a few months, it has generally happened tbat they have returned, either with the same disease in the other testicle, or in the glands of the groin, or with such wan complexions, such pale leaden countenances, such a total loss of strength, and such frequent and acute inter- nal pains, as have sufficiently proved a dis- eased state of some of the viscera, and which have soon been followed by a painful death. " If extirpation ever bids fair for the une of a cancer, it seems to be in this case ; but then the operation should be immediate, and before the habit is tainted^ The disease, in these people, seems to derive its origin from a lodgment of soot in the rugae of tho scrotum*, and at first not to be a disease of the habit. In other cases of a cancerous nature, in which the habit is too frequently concerned, we have not often so fair a pros- pect of success by the removal of the dis- tempered part; and are obliged to be con- tent with means which I wish I could say were truly palliative ; but here tbe subjects are young, in general in good health, at least at first; the disease brought on them by their occupation, and in all probability- local ; which last circumstance may, I think, be fairly presumed from its always seizing the same part: all this makes it (at first) a very different case from a cancer wliich appears in an elderly man, whose fluids are become acrimonious from time, as well as olher causes; or from the same kind of complaint in women who have ceased to menstruate. But be all this as it may, the scrotum is no vital organ, nor can the loss of a part of it ever be attended with any, the smallest degree of inconvenience ; and if life can be preserved by the removal of all that portion that is distempered, it will be a very good and easy composition ; for when the disease has got head, it is rapid in its progress, painful in all its attacks, and most certainly destructive in its event." (Pott'sWorks, Vol.3. See also W. Simmons's Cases and Obs. on Lithotomy, to which are added Obs. on Chimney-sweeper's Cancer,Sue. Manchester, 1808.) SCROTUM. Sarcomatous Thickening and- Enlargement of The investigations of Ba- ron Larrey lead him to believe, that cases of enormous growth of the scrotum are ende- mial in warm countries, or, at least, that tbey are seldom observed in cold climates; since most of the examples which have been seen in Europe came from Asia and Africa. The scrotal tumour of Delacroix, formerly minister of external relations, says Larrey, is perhaps the only well-authenticated in- stance of the origin of such a disease in our own climate ; and it was also much smaller than the instances related in the Epheme- rides German, for the year 1692, in the surgical writings of Dionis, in the 9th vol. ofthe Bibliotheque de Medecine, and those which Larrey was surprised to meet with in Egypt. The smallest of these latter, after they bad attained their full size, weighed more than 25 kilograms (between 60 and 70 pounds.) Several cases of this curious disease are recorded by other writers, particularly by Dr. Cheston, Dr. Titley, and the celebrated Sandifort. I lately saw in Mr. Abernethy's museum., a considerable fleshy substance, which was a portion of diseased scrotum. In the cases which Larrey bad an oppor- tunity of seeing in Egypt, the fleshy mass, into which the scrotum Was converted, was broad below, and suspended from the pube*** shluA ' 417 by a sort ol pedicle. "Externally, (as Lar- rey observes) the tumour presents rugosi- ties of different sizes, separated by particu- lar lines or sinuses, to which the mucous cryptic and roots of the hairs correspond. I'pon a large portion of its surface, espe- cially when the case is of long standing, yel- lowish scaly crusts are always seen, the detachment of which constantly leaves so many small herpetic ulcers, which emit an ichorous discharge. The tumour is indolent and hard at some points, but softish at others. It may be handled, and pressed in different directions, without the least pain. The patient is only incommoded by its weight, and the impediment which it causes (o bis walking well. Hen-ce he is necessi- tated to employ a suspensory bandage. In consequence ofthe situation of the urethra, the urine dribbles over the swelling; but without causing any excoriation." Inmost ofthe cases seen by Larrey, tbe spermatic chord and testicles were in the natural state, situated at tbe sides and at the root of the swelling. The spermatic vessels, however, are somewhat enlarged and elongated. All the patients were likewise more or less affected with elephantiasis. Baron Larrey attempts to explain the cau- ses of the complaint in Egypt,but, as I think, without any degree of success. As the af- fection is seldom seen in old countries, cli-i mate has certainly a chief effect. Employ- ments which keep persons a good deal in a sitting posture ; the loose breeches worn by the Egyptians, and the consequently pendu- lous state of tlie scrotum; diseases of the humours, and particularly itchy pustules on the part, an ordinary consequence of syphi- lis in that country ; bad regimen ; abuse of venery; and the immoderate use of the warm bath ; are merely conjectures, which will not bear the test of reasoning. The enormous magnitude, which this sort of disease may attain, is almost incredible. The case, recorded in the Ephemerides Ger- man, weighed about a hundred kilograms, or more than two hundred weight. Another, described by Larrey, was calculated to weigh about one hundred and twenty pounds, and this surgeon likewise saw in Egypt ten or twelve more instances, nearly as large, and all ofthe same character. A very curious example,in which a simi- lar disease affected the labia pudendi in a surprising degree, is also detailed by Larrey. The woman was a native of Cairo. In the early stage ofthe disorder, we may try preparations of antimony combined with sudorifics; drinks acidulaled with sulphuric acid, lotions containing the same acid, or the oxymuriate of mercury, the oxyde of copper, or the muriate of ammonia. These means are to be assisted by a gradual, uni*- form compression of the whole lumour. In one case, incisions and the application of caustic, proved of no service, and Larrey very properly condemns such experiments. When the disease resists every plan tried for its relief, and its increase renders the pa- dent's life irksome, and wretched, the extir- Vor. If ft:« pation of the tumour with a kniic becomes proper. In this proceeding, the chief skill consists in doing no injury to the spermatic chords and testicles, which are generally perfectly sound. As the substance of the swelling is not furnished with large vessels, the hemorrhage need riot be feared. Care must also be taken not lo injure the corpora cavernosa penis, and the urethra. After the operation, the skin is to be brought over the exposed testicles, as much as possible, with adhesive plaster and a bandage. M. Delonnes successfully removed the dis- eased mass in the celebrated case of the French minister Delacroix, and Larrey per- formed the same operation with success, when he vvas in Egypt. Dr. Titley, of the island of St. Christopher, also cut away such a tumour, which weighed, seventy- pounds, and the patient, who was a negro, and also affected with elephantiasis, speedily recovered. (See Medico-Chirurgical Trans. Vol. 6, p. 73, 4-c). It is probable, that some of the cases, which occur in warm countries, are analo- gous to the elephantiasis; but 1 do not be- lieve, (hat the scaly incrustations, which are represented by Larrey as occurring in the cases which he saw in Egypt, have been always noticed in tbe instances which have taken place in colder countries. Nor, in- deed, did Ihey take place in the instance re- corded by Dr. Titley, the surface of the tu- mour having been quite smooth. (Larrey, Mimoires de Chirurgie Militaire, T. 2, p. 110, et seq. Richerand Nosographie Chir.T. 4, p. 314, fyc. Edit. 4. Also Delonnes' Memoir. Dr. Cheslon's Case, fyc. Med. Chir. Trans. Vol. 6.) SEARCHING. The operation of intro- ducing a metallic instrument, through the urethra into the'bladder, for the purpose oi ascertaining whether the patient has a stone or not. See Sounding. SETON. (Setaceum, from seta, a bristle, because horse-hairs were formerly used for keeping open the wound.) A kind of issue. It is usually made by means of a particular needle, which is of various breadths, from half an inch to a full inch. The needle is commonly a little curved, but, if straight, it would be better calculated for the purpose. From the point to its broadest part, it is dou- ble edged, and behind it bas a transverse eye, through which a skein of thread or silk, of exactly the same breadth as the needle, is placed. A fold of skin is to be pinched up at the part where the seton is designed to be made, and the needle is to be pushed through it, together with the skein of thread, which is first dipped in sweet oil. The instrument is not to be introduced too low into the base of the fold, nor too high, near its eHge. In the first case, the muscles, and parts which ought to be avoided, might be wounded; in the second, the interspace between the two wounds would be very narrow, and the se- ton soon make its way through it. When no seton needle is at hand, the fold of the skin may be punctured with a lancet 418 Mln nnd the skein of turcadiiniroduced by means of an eye-probe. A seton may be a'lplied almost to any part of the surface of (he body, when circumstance's require it; but one of i(s opening- should always be made lower than the other that.the matter may readily flow out The skein of thread is to remain untouched for a few days after the operation, until the suppuration loosens it. Afterward the part of the thread nearest the wound is to be smeared with oil, while cerate, or any digestive ointment, and drawn under the fleshy interspace between the two wounds, and what was there before is to be cut off. The seton is to be drawn in this manner once or twice a day, according as the quan- tity of matter may require. A new skein of silk, or thread, is to be attached to the pre- ceding one, as often as necessary. Care is to be taken to keep the thread on the outside of the wound well covered, and free from the discbarge, which would make it stiff and hard, and apt to occasion paiu aud bleeding on being drawn into the wound. If the discbarge should be deficient in quan- tity, powdered cantharides may be mixed witb the digestive ointment. SHINGLES. See IRsrpes. SIGHT, DEFECT OF. There are per- sons, who, from their infancy, are incapable of distinguishing one colour from another. A man who was affected with this infirmity, could not distinguish green at all. Green and red appeared to him the same. Yellow and blue he could discern very well. With regard to dark-red and dark-blue, he fre- quently made mistakes. In other respects, his vision was sound and acute. The father of this patient was ufllicted with the same infirmity. The mother and one sister were free from it. Another sister and two of her children had it. The patient himself had two children, who did not labour under the dis- order. (See Phil. Trans. Vol. 68, Part 2.) Another subject, whose eyes were in olher respects healthy, and whose eyesight was sharp, could not distinguish a dark-green from a dark-red. An interesting example of this curious imperfection of vision has lately beeu pub- lished by Dr. Nicholl, of Cowbridge. (See Med. Chir. Trans. Vol. 7, p. 477, fyc.). The subject was a healthy boy, eleven years of age, whose eyes were gray, with a yellow dtige surrounding the pupil. He never call- ed any colour green. Dark bottled green he called brown. He could distingufsh light yellow ; but darker yellows and light browns he confounded with red. Dark brown he mistook for black. , Pale green he called light red; common green he termed red. Light ijed and pink he colled light blue. Red he called by its proper name. He could distinguish blue, both dark and light. On the mother's sid^ the boy had some rela- tions whose sight was similarly affected. An interesting chapter on what is termed coloured vision, may be read in a modern valuable work, to which I have great plea- sure m referriujr. fSe.e Win drop's Essays on 11 •» the Morbid Anatomy of tue tinman E$Cf Vol. 2, p. 196. Svo. Lond. 1818.) Sometimes objects appear to the eye to be of a different colour from what they real ly arc, not because there is any thing wrong in the eye itself, but in consequence of the unclear and coloured light by which the ob- ject is illuiriinated. Thus, for instance, a bad tallow candle, which emits a yellow flame, makes eveiy thing appear yellow When brandy is burning, all objects appear blue. In short, it is only by the light ofthe sun, that any object can be seen in its clem natural hue. Iu certain cases, the infirmity- is owing to the transparent parts aud hu- mours of the eye, which do not happen to be of a proper'colour. Thus, persons hav- ing (he jaundice iu a high degree, sec all things yellow, because the transparent parts of the eye are of that colour. When, in consequence of external violence applied to the eye, blood is effused, and the aqueou* humour rendered red by this fluid, all ob- jects seem to' the patient to be red; and white, when the aqueous humour has been made of this colour by (he couching of a milky cataract. Sometitoes this defect in vision is ascribable to the duration of an impression. When one has surveyed a bright-coloured object a long while, as, for example, a bright red or yellow wall, on wliich the sun shines, that colour will often remain a good while before the eyes, al- though one may not be looking any more at au object of this hue. There are some eyes, which seem much disposed to retain the impression of objects, which are not very bright coloured; but, such a disposition always betrays great weakness and irrita- bility of those organs. The most frequent cause* of this defect in vision, is an irrita- tion operating upon (he optic nerves, so as to produce the irritability in them, which alone makes objects appear of one colour. The seat of such irritation, according In Richter, is:also «nost commonly in the abdo- minal viscera, and the case demandfevacu ations, tonics,and anodyne medicines. But, the disorder may also originate from other causes. The operation of bright-coloured or shining objects upon the eye, sometimes bas, for a certain time afterward, the effect of making objects of diverse colours appear to be moving before the eyes. In extreme terror, or fright, things may also seem to have a different colour from their-real one The same often happens in fevers attended with delirium. A sudden exposure of the head to cold, at a period when it vvas per- sp.ring much, in one instance, caused many coloured appearances before the eyes; but, die disorder subsided in a couple of days*. (Richter, Anfangsgr. der Wundarzn. B.3,p. 523:) Also a healthy eye sees a distant object with uncertainty, and error, in a room, or space, the extent, length, and breadth, of which are unknown, when the size of tho object itself is unascertained, and when there are few or no other objects interve- ning at a smaller distance between die eye . rAK> aOL 419 and illv tbing looked at. The uiuie nume- rous the objects are between (he eye and die principal thing looked at, the mure dis- tant it is made to appear; the fewer they are, the nearer it seems to be. In a coun- try covered with snow, and upon the sea, very distant objects appear to be close. The smaller an object is to the eje, in rela- tion to its known magnitude, the further off it seems. The errors which the eye makes in regard to the distance of objects, also tend to deceive. But, there are certain ca- es, in which the eye is almost entirely inca- pable of judging of (he distance of objects. The first is, when the object, of which we wish to ascertain the distance, is looked at with only one eye. ' Hence all one-eyed persons, and persons affected with strabis- mus, are unable to judge well of the real distance of objects. However, they are only so for a certain time; and. by practice ihey gradually acquire the faculty. Even when two eyes are employed, it requires some exercise, in order to enable them lo judge of the'right distance of objects. Per- sons, born blind, but who have their sight restored in both eyes by the operation f6r the cataract, are a long while incapable of judging of distance's, and only obtain this power very gradually. Lastly, this infirmity ii sometimes owing to an irritation affecting tlie optic nerves, whereby their sensibility is so altered, that distant objects make the impression upon them of near ones. In this circumstance, all objects appear to the pa- tient closer than they really are! This is the only case, which admits of being treated as a disease. The irritation, producing the disorder, is mostly "seated in the abdominal viscera, and requires evacuations and such medicines as invigorate the nerves. A sup- pression of the perspiration is alleged to be sometimes a cause (Richter, .9nfangsgr. dcr< Wundarzn. B. 3, p. 525.) A sound eye likewise does not always judge with accuracy and uniformity of die magnitude of object^. This may arise from three causes. In order to judge rightly of the size of any thing, its "precise distance must be known ;. for the more remote it is, the smaller will it seem, to the eye. Hence, any conjecture respecting the magnitude of an object is constantly erroneous, unless the distance be ascertained. Size is invari- ably something relative. A single large ob- ject, surrounded by many small ones, always appears to be larger than it really is, et vice versa. \n object whose magnitude is known, seems smaller than it actually is, when one has been a little previously looking at ano- •ther that is still larger. Lastly, the refrac- tion of the rays of light in the eye, by which operation an object is made to appear large or small, is not always accomplished in the same degree, as the eye is not at all times equally full and distended with its humours. Hence, at one time, the same object will appear to the same eye, and at the same distance larger; at another time smaller. Sometimes, however, the eye judges so er- roneously of the magnitude of objects, that liit-re i reason for regarding (he case as an infirmity, or disease. It is for the most part owing to a defective sensibility in the nerves, caused by some species of irritation acting upon the eye, and generally seated in the gastric organs. A man, to whom every thing seemed one half smaller and nearer than it really vvas, was cured by means of an emetic, bark, an issue and valerian. (Leutin, obs.fascic.) Sometimes to the eye, under circum- stances of disease, straight lines appear ser- pentine; perpendicular objects, sloping, things standing upright, to be inverted, &.c. All these cases are set down by Richter as depending upon a wrong sensibility of the nerves, occasioned by the effect of some irritation. The irritation, he says, may be of many kinds ; but experience proves that it is mostly seated in the gastric organs. These defects of si.;ht may generally be cured by first exhibiting emetics and purga- tives, and afterward having recourse to re- medies for strengthening the nerves, bark, oleum auimale, valerian, issues, be. One mark Of a very weak and irritable eye, is when objects, afler being looked at a good while, and presenting a right appearance, begin to move, swim about, mix together, and, at length, become quite indistinguish- able. This principally happens when the objects regarded are small and strongly illuminated. Here such remedies, both general and topical, as have the effect of invigorating the nerves, are indicated. How- ever, sometimes, the infirmity is partly ow- ing to the operation of some species of irri- tation, which will require removal, ere the tonic medicines and applications can avail. Indeed, in particular cases, the dispersion of such irritation is alone sufficient to ac- complish the cure. Sometimes, all objects appear to fhe eye, as if they were in a more or less dense mist. This defect in vision is always owing either to some slightopacity of one of the humours of the eye, or to excessive debility ofthe optic nerves. * (See Richter, Anfangsgr. der Wundarzn. D. 3, p. 521, fyc.) SI NFS.—A long, narrow, hollow track, leading from some abscess, diseased bone, be. SOLUTIO ARGENTI NITRATI.—R-. Ar- genti nitrad 3j. Aq. distillat. ^ss M. This is a very good application for sores, which are frequerftly met with round the roots of the nails, both of the fingers and toes. It is also useful in herpetic affections, noli-me- tangere, and several kinds of ulcers. The proportion of the argentum nitratum may be lessened, or increased, as occasion re- quires. A strong solution of this substance is a good application for destroying warts, to which it must be applied, by means of a hair-pencil. When used for sores, it is best to dip little bits of soft lint in it, lay them on the part affected, and cover them with a common pledget. SOLUTIO FERUI SULPHATIS.—ft. Ferri sulphatis ad albidinem calcinati 3j Aq. Distillat. ^viij. Misce. Has been " - l^t'i hub commanded as an application for me-s on fhe nipple, and other ulcers. SOI'MX An instrument, which surgeons introduce through the urethra into the blad- der, in order to discover, whether there is a stone in this viscus, or not. The sound is usually made of very highly polished steel, that it may be well calculated for conveying to the surgeon's fingers the sensation of any thing, against which its end may strike, it is also generally rather less curved, than a catheter, so that its extremity may be more easily inclined to the lower part ot the blad- der, where the stone is most frequently si- tuated.. SOUNDING. The operation of introdu- cing the foregoing instrument. Sounds are generally introduced much in the same way as catheters, either with the concavity towards the abdomen, or the con- vexity, in which last method, it is necessary, as soon as the beak of the sound has arrived in the perineum, to bring the handle of the instrument downward by a semicircular movement to the right, while the other end is kept as much fixed as possible. 'Ibis is what the French term the coup, or tour dc maitre ; a plan, that is often followed at the present day, though, except in very cor- pulent subjects, il has no particular recom- mendation. When a patient is to be sounded, he is usually put into a posture very similar to that adopted in the lateral operation for the stone, with the exception that he is not bound in this position, as there is sometimes an advantage in making the patient stand up, in order that the stone may come into contact with the end of the sound. The instrument having been introduced, its ex- tremity is to be turned, and moved in evej-y direction, when if there be a calculus, its presence will usually be indicated by the collision against the beak of the sound. Stones have sometimes been found in the bladder after death, although they, could never be discovered with a sound while the patient was alive, suffering all the symptoms of the complaint. The celebrated French surgeon La Peyronie was thus circumstan- ced: he was so fully convinced pf there being a stone in bis bladder, notwithstand- ing neither he, nor any of his friends could feel it with a sound, thai on his death-bed, he gave directions for ascertainingjthe fact. Hence, when the usual symptoms of a slone in the bladder continue, patients should be searched several times, before a positive opinion is delivered respecting the nature of the disease. When during the operation of sounding, all the urine has escaped from the bladder, the inner surface of this viscus comes into contact with the en'd of the sound, and such a sensation may be communicated to the surgeon's fingers as leads him to suspect that a fungu?, or some other hardish extraneous substance is con- tained in the bladder. In such cases, pa- tients have actually been cut for the stone, when ho foreign body whatever was pre- sent ("See Sabatier. Midecine Opcratoire. rtPl loin. 3, p. L21. 128, Edit. 2. See Ijlho tomy.) SPECULUM. An instrument intended for facililating the examination of parts, and al-o (be performance of operations on them : thus we have specula ani, specula oculi, auris, be. SPHACELUS. (from Sir Ast- ley Cooper, will serve (o sh< .v die uenefit wliich may he derived from pressure. "James App'ebee, Bald'.vin-Street, Old- Slreet, wa- bum on £he 19th of May. 1S07, and his mother, immediately after hi\ birth, observed •■ round and transparent tumour on the loins, ofthe size of a larce walnut. On the 22dwf June. 1807, the child vvas brought to my house, and I found, lhal although it had spina bifida, the head was not unusually large ; and the motions of its legs were per- fect ; and its stools and urine were dischar- ged naturally. I applied a roller around the diild's waist, so as to compress the lumour, being induced (o do so from considering it us a species of hernia, and that the deficien- cy of the spine mighl be compensated for by external pressure. The pressure made by the roller, had no unpleasant influence on ils voluntary powers; its stools and urine con- tinued to be properly discharged, but the mother thought that the child was occasion- ally convulsed. At the end of a week, a piece of plaster of Paris, somewhat hollow "d. and that hollow partly filled with a piece of loose iinl, was placed upon (ne surlace of (he tumour: a strap of adhesive plaster was applied to prevent its changing ils situation, and a roller was carried around the waist, to bind (he plaster of Paris firmly upon the back, (H and to compress Ihe tumour as much as the child could bear. This treatment was con- tinued until the mooth of October, during which time, the tumour was examined about three limes a week, and the mother reported that the child vvas occasionally convulsed. When the child was five months old, a truss was applied, similar in form to that which I sometimes use. for umbilical hernia in chil- dren, and this has been continued ever since. At tbe age of fifteen months, il be- gan to make use of its limbs; it could crawl along a passage, nnd up two pair of stairs. At eighteen months, by some accident, the truss slipped from the tumour, which had become of (he size ol a small orange, and (he mother observed, when it was reduced, that the child appeared in some degree dull; and (his was always the case if the truss was left off for a few minutes, and then reapplied. At fifteen months he began to talk; and nt two years of age, he could walk alone. He now goes to fcnool, runs, jumps, and plays about as other children. His powers of mind do not appear to differ from those of. other children. I lis memory is retentive, and he learns with facility. He had (lie measles and small-pox in (he first year, and Ihe hooping-cough at three years. His head previously and subsequently to the bones closing, has preserved a due proportion to other parts of the body. The tumour ii kept by the truss entirely within (he channel of the spine ; but when the truss is removed, it soon becomes of the size of half a small orange. It is therefore necessary, lhat the use of the truss should be continued. When Ihe iruesis removed, Ihe finge-rcan be readily pressed through tne tumour into ihe channel of the spine." (Med. Chir. Trans. Vot.2,p. 323. fyc.) The next case, also published by Sir Astley Cooper, will prove, lhat spina; bifi- da; may sometimes be treated on another plan, so as to accomplish a permanent cure. "January 21si. 1809, Mrs. Little of No. 27 Limehouse Causeway, brought to my house her son, aged (en weeks, who was the subject of spina bifida. The turnout was situated on the loins; it was soft, elas- tic, and transparent; and its size about as large as a billiard ball wiien cut in half; his legs were perfectly sensible, and his urine and feces were under the power of the will, be. Having endeavoured to push the water contained in (he tumour, into ihe channel of the spine, and finding that if the whole was returned, the pressure would be too great upon the brain ; I thought it a fair opportunity of trying what would be the effect of evacuating ihe swelling by means of a very fine pointed instrument, and by subsequent pressure to bring it inlo the state of the spina bifida in Applebee's child I therefore immediately punctured the tumour wilh a needle, and drew off about two SPINA VLM'O&A 4*4; •'uncei oi water. On die 2olii January, finding the tumour as large as before it had been punctured, I opened it again, and in the same manner, and discharged about ^ four ounces of fluid. The child cried when the fluid was evacuated, but not whilst il was passing off. On January 28th, the tu- mour was as large as at first ; I opened it again, and discharged the fluid. A roller was applied over Ihe tumour, and around the abdomen. February 1st, it was again pricked, and two ounces of fluid discharged. On the 4ih, three ounces of fluid were dis- charged. On the 9th, the same quantity .of fluid was evacuated as on the 4th ; but in- stead of its being perfectly clear as at first. it was now sanious, and it had been gradu- ally becoming so in the three former opera- tions. On the 13lh, the same quantity of fluid was taken away; a flannel roller was applied over the tumour and around the ab- domen ; a piece of pasteboard was placed upon tbe flannel roller over the tumour, and another roller over the pasteboard to confine it. On tbe 17th, three ounces of fluid, Of a more limpid kind, were discharged; the pasteboard was again applied. On the 27th, the surface of the tumour inflamed ; the fluid not more than half ils former quantity, was mixed with coagclable lymph, and the child suffering considerable constitutional irrita- tion, was ordered calomel and scammony, and the rollers were discontinued. On the 26th, the lumour was not more than a quar- ter of ils former size ; it felt solid ; Ihe inte- guments wero thickened, and it had all ihe appearance of having undergone the adhe- sive inflammation. On the 28th, it was still more reduced in size, and fell solid. March 8th, the swelling was very much lessened; the skin over it thickened and wrinkled ; a roller was again had recourse lo ; a card was put over the tumour, and a second roller was applied. March 11th, the tumour was much reduced ; die skin covering it was a little ulcerated. On (he 151h, i( was find bul still a little ulcerated. On the 27th, the effused coagulable lymph was considerably roduced in quBnlily, and of a very firm consistence. On ihe 2d of May, nothing more (ban a loose pendulous bag of skjn remained, and the child appearing lo be perfectly well, (he bandage was soon left off. On December ihe 18lh, the child was attacked with the small-pox, and went well through the dis- ease. The skin now hangs flaccid from the basis of the sacrum; ils centre is drawn to the spine, (o which it is united, and thus (he appearance of ihc navel is produced iu ihc (umour by retraction of the skin Tbe pricks of the needles are very obvious forming slight indentations." (See Med. Chir. Trans. Vol. 2, p. 326—329.) At Ihe lime when Sir A. Cooper trans- milled this ca=e to the Medical and Chirur- gical Socic-iy, it had been under his observa- tion two years and a half. The first of the preceding observations exemplifies the palliative treuiinent, adopted by the bilter gentleman, and consisting of Mic application of pressure, iu (he manner of a fruss for hernia; (he second shows li,." radical mode of" cure by puncturing (he swelling from time (o dme with a needle, and exciting the adhesive inflammation, which, with Ihe assistance of pressure, stops the disease altogether, that is to say, in such examples as admit of cure. Children are sometimes born with tu- mours, analogous to spina? bifida;, but situs ted on the head. There is a deficiency e. bone at some part of the skull, and through Ihe opening -i sac, composed of Ihe dura ma ter, protrudes, covered only by the integu- ments. Mr. Eiric lately met with such a swelling situated upon the occiput of a fc male infant. The plan of repeatedly making small punctures wilh a common needle, dis- charging Ihe fluid, healing up the punctures and applying pressure, was tried, and fol lowed up for some lime without tbe occur- revi-t' of any unpleasant symptoms. Even punctures were sometimes made witb an ordinary lancet; yet the child suffered no harm from the operation, and some hopes of a cure were indulged. At length, howe ver, ulceration of (he swelling look place, the child became indisposed, and rapidly sunk. (See Med. Chir. Trans. Vol. 7, p. 427.) Con suit Ruyschii Obs. Anat. Warner's Cases in Surgery. B. Bell's System of Surgery. Vol. b. Acrel in Schwed. Abhandl. x. B. p. 291, i^e. Murray, Opusc. 2, No. b, et Med. Prad. Bibl. 3, p. 612. Portal Cours d'Anal. Med T.4,p.66. Lassus, Pathologie Chir. T. 1, p. 260, cl seq. Edit. 1809. Abernethy's Sur- gitql und Physiological Essays, Part 1 and 3. 1KV, Okes, An Account of Spina Bifida, with Remarks on the .Method of Treatment pre posed by Mr Abernethy, Sro. Cambridge 1S10. EiU'.c'np.'dieMithodiquc, Part. Chir Art. Spina Difil'j. Richter, Anfangsgr. der Wundarzn. II. b, Kap. A. Cooper, Mcf Chir. Trans. Vol. 2, p. 322, fyc. H. Earle. in the same work, Vol. 7, p.427, fyc. Edinb. Med and Sur*. Journ. No. 67. SP1MA VE.M'OSA. The Arabian writers first.employed this term, to express a dis- ease, in which mailer formed in the interior of a bone, and afterward made ils way out- ward beneath tlie skin. Until the matter had escaped from within the bone, these au- thors describe the pain as being incessant and intolerable ; but (hat after the pus had made its way outward by fistulous openings, the [lain underwent a considerable diminu- tion. The matter sometimes insinuated it- self, from the interior of the bone, into the cellular substance, so as to render it soft and flabby, though not always attended with any change of colour in tbe skin. The swelling had some of the appearance of emphysema. To express this state, tho Arabians added the term ventosa to that of spina, w hich was employed, before their time, to express the nature; of the pain at- tendant on the disease. (See au account of this subject in the Encyclopedic. .Vithodiquc, Part. Chir. Art. Spina)Vcutosa.) The t«-rm spina vrntosa has, since the time of the Ar.ibian writers, been used by many "!■■» signify the disease nanvd whi'c-fcellwL:, 4*4 ^l and tlie former might also mean by il a »iiui- lar affeclion, though the contrary may be inferred from their account of the matter passing from the interior of the bone under the integuments, a thing which I believe never vet happened io any case of white- swell'in""-. Another, and perhaps a decisive argument, against tbe original signification of°the word being the same as that of white-swelling, is, that it was not restricted to diseases of the joints and heads of the bones; but was also applied to abscesses, which commenced in the cavities of the middle portions of the long bones, where, I need hardly observe, white-swellings never make their attack. For these reasuns. many respectable au- thors have implied by the term spina vento- sa, an abscess in the interior of the bone. (See, on this subject, Lalla's System of Sur- gery, Vol. 1, p. 16b.) Cases of this latter kind, 1 know, are infinitely rare, compared with that common disorder, the white- swelling ; and, I am also certain, from the descriptions given by some authors, that their cases of spina ventosa were in reality instances of necrosis. But that abscesses do occur, and begin in tbe interior of the bones, more particularly of those of young persons, I have no doubt myself, both from two or three cases, which I remember ha- ving seen in St. Bartholomew s Hospital, and from some cases recorded by the most authentic writers. 1 cannot conceive, how- ever, that suppuration can take place to any extent within a long bone, without being followed by necrosis. J. L. Petit relates, that a man, with a tu- mour* on the middle of the tibia, who had been treated by him as a venereal patient, found, a fortnight afterward, that the pains which had never ceased, now began to grow more violent. The patient was feverish, his legs became red, and even painful, exter- nally. An incision was made in the situa- tion of the tumour with a view of letting out the matter which was suspected to be fhe occasion of the bad symptoms, and to have insinuated itself under the periosteum. The incision was of no service, and, two days afterward, the trepan was applied, by which means, a large -quantity of matter vvas let out. The medullary part of the bone seemed quite annihilated, and the ca- vity almost empty. Petit made three other perforations with the trepan, and cut away the intervening pieces of bone. The actual cautery was also used several times to de- stroy the caries, and the patient at length got well. ( Traiti des Maladies des Os, de J. L. Petit.) If any one doubt, that abscesses now and then form in the middle of the. long bones, I must request him to consult Mr. Hey's Practical Observations in Surgery, p. 22, where he may peruse two very inter- esting cases illustrative of what.Mr. Hey calls Abscess in the Tibia with Caries. It must be confessed, however, lhat these were only cases of necrosis, for which af- fection the term caries is too often inaccu- rately used Indeed, it would appear, from SPI. tiiei observations of Dr. Mncunut-y, that a very small suppuration iu the medulla is ac- companied with the beginning of those changes of the periosteum, which attend necrosis. (See Necrosis, p. 762.) For au account of spina ventosa, in the sense of while-swelling, refer to Joints. J. Pandolphinus, De Vcntositatis Spina Stevissi- mo Morbo, 12mo. Norib. 1674. A. J. van der Meer, di Spina Ventosa, Duisb. 1729. F. L Augustin, de Spina Ventosa Ossium, Icon. 4, 4/o Halo:, 1797. F. H. Schuchardt, Annota- ta qutcdam de Spina Ventosa, cum annexa singulari kujus morbi observatione, 12mo. Marburg. 1817. SPIRITUS AMMONleF. COMPOSITUS. Besides the well-known uses of this medi- cine internally exhibited, its vapours are an exceedingly proper application to the eye in some cases of chronic ophthalmy. Scar- pa recommends a remedy of a similar na- ture. SPLINTS. Long thin pieces of wood, or tin, or strong pasteboard, employed for preventing the ends of broken bones from moving so as to interrupt the process by which fractures unite. These instruments are sometimes used in other cases, for the purpose of keeping limbs from moving, particularly in some kinds of dislocations, wounds, be. In simple fractures of the arm, forearm, or even of the thigh, or leg, in young in- fants, it matters not whether the splints he made of wood, pasteboard, or tin. In this country, surgeons usually keep sets of splints made expressly for tbe leg. These are of different sizes, excavated and shaped to the part, and furnished below with apertures for the projecting malleoli. When the limb is laid upon its outside, the foot is also usu- ally supported and kept steady by the under splint, extending some distance towards the toes. Very excellent splints for the legs of young children are made of strong paste- board, accommodated in shape to the con- tour of the limb. Splints for the thigh, arm, and forearm, whether made of tin, or wood, should always be slightly concave on the side, which is to be applied to the broken limb. They should likewise be made aa thin and light, as is consistentwith the neces- sary degree of strength forprevehtiogthe bro- ken bone from bending. The sets of splint? w I. icha re used for fractured legs and thighs in I'.ngland,arefrequently furnished withstraps, which have a great many small perforation in them at stated distances, and can thus be easily fastened by means of little pegs for the purpose. Tapes are also sometimes em- ployed ; but they often get loose, and can not be depended upon so well as leather straps. Pasteboard, as a material for splints, has one advantage, viz.; when wet, it becomes soft, and admits of being accurate- ly applied to every point of the surface of the limb: consequently, as soon as it dries and recovers its firmness again, it retains the exact shape ofthe part, and makes every where equal pressure on it, without incom- moding the padf"**\ I'astphoard, however. SPO is hardly strong and durable enough for many fractures ; nor will it answer when there is any discharge, nor when the sur- geon wishes te employ any fluid applica- tions. But, it is generally allowed, that no substance is better calculated for supporting the fractured lower jaw ; for, it is perfectly strong enough for this particular case, and if wet before being applied, it forms when dry a solid covering, roost accurately corres- ponding to the shape of the jaw. Whatever may be the substance of which splints are made, they ought always to be at least as long as the fractured bone ; and, if the situation of the limb will allow, ihey ought, says Boyer, to extend its whole length. " For instance, (says he) for sim- ple fractures of the thighs of very young children, the pasteboard splints, which I employ, reach from the upper part of the thigh, to the lower part of the leg. Gene- rally speaking, the longer splints are, the better they fix the limb, and keep the frac- ture steady." (Boyer Traili des Mai. Chir. T. 3, p. 60.) The number of splints must depend upon their breadth, and the thickness of the limb. For the forearm, two are sufficient; for the upper arm and thigh four are often used ; and for the leg two, and sometimes three. In cases of fractured thighs, when the straight position is preferred, the external splint should extend from the crista of the ilium to some little distance beyond the sole of the foot; while the inner one should reach from the upper and internal part of the thigh also beyond the sole of the foot. With respect to the anterior splint it is indif- ferent whether itonly reachesfrom the groin to the knee, or as far as tbe lower part of, the leg. The lateral splints for a broken leg ought to be sufficiently long to embrace the knee, and confine the motions of the foot and ankle. When the straight posture is adopt- ed, a splint is frequently .laid along the frout of (he leg, from the patella to the lower part of the tibia. None however can ever be required under the limb, as there the bedding itself more conveniently affords the necessary degree of support. Of allthe different pieces of the appara- tus for the treatment of fractures, the splints are by far the most important and essential Without them, indeed, it would be in vain to attempt to keep the extremities of the fracture from being displaced. As splints are generally composed of hard materials, the bad effects of their pres- sure upon the skin must always be counter- acted by placing a sufficient quantity of tow, wool, or olher soft substance between them and the limb. In order to understand, however, the principles, which should guide tbe surgeon in the choice and application of splints, many remarks, offered in the article Frac- ture, must be consulted. SPONGIA PRdSPARATA. (Prepared sP**ge ; Sponge-tent.) Formed by dipping *'0''..n 54 51A 425 pieces of sponge in hot melted emplastrum cera? compositum, and pressing them be- tween two iron plates. As soon as cold, the substance thus formed may be cut into pieces of any shape. It was formerly much used for dilating small openings, for wfiich h was well adapted, as when the wax melt- ed, the elasticity of the sponge made it ex- pand and distend the opening. However, (ha best modern surgeons seldom employ it. SPONGIA USTA. (Burnt Sponge.) This is often given in the form of lozenges, in cases of bronchocele, in which particular instances much efficacy is imputed to allow- ing the lozenges to dissolve gradually iu the mouth, after putting them under the tongue. Burnt sponge is also exhibited in many scro- fulous diseases, and in cases of chronic en- largement of the prostate gland. The dose is from a scruple to a dram. STAFF. An instrument of considerable importance in the operation of lithotomy, being in fact the director for the gorget, or knife. It is made of steel, and its handle is generally rough, in order that it may be more securely held. As it is intended to bo introduced through the urethra, its shape ought to be principally determined by the natural course of that passage. The Lfoglfsh generally employ a staff, the curvature of which forms the segment of a larger circle than that described by the curvature of a staff used by the French practitioners. (See Roux, Voyage fait a Londres en IS 14, ou Pa- rallile de la Chirurgie Angloise, fyc. p. 319.) In other words, the French staff turns more upward than ours, as it approaches and en- ters the bladder. There may be some ad- vantage in this construction, inasmuch as it tends to make the gorget enter in the direc- tion of the long axis of the bladder; yet, a great deal more seems to me to depend upon the position in which tbe staff is held, than upon its shape. Lithotomists should always employ as large a staff as can be easily in- troduced, because the operation will thereby be facilitated. The groove, the most im- portant part of the staff, is of course situated upon the convexity of the curved part of tbe instrument, or upon that portion, which, when introduced, lies in the membranous part of the urethra, prostate gland, and the bladder. It should always be made very broad and deep, as recommended by Lan- genbeck, and Mr. Martineau. (See Lithoto- my.) The termination of the groove at the end of the instrument should be closed, so as to stop the further entrance of the gorget, and prevent the beak of tbe latter instrument from doing mischief. English y surgeons have been justly censured by De- sault and Sabatier, for neglecting this es- sential caution ; for, certainly, the most fa- tal injury maybe done by the gorget slipping beyond the end of the slaff. (See Lithoto- my.) For my own part, if I am more sure of any one thing in surgery, than another, it is this, that the beak of a gorget in tbe bladder ought never to pass out of, or be- yond the groove of the staff. •STAPHYLOMA, (from rww, •*» grape 4-Jc .-il'Ai'HYLOM.V from its beini, though: to rosemblea grape.) Is that disease of the eyeball, in which the cornea loses its natural transparency, rises above the level of the eye, and even pro- jects beyond the eyelids, in the form of an elongated, whitish, or pearl-coloured tu- mour, which is sometimes smooth, some- times uneven, and, according to Scarpa, attended with total loss of sight. However, staphyloma is either partial or total, that is to say, it affects only a part or the whole ofthe cornea ; and in the first case, if there be not too much additional injury of the eye, a degree of vision may yet be left, nnd even admit of further improvement. The circumstance of Scarpa's observations ap- plying only lo cases in which the eyesight is already destroyed, accounts for some im- portant differences between him and other writers, who, in the practice which Ihey advise, refer to the partial staphyloma, and cases in which the sight is not quite annihi- lated. Scarpa does not mention adhesion of the iris to the diseased cornea, as a part ofthe definition of staphyloma; a point in which he differs both from Richter and Beer. (Lehre von den Augenkr. B. 2, p. 69.) Yet Scarpa may be correct; for though, as Mr." Wardrop remarks, " the internal sur- face of the cornea adheres to the iris in al- most every case of staphyloma." (Essays on the Morbid Anat. of the Eye, Vol. 1, p. 101.) yet, as it does not invariably do so, tbe cir- cumstance forms no essential part of the nature of the disease. In some instances, Mr. Wardrop has seen the opacity confined to one half of the cornea, and this generally the lower one. (Vol. cit.p. 100.) Scarpa observes, that infants are often at- tacked by this disease soon after their birth, and mostly in consequence of the purulent ophthalmy. It is also produced by the small- pox, yet never during its eruption, which is singular; nor during the stage of suppura- tion ; but, when the pustules dry, and even after the detachment of the variolous scabs. In a great number of subjects, says Scarpa, when the staphyloma has attained a certain elevation above the cornea, it becomes sta- tionary, or only increases in due proportion to the rest of the eye. In other instances, the small tumour of the cornea enlarges in all its dimensions, and in such a dispropor- tion to the rest of the eye, that at length it protrudes considerably between the eyelids, to the great molestation and deformity of the patient. This disease is justly considered as one of the most serious to which the eyeball is sub- ject ; for, to the total and irremediable loss of sight that it occasions, are added all the evils which necessarily result from the bulk and protuberance of the staphyloma, after the swelling of the cornea has acquired such a size, that it can no longer be covered by the eyelids. In such circumstances, the continual exposure of the eyeball to the contact of the air, and particjes of matter suspended in it; the friction of the eye- lashes ; the. incessant flux of tears down the subiacrr.t cheek : render the- eve painfol and inflamed ; the "sound one is affected by sympathy, and the diseased one at length ulcerates, together with the lower eyelid and cheek, onwhieh it presses. According to Richter (Obs. Chir. Fasc. 2.) staphyloma is generally formed, without tbe swelling of the cornea being preceded by any of those morbific dispositions, which are generally considered capable of weakening the texture and elasticity of the cornea; which, in fact, acquires a much greater thickness, than what it has in its natural state, and consequently, staphyloma, far from being concave within, is every where compact and solid ; though it ought to he quite the contrary, if the tumour were oc- casioned, as Beer yet appears to believe, by un immoderate distention, operating oh the cornea from within outward, witb absorp- tion of its natural texture. Scarpa thinks, that Richter has general- ized his doctrine too much, by not drawing any line of distinction between the staphy- loma of recent occurrence in infants, and that of odult subjects, in whom the disease has acquired so large a volume, as to pro- trude considerably beyond the eyelids. He agrees with Richter, mat the recent staphy- loma in infants is quite compact and solid, on account of the augmented thickness of the cornea; but he is convinced by repeated observation, that, in this very same staphy- loma, originally quite solid and compact, the cornea becomes thinner, or,at all events, is not thicker than natural, after the disease has existed a series of years in adult sub- jects, and in whom the swelling ofthe cor- nea has attained such a size as to protrude beyond the eyelids. The tumour, he ob- serves, is not solid throughout, except iu regard to its containing, in its amplified state, tbe iris, the crystalline, and very often, also, a portion of the vitreous hu- mour. The cornea of infants, in its natural state, is at least twice as thick and pulpy as that of adults, and, consequently, the anterior chamber of the aqueous humour, in the former, is comparatively so contracted, to what it is in the latter, that, in infants at the breast, the cornea may be considered as in contact with the iris. To such qualities ofthe cornea, in child- ren of tender years, and to the natural nar- rowness of the anterior chamber of the aqueous humour, Scarpa imputes the cause why ophthalmies in infants so often pro- duce opacity and thickening of this mem- brane. The cornea swells, becomes preter- naturally thickened, and is very soon con- verted into a pointed, whitish, or pearl-co- loured tumour, without any cavity inter- nally, and either in perfect contact with, or adherent to, the iris. In the course of years, however, Scarpa remarks that this disease undergoes new modifications. For, as the whole eye enlarges with age, tbe iris and crystalline, from causes not sufficiently un- derstood, abandon their natural situation, and are propelled forward, nearer and r«»Rr<=- fo the corcea. which thev in time STAPHYLOMA \"2; distend in all ils dimensions, so as to make it project beyond the eyelids, at the same time rendering it thinner in a ratio to its bulk and magnitude. Scarpa has never met with a voluminous staphyloma, projecting beyond the eyelids in adult persons, which had not originally made its first appearance in infancy; and he has invariably found, tbat the thickness and density of the cornea, both in the living and dead bodies of those who have been affected with this disease, were in an inverse ratio to the eye. In in- veterate cases of staphyloma, forming a large protuberance beyond the eyelids, the iris may here and there be clearly discerned through the diseased cornea, and if it be not equally manifest at all points of the tu- mour, it is because the conjunctiva exter- nally spread over the cornea forms, in con- junction with its varicose vessels on the .urface of the tumour, a stratum of matter, not every where equally dense and opaque. This dense stratum of the conjunctiva, spread over the cornea, easily causes decep- tion in a staphyloma of considerable bulk, The more the tumour increases, the more the substance of the cornea seems to be- come dense and thickened ; while in reality tbe contrary happens; for the augmentation in the density of the layer of the conjunc- tiva, covering the cornea, only partly sup- plies the diminution iu the thickness of the latter membrane. In staphyloma, as Mr. Wardrop observes, " the pupil is hid accord- ing to the situation and degree of tbe opa- city of the cornea ; but, in most cases it is altogether obliterated, and even in those, where a transparent portion of the cornea is opposite to it, the vision is much impair- ed ; for, as Ihe eye has lost its form as an op- tical instrument, the change in ils refractive power must render objects very indistinct." (Morbid Anat. of the Eye, Vol. l,p. 101.) The sclerotica is also subject to staphy- loma, that is, to a partial distention and pro- minence of its anterior hemisphere in the white ofthe eye. Scarpa never met with any tumour or prominence on the front sur- face ofthe sclerotica, corresponding to the white of the eye ; but in the dead subject he has met with two examples of staphyloma In the posterior hemisphere of the sclerotica. According to Mr. Travers, in the spheroidal staphyloma of the cornea, the sclerotica sometimes yields so much as greatly to in- crease the deformity. "This happens in hydropic and other degenerations of the humours. It also frequently becomes ex- tenuated, or bulged near its junction with the cornea in the amaurosis, which follows inflammation of the choroid. This protru- sion, larger or smaller, is sometimes cir- cumscribed, and in other instances diffused over a large portion of the ball. It is often seen euclrcling the cornea, and presenting i sacculated or pouched appearance. It has a bluish gray lint, &c.'' (Synopsis of '.he Diseases of Ihc Eye, p. 130.) When in the staphyloma of the cornea, this part is affected with irremediable opa- «uty, Scarpa thinks that if the disease be re- vnt, and in a 'b'lrj, the only object must be to hinder the increase ofthe swelling of the cornea, the organization of which is already destroyed. The tumour must be levelled. and flattened as much as possible; and when the swelling of the cornea is invete- rate, very large, and prominent beyond the eyelids, it is to be diminished by surgical means, so as to return within the orbit, suf- ficiently to permit the deformity ofthe face to be amended by the application of an ar- tificial eye. In cases of recent staphyloma, Richter used to make at the bottom of the tumour ofthe cornea an artificial ulcer, by repeat- edly applying the argentum nitratum, or the oxygenated muriate of antimony (butter of antimony,) and to keep the little sore open by the continued use of the same caustic, with the view of effecting a diminution of the swelling of the cornea. In tuis way Richter frequently succeeded in lessening staphyloma, and ia one particular case he even restored the transparency of the cor- nea. ' Ter repetita operatione, quarto scilicet, septimo et decimo die, ne vestigium quidem morbi die decimo-quarto superabat. Obs. Chir. Fasciculus 2. Though Scarpa has frequently attempted to cure the recent staphyloma of infants by the above method, he has never yet met with such success, as can be at all compared with Richter's, either in restoring the trans- parency of the cornea, or accomplishing a diminution ofthe volume ofthe staphyloma. Having formed with the argentum nitratum a small ulcer, at the bottom of the cornea, and kept the sore open thirty days and more, he failed in obtaining any benefit, in respect to the diminution, much less the opacity ofthe cornea, in three infants, one a year and a half old, aud the two others somewhat more than three, all which sub- jects had been recently attacked with sta- phyloma in one eye, in consequence ofthe small-pox. A violeut chemosis, in a very short time produced a staphyloma in tbe eye of a child five years old. Scarpa made an ulcer at the bottom of the cornea, in the unorganized swollen substance of which he introduced, for a little depth, the flat part of a lancet. Scarpa kept the sore open for five weeks, with a solution ofthe argentum nitratum, and he remarked that the staphy- loma became somewhat flatter, so as to lose the acule prominence which it had at its centre ; but the cornea continued, as be- fore, every where opaque. Though Scarpa employed the same method in two other subjects, of about the same age, and in dm same circumstances; though he kept the ulcer open fifty days, be was never able to effect any depression or diminution of the staphyloma; and, consequently, the point- ed, pearl-coloured projecting part of the tumour continued in the same state as it vvas before. The conical shape which the cor- nea assumes in this disease, he observes, is a characteristic symptom by which a st - phyloma may be distinguished from a leu- coma, with total opacity of the cornea. If, also, in the course of further trials, partial benefit be found to acr-ue from this 428 -IAFHYLUMA. plan, adopted not lor the purpose of re- establishing the transparency ofthe cornea, but for that of merely checking and dimi- nishing the recent staphyloma in infants, still Scarpa is of opinion, that no one will be easily persuaded tbat (he same treatment can ever prove of tbe least service in dimi- nishing the size of the large, inveterate staphyloma in adults; in other words, of that which projects beyond the eyelids, and rests on the cheek. Under these circum- stances, he believes, that there is no effect- ual means of restraining the progress of the complaint, and removing the deformity, but cutting away the staphyloma, and when the place is healed, an artificial eye may be ap- plied. Celsus thus expresses himself on the sub- ject of this operation :—Curalio duplex est. Altera ad ipsas radices per medium transuere acu, duo Una ducente, deinde alterius lini duo capita ex superiore parte, alterius ex inferiore adstringere inter se qua paulatim secando id excidant. Altera in summd parte ejus ad Icn- tieulm magnitudinejn exscindere ; deinde spo- dium, aut cadmiam infricare. Utrolibet au- tem facto, album ovi lana excipiendum, et im- ponendum; posteaque vapore aquae ealidce fovendus oculus, et lenibus medicamentis un- guendus est. De Medicina, lib. 7, cap. 6. Though, says Scarpa, the first plan, or that of the ligature, is at present abandoned, Ihe majority of surgeons still persevere in pass- ing a needle and ligature through tbe lower part of (he staphyloma, not for the purpose of tying or constricting (he tumour, i( is true, but of making a noose, in order to fix the eye conveniently, when Ihe s(aphyloma is (o be cut off in a circular manner. This use of a needle and ligature, which I observe is sanctioned by Mr. Travers, (Synopsis, fyc. p. 285,) is sirongly disapproved ot by Scarpa. Wilh regard (o (be second method of re- moving tbe staphyloma, or lhat of excision, Scarpa thinks that sufficient attention has not hitherto been paid to what Celsus has written on this subject. In fact, Celsus does not for- bid cutting away the staphyloma, by a circu- lar incision al its base, as is practised at the present day, but says that this operation is to be done in tbe cenlre, or conical point of (he tumour, and tbat as much of this part of the staphyloma is to be cut away as will equal a lentil in size: In summd parte ejus ad lenticu- lemagnitudinem exscindere. Scarpa remarks, lhat tbe great importance of (his precep( of Celsus, in regard (o the successful treatment of the staphyloma, can only be duly appre- ciated by surgeons who have often had oc- casion (o compare the advantages of Celsus's doctrine, with the serious inconveniences which result from the common practice of cutting away the staphyloma circularly at its base ; and with the evils produced by a se- micircular section, comprehending the scle- rotica, in Woolhouse's manner, always fol- lowed by acute inflammation of (be eyeball and eyelids, violent pains in the head, rest- lessness, spasms, copious, and sometimes gan- grenous, suppurations of the eye and eyelids The patient being seated, Scarpa directs an assistant to support his head properly • then taking in his hand u knife, similar u what is used in the extraction of tbe cata- ract, he passes the instrument completely across ibe staphyloma, at the distance of one line and a half, or two lines, from tbe centre or apex of the tumour, from the external to- wards the internal angle of tbe eye, and by passing the knife forward in die same direc- tion, just as is done in the extraction of tbe cataract, he makes a semicircular incision downwards, in tbe most prominent part of the tumour. Having done this, he takes hold of ihe segment of the staphyloma with Ihe forceps, and turning the edge of the knife upward, he completes the circular re- cision of the apex of the tumour, in such a way that the detached portion is one, two, three, or four lines in diameter, according (o the size of the staphyloma. As a portion of (he iris adhering to the cornea, from the very commencement of tbe disease, is commonly included in (bis section of the pointed part of the tumour, no sooner is the circular di- vision of tbe apex of the staphyloma made, than the crystalline, or its nucleus, issues from tbe eye, followed by a portion of tbe vitreous humour. In consequence of this evacuation, the eyeball often diminishes in such a degree, that il can be covered by Ihe eyelids, lo which Scarpa immediately ap- plies a pledget of dry lint, supported by a retentive bandage. When the eye and eyelids begin lobe pain- ful, inflame, and swell, as they generally do on the fourth day, the eye is to be covered with a bread and milk poultice. When things proceed in a regular manner,tbe swell- ing of (he eyelids subsides about (he seventh or nintii day, and purulent matter is seen on (he poultice, blended wilh the vitreous ho- mour. The matter afterward becomes thick and whitish, the patient feels great relief, and the eyeball shrinks and sinks into the orbi(. At (his period, on gently separating tbe eyelids, the conjunctiva is found swelled, and reddish, and the margin of tbe wound seems like a whitish circle. This is usually detached on (he twelfth or fourteenth day al- ter the operation, when (be edge of the sur- face, from which the staphyloma was cut, becomes red, contracts, and daily diminislies, so tbat at last the wound is entirely closed. There only remains in Ihe centre of (he cor- nea, for a few days, a small fleshy promi- nence, resembling a little reddish papilla, which, afier being touched a few times with the argentum nitratum, contracts, and heals. So far, says Scarpa, are alarming symp- toms from following this operation, that in a great number of cases the surgeon is even obliged, several days afterward, to stimulate the eye on which it has been performed, in order to make it inflame, partly by leaving it a long while uncovered, and exposed to Ine air, portly by enlarging tbe circular recision, made in the centre of (be staphyloma, of which another circular portion, half a line broad, is removed, in order to facilitate the more abundant discharge of the humours, and the ingress of air into the cavities of the eye, which are so backward to inflame. As sopn as inflammation has invaded ih« inte- STE a 01, 429 rior of tbe eye, and suppuration has taken place, the rest of (he cure regularly follows under the use of topical emollients, and is soon completed with all possible mildness. It should be particularly recollected, that Scarpa means the foregoing practice for in- veterate cases of staphyloma, where the eye- sight is totally lost, and the projection of the diseased cornea produces serious annoyance. Under olher circumstances, tbe method oan hardiy be admissible. Among others, Dr. Vetch particularly objects lo the remo- val of Ibe apex of (he tumour, as destructive of all chance of the recovery of a degree of vision; a consideration, however, which would not exist iu the hopeless cases spoken of by Scarpa. Dr. Vetch also disapproves of letting out the aqueous humour in cases of staphyloma as an endless operation, from which no permanent effect takes place, the humour collecting a^ain in a few hours; a sentiment which is likewise expressed by Mr. Travers. (See Vetch on the Diseases of the Eye, p. 63; and B. Travers, Synopsis, fyc. p. 286.) For the purpose of accomplishing the gradual diminution of the tumour, and bringing the eye into a state in which an arti- ficial pupil may be made, Dr. Vetch has em- ployed caustic (the method commended both by Richter and Beer) and the introduction of a selon through the lumour. Beer confirms the statement of Scarpa, concerning the im- possibility of restoring Ihe transparency of any part of the cornea afl'e.-ted with staphy- loma. For the relief ot a partial staphylo- ma, he prefers the cautious application of Ihe oxygenated muriate of antimony, by means of tbe point of a camel-hair brush, while the eyelids are held asunder. The dis- eased part of the cornea is to be smeared wilh it until a small white superficial slough is formed, when every particle of (he caus- tic must be immediately washed out of the eye with another larger camel-hair brush, dipped in water, or milk. The application is not to be repeated until tbe subsequent in- flammation has quile subsided, and (he slough been thrown off. Beer condemns all escha- rotic salves, because their action extends to parts which should he left uuirritated. (Lehre con den Augenkr. B. 2, p. 74.) Wenzel, and numerous other writers, im- ply by staphyloma, a protrusion of a piece of the iris through a wound or ulcer of the eye. (See Iris, Prolapsus of.) R. Fr. B. Hoelder, De Staphylomate, Tu- binga, 1748. Scarpa Sulk Malattie Degli Occhi, Ed. 5. G. J. Beer's Ansicht der Sla- phylomatosen Melamorphosen des Auges, fyc. Wien. 1805. Nachtrag zur Ansicht, fyc. 1806; and Lehre von den Augenkr. B. 2, p. 69,Svo. Wien. 1817. Richter, Anfangsgrundc der Wundarzneykunst. B. 3 p. 153,^-c. Gott. 1795. Sabatier, Midecine Operatoire, T 2 P- 191, Ed. 2, 1810. James Wardrop. Essays mi the Morbid Anatomy of the Human Eye, Vol. 1, p. 99, Svo. Edinb. 1808. B. Travers, Synopsis of the Diseases ofthe Eye, 8vo. Lond. n-20- J' Vtlch> A Pwliral Treatise on the Diseases of the Eye,Svo. Lond. 1821. STE ATOM A. (from taken place, the pain iu touic degree sub- sides. (Hunter.) The redness that took place in the adhe- sive stage is now increased, and is of a pale scarlet colour. The part which was firm, hard, and swelled, in the previous stage of tbe inflammation, now becomes still more swelled, in consequence of the greater dila- tation of the vessels, and the greater quan- tity of coagulating lymph thrown out. (Hunter.) TIIEOBY OK SUPPURATION. The dissolution of the living solids of an animal body into pus, and the powerof ihii fluid to continue ihe dissolution, are opinions which are no longer entertained by any well-informed surgeons of the present day ; and the use of such phrases as "pus corrodes," " it is acrid," be. expressions which imply an erroneous way of thinking, is very pro- perly almost entirely discontinued in Ihe language of every sinsible medical man. If (hese notions were true, no sore which dis- charges matter, could be exempted from a continual dissolution. Such ideas probably arose from the circumstance of an abscess being a hollow cavity in the solids, and from the supposition, that (he whole of (he original substance of lhat cavity was now the matter, which vvas found in it. This was u very natural way of accounting for tbe formation of pui by one entirely igno- rant of the moving juices, the powers of the arteries, and what lakes place in an abscess after it is opened. The knowledge of these three subjects, abstracted from the know- ledge of the abscess before its being opened, should have led surgeons to account for the formation of pus from the blood by the pow- ers of the arteries alone. According to the above- erroneous principle, abscesses would - cntinue to increase afler being opened, as fast as before. Upon the principle of the solids being dissolved into pus, was founded the practice of bringing all indurated parts to suppuration if possible, and not making au early opening. This was done for the purpose of giving time for the solids to melt down into pus; but it was apparently for- gotten, that abscesses formed matter after they were opened, and therefore the parts stood the same chance of dissolution info pus as before. Blinded with the idea that tbe solids entered into (he composition of pus, the partisans of this doctrine could never sec pus flowing from any internal canal, as from tbe urethra, in cases of gonorrhoea, without supposing the existence of an ulcer in the passage. Such sentiments might be forgiven before it was known thai tliese sur- faces could, and generally did, form pus without a breach of the solids; but the con- tinuance of this way of thinking now is not mere ignorance, but stupidity. Tbe forma- tion of pints of matter hi Ibe cavities of (he chest and abdomen, w ithout any breach in the solids, could not have been overlooked by the most zealous advocates for the doc- trine of dissolution. (ffurUer.) The moderns have been still more ridicu- 'rvis; for hno'vinr dn* it was denied, that the solids were ever dissolved into pus, ami that there was not n single proof of it, Ihey have been busy in producing what lo (hem seemed a proof. They have been pulling dead animal matter into abscesses, and find- ing that it was either wholly or in part dis- solved, they therefore attributed the loss io its being formed into pus. This, howe- ver, was putting living and dead animal matter upon tbe same footing, which is a contradiction in itself; for if the result of this experiment were really what they sup- posed it to be, the idea of living parts being dissolved into pus must bo abandoned, be- cause living and dead animal matter can never be considered in the same light- (Hunter.) It might have been remarked, that even extraneous animal matter would lie in ab- scesses for a considerable time without be- ing dissolved, and lhat in abscesses arising either from violence, or from a species of erysipelatous inflammation, (here were often sloughs of tbe cellular membrane, which sloughs would come away like wet low, and therefore were nol dissolved into pus. (Hun- ter.) It might also have been noticed, that in abscesses in tendinous parts, as about (he ankle, a (endon often mortified and sloughed away, and that the sores would not heal till such sloughs were detached ; but though this separation was sometimes not completed be- fore the expiration of months, yet the sloughs al last were thrown off, and consequently could not be converted into pus. Pieces of dead bone often lie soaking in malter for many months, wilhout being changed into pus; and although bones, so circumstanced, may lose a considerable deal of their substance, a loss which some might impute to tbe dis- solution of the bone into pus, yet that waste can be accounted for and proved on the principle of absorption. Tbe loss is always upon tbat surface, upon which tbe continuity is broken off, and it is a part of the process by which exfoliation of a dead piece of bone is accomplished. The forma- tion of pus has been attributed to a kind of fermentation, in which both the solids and fluids were concerned. This doctrine is easily reluted by stating what happens in internal canals, wbicb naturally setrele mu- cus, but frequently form pus, without any loss of substance, or any previous ferment- ing process. Were we to supitose a fer- mentation of the solids and fluids, the imme- diate cauie of the production of pus, whence could the solids come, which enter into tbe composition of discharges from tbe urethra f for tbe whole penis could nol afford matter enough (o form the pus, which is discharged in a common gonorrhoea. How also could the fermentation of tbe solids ever cease ? for there is the same surface secreting its mucus, whenever the formation of pus is discontinued. It may be asked likewise, by w bat power the first particle of pus in an abscess, or on a sore, is formed, before there is any particle existing, which is capable of dissolving tbe solids.' An abscess (Bay be .TdJPPU RATION. JOei •stationary for month?, nnd at last be absorb- ed^ what becomes of the fermentation all the while the collection of matter continues stationary P Extravasated blood has been supposed to he capable of being converted into pus. We find, however, (hat blood, when extravasa- led, either from violence, or a rupture of a vessel, as in aneurism, neverof ilself becomes pus ; nor was pus ever formed in these cases, without being preceded by inflammation. Both the blood and matter are also found together in the same cavity, under such cir- cumstances. If the blood had coagulated, which it seldom does in cases of violence, it would be found still coagulated ; and if it had not coagulated, the pus would be bloody. f Hunter.) The modern theory of suppuration is, lhat the matter is separated from (he blood by the secreting power of (he vessels of the inflamed part, which acquire a new mode of action. That pus is formed in the vessels from which it exudes, by an action of (hese ves- sels analogous to secretion, was, so far as I know, (says Professor Thomson) first dis- tinctly suggested by Dr. Simpson of St An- drew's, in his " D'Jsqerlaliones de Re Medica,' published in (he year 1722. An opinion similar to that of Dr. Simpson's suggested ilself, about the year 1756, to De Haeu,from the consideration of what takes place in some cases of phthisis pulmonalis. This author observes, fba( pus was often expecto- rated, for a great length of time, by patients affected with phthisis, in whom, after death, no mark of ulceration could be perceived, not even the place in which the pus had been formed. The hypothesis of pus being a secretion was afterward more fully con- sidered by Dr. Morgan of Philadelphia, in his inaugural thesis printed at Edinburgh in 1763, entitled " Puopoioses, sive Tentamen Medicum de Puris Confeclione." Tbe belief tbat pus is a secretion, or formed at least by an action of the vessels analogous to secre- tion, was adopted by Mr. Hunter. Indeed, the merit of the original suggestion of this hypothesis has been ascribed to him, though improperly. Brnggman, professor of bolany at Leyden, has •maintained ihe same doe-t trine in an excellent thesis " De Puogenia," published in 1786; and it is that which is now very generally taught all over Europe. (See Thomson's Ledures on Inflammation, p. J16, 317.) With respect to suppuration from exposed surfaces, however, it is more proper to say, that the vessels secrete a fluid, which becomes pus; for Sir Everard Home has proved, that this fluid has not the puru- lent appearance, * hen" first secreted, but acquires it while it remains on the inflamed surface, and does not acquire it (he less readily, when removed from that surface in a colourless slate, provided its proper tem- perature be preserved, and it be kept ex- posed to the air, which promotes the change. The opinion tbat suppuration is a process analogous to glandular secretion, was at first hastily rejected by many who were Vol II. •.. - 55 swayed by Ihe fact, lhat no pus is ever found blended with the blood in the circulating syslem. By (his mode of reasoning, howe- ver, such thinkers must be led to deny (he universally received and undoubted doctrine, that the bile is a secretion ; and yet it is well known, that nothing like this fluid can be detected in an analysis of the blood, and, in- deed, a very small quantity would be suffi- cient to tinge Ihe whole mass of circulating blood wilh a yellow colour, the same as we see in cases of jaundice. No one would wish to defend the idea of there being either pus, or bile, actually in the circula- tion ; but only the matter, or modifications of the mntter, wbicb, by (he combinations, or whalever changes we may choose to term them, taking place in the secreting vessels, and by their operations are con- verted into one of the particular fluids in question. Violence done (o parts is one of the great causes of suppuration ; but simply, violence does nol always occasion i(. The violence must be followed by a prevention of a cure in a more simple way, viz. by a restoration ofthe structure, so as to carry on tbe animal functions of Ihe part. The parts must be kept long enough in that state into which (hey were put by (he violence. Or what i*. somewhat similar to this, Ihe violence must be attended with death in a part, as, in many bruises, all mortifications and all sloughs, in consequence of the application of caustic, which, when the dead parts separate, leave internal surfaces exposed. (Hunter.) As every injury or effect of outward vio- lence, under the above circumstances, is more or less exposed to (he surrounding air, (he application of air (o internal surfaces has been assigned as a cause of suppuration ; but certainly the air has not the least effect on parts, circumstanced as above, for a stimulus would arise from a wound, were it even contained in a vacuum. In circumscribed abscesses, (he air cannot possibly get to the parts, so as to have any share in making them suppurate. In cases of emphysema, when the air is dif- fused over the whole body, no suppuration is the consequence, unless an exposure or imperfection of some internal surface should be made, for the purpose of allowing the air to escape. A s(ronger proof, (hat it is not the admission of air, which makes parts in- flame, is, tbat the cells iu the soft parts of birds, and many of the cells and canals of their bones, communicating with the lungs, and always containing air, never inflame : but if these cells are exposed in an unnatural way, then the stimulus of imperfection is given, these cavities (hen inflame, and their surfaces either form adhesions together, or produce pus. (Hunter.) When the interior of an abscess is exa- mined, the cavity which contained the mal- ter is observed to be lined with a smooth, membranous-looking substance, which is of a whitish ash-colour, and has a strong re- semblance to coagulating lymph. This membrane-like substance has been termed 431 >l PPL RATION the sac or cyd of the abscess. This sac or cyst seems in general to adhere by a vascu- lar union lo the surrounding cellular mem- brane, which is itself likewise denser in tex- ture, and more vascular than in the natural state, (Thomson's Lectures, p. 310.) ils cells being clo*ed by coagulating lymph, effused in consequence of thai species of inflamma- tion which Mr. Ilunler termed die adhesive. Thus by tbe formation of a cyst, aud the effusion of coagulating lymph iu tbe cellular substance around tbe abscess, the collection for in speaking of the cases of suppuration, which he has adduced, he observes, thkt " in many of them no previous loss, or con- sumption of substance could be perceived." An observation similar to this was made about the same time, or perhaps a little earlier, by Dr. William Hunter, aud an account given of it in tbe second volume of the London Medical Observatious and Inquiries. «• Mr. Hunter, though he endeavours to establish it as an invariable fact, that no of malter is hounded, and cannot become suppuratiou takes place, which is not pre- rliftliepH S*G il Attio.iiljA M....lrl At. in t 111* f- ** 11 f. 11 * i ir iiiflutntnotmn iu r,t' nr.'...lr.~ . U. i communicating cavities of the cellular mem- brane, like the water in cedeina. Something like this diffusion of pus seems to occur in erysipelas phlegmonoides. " But in this case, (says Professor Thomson) the vitality of gre-ater or less portions of the cellular substanceri-, destroyed, iho deadened portions are converted into dirty, whitish, ash-colonred sloughs, and it becomes ex- tremely diflicult to say, whether any part of the pus contained in the deadened cellular membrane has been formed in the cells, in which it is contained, or has been absorbed into these cells, efter being separated from the parieles of the cavities containing the sloughs themselves." (Lectures, fyc. p. 310.) There can be no doubt, that after an ab- scess has received a membranous lining or cyst, tbe secrelion of pus is continued from the surface of (he lader part entirely, as well as whatever degree of absorption of (he same fluid happens to be going on. In fact, the cysts must be holh secreting and absorb- ing surfaces. The circumstances wliich leave no doubt of this point, are the frequent, sudden, or gradual removal of very large manifest collections of malter ; the continu- al change? occurring in the quantity and con- sistence of the pus; and the speedy filling of the cavity with purulent matter again alter Ihe first contents of tbe abscess have been discharged. collections of what he terms extraneous matter, something like pus, may form in various ports of the body, without the pre- vious i xistence of inflammation in the parts in which it is formed ; and accordingly you will find, at page 300 of his Treatise on In flammation, a chapter entitled, ' Of Collec- tions of Matter without Inflammation.' " Professor Thomson doubts, however. " whether these collections of matter, said to be formed without inflammation, would not have been more properly denominated scrofulous abscesses, or chronic suppurations 1 am disposed to believe (says he,) that, in whatever texture or organ of the body scrofula manifests itself, there inflammation will be found to exist. The phenomena, it is true, of inflammation, both local and con- stitutional, are modified by the existence of the scrofulous diathesis; but they are, 1 be- lieve, always present in such a degree as to justify us in giving to them the name of in- flammation, and iu classing most, if not all, local scrofulous affections, among inflamma- tory diseases. When the indolent swelling.', of which Mr. Hunter speaks, occur near to the surface of the body, that part feels warmer than usual, as may be felt m white swellings of the joints. The swelling also is either preceded or accompanied with some degiee of pain, though, when tbe affection is internal, the patient may nol Another thing which is yet a subject of alvvays be very accurate with regard to tbe controversy is, whether suppuration ever happens unpreceded by inflamnantion ? Pro- fessor Thomson, of Edinburgh, believes that the affirmative opinion on (his point was first suggested by De Haen of Vienna; but be thinks that much of the difference of sen precise seat of this pain. When cut into, the parts also affected with scrofulous swel- lings are always found more vascular than usual; in short, all the symptoms occur by which the state of inflammation is charac- terized." (See Thomson's Lectures on In- timent in this matter has proceeded from flammation, p. 313, 314.; In another place, the vague "notions entertained with regard V,IS author admits that the matter, jjrhich is formed in chronic suppurations, does-not fo the symptoms which necessarily charaL terize the state of inflammation, and also with regard lo the properties by which pus is to be distinguished from other animal fluids. Accordingly, in almost all the exam- ples which De Haen has adduced to prove the formation of pus, without die previous always accurately resemble that which i- formed in acute abscesses ; but yet he con- tends that it is so analogous both in its physical aud chymical characters, as well as in the circumstances in which it is produced, that he enn see no reason why it should not existence of inflammation, he has himself be called pus, or a puriform fluid. (P. 315.) occasion to remark the exudation of coaeu- .. coag„ ■aling lymph, and die existence of prelerna tural adhesions; phenomena which we know are produced by thai state, which Mr. Hun- ter denominaled adhesive inflammation." But De Haen.uses the lerm inflammation 'o express that sla(e, which we denomi- nate ulccraii. •, or ulcerative ab-orp'ion • QUALITIES OP PUS. True pus has certain properties, which, wheu taken singly. may belong to other se- cretions, iwit which, conjointly,*) form Ihc peculiar diameter of this fluid, viz. globnlfi sivirnmmjr in n fb-jjd, which it* c<*g2ni:.*-ii' sUPPURATIOxY 43:. ny a .solution ot the muriate of ammonia, which no other animal secretion is, and at the same time a consequence of inflamma- tion. The colour and the consistence of pus are the two qualities, which first attract the notice of every, the most superficial obser- ver. The colour arises from the largest portion of this fluid being composed of very small round bodies, very much like the globules of cream. The fluid iu which the globules of pus swim, might at first he supposed to be the serum of the blood, for it coagulates with heat like Ihe latter fluid. Pus is also probably mixed with a small quantity of coagulating lymph ; as it partly coagulates after it is secreted. However, the fluid part of pus is found to have pro- perties which serum has not. There being a similarity between pus and milk, experi- ments have been made to ascertain whether the fluid of pus could be coagulated with the gastric juice of animals; but no coagu- lation could be effected in this manner ; a solution of muriate of ammonia made the fluid part of pus coagulate ; but not any other secretion or natural fluid ; and hence it was concluded, that whenever globules vvere found swimming in a fluid, coagulable by muriate of ammonia, the matter was to be considered as pus. (Hunter.) The proportion which the white globules bear to (he other parts of pus, depends on the health of the parts producing the dis- charge. When the globules are very abun- dant, the matter is thicker and whiter, and is called healthy pus ; the meaning of which is, that the solids which produced it are in good health ; for 'these appearances in the matter are no more than the result of certain salutary processes going on in the solids, the effect of which processes is (o produce the disposition, on which both suppuration and granulation depend (Hunter.) Pus is specifically heavier than water, and is probably about as heavy as blood. Besides the above properties, pus has a sweetish mawkish taste, very differeut from that of most other secretions, and the same taste takes place, whether it is pus from a sore, or an irritated inflamed surface. Pus has a smell in some degree peculiar to itself; but this differs in different cases. Some diseases, it is said, may be known by the smell, as for instance, a gonorrhoea. Pus sinks yi water; mucus floats. Pus communicates to water an uuiformly trou- bled white colour; mucus gives the appear- ance of stringy portions floating in it. Mucus is said to be more readily dissolved by sulphuric acid than pus is. It has also been asserted, that if water be added to such solutions, the pus is precipitated to the bottom of the vessel; while the mucus, instead of being completely precipitated, forms swimming flakes. A solution of caus- tic alkali dissolves both pus aqd mucus ; but when water is added, the pus is said to become separated,*but not the mucus. Though solutions in chymical menstrua and precipitations, have been thought a test of the dutincdon betweau these two fluids, yet the method has been thought absurd and unphilosophical. It has been conceived, that all animal substances what- ever, when in solution, either in acids or alkalies, would be in the same state, and therefore, that the precipitation would be the same in all. Calcareous earth, when dissolved in muriatic acid, is in that acid in the same state, whether it has been dissolved from chalk, limestone, marble, or calcareous spar,and precipitations from all are the same. Hence, experiments were made on organic animal matter, such as muscles, tendon, car tilage, liver, and brain ; and on inorganic, such as pus and the white of an egg. All these substances were dissolved in sulphuric acid, and precipitated with potassa. Each precipitation vvas examined with such mag- nifiers, as plainly showed the forms of the precipitates, all which appeared to be flaky substances. The precipitate by ammonia had exactly the same appearance. The same appearances were seen, when the above kinds of animal matter were dissolved by caustic potassa, and precipitated with the muriatic acid. A flaky substance, void of any regular, form, composed each precipi- tate. (Hunter.) For additional observations on the tests of pus, and an account of those suggested by Dr. Young and Grasmeyer, see the First Lines of the Practice of Surgery, Vol l,p.32, Ed. 4. Pus does not irritate the particular surface which secretes it, though it may be very ir- ritating lo any other. Hence, no suppura- ting surface of any specific kind, can be kept up by its own matter; if this had not been the case, no sore of a specific quality, or producing matter of an irritating kind, could ever have been healed. Thi3 is simi- lar to every other secretion of stimulating fluids, as the bile, tears, fccMvhich fluids do not stimulate their own glands, or ducts, but are capable of stimulating any other part of the body. (Hunter.) Whenever a real disease attacks, either the suppurating surface, or the constitution, the production of true pus ceases, and the fluid becomes changed in some measure, in proportion to these morbid alterations. In general it becomes thinner and more transparent, and it partakes more ofthe na- ture of the blood, as is the case in most othersecretions under similar circumstances. Sanies is the term usually applied by surge- ons to pus, in this degenerated state. This unhealthy sort of'matter has more of the se- rum, and frequently more ofthe coagula- ting lymph in it, and less of the combination which renders it coagulable by a solution of muriate of ammonia. It has also a greater proportion of the extraneous parts of the blood, which are soluble in water, such as salts; and it has a greater tendency, than true pus, to become putrid. Such unheal- thy matter may even be irritating to the surface which produces it. The discharge, when of an irritating sort, is more stimulating to the adjoining parts with which it comes in contact, than to its SUPPURATION own secreting surface. In this manner it frequently produces excoriation of the skin !»id ulceration. Thns the tears excoriate tne skin of the cheek, in consequence of the" quantity of salts which they contain. From this effect, matter has been called corrosive, a quality which it has not; the only proper- ty which it possesses being that of irritating parts which it touches, .so as to cause their absorption. (Hunter.) When the vessels thus lose the power of producing good pus, they also lose more or less the power of forming granulations. This may depend on some deviation from the due structure and action, which-such vessels should possess, in order to be qua- lified for tbe performance of these two ope- rations. Pus, from several circumstances, would appear in general to have a greater tenden- cy to putrefaction than the natural juices have ; but, perhaps, this is not the case with pure pus, which, when first discharged from an abscess, is common^ perfectly sweet. There are, however, sonW exceptions to this, but these depend on circumstances entirely foreigu to the nature of pus itself. Thus, if the abscess had any communication with the air, while the matter was confined in it; or if the collection has been so near the colon or rectum as to have been infected by the feces, then we cannot wonder that the mat- ter should become putrid. When blood is blended with pus; when sloughs are mixed with it; when the parts forming the seat of the abscess are in a gangrenous state from an erysipelatous affection ; the matter has a greater tendency to putrify thau the pure pus discharged from sound abscesses or heal- ing sores. Pure matter, though easily ren- dered susceptible of change, by extraneous additions, is in its own nature tolerably uni- form and imr-fcitable. It appears so un- changeable, that we find it retained in an abscess for weeks, without having undergone any alteration. These qualities, however, only belong to perfect pus. If a healthy sore inflames, the matter now produced from it, though unmixed with extravasated blood, or dead solids, becomes much sooner putrid, and much more irritating, than the discharge formed before this alteration of the ulcer. (Hunter.) In the "preceding paragraph it is stated, that matter remains very often unchanged in abscesses for weeks. " This expression of Hunter's is not strictly correct; for it is well known, that the surfaces of the cavities of abscesses are always absorbing,, as well as secreting ones ; consequently, there must be a continual mutation going on in the con- tained matter. Wrhen there are diseased bones, or other extraneous bodies, exciting irritation, some- times even in so great a degree as to make the vessels bleed, and often wounding the vessels of the part, the matter is always found to be very offensive. This state of the discharge is one mark of a diseased bone. The discharge of an unhealthy sore black- ens silver probes, and preparations o( leaf. This effect is imputed by Dr. Crawfotd to the sulphurated hydrogen gas, generated iu the matter. (Phil. Trans, vol. SO. Year 1790, p. 385.) Further interesting observations on the nature of pus may be found in an Essay on the Differences between Pus and Mucus, by Dr. Darwin, junior; also in Dr. O. Pearson's Paper in Philos. Trans. 1811. USE OF PUS. By some it is supposed to carry off hu- mours from the constitution. Suppuration is sometimes regarded as a coiistilutional disease, changed into a local one, which con- stitutional malady is discharged, or thrown out of the body, either in the form of pus, or together with this fluid. Critical abscess- es have been thought to be cases of this sort. Suppuration bas also been imagined to carry off focal complaints from other parts of the body, on the old principle of derivation or revulsion. For this reason, sores or issues are made in sound parts be- fore allowing other sores to be dried up. Suppuration is sometimes excited with a view of making parts, such as indurated swellings, dissolve into pus; but I bave en- deavoured to show, that no dissolution of the solids is concerned in the production ot pus. A secretion of pus is looked upon as a ge- neral prevention of many, or of all the cau- ses of disease. Hence, issues are made to keep off both universal as well as local dis- eases. However, the use of pus is perhaps unknown; for it is formed most perfectly from healthy sores, and in healthy constitu- tions ; and large discharges from parts not very essential to life, produce very.little change in the constitution, and as little upon* being healed up, whatever some may sup- pose to the contrary. (Hunter.) This is certainly the case with many old ulcers, the suppuration from which seem.- to. have little or no effect in impairing the health. Nor is there any real reason to be - afraid of healing such ulcers, when possible. lest a worse disease should follow from the stoppage of a discharge to which the system is supposed to be so habituated that tbe coutinuance of it must be essential d- health. Every one knows, that when there is no interference of art, that is, when the surface of a sore is left uncovered, the thin part of the matter evaporates, and the thick part dries and forms a scab. Nature, therefore, seems to have designed that one use of pus should be to make a cover, or protection for ulcerated surfaces. But I cannot agree with what has been asserted, (Hunter) that tbe natural healing of a sore under a scab takes place more quickly than when surgi- cal dressings are employed. On ulcers, as would appear from modern microscopical observations, " the coagula- ted pus is rendered tubufhr by the extrica- tion of its carbonic acid gas, and (bat these lubes, or canals, are immediately fillet! wi'h .-SUPPURATION. 4& vto keep the surround- ing parts clean. The continuation of tin* same kind of poultice, which was before used, is, perhaps, as good a practice as any ; and wben the t<*»irfoniess. arisinir from (be intlammation, is over, but and a pleoget may be made use of, instead of the poul- tice. But, an abscess, opened by a cutting in - sti-uinent, is both a wound and a sore, and partakes more of the natrfre of a fresh wound in proportion to the thickness ofthe parts cut. Hence, it is necessary that some- thing should be put into the opening to keep it from healing by the first intention. If it is lint, it should be dipped in some salve, which will answer better than lint alone, a« it will allow of beiug taken out sooner. This is advantageous, because such sores should be dressed the next day, or at latest on tho second day, in order that the pus may be discbargf-^kgain. When the cut edges of the opening^ave suppurated, which will be -in a few days, the future dressings may be as simple as possible, for nature will, in gene- ral, complete the cure. If the abscess has been openui with cans tic, and the slough has either been cut out or separated of itself, the case is to be re- garded altogether as a suppurating sore, and dressed accordingly. Perhaps, dry lint is as good a dressing a1 any, till the nature of the sore is known. If it should be of a good kind, the same dressing may be continued ; but, if not, (hen it must be dressed accordingly. Parts, which at first appear to be sound, some- times assume every species of disease, whether from indolence, from irritability, from scrofulous, and other dispositions. This tendency to disease arises, in some ca- ses, from the nature of the parts affected, as, for instance, bone, ligament, be. (Hun- ter.) Consult particularly John Hunter's Trea- tise on the Blood, Inflammation, and Gunshot Wounds, a work, in which more interesting knowledge respecting Abscesses and Suppura- tion is contained, than in any other ever pub- lished. See also Traiti de la Suppuration de F Quesnay, 1749." J Grashuis, A Diss. on Suppuration, 8vo. Lond. 1752. Various parts of the Mimoires de I'Academie de Chi- rurgie. J. B Boyer, De Suppuralione d Cu- ratione Inflammati mis per Suppurationem ier- minanda. Monsp. 1766. L'Encyclapidie M6- thodiquc, Par tie Chirurgicale, article Abcis. Dissertations on Inflammation by John Burns, 1800. -Sir E. Home's Dissertation on the Properties of Pus, 1788 ; and his Prad. Obs. on Ulcers, 2d Edit. 1801 James Hendy, Essay on Glandular Secretion, containing an experimental Inquiry into the Formation of Pus, fyc.8vo. Lond. 177b. N. Romayne, De Puris GeneralioncSvo. Edinb. 1780. C. Dar- win's Experiments, establishing a criterion be- tween mucilaginous and purulent matter, fyc- Litchfield, 1780. P. Clare, Essay on Abscesses. Lond. 17S1. Several parts of Pott's Chirurgi- cal Works, but especially his Treatise on the Fistula in Ano. T Brand, Strictures in Vin- dicalionof some ofthe Doctrines misrepresented by Mr. Foot in his two pamphlets, entitled" Ob- servations upon the new opinions of J. Hunter, in his Treatise on Ihe Venereal, including Mr. Pali's Pla-jiar'ums, and misinform a'if>v or. bURGERY 411 Pus," fyc. 4to. Lond. 1787. Richter, Anfangs- grunde der Wundarzneykunst, B. 1, Kap. 2. Dr. J. Thomson's Lectures on Inflammation, p. 305, fyc. Edinb. 1813 ; a work, in which a profound knowledge of medical science, and of surgery in particular, is every where con- spicuous. J. F. CrevecoRur, De Diagnosi Puris; Longchamps, 1798. Pearson's Prin- ciples of Surgery, p. 34, c^c. Edit. 2. Lassus Pathologie Chirurgicale, T. I, p. 21, fyc. fyc. Edit, of 1809. Set. J. Brugmans, De Pro- genia, site mediisquibus naturautilur in ere- andopure, Svo Groningai, 1785. Dr. G. Pearson's Obs. and Experiments on Pus in the Philosophical Trans, for 1811. C. J. M. Langenbeck, Von der Behandlung der Fislel- gange, der Schusscanale, und grosser Eiler absondernder Hnhlen, in Neue riibl. fur die Chirurgie, 12mo. Hanover, 1817. SURGERY, or CH1KURUEHY, (derived from chirurgeon, from ^s/g, the hand, and tgyov, work,) has been by many considered to be that branch of medicine, which prin- cipally effects the cure of diseases by the application of the hand alone, the employ- ment of instruments, or the use of topical remedies. (Encyclopidie Mithodique, Parlie Chir. Tom. I, Art. Chirurgie.) But, although this definition certainly conveys to us some idea of the nature of this most useful pro- fession, it is not entirely accurate as applied to the present stale of practice. It might, indeed, be correct during that short unfa- voured period of surgery upon the conti- nent, some centuries ago, when its practice was denounced by the Council of Tours, as unfit for the hands of priests and men of literature, and when the surgeon became little better than a sort of professional ser- vant to the physician, the latter alone not only having the sole privilege of prescribing Internal medicines, bul even that of judging ahd directing wnen surgical operations should be performed. Then the subordi- nate surgeon vvas only called upon to exe- cute with his knife, or his hand, duties which the more exalted physician did not choose to undertake ; and, in fact he visit- ed the patient, did what vvas required to be done, and took his leave of the case alto- gether under the orders of his master. In modem times, however, the good sense of mankind has discovered that surgery is de- serving of an eminent rank among such arts as ought to be cultivated for the gene- ral benefit of society ; that the man who is not himself accustomed to the performance of operations, cannot be the best judge of their safety and necessity ; and tbat, in every point of view, the surgical practition- er merits as much favour and independence in the exercise of his profession, as he whose avocation is confined to physic. Hence, the surgeon is now exclusively con- sulted about many of the most important diseases to which the human body is liable. Being no longer under the yoke of the phy- sician, he follows the dictates of his own judgment and knowledge; he prescribes whatever medicines the case may demand, internal as well as external; and under the Vol. If -..; rncourageraent ot an enlightened age, br sees bis profession daily .becoming more scientific, more respected, and more exten- sively useful. By some writers, physic is said to have for its object the treatment of internal, surgery that of external diseases. This definition, however good and plausible it may at first appear, can only be received with numerous exceptions in regard to modern surgery: for instance, the psoas abscess, stone in the bladder, an extravasa- tion of blood within the skull in consequence of accidental violence,are universally allow- ed to be strictly chirurgical cases ; yet no man in his senses would call these disorders external. Others have defined surgery to be the me- chanical part of physic, " quod in Iherapeia mechanicum ;" but, although this has obtain- ed the assent of so eminent a modern sur- geon as Professor Richerand, of Paris, (Did. des Sciences Medicates, Tom. 5, p. 85.) I believe few on this side of the water will be of his opinion. As Mr. John Pearson has observed, " Many people have imagined that when a man bas learnt the art of dress- ing sores, of applying bandages, and per- forming operations with a little dexterity, he must necessarily be an accomplished surgeon. If a conclusion so gross and falla- cious had been confined to the vulgar and illiterate, the progress of scientific surgery would have suffered little interruption ; but if young minds are directed to these objects, as the only important matters upon which their faculties are to be exercised; if the gross informations of sense constitute the sum of their knowledge, little more can be expected from such a mode of study, than servile imitation, or daring empiricism. In- deed, some people have affected to oppose surgery as an art, to medicine as a science ; and if their pretensions were justly founded, the former would certainly be degraded to a mere mechanical occupation. But it is not very easy lo comprehend the grounds of such a distinction. The internal and external parts of the body are governed by (he same general laws during a state of health; and, if an internal part be attacked with inflammation, the appearunces and effects will bear a great similarity to the same disease situated externally ; nor are the indications of cure, in general, materi- ally different. If by science, therefore, be meant 'a knowledge of the laws of nature,' he who knows what is known of the order and method of nature, in tbe production, progress, and termination of surgical dis- eases, merits as ju-tly the title of a scienti- fical practitioner as the well-educated phy- sician. The practical parts of physic aud surgery are very frequently disunited ; but their theory and principles are indivisible, since they truly constitute one and the same science." (Pearson's Principles of Surgery, Preface.) dut, though wc can object on good grounds to the above-mentioned definitions of surge- ry, it seems iraposri'dc- to offer nny othpr, 442 -URGEHY against .which equal objections could not be brought. In fact, how is it possible to define surgery wilh any degree of accuracy, until the boundaries between it and physic can be determined ? Richerand talks indeed of the Medical School of Paris having now successfully established the limits and 'ob- jects of surgery, aud he boasts of this as an original improvement reflecting credit on his countrymen. (See Did. des Sciences Med. T. b, p. 88.) Yet, what are we to think, wheu we remember, not only that he has, in the commencement of the very same article, defined surgery to be " quod in therapeia mechanicum" but that by way of illustrating what the Parisian School has accomplished, be says, that surgery vvas first demonstrated by it to be only a means of physic, and not a separate and distinct science ? (See also Did. des Sciences Med. article Chirurgicales, Maladies.) As a learned Professor notices, the limits between physic and surgery are not very precisely marked, and the respective func- tions of the physician and surgeon, long as those names have existed, are still but very i taccurately defined. " The most superfi- cial acquaintance with the symptoms, pro- gress, and termination of the various mor- bid affections to which the human body is liable, must be sufficient fo convince every unprejudiced inquirer, that there is bul a slight foundation, if indeed there be any, for this distinction, in the nature of the dis- eases, which these practitioners are required »o treat, or in the modes of treatment, by which the diseases themselves may be cured or relieved. Experience has long shown, that the use of internal remedies is not only required in a large proportion ofthe diseases, which are regarded as strictly chirurgical, but also, that there are few diseases, which come under the eare of the physician, in which morbid affections, requiring the manual aid, > i- practical skill of the surgeon, do not fre- quently occur. " The treatment of febrile and internal inflammatory diseases, it will be allowed, belongs exclusively to the province of the physician, wherever the distinction between physician and surgeon has been introduced, and is rigidly observed ; yet, in some species of fevers, and in all internal inflammatory diseases, blood-letting is often the principal, if not the only remedy that is required. But this is an operation, however urgent the necessity for it be, which from engagement the physician cannot, and, from the fear of degrading his province of the profession, will not perform. Retention of urine not unfrequently takes place in symptomatic febrile diseases, and this is an affection which does not always yield to the use of internal remedies; but it is an affection also, from the painful uneasiness, which it immediately excites, as well as from the dan- ger which it threatens, tbat will not admit of delay. When internal remedies, therefore, fail iu relieving the patient, the urine must he speedily drawn off by means of a chirur- gic.il operation; otherwise inflammahoi., mortification, and rupture of the bladder, must necessarily ensue. Febrile and in- ternal inflammatory affections terminate not unfrequently in the formation of fluids, which it is necessary to let out by a chirur- gical operation ; and abscesses, fistulous openings, and ulcers are formed, which re- quire the aid of the surgeon. In patients, also, affected with severe febrile diseases, from being long fixed down to their beds \a one position, some of the parts of the body, upon which they rest, occasionally acquire a disposition to mortify, larger or smaller portions of the skin and subjacent cellular membrane becoming dead, separate from the living parts, and sores are formed, which are but too often the subject of unavailing chirurgical practice. To employ, in the different stages of this species of mortifica- tion, from its first commencement to tbe complete separation of the dead parts, and the formation of a new skin, the appropri- ate external and internal remedies, requires a greater share of chirurgical skill than can reasonably be expected in those who make a profession solely of physic. Unhappy, therefore, must be (he lot of that patient, who in circumstances similar to those which I have described, has the misfortune lo have for his sole medical attendant, a physician ignorant of surgery. " Bul (continues Professor Thomson,^ if a knowledge of surgery be necessary to the student who intends to practise physic, the knowledge of physic, ou the other hand, is no less necessary to him who intends to devote his attention exclusively to the pro- fession of surgery; for, indeed, there are few chirurgical diseases, which are not in some period or another of their existence, accompanied by mobid affections of tie same nature with those which fall property, and most frequently under the care of the physician. It will only be necessary to men- tion, as examples of these affections, tbe symtomatic fever, which attends inflamma- tion, whethertbis affection has been induced by external injury, or has occurred spontane- ously in the body from internal disease ; the hectic fever, supervening to long-continued processes of suppuration ; the febrile state and other morbid affections, which are some- times brought on by the too sudden and in- judicious use of mercury ; bilious fevers, and the various derangements of the di- gestive organs, which are sometimes the cause, and at other times the consequence, of focal diseases; the nervous affections, such as apoplexy, convulsions, paralysis, and mania, which arise not unfrequently from injuries of the head ; and locked jaw, or tetanus, which, in warm climates parti- cularly, is so very liable to be induced by punctured wounds. These are morbid af- fections, the proper study and treatment of which, when they occur without local inju- ry, are supposed to belong to tbe physician, rather than the surgeon ; but occuring very frequently as they do in chirurgical diseases, and always modifying, or aggravating, the SURGER\ 443 eftecisot these diseases, ignorance of their nature, relations, and modes of cure, is not only inexcusable, but highly criminal in the practitioner, who ventures to undertake their treatment." (Thomson's Lectures on Inflammation, Introduction. Also J. R. C. Bollman, Tcntamen, oslendens Chirurgiam a Medicinahaudimpune scparari, 12mo. Rintel, 1803.) From what has been stated, I think it very certain, that there never can be a com- plete scientific division of the healing art into physic and surgery; and that all at- tempts to distinguish the numerous diseases and injuries of the human body into medi- cal and surgical cases, must in a great mea- sure be decided by custom, and the mutual agreement of practitioners, rather than by any rules, or principles, which are at all consistent. In the earliest periods, the same men cultivated the whole field of medicine. The writings of Hippocrates, Galen, Celsus, Pau- lus OSgineta, Albucasis, be. prove that the Greeks, Romans, and Arabians never had au idea ofthe human body being susceptible of only two classes of diseases, one of which formed the province of physic, while the other constituted a separate and distinct science called surgery. All these ancient authors treat successively of fevers, frac- tures, wounds, and nervous diseases, and none of them appear to have supposed, that there could be any disorders which really deserved to be called exlernal, and others internal. Nor was it until the middle of the twelfth century, that the ecclesiastics were restrained from undertaking any bloody ope- ration. Surgery was then rejected from the universities, under the empty pretext, " Ee- clesia abhorrtt a sanguine," often expressed in its decrees, as Professor Thomson well observes, but never acted upon, except in this instance, by the church of Rome. It is to this epoch that we must refer the true separation of physic from surgery, the latter being abandoned to the laity, who. in those ages of barbarism, were totally illiterate. It is an observation made by the celebra- ted Bichat, that two things are essentially necessary to form a great surgeon, viz. genius and experience. One traces for him the way, the other rectifies it; both recipro- cally assist in forming him. Without expe- rience, genius would be unprofitably fertile ; without genius, experience woulrl only be a barren advantage to him. (CEuvres Chir. de Desault, par Bichat, T. 1, Discours Prelim.) Out of the large number of hospital surgeons, who are to be met with in every country of Europe, and who enjoy ample opportunities of profiting by the lessons of experience, how few distinguish themselves, or ever contri- bute a mite to the improvement of their profession. Opportunity, without talents aud an aptness to take advantage of it, is not of more use than light to a blind man. On the other hand, splendid abilities, with- out experience, can never be enough to make a consummate surgeon, any more than a man with the greatest genius for painting can excel in his particular art with- out having examined and studied the real objects which he wishes to delineate. In short, as a sensible writer has remarked, " Les grands chirurgiem sont aussi rares, que le ginie, le savoir, et les talens." (Mim. de I' Acad, de Chir. T. 1, Pref. p. 41, Edit. 12mo.) The description of the qualities which a surgeon ought to possess, as given by Celsus, is excellent as far as it goes. A surgeon, says he, should be young, or, at any rate, not very old; bis hand should be firm and steady, and never shake; he should be able to use his left hand with as much dexterity as bis right; his sight should be acute and clear ; his mind intrepid and pitiless, so that when he is engaged in doing any thing to a patient, he may not hurry, nor cut less than be ought, but finish the operation, just as if the cries of the patient made no impression upon him. (A. C. Celsi Med. Prcef. ad . lib. 7.) By the word " immisericors," a» Richerand has observed, (Nosogr. Chir. Tom. 1, p. 42, Edit. 2,) Celsus did not mean that a surgeon ought to be quite insensible to pity; but that during the performance of an operation, this passion should not influence him, as all emotion would then be mere weakness. This undisturbed coolness, which is still more rare than skill, is the most valuable quality in the practice of surgery. Dexterity may * be acquired by exercise; but firmness ot mind is a gift of nature. Haller, to whom nature was so bountiful, iu other respects, was denied this quality, as he candidly con- fesses. " Although (says he) I have taught surgery seventeen years, and exhibited the most difficult operations upon the dead body, I have never ventured to apply a cutting in- strument to a living subject, through a fear of giving too much pain." (Bibl. Chir. 1775, Vol. 2.) Surgery may boast of having had an ori- gin, that well deserves to be called noble; for tbe earliest practice of it arose from the most generous sentiment which nature has implanted i*njthe heart of man, viz. from that sympathetic benevolence, which leads us to pity the misfortunes which we behold, and inspires us with an anxious desire to alleviate them. He who first saw his fellow-creature suffer could not fail to participate in the pain, and endeavour to find out the means of affording relief. Opportunities of exercising this useful inclination were never wanting. In the first ages of the world, man in bis des- titute state was under the necessity of earn- ing by force or stratagem, a subsistence which was always uncertain, and in the combats into wliich this sort of life drew him, he frequently met with wounds and other injuries. Wherever the chare was in vogue as a means of livelihood or amuse- ment ; wherever broils and contests occa- sionally arose ; and man was the same ani- mal he now is, liable to various diseases and accidental hurts; there must have ex- i;4ex a ne-e- -i y for ?'trgery , r.or e-*** 'V-re 444 SURG LIU bo a doubt, thai the origin of this valuable practice is as ancient, as the exposure of mankind to several of the same kinds of in- juries, as befall the human race at the pre- sent day. At length wars became more frequent and extensive; wounds were conse- quently multiplied; and the necessity for surgical assistance was increased, and its value enhanced. In fact, among the ancients, the profes- sion of medicine and surgery constituted a sacred kind of occupation, and the practice of it belonged only to privileged persons. iEsculapius was the son of Apollo. In the armies, the highest princes gloried in dress- ing the wounds of those who had fought the battles of their country. Among the Gre- cians, Podalirius, Chiron, and Machaon, were not only distinguished for their valour, but also for their -skill in surgery, as we learn from tbe poem of the immortal Homer. The value which was placed upon the ser- vices of Machaon by the Grecian army may well be conceived from tbe anxiety which they evinced to have him properly taken care of when he was wounded in the shoul- der with a dart. " O >'est:or, pride of Greece, (cries ldomeneus) mount, mount upon thy chariot! and let Machaon mount with thee! Hasten with, him toourship3; for a warrior, wbo knows, as he does, how to relieve pain, and core wounds, is himself worth a thou- sand other herees." (See Iliad, lib. xi.) Hip- pocrates was one of the first citizens of Greece; he nobly refused all the rich offers of several kings, enemies of his country, to entice him into their service ; and, in parti- cular, he disdained to accept those of Xerxes, whom he regarded as a barbarian. It is in the immortal poems of the Iliad and Odyssey, that we find the only certain traditions respecting the state of the art be- fore the establishment of the republics of Greece, and even until the time ofthe Pelo- ponnesian war. There it appears that sur- gery was almost entirely confined to the treatment of wounds, and that the imaginary power of enchantment was joined with the use of topical applications. *• In the cures recorded in the sacred wri- tings of the Christian religion, the interven- tion of a supernatural power is always com- bined witb what is within the scope of hu- man possibility. The same character evinces itself in the infancy of the art in every na- tion. The priests of India, the physicians of China and Japan, and the jugglers of the savage or half-civilized tribes of the old and new continents, constantly associate with drugs and manual operations certain myste- rious practices, upon which they especially rely for the cure of their patients. Such was also, no doubt, the character of the medicine of the Egyptians, in the remote times, previous to the invention of the alpha- bet, and upon which so very little light is now thrown. It is curious, however, to find, from some late observations made by the men of science, who accompanied the French ex- pedition to Egypt, in 1798, that among the ruins of ancient Thebes there are documents, which fully prove that surgery, in the early limes of the Egyptians, bad made a degree of progress, of which few of the moderns have any conception. It is noticed by Lar- rey, that when the celebrated French Gene- ral Desaix had driven the Mamelukes beyond the cataracts of the [Nile, the Commission of Arts had an opportunity of visiting the monuments of the famous Thebes, and the re- nowned temples of Tentyra, Karnack,Medy- net, Abou, and Luxor,'the remains of which still display their ancient magnificence. It ii upon the ceilings and walls of these tem- ples that basso-relievos are seen, representing limbs that had been cut off with instruments very analogous to those which are employed at the present day for amputations. The same instruments are again observed in the hieroglyphics, and vestiges of other surgical operations may be traced, proving that, in these remote periods, surgery kept pace with the other arts, which had already attained a high degree of perfection. (Larrey, Me- mo ires de Chir. Militaire, T. 1, p. 233; T. 2, p. 223.) •We next come to the eppch when, by the union and arrangement of scattered facts, the science truly arose. Hippocrates, born in tbe island of Cos, four hundred and sixty years before the common era, collected the observations of his predecessors, added the results of his own experience, and composed his first treatises. In the hands of this great genius, medicine and surgery did not make equal progress. The former reached the highest deuree of glory. Hippocrates drew up the history of acute diseases iu so mas- terly a style, that twenty past centuries have hardly found occasion to add any thing to the performance. But surgery was far from attaining the same degree of perfection. The religious veneration for the asylums of the dead, and the impossibility of dissecting the human body, formed an insurmountable obstacle to the study of anatomy. An im- perfect acquaintance with the structure of animals, reputed to bear the greatest resem- blance to man, could only furnish venture- some conjectures, or false inferences. These circumscribed notions sufficed for the study of acute diseases. In these cases, the atten- tive observation of strongly-marked symp- toms, and Ihe idea of the operation of a sa- lutary principle, derived from remarking the regular succession of such symptoms, and their frequently beneficial termination, en- lightened the physician in the employment of curative means ; while surgery, deprived of the assistance of anatomy, was too long kept back in an infant state. Whatever praises may have been bestowed on those parts of the works of Hippocrates particu- larly relating to surgery, and which amount to six in number (de officina medici ; defrac- tnris; de capitis vulneribus; de articuhsvel luxatis; de ulccribus; defislulis;) when com- pared with his other acknowledged legiti- mate writings, they appear only as the rough sketches of a picture by a great master. Kxcepting the fragments, collected o- aURGER\ 446 cited by Galen, we possess no work written by any ofthe successors of Hippocrates un- til the period of Celsus ; which leaves a bar- ren interval of almost four centuries. In this space lived Erasistratus, as well as He- rophilus, celebrated for the sects which they established, and particularly for having been the first who studied anatomy upon the hu- man body. Celsus lived at Rome in the reigns of Au- gustus, Tiberius, and Caligula. He appears never to have practised the healing art, on which, however, he has written wilh much precision, elegance, and perspicuity. His work is the more precious, inasmuch as it is the only one, which gives us information, with regard to the progress of surgery in the long interval between Hippocrates and him- self. The four last books, and especially the seventh and eighth, are exclusively al- lotted to surgical matter. The style of Celsus is so elegant, that he has generally been regarded quite as the Cicero of medi- cal writers, and long enjoyed high reputation in the schools. His surgery was entirely lhat of the Greeks, notwithstanding he wrote at Rome: for, in that capital of Ihe world, physic was then professed only by persons who had either come from Greece, or bad received instruction in the celebrated schools of this native soil of all the arts and sciences. Let us pass over the interval which sepa- rates Celsus and Galen This latter was born at Pergamnsin Asia Minor, and came to Rome in the reign of the emperor Marcus Aurelius. He practised surgery and physic there about the year 165 of the christian era. (Galeni Opera Omnia, 1521, Edit. Aldi, 5 Vols, in fol.) These two sciences we re at that lime still united, and though some wri ters of much earlier date speak of the divi- sion of physic into dietetical, chirurgical, and pharmaceutical, no such distinction was followed in practice. As Galen had been a surgeon at Pergamus, he continued the same profession at Rome ; but, being soon attract- ed by the predominating taste of the age in which he lived, for a science which more easily yields to the systems and dazzling speculations of philosophical seels, he after- ward neglected surgery which strictly re- jects them. His writings prove, however, that he did not abandon it entirely. His commentaries on the treatise of Hippocrates, De Offtcina Medici, and his essay on banda- ges, and the manner of applying them, show- that he was well versed even in the minor details ofthe art. Besides it is known, that he paid great attention to pharmacy, and in his work upon antidotes, chap. 13, he tells us himself, that be had a drug shop in the Via Sacra, which fell a sacrifice to the flames that destroyed, in the reign of Corn- modus, the Temple of Peace, and several other edifices. To Galen succeeded the compiler Oriba- sius, (Etius of Amida, a physician, who lived towards the close of the fifth century, Alex- ander of Tralles, and Paulus OZgineta, so called from the place of bis birth, though he practised at Rome and Ab-j imperfect extracts from Galen, and alter bis teat, in order lo rob himself, in favour of the ancients, ofthe glory which this distinguished improvement deserved. Surgeon of King Henry the second, Fran- cis (he second, Charles the ninth, and Henry the third, of France, Pare practised his pro- fession in various places, followed the French armies into Italy, and acquired such esteem, that his mere presence in a besieged (own was enough to reanimate the troops employed for its defence. In the execrable night of Saint Bartholomew, his reputation saved his life. As he was of the reformed religion, he would not have escaped the massacre, had not Charles the ninth himself undertaken to protect him. The historians of these days Mem de Sully) have pre- served the remembrance of this exception, so honourable to him who was the object of it; but which should not diminish tbe just horror which the memory of the most weak and cruel tyrant must ever inspire. "II n'en voulut jamais sauver aucun (says Bran- tome) sition maistre Ambroise Pare, son premier chirurgien, et le premier de la chre- tiennet6 ; et l'envoya querir et venir le soir dans sa chambre et garderobe, lui comman- dant de n'en bouger; et disait qu'il n'etait raisonnable qu'un qui pouvait servir a tout un petit monde, feust ainsi massacr6." Ambroise Pare was not content, like his predecessors, with exercising his art with reputation ; he did not follow the example of the Quatre-Maitres of Pitard, so justly celebrated for having composed the first statutes of the College of Surgeons at Paris, in the reign of St. Lewis, whom he had at- tended in his excursions to the Holy Land; and of several other surgeons, the fruits of whose experience were lost to their suc- cessors. Pare transmitted the result of his own experience in a work that will remain immortal. (See QZuvrcs d' Ambroise Pari, Conseiller et premier Chirurgien du Roi, di- visies in 28 livres, in folio, Edit. 4to. Paris, 1535.) His writings, so remarkable for the vari- ety and number of facts in them, are emi- nently distinguished from all those of his time, inasmuch as the ancients are not looked up to in them with superstitious blindness. Freed from the yoke of autho- rity, he submitted every thing to the test of observation, and acknowledged experience alone as his guide. The French writers arc with reason proud of their countryman Pare to this day : they allege, that he must ever hold among surgeons the same place that Hippocrates occupies among physi- cians. Nay, they add, that perhaps there are none, either of the ancients or moderns, who are worthy of being compared with him. (Richerand Nosogr. Chirurg. T. 1.) After the death of this great man, surgery, which owed its advancement to him, con- tinued stationary, and even took • retro- grade course. This circumstance is alto- gether ascribable to the contemptible slat-""- into which tho<-e who profeB5<,d the artfel1 M.RGERY. ■H\ after being united to tbe barbers by the most disgraceful association. Pigrai, the successor of Ambroise Pare, was far from being an adequate substitute for him. A spiritless copyer of his master, he abridged his surgery in a latin work, where the unaffected graces of the original, the sincerity, and the ineffable charm inse- parable from all productions of genius, en- tirely disappeared. He received, however, to the grave the secret of his admirable in- jections. (See also his Thesaur. Anat. x. in 4to. Adversariorum anatomicorum medico- ehimrgicorum Decad. 3, in 4to. Amstelodam.) Roonhuysen also made a secret of his lever, which, before tbe invention of the forceps, was tbe only resource in difficult labours. Raw, who successfully cut fifteen hundred patients for the stone, took such pains to conceal his manner of operating, that Heis- equal praise from his contemporaries •rter and Albinus, his two most distinguished doubtless, because he filled a high situation ; but, as Richerand remarks, his name, which is to-day almost forgotten, proves sufficient- ly, that dignities do not constitute glory. Rousset and Guillemeau distinguished themselves, however, in the art of mid- wifery, while Covillard, Cabrol, and Habi- cot enriched surgery with a great number of curious observations. (See Obs. Chir. pleines de remarques curieuses, Lyon, 1639, in Svo. Alphabet Anatomique, Genire, 1602, in 4to. Semaint Anatomique; Question Chir. sur la Bronchotomie, Paris, 1620, ro 8io.) In the next or seventeenth century, a fresh impulse produced additional improve- ments. Then appeared in Italy, Ca?sar Magatus, who simplified the treatment of wounds, (de rara vulnerum medicatione, Ubri2, Vend. 1616, in folio ;) Fabricius ab Aquapendente, even less praise-worthy as a surgeon than as a physiologist, (Opera Chir. Paris, 1613 in fol.;) and Marcus Au- relius Severinus, that restorer of active sur- gery. De efficaci Medicina, libri 3, Franco- furt, 1613, in folio. De recondila abscessu- um natura libri 7, Neapoli, 1632, in 4lo. and Trimembris ( hirurgia fyc. Francofurt. 1653, in 4/o.) Among the English surgeons flourished Wiseman, who was the Pare of England (See Several Chirurgical Treatises, Lond. 1676, in fol.;) and William Harvey, whose discovery of tbe circulation of the blood had such an influence over the ad- vancement of surgery, that he must be class- ed among the principal improvers of this science. (See Exercitatio Anatomica de motu cordis et sanguinis in animalibus, Fran- cojurti, 1653, in 4to.) In Germany, Fabri- cius Hildanus, (Obs. et Curationum, Cen- turiai 6, 2 Vol. in 4to. 4641.) who was far superior, as a surgeon, to the Italian Fabri- cius Scultetus, so well known for his work, entitled Armamentarium Chirurgicum; Ul- ma, 1653, in folio. Purmann and Solingen, who had tbe fault of being too partial to the use of numerous complicated instruments. (See Curscc Obs. Chir. Lipsim, 1710, in 4to. Manuale Obs. der Chirurgie, Amsterdam, 16S4,i'rc 4/o.) Holland, restored to liberty by the gene- rous exertions of its inhabitants, did not remain a stranger to the improvement of surgery. This nation, so singular in many respects, presents us with one particularity vyhich claims the notice of a medical histo- rian. Ruysch, who was an eminent ana- tomist, and merits equal celebrity for his Obs. Anatomico-Chirurgicarum Ccnturim, Amstelodam. 1691, i.i 4lo. carried with him pupils, have each given a different explana- tion of it. Sucb a disposition, which was extremely hurtful to the advancement of surgical knowledge, would materialy have retarded the progress of surgery in Holland, bad not Camper, in the following century, effaced this imputation by the great number of his discoveries, and his zealous desire to make them public. While great improvements were going on in Italy, England, and Holland, surgery lan- guished in a humiliated state in France. The accoucheur Mauriceau (Traiti des Ma- ladies des Femmes grosses, Paris, 1068, in 4/o.) Dionis, (tours d'Opirations de Chi- rurgie, Paris, 1707, 8ro.) Saviurd, (Nou- veau Recueil d' Obs. Chir. Paris, 1702, in, 12f*io.) and Belloste (Chirurgien d'Hopital, Paris, 1696, in 8no.) were the only French surgeons of note who could be contrasted with so many distinguished men of other nations. Richerand observes, tbat the splen - did days of Louis the Fourteenth were an iron age for discouraged surgery. And yet this monarch seems to have been personally interested in the melioration of this impor- tant art; for he was very nearly falling a victim to a surgical disease, a fistula in ano, and was not cured till altera great number of blundering operations and useless experi- ments. Chronology teaches simply the history of dates. In the study of the sciences, the only method of impressing the memory with facts, consists in connecting (he epoch of them with tbe learned men by whom Ihey have been illustrated. But the great- est surgeons of the eighteenth century have not altered the face of their profession, although they have powerfully conlributed to its advancement. In surgery, as an au- thor has remarked, some feeble rays always precede brilliant lights, and it approaches perfection in a very gradual way. In the last century, how ever, among the distin- guished surgeons of France, there are two of extraordinary genius, round whom, as it were, all the others might be grouped and arranged, and whose names deserve to be affixed to the two most brilliant epochs of French surgery. These are, first, J. L. Petit, whose glory vvas shared by the Aca- demy of Surgery ; and, secondly, the cele- brated Desault. Ii is not wilh surgery, as wilh physic, slricdy so called ; the epochs of the latter are distinguished by hypotheses; while those of surgery are marked by discoveries. The eminent men in this Inst branch of (he pro- fession have not, like tbe most renowned 448 SURGERY physicians, created sects, built systems, de- stroyed those of their predecessors, and con- structed a new edifice, which in its turn has been demolished by other hands. All of them have been satisfied with combating an- cient errors, discovering new facts, and con- tinuing their art, the sphere of which (hey have enlarged hy their discoveries, without making it bend under the yoke of systems, which it would have ill supported. To this steady und uniform course, (says Richerand,) which is a striking proof of the superiority of surgery, and of ibe certainty and invaria- bleness of its principles, shall we oppose the numerous revolutions of physic ? The Chris- tian religion, which abounds in sects, has not a greater number of them than physic. -' Ma- turates, solidistes, humoristes, vitalistes, ani- mistes, semi-animistes, mecaniciens, chi- roistes; le plus grand nombre des medecins bonore Hippocrate d'un culte presque super- stiticox; ceux-ci marcbent sous les ban- nieresde Staahl; ceux-las'appuient du grand nom de Boerhaave ; tels autres invoquent Sydenham, Hoffmann, Stoll, absolumenl comme les theologiens combattent pour Lu- ther, Zuingle, Calvin, ou Jansen." (Nosogr. Chir. T. 1.) The elogy on J. L. Petit, delivered in the midst of the Royal Academy of Surgery, of which he was one of the first and most dis- tinguished members, represents bim as blend- ing the study of anatomy wilh his amuse- ments when a boy ; and ardently seeking every opportunity lo increase his knowledge by observation. He bad had experience enough to publish at an early period of his life his TYatle sur les Maladies des Os, Paris, 1705, in \2mo.; a work which for a centu- ry was esteemed the best upon the subject. His success was mosl virulently opposed by Ihe envious critics; and it was nol till after more than thirty years of academical labours and extensive practice, that he was unani- mously chosen the head of bis associates. This acknowledged superiorly, however, was the more flattering, as the honour was obtained at a period when surgery was in a flourishing state in France, and when Petit held no of- fice, from which he could derive an influence foreign to his personal merit. While Mares- chal, La Peyronie,and La Martiuiere assured him of the royal favour, Qn-snay, Morand, and Louis, who corrected bis writings, made bim speak a language which does honour to that famous collection, to which he contribu- ted his observations, (see Mimoires et Prix de VAcademic Royale dc Chirurgie, 10 Vols, in 4to.) and in which, if some theoretical ex- planations be put out of consideration, no- thing ha3 lost its value by age. J. L. Petit was also ine author of a " Traili des Mala- dies Clururgicales et des Opirations qui leur conviennent. Outrage Posthume ;" a pro- duction thai will a ways stand high in tbe estimation of the judicious surgeon. Tbe history of this epoch, so glorious for ihe profession of surge-ry, is completely de- tailed in tbe Memoires aud Prix of tbe Royal Academy of Surgery ; a work which is ab- solutely indispensable, and the various parts of which cannot be too often considered. In it are preserved the labours of Mareschal, Quesuay, La Peyronie, Morand, Petit, De la Martiniere, Le Drau,Garengeot, De la Faye, Louis, Verdier, Foubert, Hevin, Pibrac, Fa- bre, Le Cat, Bordenave, Sabatier, Puzos, Levret, and several other practitioners, who, though less famous, contributed by their ex. ertions and knowledge to form this useful body of surgical fads. Many of the prece- ding surgeons also distinguished themselves by other productions, which, however, I shall nol here enumerate, a» they are quoted in many other parts of ibis work. To Ihe foregoing list of eminent French surgeons, must be added the names of La Motle, Maitre-Jean, Goulard, Daviel, Rava- ton, Mejean, Pouteau, David, and Frere Cosme. While surgery was thus advancing in France, other nations were not neglectful of it. At this period flourished in England, White, Cheselden, Douglas, the two Monros, Sharp, Cowper, Warner, Alanson, Percival Potl, Hawkins, Srnellie, and the (wo Hun- ters. White's Cases in Surgery, 1770; Chesel- den's Treatise on the High Operation for thi Slone, London, 1723. in Svo. and his Treatise on the Anatomy of the Human Body; Dou- glas's Tract, entitled.»' Lithotomia Douglass- iana;" Shai p's Treatise of the Operations'; and bis " Critical Inquiry into the present Stats of Surgery;" Monro's Works by hit son; Warner's Cases in Surgery, 1754, and his Description of the Eye and ils Diseases, 1775; Alanson's Treatise on Amputation; Pott's Chirurgical Works; Smellie's Midwife- ry ; and John Hunter on the Blood, Inflam- mation, fyc. ; his Treatise on the Venereal Disease ; Animal Economy, the Teeth, and all tbe papers written by himself and bis brother, in the Phil. Trans. Med. Obs. and Inquiries, and Tram, of a Society for the Im- provement of Med. and Chir. Knowledge; are productions which reflect the highest credit ou the state of surgeiy in England. But of all these eminent men, none con- tributed more powerfully than Mr. Percival Pott, to the improvement ot the practice of surgery in England. Hi- life, indeed, forms a sort of epoch in the history of the profes- sion. Before bis inculcations and example bad produced a desirable change, the maxim of " dolor medicina doloris," as we learn from Sir James Earle, remained unrefuted Tbe. severe treatment of the old school, in Ihe operative part and in the applications, continued in force. The first principles of surgery, the natural process and powers of healing, were either not understood, or nol attended to; painful and escharolic dress- ings were continually employed; and tbe actual cautery was in such frequent use, that at ihe times when the surgeons visited tbe hospital, it was regularly heated, and prepa- red as a necessary part of die (apparatus. Where shall we find more sensible, or more truly practical observations on the treatment of abscesses, than in his excellent treatise on the fistula in ano s Where shall we meet w'1'. SURGERY 44« "(letter remarks on Ihe local (realment of gan- grenous parts, (han in his valuable tract on the mortification of the toes and feet ? What author abounds with so many just observa- tions on the injuries of the head, blended, it is true, with rather too great a partiality to the trepan, the so frequent necessity for wliich is now less generally acknowledged ? His description of the inflammation and suppu- ration of the dura mater, and of the treat- ment, is matchless. The account which he has left us of the disease of the vertebrae, at- tended with paralysis of the limbs, is per- haps his most original production. His ce- lebrated essay on fractures, was also very original, and has had in this country consi- derable influence over the treatment of these injuries ; but there can now be no doubt, that the effects of position were exaggerated in this part of his writings, and lhat surgeons ought still to make every possible exertion to render their apparatus for broken bones more effectual. (See Fractures.) A more really valuable production of jhis eminent surgeon is his remarks on amputation. The necessity for that operation in certain cases is there convincingly detailed ; and ihe most advantageous period for its performance clearly indicated. The urgency for its prompt execution, after particular injuries, he has indeed so perfectly explained, (hat the late inculcations on tne subject by Larrey, and several other modern surgeons, appear to he in a great measure anticipated ; the only dif- ference being, that Pott's remarks applied principally to compound fractures, while Larrey's refer to gunshot wounds. All these, however, are cases of accidental violence, and of course should be treated upon the same geueral principles. A longer comment on the writings and improvement of Percival Pod would here be requisite (o do him every degree of jus- tice; bul his name, advice, and opinions are so conspicuous throughout this volume, that 1 shall be excused for not saying any thing more in the present place, than that he was in his time, the best practical surgeon, the best lecturer, the best writer on surgery, the best operator, of which this large metropo- lis could boast. Another character Of still greater genius and originality, though of inferior education, was the ever memorable John Hunter, sur- geon to St. George's Hospital, who was at once eminent as a surgeon, an anatomist, a physiologist, a naturalist, and philosopher. If Pott materially improved many parts of the practice of surgery in England, and evinced himself to be the most skilful ope- rator of bis lime, John Hunter was also not less importantly employed in extending tbe boundaries of physiological knowledge, and in the investigation of human, and particu- larly comparative anatomy. The knowledge which he derived from his favourite studies, be constantly applied to the improvement of the art of surgery, and be omitted no oppor- tunity of examining morbid bodies, whereby be collecied fads which are invaluable, as Vol. IF- 57 (hey tend fo explain the real causes of the symptoms of numerous diseases. In the practice of surgery, whenever ope- rations proved inadequate to (heir intention, Mr. Hunter always investigated with uncom- mon, zeal the causes of ill success, and in this way he detected many fallacies, as well as made some important discoveries in the healing art. He ascertained the cause of failure, common to all the operations in use for the radical cure of the hydrocele, and was enabled to propose a mode of operating attended with invariable success. He ascer- tained, by experiments and observations, that exposure to atmospherical air, simply, can neither produce nor increase inflamma- tion. He discovered in the blood so many phenomena connected with life, and not to be referred to any other cause, thai he con- sidered it alive in its fluid state. He impro- ved the operation for the fistula lachrymalis, by removing a circular piece of tbe os un- guis, instead of breaking it down With the point of a trocar. He explained belterthan any of his predecessors, all the highly inte- resting modern doctrines relative to inflam- mation, union by the first intention, suppura- tion, ulceration, and mortification. His writings also throw considerable light on the growth, structure, and diseases of the teeth. As instances of his operative skill, it deserves to be mentioned, thai he removed a (umour from the side of (he head and neck of a pa- tient at St. George's Hospital, as large as tbe head to which it was attached ; and by bring- ing the cut edges of the skin together, the whole wound was nearly healed by the first intention. He likewise dissected out of the neck a tumour, which one of the best opera- tors in this country had declared, rather too strongly, that no one but a fool or a mad- man would meddle wilh ; and the patient got perfectly well. Bul perhaps the greatest improvement which he made in the practice Of surgery, was his invention of a new mode of performing the operation for the popliteal aneurism, by taking up the femoral artery on (he anterior part of die thigh, without open- ing the tumour in the ham. (See Trans, of a Society for the Improvement of Med. and Chir. Knowledge.) The safely and efficacy of this method of operating have now been fully established, and the plan hns been ex- tended to all operations for the cure of this formidable disease. (See Aneurism.) According to Sir Everard Home, Mr. Hunter was also one of the first who taught, lhat cutting out the bitten part was the only sure mode of preventing hydrophobia ; and be lengthened the time in which this pro- ceeding might be reasonably adopted, be- yond the period which had been generally specified. His researches into the nature of the ve- nereal disease, and his observations on (he treatment, will for ever be a lasting monu- ment of his wonderful powers of reasoning and investigation. If he left some points of tbe subject doubtful and unsettled, be has admirably succeeded in the elucidation of others ; and his work on this interesting dis- 4*V al-RGER\. order, is, wilh all its defects, tbe best which is yet extant. Even the language and mode of expression of this great man were his own ; for so ori- ginal were his sentiments, that they could hardly be delineated by any ordinary arrange- ment of words. His phrases are still adopt- ed in all the medical schools of this country, and continue to modify the style < f almost every professional book. Great as Mr. Hun- ter's merit as a surgeon was, it was still great- er as a comparative anatomist and physiolo- gist. The museum of the Royal College of Surgeons, and his papers in the Phil. Trans. will for ever attest his greatness in these cha- racters. At the period, when the preceding distin- guished men upheld the character of their profession iu Great Britain, Lancisi. Mor- gagni, Molinelli, Bertrandi, Guattani, Mas- cagni, Matani, Troja, and Moscati, were doing the same thing in Italy. Bertrandi's Treatise on the Operations of Surgery, and Troja's Work on die Regeneration of Bones, are even at this day works of the highest repute. Of late years, the credit of the Ita- lian surgeons has been honourably main- tained by Montcggia,. Scarpa, Paletta, Qua- dri, Assalini, Morigi, and others. In Hol- land floiiridied Albinus, Deventer, Sandi- fort, aud Camper; and in Germany, and the north of Europe, tbe immortal Haller, Heister, well known for his " Institutions Chirurgia;;"' Platner; Rmderer (Elementa Arlis Obsletriciai. Goelt. 1752. Obs. de Partu Laborioso. Decad. 11, 1756.) -item, Bilguer, Acrell, Callisen, (Syslema Chirurgiae, Hodi- ernm, 2 Vol. Sro.) Brambilla, Theden, (Pro- gres ulterieurs de la Chirurgie.) Schmucker, (Vermischte Chirurgische Schriften,B.3, and Chir. WaJirnehmungeQ.) Richter, (Traite des Hernies, 2 Vol. Svo. Bibl. fur die Chirurgie ; Ansfangsgr. der Wundarzn. 7 B. and Obs. Chirurgkarum Ease.) Also Amemann, Weid- mann, Beer, Soemmering, Creutzenfeldt, Hesselbach, Hufeland, Graefe, Klein, Him- ly, Langenbeck, Walther, J. A. Schmidt, G. J. Beer, be. should not be forgotten, seve- ral of whom are still pursuing their useful and honourable career. Be it also record- ed as a part of the jireat merit of the Ger- mans, that they now rank among the best and most minute anatomists; that tbey are zealous cultivators of comparative anato- my ; that their industry allows no improve- ment in medical science, wherever made, to escape their notice ; and that surgery is greatly indebted to them for the best descrip- tions of the diseases of the eye. On the continent, the Academy of Surge- ry at Paris was long considered quite as the solar light of this branch of science. The French Revolution, which, by a fatal abuse, involved in the same prohibition both use- ful and pernicious societies, did not spare even this beneficial establishment. Al- though the Academy was deprived of the talents of Louis, who di*d a short time be- fore its suppression, it yet had at this period several members, worthy of continuing its tybours, and supporting it*- rep t'-Uiou : Sa- batier, Desault, who may be regarded as the Pott of Trance, Chopart, Lassus, Pey- rilhe, Dubois, Percy, Baudeloque, Pelletan, Sue, be. The Academy of Surgery in France was succeeded by what is named the Ecole dc M6decine. Desault, who was almost a stran- ger in the former, became quite the leading character in the latter. Several things re- commended him strongly to the remem- brance and admiration of posterity ; (he ex- actness and method which he introduced into the study of anatomy ; the ingenious kinds of apparatus which he invented for the treatment of fractures,; a noble ardour in his profession, which he knew how to impart to all his pupils ; his clinical lectures upon surgery, which were the first ever de- livered ; and the boldness and simplicity of his modes of operating. Indeed, such um bis genius, that even when he practised only methods already understood, he did them with so much adroitness, that he rather ap- peared to be the inventor of them. From the Ecole de Me*d6cine have issued Dupuy- tren, Boyer, Richerand, Dubois, Lheritier, Manoury, Lallemant, Petid de Lyon, Bi- chat, be. The researches of Bichat, who quitted surgery, powerfully contributed to the ad- vancement of physiological science. His mind, richly stored with the positive facts which he had learned in the study of surge- ry, conceived no less a project than that of rebuilding the whole edifice of medicine. Some courses of lectures upon the materia medica, internal clinical medicine and mor- bid anatomy, announced this vast design, which was frustrated by a premature death. Bichat, as a physiologist, and man of very original genius, may be consideral as the John Hunter of France; but his qualities were of a different cast, and hardly admit of comparison with tbpse of Hunter, whose investigations were not limited to man, but extended to the whole chain of animated beings. Bichat died in the midst of his la- bours, and in dying his greatest regret was that of not having completed them. His example, says Richerand, proves most con- vincingly what Boerhaave always inculca- ted, how indispensable the study and even the practice of surgery are to him, who would wish to be a distinguished and suc- cessful physician. (Nosogr. Chir. Tom. 1, p. 25.) Perhaps nothing contributed so materially to the improvement of surgical knowledge, as the establishment the Royal Academy ot Surgery in Prance; a noble institution, which, for a long while, gave our neighbours infinite advantage over us, in the cultivation of this most useful profession. Indeed, every one truly interested iu the improvement of sur- gery, cannot fail to regret the discontinu- ance of a society, in which emulation and talents were so long united for the benefit of mankind. The various dissertations pub- lished by the illustrious members ofthe aca- demy, will serve as a perpetual memorial of the =pirit, ability, and suoe-s. with '.-hirh SURGERY. 45 J the objects of the institution were pursued ; and centuries hence, practitioners will reap from the pages of its memoirs the most va- luable kind of surgical information. Unfor- tunately, this establishment, which vvas overthrown by the agitation of the French Revolution, has had only a very inferior substitute in the Ecole de Medecine. Were I to name any one thing, which, in my opinion, would have the greatest influ- ence in giving life to the study and cultiva- tion of surgery in this country, I should wi(hou( hesitation assign such importance to the establishment of an institution in the metropolis, on the same grand, liberal, and encouraged plan, as the late Royal Acade- my of Surgery in France. At the same time, I am conscious that the present Medical and Chirurgical Society of London have every claim to the encourage- ment and gratitute of the profession. No other institution of the kind has ever done f-o much in so short a space of time. Many of the facts which they have collected and published, are of considerable importance, especially those relating to the subjects of aneurism and hemorrhage. Their library is already the most select, valuable, and com- plete collection of medical literature in Great Britain ; and it is daily receiving ad- ditions both by large purchases at home and abroad, and by the liberal donations of its members. The intercourse and correspond- ence v- hich such a society continually main- tain among the innumerable scattered mem- bers of the profession, cannot fail to be at- tended with the most beneficialconsequences. A generous and useful sort of emulation is thus kept alive ; the spirit of inquiry is pre- vented from slumbering; and every indivi- dual who ascertains a new fact, has now the means of making it known to the world, with all the expedition which its import- ance may demand. Within the last twenty or thirty years, most important improvements have certain- ly been made in almost every branch of surgery ; and it must gratify every English- man to find, that his own countrymen have acted a very leading part in. effecting an object, in which the interests of mankind are so deeply concerned. Before the time of Mr. John Hunter, our ideas of the venereal disease were surround- ed with absurdities ; and it is to this lumi- nary that we, are in an eminent degree indebted for the increased discrimination and reason, which now prevail, both in the doctrines and treatment of the complaint. It must be confessed, however, that much yet remains to be made out, respecting the nature and treatment of syphilitic disorders. Need I mention a greater proof of the truth of this remark, than the sudden change of practice in some of the principal hospitals in London, mercury being now not exhibited in more than one out of ten cases, for which this medicine a few years ago was always deemed indispensable ? Numerous cases, having all the characters of primary vene- real sores, seem now to be curable by sim- ple dressings and cleanliness. In short, so different is every thing from what it used to be, that many surgeons are tempted to sup- pose the nature of the venereal disease to- tally altered. Some observations on this important topic are offered in another place. See Venereal Disease. Strictures in the urethra, an equally com- mon and distressing disease, were not well treated of before Mr. Hunter published on the venereal disease ; and the advantage of armed bougies in the treatment of certain cases has been subsequently pointed out by Sir Everard Home. In modern times, hernial diseases, those common afflictions in every country, have received highly interesting elucidations from the labours of Polt, Camper, Richter, Sir Astley Cooper, Hey, Gimbernat, Hes- selbach. Scarpa, Lawrence, be. The treatment of injuries of the head has been materially improved by Quesnay, Le Dran, Pott, Hill, Desault, and Aber- nethy. The disease of the vertebra?, which oc- casions paralysis of the limbs, formerly al- ways baffled tbe practitioner; but Ihe me- thod proposed by Air. Pott is now frequently productive of considerable relief, and some- times of a perfect cure. The diseases of the joints in general may also be said to be at present viewed with much more discrimina- tion than 'hey were a very few years ago; and Ibis great step lo better and more successful practice reflects great honour on Mr. Brodie, while it keeps up a well-founded hope, lhat morbid anatomy, the study which has of late banished so much confusion from this part of surgery, will yet be the means of bring- ing to light other useful facts and observa- tions, relative to the diseases of the joints in general. The mode of (reatinglumbar abscesses bas been rendered much more successful than formerly, and for this change the world is in- debted to Mr. Abernethy. The almost infallible plan of curing hy- droceles by an injection, as described by Sir James Earle, may also be enumerated among modern improvements. The increasing aversion to the employment of the gorget in lithotomy, and the many dis- tinguished advocates for the use of better in- struments in this operation, may be hailed as propitious omens of beneficial changes in Ibis part of practice. The diseases ofthe eyes, to which affec- tions English surgeons seemed to pay much less attention than was bestowed by foreign practitioners, now obtain due attention in this country. Although we have generally had some distinguished oculists, our regular surgeons have generally been wonderfully ignorant of this part of their profession, and uninformed on the subject, they have given up to professed oculists and quacks one of the most lucrative and agreeable branches of practice. However, the able writings of Daviel, Wenzel, and Ware, begin now to be familiarly known to practitioners: and the observations of Scarpa, Richter, Reer, SURGERY Wardrop, Travers, and Saunders, will 60011 have ituineuse effect in diffusing in the pro- le? .i*n a due knowledge of the numerous diseases, to which the organs of vision are liable. As likewise the generality of the hospital surgeons of London, have, during the last thirty years, grossly neglected the study ofthe diseases of the eye, and consci- entiously refused to have any thing to do with these cases, the public at length saw the necessity of establishing Eye Infirma- ries, where such afflictions might be more attentively observed and relieved. Some of these have now become excellent schools, in which the rising generation of surgeons have abundant opportunities of study ing the nature of all the diseases of the eyes, and the most approved methods of treatment. While, however, 1 am thus commending separate institutions for disorders of the eye, it becomes me to express my regret for the long-continued neglect, and the ignorance of these diseases, manifested by several hospital surgeons, which were in fact the original causes of those distinct establish- ments. For, according to my conceptions, it would have been far better to have had the practice in eye-cases exhibited in the common great schools of surgery, the large hospitals of Loudon. 1 am of this opinion, not only because I think these diseases would then have met wilh more general and public observation; but also because I have always considered all unnecessary sub- divisions ol practice, in short all measures which tend to throw particular cases into the hands of a few individuals, hurtful to the best interests, and degrading to the charac- ter of the profession. In (he treatment of aneurismal diseases, English surgeons have much to be proud of. All the boldest operations in this biancb of surgery have been devised by the genius, and executed by tbe spirit and skill of British surgeons. Even M. Roux himself is he-re obliged to confe-s our superiority. (Paral- lele de la Chirurgie Angloise, fyc. p. 249.) The carotid artery, the external and internal iliac, and (he subclavian, have all been suc- cessfully tied by surgeons of ihis country. The first operation, in which Ihe external iliac was lied, i was a spectator of: it was performed by Mr. Abernethy in Bartholo- mew's hospital, and it bas subsequently been repeated in many examples, both in this country and others, with considerable suc- cess. I had also the honour of seeing the same gentleman likewise lie the carotid, in ine first instance of that operation in Eng- land. This important measure has also now been frequently practised wi|h success, and it constitutes 01,e of (he great improvements in the operative part of modern surgery. In tbe article Aneurism, 1 have cited many examples, in which ibe carotid artery has been successfully tied; and Ihe safety and propriety of the operation are now ge- nerally known and acknowledged. Indeed, so little are surgeons now afraid of the ill effects upon the brain, lhat the carotid arte- ry has lately been tied merely for tbe purpose of enabling the operator to take away a large tumour, including the whole of the parotid gland, from the side of the neck, without risk of hemorrhage; a mode of proceeding, however, w hich ought not (o be encouraged into a common practic t*. (See Mcdico-Chir. Trans. Vol. 7, p. 112.) Before I quit tins subject, my feelings call upon me to express the high opinion which 1 entertain of Mr. Hodgson's Treatise on ihe Diseases of Arte- ries and Veins, published in 1815, a work which reflects great credit ou English sur- gery, and contains praniual precepts far su- perior to tho-e of Sc arpa. In the modern practice of surgery, a variety of old prejudices are gradually va- nishing. Peruvian bark not many years ago, was regarded as a sovereign remedy and specific for nearly all cases of gangrene; and in these and many other instances, it was prescribed without any discrimination, and in doses beyond all moderation. But Ihe folse idea, thai this medicine has any specific effect in checking mortification, no longer blinds the senses of the most superfi- cial practitioner. He* neither believes tliii doctrine, nor Ihe still more absurd opinion, that strength can be mysteriously ex- tracted from this vegetable substance, and communicated to tbe human constitution, in proportion to the quantity which can be made to remain in Jhe stomach. This sub- ject, howevrr, has been duly discussed in tbe articles Cinchona and Mortification. Tlie removal of this deeply-rooted pre- judice, concerning the virtues of bark, in stop/big mortification, will pave the way to better and more successlul pr ctice. Bui upon tbe subject of mortification, the present day opens to us the investigation ot a point, which is of the first-ra(e conse- quence. Every surgeon is aware, that when a limb is affecled wi(b mortification, ampu- tation is absolutely necessary to effect a cure. This is geneeally acknowledged; but the performance of (be operation has, since tbe time of Mr. Poll, only been sanctioned when the mortification has manifestly ceased lo spread, and a line of separation is formed between the dead and living parts. All olher instances, in which the disorder was in a spreading state, were left to their fate. It is true, some of (he old surgeons occasion- ally vei.tmed to deviate from this precept; bul as they did so without any discrimina- tion, or knowledge of the particular exam- ples which ought to form an exception to (he general rule, (heir ill success cannot con- stitute a just argument against the plan of amputating earlier iu a certain description of cases. Now if modern experience can prove, that many lives may be saved by a timeiy performance of amputation, under circum- stances in which it has until lately been ge- nerally condemned, it must be allowed lhat the established innovation will be one of the greatest improvements in ibe practice of the present time. For reviving (he consideration of (bis question, and venturing (o deviate from the SURGERY 4V3 beaten path, Cue world is mnch indebted to (hat eminent mHilary surgeon, Baron Lar- rey. How differeni his doctrines and prac- tice are from those usually taught in the schools, tbe article Mortification will suffi- ciently prove. In tbe treatment of ununited fractures, the simple and ingenious practice proposed by Dr. Physic k of Philadelphia, merits particu- lar police, not oniy on account of the seve- ral successful trials which have been made of it in thi9 country and Frame; (See Me- dico-Clur. Trans. Vols. 5 fy 7, and Buyer's Traiti des Maladies Chir.) hui also because it is perhaps Ibe first improvement of con- sequence, that has hitherto lieen made in the practice of surgery by our transatlantic brethren. The inestimable treatise of Dr. Jones on Hemorrhage, has now produced quite a re- volution in all the principles, by which the surgeon is guided in the employment of the ligature, foi the stoppage of bleeding and the cure of .itieurisms. Instead of thick clumsy cords, small firm silks or threads, are now generally used ; and so far is the practitioner from being fearful of lying arteries too light- ly, lest tbe ligature cul through them, thai it is now a particular object with him to "pply the silk or thread, with a certain degree of force, in order that the inner coat of the ves- sel may be divided. It this be not done, the effusion of coagulating lymph within the ar- tery, an important part of the process of ob- literation, cannot be expected as a matter of certainly, and secondary hemorrhage is more likely to occur. But in order to con- vey an adequate idea of the beneficial changes which Dr. Jones's observations are tending to produce in practice, we have been careful in the article Hemorrhage, to give a tolerably full account of (tie results of all his interesting experiments. Besides using very small, firm, round threads, instead of large flat tapes or cords, as was tbe custom a few years ago, modern surgeons begin lo suspect, tbat much benefit rany also arise from cutting off both portions of the ligature close to the knot, afler am- putation, the removal of the breast, be. No one has insisted so much as Mr. Lawrence upon Ihe propriety of examining further (he merits of this innovation, if no bad effects result from leaving so small a particle of ex- traneous substance in the flesh, as the little bit of silk composing Ibe knot * id noose on Ihe artery, tbe practice will form a consider- able improvement. The wound may then be brought together at every point ; the quantity of extraneous matter in the wound wHI be lessened to almost nothing ; the dan- ger of convulsive affections ivill be reduced iu proportion as a serious cause of pain or irritation is diminished; and the chance of accomplishing perfect union by the first in- tention will be materially increased. Mr. Lawrence ha tried the plan in many instan- ces, and hitherto his e-iprience has not found any ill consequences follow, while it has proved, lhat many advantages are un- doubtedly the result of it. In amputations, the method has been practised by several of our military surgeons ; and although they have probably nol employed exactly such ligatures as this mode absolutely requires, the greater part of them have met with hard- ly any instances of future trouble from (he bits of ligature enclosed in the wound. However, if large ligatures be used, the prac- tice is not tairly tried, or rather the practice is not tried ai all; because the great princi- ple, on which il answers, is the very small atom of silk composing the extraneous sub- stance left in the wound, when such liga- tures as Mr. Letwrence particularly recom- mends are employed. Delpech and Roux have also sometimes adopted Ihe plan of re- moving the ends of ihe ligature close to Ihe knot. (See Parallile de la Chir. Angloise avec la Chir. Fancoise, p. 131.) See Ampu- tation, Aneurism, Hemorrhage, and Lig-a- turc. Among other real improvements in mo- dern practice. I must not forget (he present moie rational method of dressing (he wound, alter (he majority of capital operations, with light, cooling applications, instead of lnying on ihe part a farrago of irritating pledgets and plasters, and a cumbersome mass of lint, tow, flannel, and other banda- ges, woollen caps, be. The fewer Ihe adhe- sive sirips are the better, if they hold the lips of the wound together. This is all they are intended to do. Whereas, if you apply more than are necessary for this purpose, they do harm by heating the part, and co- vering the wound so entirely as to prevent the issue of ihe discharge. Over the adhe- sive plasters, let the surgeon be content with placing -a simple pledget of spermaceti cerate, and some linen wet wilh cold wa- ter, which will often avert hurtful degrees of pain and inflammation, by keeping the parts cool. Wars, which are unfavourable to most other sciences, are rather conducive to ad- vances in surgery. The many new and in- teresting observations which Baron Larrey has made in ihe course of bis long and ex- tensive military experience, are a proof of (be foregoing remark. Pilard, almost the founder of surgery in France, was a milita- ry surgeon. Ambrose Pare and Wiseman also collected iheir most valuable knowledge pnncipally in the service of the army. Mr. Hunter himself gained much of his practical information in the same line of life. To Baron Laney surgeons are indebted for many highly importam observations, relating to amputation in cases of gunshot wounds. In particular he has adduced a larger and more convincing body of evidence, than was ever before collected to prove, tbat in gunshot injuries, the operation of amputation should always be performed without the least delay in every instance iu which such operation is judged to be unavoidable, and the ultimate preservation of the limb either impossible or beyond the scope of all rational probabi- lity. He has established the truth of this most important precept in military surgery by innumerable facts, drawn chiefly from it>4 .iv. .j bis own ample experience, and partly from the practice of many able colleagues. The great operations of the shoulder-joint, and hip-joint amputations, he has executed with success. The necessity for the former, however, he proves may sometimes be su- perseded, and the limb be saved, by making a suitable incision for the extraction of the splintered portions of the upper part of the humerus. This method, which was in many instances done wilh success in the peninsu- lar war was, I believe, originally proposed and practised by Boucher. (See Mtm. de I'Acad. de Chir. T. 2, 4to.) However, it was more particularly described and even practised by Mr. C. White, of Manchester. (See bis Cases in Surgery.) It has been re- peated witb success by Mr. Morell in the York Hospital. (See Med. Chir. Trans. Vol. 7.) See Amputation. Amputation at the hip-joint, performed only in the most dreadful cases, because itself (ho most dreadful operation iu surgery, Bar >n Larrey has performed five times, and twice (I believe) with success. This pro- ceeding has also been udopted by Mr Brownrigg and Mr. Guthrie, and their pa- tients recovered. As must be the case, however, on account of tbe desperate cir- cumstances under which the operation is performed, and the severity ofthe operation ilself, (he examples of recovery bear only a small proportion to the large number of deaths, known to have followed amputation at the hip in ihe many cases, in which it has now been undertaken. However, the un- fortunate truth should not be exaggerated into a reason for a general condemnation ofthe practice, which is adopted as the only means affording a chance of life. But as there may be diffic ilty in deciding whether the patient will have the best chance wilh or without the operation, it is to be hoped that no sur- geons will perform it, except under the authority of ihe united opinion ol a board, or consultation ot the best-informed practition- ers, whom circumstances wHI allow lo assem- ble. See Amputation. In military sui^iiy, the u«eful innovation of ambulances, or light caravans, furnished wilh a proper number of surgeons, assist- ant-, and orderlies, and capable of keeping up with ihe vanguaid, if requisite, is un- doubtedly the best means ot affording speedy surgical assistance to the wounded on tbe field of baltle, and ought to be enumerated as out ol the greatest nodern improvements Barons Percy and Larrey deserve the chief praise tor their succes-ful exertions in organi- zing and bringing to perfection so indispensa- ble an establishment. The account of Ibis subject well de>erves perusal ; and ii may be s. en either in Larrey's Mimoires de Chi- rurgie Militaire, or in tht Diet, des Sciences Meuicales, T. 5 SUSPENSORY. A bandage for support- ing ihe scrotum ; a bag-truss. Bandages of this kind are now usually sold at the shops, and seldom made by surgeons themselves; therefore a particular description of them is not essential in this work, in ca bougies, or quills, keep the mid- dle of the wound, and lips of it pressed to- gether with moderate closeness, and prevent any strain upon the threads, or any coarse? and painful tying across the face of tho wound." In a note Mr. J. Bell says, that Dionis violently reprobates the quilled su- ture ; but, that De la Faye (tbe annotator on Dionis) says, it is good for deep muscular wounds. The quilled suture is now scarcely ever employed ; nor has it any advantages, except, perhaps, in some wounds in the belly. (See Principles of Surgery, Vol. 1, p. 50.) I think the reader will more easily com- prehend the manner of making the quilled suture, from the following simple directions. Take as many needles, as stitches intended to be made ; arm them with a double liga- ture, or one capable of being readily split into two ; introduce the ligatures through the wound ; cut off the needles : lay a piece of bougie along one side of the wound, and tie the ends of the ligatures over it. Next draw the other extremities of the ligatures, so as to bring the first piece of bougie into close contact wilh the flesh ; lay the second piece of bougie along the opposite side of the wound, and tie the other ends of the li- gatures over it with sufficient tightness. Glover's Suture. This had also the name of the continued suture. It was executed by introducing the needle first into one lip of the wound, from within outwards, then into the other in the same way ; atid, iu this manner the whole track of the wound was sewed up. The glover's suture has long been rejected by all good surgeons, as improper to be em- ployed in cases of common wounds. It was not, however, till very lately, that this suture was totally abandoned; for Mr. Sharp, and several eminent writers since his time, have advised its adoption in wounds of the stomach and intestines. From what has been said in the articles Wounds ofthe Abdo- men and Hernia, the reader will perceive, that even in such particular instances, the glover's suture would hot be adviseable ; so that it may, in every point of view, be now considered as'totally disused in every case of surgery which can possibly present itself. When we remember, in making this suture, how many stitches are unavoidable; how unevenly, and in what a puckered state the suture drags the edges of the skin together, and what irritation it must produce, we can no longer be surprised at its now being ne- ver practised on the living subject. It is commonly employed for sewing up dead bodies; a purpose for which it is well fitted, but for the-bonour of surgery, and the sake of mankind, it is to be hoped that it will never again be adopted in practice. False, or Dry Suture.—Modern surgeons commonly understand by this expression nothing more, than the plan of bringing the sides of a wound together, by means of adhesive plaster ; nor did Mr Samuel Sharp attach any other meaning to the phrase, which he sets down as highly ridiculous, as there is no -^'* ing employed. For ():•; j56 birUREb following remarks, 1 am indebted lo Mr. larwardine, of Earls Colne Priory, near Halsted, Essex. Alluding to what was sla- ted in the last edition of this Dictionary, concerning the dry suture, he observes, " you do not appear to be aware any more than Mr. Sharp, ofthe precise mode of its application, or why it was so called. In- deed, it is a curious circumstance, how this method of dry suture should have been so lost, as not to be described by any modern purgeons. who laugb at the very term,speak- ing of it as a mere application of a strip of adhesive plaster. In the sutura sicca, so call- ed in opposition to the sutura criunta, where blood followed the needle, some ad- hesive plaster vvas spread on linen, having a selvage. A piece of this was applied along each side of the wound (the selvages being opposed to each other,) and then drawm together by sewing them with a com- mon needle, without bloodshed. Hence the term sutura sicca. The dry suture was used in all wounds of the face to avoid scars. You will find it thus described by our countryman Thomas Gale in his Enceiridion, 1563; and also by A. Pa- rey, who gives a figure of it in his folio work, 1579." I feel much obliged to my friend Mr. Carwardiue for this explanation, without which the expression dry suture is undoubtedly absurd. As the common way of dressing wounds with sticking plaster will come under consideration in a future gart of this work, (see Wounds,) I shall not here detain the reader upon that topic. Sutures, by which 1 mean such as were made in the flesh with a needle and ligature, were much more frequently employed by the old surgeons, than they are by the moderns. The best practitioners of the present day never resort to this method of holding the sides of a wound in contact, except in cases in which there is a real necessity for it, and other modes will not suffice. There were, indeed, certain instances, in which the employment of sutures was long ago forbidden. Of this kind were enve- nomed wounds, in which accidents the des- truction ofthe poison always formed a prin- cipal indication in the treatment.—Wounds, accompanied with considerable inflamma- tion, were not deemed proper for the use of sutures, as the stitches had a tendency to in- crease the inflammatory symptoms. Also, as contused wounds necessarily suppurated, and, consequently, could not be united, su- tures were not recommended for them ; nor were they judged expedient for wounds at- tended with sucb a loss of substance as pre- vented their lips from being placed in con- tact. Formerly,' wounds penetrating the chest, were not united by sutures ; nor were those in which large blood-vessels were in- jured ; at least, until all danger of hemor- rhage was obviated by the vessels being tied. Dionisbelieved, with several otherauthors, that wounds should not be united, when bones were exposed, on account of the ex- foliations which miibt b«* expected. This precept is no longer valid ; for when boue-j are neither altered nor diseased, and are only simply denuded, or divided with a cut- ting instrument, no exfoliations will com- monly follow, if the surgeon take care tn replace the fresh-cut soft parts so as to cover tbe exposed portion of the bone. The practicableness of uniting wounds, attended with the division of a bone, is confirmed by numerous facts. De la Peyronie com- municated to the French Academy of Sur- gery, a case conclusive on this point. A man was wounded with a cutting instru- ment, in an oblique direction, on the exter- nal and middle part of the arm. The bone wa3 completely cut through, together with tbe integuments and muscles, in such a manner that the arm only hung by an un- divided portion of the skin, about an inch wide, under which were the large vessels. De la Peyronie tried to unite the parts, be- ing convinced that it would be time enough to amputate afterward if the case should require it. He placed the two extremities of the divided bone in their natural situa- tion ; made several sutures for promo- ting the union of the soft parts, and ap- plied a bandage to the fracture. In this ban- dage there were slits, or apertures, over the wound, to allow the dressings to be applied. Spirit of wine, containing a little muriate of ammonia, was used as a topical application, and the forearm and hand, which were cold, livid, and insensible, were also fomented with the same. By these means the natural warmth was restored, and the wound was dressed In a week the dressings were re- moved, through the opening in the bandage; in a fortnight they were changed a second time, and the wound seemed disposed to heal. On the eighteenth day, the healing had made considerable progress; the part bad a natural appearance; and the beating of the pulse was very perceptible. De Iu Peyronie now substituted a common roller for the preceding bandage, and care vvas ta- ken to change the dressings every ten days. Iu about seven weeks all applications were left off, and at the end of two months the patient was quite well, with the exception of a little numbness in the part. This case is one of the most important in all the records of surgery; for it displays, in a most stri- king manner, what very bad wounds it is tbe duty of the surgeon to attempt to unite; and above all, it exemplifies the propriety of attempting to save many compound frac- tures, which, judged of only from first ap- pearances, would lead almost any one to resort to amputation. In such cases, when the divided parts are put in contact, the ap- pearances are quite altered. From what has been already stated, it ap- pears that surgeons, a considerable time back, did not at once sew up every sort of wound ; though the considerations, which led them not to close the wound, were erroneous, as may, perhaps, be said with re- spect to tbe apprehension of bleeding and exfoliations. The best modern practitioners employ sutures much I**?* frequently than suit RES. 457 their predecessors. Pibrac s dissertation on the abuse of sutures, inserted in the third volume of the Memoirs of the Academy of Surgery, has had considerable effect in pro- ducing this change, and I may safely add, this improvement in practice. This judi- cious and enlightened practitioner opposed the method of uniting wounds by means of sutures, which, he contended, ought never to be adopted in practice, except iu certain cases in which it was absolutely impossible to keep the sides of the wound in contact, by means of a suitable posture, and the aid of a methodical bandage. Such circum- stances Pibrac represents as exceedingly rare, if they ever occur at all. He speaks of sutures as seldom fulfilling the intention of the surgeon, who, in the majority of cases in which he employs them, finds himself ne- cessitated to remove them, before they have accomplished the wished-for end. Pibrac believes that sutures are generally more hurtful than conducive to the union of wounds; and that when they succeed, they do not effect a cure more speedily than a pro- per bandage. He cites numerous cases of very extensive wounds of the abdomen, neck, be. for the cure of which a bandage proved effectual, and this even in many in- stances in which sutures had previously failed, and cut their way through the flesh. Louis, who adopted the opinions of Pibrac, published in the fourth volume of Mim. de I'Acad de Chirurgie, a valuable dissertation, in which he endeavours to prove, tbat even the harelip can be better united, by means of the uniting bandage than sutures ; a case, however, which the best modern surgeons very rightly agree to consider, for particular reasons, elsewhere noticed, (see Harelip,) as an example, in wliich a suture is adviseable. As far as I can judge, the fair statement of the matter is, that sutures are by no means requisite in the generality of wounds; but tbat there are particular cases, in which either their greater convenience, or superior efficacy, still makes them approved, and employed by all the most eminent practi- tioners of the present day. Since sutures cannot be practised, without additional wounds being made, and pain occasioned, and since the threads always act as extrane- ous bodies in the parts, exciting more or less inflammation and suppuration round them ; there can be no doubt that their employ- ment is invariably wrong, whenever the sides of a wound can be maintained iu con- tact by less irritating means, with equal steadiness and security. For, what is it which generally counteracts the wishes of the surgeon, aud renders his attempts to make the opposite surfaces of wounds grow together unavailing ? Is not the general cause too high a degree of inflammation, which necessarily ends in suppuration ? Are not sutures likely to augment inflammation, both by the additional wounds of the needles, and the still more pernicious irritation of the threads which always act as foreign bodies, sometimes producing not merely an increase nf inflammation and suppuration in their Vql.H. fi.8 track ; but frequently such ulceration as en- ables them to cut their way oul, or else sloughing of the parts , or, in particular con- stitutions, a very extensive erysipelatous redness. In consequence of the ulcerative process, sutures very often cease to have the power of any longer keeping the edges of wounds in contact; as the observations of Pibrac, and, indeed, what every man may daily remark in practice, fully testify; and the violent inflammatory symptoms which are excited, frequently oblige the surgeon to cut the threads, and withdraw them altogether. But, even admitting, that by the general adoption of sutures some wounds would be united, which could not be so vvere this means of accomplishing the union aban- doned, still it must be allowed, on the other hand, that the cause of some wounds not uniting is entirely ascribable to the irritation occasioned by tbe sutures themselves. Hence, if it be only computed, that as many wounds are prevented from uniting by the irritation of sutures, as other wounds which are united by their means, and could be united by no other methods, we must still perceive, that mankind would be no sufferers, and surgery undergo no deterioration, were sutures alto- gether rejected from practice. 1 believe, however, that every man, who has had op- portunities of observation, and has made use of them with an unprejudiced mind, will feel persuaded that more wounds are hin- dered from uniting by sutures, than such as are healed by them, and could not be united by other means. But prudent practitioners are not obliged, either to condemn or praise Ihe use of su- tures, in every instance, without exception. Men of independent principles will always adopt the line of conduct which truth points out to them as that which is right; nor will they obstinately join Pibrac and Louis, in contending that sutures are always improper and disadvantageous, nor with other bigoted persons, who may use sutures in every kind of wound whatever. Perhaps, sutures are still rather too much employed, and, in all probability, will long be so. It will be difficult entirely to eradicate the prejudices, on which their too frequent use is founded, as long as, what may be called, the teachers of surgery are seen holding up the practice for imitation in every principal hospital in the kingdom. Such surgeons, however, as are ready to imbibe fair and candid senti- ments on the subject, and to qualify them- selves for practising this part of surgery with judgment, should by no means neglect to read both what Pibrac and Louis have writ- ten on the subject. I know that the latter authors are a little too sanguine in their re- presentations ; but, as I have already re- marked, sutures are still rather too much used, and something is yet necessary to do away a certain unwarranted habit of having recourse to them without real necessity. Nothing will tend to produce this desirable change so much, as tbe perusal of every ar- gument against their employment. 4ft* T liAM'AI.*-. I am decidedly of opinion, not from what or not . but, atter the amputation ot the I have* read, but what I have actually seen, breast, I have no hesitation in pronouncing that the sides of the generality of wounds their employment wrong and injudicious. are capable of being effectually kept in con- I shall conclude with referring to what Pi- tact, by means of a proper position of the hrac and Louis have written on the above part, and (he aid of strips of adhesive plaster, subjects, in Mim. de I'Acad. de Chir. Tom. 3 compresses, and a bandage. 1 believe that and 4, Sharp, Dionis, Gooch, Le Dran, Ber- sucb success can be obtained with everv ad- trandi, Sabatier, B. Bell, and J. Bell, have all vantage which can be urged in favour of treated of sutures. Nee also C. E. Boeder, sutures, and without their disadvantages; Sulura Vulnerum ; Upsnl, 1772. such as greater pain, inflammation, &.c I SYMPATHETIC BUBO, see Bubo. even think, with Louis, lhat the harelip SY.sCHYSIS. (fromo-t/^t-a.to confound.) might in general be united very well by The term synchysis sometimes denotes tbe means of a bandage ; but still 1 am of opi- confusion of the humours of the eye occa- nion, that Ihe twisted suture is attended with sioned by blows, and attended with a rup- least trouble, is most suited for universal ture of the internal membranes and capsules. practice, and that, unless such pains were Keer understands by the expression, a taken as many practitioners would not, and dissolution ofthe vitreous humour, or the others could never take, the method by ban- state of it in which its consistence is en- dage would frequently fail. tirely destroyed. (See Lehre von den An- I find it exceedingly difficult to lay down genkr. B. 2, p. 257.) any fixed principles for the guidance of the SYNECHIA. The case in which the iris surgeon, in respect to when he ought, and adheres to the cornea is termed synechia when he ought not, to use sutures. anterior ; that in which the uvea adheres to Perhaps, sutures should be made use of the capsule of the lens, synechia posterior. for all cuts and wounds, which occur in Beer has delivered two valuable chapters parts which are subject to an unusual degree on these subjects. The synechia posterior, of motion, such as would be apt to derange on account of the frequent delicacy of (he (he operation of bandages, sticking plaster, adhesions, is apt not to be detected, unless nnd compresses. Hence the propriety of the eye be examined with particular care. using the twisted suture for the harelip. A magnifying glass should be used, and Sutures are probably, for the most part, the pupil be first dilated with hyoscia- advantageous in all wounds of the abdomen, mus, or belladonna. '1 he treatment, as far of a certain length, and attended with ha- as the prevention and removal of such ad- zard of tbe viscera making a protrusion. In hesions are practicable, strictly belongs to this situation, the continual motion and ac- the subject of iritis. (See Ophthalmy.) With tion of the abdominal muscles, in respiration, the view of dispersing them, Beer praises besides the tendency of the viscera to pro- the good effects of applying to the eye itself trude, may be a reason in favour of the use ointments containing preparations of mer- of sutures. cury, or a coilyrium hydrarg. oxymuriatis, When two fresh-cut surfaces positively to which some of the thebaic tincture is cannot be brought into contact by sticking added. As an inward medicine, he says, plaster, bandages, the observance of a pro- calomel is the most effectual. When per posture, be. there can he no doubt of eye-salves are used, Beer recommends a the advantage of using sutures, if they will little of the extract of hyosciamus to be answer the purpose. Some wounds of tbe mixed with them, so that they may dilate trachea; some wounds made for the cure of the pupil, and thus suddenly break any certain fistulous communications between slight threads of lymph. (B. 2, p. 58.) For the vagina and bladder, or others for the cure additional information on ihe synechia pos- of similar affections in the perinaeum, afford terior and anterior, see Lehre von den Au- instances of cases to which I allude. gc«Ar. B. 2, p. 54 and p. 263. Also Beger, 1 observe, that many surgeons in this me- De Synechia seu preternaturali ndhesione cor- tropolis use sutures for bringing the sides of n-e cum iride. Haller, Disp. Chir. T. l,p the wound together after several operations ; 435. as that of removing a diseased breast, castra- SYNTHESIS, (from truv, together, and tion, and operations for strangulated hernia. St-cr/c, position, situation.) A generic terra, The reason for using sutures in the scro- formerly much used in the schools of surge- turn, I suppose, arises from the difficulty of ry, and comprehending every operation, by keeping the edge* of the wound in contact, which parts, which had been divided, were owing to the great quantity and looseness reunited. of the part. In this case, I cannot deter- SYPHILIS. Lues Venerea. The vene- raine whether sutures are really necessary real disease. (See Venereal Disease) T. FT! BANDAGE. A bandage, so named tion for the cure ol fistula in ano, in diseases A from its figure. It is principally used of the perinamm, and those of the groins, tor supporting the dressings after the opera- anus, be. It is composed of two longitud:- ]ENDONS 45 S nal pieces of cloth, of greater or lesser breadth, according as occasion requires. The transverse piece of cloth serves to go round the body above the hips: the per- pendicular piece is sewed at one of its ends te the middle of the latter; and in general, its other extremity is slit into two portions, or tails, about six or eight inches long. The perpendicular piece of the 1 bandage applies itself between the glutari muscles, and lo the perinaeum : while its two ends, just descri- bed, are to be carried between the ttiighs and the pudenda to the right aud left, a,.d fasten- ed to the transverse piece surrounding the body. Besides the common T bandage, there is another one named d.uble, which has two perpendicular pieces, sewed to the transverse one, about four inches apart. The double T bandage is said to be more particularly applicable after lithotomy, and lor the diseases of the perinaeum ; because one may make the two perpendicular pieces cross each other on the part affected, and leave the anus uncovered; an advantage which the simple T bandage certainly has not. The T bandage may be used in some other ways, which have been noticed in the article Bandage. TALPA. (a mole.) A tumour which creeps under the skin as a mole under the surface of the ground. Such is the etymo- logy. It is often applied to an encysted tu- mour, which forms on the head, and contains a paplike matter. (See Atheroma, and Tu- mours, Encysted.) TAPPING. See Paracentesis. TARAXIS. (from vagaro-a, to disturb.) A slight ophthalmy,or inflammation of Iheeye. TAXIS, (from rua-, to put in order.) The operation of reducing a hernia with the band. (See Hernia.) TENDONS, RUPTURE OF. The tendons liable to be broken by the violent action of the muscles witb which they are connected, are the tendo Achillis, that of the extensor muscles of the leg, and the tendon of tbe triceps extensor cubiti. The ancient sur- geons seem not to have been well acquaint- ed with the rupture of the tendo Achillis, which they probably might mistake for a sprain, or some other complaint. In cases in which this part had been cut, tbey re- commended approximating the separated portions, and maintaining them in contact by means of a suture. 4* When the ruptured wndo Achillis was afterward better understood, the plan just mentioned was even adopted in this case, the integuments having been previously divided, for the purpose of bringing the tendon into view. But there is no necessity for having recourse to this painful proceed- ing. (Encyclopedic Mitlwdique, Partie Chir. T.l,p. 55.) The superficial situation of the tendo Achillis always renders the diagnosis of its rupture exceedingly obvious, and the acci- dent can only become at all difficult to detect, when there is a considerable de- gree of swelling, wliich is very rare. When die tendon has been cut, the division of the skin even allows the. accident to be seen When the tendon has been ruptured, the patient bears a sound, like that of the smack of a whip, at the moment of the occurrence. In whatever way tbe tendon has been di- vided, there is a sudden incapacity, or at least, a.i extreme difficulty either of standing or walking. Hence, the patient falls down, and cannot get up again. Besides these symptoms, there is a very palpable depres- sion between the ends of the tendon, which depression is increased when the foot is bem and diminished, or even quite removed when the foot is extended. The patient can spontaneously bend his foot, none of tbe flexor muscles being in- terested. The [tower of extending the foot also is still possible, as tne peroii&i muscles; the tibialis posticus, and long flexors of the toes t^see a cast recorded by J. L. Petit) re- main perfect, and iiiay perforin this motion. (CEuvres Chir.ue Desault, par Bichat, T. 1.) Ihe indications are to bring the ends ot the divided part together, and to keep them so, u.itil they have become firmly united. The first object is easily fulfilled, by putting the foot in a state ot complete extension : the second, namely, that of keeping the ends of the tendon in contact, is more dif- ficult. In order to have a right comprehension of the indications, we should consider what keeps the ends of the tendon from being in contact. The flexion of the foot has this effect on the lower portion ; the contraction of the gastrocnemius, and solaeus, on the upper one. The indications then are to put the foot in an unalterable slate of extension, and to counteract the action of the above muscles. The action of the muscles may be oppo- sed :—I. By keeping these powers in a continual 3tale of relaxation. For this purpose the leg must be kept half bent upon the thigh. 2. Bv applying methodical pres- sure to the muscles; methodical, because it is to operate on the fleshy portion of the muscles, and not on the tendon, the ends of which, being depressed by it, would be separated from each other, and, instead of growing together, would unite to the adja- cent parts. The pressure should also operate, so as to prevent the ends of the tendon from inclining either to the right or left. J. L. Petit seems entitled to the honour of having first devised the plan of treating the ruptured or divided tendo Achillis, by keep- ing the leg and foot in a particular posture, with the aid of an apparatus. Seeing that the extension of the foot brought the ends of the tendon into contact, it occurred to him, that such extension should be main- tained during the whole of the treatment, in order to bring about a permanent union. This aim is, in fact, the common basis of all the numerous methods of cure, which have been since recommended. Dr. Alexander Monro,primusjhappened to rupture his tendo Achillis. When the acci- dent took place, he heard a loud crack, as if he had suddenly broken a nut with, his TEN £E* heel, H"d he experienced a seusation as it the heel of his shoe had made a hole in the floor. This sensation, he says, has also heen observed by others, though some have complained of a smart stroke, like what would be produced by a stone or cane. Immediately suspecting what bad happened, the doctor extended his left foot, in which tbe occurrence had taken place, as strongly as he could with his right hand, while with the left he pressed the muscles of the calf downward, so as to bring the ends of the liroken tendon as near together as possible. In this position he sat, until two surgeons came to his assistance. They applied com- presses, and a bent board to the upper part of Ihe foot and forepart of the leg, both which they kept, as nearly as possible, in a straight line, by a tight bandage made with a long roller. But as this mode of dressing soon became very uneasy, it was changed for the following one. A foot-sock, or slip- per, vvas made of double quilted ticking, from the heel of which a belt or strap pro- jected, of sufficient length to come up over the calf of the leg. A strong piece ot the same materials was prepared of sufficient breadth to surround the calf, and this was fastened with lacings. On the bac k part of this was a buckle, through which the strap of the foot-sock was passed, so that the foot could be extended, and the calf brought down at pleasure. The leg and foot were wrapt up iu soft flannel, fumigated with benzoin, and the bandage was kept on day and night, the belt being made tighter when the doctor was about to go (o sleep, and loosened when he was awake, and on his guard. For a fortnight he did not move his foot and leg at all, bul was conveyed in a chair on castors from one part of the room lo another. After this, he began to move the ankle-joint, but in such a gentle manner as not to give any pain. The de- gree of motion was gradually increased as the tendon became capable of bearing it, care being taken to stop when the motion began to create uneasiness. The affected limb was moved in ibis way for half an hour at a time*, In a few days the hollow, between the separated ends of the tendon became imperceptible, though the part con- tinued soft much longer. It became, how- ever, gradually thicker and harder, until a knot was at last formed in it, apparently of a cartilaginous nature. Though this was at fust as large as a middling plum, and gra- dually became softer and smaller, yet it did not disappear entirely, having occasion to go out six weeks after the accident, the doctor put on a pair of shoes, with heels two inches high, and contrived a steel ma- chine to keep his foot in the proper position. This machine,however, he afterward changed for another, made of the same materials as the former. It was not till five months after the accident, that bethought proper to lay aside all assistance, and to put the strength of the tendon to a trial. (See Monro's Works, p. 661.) ' Both in a wound and rupture in the tendo Achillis, the ancient method ol using a suture for keeping the ends of (he tendon in contae t, is at present quite exploded, and position of the limb is the grand agent, by which the cure is now universally accom- plished. The following was Desault's method, which, though it was expressly designed to fill all tbe above-mentioned indications, may not be a more valuable practical plan than what was adopted by Dr. Monro. After (he ends of the tendon had been brought into contact by moderate flexion of the knee, and complete extension of the foot, Desault used to fill up the hollows on each side of the tendon, with soft lint and com- presses. The roller, applied to the limb, made as much pressure on these compresses as on the tendon ; and hence, this part could nol be depressed too much against the sub- jacent parts. Desault next took a corapresi about two inches broad, and long enough to reach from the toes to the middle of tbe thigh, and placed it under the foot, over the back of the leg and lower part of the thigh He then began to apply a few circles of a roller round the end of the foot, so as to fix the lower extremity of the longitudinal compress. After covering the whole foot with the roller, he used to make the bandage describe the figure of 8, passing it under tbe foot, and across the place where the tendon was ruptured ; and the method was finished by encircling the limb upwurd with the roller, as far as the upper end of the longi- tudinal compress. (See Monro's -Works. Encyclopedic Milhodique, article Athillc, ten- don de, and Memoire sur la Division du Tendon d'Achille, in CEuvres Chirurgicales de Desault, par Bichat, T. I,p. 806.) A rupture of the tendon of the extensor muscles of the leg, would require nearly the same kind of treatment as a fracture of the patella. However, pressure exactly on the broken part of the tendon should be avoid- ed, the limb should be kept extended, and somewhat raised; a bandage might be put round ine thigh, aud antiphlogistic treatmeiu be at first adopted. In the course of two or three weeks, the surgeon should caiiM" tl'.e-ejwint to be very gently moved, without any muscular exertion on the part of the patient himself. When the tendon of the triceps extensor cubiti is ruptured, the limb is to be kept straight; cold applications are to be used for a few^ays, and if necessary, strict antiphlogistic treatment pursued. TENT. A roll of lint for dilating open- ings, sinuses, 6ic. TEREBELLA. (dim. of terebra, a perfo- rating instrument.) A trepan, or instrument for sawing out circular portions of the skull A trephine. TEREBRA. (from re^ta, to bore.) A tre- pan, or trephine. Also au instrument called a perforator. TKStlCLE, DISEASES OF. For an account of many of these affections, I must refer to distinct articles in this Dictionary; for instance, Cirsocele, Fungus Haimalodes, Hernia Humoralis, Hematocele. Hydrocele. fyc. TESTICLE. 461 .Mr. Pott defines surcxtccle to be a disease of the body of the testicle, and, as the term implies, it consists, in general, in such an •Iteration, made in the structure of that or- gan, as produces a resemblance to a hard, fleshy substance, instead of that fine, soft, vascular texture, which it naturally presents. " Sarcocele (says Callisen) is a name applied to every chronic swelliug of the testicle, intended with a total, or partial, conversion of the part into an heterogeneous sub- stance." (Si/slema Chirurgim Hodiernal, Pars 2, p. 144.) According to these defini- tions, sarcocele becomes a term admitting of almost general application to the mor- bid affections of the testicle, since most of them are attended with induration and swelling of the part. In fact, we find that the old writers, and a great many of the moderns, call all diseased indurations and enlargements of the testicle sarcoceles, whe- ther the disorder be a simple, chronic, in- dolent tumour, unaccompanied with any symptoms of specific disease, or malignan- cy, or whether it be a scrofulous, or, what is still more different and more serious, a truly scirrhous disorder of Ihe organ. Even the fungus haematodes of the testicle was, until lately, often termed sarcocele. That this vague method of employing the word sarcocele can be attended with no advantage, but, on the contrary, must have a tendency to destroy all useful discrimina- tion, is a proposition, the truth of which is self-evident. I am well aware, (hat Mr. Pott, and many late writers, set out with an idea that every sarcocele has a propensity to change* into scirrhus, and actual carcino- ma, and, therefore, the latter states arc con- sidered by these authors only as stages of (he same disease. Indeed, it is universally admitted by the best and most experienced observers, that a common indolent sarco- cele, a simple fleshy enlargement of the testicle, may change into the peculiar ma- lignant disease, called scirrhus, or cancer. But yet it is by no means proved, that all the diseases which are comprehended under the name of sarcocele, are accompanied with a risk of their assuming the nature of scirrhus and cancer; for nothing can be more certain, than that the enlargement of the testicle, produced by fungus ba-matodes, is, from the first to the last, always of one character, and can never change info ordi- nary scirrhus, or carcinoma. Neither do indolent scrofulous swellings of this organ ever undergo such an alteration as to de- serve the epithets of s irrhous and cancerous. In opposition to the belief of Mr. Hunter, (see his Treatise on the Venereal Disease, p. 59,) some surgeons still imagine, that there is really one kind of chronic enlargement of the testicle, arising from a venereal cause. (Roux, Parallile de la Chirurgie . Ingloise, fyc. p. 3()5. Richerand, Nosographie Chir. T. 4, p. 300, Edit. 4.) Now this also has usu- ally been called a sarcocele ; it was so na- med by Pott himself, and if there be such a case, no one will suppose that it, or any other form of liros venerea, is capable of changing info a true scirrhous or cancerous disease. Perhaps, therefore, it might be more consistent and advantageous to restrict the appellation of sarcocele. to an indolent fleshy enlargement of the testicle, unac- companied with any present symptoms of malignancy, or any marks of its being the effect of a specific disease ; and as soon as the case evincesanothercharacter, the* name should correspond with the particular nature^ of the disease. We need not here enter into a minute ac- count of the various sarcomatous diseases to which the testicle is subject ; for, they have no peculiarity in them, except what depends upon their situation, and the gene- ral characters ofthe different species of sar- coma will be considered in a future article. (See Tumour.) The testicle is especially liable to three kinds of sarcoma, which have been named, by Mr. Abernethy, the common vascular the cystic, and the medullary. The latter case, however, which is often called soft cancer of the testicle, I shall describe in the present article, in order that the reader may judge whether there is any material difference between this case and another distemper to which the testicle is subject. (See Fungus Haimatodes.) l-rometimes the testicle is converted into a truly scrofulous mass. It is increased in size, and when cut into, a whitish, or yellowish coagulated matter is discovered, mixed with pus. The complaint is not attended with so much pain and induration as a scirrhous disorder of the testicle ; nor does it produce any un- favourable state of the health. As Dr. Baillie observes, the testicle is of- ten found converted info a hard mass, of a brownish colour, and generally in(ersected with membranes. Sometimes, there arc cells in the tumour, which are filled with a sanio-is fluid. (Morbid Anatomy, fyc. p. 352 353, Ed'd. 2.) This is the truly scirrhous tes- ticle which is attended with great hardness, severe pains darting along the spermatic chord to the loins, and an unequal knotty feel. In general the health becomes impair- ed. To use Mr. Pott's words, sometimes the fury of the disease brooks no restraint; but, making its way through all the mem braties, which envelope the testicle, it either. produces a large, foul, stinking, phagedenic ulcer, with hard edges, or it thrusts forth a painful gleetingfungus, subject to freqm nt hemorrhage. (Poll's Chirurgical Works, Vol. 2, p. 390, Edit. 1808.) These latter states of the disease are denominated cancer of thetesticle. Sooner or later, the scirrhous induration extends from the epididymis upward along the spermatic chord, even within the abdo- minal ring. Iu the latter circumstance, the lymphatic glands in the groin usually be- come diseased ; and this extension of mis- chief, together with the impossibility of re- moving the whole of the diseased chord, too frequently deprives the patient of every chance of getting well. I have already stated, that some of (he mo<-t rimple sarcomatous enlargements of 4<>_ 1ESTICLL. the te.-licle are capable ol assuming, in n very sudden manner, a malignant and can- i-fcrous tendency ; and that sometimes the scirrhous induration of the chord makes a rapid progress upward. Hence, that sur- geon acts with prudence, who recommends (be early extirpation of every testicle, which is incurably diseased, and so deprived of its original organization, as to be totally unfit forthe secretion of the semen. Chronic enlargements of the testicle are sometimes attended withan accumulation of limpid fluid in the tunica vaginalis, and the disease is then termed, hydro^arcocelc, an ap- pellation first employed by Fabricius ab Aquapendente. The hardnc-s and swelling of the epididy- mis, remaining after an acute inflammation of the testicle (see Hernia Humorali*,) do not constitute a complaint, which surgical authors class with sarcocele; for, (he dis- ease hardly ever increases so as to give trouble. I have slated, that sarcoceles, in common with the generality of odier sarcomatous tu- mours, may change into distempers, which, in point of malignity, and the manner in which they injure the health, are quite as bad as cancer itself. It is said, however, that sarcocele of the epididymis rarely be- comes malignant, and is much more easy of cure, than the same disease of the glan- dular portion of the testicle ; but both parts are often diseased together. Sarcoceles sometimes continue for years, without undergoing any particular change ; in other instances, they increase with sur- prising rapidity. The; inconveniences, which ihey excite, often proceed chiefly from their weight and magnitude : their weight occa- sions an uneasy, aud even a painful sensa- tion in the loins, especially when the pa- tient neglects to wear a suspensory bandage, or a bag truss for the support of the part. The danger of a sarcocele arises irom the increase and extension of tbe hardness up the spermatic chord, and from the change of tbe tumour from i(s indolent state into a painful, ulcerated, and incurable disease. A sarcocele sometimes bears aresemblance to hydrocele of the tunica vaginalis. It sometimes has the usual pyramidal shape of the latter disease, and, like it, is always situated at the I wer end of Ihe spermatic chord. The chief difference between the two cases seems to be, that the sarcocele is hard, while the hydrocele has a soft, yield- s' i. elastic feel. It should be known, how- e ?r, that the fungus hamiatodesof the tes- tide is remarkable for tbe deceitful feel of fluctuation anel elasticity, w hich it presents ; and every surgeon ought to be a«\ are, that a sar-o< ele is not always particularly bard, and that hydroceles are sometimes exceed- ingly indurated. The sarcocele, indeed, is not transparent; neither is the hydrocele in certain instances ; and these are cases, ii which a mistake may easily be made. Still, with due attention, both diseases nay be discriminated with tolerable precision. The sarcocele, w hen held in the surgeon's hand, seems heavier than the hydrocele. Evei? pari of a diseased testicle is seldom equally indurated, so that the sarcocele is usually much softer in some places than others. The hydrocele presents the same kind of feel at every point, except behind, where the testicle is felt. When, in tbe case of hydrocele, pressure is made in this latter situation, the patient experiences a much more acute sensation, than wheu the pres- sure is made upon any other part of the tu- mour ; but, in the example of sarcocele, the patient commonly has the same kind of feel let the pressure be applied to any part of the ^welling whatsoever. When the up- per portion of the spermatic chord can he felt, and it seems quite hard and thickened, the surgeon has reason for suspecting the case to be a sarcocele. Lastly, though n hydrocele, when gently handled, may seem very hard, yet, on being more strongly com- pressed, it will generally betray a soft, elas- tic feel, which, excepting instances of fungus haematodes, is never the case with an indu- rated sarcocele. It has been already explained, that a sar- cocele is sometimes conjoined with a hy- drocele, wliich case is well known among surgeons by the appellation of hydro-sarco- ecle. As the diseased testicle is then sur- rounded with fluid, it cannot be felt and examined by the fingers. However, when au unusual degree of hardness is percepti- ble at tbe back part of the tumour, where the testicle is situated, or when the upper portion of the spermatic chord is found to be Cjuite indurated, there is reason for sus- pecting that the testicle is diseased. The sarcocele also is commonly the original and principal complaint, the hydrocele not oc- curring till some time after the enlargement of the testicle. In some unusual cases, the substance of the scrotum is converted into an indurated mass, which occasionally attains a vast size, and presents the appearance of an enormous sarcocele. An example in which the tu- mour weighed 701b. has been lately publish- ed by Dr. Titley (See Med. Chir Trans. Vol. 6, p. 73.) In one case, recorded by Dr. Cheston, a swelling of this kind was as large as a child's head. On dissection of tbe parts, the testicle and tunica vaginalis were found to be quite free from disease. The tumour proceeded entirely from an indura- tion of the cellular membrane, which im- mediately covers the external surface of the vaginal coat. This curious disease is more common in warm climates, and seve- ral instances of it were met with in Egypt by Baron Larrey. (See Mem. de Chir. Mili- taire, T. 2, p. 110, et seq.) Some interesting particu ars iel live to it will be found in another part of this Dictionary. (See Scro- tum) The operation of castratipn is the most certain means of relieving the patient from scrcocele This measure, however, is not invariably practicable, nor is it always ne- cessary ; for, sometimes the induration of the teMirlc admits of being dispersed by (he IESTICLE 468 judicious employment ot internal medicines and exlernal applications. The hope of ac- complishing this desirable object may be reasonably entertained, when ihe swelling is not very large, when it has not existed a considerable time, and when it is not at- tended with very great induration Expe- rience has proved, that some kinds of sar- cocele have yielded to the exhibition of emetics, (Warner, Pringle, and Home in Chymical Experiments;) to a decoction of ononis spinos. (Bergius Mat.Med. Richter's Chir. Bibl. 7 R.p 605;) to cicuta and bark (Wamer;) to mercurial fricti ms (Le Dran, B. Bell, Richerand, Deipech ; to the external use ofthe liquor amnion, acetatis (Richier's Chir. Bibl. B.p. 127 ;) to poultices contain- ing opium (Fothergill, in Med. Obs.fy tnq. Vol. 6;) to a lotion made of a strong de- coction of hemlock (Warner,") to the steam of vinegar, tbe repeated employment of leeches, and tbe application of cold, &.c. The operation of all these means will be ad- vantageously assisted by the continual use of a bag-truss, the observance as much as possible of an horizontal position, aud attention to a suitable low diet. Mr. Pott believed, that the man who has tbe misfortune to be afflicted with a sarco- cele, has very little chance of getting rid of the disease by any plan except extirpa- tion; and all the time tbe operation is de- ferred, he carries about him a pari, not only useless but burdensome, and which is every day liable to become worse, and unfit for such an operation. Now, although there is a great deal of truth in this opinion, yet, I conceive, it is rather exaggerated, and that it would tend to authorize the practice of castration to an extent beyond all necessity. I certainly think, with Mr. Polt, that Ihere never was a sarcocele cured, w here the or- ganization ofthe testicle had been destroy- ed by disease, or where its structure bad suffered so much as to render it incapable ofthe office for which it is destined. But such state cannot always be known by in spection or manual examination, and were a surgeon to condemn to the knife every testicle which he finds affected with indo- lent swelling and induration, he would re- move many wliich, under some ofthe above plans of treatment, might be perfectly cu- red. That there are some chronic enlarge- ments ofthe testicle which may be resolved, is a truth of which experience must have convinced the generality of surgeons. The scrofulous induration, and several other swellings of this organ, which are very imperfectly understood, may some times be benefited, and even entirely cured, just like some analogous affections f the breast. What is termed the venereal sarco cele (Mr. Pott allows) always gives way to a mercurial course properly conducted. The diagnosis of this case, it must be con- fessed, is not very clearly explained by sur- gical writers, nor was its reality acknow- ledged by Mr. Hunter. According to Mr. Pott, it is seluom an early symptom, and !>e does not remember ».*ver to have seen an instance in which it was not either im- mediately preceded, or accompanied by some other appearances plainly venereal. He adds, that it has neither the inequality nor darting pains of scirrhus. But the question, whether the case is truly syphilitic or not, is tar les.*> interesting than the ques- tion, whether there are not many sarcoceles which may be diminished and cured by mercury ? The affirmative cannot be ques- tioned. I have seen many such cases my- self, and there are numerous examples on record. A statement of several has been lately published by Richerand. (See Non- graphic Chirurgicale, T. 4, p. 300, et seq. Edit. 4.) The authority of Delpech is also on Ihe same side. Pricis Elimentaire des Maladies Reputies, Chir T. 3, p. 564.) Indeed this last writer maintains, that many common sarcoceles and scirrhi of the testicle are so much alike in their symp- toms, that the difference of their nature cannot always be at once detected by the practitioner. Hence, although I am an advocate lor the early perlormance of cas- tration in cases of sarcocele, where there is reason to suppose the disease so far advan- ced, that the organization of the testicle is totally destroyed; or where internal and external remedies have been tried a certain time in vain; yet these sentiments do not incline me to recommend the operation for other examples in which the disease is quite recent, and no plan of treatment what- soever has been fairly tried. I have already enumerated various plans of treatment, which have been proved by experience to be sometimes capable of affording relief. The disease of the testicle, which is usually called the scrofulous sarcocele, like other forms of scrofula, often gets well spontane- ously after a certain time, and it may fre- quently be considerably benefited by admi- nistering internally the conium maculatum, and small doses of the submuriale of mer- cury ; lotions of sea-water, or poultices of sea-weeds, being applied to the scrotum. Several other indolent enlargements of the testicle yield to frictions with ca.phorated mercurial ointment on the scrotum. The late Mr. Ramsden thought that some sarco- celes might be relieved by removing with bougies a supposed morbid irritability of the urethra, with which his theories led him to coni.eetthe origin of the complaint. (See Prad. Obs. on Sclemcele, fyc.) The novelty of this suggestion for a time attracted con- siderable notice ; but the interest which it once excited has now died away ; a suffi- cient proof to my mind, that the practice inculcated vvas not of much value. From the preceding observations, it may be inferred, that all chronic enlargements ofthe testicles are not incurable; but that we ought at the same time to be duly im- pressed with the expediency of not wasting too much time in the trial ot means which are not (o be depended upon, and which, if continued immoderately long, might allow the disease to advance too far to be capable of being afterward pffecfually extir- ,.,4 lEs'l'lCLF pated. According io Mr. Poll, die circum- stances in which the operation of castration is adviseable, or not. are of two kinds, and relate either to the general habit of the pa- tient, and the disorders and indispositions of some of the viscera, or to the state of the testicle and spermatic chord A pale, sallow complexion, in those who used to look otherwise; a wan counte- nance, and loss of appetite and flesh, with- out any acute disorder ; a fever of the hec- tic kind; and frequent pain in the back and bowels are, in those who are afflicted with a scirrhous testicle, such circumstances as would induce a suspicion of some latent mischief in some of the viscera; in which case, as Mr. Pott truly observes, success from tbe mere removal ofthe testicle is not to be expected They whose constitutions are spoiled by intemperance, previous to their being attacked with this disease ; who have hard livers, and anasarcous limbs; be says, are not proper subjects for such an operation. Hard tumours within the'abdo- men, in the regions of the liver, spleen, kidneys, or mesentery, implying a diseased state of the said viscera, are very material objections to the removal of the local evil in tbe scrotum. In short, whenever there are manifest appearances, or symptoms of a truly diseased state of any of the principal viscera, the success of the operation be- comes very doubtful. " The state of the mere testis can hardly ever be any objection to the operation ; the sole consideration is the spermatic chord : if this be in a natural state, and free from disease, the operation not only may, but ought to be performed, let the condition of the testicle be what it may ; if the sperma- tic chord be really diseased, the operation ought not to be attempted." And Mr. Pott afterward remarks, '* when the spermatic vessels are not only turgid and full, but firm and hard ; when the membrane which in- vests and connects them has lost its natural softness and cellular texture, and has con- tracted such a state, and such adhesions as not only greatly to exceed its natural ■size, but to become unequal, knotty, and painful, upon being handled, and this state has possessed all that part of the chord which is between the opening in the oblique muscle and the testicle, no prudent, judi- cious, or humane man, will attempt the operation; because he will, most certainly, not only do no good to his patient, but will bring on such symptoms as will most ra- pidly, as well as painfully destroy him.1' " On the other hand," says Pott, "every enlargement of the spermatic chord is not of this kind, nor by any means sufficient to prohibit or prevent the operation. "These alterations or enlargements arise from two causes, viz. a varicose dilatation of the spermatic vein, and a collection, or collections, of fluid in tbe membrane in- vesting and enveloping the said vessels." Shortly afterward tbe'same practical writer continues :—" The diseased slate of a truly ?cirrhon-^ te^'ide. i<= weight, nnd die altera- tion that must be made in the due and pro- per circulation of the blood, through both it and the ves-els from which it is depend- ent, may and do concur in inducing a vari- cose dilatation ofthe spermatic vein, with- out producing that knotty, morbid altera- tion and hardness, which forbid our at tempts. Between these, a judicious and experienced examiner will generally be able to distinguish " In the former, (the truly diseased sta(e), the chord is not only enlarged, but feels unequally hard and knotty; the parts of which it is composed are undistinguishably blended together; it is either immediately painful to (he touch, or becomes so soon after being examined; the patient com- plains of frequent pains shooting up through Ids groin into his back ; and from the dis- eased state of the membrane composing the tunica communis, such adhesions and connexions are sometimes contracted, as either fix the process in the groin, or render it difficult to get the finger and thumb quite round it. " In the other (the mere varicose disten- tion) the vessels, though considerably en- larged and dilated, are nevertheless smooth, soft, and compressible; the whole process is loose and free, and will easily permit the fingers of an examiner to go quite round it, and to distinguish the parts of which it is composed; it is not painful to the touch ; nor does the examination of it produce or occasion those darting pains which almost always attend handling a process malig- nantly indurated." Mr. Pott next explains that, " in the cellular membrane, leading to a diseased testicle, it is no very uncommon thing to find collectionsof extravasated fluid. These, as they add considerably to the bulk and apparent size of the process, make the com- plaint appear more terrible; and, as I have just said, less likely to admit relief. " When the extravasation is general, through all the cells of the investing mem- brane, and the spermatic vessels themselves are hardened, knotty, and diseased, the case is without remedy ; for, although a puncture, or an incision, will undoubtedly give discharge to some, or even the greatest part of the fluid; yet this extravasation ia so small and so insignificant a circumstance of the disease, and the parts, in this state, are so little capable of bearing irritation, that an attempt of this kind must be inef- fectual, and may prove mischievous. "But, on the other hand, collections of water are sometimes made in the same membrane, from an obstruction to the pro- per circulation through the numerous lym- phatics in the spermatic process, while the vessels themselves are really not diseased, and therefore very capable of permitting the operation. In this case, the fluid is generally in one cyst, or bag, like to an encysted hydrocele, and the spermatic chord, cyst and all, are easily moveable from side to side ; contrary to the preceding state in •"''hich die general load in the membrane TESTICLE. 466 fixes the whole process, and renders it almost immoveable. " A discharge of the fluid will, in this case, enable the operator to examine the true state of the process, and, as I have twice or thrice seen, put it into his power to free his patient from one of the most terri- ble calamities which can befall a man." (See Pott on Hydrocele, fyc.) The testicle is subject to a disease often called soft cancer, which, though of a very malignant and incurable nature, is different from the true ^cancer, already de- scribed. It has been particularly noticed by Mr. Abernethy, under the name of Me- dullary Sarcoma. In most of the instances which this gentleman has seen, (he tumour, when examined after removal, appeared to be of a whitish colour, resembling on a general and distant inspection, the appear- ance of the brain, and having a pulpy con- sistence. He has also often ?een It of a brownish red appearance. The following case is related, to illustrate the nature and progress of the disease. " A tall, thin, healthy-looking man, of about fortv years of age, had, about fifteen years before, a swelled testicle from a go- norrhoea ; the epididymis remained indura- ted Six years afterward it became enlar- ged, and a hydrocele at the same time formed. Haifa pint of water was dischar- ged by a puncture, but inflammation suc- ceeded the operation, and this testis became very large. An abscess formed, and burst in the front of the scrotum, and the testis subsided in some degree. Mercury was employed to reduce it, but without effect. The part, however, was indolent, and gave the patient no trouble but from its bulk. "About a year afterward, a gland enlar- ged in the left groin, (the same side as the testis,) another then became swoln in tbe right groin, and in the course of two years, several glands in each groin had attained a very considerable magnitude. At this peri- od, he was admitted into St. Burlholomew's Hospital, under the care of Mr Long. The testis was, at this lime, between four and five inches in length, nnd about (hree in breadth; it resembled its naturcd torn, and wa indolent in its disposition. The spermatic chord was thickened, but not much indurated. Four or five glands were enlarged in the groin on both sides; each of which was of the size of a very large orange ; and when observed together, they formed a tumour of very uncommon shape and magnitude. " They gradually increased in siae for several months, till at last the skin appeared as if unable to contain them any longer. It became thin, in/lamed, and ulcerated, first in the left groin, and thus exposed one of (he mos( prominent tumours. The exposed tumour inflamed and sloughed progressive- ly, till it entirely came away. As (he sloughing exposed ils vessels, which were large, Ihey bled profusely, insomuch that the students endeavoured, but in vain, to secure them by ligatures : for the substance Vol II 59 of the (umour was cut through, and torn away in the attempt. Pressure by the fin- ger, continued for some time, was the only effectual mode of restraining this hemor- rhage. " The loss of one gland relieved the dis- tended skin, which had only ulcerated on the most prominent part of (he tumour, and had not become diseased. It now lost its infl lined aspect: granulations formed, and a cicatrix took place. In the opposite groin a similar occurrence happened. One gland, exposed by the ulcerntion of the skin, slough- ed out, being attended by the circumstances just recited. However, before the skin was cicatrized, ulceration had again taken place in the right groin, in consequence of the great distention of the skin from the growth of the tumour; and sloughing bad begun in the tumour, when the patient, whose vital powers had long been greatly exhausted, died." (See Abemethy's Surgical Observa- tions, fyc. 1804.) Tne preceding kind of disease is now ge- nerally considered to be fungus haematodes. It there are any differences, they consist in the parts sloughing out, and then healing, instead of a fungus shooting out, and con- tinually increasing in size. (See Fungus Heematodes.) D-. Baillie has noticed some affections, in which the testicle becomes bony, cartilagin- ous, b>-.; bui on these it is not necessary for us lo dwell in this Dictionary. The preceding observations may be considered as relating expressly to the diseases for which casual ion is generally performed. (See Cas- tration.) B. .sides 'he fungus, which arises from the testicle in (he advanced stage of carcinoma, and the bleeding fungous growth, which arises from this organ in the ulcerated state of fungus haematodes, there is another su- perficial fungous excrescence, (o which the testicle is subject, and which is entirely free from all malignancy. The disease to which I refer, has been noticed by Callisen, under the name of lipoma of the testicle. " Si ex superlicie albuginea-* vel ipsa tunica vaginal! excrescentiae surgunt, (o(um demum testem involventes, e( scirrhum seu fun gum, men- (ienies, ipsius tamen testis substantia parum aut vix de siatu naturali aberranle; malum naturam lipomalis sequitur, vix unquam in scirrhum et carcinoma abiens." (See Sys- tema Chirurgiai Hodiernal, Vol. 2, p. 145, Edit. .81)0.) I'lie superficial fungus, or lipo- ma of the testicle, was noticed in an early edition ot niiotner publication, and described as " a particular affection of the testicle, in •» hich a fungus grows from Ihe glandular substance ol this body, and iu some instances, Irom the surface of the tunica albuginea. This excrescence is usually preceded by an enlargement of the testicle, in consequence of a bruise, or some species of external vio- lence. A small abscess takes place and nursts, and Irom the ulcerated opening the fungus gradually protrudes." I then proceed- ed lo represent how unnecessary and impro- per it was lo extirpate the testicle, on account 1ES TET of (his affection, if after Ihe subsidence of the inflammation, the part should not seem much enlarged and indurated. I recom- mended ihe fungus to be cut off, or else de- stroyed with caustic ; and 1 founded my ad- vice on a successful attempt of the first kind, which was made in St. Bartholomew's Hos- pital, by Sir James Earle, a little while before my book vvas published. (See First Lines of the Practice of Surgery, p. 399.) An interesting liltlt paper has also been written on the subject, by my friend Mr. Lawrence, who has favoured the public with a more particular account, and nine cases illustrative of the causes, symploms, and Erogressof the disorder. According to Mr. awrence, the patient generally assigns some blow, or other injury, as the cause of the complaint; iu other instances, il originates in consequence of (he hernia humoralis from gonorrhoea, and sometimes appears spontaneously. A painful swelling of the gland, particularly characterized by its hard- ness, is the first appearance of the disease. After a certain length of time, the scrotum, growing gradually thinner, ulcerates; but the opening which is thus formed, instead of discharging matter, gives issue to a firm, and generally insensible fungus. The surround- ing integuments and cellular substance are thickened and indurated by the complaint, so lhat there appears to be altogether a con- siderable mass of disease. The pain abates, and the swelling subsides considerably, when the scrotum has given way. In this slate, the disorder appears very indolent; but if the fungus be destroyed by any means, Ihe integuments come together, and a cicatrix ensues, which is inseparably connected with tbe testicle. Mr. Law rence next informs us, that if Ihe part be examined while (he fnn- gus still remains, Ihe excrescence is found to have its origin in the glandular substance of Ihe testicle itself; that the coals of the part are destroyed to a certain exlenl ; and (hat a protrusion of the tubuli seminiferi takes place through tbe aperture (bus formed. Mr. Lawrence says, be has often ascertained the continuity of (he excrescences with the pulpy substance of the testicle, of which more or less remains, according lo the differ- ence in the period of the disorder. The same gentleman thinks, that tbe glandular part of the testicle experiences an inflamma- tory affection in tbe first instance, in conse- quence of the violence inflicted on it; and (bat tbe confinement of the swollen sub- stance, by (he dense and unyielding tunica albuginea, sufficiently explains tbe peculiar hardness of tbe (umour, and (he pain which is always attendant on this stage of the dis- order. Tbe absorption of the coats of the testis, and of the scrotum, obviates the ten- sion of the parts, and thereby restores ease to the patient, at the same time tbat the fungus makes its appearance externally. With regard to the treatment, Mr. Law- rence is of opinion, that if the complaint were entirely left to ilself, the swelling would pro- bably subside, the fungus shrink, and a com- plete cure ensn**. without r.nv professional assistance , but he adds, that (he disorder is so indolent in (his stage, that a spontaneous cure would not be accomplished till after much time. He says lhat (he excrescence may be removed with a knife, or if the na (ure of its attachment permit, with a ligature, or lhat il may be destroyed wilh escharoiic applications. Mr. Lawrence very judicioui- ly gives ibe preference to removing (fie tumour to a level with the scrotum, by means of Ihe knife, as Ihe most exppditious and ef- fectual mode of treatment. He can discern no ground whatever for proposing castration in this malady, since in no part of its progress nor in any of ils possible consequences and effects, can it expose the patient to tbe slight- est risk. Mr. Lawrence also mentions (he possibili- ty of there being other kinds of fungi, which may be met with, growing from the testicle, and quoles an instance, in which Dr. Ma- cartney found a fungus, of a firm and dense structure, growing from the tunica albugi- nea, while all the substance of tbe testicle ilself was sound. Dr. Macartney was so kind as to show me (he preparation, affording a clear specimen of the second kind of fungus. The cases drawn up by Mr. Lawrence are, in ray opinion, highly interesting, and may be read in the Edinb. Med. and Surg. Jour- nal, for July, 1808. I have already noticed, tbat Callisen repre- sents the lipoma, as sometimes originating from tbe surface of the tunica vaginalis, a kind of case which has not yet fallen under my observation. In the preface to (he last edition of Ibis Dictionary, p. 10, I quoted a case, published by Dr. H. Weinhold, in which the operation for bubonocele was performed, and as tbe (esticle was diseased, the surgeon made a complete division of the spermatic chord, tied the spermatic arteries, and (hen left the tes- ticle in its natural situation. After a time, the absorbents had diminished the part lo a very inconsiderable little tumour. (See Journ. der Prad. Heilkunde von C. W. Hufe- land and K. Himly, 1812, Zehntes, Stack, p. 112.) This case merits attention, ind ought to have been cited in the article Cas- tration, because it is the first instance, I be- lieve, in which such practice was (ned. Subsequently, the following work has been published, though I have nol yet met with it. " Nouvelle Melhode de trailer le Sarcocele, sans avoir recours a Textirpation du Testicule, par C. Th. Maunoir, 8vo. Geneve, 1820 The new plan consists in dividing and lying the spermatic arteries, and leaving the rest of the chord and the testis undis- turbed. TETANUS. (from two, to stretch.) Tetanus is defined by all authors to be a more or less violent, and extensive contrac- tion of tbe muscles of voluntary motion, at- tended with tension and rigidity of the parts affecled. The excessive contraction of the muscles is kept up without any in(ervals of cornplele relaxation, in which respect (he disorder dif- fers from ordinary spasms and convulsion?, TETANIA. 467 where the contractions and relaxations alter- nate in rapid succession. In tetanus, the powers of sensation and intellect also re- main unimpaired, in which particularity it forms a contrast to epilepsy. (Rees's Cyclo- paedia, art. Tetanus.) When its effects .ere confined to the mus- cles of the jaw or throat, it is called trismus, or locked jaw ; when all the body is affected and becomes rigid, bul retains its ordinary straightness, the case is named tetanus. When Ibe body is ben( forwards, (he di-ease is termed emprostholonos.- and opisthotonos, when (be muscles of the back are principally affected. To these four forms, some writers have added a fifth, which they denominate p/e«- rosthotonos, and which is characterized by tbe body being drawn to one side. It is the tetanus lateralis of Sauvages. The different terms which are applied to tetanic affections, do not imply so many particular diseases; but only tbe seat nnd various degrees of one and the same com- plaint. A far more important division of tetanus, is into the acule and chronic, according to its greater or lesser intensity. The first is ex- ceedingly dangerous,and usually fatal; while the latter, on account of tbe more gradual progress of tbe symptoms, affords more op- portunity of being successfully treated. (Lar- rey, in Mim. de Chirurgie. Militaire, T. I, p. 235, 236.) Tetanus may also be distinguished into the traumatic, or that arising from wounds, being the case wilh which surgeons have principally to deal; and into the idiopathic, or that proceeding from a variety of other causes. Traumatic tetanus sometimes comes on in a surprisingly sudden manner, and quickly attains its most violent degree. The most rapidly fatal case that has ever been record- ed, is one that we have on the authority of the late Professor Robison of Edinburgh. It occurred in a negro, who scratched his thumb with a broken china plate, and died of tetanus a quarter of an hour after this slight injury. (See Rees's Cyclopaedia, ail. Tetanus.) But commonly, the approaches of (he disorder are more gradual, and it slowly advances to its worst stage. In this sort of case, tbe commencement of the dis- order is announced by a sensation of stiff- ness about the neck, a symptom, which in- creasing by degrees, renders the motion of tbe bead difficult and painful. In propor- tion as the rigidity of the neck becomes greater, the patient experiences about the root of (he (ongue, an uneasiness which soon changes in(o a difficulty of mastication and swallowing, which after a time became totally impossible. The attempt at degluti- tion is attended with convulsive efforts, es- pecially when an endeavour is made to swallow liquids; and so great is the distress which accompanies these convulsions, that tbe patient becomes very reluctant to renew the trials, and refuses all nourishment. Sometimes it even inspires him with a dread of (he sight of wuter,and a great resemblance to hydrophobia is produced. One of the next remarkable symptoms is a very severe pain at the bottom ofthe ster- num, darting from this point backward to the spine, in the direction ofthe diaphragm. As soon as this pain commences, the spasms of all the muscles about the neck become exceedingly violent, and the head is drawn backwards or forwards, according as the contraction of the extensor or flexor mus- scles happens to be strongest; but in the majority of cases, the head and trunk arc curved backwards, (Boyer, Trailt' des Mai. Chir. T. I, p. 288.) and the contractions in- creasing in force, the body is frequently raised in the form of a bow, resting upon the head and feet alone ; a state which is more particularly denominated opisthotonos. (Rees's Cyclopaedia, art. Tetanus.) At the same time, the muscles which close the lower jaw, and which were affected with . spasm and rigidity in (he very beginning of the disorder, now contract with great pow- er, so as to maintain the lower jaw-bone in- separably applied to the upper one. The last sta(e, which has been considered as a particular affection under the name of tris- mus or the locked-jaw, Boyer conceives may be regarded as the pathognomonic symptom of tetanus, which in many instances is limit- ed to such an affection of the jaw. The muscles affected in tetanic cases are never altogether relaxed, as long as the dis- ease continues ; but still they become more violently contracted in the frequent parox- ysms of spasm, which always attend the complaint, and increase as il advances. The continuance ofthe disease is marked by the increasing spasm of the diaphragm, which now returns every ten or fifteen mi- nutes, and is instantly succeeded by a stronger retraction of fhe head and rigidity ofthe muscles ofthe back, and even of those of the lower extremities. The abdominal muscles are also strongly contracted, so tbat the belly feels as hard and tense as a board. By the violence ofthe contractions, indeed, the recti muscles have been known to be lacerated, as I shall relate an example of hereafter. Sometimes the spasm and ten- sion extend only to tbe muscles on one par- ticular side of the body : the tetanus lateralis of Sauvages, and thepleuroslholonos of other nosologists. When the disease reaches its most violent stage, the flexor muscles of the head and trunk contract so powerfully, that they counterbalance the force of the extensors, and hold those parts in a straight, fixed, im- moveable position. This is the condition to which the appellation of tetanus more par- ticularly belongs. The muscles of the low er extremities become rigid; and even the arms, which till now were little affected, also partake of the general spasm and stiff- ness, with the exception of the fingers, which often retain their moveableness to the last. The tongue likewise continues a long while endued with the power of volun tary motion : but, at length, the violent TETANUS. spasm? do not leave it unaffected, and it is then liable to be forcibly propelled between Ihe teeth, where it is sometimes dreadfully lacerated. In the extreme period ofthe disorder, all the muscles destined for voluntary motion, are affected ; among others, those of the face; the forehead is drawn up i to fur- rows ; the eyes, sometimes distorted, are generally fixea and motionless in their sock ets; the nose is drawn up, and the cheeks are retracted towards the ears ; so thai the features undergo a most extraordinary change When tetanus arrives at this stage-, and the spasms are universal, a violent con- vulsion usually puts au end to the patient's misery. Wherever the muscular contractions are situated in cases of tetanus, they are always accompanied with the most excruciating pain. They sometimes last, without any manifest remission, to the end ofthe disor- der; but in almost all cases, their violence, and the sufferings excited by them, undergo periodical diminutions every minute or two. The relaxation, however, is never such as to let the muscles, which experience it yield to the action of their antagonists ; and it is in nearly all cases followed, in ten or twelve minutes, by a renewal of the previous con- tractions and suffering. The recurrence of diese aggravated spasms frequently happens, without any evident cause; but it is often determined by efforts which the patient makes to change his posture, swallow, speak, be. As Dr. Cullen observes, the attacks of this disease are seldom attended with any lever. When the spasms are general and violent, the pulse is contracted, hurried, and irregular, and the respiration is affected in like manner; but during the remission, both the pulse and respiration usually return to their natural state. The heat ofthe body is commonly not increased ; frequently the face is pale, with a cold sweat upon it; and very often the extremities are cold, With a cold sweat over the whole body. When, however, the spasms are frequent and vio- lent, tbe pulse is sometimes more full and frequent, than natural; the face, is flushed, and a warm sweat is lorced out over the whole body. " Although fever be not a constant attend- ant of^this disease, especially when arising from a lesion of nerves . yet in those cases proceeding from cold, a fever sometimes has supervened, and is said to have been adended with inflammatory symptoms. Blood has often been drawn in this disease, but it never exhibits any inflammatory crust; and all accounts seem to agree, lhat the blood drawn seems to be of a looser texture than ordinary, and that it does not coagu- late in the usual manner. " In this disease the head is seldom af- fected with delirium, or even confusion of thought, till the last stage of it; when by the repeated shoeks of a violent distemper, every function of the system is greatly dis- ¥..-fb.,.p.i. " It is no less extraordinary, lhat iu thi.- violent disease the natural functions are not either immediately or considerably affected. Vomitings sometimes appear early in the disease but commonly they are not conti- nued ; and it is usual enough for the appe- tite of hunger to remain through the whole course of the disease ; and what food hap- pens to be taken down seems to be regularly enough digested. The excretions are some- times affected, but not always. The urine is sometimes suppressed, or is voided with difficulty and pain. The belly is costive; but as we have hardly any accounts, ex- cepting of those cases in which opiates have been largely employed, it is uncertain whe- ther the costiveness has been the effect of (he opiates or of the disease. In several instances of this disease a miliary eruption has appeared upon the skin, but whether this be a symptom of tbe disease, or tbe ef- fect of a certain treatment of it, is undeter- mined. In the mean while, it has not been observed terdenote either safety or danger, or to have any effect in changing the course of the distemper."'—(First Lines of the Prac- tice of Physic, Vol 3.) According to Baron Larrey, the opistho- tonos is not so often observed in Egypt as the emprosthotonos, and the experience of this gentleman taught him that the former was the most rapidly fatal. We must not adopt, however, his curious opinion, that the violent extension ofthe vertehra? ofthe neck, and the manner in which the head is (hrown back, cause slrong compression of the. spinal marrow, and a permanent con- traction of the larynx and pharynx, (•Mf/n. de Chirurgie Militaire, T. I, p. 240.) since this sort of compression, if it did not at once destroy the patient, would at any rate pura- lize most of Ihe muscles, and instantly stop their extraordinary contraction. This experienced w riter notices how much the nerves of the neck and throat seem generally to be att'ected on the inva- sion of this disease. The consequent con- traction of the muscles of these parts, be says, is soon attended with difficulty of de- glutition and respiration. The* patients then experience, if not a dread ol liquids, at least a great aversion to them, which often pre- vents the administration of internal reme- dies ; and if the wound is out of reach of the interference of art, the patient is doom- ed to undergo the train of sufferings attend- ant on this cruel and terrible disorder. "No- thing can surmount the obstacles which present themselves in the cesophagus. The introduction of an elastic gum-catheter into this canal, through the nostrils, is followed by convulsions and suffocation. " I have died this means (says Larrey) on the per- son of Al Navailh, a surgeon ofthe second class, who died of a locked-javv, brought on by a wound ofthe face, accompanied with a comminuted fracture of the bones ofthe nose, and part ofthe left orbit. " In the examination ofthe bodies of per- sons dead of tetanus, I have found the pha- rynx and oesophagus much contracted, and TETANUS. 469 their internal membrane red, inflamed, and covered with a viscid reddish mucus. " Hydrophobia, hysteria, and several other nervous diseases, likewise produce their chief effects upon these organs, and the result appears to be the same. So, I have just remarked, when tetanus is ar rived at its worst degree, the patients have a great aversion to liquids, and if they are forced to swallow them, immediate convul- sions are excited. This circumstance was particularly observed in M. Navailh."— (Mt'm. de Chirurgie Militaire, T. 1, p. 247, 248) Sometimes tetanic affections deviate from their ordinary course and nature. The most singular of these anomalies is recorded by Sir Gilbert Blane ; it is a case in which tetanus prevailed to a very considerable extent, without any degree of pain. The spasms were accompanied with a tingling sensation, which was even rather agreeable than dis- tressing. The case, however, terminated fatally ; but, to the last, no pain was expe- rienced. In two examples, mentioned by the same author, the spasms att'ected only the side of the body in which the wound was situated. The dissection of patients who have died of tetanus, has thrown no light upon the nature of this fatal disorder. Sometimes slight effusions are found within the cra- nium ; but, in general, no morbid appear- ance whatever can be detected in the head. There is always more or less of an inflam- matory appearance in (he oesophagus and in the villous coat of (he stomach about (he cardia. But those who are conversant w ith dissections must be well aware, that these appearances are common to a great numJ' ber of diseases, and are uniformly met with in every case of rapid or violent death. Besides the redness and increased vascula rity of these parts, Baron Larrey, as I have already stated, found the pharynx and oeso- phagus much contracted, and covered with a viscid reddish jnufus. He also found nu- merous lumbrici in the bowels of the seve- ral patients who died.—(See M'-.m. de Chir. Militaire, T. 3, p. 287.) This, however, could only be an accidental complication, and not a cause. In several cases, Dr. M'Arthur found (he intestines much inflamed, and in two of (hem a yellow, waxy fluid, of a pe- culiar offensive smell, covered their internal surface ; but whether die inflammation was primary, or only a consequence ofthe pres- uiv of the abdominal muscles, which con- tract so violently in this disease, be is una- ble to decide.—(See Afd. Chir. Trans. Vol. 7, p. 475, and Rees's Cyclopaedia, art. Teta- nus. ) Dr. Lionel Chalmers, of Charleston, South-Carolina, si,ties, that when the disease forms very quickly, and invades the unfor- tunate persons w ith the whole train of its mischievous symptoms, iu a few hours, the danger is proportioned to the rapidity ofthe attack, and that the patients thus seized, generally die in 24, 36, or 48 hours, and very rarely survive the third day. But when the disease is less acute, few are lost after the ninth or eleventh. (See Mid. Obs. and Inq. Vol. 1, p. 92,93.) From the valuable reporjl of Sir Jame.- Macgrigor, it appears, that several hundreds of cases of tetanus occurred in our army, during die late campaigns in Spain and Por- tugal. The disease was observed to come on at uncertain periods after the receipt of the local injury ; but it terminated on the second, third,'and fourth days, and even as late as the seventeenth and twentieth day ; thou b it was usually not protracted beyond the eighth. (Med. Chir. Trans. Vol. 6, p. 353.)—I had a patient, however, who lin- gered in the military hospital a( Oiidenbosch five weeks, wilh chronic tetanus, before he died. This happened in the year 1814. soon after the assault on Bergen-op-Zoom, where the patient had been wounded, and suffered amputation ofthe thigh. Although tetanus is a disease which has been observed in almost all parts of the world, experience proves that its frequency is much the greatest in warm climates, and especially in Ihe hot seasons of those cli- mates. It is also more common in marshy situations, and countries bordering upon the sea, than in places which are very dry, ele- vated, and at a distance from the sea-Coast. Every class of individuals is exposed to its attacks . but infants, a few days after their birth, and middle-aged persons, -ire said to be oftener affected than older subjects, or others in tbe youthful period of life. The male sex more frequently suffer than the female ; and the robust aud vigorous more frequently (ban the weaker. According lo Dr. Cullen and other medi- cal writers, the causes of tetanus are cold and moisture applied to the body while it is very warm, and especially the sudden vicis- situdes of heat and cold. Or the disease is produced by punctures, lacerations, or olher injuries. Cullen admits, however, that there are probably some other causes, which arc not distinctly known. Baron Larrey observed, that gunshot wounds in the course of the nerves, and injuries of the joints, often produced teta- nus in the climate of Egypt, particul ,rly wheu the weather, or temperature, passed from one extreme to the other, in dump situations, and in those which were adja- cent to the Nile, or the sea. . What he.terms dry and irritable temperaments, were the most subject to the disorder, the event of which was found to be almost always fatal. (Larrey, Op. et Loc. cit.) Traumatic tetanus is remarked to proceed oftener trom wounds of the extremities, than from similar injuries ofthe trm k, head, and neck, sometime* it originates at the moment of the acchh* t, as in the instance mentioned by he late Professor Robison of Edinburgh b.it in general, it does not come on till several days afterward, some- times not till the wound is nearly or per- fectly healed, and free from all pain and uneasiness. Wounds of every description may give rise to tetanus, and in warm cli 1EI AN Is. mates, very mvial injuries produce it Thus, in Egypt, Larrey had one case which pro- ceeded from the lodgment of a small piece of fish-bone in one of the sinuses of the fauces. (Mim.dc Chirurgie Militaire. T. 1, p. 254.) There can be no doubt, hovvever, that in colder regions, traumatic tetanus seldom happens except from contused, punc- tured, or la-jerated wounds ; or wounds of the ginglimoid joints, with laceration ofthe tendons and ligaments; compound fractures, or dislocations; deep pricks in the sole of ihe foot; and especially lacerations of the fingers and toes. A partial division of a nerve has been suspected as a cause ; but as some nerves must be imperfectly cut through in almost every wound, and yet tetanus does not arise, the reality of this cause is doubtful. Besides, if it were true, tbe cure would be easily effected by making the division of the nerve complete, which experience contradicts. Baron Larrey, how- ever, has recorded a fact, which favours the opinion, as I shall presently notice. The inclusion of the nerves in the ligatures ap plied to arteries ?s another alleged cause of tetanus ; but as this fault is very common, and tetanus rather rare in this country, while il may follow all sorts of wounds, whether accidents or operations, the accu- racy of this opinion may also be doubted. In support of it however there are some cases and observations adduced by Larrey, which will be quoted in the sequel of this artic le. i, ^>ee T. 3, of his Mem. de Chir. Mil.) I do not mean to hint, however, that the nerves are not sometimes tied in tetanic cases, or that the practice is not on every account blameable. Amputation and cas- tration are the only great surgical operations to which I have seen tetanus succeed ; (hough it may follow the employment of the kuife on less severe occasions. In warm countries, tetanus is an ordinary consequence of all kinds of wounds. There cannot be a doubt, that difference of climate makes considerable difference in the degree and danger of tetanus. Larrey found, that in Egypt the disease vvas more intense, and bore a greater resemblance to hydrophobia, than iu the colder climate of Germany. In both these countries, he re- marked, lhat when the wounds causing te- ' tan us, injured nerves situated on the* fore- part ofthe body, emprosthotorios was occa- sioned ; that if the** posterior nerves were hurt, opisthotonos followed ; and that when the wound extended quite through a limb, so as to injure equally both descriptions of nerves, complete tetanus ensued. He no- ticed, also, that the disease commonly arose from wounds, when the seasons and tempe- rature passed from one extreme to another. Exposure to the cold damp nocturnal air, he found particularly conducive to it. (See M?m. de Chirurgie Militaire, T. 3, p. 286.) In the late campaigns of our armies in Spain and Portugal, according to tbe report of" Sir James Macgrigor, tetanus occurred in every description, and iu every stage of wounds, from the slighte--t to the most for- midable -. it followed the healthy and Ine sloughing; the incised and the lacerated; the most simple, and the most complicated. It occurred at uncertain periods; hut it was remarked, that if it did not commence before 22 days from the date of the wound, the patient was safe. (See Med. Chir. Trans. Vol 6, p. 453.) In Egypt, as we learn from Larrey, the latest period of tiie commence- ment of tetanus after a wound, was from the fifth to the fifteenth day. (Mem. dc Chir Militaire, T. I, p. 203.) It is observed by Dr. Dickson, that as the acute form ol tetanus is so uniformly fatal, it is of the greatest consequence lo attend to whatever may assist in detecting the dis ease early, or in warding it off. Hicherand states, that in wounds threatening convul- sions and tetanus, a persevering extension of the limbs during sleep often manifest? itself, before any affection of the lower jaw ; and we should naturally pay more attention to any admonition of this kind in punctured, or extensive^, lacerated wounds, particularly of tendinous, or ligamentous parts, and es- pecially in injuries ofthe feet, hands, knee- joint, back, &c. Some prelusive indications of danger may often be derived from the increase of pain, irritation, restlesness, ner- vous twitchings, pain and difficulty in de- glution,or in turning the head ; spasms, or partial rigidity of some of the voluntary muscles; pain at the scrobiculus cordis, a suppressed, or vitiated state ofthe discharge, &.c. which mark the slower approaches of the disease. Larrey adduces several in- stances of tetanus, in which the wound was either dry, or afforded only a scanty serous exudation, and where the symptoms were •relieved on suppuration being re-establisb- ed; and Dr. Reid, in the Edinburgh Medical and Surgical Journal for July 1816, remarks, that on removing the dressing, the wound was covered with a darkish unhealthy-look- ing matter, and that he had seen this change tha forerunner of tetanus in two other in- stances. A torpor of the jntestines has ge- nerally been observed to precede, as well as accompany the disease, and Boyer, in particular, enumerates an obstinate consti- pation among the predisposing causes. (Traiti des Mai. Chir. T. \, p. 287.) Mr Abernethy also informs us, tbat in four cases where he inquired into the atate of the bow- els, the evacuations were not like feces; and he proposes as a question, in investiga- ting the cause, what is the state of the bow- els between the infliction of the injury, and the appearance of this dreadful malady? (Abernethy's Surgical Works, Vol. 1, p. 104.) Dr. Parry thinks the velocity of the circula- tion an useful criterion of the danger of the disease, and observes, that if the pulse be not above 100, or 110, by tbe fourth or fifth day, tbe patient almost always recovers; but that if it be quickened early, the disease mostly proves fatal, and yet there are a few instances of recovery, where the pulse has risen to 120 on the first day. Baron Larrey remarks, that when the perspiration, which so often attends the di«pa*-e js symptomatic. TETaNLo il begins upon the head and exiremities ; but that when it is critical, it occurs over the chest and the abdomen. (Mtmoires de Chir. Militaire, T. I,p. 256.) It must be confess- ed, however, lhat in many cases, perspira- tion flows very freely, without bringing re- lief. (Rees's Cyclopedia, art. Tetanus.) I next proceed to consider tbe treatment of tetanus a subject of infinite difficulty, be- cause the disease frequently baffles every mode of practice, and in certain instances, get well under the employment of tbe very same remedies, which*decidedly fail iu other similar cases of the disorder. Every plan has occasionally succeeded, and every plan has still more frequently miscarried. The great difficulty, therefore, is to ascertain, among numerous discordant accounts, what practice is found on the whole to be attend- ed witb the least ill-success? For, in the pre- sent state of our knowledge, the most cre- dulous practitioner will not flatter himself with the supposition, that any effectual re- medy for tetanus has yet been discovered. As, however, tetanus was regarded by Hip- pocrates and the ancients as certainly mor tal, and it does not always prove so in mo- dern times, it seems allowable to conclude that the recoveries, which now happen, must be ascribed to improvements in prac- tice. This reflection should lead us not to give up the subject as hopeless; but to re- double our exertions for the discovery of a more successful method of treatment, and if possible, of some new medicine, possess- ing more specific power over the disorder. As it is justly observed by a well-inform- ed writer, when we reflect upon the obscu- rity which involves both the ratio sympto- malum, and the proximate cause of tetanic affections, we need not wonder, tbat the practice in these disorders should still be entirely empirical. The indication of cure, which is generally applicable in all diseases, namely, the removal of the exciting causes, has but little place in a morbid condition, which is the consequence of causes, that in general have ceased to act, or which it is not in our power either to remove or con- trol. In those cases, where we could sup- pose local irritation to be still operating, the most effectual method of counteracting its effects on the system, would obviously be to intercept all communication between the seat of the irritation and the sensorium. If, hovvever, the disease has already esta- blished itself, and the severe symptoms have come on, it does not appear that this would succeed in arresting the course of the disor- der. Experience has but too fully shown, that the amputation of the limb, from the injury of which the tetanus has arisen, will very seldom procure even a mitigation of the symptoms, if performed after a certain period from their first appearance. (Rees's Cyclopadia, art. Tetanus.) Baron Larrey has been the greatest modern advocate for (he performance of amputation in cases where tetanus depends upon a wound of the rxtremities ; but the facts which he has ad- dn'-<*d it) if* favour are not numerous, and he limits his recoutuu/uauitoii oj" the uieasure chiefly to chronic cases, and extends it to no others, except on the very first accession of the symptoms. " The equally unexpected and entire suc- cess (observes Larrey,) obtained by the am- putation of the injured limb, in the person of an officer attacked with chronic tetanus, leads me to propose the question, whether, in this disorder, occasioned by a wound oj' some part of the extremities, it would not be better to amputate the injured limb immedi- ately the symptoms of tetanus commence, rather than expect from the resources of nature, and from very uncertain remedies, a cure which so seldom happens ? " If tetanus is chronic, as is sometimes ob- served, amputation may be done at every period of the disorder, provided a choice be made of the time when there is an inter- mission of the symptoms. The operation would not answer so well in acute tetanus, if tbe disease were advanced, and (he mus- cles (o be divided were strongly contracted and rigid, as I have observed at the siege of Acre in a soldier, who was seized with tc(a- nus in consequence of a gunshot wound of (he left elbow." (Mim.deChir. Militaire, T. I, p. 262.) Larrey did, indeed, try amputation in a few instances of acute tetanus. In tbe case last cited, the symptoms were already considera- bly advanced, when the experimenl of am- putating the arm was made ; yet, says Lar- rey, the operation was followed by consider- able ease. The symptoms recurred, how- ever, a few hours afterward, and proved fatal on the third day. In another example, (bis genlleman repealed (he experiment, (hough acute tetanus had begun. The ope- ralioo is described as having stepped all (he symptoms, as it were, by enchantment ; the patient even passed twelve hours in perfect ease ; but being exposed to the damp cold air, the disorder returned, nnd carried him off. (See Mem. de Chirurgie Militaire, T. 1. p. 263—269.) The Baron also records some cases in favour of amputation at the com- mencement of tetanus from wounds, and es- pecially for (he relief of (he disease in (he chronic form. He has likewise adduced an interesting example, in which speedy relief and a cure followed cutting off all commu- nication between tbe nerves of the wound- ed part and the sensorium by a suitable in- cision. In this place I think il right to remind the reader, that although Baron Larrey once or twice amputated when acute tetanus was somewhat advanced, he does not advise the practice, and he expressly restricts bis sanc- tion of amputation to chronic or quite inci- pient cases of tetanus, and to a few instances iu which the ginglinioid joints are fractured, accidents, which, independently of tetanus, would generally require the operation. (See Mim. de Chir. Mil. T. 3.) The report of Sir James Macgrigorfully confirms the statement of Larrey ; namely, that free incisions are of little avail in the acute and fully formed disease, and that -imputation f>;u in* rbe samr '1'E.I A.MJd. kind of ca*e. Alter the baffle of Toulouse, this operation was extensively tried ; but wilhout success. The French are also said to have lost an immense number of s ddiers from tetanus afier the battle of Dresden, when Sia James infers that the practice of amputation must have been fairly tried. (See Medico-Lhirurgical Trans. Vol. 6, p 456.) We have seen, however, thai according to the precepts of Larrey, the French surgeons would only have performed the operation in chronic cases, which are not the most fre quent, or if in other instanci only on the very first accession of the symptoms. But upon the whole, notwithstanding the partial degree of success attending Larrey's experi- ments, I have no hesitation in d**clarin? my belief, thai amputation of the injured part in cases of chronic tetanus will never be exten- sively adopted. The uncertain efficacy of this severe measure, and the occasional pos- sibility of curing thi f<*rm of the complaint by milder plans, will lor ever constitute insu- perable arguments against the practice. Since ihe last edition of this Dictionary was printed, Sir Aslley Cooper has published his sendinents respecting the plan of ampu- tating in ca-es of tetanus, and ihey tend lo confirm 'hi opinion which I have always given upon (he subject.. In one case of te- tanus, Irom a compound fracture just above the ankle, tbe operation seemed to precipi- tate the fatal event. In another case, tbe linger was amputated without any good ; and a third case is referred to, in which the ope- ration also failed in saving the patient's life. In chronic tetanus, amputation is regarded by Sir A. Cooper as unjustifiable, as the pa- tient often recovers without this proceeding. The medicine which bus appeared lothis gen- tleman most useful in such cases, is the sub- muriate of mercury, joined with opium (Surgical Essays, Part 2, p. 190.) On tbe subject of making incisions for die purpose of separating Ihe nerves of the wounded part from the sensorium, Larrey states, that the*y should be practised before inflammation has come on ; for if ibis has made progress, they would be useless, and even dangerous. Tbey should comprehend, as much as possible, all die nervous filaments and membranous parts; but he condemns all incisions into j-dnts, as exasperating the symptoms of tetanus, instances of which he has witnessed. The Baron bas recorded some convincing proofs of the benefit some- times arising from completely dividing the trunk ofthe injured nerve. In one instance, tetanic symptoms followed an injury of ihe supraorbilary nerve, but were immediately stopped by dividing some of the fibres of (he occipito-frontalis, and ihe nerves and vessels, down ;o th. bone. On the principle of destroying the parts, which are ihe seat of the local irritation, Baron Larrey also frequently applied the actual and potential cautery to the wound. The application ot causlics, says he, may be practised with advantage on the first attack of the symptou.s, the same precept being ob- served as in making the i ucisions Bleeding, if necessary, and ths use of topical emollients and anodynes, may follow these operations; (hough in general (hey have little effect. (Mim. de Chir. Militaire, T.l,p. 249.) In the third volume of this interesting work, p. 297, be are/several cases, in which the cautery was employed with success. We must not conclude, however, dial much dependence ou Jit 'o be placed in the use of Ihe cautery, si,ice Larrey observes in another place : " Tiie moxa and actual cautery recommend- ed by the Father of Medicine, have been equally unavailing. 'Hbe moxa was employ- ed at Jaffa upon (hree wounded men ; (he disease notwithstanding followed its usual course, and terminated fatally. '- 1 have cited a striking instance of the inefficacy of (he second method, in a case of opisthotonos." (T. l,p. 258.) This au- thor also adduces some cases which tend to support (be opinion, that tetanus occasional- ly proceeds from the inclusion of a large nerve in the ligature applied to an arfery. Tbe son of General Darmagnac died of te- tanus consequent to amputation, and upon examining tbe stump, ihe median nerve was found included in the ligature with the arte- ry, and its extremity reddish and swollen, (Mim. de Chir. Mil. T. 3, p. 287.) In ano- ther case, Larrey suspected the tetanic disor- der to proceed from a principal branch of the crural nerve being tied together with the femoral artery, and he cut the ligature ; but the relief was only partial and temporary. The cautery was (herefore applied deeply (o (be whole surface of (he stump. A marked amendment took place a few hours after- ward, and the patient recovered. A diapho- retic mixture, with camphor and opium, was also exhibited. (T. 3, p. 297.) Among other local means for the relief of tetanus, we mighl as well notice the employ- ment of blisters as near as possible to the wound, or their application, or (hat of the ointment of cantbarides, io the wound itself. Almost all modern writers have observed, lhat tetunus is accompanied at its commence- ment and in its progress with an interruption, or total cessation of suppuration in the wound. Hence the indication to excite this process again by the means which I have specified. Larrey seems to have adopted both plans, bul he particularly applied the ointment of cantbarides to the wound itself in an early stage of the symptoms, and in cases where there not only was a suppression of the discharge, but where he suspected Ihe nerves of the wounded part had suffered from exposure to the cold damp air, on tbe detachment of the sloughs. For facts in fa- vour of these local means, the reader must refer to tbe first and second volumes of tbe Meraoires de Cnirurgie Militaire. Il appears also from Larrey's experience in Egypt, that poultices made of the leaves of tobacco, and applied to (be wounds of persons labouring under tetanus, are follow- ed by no advantageous effect. The alka- lies also proved of no service. (Tom. l,p- 257.) I shall conclude these remarks ou what TETANLs 47.3 tnay be called tho local treatment of tetanus, wilh mentioning, that the celebrated Dr. Rush recommended the wound to be dilated nnd dressed witb oil of turpentine. (See Trans, of Ihe American Philos. Society, Vol. 2;) and that our naval surgeons often use tincture of opium as a dressing. A great degree of obscurity prevails re- specting (he most eligible general or constitu- tional plans of treating tetanus, and I am afraid it must be confessed, that our internal remedies cannot be more depended upon, than the local means already described. This opinion is fully confirmed by adverting lo the discouraging fact, recorded by Sir James Macgrigor, viz. thai out of several hundreds of cases which occurred in the British army during (he late campaigns in Spain and Portugal, there were very few which terminated successfully, or in which the remedies, however varied, seemed to have any beneficial influence after the disease had made any progress. (Medico-Chir. Trans. Vol. 6, p. 449.) The possibility of doing much good by internal medicines is also sometimes totally prevented by (he inabili- ty of swallowing which afflicts the patient. In short, the present state of our knowledge respecting tetanus, will not allow us to in- dulge much hopes of cure from any means yet discovered, except in the chronic form of the complaint, the instances of success in the treatment of acute tetanus being by no means numerous. Of all medicines, opium is that which has raised the greatest expectation, and been the most extensively tried in cases of tetanus. Indeed, there cannot be a doubt, that in many chronic, mild cases, it is competent to effect a cure. But for this purppse, i( is ab- solutely necessary that its use be begun from (he earliest appearance ofthe symptoms; tbat it be given in very large doses ; and that the doses be repeated at short intervals, so (hat the syslem be kept cons(an(Iy under the influence of the remedy. It is, indeed, as- tonishing how (he syslem, when labouring under a tetanic disease, will resist the opera- tion of this and other remedies, which, in its ordinary state, would have been more than sufficient to overpower and destroy it. Pa- tients with te(anus will bear, with impunity, quantities of opium, which at any other time would have been certainly fatal. Instances are upon record of five, ten, and even twen- ty grains, being taken every two or three hours, for many days, without any extraor- dinary narcotic effects being produced upon the sensorium. It is always adviseable, how- ever, to begin with comparatively moderate doses, such as forty or sixty drops of the tincture of opium, which may be repeated at intervals of three or four hours, and in- creased at each repetition, until some sensible effect is produced on the spasms. It seems requisite to augment (he dose rapidly, as the disease presses upon us every hour, and no time mu9t be lost while there is yet a chance of controlling its fury. The approaching closure of the jaw, and difficulty of degluti- tion, which mav increase '.o as to render it Vor. II fit) hardly possible to introduce medicines info the stomach, are additional motives for push- ing our remedies before such obstacles arise. (Rees's Cyclopaedia, art. Tetanus.) I once sup- posed it might be possible to overcome (his impediment by introducing a flexible cathe- ter down the cesophagus from one ofthe nos- trils; but the attempt to do this always brings on a violent paroxysm of spasms, at- tended with such a sense of suffocation that it cannot be endured. The experience of my friend, the late Mr. Cruttwell, of Batb, and that of Baron Larrey, have fully proved, that no assistance can be derived in these circumstances from the use of any flexible tubes. (See Mim. de Chir. Militaire, T. l,p. 247.) Sometimes, however, the obstacle to the administration of medicines, arising from (he closure of the jaw, is prevented by loss of some of the incisor teeth, aud, in a few- instances, Baron Larrey adopted the plan of extracting two of (hem. This would be use- less; however, when degludon is totally hin- dered, as happened in one instance recorded by the latter eminent surgeon. (Op. cit. T. 3, p. 301.) Glysters are the only resource, when the spasms of die fauces cannot be overcome. In this way, as much as a drachm of the extract of opium has been in- troduced into the bowels at one dose. Opi- ate frictions upon the jaws, throat, and other parts of the body, have been practised. Opi- ate plasters have also been applied to the masseter muscles, and behind the ears. This external use of opium, however, can only be regarded as a feeble, and probably useless method. As the costiveness always produced by (etanus is rendered still more obstinate by opium, laxative medicines and glysters should constantly accompany its employment. The testimony ofthe army physicians, as we learn from the report of Sir James Macgrigor, is highly in favour of a rigid perseverance in the use of purgatives, given in adequate doses to produce daily a full effect. Dr. Forbes states, that a solution of sulphate of magne- sia, iu infusion of senna, was found to an- swer better than any other purgative; and it was daily given in a sufficient quantity to procure a copious evacuation, which was always dark-coloured and highly offensive ; and (o this practice he chiefly attributes, in one severe case, the removal of the disease. (Medico-Chir. Trans. Vol. 6, p. 452.) A spasmodic rigidity of the muscles being the most prominent symptom of tetanus, it was natural for practitioners to try the effica- cy of some other antispasmodic medicines be- sidesopium, and those which have been prin- cipally the subject of experiment, are casto- reum, aether, the conium maculatum, musk, camphor, and latterly the digitalis. In many cases, opium and camphor have been exhi- bited together. Indeed, Larrey asserts, that of all the medicines hitherto proposed by skilful practitioners, the extract of opium combined with camphor, and the nitrate ot" potassa, dissolved in a small quantity ofthe almond emulsion, and given in dose3 moro or less 'frong, produces the m*'*t{avo*irp.h.'e IETA-NLS. effect?, since patients, who Lave an aver- sion to other fluids, take with pleasure this mixture, the action of which must bt pro- moted by bleeding, if necessary, and blis- ters, under the circumstances which have been specified. (See Mim. de Chir. Militaire, T. 1, p. 271.) In the same work several cases are detailed which were benefited by such treatment. Although some practitioners have thought that they have seen good etfects result from musk, yet the majority of practitioners, who have made trial of both this and camphor, in cases of tetanus, have found no reason to recommend these medicines. Possibly this may be owing, in some instances to sufficient doses not having been exhibited, or to the musk not being of a good quality. One hundred and fifty grains of musk, however, have been given in the space of twelve hours, to a young girl, thirteen years old, affected with an incipient tetanus; but no salutary effect on the disorder was produced, We learn also from Sir James Macgrigor, that aether, camphor, musk, and other anti- spasmodics, as likewise the alkalies, vvere tried by our military s,'iVgeons in Spain, and found unsuccessful. (Medico-Chir. Trans. Vol. 6,p. 458.) From the same authority we find, that digitalis, in large doses, was tried in several cases in the peninsula ; and that it, with se- veral olher medicines enumerated, failed in almost every case of acute tetanus which occurred. (P. 454.) In one case recorded, the jaw remained fixed to tbe last, and the patient was never entirely free from spasms. (P. 458.) I am not acquainted with any cases in which belladonna has been given ; but it is certainly a remedy well worthy of trial. Analogy has also led to the employment of the warm bath, as a plan which seemed to promise great benefit, by producing a re- laxation of the contracted muscles. But, notwithstanding this means has appeared in a few instances, to occasion some little re- lief, particularly when the practitioner has been content with mere fomentations, it generally fails and often has even done mischief. This may perhaps be, in some measure, ascribable to the disturbance and motion which the patient must necessarily undergo, in order to get into the bath ; for it is very well known, tbat every exertion on the part of the patient is very apt to ex- cite most violent paroxysms of spasm. The author of the article Tetanus, in the Ency- clopedic Methodique, mentions his having seen the warm bath do harm, in two or three e;ases in which it was expected to do good. Though numerous writers have recommend- ed the (rial ofthe plan, it would be difficult to trace, in their accounts, any facts which decidedly show that its adoption bas ever been followed by unequivocal benefit. Tbe warm hath was tried in Spain, and found to produce only momentary relief. (Medico- Chir. Trans. Vol. 6, p. 457.) Dr. Hillary, who practised a long while in tbe warm < bmate of America, where tetanus is verv common, disapproves of this method t-i treatment. He observes, that although the use of the warm bath may appear (o be very rational, and promise to be useful, he has" always found it much less serviceable than emollient and antispasmodic fomenta- tions; mid he also mentions, that he has sometimes seen patients die the very mo- ment when they came out of the bath, not- withstanding they had not been in it more than twenty minutes, the temperature ofthe water being likewise not higher than 29 or 30 of Reaumur's thermometer. (See /Ma- ry on the Air and Diseases of Barbadoes.) De Haen also relates a similar fact of a patient dying the instant he was taken out of the warm bath. It was in all probability, the bad effects and inefficacy of the warm bath which in- duced practitioners to try what might be ef- fected by the cold one. Tbe advantages of the cold bath were first explained by Dr. Cochrane, in the Edinb. Medical Commen- taries ; and the plan has subsequently re- ceived tbe praises of Dr. Wright, the emi- nent Dr. Currie of Liverpool, and others. Of all the remedies, which have been em- ployed in cases of tetanus, the cold bath seems to be that which has been attended with the greatest success. Dr. Wright has published, in the Medical Observations and Inquiries, Vol. 6, a paper, iu which may be found a narrative of the first trials of this method, which were all successful. The plan is said to be at present preferred throughout the West Indies. The way adopted consists in plunging the patient in cold water, and in that of the sea, when at hand, in prefer- ence to any other, or else iu throwing from a certain height several pails of cold water over his body. After this has been done, heis to be very carefully dried with a towel, and put to bed, where he should only be ligbily covered with clothes, and take twenty or thirty drops of laudanum. The symptoms usually seem to give way, in a certain de- gree, but the relief which the patient expe- riences is not of long duration, and it is ne- cessary to repeat the same measures at the end of three or four hours. They are to be repeated in this manner; that is to say, at such intervals, until those of freedom from the attacks ofthe disorder increase in length. This desirable event generally soon follows, and ends in a perfect cure. Wine and bark »* were sometimes conjoined witb the forego- ing means, and seemed to co-operate in tbe production of the good effects. Dr. Wright concludes the account with the following remark, sent to him with a case by Dr. Drummond of Jamaica :—" I am of opinion that opiates and the cold bath will answer every intention in the tetanus and such like diseases; for whilst the opium diminishei the irritability, and gives a truce from the violent symptoms, the cold bath produces that wonderful tonic eft'ect so observ- able in this and some other cases. Per- haps the bark, joined witb these, would render the cure more certain. May we not then have failed in many cases, by using IETANUS. •475 opiates alone m large doses, or what proba- bly is worse, with the warm bath, instead of the cold bath ? And have we not reason to suspect that the increased doses of opium, that seemed requisite when the warm bath was used, may have proved pernicious ?"— (Vol. 6, p. 161.) Our army surgeons, who were in Spain, are said to have found the. cold bath worse than useless, (Medico-Chir. Trans. Vol. 6. p. 254.) and here 1 beg to remark particularly, that 'he plan seems to present no hope of benefit in cases of tetanus from wounds, however strong the evidence is of its utility in other examples of the disease. This was the opinion of Dr. Cullen, and it is adopted by Callisen, who observes, "Immersio subita iterate totius corporis in aquam frigidam in tetano a causa interna mire prodest, in teta- no a causa externa minorem effectum praes- tat." (Systema Chirurgiai Hodiernal, Part. J, p. 169, 170, Edit. 1798.) On the sub- ject of cold effusion and bathing, there are on record two cases, which are curious. One is related by Baron Larrey. It was an instance of tetanus from a gunshot wound. The cold bath was used. The two first trials gave the patientextreme pain,andno amend- ment followed. The sight of the bath the next time filled him with an invincible dread of the water, into which he refused to be put. He was covered, however, with a blanket, and immersed. The tetanic stiffness wasim- mediately increased, and dreadful convul- sions excited. It became necessary to re- move him directly from the bath, and put him to bed. Deglutition was from the moment utterly impeded, and the contraction of the muscles carried to the most violent degree. A tumour, about as large as an egg, suddenly made its appearance near the linea alba, below the navel. After death, this was found to be caused by a rupture of one of the recti muscles, and a consequent extrava- sation of blood. (See Mim. de Chirurgie Mil. T. 8, p. 287—289.) This case is deci- dedly in support of the truth of what Pro- fessor Cullen and Callisen have observed. The next is not so: it is mentioned by Sir James Macgrigor, that, in tin march of the guards through Gallicia, on.* of them was attacked with tetanus, in consequence of a slight wound of the finger. As it was impos- sible to think of leaving the man in the wretched village where he was (aken ill, he was carried ou a bullock car, in the rear of (he battalion. During the first part of the day he was drenched with rain, the thermo- meter standing at 52°; but, after ascend- ing one ofthe highest mountains in Gallicia, the patient was iu a cold of 30°; and he was exposed from six in the morning till ten at night, wheu he w as found half starved to death, but free from every symptom of tetanus. (See Medico-Chir. Trans. Vol. 6,p. 450.) Another remedy, which is said to have frequently effected a cure in tetat us, is mercury. It has been employed in France with the greatest success, as may be seen by referring to tbe forty-fifth volume of Journal de Medecine. This remedy, however, should be resorted to, in an early period of the dis- order. Mercurial frictions are preferred, and these are to be put in practice so as to bring on a quick affeclion of the mouth ; care being taken, however, not to render the soreness and salivation too violent. Some contend,that it matters not, whether mercury be rubbed into the body, or given internally. It is generally allowed, that opium may be ad- vantageously exhibited at the same time. '1 his practice was first adopted in the West Indies, (see Edinb. Physical and Literary Essays, Vol. 3,) where it succeeded in many cases. Whatever benefit, however, may have been experienced from this plan in mild cases, it completely fails in the acute form of the disease. Mercurial frictions appeared to Baron Larrey to aggravate the symptoms, in the cases where the plan was tried in Egypt (Jlfem. de Chir. Mil. T. I, p. 257;) and Dr. Emery, Mr. Guthrie, and other me- dical officers, attached to our army in the peninsula, tried inunction of the whole body, three times a day, with strong mercu- rial ointment, in unlimited quantity, with no degree of success. After the battle of Tou- louse, a fatal case even occurred in a man strongly under the influence of mercury, which he had been previously using for the cure of the itch. (Sir J. Macgrigor in Medico-Chir. Trans. Vol. 6, p. 454.) The submuriale of mercury, combined with ipecacuanha, also proved inefficacious in acute cases; but, in chronic ones, the for- mer medicine proves serviceable in keeping open the bowels. Another method of treating (etanus is that of administering the most powerful tonics and stimulants, such as wine, brandy, aether, preparations of ammonia, bark, cor- dials, be. The introduction of this plan was chiefly owing to the eminent Dr. Rush, Professor of Medicine in Philadelphia, who published in the Transactions of the Ame- rican Philosophical Society, Vol.2, a paper entitled " Observations on Uie Cause and Cure of Tetanus.'' Dr. Rush considers tetanus as a disease essentially connecled with de- bility, and he recommends for it the exhibi- tion of the preceding class of remedies, fie particularly advises the liberal use of wine and Peruvian bark ; and, as we have already stated, when tetanus arises from a wound, he directs the dilatation of it, and dressings with oil of turpentine. Considerable suc- cess is represented as having attended the practice. Several other instances of suc- cess are elso recorded by Dr. Hosack. (American Medical Repository, Vol. 3.) Nothing is a more certain proof of our not being acquainted with any very effectual method of treating a disease, than a multi- plicity of remedies, which are as opposite as possible in their effects. We have seen that the celebrated Dr. Rush conceived, that tetanus vvas a disease connected with debili- ty, and he has recorded examples, in which it was successfully treated by tonics and stimulants. Extraordinary, however, as it may appear, many practitioners are advo- "JTii J EI rates fof veueseetion,especially in the early stage of tetanus. Dr. Dickson thinks, that in a full habit, where (he wound is swelled, inflamed, and painful, venesection, wi(h free purging, and such other means as are calculated to allay the general and local irritation, aflbrds the fairest chance of avert- ing the danger. (See Medico-Chir. Trans. Vol. 7, Pari 2.) Larrey has also published several cases, in which bleeding had a good effect. We are informed by Sir James Mac- grigor, that, in our military hospitals in Spain, venesection bad a fair trial. In three cases at St. Andero, detailed by Mr. Gu- thrie, this vvas the principal remedy. One patient with tetanus, from a wound of the back part of the hand, was bled nearly ad deliquium several times with good effect, calomel and diaphoretics being also given, and be recovered. Another patient was bled iu the same manner with such amend- ment, that he suffered but little from spasm, and could open his mouth very well, .when be was seized with diarrhoea, which in his debilitated state, carried him off. In the third case, which was one of acute tetanus vein section, pushed to the utmost, totally failed. (Op. cit. Vol. 6,p.455, 456.) The powerfully relaxing effects of tobac- co clysters, in cases of hernia and enteritis, have suggested a trial of them in tetanus. In one very acute case, the plan was tried by Mr. Earle, but it only afforded a tempora- ry alleviation of the spasms, and, as it caused severe agitation, it was discontinued. Ac- cording to Sir James Macgrigor, tobacco clysters, tried in the advanced stage of the disease, seemed to have no effect. He con- siders, hovvever, the tobacco fume as deserv- ing further trial. A remarkable case is recorded by Dr. Phillips, in which the jaw suddenly fell upon die exhibition of an enema with oil of tur- pentine. (See Medico-Chir. Trans. Vol. 6, p. 6b.) According to Baron Larrey, frictions, with oily liniments, as recommended by some authors, were tried by the French surgeons at Cairo; but they produced no change in die slate of the disease. We learn, from the same authority, that the application of blis- ters to the throat also failed in checking the symptoms. _ The Barbiidoes tar, mentioned by Cullen, electricity, the colchicum autumnale, or meadow saffron, recommended by Dufres- noy, and several other means formerly in repute for their virtues in cases of tetanus, hi.ve now been fully proved by experience to possess little or no claim to this character. Consult Hippocrates de Morbis Populari- ty, Lib. 6 et 7. Crtlius Aurelianus de Morbis itculis. Medical Observations and Inquiries, Vol. 1. p. 1 and 87; For!. 6, p. 143. Hillary on the Air and Diseases of Barbadoes, Edin. Physical and Literary Essays, Vol. 3. Dr. Carter, in Medical Trans. Dr. Cochrane in Edin. Medical Commentaries. Cullen's First J.uics ijf the Practice of Physic, Vol. 3. Rush's Observations on the Cause and Cure of Tetanus, in Vol 2 of the. Tranr-'rthns of the THR American Philosophical Society. Sir Gilbert Blanc's Observations on the Diseases of Sea- men, Edit. 3. M. Ward, Facts establishing the Efficacy of the Opiate Friction in Spasmodic and F'ebrtle Diseases, fyc. Svo. Manchester, 1809, Larrey, Mimoires de Chir. Militaire T. l,p. 235, fyc.; T. 3, p. 236, fyc. Calliuti', Sysiema Chirurgice Ilodierncc, Pars 1, p. 16b, fyc. Sir James Macgrigor, in Med. Chir. Trans. Vol. 6, p. 449, fye. Dr. Phil- lips's Case in the same work and volume, p. 65. Dr. Dickson's Observations on Tetanus, and Dr. Macarlhur's Letter in Vol. 7, p. 448 fyc. of the same book. Trnka de Krzowits, de Tetano Commentarius, Vindob. 1777. Riche- rand, J\osogr. Chir. T. 2,p.33S,fyc. Edit. 4. Edinb. Med. and Surgical Journal, Vol 1 p. 67 ; Vol. 2, p. 255—430 ; Vol. 4, p. 45,' fyc.fyc. Boyer, Traiti des Mai. Chir. T. I, p. 28b, fyc. Paris, 1814. Rees's Cyclopedia, art. Tetanus. C. H. Parry, Cases of Tetams, and Rabies Contagiosa, fyc. 8vo. Lond. 1814. John Morrison, a Treatise on Tetanus, Svo. Newry, L816. Robert Reid, on the Nature and Treatment of Tetanus and Hydrophobia, Svo. Dublin, 1817. Stewart, in Med. Chir. Journ. ; Oil of Turpentine tried. Sir Aslley Cooper, Surgical Essays, Part 2, p. 190. Burmester, in Med. Chir. Trans. Vol. 11 THORAX, WOUNDS OF. See Wounds of the Thorax. THROAT, WOUNDS OF. Injuries of this kind are often attended with considera- ble danger, on account of the great number of important parts, which are interested; but mere cuts of the integuments of the throat and neck are not (generally speaking) dangerous cases, and do not materially differ from common incised wouuds of the skin in any other part of the body. They are not liable to be followed by any parti- cular consequences, and require the same kind of treatment as cuts in general. (See Wounds—Incised Wounds.) In wounds of the throat and neck, how- ever, the larynx and trachea, pharynx and cesophagus, the trunk of the carotid artery, and all the principal branches ofthe exter- nal carotid, the large jugular vein, the eighth pair of nerves, and the recurrent nerve,are all exposed to injury ; some much more so than others, but all of them being occasion- ally reached by the edge of the knife or razor, or the point of the/ sword, or other instruments. It would be absurdity to offer an account of what is to be done in cases attended witb some part of the mischief above pointed out ; for no patient thus wounded would ever be found alive. Wounds of the eighth pair of nerves are generally considered fatal, though some doubts begin to be entertained on the point. Indeed, Klein positively states, that such an injury is not fatal. (See Journ. der Chir. B. 1, p. 123, 8ro. Berlin, 1820.) However, if such a wound is not absolutely fatal, there can be no doubt of its being highly perilous, and that it should be cautiously avoided. These nerves as is veil known, proceed down 'he neck in the THROAT. -i;; tiue sheath ot cellular substance which includes the carotid artery, and lie on the outside of this vessel, between it and the internal jugular vein. Wounds, either of the carotid artery or internal jugular vein, must generally prove immediately fatal, in consequence of tbe great and sudden loss of blood. However, were any surgeon on the spot at the mo- ment, be should instantly secure the wound- ed vessel. In tying the carotid, one cau- tion is highly necessary, viz. always to be sure that the par vagum is excluded from the ligature : for were this nerve to be tied, the mistake, if not absolutely mortal) would leave but a slight possibility of recovery. If the mouth of tbe vessel could not be at once secured, pressure should be instantly resorted to, for the purpose of producing a temporary suppression of the hemorrhage. The surgeon should then either make the necessary enlargement of the wound in the integuments, with a due and constant recol- lection of the important parts near the place, or else, in the case of the carotid being in- jured, he should cut down to this vessel in the manner explained in the article Aneu- rism. In lacerated wounds, tbe carotid artery may be injured, and yet the patient not immediately bleed to death ; for it is the nature of all wounds, attended with much laceration and contusion, not to bleed so freely as clean cuts. Mr. Abernethy has related a case in which the carotid, and all the chief branches of it, were wounded in a man who was gored in the neck with a cow's horn; yet death did not directly follow, and there was time to have recourse to the ligature. Baron Larrey even reports one or two cases in which the bleeding from the carotid, injured by a gunshot, was permanently stopped by pressure. (See Mim. de Chir. Milit.) Dr. Hennen also refers to another instance of a similar na- ture. (On Military Surgery, p. 106, Ed. 2.) Punctured wounds might obviously injure cither the carotid, or the internal jugular vein, without the patient expiring of hemor- rhage at once ; because the smallness of the wound in the skin might hinder the fa- tal effusion of blood. However, frequently, when tliese vessels are wounded, the par vagum is also injured, and the case is mortal, either immediately, from the direct effects both of the injury of the nerve, and sudden loss of blood, or very soon afterward, the bleeding being of a slower and more interrupted kind ; which circumstance must depend on the lacerated nature of the wound, the small size of the opening in the vessel, or of that in the skin, be. Persons who attempt suicide, by cutting their throats, do not often divide the carotid artery, on account of their incision being made too high up. Where the carotid arte- ries emerge from the chest, they are situa- ted by the side of the trachea, and even a little more forward than it- However, as * 'icse vessels proceed or the nc-'c, tiiey be- come more laterally situated with respect to the trachea ; and when they have arrived at the upper part of the neck, where per- sons, who aim at suicide, almost always cut, they become situated more backward than the trachea, inclining towards the angle of the lower jaw. The cesophagus is so deeply situated, lying close to the bodies of the vertebra;, and be- hind the trachea, that it is not often interest- ed in any incised wounds, which do not immediately prove fatal, in consequence of the division of other important partis. Yet numerous cases are recorded, in which the cesophagus is said to have been wound- ed ; and what is usually set down as a crite- rion of the fact, is the passage of victuals through the wound. In many of these narrations the writers seem to have forgot- ten, that wounds, made above the os hyo- ides, as they frequently are, may enter the mouth, and the victuals escape through the cut, without the cesophagus, or pharynx, be- ing at all concerned. Hovvever, no doubt, the cesophagus has occasionally been wounded, together with the trachea, not only without the patient perishing so immediately as to be incapable of receiving any succour, but without every chance of recovery being destroyed. Stabs, and gunshot wounds, may injure the ceso- phagus, and leave all other important parts untouched. Nay, when other parts of con- sequence are injured, the patient is some- times saved. (See Hennen's Military Sur- gery, p. 363, Ed. 2.) Even where the oesophagus is known to be wounded, its deep situation would pro- hibit us from doing any thing to tbe breach of continuity in the tube itself. The best plan would be to have recourse to antiphlo- gistic means, and to introduce a flexible elastic gum catheter from one of the nos- trils down the oesophagus, for the purpose of conveying nourishment and medicines into the stomach, without any risk of their passing out at the wound. An instrument of this kiud will lie in the above situation for any length of time withotit occasioning much inconvenience; and, besides being advantageous for injecting nourishment and medicines down the passage, and keeping them from issuing at the wound, it prevents all necessity for the wounded cesophagus to act and become disturbed, when there is occasion to take any kind of liquids, whe- ther in the way of medicine or food. The outer wound "should he brought together, and treated on common principles. When persons cut their throats, as I have explained, they do not often divide the carotid artery, owing to their incision being usually made high up in the neck, where this vessel has attained a very backward situation. When any serious hemorrhage does arise, it is sometimes from the lower branches of the lingual artery, but most frequently from the superior thyroideal ar- teries. Such arteries may occasion a fatal bleeding, which, indeed, would more fre- quently be the even', than it actually is, di' 4:s THR not tbe patient often faint, in which state the bleeding spontaneously ceases, and gives time for the arrival of surgical assistance. s I need hardly tell the reader, that these arteries are to be tied, and that this impor- tant object is the first to w hich the surgeon should direct his attention. Tbe danger of bleeding to death being obviated, as soon as possible, tbe other requisite measures may be more deliberately executed. With respect to wounds of the trachea, the same plan of conveying food and medi- cines into the stomach, through an elastic gum catheter, introduced from one of the nostrils down the oesophagus, is highly proper, though too much neglected. For nothing creates such disturbance of the wound as the convulsive elevation and de- pression of tbe larynx and trachea, which are naturally attendant on the act of swal- lowing. When the trachea is cut, the patient's power of forming the voice is more or less impaired, in consequence of the air passing into and out of the lungs, chiefly through the wound. Besides air, a considerable quantity of tbe natural mucus of tbe trachea is also continually coming out of the wound. The grand means of accomplishing the union of wounds of the trachea, are a pro- per position of the head, and a rigorous observance of quietude. By raising the patient's head with pillows, and keeping his fhin close fo his breast, the edges of the wound, both in the skin and trachea, are placed in contact even without any other assistance, unless the division of the trachea be exceedingly large. It is proper, howe- ver, to assist the effect of a suitable position with strips of sticking plaster, and some- times with a suture or two. But the neces- sity for sutures must depend on the extent of the division of the trachea; for unless most of the circle of this tube be cut, and position be neglected, the wound in it will not gape. The stitches should never be passed through the lining of the trachea, as this method would be likely to make it in- flame, and occasion considerable coughing and irritation, attended with very pernicious effects. Should there be much coughing, apparent- ly arising from irritation and inflammation in the trachea, bleeding is proper if other considerations do not forbid it. The sperma- ceti mixture, with opium, is also frequently of great service 1 never saw a wound of the trachea unite by the first intention. (See John Bell on Wounds, Ed. 3. Hennen"s Military Surgery, p. 3b6,fyc. Ed. 2.8vo. Edinb. 1820. Among olher references made by Dr. Hennen, the following seem to me to merit particular notice .-—An interesting case of wound of the neck, succeeded by hemiplegia, and another of gunshot wound of the throat, succeeded by paralysis and convulsions, says Dr. Hennen, is given by Farestusin his Surgical Observations. Another, wilh loss of motion in the arm, from a wound in the neck, is to be found in the Edinb. Med. Essays, Vol. I. And in the Med. Commentaries, by Dr. Duncan, Vol.4, p. THR 434, and Vol. 8, p. 366, are two interesting cases. Murinna, in his Med. Chir. Beobach- tungen, relates a case of removal of the thyroid gland by a cannon ball; the patient survived fourteen days, and died of dysentery. Wounds ofthe cesophagus often remain open for inde- terminate periods, as is exemplified in a case reported by Trioen, in his Fasciculus Obstr- raiionum, Ludg. 1745. p. 40. Mr. Bruce has recorded an interesting case of wound of the (Esophagus, in Med. Chir. Journ. Vol. 1, p. 369. / would also refer to various parts of Mim de Chir. Mtlit. 4 Tomes, by Baron Lar- rey. And Thomson's Report of Obs. made in Mil. Hospitals in Belgium, Svo. Edinb. 1816) THROMBUS, (.from d^&c, coagulated blood.) A clot of blood. The term is also applied to a tumour, formed by a collection of extravasated, coagulated blood, under tbe integuments after bleeding. When such an extravasation is not considerable, it is usual- ly called an ecchymosis. (See this word, and Bleeding.) A thrombus after bleeding generally arises from the opening in the vein not corres- ponding to that in the skin. The patient's altering the posture of his arm, while the blood is flowing into the basin, will often cause an interruption to the escape of the fluid from the external orifice of the punc- ture ; and consequently, it insinuates itself into tbe cellular substance in the vicinity of the opening in the vein. In proportion as the blood issues from the vessel, it is effused, in the cellular membrane, between tbe skin aud fascia, covering the muscles, and this, with more or less rapidity, and in a greater or lesser quantity, according as the edges of the skin more or less impede tbe outward es- cape of the fluid. Sometimes, also, a throm- bus forms after venesection, when the usual dressings, compress, and bandage, have been put over the puncture, and the patient im- prudently makes use of the arm on which the operation has been^done. This is more particularly liable to happen when the open- ing in the vein has been made large. When the extravasation is not copious, it is of little importance, the tumour generally admits of being easily resolved, by applying linen, dipped in any discutient lotion. If the swelling be more extensive, applying to it a compress, wet witb a solution of com- mon sea-salt, is deemed an efficacious plan of promoting the absorption of the extrava- sated blood. Brandy, and a solution of the muriate of ammonia in vinegar, are likewise eligible applications. It sometimes happens, that a thrombus induces inflammation and suppuration of the edges of the puncture. The treatment is now like that of any little abscess : a com- mon linseed poultice may be applied, and any considerable accumulation of matter should be prevented by making an opening with a lancet in proper time. As soon os the inflammatory symptoms have ceased, discutients should be employed again, for the purpose of dispersing the remaining clots of blood, and surrounding induration. When tbe quantity of blood is large, many THYROID GLANU. 479 author*" recommend opening the tumour at once ; and, despairing of the power of the absorbents to remove the extravasation, they recommended as much of the blood as possi- ble to be pressed oat through the incision. I believe, however, that making an opening is seldom necessary, and often brings on iu- flammation, and suppuration, when they might be avoided. I have never seen any case, iu which there was real occasion to make au opening tor the discharge of the blood. A case of this kind, however, may be conceived. THYROID GLAND, DISEASED. (See Bronchocele.) THYROID GLAND, EXTIRPATION OF. Thai such an operation, though attended with great difficulties, is not impracticable, is proved by the following example :— On the 20th of March, 1791, a woman presented herself for admission at the H6lel- Dieu, with a tumour of the right portion of the thyroid gland. The swelling was two inches in diameter, round, hard, and at- tached to the right and middle part of tbe trachea, and it pushed outwards the sterno- mastoideus muscle. Independently of its being sensibly raised by each pulsation of the arteries, it obeyed the motions of de- glutition, aud in a slight degree impeded the passage of solid aliment. The patient earnestly desiring to get rid of so inconve- nient a deformity, determined to submit to its extirpation, which appeared the only re- source. The danger, the length of time, and the pain necessarily annexed to the ope- ration, were not concealed from her. De- sault made a longitudinal incision through the middle of the tumour, beginning one inch above, and finishing one inch below the swelling. By the first stroke, he cut down as far as the gland, dividing the integuments, the platysma-myoides, and some fibres of the sterno-hyoideii and sterno-thyroidei muscles. An assistant, with the view of fixing the tumour, drew towards aside the inner edge of the wound, whilst the surgeon detached the swelling from the sterno-mas- toideus muscle. In dissecting the cellular substance, which united the parts, two small arteries were divided, which were secured with ligatures. The outer portion of the tumour being thus disengaged, the inner was detached in the same way. The tumour was then drawn outwards by means of a hook, that it might be separated with more ease from tbe trachea. In the course of this dissection, the branches of the thyroid arte- ries were successively tied, as fast as they were divided. The assistant, who held the book, pulled tbe gland from within and for- wards, whilst (be surgeon finished the dis- section outwards and from above down- wards. This part of the operation was the most difficult: it was necessary continually to wipe away the blood with a sponge, which necessarily prevented the parts from being easily distinguished, and obliged the surgeon to cut but a little at a time, and always to examine well witb his finger those parts which he was about to cut. By this cautious dissection, tbe superior and inferior thyroid arteries were laid bare, and after- ward tied with the aid of a blunt crooked needle. They were then transversely di- vided, and the remaining part of the tumour detached from the trachea, to which it strongly adhered, fhe wound resulting from this operation was near three inches in depth ; it vvas outwardly bounded by the sterno-mastoideus muscle, and inwardly by the trachea and cesophagus ; posteriorly by the carotid artery, and par vagum, which were exposed al the bottom of the wound. The extirpated tumour was five inches in circumference; and on examination was found to differ in no particular from scirrhous glands, except that in the centre there was a cartilaginous nucleus. The patient left Ihe hospital perfectly well, the thirty-fourth day after the operation. (See Desault's Paris- ian Chir. Journ. Vol 2, p. 292, 296.) The extirpation ofthe thyroid gland is an operation extremely difficult, and certainly highly dangerous, when performed by an operator but moderately exercised in the practice of his profession. The number and size of the arteries divided, the proxi- mity of the trachea, cesophagus, and carotid. near which the knife i\ist necessarily pass, are the principal dangers. They have de- terred the majority of practitioners from performing Ihe operation, and it must be allowed, that ihey are such as ought to in- timidate every man, who is not endued with anatomical knowledge, and the most un- daunted coolness. Examples of this opera- tion are very rare. The first time that Gooch undertook it, he was deterred from finishing it by the hemorrhage, and his pa- tient died on the eighth day. The second time he succeeded better, but was incapable of securing the vessels, and succeeded in stopping the hemorrhage, which would oth- erwise have been mortal, by causing the parts to be compressed by the hand of an assistant for the space of eight days. (Gooch's Mid. and Chir Obs. p. 130. Bell's System of Surgery, Vol. 5, p. 525. Richter's Bibl. T 2, p. 128.) A. F. Vogel and Theden practised the operation with complete success. AH dan- ger from the hemorrhage, or inconvenience arising from the discharge of blood, may be obviated by taking up the small vessels, ty- ing them as fast as they are divided, and by discovering and tying the large vessels pre- vious to their division. Other parts that cannot be wounded without danger, are to be avoided by dissecting slowly and a little at a time, and feeling with the finger every part previously to its division with the bis- toury. A case, in which Klein removed a very large thyroid gland, has been recently pub- lished. The patient, a boy eleven years of age, died, however, on the operating table as would seem from Klein's account, in con- sequence of apoplexy. (See Journ. der Chir. B. 1, p. 120, Svo. Berlin, 1820; or the Quarterly Journ. of Foreign Medicine, Vol 2 p. 380.) On the whole, I consider that the' TIC DOULOUREUX practice of tying tlie thyroidal arteries is generally a safer experiment than the re- moval of the enlarged gland with a knife. (See Bronchocele.) *TIC DOULOUREUX. This term is used to signify a disorder, the most prominent character of which consists in severe at- tacks of pain, affecting the nerves ofthe face; most frequently the filaments of that branch of the fifth pair, which comes out of the infra-orbitary foramen ; but sometimes the other branches of the fifth pair, and oc- casionally the numerous filaments of the portio dura of the auditory nerve, which are distributed upon the face. The com- plaint is not continual, but occurs in violent paroxysms, which vary in duration in dif- ferent instances. It is the trismus dolorificus of Sauvage ; the Faciei Morbus Nervorum Crucians of Dr. S. Fothergill; and of that order of diseases which Professor Chaussier has so aptly denominated ncuralgies (from vivepv, a nerve, and «a^oc, pain;) for it should be known, that many other parts of the body are subject to a similar affection. The fir3t excellent description of the tic douloureux was published in the year 1776, by the late Dr. Fothergill. (See Med. Obs. and Inq. Vol. 5.) It is not true, hovvever, as is generally stated in modern medical works, that this gentleman was the first au- thor who noticed the complaint. This in- deed is so far from being correct, that we even find an account of an operation done long ago by Louis, for the relief of the dis- ease, (See No. 36 de la Gazelle Salutaire, 1766 ;) and this identical case actually be- came a subject of hot dispute between the physicians and surgeons of tbe French me- tropolis. (See a Thesis, entitled " Utrhm in pertinacibus capitis et faciei doloribus aliquid prodesse possit, seclio ramorum nervi quinli paris? Proponebat Viellart, 1768, conclusio negativa." Tic douloureux conveniently admits of being divided into four species, called by the French frontal, suborbitary, and maxillary neuralgia, and the neuralgia of the facial nerve. In tbe frontal neuralgia, tbe pain usually begins in the situation of the supra-orbitary foramen, extending at first along tbe branch- es and ramifications of the frontal nerve distributed fo the soft parts upon the crani- um, aud afterward shooting in tbe direction of the trunk of the nerve towards the bot- tom of the orbit. In a more advanced stage, the conjunctiva and all the surface of the eye participate in the effects of the dis- order, and become affected with chronic in- flammation, which is described as a particu- lar species of ophthalmy. At length, the pain passes beyond the distribution of the branches of tbe frontal nerve, and affects all the corresponding side of the face and head. It seems as if it extended itself to the facial, sub-orbitary, maxillary, and even to the temporal and occipital nerves, through the communications naturally existing between the filaments of all those organs of sensa- tion. Each paroxysm produces a spasmo- dic contraction ot the eyelids, aud a copi- ous effusion of tears. The sub-orbitary neuralgia is first felt about the sub-orbitary foramen. The seat is probably in the nerve of this name, and the pain extends to the lower eyelid, the inner canthus of the eye, the muscles about the zygoma, the buccinator, cheek in gene- ral, ala of the nose, and the upper lip. At a later period, the pain appears to extend backward to the trunk of tbe nerve, and those branches which are given oft' in its passage through the sub-orbitary canal. Hence, pains are then experienced in the up- per teeth, the zygomatic fossa, the palate, tongue, and within the cavity of the nose. As the disorder advances, it may extend, like other neuralgia? of the face, to all the same side of the head. During the pa- roxysms, when the disease is fully formed, an abundant salivation usually takes place. In general the attendant toothach deceives* the practitioner, who in the belief that the pain arises from another cause, uselessly extracts several of the teeth. The tic douloureux of the lower jaw, or maxillary neuralgia, is usually first felt about the situation of the anterior orifice of the canalis mentalis, and it extends to the lower lip, chin, neck, teeth, and temple. This form of the complaint is more uncommon than the preceding; but, after it has pre- vailed some time, is equally remarkable for its intensity. With respect to the neuralgia of the facial nerve, or portio dura of the auditory nerve, it is a case, which very soon cannot easily be distinguished from the other species of tic douloureux. The pains at an early pe- riod are no longer confined to the passage of the principal branches of this nerve be- tween tbe parotid gland and ramus of tbe jaw. The numerous communications of tbe portio dura with the res! of the nerves of the face seem to facilitate the extension of the disease, so that the agony is soon felt over the whole side of the head. The original source of the disorder can only be detected by attentively considering the progress of the complaint in all its stages. (See Del- pech, Traiti des Maladies Reputies Chirurgi- cales, T. 3, Sect*. 7, p. 214, fyc.) .<\ Tic douloureux may be known from rheumatism by the paroxysm being excited by the slightest touch, by the shortness of its duration, and the extreme violence of the pain. In acute rheumatism, also, there is fever, with redness, heat, and generally some degree of swelling; and, in chronic rheu- matism, the pain is obtuse, long-continued, and often increased at night; none of which symptoms characterize tic douloureux. It may easily be distinguished from hemi- crania by the pain exactly following the course of the branches of the affected nerve. It is known from the toothach by the com- parative shortness of the paroxysms; the quickness of their succession ; the intervals of entire ease; the darting of tbe pain in the track of the particular nerve affected; t)ie more superficial and lancinating kind of TIC DOULOUREUX 481 pain; and the convulsive twitchings, which ::ometiines accompany the complaint. The causes of tic douloureux may be said to be in general unknown ; but there are a few instances recorded which appear to be the consequence of external violence, wounds, contusions, &c. A modern writer has related a very curious instance of a re- sembling disease in the arm, where (he af- fection proceeded from the lodgment of a small bit of a bullet intheradial nerve. (Den- mark, in Med. Chir.' Trans. Vol. 4, p. 48) Dr. Parry attributed the pain to increased vascularity, or determination of blood, (per- haps amounting to inflammation) to the neu- rilema, or vascular membranous envelope of the nerves affected. (Elements of Pathology and Therapeutics.) Stimulating embrocations, blisters, caustic issues, fomentations, leeches, frictions with mercurial ointment, (Edinb. Med. and Surg. Journ. Vol. 3,) electricity, opium in large doses, the arsenical solution, and a variety of antispasmodic medicines, are the princi- pal means, which have been tried ; but for the most part, they only afford partial and temporary relief. From some facts recent- ly published by Dr. Marcet, the extract of stramonium, in doses of one-eighth and half a grain thrice a day, seems to be'sometimes capable of alleviating the distressing agony of the present disorder. (See Med. Chir. Trans. Vol. 7, p. 76, fyc. also Kirby's Cases, Suo. Lond. 1819.) The operation of dividing the trunk ofthe affected nerve, and even of dissecting out a portion of it, so as to prevent all chance of a relapse from the reunion of the ends of the nerve, is a plan, which has sometimes been practised with permanent benefit. Thus, any one of the three branches of the fifth pair of nerves may be divided at the point, where it comes out upon the face. But, before having recourse tothis means, tbe surgeon should be sure, that the particular nerve, which he is about to expose and divide, is really the prin- cipal seat of the disease ; for, wheif all the nerves ofthe face generally are affected, or when the branches of the portio dura are especially concerned, there is little hope of success. In fact, it must be confessed, that the operation has had many failures and re- lapses, either from the cases not having been duly discriminated, or from the neglect to remove a portion of the exposed nerve. Richerand, Delpech, and most of (he lead- ing surgeons in France express (heir prefe- rence to tbe application of the moxa, or cautery, which, they say, proves more fre- quently successful than the knife. This should be done directly over the apertures, from which the nerves emerge on the fore- head, cheek, or chin, and Richerand asserts, that by such treatment, the pains may al- ways be cured, or at all events, rendered supportable. (Nosogr. Chir. T. 2, p 218, Edit. 4.) Delpech also affirms, that the sec- tion of the nerve very often fails, and that issues, and the repeated use of the cauterv have been attended with (he greatest suc- ceps (See Pricis des Ma' Chir. T. 3, p. 21-1 1 Tt IT --.j The disfigurement oi the countenance by burning applications must, however, be very objectionable, and, as I think there is no positive evidence of the superiority of this method over the use ofthe knjfe, I consider what Richerand and Delpech have stated only as another instance of the extreme partiality of tbe French surgeons to the moxa and cauterization. Delpech confesses, however, that, when the pains seem to be the consequence of a ganglion, or thicken- ing of a part of a nerve, the excision of such part is indispensable. There can be little doubt, that this would have been more proper than amputation in Mr. Denmark's case, to which I have already referred. The theories of Dr. Parry, senior, who was generally inclined to refer the effects of dis- ease to increased determination of blood to the parts affected, led him to believe that the operation of cutting the nerve, as performed by Dr. Haighton and others, did good rather by the division of the arterial branch sup- plying the affected ramification of the trige- minus nerve, than by the division of that ra- mification itself. (Parry, Elements of Pa- thology, fyc.) There have been many examples of tic douloureux, which, after resisting all at- tempts to cure them, have been left to them- selves, and, after a long time spontaneously subsided. (Delpech, Traiti des Maladies Chir. T. 3, p. 212, 215.) This author has seen the operation of dividing the chief branches of the portio dura, in front of the parotid gland, undertaken, and even a por- tion of the soft parts cut away; but without any favourable consequences. (P. 218.) I have already stated, that the nerves of the extremities are subject to affections very analogous to tic douloureux. The following instance related by Mr. Abernethy will be found interesting;— A lady became gradually affected with a painful state of the integuments under, and adjoining to, the inner edge of the nail of (he ring-finger of the left hand. No injury (o the part was remembered, which could have brought on this disease. The pain oc- curred at irregular intervals, and was ex- tremely severe during the time of ils con- tinuance, which was for a day or two, when it usually abated. Accidental slight injuries always produced great pain, nnd frequently brought on the paroxysms, which however occasionally occurred spontaneously, or without any evident exciting cause. In all these particulars, the disease correctly re- sembled the tic douloureux of Ihe nerves of (he face. As (he pain increased, (he disor- der seemed to extend up the nerves of the arm. Afler the patietK had endured this painful affliction for seven years, she sub- mitted lo have the skin, which was the ori- ginal seat of the disorder, burnt wilh caustic. This application gave her intense pain, and on the healing of (he wound, she found her sufferings ratiier augmented than diminished, by Ihe experiment. After four more years of suffering, she consulted Mr. Abcrnelhy, when the circuius'.ances of the case were 46- TIC rob such a3 to render an operation indispensably necessary. The pain of the part was into- lerable, and it extended all up tbe nerves of the arm ; and this general pain was so con- stant during the night, as to deprive the pa- tient of rest. The muscles of the back of the neck were occasionally affected witb spasms. The integuments of the affected arm were much hotter than those of the opposite arm, and sometimes the temperature was so in- creased as to cause a burning sensation in them. Under these circumstances, Air*. Aber- nethy did not heshale to divide the nerve of tbe finger, from which all this disorder seem- ed to originate. He laid it bare by a longi- tudinal incision of about three quarters of an inch in length, from the second joint of the finger, and divided it opposite to that joint, by a curved sharp-pointed bistoury, which was conveyed under it. He then took bold of the nerve with a pair of forceps, and re- flecting it downwards, removed a portion of it, half an inch in length, so that the possibi- lity of a quick reunion might be prevented. The wound was brought together with stick- ing plaster, and it united by adhesion ; but the upper part ofthe wound, opposite to the upper end of the nerve, became slightly in- flamed, and was very painful. However, iu the course of three weeks, tbe appearance of inflammation gradually went off. After the operation, Mr. Abernethy pinched the originally affected integuments sharply with bis nails, without causing any sensation; but if, in so doing, he moved the finger, then pain was fell. He found it difficult to con- vince the patient that the skin at that part was actually devoid of sensation ; for she still continued to feel similar sensations to (hose which formerly occurred, though in a much diminished degree; but she became gradually as perfectly convinced as any me- dical man could be, that these sensations arose from the irritated state of the end of the nerve, above the place where it was di- vided. The painful affeclion of the nerves of the arm still continued, though considera- bly lessened in violence ; however it was suf- ficiently severe to make the patient appre- hend that little permanent benefit would arise from the operation. This pain conti- nued occasionally about four months with varying degrees of severity, bul the tempe- rature of the skin was not hotter (ban dial of ihe opposite side, as it had been before tbe operation. At tbe expiration of three months, the patient ascertained that tbe in- teguments at the end of the finger actually felt when any thing was applied to them, and this proved a new source of alarm. Mr. Abernethy adds, that more than nine months have now elapsed since the performance of the operation, and the general pains in the nerves have become very trivial; but (he sensation in the integuments at the end of the finger, has during thatlirne gradually in- creased, and ihe skin has now i(s natural sensibility, so as accurately to distinguish the tangible properties of any body applied to it. If al-o die originally affocted part be slightly compressed, painful sensations re- s-*»mb*ing *r ; e which formerly occur^d lake place. (Abernethy's Surgical Work:, Vol. 2, p. 203.) In h case resembling (he former, bu( (he consequence of a wound of (he finger, Mr. Lawrence also cut down to tbe nerve, and removed it portion of it with per- manent succes-*. Fotheririll's Paper in rol. 6 of the Medical Obs. and Inq. Dr. Haigh- ton's Obs. in the Med. Records and Researches. Darwin's Zoonomia. Abernethy's Surg. Works, Vol. 2, p. 203, fyc. Richerand, No- sogr. Chir. T. 2 p. 2\6,fyr. Edit 4. Del- pech, Pricis des Maladies Chir. T. 3, p. 20(5, fyc. Dr. S. Fothergill's Systematic Actonnlof Tic Douloureux, 18U4. Medico-Chir. Trans. Vol. 4, p. 48, Vol. 7, p. 575, fyc. Kirby's Cases, Svo. Lond. 1819. TINCTURA KEIiRl MURIATIS. This tincture has sometimes been exhibited in gleets; but a more importnnt use has been assigned it by Mr. Cline, who orders it in dysuria from stricture, in the dose of ten drops every (wenty or thirty minutes, until nausea is excited. Where chalybeales are indicated, this preparation is one very much approved of " Mr. Justemond's liquid for external use in cancers, and which the original inventor called his panacea anticancrosa, partook con- siderably of the nature of this tincture, which, indeed, with an equal quantity ot spirit of wine, was sometimes substituted for it. " Lastly, il is remarkably efficacious in destroying venereal or olher warls, either used alone, or diluted with a small propor- tion of water." (Pharm. Chir.) TINCTURA LYTT^E. Sometimes em- ployed in cases of gleets, and incontinence of urine, arising from a want of proper ac- tion in the sphincter vesicas muscle. The usual dose is from ten to forty drops, twice or thrice a day ; but its effects should be carefully watched ; for it is apt to occa- sion dangerous inflammations of the urinary organs, violent stranguries, and retention ot urine. It is occasionally used in various liniments, when the object is to stimulate the skirmousiderably, and rouse tbe action of the nerves and absorbents, as in rerlain ca- ses of ptosis, paralysis, be. Mr. Anthony Todd Thomson has found it an useful appli- cation in Ihe mortification of the extremities, sometimis happ-ning without any apparent cause ; and also to (mat-bitten parts. (Lon- don Dispensatory, p. 65*-*, Ed. 2.) TINCTURA THEBAICA. (See Vinum Opii.) TINEA CAPITIS. (See Porrigo.) TOBACCO is used for promoting the re- duction of strangulated hernia, either in the form of a fluid clyster, or of smoke, which latter is introduced up the rectum by means of an apparatus. Excepting the operation, the power of tobacco, particularly, when assisted by the topical application of cold to the tumour, is most to be depended upon for bringing about the"return of the protru- ded viscera. (See Hernia, and Enema.) It has also been tried in tetanus ; and Mr. Earle has found tobacco clysters very efficacious in certain cases of retention of urine. (See Tetanus, and Urine, Retention of) Consult T. Fovler, Medici Renorts of the Effcr.U "' fONGLi: 1--3 fooacco, svo. Lond. 1785. A. P. Wilson, An Experimental Essay on the manner in whith Opium and Tobacco act on the living animal Body, Svo. Edinb. 1795. R. Hamilton, De Nicotianac Viribus in Medicina, fyc. Svo. Edinb. 1780. TONGUE, DISEASES OF. This part is subject to various diseases, as ulcers, tu- mours, and such enlargements as sometimes put the patient in imminent danger of suffo- cation. Carious teeth, with points and inequali- ties, producing continual irritation, are the most frequent cause of ulcerations of the tongue, fhe sores, thus arising, ofteir re- sist every kind of remedy, and ignorance of the cause sometimes leads the practitioner to consider them as incurable ; whereas, a cure may easily be effected by extracting the carious tooth, or simply filing off its sharp irregularities, as was anciently direct- ed by Celsus. The glandular papillae which are situated on the dorsum, or upper surface of the tongue, have a narrow base, and a broad termination or head, like a mushroom, They are capableof becoming considerably enlarged, so a6 to form preternatural tumours, which may be mistaken for can- cerous excrescences. A young man, eighteen years of age, had on the middle of his tongue a circumscribed tumour, about as large as a middle sized nutmeg. Louis, who vvas consulted, per- ceived that the swelling was only of a fun- gous nature, and he tied its base with a liga- ture, with the noose of which he con- tracted (he diameter of the pedicle, while, with the ends, he ke^t down the tongue. Then with one stroke of a pair of cur- ved scis ors, he cut off the tubercle. Caus- tic was afterward applied to the base of the tumour, and the patient was perfectly well in five or six days. (Sur les Maladies de la Langue, in Mimoires de I'Acad. de Chir. T. 5.) Morgagni speaks of similar tubercles; but he never advised their extirpation,-not even when tbey vvere hard and scirrhous ; for, if he had not deemed the operation im- practicable, he should not hive had any confidence in the surgeons who were con- sulted. The tongue is occasionally affected with a true cancerous disease; one of the most afflicting cases, indeed, which can possibly happen, as may be conceived, when it is known, that, in tbe advanced stage of the disease, the patient can haidl) tike his food, which must be conveyed over the tongue by some means or another, before it can be swallowed, while he is obliged to write what- ever he wishes to say. (See Hume's Prad. Obs. on Cancer, p. 112.) Cancer of the tongue seems to lii.I'.r from other carcino- matous affections, in frequently occurring in youngish subjects. In the course of the disease, the glands behind the jaw and in the neck are sometimes affected. Louis ^aw a lady, who had an ulcerated-cance- rous tubercle on the left ed^e ofthe tongue. The tittle* «wc|iia» vva= evrcimsrribed : its size did not exceed that of a filbert; the pains were lancinating ; the sore had pene- trated deeply; and its tuberculated edge were affected with a scirrhous hardness. Extirpation of the disease seemed to present the only chance of cure ; but the patient refused to accede to any thing but palliative plans, and she died in the course of a few months. Forestus makes mention of four women, who were attacked with cancer of their tongues, and died from the ravages ofthe disease, and hemorrhage. In the writings of Hildanus, there is a description of the origin and progress of a cancerous tubercle on a young man's tongue, whose breath was intolerably fetid-and who died in the most excruciating pain. The same author informs us of another case, exhibiting the good effects of sedative remedies in palliat- ing a cancerous ulcer of the tongue, and the fatal consequences of an opposite line of conduct. In authors, many other ex- amples of the same kind are to be met witb. Surgery, however, is not destitute of re- sources against diseases of so formidable a nature. The following case exemplifies the benefit which may be effected by this useful profession, when not exercised by men of too timorous a character. An elderly woman had an ulcerated hard- ness on her tongue. It-had been several times cut away, and as repeatedly returned. Ruysch was called into consultation with one ofthe surgeons, who was attending the patient, and who had already extended his incisions very deeply for the removal of the disease. The result of their deliberations was another attempt to extirpate the tu- mour, and they also determined that after it had been cut away, the actual cautery should be freely applied, with a view of destroying the roots ofthe fungus. The pa- tient consented to the plan, and bore the operations with great fortitude. The tongue was taken hold of with a cloth, and Pierre Le Memnonite, a surgeon of emi- nence, removed the disease with a curved bistoury. The inside of the mouth was then protected with wet cloths, and the actual cautery applied several times to the wound in the tongue. The pain was appeased, and the separation of the eschar promoted by emollient gargles. Under the use of a gar- gle of honey of roses, and the tincture of myrrh and aloes, the place soon healed. It is much easier to cut off a portion of the tongue, through all its diameter, than to remove a cancerous ulceration, situated at one of its edges. In both cases, there is a good deal of dif- ficulty in fixing the part, for it is so very moveable, that it is not easy to keep it in a steady position. For this purpose*, Louis re- commended the employment of forceps, with blades terminating in hook-like extre- mities. With this instrument, the part of the tongue to be amputated can be kept from slipping away. Hovvever, very malignant nicers on the tongue have sometimes been cured by mild- er means. *-sr*rPc r»f tiit<- 'iejeriptinnnre re- -134 iONGl'E. ported to have yielded to the repeated ap- plication of leeches under the tongue, after a vast number of other remedies had been tried in vain. In the Encyclopidie Milho- dique, art. Langue, there is an account of a very alarming affection of the tongue, (re- puted lo be cancerous, though this may be doubted,) which got completely well under a very simple plan of treatment. A woman, thirty-five years of age, subject lo cutaneous diseases, and ill-conditioned ulcers, com- plained, for seven or eight mouths, of little swellings, accompanied with heat and pain, which made their appearance on tbe edge, and towards the apex of the tongue. At length, the part affected began tosweii, grow hard, and cause lancinating pains. Its sur- face became irregular and rough ; and all the side of tho tongue was considerably swelled. The patient could not put her tongue out of her mouth, nor swallow any thing except liquids; and her breath was intolerably fetid. Various sedative remedies had been employed without success. Ci- cuta bad been used as a topical application ; it had been exhibited internally in large doses; tbe patient bad taken for a long while, the oxymuriate of mercury ; but no- thing proved of any avail. At length the patient was so tired of trying the effects of medicines and applications, that she gave them up entirely; and contented herself with trying the experiment of keeping some ho- ney continually in her mouth. As this method seemed to give her some ease, she was pre- vailed upon to persist in il, and in this way, the pains were gradually appeased; the swelling was diminished, and at the end of two or three months, the woman was quite well, except that an indurated cicatrix re- mained on the part affected, and considera- bly obstructed the extension of the tongue on lhat side. On this case, however, it might be re- marked, the retardation of the cure seems olso ascribable to the injury of (he health produced by the hemlock, mercury, be. and that the amendment, following their dis- continuance, might rather arise from the consequent improvement of the patient's health, than from any effect of the honey. Many writers confirm the fact, that very inveterate di-ieases ofthe tongue are some- limes cured by hemlock. In the work last citeci, is mentioned an instance of a very unhealthy looking ulcer, near the apex of i.e tongue, attended with a considerable thickening of the part, and of some dura- tion, which was cured by giving large doses of cicuta. But of all the medicines which have the greatest reputation for their bene- ficial effects upon malignant ulcers of the lip arid tongue, none peihaps is deserv- ing ol so much confidence, as arsenic. (See C. Lane's case of ill-conditioned Ulcer of the Tongue, successfully treated by arsenic ; Med Chir. Trans. Vol. 8, p. 201.) However, notwithstanding many facts of • ;s kind on record, medicines should not bo i lie J too long, that is to say, so as to let .ne disease attain a condition, in which it nill no loiifr af!-V,:. of b?:n? cut awav. When the disease makes progress, the huuc- should be employed before it is too late. When any part of the tongue is to be am- putated, authors very properly recommend the chief vessels to be tied, if possible ; but when this cannot be accomplished, they advise tbe employment of astringent gar- gles, such as a strong solution of alum, dis- tilled vinegar, or diluted sulphuric acid. When these iiv thoiis fait, die continental surgeons recommend the actual cautery as the only resource. Where only a piece of the tongue is cut out, in the shape of the letter V, the best mode of slopping tbe bleWing is (o bring the sides of the in- cision together with a suture, by which means tbe deformity will also be lessened, and the union expedited, as is exemplified in a case recorded by Langenbeck. (Ntue Bibl. B. 2, p. 489.) Bather (han suffer u patient to die of hemorrhage, if the cautery and other means fail, the lingual artery should be taken up where it passes over the cornu of the os hyoide3. Diseased portions of the tongue admit of removal with the ligature. (La Motte Chirurgie Obs. 208; Godarl in Journ. de Med. T. 13, p. 66; Sir Everard Home, Praci. Obs. on Cancer, p. 2U7; Inglis, in Edinb. Med. and Surgical Journ. 18115, No. 1, p. 34.) Sir Everanl Home generally passed a double ligature through the centre of the tongue, behind the diseased portion, and then tied the threads tightly over each half of the organ, so as to make all the part in front of (he constriction slough away. The whole of the tongue sometimes in- flames, and becomes considerably enlarged, either spontaneously, and without any ap- parent cause, or in consequence of some other disease ; or else from some particular irritation, such as (hat of mercury, or some poisonous substance. Siege!, a German physician, who was at Paris about the mid- dle of the 17th century, saw a patient in a salivation, vvhose tongue became so enor- mously enlarged, that the mouth could not contein il. Pimprenelle, an eminenl sur- geon of (hat time, was sent for, and finding that all trials to relieve the affection were iu vain, amputated one half of the tongue, vyith the view of preventing its mortifica- tion. After the wound had healed, it is said the patient could articulate very well. Louis, from whom this fact is quoted, very justly remarks, that the measure resorted to by Pimprenelle was au exceedingly violent one ; for he has often seen urgent symptoms occasioned, during a salivation, by a rapid and enormous swelling of the tongue, very quickly yield to bleedings, purgative glys- ters, change of air, and leaving off mercu- cury. Two or three facts, confirming this statement, have fallen under my own notice. Triucavellius mentions two women, whu had considerable enlargements of their tongues. One of these patients, who was young, had been rubbed with mercurial ointment even on her head ; and the other, who was about fifty years old, had her tongue attacked with the ravages of tbe sm.**ll-pox. The excessive swelling of the NSIL*r 48.S longue, in both tliese instances, terminated in resolution. When the urgency is such, that an imme- diate diminution of the swelling becomes necessary for the relief of the symptoms, the plan of making one or two deep inci- sions along the tongue is strongly recom- mended. See the cases inserted by De la Made, in the 5th vol. -4to. of the Mem. dt I'Acad. Chirurgie, and some others, related by Louis in (he paper above cited. A man, recovering from a bad fever, was suddenly attacked with a pain in his tongue, followed by a swelling equally large and rapid in its formation. In less than five hours (he part became thrice as large as it is in its natural state, and in this space of lime De la Malle, who had been consulted, had bled the patient successively in his arm, neck, and foot. The man felt very acute pain ; his skin was excessively hot; his face was swelled; bis pulse was hard and con- tracted ; and bis look wild. He could hardly breathe.- the tongue filled all tbe cavity of the mouth, and protruded out between the lips. In this very urgent case, the mouth was kept a little more open than the swell- ing ofthe tongue actually caused it to be, and three parallel incisions were made along this organ, one along its middle, and tbe other two between tbe one in the centre and the edges of the part affected. The cuts extended through two-thirds of the preternatural swelling, and had all the t;ood effect which could possibly be desired. There was a great deal of hemorrhage, and the enlargement of the tongue subsided so much, that, an hour afler tbe operation, the patient was able to speak. The next day (be incisions had the appearance of being only superficial scarifications, and tbe tongue was in its natural state. In short, the inci- sions healed in a few days, with the use of a simple gargle. De la Malle quotes several other cases, all of which tend to show the success which he met with from (his practice in olher similar cases. He confirms his own senti- ments, by quoting the testimony of some authors, antecedent to him, who have re- commended the method ; and in particular, be cites a case, in which Job a Meckren adopted this practice, in a case where the tongue, together with the tonsils and palate, became spontaneously affected with a sud- den and dangerous degree of swelling. From the preceding observations it may be concluded, that making incisions in the tongue would have saved numerous patien(s, who have been suffocated in consequence of enormous enlargements of Ibis organ. In the small-pox, the tongue sometimes be- comes immensel*, swelled; aud it is more than probable, tbat, in many instances, the employment of the above method would have afforded great relief to patients, whom the disease has been known lo have entirely iereuved of the power of swallowing. It is a curious fact, that after the loss of Very considerable portions, or even what may be called fhe whole totrme, vti-nis often re- cover the power of speech, mastication, and deglutition. (Louis in Mim. de I'Acad. de Chir. T. 5; also, J. Rowland, Aglossostomo- graphie, ou Discription d'une Bouche sans langue, laquelle parte, et fail naturellement toutes sts autres fondions, 12mo. Saumur, 1630. Louis, sur les Maladies de la Langue, Mimoires de I'Acad. dc Chir. T. 5 ; also the memoir of De la Malle in the same volume. Encydopidie Mithodique, Parlie Chir. art. Langue. Sir Everard Home's Prad. Obs. on C ncer, Svo. Lond. 1806. Langenbeck, Neue Bibl. B. 2, p. 487, Svo. Hanover, 1820.) TONSILS. The tonsils, like all other parts at the back of the mouth, are subject to different kinds of swelling, which vary as much in their nature as their consequences. Some are rapid in their progress, and these are frequently observed to affect persons of, what is termed, a sanguineous temperament. They are also Drone to attack young peo- ple, and such as labour hard, and tbey have all the essential characters of inflammation. Other swellings of tbe tonsils are slower in their progress, occur in damp cold wea- ther, and in indolent, and, what tbe old physicians used to call, phlegmatic consti- tutions. Lastly, another kind of enlargement of the tonsils, which is usually contagious, readily falls into a sloughing, gangrenous state, sometimes extends to the neighbour- ing parts, and too often proves fatal. Hence tbe various species of angina have been named by some writers inflammatory, ca- tarrhal, and gangrenous. The two first kinds frequently terminate in resolution ; but sometimes the affected tonsils after- ward assume a scirrhous hardness, obstruct respiration and deglutition, so that it be- comes indispensably necessary, either to extirpate tbe diseased parts with the ligature or knife. The cutting away of enlarged tonsils was an operation which was performed by tbe ancients, and in different ways. Sometimes they tore with their fingers the membrane covering the tonsil, and then pulled this part out of the situation which it occupies between the pillars of the velum pendulum palati. In other iusthiices, in which they experienced too much resislance,_they sei- zed (he diseased tonsil with a kind of hook, and then cut it away with a bistoury, which, Paulus iEgineta inlonns us, was concave on the sid. towards the tongue. The moderns, who, for a long while, were timid in the employment of both these me- thods, adopted plans of a more cruel de- scription. The actual cautery w as proposed, and some partial success which followed its use, at oi:g. established its reputation. Caustics were afterward employed, instead of actual fire . but the inconvenience of not being able to limit their action, and the hazard of their falling down the oesophagus, soon caused them to be relinquished by all rational practitioners. Then the operation of cutting away tee tonsils vvas revived, and it was performed, sometimes in Ihe manner of thp obi surgeons, sometimes with virions 486 TONSILb kinds of carved scissors, or knives. Instead of the simple tenaculum used by the ancients, a sort of double one came into fashion. Bichat describes the following, as once tbe common plan: the surgeon is to open the mouth very wide, and depress the tongue with any flat instrument, which is to be held by an assistant. The operator is then to take hold of the diseased tonsil with a tenaculum, and witb a qommon scalpel, having the back half of its blade covered with rag, he now removes as much of the tonsil as ought to be taken away. In com- mon cases, it is deemed sufficient to cut on a level with the pillars ofthe velum pendu- lum palati. Any other portion, needing re- moval, should next be taken away. The operation being finished, the patient is fre- quently to wash his mouth with proper gar- gles. The preceding method was long adopted by Desault. However, one objection is urged against it, viz. that w hen the end of the knife is conveyed far into the mouth, it may do mischief, not (as has been alleged) to the internal carotid artery, the backward situation of which completely keeps it out of all danger of being wounded, but to the membranous covering of the palate, in a place not corresponding to the tonsils. De- sault thought this objection was tbe more forcible, as when the hook is introduced in- to the tonsil, the danger of tbe above mis- chief is considerably increased by a general spasm, which seems to affect every part of tbe mouth. Hence this eminent surgeon used to employ, for the removal of diseased tonsils, an instrument, which was first in- vented for dividing cysts of the bladder. It consisted of a sharp-edged blade, which was included in a silver sheath. The latter had at its extremity a kind of notch, in which the gland, which was to be extirpated, was re- ceived. The rest of the instruments were similar to those commonly used. Desault proceeded as follows: 1. The patient being seated on a high chair, with his head supported on an assist- ant's breast, he is to open his mouth very wide, and the lower jaw is to be kept thus depressed, by some solid body placed be- tween the teeth, and held there by an assist- ant. 2. The tongue is to be kept down with a broad spatula. 3. The surgeon is next to take bold ofthe tonsil with a double hook, with which he is to raise and draw it a little towards bim. He is then to take the above cystitome, and put the tonsil in the notch, on a level with the place where the incision is intended to be made. 4. When the portion which is to be cut off, is engaged in the notch, the operator is to draw the part towards him, so as to stretch it, and press the instrument against it from below upward. Tbe blade bein? next pushed across the iiob.b, the necessary section is accomplished. When the division i? v.or complete, wh'cb is particularly liable to happen, when the diseased glanu i, 0f considerable magnitude the blade is to be drawn back, and the section completed by applying the instrument to the wound, which it has already made. Sometimes even a third application may possibly be- come requisite. 6. The patient is to be directed to wash his mouth. Bichat states, that this plan of operating, adopted by Desault, is as simple and easy as tbe method above related, with the advantage of being saler. Such is the construction ofthe blade of tne instrument, that when it slides across the notch, it presses against, and steadily fixes die parts which are to be divided ; an advantage which neither the kuife nor scissors have, under the action of which the parts are quite moveable. Hence there is difficulty in cutting them. When the introduction of the instrument from above downward is difficult, it is better to withdraw it; and, after turning the notch in the opposite di- rection, pass it from below upward. In general, however, the first of these methods is preferable, because the gland, when half cut through, cannot now tall back and ob- struct the rima glottidis, so as to bring on danger of a sudden suffocation ; a circum- stance which Wiseman and Moscati saw happen. With a view of preventing this occurrence, Louis recommended the com- mon scalpel to be used, with its edge direct- ed upward, as has been advised for the above instrument; which latter contrivance, however, being, according to Bichat's ac- count, more easy and safe, merits the pre- ference. Besides the advantage of fixing the soft parts, which are to be cut, it has tbat of not contusing them, like most other instruments of this nature, as, for instance, scissors. The oblique disposition of its blade enables it to divide parts, in tbe man- ner of a saw. This invention, as Bichat allows, is cer- tainly increasing the number of surgical in- struments ; a thing, wliich all the best mo- dern surgeons endeavour to avo.d But it is to be recollected, that this instrument is not exclusively applicable to any particular operation. It may be employed for cutting away the tonsils and uvula ; dividing mem- branous fraena in the rectum, vagina, and bladder; amputating mugous excrescen- ces, polypi of the nose, (if this mode of extirpating them were preferred) and va- rious tumours in general, which are deeply situated in differeni cavities of the body, where instruments introduced unguardedly might injure parts which should be avoided, or where the base of the tumour should be steadily fixed, when its division is to be ac- complished. Tbe latter object cannot safely be effected by scissors When the base of t-ie tumour is too large to be received in tbe notch, one part is first to be divided, and then another, till ils whole thickness is cut through. In England, when a diseased tonsil is to be cut away, surgeons generally prefer *•- cr>p;'j-*""''i scalpel. roi** As a general practice, I consider, that the excision of an enlarged tonsil is a better practice than the extirpation of it with a li- gature, which also sometimes answers very well, and, perhaps, in children and timid patients may merit the .preference. The chief objections to the ligature are. that its operation is rather tedious, sometimes pro- ductive of a great deal of irritation, and, on the whole, at least as painful as the kniie. Moscati having once adopted this plan, very severe pain aud inflammation ensued; tbe difficulty of swa lowing and breathing compelled bim to amputate the tumour at the place where the ligature was applied, and all the bad symptoms immediately ceas- ed. Besides, when the ligature is used, there is no oozing of blood from the vessels, a circumstance which tends so much to di- minish the inflammation. The base of the swelling is also sometimes broader than its upper part, and does not admit of being properly surrounded with a ligature. And, when it bas a narrow base, it can then be so easily removed with a scalpel, or with Desault's instrument, and with so little pain, that one of the last modes is generally pre- ferable. The ligature, however, has had its advo- cates. Heister recommends it, in certain cases ; Sharp praises it; and others approve its use; while the plans ot employing it have been as various as the inventive genius of the different partisans of the practice. Some make use of Levret's double cannula, which is furnished with a silver wire noose, in which the tumour is to be engaged By twistingthe instrument, the diseased part be- comes constricted; and this plan being repeated every day, the circulation is inter- cepted, and the gland mortifies, and sloughs away. Some, after putting the noose of a ligature over a kind of tenaculum, hook hold of the tonsil, push the ligature over the enlarged gland, which they tie, wilhout having any means of increasing the con- striction afterward. Some employ Bello- que's instrument for putting the ligature over the tonsil. Others require no instru- ment whatever for the purpose, and accom- plish the business with their finders. Desault employed an instrument, which the French call un Serre-mrud, which is in fact, nothing more, than a Ion.:, narrow, round piece of silver, terminating at one end in a little ring, or bole, and, at the other, in a kind of groove or notch. The following was Desault's method of extirpating the tonsils with a ligature. 1. The patient was seated on a high chair, with his head held back, on an assistant's breast; his mouth was opened very wide, his tongue depressed, and the diseased ton- sil taken bold of with a double hook. 2. The surgeon took the serrc-nceud, in wliich a ligature had been passed, so as to form a noose. The noose was put over the handle of the book, which was committed to the charge of an assistant, and the noose then pushed over the tonsil, so as to embrace i' completely. XOt; 487 3. The surgeon now drew the ligature strongly towards him, and pushed forward the serrc-naud, so as to produce the requisite constriction of the tumour. In general, the ligature was not made very tight the first day. 4. When the necessary constriction had been made, the double-hook was withdrawn, and the ligature tw isled round the notch, at tbe outward end of tbe instrument. 5 The next day, the gland became unu- sually 1 trge, in consequence of tbe impedi- ment to the return of the venous blood. The ligature was unfastened from the notch- ed end of the instrument, and drawn more out, so as to increase the constriction, after which it was again twisted round the notch. This plan was followed up till the tumour was detached, which usually happened on the fourth, or fifth day. Mr. Chevalier, a few years ago, described a particular mode of passing and securing the ligature. He passes a flat spear pointed hook behind the diseased tonsil, and its point is then pushed forward, so as to perfo- rate it through the middle of its base. The needle is then to be withdrawn, and an eye- probe, very much curved, and armed witb a long double ligature, may then be readily- passed through the perforation, and brought out at the mouth, the ligature divided, and one portion tied round the upper half of the tonsil, and the other round the lower. " A single knot being first made upon one end of Ihe thread, the end so knotted, is to be brought forward upon the other, and to make a single noose upon itself including the other, and to be drawn tight upon it, close to the first knot. The free end of the thread is (hen to be passed" through a ring at the end of au instrument for the purpose, and * beinglhen held firm, and thering push- ed forward upon the knot, the loop, now formed, may be readily tightened, so as completely to strangulate the diseased part; and in the same manner, it may be tighten- ed, from day to day, till ihe part is entirely detached." (Sec Med. Chir. Trans. Vol. 3,p. 80, fyc.) The subject is more intelligible with the plate. In cases of angina, the tonsils are some- times suddenly attacked with such a degree of swelling, that respiration is dangerously obstructed. This c; se is analogous to the occasional enormous inflammatory swelling of the tongue, and, if it resist venesection and leeches, the most prompt mode of re- lief is that of making several deep scarifi- cations with a knife in the part. Many cases, confirming the good effects of this practice, have been seen by Langenbeck (See Neue Bibl. B. 2, p. 492, fyc.) TOPHUS. A swelling, which particular- ly affects a bone, or the periosteum. See Node. TORTICOLLIS, (from torqueo, to twist; and collum, tbe neck.) The wry-neck. See Wry-neck. "TOURNIQUET. (French, from tourner, to turn.) An instrument used for stopping the flow of blood into a limb, until some reqni- •ifab TOURNIQUET. site operation bas been performed, or some more permanent plans of checking hemor- rhage have been put in practice. The old surgeons used to surround the limb with a band, with which they made such a degree of constriction, that the cir- culation was quite stopped. They also be- lieved, tbat the pressure of (he/band was ad- vantageous, in benumbing the limb, aud moderating the pain of operations. The violent pain and contusion, how- ever, which such a tourniquet occasioned, being frequently followed by mortification and abscesses, surgeons found it necessary to devise some other method of checking hemorrhage. The application of the circu- lar band was first improved, so that it caused less pain, and less mischief to the skin. Ihe limb was surrounded with a very thick corn- press, over which the band was pUced. Two small sticks were next put under tbe band ; one on tbe inside, the other on the outside of the limb; and they were twisted till the band was rendered sufficiently tight. It is in this manner, says Dionis, in his Traiti d'Opirations, that carriers tighten the cords which fasten the bales of goods in their carts. A French surgeon, named Morel, is said to have made this first im provement in the application of tourni- quets. J. L. Petit, in 1718, presented to the Aca- demy of Sciences a tourniquet of his own invention, which was much more perfect than any previously contrived. It consists of two pieces of Wood, one of which is su- perior, the other inferior. The inferior piece is about four inches and a half long, and nearly two broad. Its under surface is somewhat concave, while its upper one is a little convex, and the ends are hollowed out. From its middle part rises a round eminence, about seven lines high, and eight and a half broad. The superior piece is almost the same as the inferior one, but rather shorter. The eminence, which as- cends from its middle part, is six lines high, and an inch and a half in diameter. This eminence is hollow within, and calculated to receive a wooden screw, the top of which is a sort of button for turning the screw. The grooves of Petit's screw were about four, or five, and each of them four lines in diameter, in order that a half turn might produce the necessary effect. Lastly, all the pieces of the instrument were fastened together with an iron pin, which went through the middle of the two pieces of wood, and through the whole length of the screw. This iron pin was riveted under the inferior piece, and at the top of the button, in such a manner, however, that the screw was capable of turning on it, as on a pivot. In order to apply this tourniquet, the limb is to be surrounded with a double strap, about four finger-^breadths wide, and made of chamois leather, which is the softest ma- terial that can be used. To one end of the strap a double little cushion is fastened, of the same length and breadth as the lower piece of the tourniquet. A narrow com- !>ress, or cylindrical pad, is also requisite. or the purpose of compressing the track of the vessels. This compress consists of a very firm roll of linen, covered with cha- mois lealher. The ends of a piece of tape are sewed to the outer part of the pad, and thus the tape leaves a passage for the lea- ther strap. By this artifice, the pad can be moved to any situation on the strap, as the bulk of the limb may require. The middle of the tape is to be fastened to the outside of the leather strap. The cylindrical com- press, or pad, is to be put over the course of the vessels. The double cushion is lo be placed on the opposite side of the member, while the leather strap is to surround the limb. All the different pieces of the appa- ratus are next to be retained by means of the tape, which is to be tied at the side of the cushion. The tourniquet is now to be put over the cushion, on that side of the limb which is furthest from the track of the large vessels, and is to be fastened in this situation with a double band, that has a hole in it for the re- ception of the upper part of the screw. In order to make the proper compression, the screw is to be half turned round, from the right lo the left. The upper piece ofthe tourniquet becoming now further from the lower one, the double band draws the pad, and presses it against the vessels, so as to make the due degree of compression. The following are the advantages, attend- ing the use of Petit's tourniquet: 1. Tt com- presses the lateral parts of the limb les? than the tourniquet previously in use. 2. It requires the aid of no assistant, either to hold, tighten, or loosen it. 3. The operator is able of himself to stop the flow of blood in the artery, by means of the screw. 4. When there is any danger of hemorrhage after an operation, this kind of tourniquet may be left on the limb, and, in case of the bleeding coming on, the patient, if no one be at hand, can tighten the instrument him- self, as much as is necessary. 5. The con- striction, which this tourniquet produces, does not create any danger of mortification, because it does not altogether stop tbe flow of blood through the collateral arteries. The tourniquet here described is certainly very complex, when compared with that which is used by the best modern practi- tioners; but, still it is the original ofthe latter, and both are constructed on the same principles. All the pieces of modern tour- niquets are kept connected together, and in- stead of two pieces of wood, used by Petit, there is contrived a brass bridge, which is capable of being elevated, or depressed, by means of a screw, made of the same metal. Over this bridge a very strong band pro- ceeds, and by passing under two little roll- ers, at each end of the bridge, it always re- mains connected witb the instrument. A convex firm pad is sewed to the band, and put immediately over the artery, where the instrument is applied. There are no cush- ions for the opposite side of the limb under the screw: but a thick piece of leather TREPHINE ,139 through which the band proceeds in two places, is always situated under the lower surface of the brass, and serves to prevent any bad effects of its pressure. It is usual also for the surgeon to fold some rag, and to put it in this situation, at the time of ap- plying the instrument. (See Hemorrhage.) The interruptioirof the circulation in parts of the body by the tourniquet, has been tried as a means of relieving diseases. (See G. Kellie, Obs. on the Medical Effects of Com- pression by the Tourniquet, Svo. Edinb. 1797.) TRACHEA, Wounds of. See Throat. TRACHEOTOMY. (from rp%ua, the windpipe, and re/tva, to cut.) The opera- tion of cutting an opening into the windpipe for various surgical purposes. See Bron- diotomy. TREPAN, (from Tfinrna, to perforate.) Trepanum; Terebellum ; Modiolus. A cir- cular saw, by means of which the skull is perforated in the operation called trepan- ning, or a circular portion of any bone may be sawn out. It bears a considerable re- semblance to the well-known instrument named a wimble, and is worked in the same manner. Formerly, the sawr was sometimes made of a conical shape ; (see Abaptislon) but this construction rendered the action of the instrument difficult. In this country, the trepan is now superseded by the instru- ment called a trephine, which has a different handle, and is not worked in the same way. On the continent, however, the trepan still has the preference. TREPHINE. The instrument now com- monly preferred for perforating the cranium, for purposes which I shall presently explain. It consists of a simple cylindrical'saw, with a handle placed transversely, like that of a gimlet; and, from the centre of the circle, which the teeth of the saw describe, a sharp little perforator projects, named the centre- pin. The upper part of the centre-pin is made to screw in a corresponding hole at the inside of the top of^he saw, and is ca- pable of being taken out, or put in, at the surgeon's option, by means of a little key for the purpose. Its use is to fix the tre- phine, when it is first applied, that is, before the teeth of the instrument have made a sufficient circular groove, in which they can steadily work. Wheji this has been ac- complished, the centre-pin must always be removed ; because now it is not only not needed, but if left, it would retard the pro- gress of the operation, and inevitably wound the dura mater and brain, when the teeth of the saw hud cut to u certain depth through the cranium. My trephines have their centre-pins contrived to slide up, or down, and to be fixed in either position by turning a little screw. This method seems to me both ingenious and convenient. The cylindrical pari of the trephine is often termed the crown of the instrument. The surgeon should have at least two or three cylindrical saws of various sizes ; for it is always a commendable rule, never to saw away any more of the cranium than is abso- lutely requisite for Ihe accomnlisbment of Vor.. II 62 some rational object. There is no occasion, however, for having any more than one han- dle, which may be made to screw on any of the saws. Trephines are also occasionally applied to other bones, besides those of the cranium. In the articles Antrum, Caries, Exostosis, Fractures of the Sternum, Necrosis, Spina Ventosa, other cases are mentioned, in which the employment of these instruments some- times becomes proper. It is not always desirable to remove a com- plete circular portion of the cranium, the taking away a piece of smaller size, and of a different shape, being frequently much more advantageous. Some surgeons, I understand, who object to removing any unnecessary quantity of the cranium, have been in the habit of employing a trephine, terminating only in a semi-circular, instead of a circular saw, by which means (hey can often cut across the base of a depressed portion ofthe skull, and take it away, without any occasion for removing also a circular piece of bone. An instrument of the latter kind may cer- tainly be sometimes useful. The saws, however, which Mr. Hey has described, should constantly be kept in every case of trephining instruments. This prac- tical writer remarks, that "the purposes for which any portion of the cranium is remo- ved, are, to enable the surgeon to extract broken fragments of bone, to elevate what is depressed, and to afford a proper issue to blood or matter that is, or may be, confi- ned, be. " When a broken fragment of bone is driven beneath Ihe sound contiguous part of Ihe cranium, it frequently happens, that the extraction cannot be executed without remo- ving some of the unbroken part, under which (he fragment is depressed. This might gene- rally be effected with very little loss of sound bone, if a narrow portion of that which lies over the broken fragment could be removed. Bul such a portion ctmnot be removed with Ihe trephine. This instrument can only saw out a circular piece. And as, in executing this, the central pin ofthe saw must he placed upon (be uninjured bone, it is evident (hat a portion of the sound bone, greater than half the area of the trephine, must be removed at every operation. When the broken and depressed fragment is large, a repeated ap- plication of Ihe trephine is often necessary, and a great destruction of sound bone must be ihe consequence. " When the injury consists merely of a fissure with depression, a small enlargement of the fissure would enable tbe surgeon to introduce Ihe point of the elevator, so as to raise the depressed bone. But a small en- largement of the fissure cannot be made with the trephine. When it is necessary to apply the elevator to different parts of the de- pressed bone, a great deal of the sound cra- nium must be removed, where a very narow aperture would have been sufficient. " Tbe same reasoning will apply (o (be cttse of openings, made fo- the purpose c.f 490 TIIEPIIIM- giving a discharge to oxtia.asaled blood or matter. " If a saw could be contrived which might be worked wilh safety in a straight, or gently curvilineal direction, it would be a great ac- quisition to tbe practical surgeon. Such a saw I can now with confidence recommend, after a trial of twenty years, during w'hicb lime I have rarely used the trephine in frac- tures of tbe skull. Ils use has been adopted by my colleagues at tbe General Infirmary in Leeds ; and will be adopted, I hope, by every surgeon who has once made trial of it." Mr. Hey nex( informs us, (hat the in- strument vvas first shown to bim by Dr. Cocked, of Ponlefract ; but that there is a saw formed on the same principle in Scul- tetus's Armamentarium Chirurgicum. The saws alluded to are very short ones, fixed at the end of a longish straight handle : their edges are made cither straight or semicircular. The latter construction qualifies tbe instrument for cutting in a curvilineal direction, which is often proper. The edge of the saw should always be made a little thicker than the rest of (he blade, by which means i( will work in the groove, which is cut witb more faci- lity. Saws made on the principle just described, are also of infinite use in culling away dis- eased portions of other bones, besides the skull, exosteses, be. In cases of necrosis, when a dead part of a bone is quite wedged iri the substance of the surrounding new bony matter, Mr. Hey's saws may often be advantageously employed for cutting away the parts, which mechanically prevent the detachment of the dead pieces. The saws invented by Mr. Machell and Professor Graefe, are also highly ingenious, and parli- vularly merit attention, when there is very little room for tbe working of the instrument, and the bone to be cut lies rather deep. They are wheel-like saws, turned by ma- chinery. Besides trephines of various sizes, and the saws jusl now noticed, the surgeon should also take care lo have in his case of (rephi- ning instruments a little brush for occasion- ally cleansing away the particles of bone from the teeth of the saw in the progress of Ihe operation ; a pair of forceps for extract- ing the round piece of bone after it bas been detached by Ibe saw; a lenticular for remo- ving any inequalities which may present themselves round Ihe sawn edge of the cra- nium after the circular piece is taken out; a raspatory for the same purpose, and also for scraping the bone in order to see whether it will bleed, which is a circumstance in some cases very important to be attended (o; (see Head, Injuries of;) a largish common scalpel for dividing tbe scalp, be.; and some elevators for raising depressed pieces of bone. The common elevator is now generally used by ail the best English surgeons ; but several others have been proposed, as, for instance, the tripod elevator; and another invented by J. L. Petit, and afterward im- proved by M. Louis. Before beginning tue description ol (ue operation, I think it highly proper (o remind (he reader of what has been «o forcibly dwelt upon in the article. Head, Injuries of',—that, generally, (he remov.d ol pressure off (be brain, which pressure must also actually oc- casion dangerous symptoms, can form the only true and vindicable reason for employ- ing the trephine, or sawing away any portion of the skull. There are very few exceptions (o this remark : it may, indeed, be now and then proper to saw away tbe bony edges around some fungous excrescences, which grow from the dura mater, and make Iheir way outward, by occasioning an absorption of the part of the skull immediately over (hem. (See Dura Mater.) Ii may also be sometimes proper to saw out diseased por- tions of the skull, though, it must be confess- ed, that in general their separation should be left to time and nature. In tbe records of surgery, innumerable facts may be consulted, where tbe prudent and judicious employment of the trepan has effected wonderful cures, and been the only thing by which tbe patients' lives could pos- sibly have been saved. The benefit winch the operation brings about, is also sometimes so sudden and stonishing, tbat in no in- stance does (he interposition of the surgical art display itself (o greater advantage. The immediate restoration of sight by the de- pression, or extraction of an opaque sub- stance trom (he eye, is not more beautiful and striking, (ban the instantaneous commu- nication of the intellectual faculties, and of the powers of speech, of feeling, be. toge- ther with voluntary motion, to a person ly- ing in au apparently lifeless state from an in- jury of the head. The utility of the trepan is occasionally manifested even in this de- gree. In the valuable essay of Mr. Aberne- thy on injuries of (he head, a case may be seen, in which the patient, who had been in a condition almost bereft of animation, rose up and spoke theJnstant (he extravasated blood was removed from tbe surface of the brain. And among (he wounded at (be bat- tle of Waterloo, there was a soldier of the 44th regiment, whose case is of equal inte- rest. He had been struck by a musket-ball on the right parietal bone, which was expo- sed, but had no appearance of being fractu- red. As however (hi symptoms of com- pression were urgent, and Ibe patient was in nearly a lifeless stale, I conceived it right to apply tbe trephine to tbe part on which tbe violence bad acted. I bad not sawn long before the external t-tble came away in the hollow of the trephine, leaving the inner table behind, which was nol only splintered, but driven at one point more than half an inch into the membranes and substance of the brain. No sooner were tbe fragments taken out with a pair of forceps, than tbe man instantly sat up in his bed, looked round, and began to speak witb Ihe utmost rationali- ty. It is a most extraordinary fact, tbat this patient got up and dressed himself the same day, without leave from the medical officers-, ?nd never bad a had symptom afterward- TREPHINE. 491 Immediately the operation was finished, the temporal arteries were opened, and some purgative medicines exhibited. In a case of fungus of tbe dura mater, with diseased bone, mentioned by Schmuck- er, the trepan was applied eleven times in less (baa a montb, and the operation used to cause so little indisposition, tbat the patient hardly ever required to go to bed afterward, and, on one occasion, actually went lo mar- ket an hour after its performance. ( Wahrneh- mungen, B. I,p. 456.) Let not the young surgeon, however, draw from these dazzling cases of success an im- moderate solicitude to perform the opera- tion ; for it should never be undertaken but in the most pressing circumstances, and when the symptoms unequivocally show tbat a dangerous degree of pressure on the brain exists. 1 recollect an unfortunate ex- ample, in which tbe late Mr. Ramsden, of St. Bartholomew's Hospital, ventured to saw out a portion ofthe frontal bone for a mere long- continued pain in tbe part: -the patient was attacked with inflammation of the dura ma- ter, and perished in three or four days. We may therefore conclude, tbat the operation is nol itself exempt from danger; and it is certain, that it ought never to be resolved on without deep consideration. " Gravis tamen satis est operatio, ut nunquam, nisi in- dicationes suffvcirnles adsint, institui debet." (Calfisen Syst. Chir. Hodiern. Tom. 1, p. 658.) The trepan, or trephine, is never neces- sary in injuries of the head, except for the purpose of relieving the brain from pressure. Such pressure may be caused by a depressed portion of the cranium, or it may be pro- duced by an extravasation of blood, or the lodgment of matter, betwixt the skull and the dura mater. The chief danger of con- cussion, when the accident is not directly or soon fatal from the disorganization and mischief done to tbe brain, depends upon the consequent inflammation of this organ, and therefore can be little likely to be be- nefited by the use of the trepan. If the operation becomes proper in such a case, it is when an abscess has formed under the cranium, and when the confined matter it- self creates bad symptoms by its pressure on the braiu. This state of things, how- ever, cannot come on till after the inflam- mation of the braiu and its membranes has prevailed a certain lime,^ind it is always accompanied with a detUhment ofthe pe- ricranium and a puffy tumour of the scalp; or, if there be a wound of the latter part immediately over the abscess, the lips of the injury suddenly acquire an unfavour- able appearance, and lose their vermilion colour. The patient has also had much preceding febrile disorder, pain and tension over the whole head, redness and tumes- cence of the eyes, and generally more or less delirium. When the matter is forming, there are usually some rigours, and, as soon as it is formed, the patient falls into a co- matose state, and paralytic symptoms show (hem-selves. Here the urgency for the prompt application of the trephine is very great, and the patient's chance of living is almost essentially connected with the imme- diate performance of the operation. This important case has been particularly dwelt upon in the writings of Mr. Pott. In tbe article, Head, Injuries of, I have laid down tbe most remarkable symptoms of concussion, and compression of the brain, a subject which every surgeon should study wilh earnest attention, before he ever pre- sumes to employ the trepan. For, some- limes these accidents are extremely difficult to be discriminated ; sometimes (hey exist together in the same individual ; a compli- cation which is peculiarly embarrassing; and in every instance where the symptoms are those of concussion, the operation, so far from being indicated, would be a step of all others the most likely to do harm, by in- creasing the irritation and inflammation of the brain and ils membranes. A fall upon the back, or upon the head, occasions a di- rect concussion of the brain, and the shock not being materially weakened by the in- tervention of any yielding elastic structure, is the more dangerous. When a person has fallen from a certain height, and pitched ou his head, bis back, tbe buttocks, the knees, or even the soles of the feet; when he bas been instantly deprived of his senses, and then by degrees recovered ihem and come to himself again ; the fact of his having suf- fered concussion of the brain is clear and indisputable. Concussion bus likewise taken place, though in a slighter degree, when the patient bas been only stunned by the fall, and experienced a sensation of sparks. But a multitude of degrees separate this feeble concussion from that in which the substance of Ihe brain is instantaneously di.-organized, so that the patient has nol the possibility of recovery. Tbe symptoms of concussion of the brain are attended witb coma, and ibe compres- sion of this organ by ap extravasation is also accompanied wii-i lethargic heaviness. How then is «l»e surgeon lo ascertain, whether Ibe comatose disorder arises from one pr*che other of these affections ? Here in order to avoid repetitions, I beg leave to refer to the observations already made in the article quoted above. But there is one criterion of such first-rate importance, that it may prevent innumerable fatal mis- takes', and, indeed, without the continual re- collection of it, no man ought to be rash enough to interfere with this dark and ab- struse part of surgery. On this account, I shall mention it here, notwithstanding it has been already noticed elsewhere. If Ibe pa- tient is knocked down and stunned directly by the blow, and remains iu a state insen- sibility, (hese primary symptoms * ascri- bable to the concussion. On the c^itrary, when the coma and loss of senseWo not take place till an hour or two after the blow, they are to be imputed to an extrava- sation. The shock given to the brain by concus- sion must, like every other impulse to nmu 492 TREPHINE nieated, continue (o diminish until it censes altogether. If at the very time of the blow, the shock bas not been forcible enough to produce alarming symptoms, such symptoms will not afterward come on when their cause is weakened. Hence the reason why com- pression can be distinguished from concus- sion of the brnin, when there has been an interval of sense between the receipt of the blow and the occurrence of tbe bad symp- toms. But the distinction of the symptoms into primary and consecutive cannot be made when concussion and extravasation exist together. Having made these few remarks on con- cussion and compression of the brain, re- marks which seemed necessary before I entered into a description of the operation of the trepan, 1 shall ne;.t premise some observations relative to contusions and fractures of the skull, cases on which the most erroneous opinions h»ye been enter- tained. It is true, that I have in another place (see Head, Injuries of) considered the subject; but it may be bettei to recapitulate certain points here, because they have such immediate connexion with the application of tbe trephine. Contusions of Ihc head not unfrequently occasion a small kind of tumour which is soft in tbe centre, but bard and resisting at the circumference, especially when the vio- lence has been considerable. Now the ease with which the centre or seat of the extra- vasated fluid admits of being depressed, while the circumference remains hard and elevated, is extremely apt to give rise to (he belief, that a fracture with depression has happened. The (rue nature of this accident was first clearly explained by J. L. Peti(, and since his time (be proper cautions nol to fall into a mistake concerning it, have been laid down by (he generality of surgical W. iters. Often nothing is more obscure, (ban (he diagnosis of fio«*.tures of the craniun : their existence indeed can only be made out with certainty, when they c»n be felt or seen. Thus a fracture of tbe skull, a-.iended with a wound of the scalp, and exposure* of the bone, shows itself in the form of a fissure more or less wide and extensive, and taking various directions. The accident may also be known by the touch even when the soft parts continue entire, particularly if (be frac- ture isaccompanied with splinters, or the edges of Ihe fissure are materially separated. When there are many splinters entirely detached, a crepitus will likewise serve to explain the nature of the accident; but unassisted by these symptoms, imparted to him by (he sight, the hearing, or (he touch, (he prac- titioner cannot at once offer a decided opinion as to whether a fracture exists or not. f In-wrder to procure more positive infor- mation, would it be right and judicious to make several incisions aud uncover the bone ? But here tbe surgeon would be em- barrassed in the very commencement of his proceedings; for how would he be able (o judge where the kife should be applied? Why also should he resort to an useless and painful operation, which (to say Ihe best of it) could only render die patient's cure more distant ? The symptoms indicating compression of the brain, can alone justify an examination of the fracture. These symptoms also must be urgent and alarming ; for when tbey pre- vail in a slight degree, bleeding and evacua- tions promise more benefit than any opera- tion on Ihe skull, and consequently all exa- mination ofthe part suppoed 10 be broken, must be unnecessary. The precept too commonly given, to cut through the scalp for the purpose o! bringing the fracture into view, will no longer be matter of surprise, when it is known, tbat among some sur- geons, the operation of the trepan is a thing of course in b11 fractures of the cranium. Even when the cranium has been denu- ded, so thai ihe sight c-m convey due infor- mation respecting the solution of conti- nuity in the bone, care must be taken not to be deceived by a suture, or by tbe groove of a vessel. In cases of doubt, a modern sur- gical aulhor advises us to scrape the outside of (he bone ; and he tells us, that if after Ibe removal of the exlernal scale, the fisiure yet appear, and a thread of blood be seen at its outer part, no doubt exists of its being a real fissure. As however making this examina- tion can answer no purpose, except with a view (o determining the place where ibe trepan should be applied, I cannot recom- mend the plan, except where the symptoms are such as to render ibis information de- sirable. On the contrary, it appears to me, (bat all examinations of the bone, made seemingly from mere curiosity, and wilhout any true surgical object, should be depreca- ted as rash and hurtful. The danger of fractures of the skull does not depend upon the simple solution of con- tinuity : it bears altogether a relation to the concussion and compression of the brain, with which the injury of the bone may be complicated. Ihe pressure which is caused by depressed splinters of bone, is less alarm- ing, inasmuch as the cause of the compres- sion is easy of removal. The pressure arising from extravasated fluid is far more serious, in consequence of ihe difficulty of ascertaining positively the existence and precise situation of such extravasation. The seat of tbevextr&vasation is sometimes between the skulrand the dura mater, which has been detached from the bone. More frequently it occurs eitiier between the dura mater and tunica arachnoides; in the sub- stance of the brain ; or else in the ventri- cles. The quantity of extravasated fluid is generally less in those extravasations, which are situated between the dura mater and tbe skull. The extravasations which are formed in the substance of the brain itself, are not only more considerable, but also, as (bey mostly depend upon concussion, are more alarming than effusions on tbe surface of the dura mater. It is indeed extremely dithcult, if not impossible, to ascertain tbe situation TREPHINE. 493 ci the extravasated fluid. Tn such cases the trepan is likewise of no use ; while concus- sion, when so violent as to produce internal extravasation, is invariably fatal. In extrava- sations between the dura mater and the skull, which are almost the only cases of the kind to which surgery can administer relief, when the effused fluid lies under a part of the skull accessible to the trepan, the exiravnsaled fluid is almost always small in quantity. The danger, however, is not the less : ten or twelve drops of fluid are sometimes enough to produce a fatal compression. When the extravasation has happened in the substance of the brain, the compression is far more perilous: in short, it may be said to prove with very few exceptions, certainly mortal. The danger is not so great, when the extra- vasation is situated belween the skull and dura mater. The lethargy, the degrees of which in- crease from mere drowsiness into the most perfect coma ; and the paralysis of the op- posite side of the body to the seat of the ex- travasation ; are (he characteristic symptoms of this accident in cases of injury of the head. Having explained elsewhere (see Head, Injuries of,) some other symptoms, such as stertorous respiration, dilated pupils, be. which usually indicate pressure on the brain, it is unnecessary here to dwell upon them. The subsequent increase ofthe coma, and paralytic affections, and the gradual augmentation of their intensity, serve to render these symptoms distinguishable from others, which are suddenly brought on by concussion. But there are instances, as every man of experience knows, in which concus- sion ruptures the blood-vessels, and produces an extravasation of blood. In this circum- stance, it is obvious that the symptoms of compression are blended with those of con- cussion. The symptoms proceeding from tbe latter cause always diminish in propor- tion (o tbe time, which has elapsed from Ibe moment of the injury; while those of com- pression succeed, and on the contrary, in- crease in intensity, in proportion as tbe quantity of extravasated fluid becomes more considerable. Notwithstanding these dis- tinctions,however, it must be acknowledged, lhat there are many cases in which the sur- geon is obliged to remain in doubt, with re- gard to the particular cause of the symptoms. This indecision is the more embarrassing, because the operation of the trepan is neces- sary in cases of extravasation, but useless in those of concussion. Even when extrava- sation is known to exist, tbe practitioner re- quires more information ; for be ought io know the precise situation of Ihe effused fluid. It is true, indeed, that paralysis of one side of the body generally indicates-the pressure to be upon the opposite hemisphere ofthe brain. But what surgeon would ven- ture to follow the practice advised by Van Swieten, and apply to the suspected side of the head three crowns of tlie trepan ? Possi- bly not one of them mighl fall on the situa- tion of the extravasated fluid. When (he rkull is broken, the extravasation exists on (he same side as the fracture. When it is the effect of concussion, or when the breach of continuity in the skull is what is termed a counter-fissure ; the effusion is generally on the side of the head most remote from the blow. If the presure is caused by a detach- ment of the internal table of (he skull, the nature of the case cannot be ascertained be- fore the operation of the trepan has been performed on the part of the skull, upon which the violence has acted. When there are two extravasations ; one depending upon a fracture, and situated immediately under it, between the dura mater and the skull ; the other arising from concussion, and situa- ted at some point directly opposite, either between the dura mater and tunica arach- noides, or within the substance of the brain itself; paralysis may occur on the same side as the fracture, and hence it may be inferred, thai the palsy does not always take place on the side opposite to (he extravasation. But, says Bicherand, an examination of the body quickly proves, that the case does not devi- ate from the common rule. The extravasa- tion produced by concussion, being almost invariably more considerable than that caused by a fracture, accounts for the ex- tension of the palsy (o (he sam;* side of the body. Sometimes the side which is not pa- ralytic, is effected with convulsions; the pulse is full and hard ; and the respiration stertorous ; iu short, the symptoms are analo- gous to those caused by apoplexy. The evacuating plan, recommended for the treatment of concussion, (see Head, Injuries of) is all that can be done, when every thing is uncertain relative to the situa- tion of the extravasation. It is all that can be done in those frequent instances, where the effusion has taken place iu the substance of the brain, so that it cannot possibly be voided. The trepan then is indicated only when there is an extravasation between the dura mater and the bone, the fracture being situated at a part of the skull accessible to instruments, and not at the base. We will not here dwell upon the doubtful example, where the fluid lies between the dura mater and the arachnoides. But, are the cases, which have just been described, as frequent as they are supposed to be ? Cannot the effused blood be sometimes discharged through the interspaces of the broken pieces of bone ? Is the trepan usually necessary for the relief of injuries of the head, as Quesnay, Pott, and the members of the French Academy of Surgery maintained ? Many of the best surgeons now think not— The operation is often useless, and some- times dangerous. I believe that it should be limited to a small number of cases, in which not only the existence and situation of the pressure are known, but in which the symptoms, arising from this cause, are ur- gent and dangerous, and the pressure can be removed by no other means. Richerand contends, that extravasations between the skull and the dura mater, so considerable as (o produce compression of the brain, and render the trepan necessary, 494 TREPHINE are much less common than many surgeons think. Even when they do occur, the dura mater is always detached to a certain extent, and, according to this writer, if tbe bone is much broken, the interspaces of the frag- ments are quite sufficient for the evacuation of the effused blood. The following case is quoted in proof of this observation. A wo- man injured ber head by falling from a height of fifteen feet. The fracture reached the whole breadth of the skull, so that when the os fronds was taken hold of with one hand, and the os occipitis witb the other, the two halves of tbe cranium admitted of being manifestly moved and separated. Blood issued trom the fissure, the edges of which were kept apart by a small wedge of wood in such a manner, that the pulsations of the brain were visible. On the sixth day, as nothing was discharged from the fissure, the bit of wood was removed, and on the fifty-second the wound had completely heal- ed without any exfoliations. On the seventy- second, the patient was discharged from the HOtel-Dieu, perfectly cured. (Nosogr. Chir. T. 2, p. 292, Edit. 3.) Thus we see, that the trepan is not always necessary iu injuries of the head with frac- ture of the skull, notwithstanding there may be some degree of bleeding from the edges of the bone. This doctrine is very different from what is taught in the memoirs of M. Quesnay in the first volume of those of the French Academy of Surgery. Desault in the last years of his practice abandoned tbe operation of the trepan altogether. It bad been remarked for many years, that, in the H6tel-Dieu,this operation was almost always unsuccessful; a circumstance, which once excited a suspicion, that the foul air of the wards of that establishment might have a share in bringing on the unfavourable event. I shall not here expatiate on the bad effect of die atmospheric air on the membranes of the braiu; a thing, of which B. Bell seems to have convinced Richerand. When the skull is fractured"by a blow, or fall, and the case is a simple fissure, the trepan ought to be. applied upon the solu- tion of continuity, if the symptoms indicate a dangerous degree of pressure on ihe brain, and the edges of the fracture are not sufficiently separated to let the extravasated fluid es- cape. When the detached portions of bone are depressed, so as to compress the brain, the operation is still requisite, if they cannot be elevated by other means. But Richerand maintains, lhat a positive indication for tre- panning is not frequent, either because it is difficult to judge of the existence and situa- tion of extravasations, or because extrava- sated fluids readily escape through the in- terspaces of the fragments, when there is a splintered fracture. Such facility is also increased, when one of the portions of broken bone is totally detached, so that it can be removed, leaving an aperture equi- valent to what would be produced by the application of the trepan. When the operation is determined on, it is more convenient to bave the head sha- ved . indeed, this is often done immediately the surgeon is called, in order that he may have a better opportunity of seeing what parts of the scalp have been struck ; for it h in such situatious tbat be has most reason to apprehend fractures of the bone, or extra. vasations beneath it. If, however, the violence has occasioned a large wound, or laceration of the scalp, the practitioner, knowing where the force has been applied is frequently content with having a little of the hair shaved off the parts surround- ing the injury. All that need be said on tbis subject is, that it is always better to bave enough of the hair taken away, lo afford the surgeon an uninterrupted oppor- tunity of examining the scalp freely, and doing whatever .may be necessary. The loss of a little hair is of very little consequence, while tbe concealment of the seat of a de- pressed fracture, or extravasation, might lead to fatal consequences. When the propriety and necessity of tre- phining are fully indicated, provided the wound, or laceration of the scalp, should not have exposed a sufficient surface of the bone for the application of the crown of the trephine, an adequate dilatation of such wound ought immediately to be made. If, in the situation of the blow, there should only be a contusion, or a lump, unattended with any wound, a division of this part of the scalp is to be made by carrying the knife quite down to the bone. In those cases, in which the swelling occasioned by the violence is considerable, and attended with the sensation of a crepitus ; as well ai in other instances, in which there is only a contusion, under which a fiacture and dis- placed pieces of bone may be felt; the scalp must be divided in the same manner, only with greater caution, lest the point of the knife should insinuate itself through the fracture, and do mischief to the duramaler and brain. Authors recommend the shape of the in- cision to be different according to the kind of fracture, and the parts of the head, on which the violence has operated. When the whole extent of the injury can be brought into view, by means of an incision, having the form of a letter T, 4he surgeon should be content with such a division ; but if this bo not sufficient, he may give it a crucial shape. When the trephine is to be applied to the squamous part of the temporal bone, we are recommended to make tbe incision as much as possible, in shape of the letter V, the branches of which are to be upward, and the angle downward, in order that as little as possible of tbe temporal muscle may be cut, and that the division of its fibres may be avoided as far as it is in our power. Having divided the scalp, the next object is to reflect it; but no man w ould be war- ranted in cutting any part of it away, al- though such practice is advised by Pott and many other eminent writers. The purposes of the operation do not require any removal TREPHINE. 495 of Ihis kind ; and the method would leave a wound, which would be long in healing, and when healed, never exempt from de- formity. In short, the reflected flaps of the scalp are capable of adhering to the parts, on which they are laid after the operation, and consequently ought never to be wan- tonly cut away. fc The scalp being reflected, authors next advise us to scrape away the pericranium, either with tbe knife, or the raspatory. Per- haps this measure may be considered as one, which does neither much harm nor much good. The design is to facilitate the application of the trephine to the bone. However, the teeth of a proper instrument, in good order, will not be impeded by the slender periosteum ; and scraping this mem- brane away from parts of the skull, which are not to be removed, must be conducive to exfoliations. Sometimes the bleeding from branches of the temporal, or occipital artery, is so co- pions, that the bone cannot be very conveni- ently perforated before the hemorrhage is sup- pressed. If it be prudent to wait a little, and the case (as it generally does) should be likely to be benefited by the evacuation of blood, it is as well to let the bleeding con- tinue for a certain time. The surgeon may then just direct an assistant to put the end of one of his fingers on the mouth of the vessel, and proceed in the operation. In some cases the bleeding might be so trou- blesome, that it would be better to tie the artery at once. All parts of the cranium do not admit of being trephined with equal convenience and safety. It has usually been set down by surgical authors, that the trephine cannot be applied below the transverse ridge of the os occipitis. There are some cases, how- ever, which prove that such an operation may be safely done, and that we ought not in urgent circumstances, to be afraid of di- viding the trapezius and complexus muscles, in order to be enabled to apply the trephine to the bone. (See Hutchison's Case in Med. Chir. Trans. Vol. 2, p. 104. fyc.) The majority of writers also forbid the application of the trephine to the frontal sinuses, in consequence of the indeterminate depth of these cavities, and the apprehen- sion of incurable fistulae. However, Larrey has deviated from (his precept in several instances, and his practice, confirms the statement of Mr. C. Bell, that, by opening the frontal sinus with a large trephine, and then using a small one, the internal parietes of this cavity may be trephined with perfect safety, and no risk of injuring the dura mater with the saw. (See Larrey's Mim. de Chirurgie Militaire, T. 2, p. 135—138, T.4.) Writers also caution us not to apply the trephine to the anterior inferior angle of the parietal bone, in consequence of the middle artery of the dura mater lying un- der it, generally in a groove of the bone, and occasionally in a canal in its very sub- stance. In the latter circumstance, this portion of the parietal bone could not pos- sibly be takeu away, without wounding the vessel. However, notwithstanding this ad- vice, which bas been unthinkingly banded down by one writer to another, from genera- tion to generation, I very much question the soundness of the doctrine. We undoubtedly ought to avoid trephining this part ofthe cra- nium, when we can prudently do so. But the causes demanding this operation are always so urgent, (hat the patient's sole chance of existence depends on their quick removal. Hence, were there pressure on the brain, either from a depressed portion of bone, from blood, or matter, and such pressure could not be removed without trephining the anterior inferior angle of the parietal bone, what operator would be afraid of do- ing so ? Besides, the fear of the hemor- rhage has been very unfounded; for the lodgment of the artery in a bony furrow, or canal, which authors have pointed out as rendering the suppression ofthe hemorrhage more difficult, is a mere visionary idea, as it is well known, that a little plug of lint pushed into the orifice of a vessel so situa- ted, will always stop the bleeding, with as much certainty and ease as can possibly be imagined. The foregoing suggestion was made in the early editions of my works, and I now see the safety ofthe practice has been confirm- ed. " I have also applied the trepan (says Larrey) over the track of the spheno-'spi- nous artery, at the inferior anterior angle of the parietal bone. The ariery was divided • but 1 stopped the hemorrhage almost imme- diately, by applying an iron probe red-hot." (Mem. de Chir. Militaire, T. 2, p. 138.) # Writers, until very lately, also prohibited us from trephining over any of the sutures and especially over the sagittal suture, be- neath which the longitudinal sinus is situa- ted. The fear of the dura mater being in- jured, and of this vessel being wounded was the reason for the advice. With regard' to the sutures in general, the trephine mav be applied to them, as well as to any other part; and as for the sagittal suture, many facts confirm the propriety of not being de- terred even by it, though situated immedi- ately over the longitudinal sinus. It is to be remembered, also, that the dura mater in cases of extravasated blood and matte/ beneath the cranium, is detached by the' intervention of such fluids from the inner table. By means of a perforation practised over the sagittal suture, Garengeot successfully- elevated a portion of bone which pressed upon the longitudinal sinus, and made tbe patient quite comatose. The depressed piece of the cranium could not have been so advantageously raised, had the trepan been applied in any other situation. But a still stronger argument ju favour of this practice, when the case at all requires it, is the fact, that wounds of the longitudinal sinus, and the hemorrhage resulting from them, are not attended with any serious danger. Sharp mentions his having twice seen a bleedint? of thi* kind. Another in 496 1'JlErHINL. stance is also recorded in Warner's Cases A child received a wound on its forehead : the two parietal bones were fractured, and a portion of each vvas depressed on the dura mater. The child lived a month, without any operation being done; but at the end of this time, Warner applied the trepan. He found a splinter of bone sticking in such a way into the longitudinal si/ius, thai it could not easily be got out; consequently, he enlar- ged with a lancet the opening in which tbe splinter was entangled. The hemorrhage, which was copious, was easily suppressed by the application of a little dry lint, and the child was relieved, though it died at the end of two months, after suffering a variety of symptoms, which had no connexion with the wound of the sinus, the opening of which soon healed. The fourth case, rela- ted by Marchettis, also proves, that wounds of the longitudinal sinus are not fatal. Pott and Callisen have since recorded other facts, tending to tbe same conclusion. (See Syst. Chir. Hodierna, Part 1, p. 659, Edit. 1798.) Whenever a depressed fracture can be ele- vated to its proper level, withoutapplyingtbe trephine, and with the mere aid of a pair of for- ceps, or an elevator, trephining should never b% performed, unless there be strong reason to apprehend, that blood, or malter, lodged on the surface of the dura matter, contributes to the production of the bad symptoms, and ought to be discharged. The scalp having been divided, if neces- sary, and the pericranium scraped from the surface of the bone, according to the com- mon precepts and practice, the next thing is the application of the crown of the trephine. The surgeon is first to make a little impres* *JiiiCI-liASA.-. that he has done all thak in; ought to do. I.el him remember the urgent necessity of keeping off, or diminishing, the inflamma- tion of the dura mater and brain, which is still to be feared. Let him bleed the pa- tient largely and repeatedly ; exhibit saline . purges, glysters, and antimonials; and if the symptoms continue, let him apply a blister to some part of Ihe head. 1 shall avoid, however, any repetitions on this subject, by referring to Head, Injuries oj. The aperture in tbe skull usually becomes closed with soft granulations, which slowly accpiire a hard consistence. Tliese almost constantly grow from the edge of the per- foration, and seldom from the surface of the dura mater. While the cicatrix is soft, it should be protected from external injury with a thin piece of horn, or metal. Exfo- liations from tbe margin of the perforation sometimes retard the healing of the wound ; but, now that the practice of dressing with drying spirituous applications has been ex- ploded, and the removal of any part of tbe scalp is condemned by all the best surgeon-, these unpleasant consequences are rendered much less frequent, Ihan iu former days. The reader may find an account of the operation of trepanning, or trephining, in every system ot surgery ; but, he should particularly consult the writings of Sharp, Le Dran, Dionis, Bertrandi, Polt, Sabatier, Schinucker, Abernethy, Desault, Callisen, Richerand, be. Several parts of the Me- moires de I'Acad. de Chirurgie are also high- ly deserving of perusal TRICHIASIS, (derived from Sg/t, the hair; denotes a faulty inclination of die eye- \ lashes inwards against the globe of the eye. According to Scarpa, tlie disease presents itself under two distinct forms . tbe first is, where the cilia are turned inwards, without tiie natural position and direction of the tarsus being at all changed ; the second con- sists in a morbid inclination ofthe tarsus in- wards, (Lntropium) and consequently of the eyelash towards the eyeball. (Trichiasis.) '1 he first form of this disease is said both by Boer and Scurpa to be uncommon, nor has it come under the observation of the latter writer more than once, and, in this in- stance, only some of the hairs had changed their direction. On this point, however, Mr. Travers is completely at variance with the foregoing authors, as he describes an inver- sion of the cilia as frequently existing inde- pendent of entropeon. (Synopsis, p. 232.) Ihe second species, or form of trichiasis, or that which consists in a folding inwards of the tarsus and cilia at the same time, is the case which is commonly met with in prac- tice. It may be either complete, affecting the whole ofthe tarsus ; or incomplete, oc- cupying only a certain portion of the edge of the eyelid, most frequently near the ex- ternal angle of the eye. Sometimes, the cli;ea*e is confined to one eyelid ; at other times, it affects both ;, and occasionally the p*coniinrra^<' kRICHIASiS H9P •-omctiines bring on (lie complaint, in conse- quence of the skin of the eyelids being kept for a long time in a state of distention and o-dema, terminating in a considerable relax- ation of it. And, according to Beer, the too long continued use of emollient poultices may have tbe same effect. (Lehre, fyc. B. 2, p. 113.) The cartilaginous margin of the eyelid then loses the proper support of the integuments, inclines towards the eyeball, and afterward turns inwards, drawing the eyelashes along with it in the same impro- per direction. Long-continued puriform discharges from the ciliary glands likewise spoil the shape and consistence of the car- tilage of the eyelid, and therefore not unfre- quently occasion trichiasis. Scarpa doubts, whether a spasmodic contraction of the orbicularis palpebrarum muscle can ever be a cause of the disease. The annoyance, which must necessarily result from the hairs perpetually pressing upon the cornea and white of the eye, as Scarpa observes, may be easily imagined. The evil is rendered still greater by the hairs, which are turned inwards, becoming much longer and thicker, than those which retain their natural direction. And although the trichiasis be confined to one eye, both fhe eyes usually suffer from the effects of the disease. Indeed, generally, the eye on the sound side cannot be moved without occa- sioning pain in that which is exposed to the irritation and friction of the inflected hairs. In almost all instances, both the eyes are very irritable, and incapable of bearing the light. As, in cases of incomplete trichiasis, the patient retains some little power of open- ing the eyelids for the purpose of seeing, and that most frequently towards the internal angle of the eye, the head and neck are often inclined in an awkward manner, so that in children a distortion of the neck und shoulders is at last produced, which cannot be rectified wilhout difficulty, even after the trichiasis is cured. Unfortunately, also, ehildrenare impatient of the uneasiness ari- sing from the inflected hairs, and, therefore, are continually rubbing the eyelids, whereby all the ill effects of the complaint are much increased. The cure of the second species of trichia- sis, or that which is commonly met with in practice, is accomplished by artificially everting the eyelid, and fixing it permanently in its natural position) together with the eyelashes, which irritate the globe of the eye. According to Professor Scarpa, this indication is perfectly fulfilled by the exci- sion of a piece of the skin close to the edge of the eyelid, of such a breadth and extent that, when the cicatrix is formed, the tarsus and margin of the eyelid may be turned out- wards, and sufficiently separated from the eyeball, the cicatrix of the integuments af- fording a point of support fully adequate to keeping the parts in their natural position and direction. Scarpa believes, that there are now very few modern surgeons, who, witb a view to the radical cure of this dis- ease, place any confidence either in pluck- rng out tbe inverted eyela-»hes, bending them outwards, and retaining lliein so by means of adhesive plaster; or in plucking them out, and destroying their roots with caustic . much less in extirpating the edge of the eyelid along with the hairs, or dividing the orbicularis muscle on the internal surface ot" (he eyelid, under an idea that the disease is sometimes produced by a spasmodic con- traction of it. The following is (he mode of proceeding recommended by Scarpa. The patient be- ing seated in a chair, if an adult, or, if a child, laid upon a table, witb the head rais- ed, and firmly held by an assistant, who must stand behind the patient; the surgeon is to push outward, with the end of a probe, the hairs, which irritate the eye. Then, with a pair of dissecting forceps, or tbe ends of his fore-finger and thumb (which answer equally well, and in many cases much better, than forceps,) the operator shouhi lift up a fold of the skin of die affected eyelid, taking great care (lint Ibe piece which is (aken hold of corresponds esnctly to the middie of the whole extent of the trichiasis ; for some- times the whole, sometimes a half, and, in olher instances, only a (bird of the extent of the tarsus is inverted. The surgeon, with liis left bund, musl raise the fold of the skin, more or less, according as the relaxation of the integuments, and the inversion of (he tarsus, are more or less considerable. The reason of (his is evident, viz. the greater Ihe quantity of skin is which is raised, the greater is the quantity which will be cut away. Sup- posing Ihe patient to be an adult, as soon as the fold of skin has been raised in a certain degree, the surgeon must request him to open his eye. and if in this acl (he tarsus and eye- lashes resume their nn'ural place and direc- tion, the portion of skin already raised will be sufficient for the purpose. When the in- teguments are elevated, by means of a pair of dissecting forceps, and care is taken lo lay hold of the skin precisely at Ihe middle point of the whole extent of the trichiasis, it necessarily follows, that the consequent sec- lion of the skin will form an oval, and that (he greatest width of the wound will cor- respond exactly, or nearly so, to the middle of (he eyelid, and its narrowest parts (o (he angles, or commissures of (he same. This contributes very materially to make the ci- catrix correspond to the natural fold of the eyelid, and hinder the origin of a disease of au opposite nature lo the one about to be re- medied, towards the angles of the eye, viz. a turning out of the commissures ofthe eye- lids. See Ectropium. Besides this caution, relative to the situa- tion and figure of the fold of the integuments (o be cu( off, the urgeon must be careful that the division of the skin be made very near the inverted tarsus. Were this circum- stance neglected, the operator might have the mortification of finding after the wound is healed, lhat although the eyelid is-tshorten- ed on the whole, from the eyebrow to (he place of Ibe recision, yet it is not equally so at the space which is between tbe edge ofthe eyelid and the cicatrix of the skin Hence the tarsus would not be turned outward snf* Jiv- IRICHIASls ficientiy io keep (ho eyehuiies from rubbing agaius( the eye. The surgeon holding up the fold of skin by means of the forceps in his left hand, is with a pair of probe-pointed, sharp-curved scissors, to cut off the wbole of the duplica- ture, being first sure lhat one of the blades of the instrument is applied close to die edge of the eyelid. II the eyelids should be affected, the same operation must immedi- ately be done upon both of them, with such cautions, and in such proportion, as the ex- tent of the disease, and the degree of inver- sion of each eyelid may require. Scarpa next dissuades us from employing any suture lo unite Ihe wound, aud repre- sents thnl il will be sufficient to keep the eyebrow as much downward as possible, if ihe operation has been done on the upper eyelid, or if on the lower, to support it against the inferior arch of the orbit, by pressing it from below upwards, so as to keep the edges ©f the wound from becoming separated. Then the lips of the wound are to be brought exactly together by means of adhesive plas- ter, which should extend from (he superior arch of Ihe orbit to the zygoma, and the maintenance of this state of (he wound will be still more securely effected, by placing two compresses, one ou the eyebrow, and another on the zygoma, together with a bandage. On the other hand, Langenbeck disapproves of the omission of sutures, by which be finds that the wound may be both more accurately and expeditiously united. Indeed, he expresses himself generally in fa- vour of sutures, w here the wounded part is liable lo be disturbed by the continual ac- tion of the muscles. (Neue Bibl. R. 1, p. 415, fye. 12mo. Hanover, 1818.) Langen- beck, however, takes care to withdraw the ligatures in about twelve, or at most twenty- four hours, as their longer continuance would produce suppuration. Beer also par- ticularly insists upon the utility of bringing the edges of the incision together with a su- ture ; and both he and Lmgenbeck employ forceps, Ihe ends of which have transverse pieces, calculated to take better hold of Ihe slip of skin to be removed. (Lehre. i-c. B. S,/>. 114.) On taking off the first dressings, the third day after the operation, the surgeon will find, says Scarpa, that the patient can open his eye with ease, and tbat the inverted tarsus and eyelashes have resumed their natural position and direction. In the par- tial or incomplete trichiasis, or that which only occupies a half, or a third of the whole length of the tarsus, and in subjects who bave had the skin of the eyelids very loose, Scarpa has often found the wound perfectly united on removing the first dressing. When, however, only a part of the inci- sion bas healed, while the rest seems dispo- sed to heal by suppuration and granulation, tbe surgeon is to cover the wound with a small piece of lint, spread with the unguen- turn cerussaj; and if the sore should be- come flabby, it must be occasionally touched with the argentum nitratum, uulii the cure is finished. With regard to the first form of this dis- ease, or that in which the eyelashes pro- ject against the eyeball, without the natural position of the tarsus being at all altered, (a case which is fortunately rare) tbe ac- complishment of a cure is very difficult, since neither (he pulling out of the hairs, nor burning (he situation of their roots, are means at all to be depended upon for pro- ducing a complete cure of the disorder- and turning the tarsus out of its natural po- sition would make the patient liable to an irremediable dropping of the tears over (he cheek, attended with a chronic thickening of the lining of the eyelid. It has only been in youngish individuals that Beer has ever seen the repeated and careful extrac- tion ofthe cilia effect a radical cure. (See Lehre von den Augenkr. B. 2, p. 121.) In the instance of this form of the disease, which Scarpa met with, only two or three ofthe eyelashes inclined against the eyeball. He found, on turning the eyelid a little out, opposite to the situation ofthe faulty hairs, that he could not, indeed, completely put them in their natural position ; but he saw that he could thus remove them so far from tiie cornea that they would not rub against it without altering the position of Ihe eye- lids so much as to occasion a perpetual dis- charge of the tears over the cheek. And, as in the patient alluded to, the skin about (he eyelid was very tense, Scarpa made an incision with the back of the lancet, near the tarsus, three lines long, and took away a small piece of skin of the same leHgth, but very little more than one line broad. When the cut healed, the operation was found to answer as well as the nature of the case would allow, though the cure vvas not complete. The trichiasis being cured, something more always remains to be done for the purpose of correcting the cause of the dis- ease, as well as curing the disorder of tbe eye, occasioned by the previous friction and irritation of the inverted hairs. The usual indications are to restore the tone of the vessels of fhe conjunctiva, to lessen the swelled Meibomian glands,and obviate opa- city ofthe cornea. Some new methods of performing the operation for the cure of trichiasis, have been proposed by Dr. Crampton, Mr. Saun- ders, and Schreger. The following is the account which Dr Crampton gives of his plan, which he tried in one instance with complete success. " Let the eyelid be well turned outwards by an assistant; let the operator then, wilh a lancet, divide the broad margin of Ihe tarsus completely through by two perpendi- cular incisions, one on each side of the in- verted hair or hairs; let him then, by a transverse section ofthe conjunctiva of tbe eyelid, unite the extremities of the perpen- dicular incisions. The portion of cartilage contained within the incisions, can then, if inverted, with ease be restored to its orf- 4-RlCHiASl&. iiU filial situation, ana ivuuued there by small strips of adhesive plaster, or, perhaps what is better, by a suspensorium palpebral, adapted to the length of the portion of Ihe tarsus, which it is intended to sustain, should one or two hairs be displaced without in- version of the tarsus." (Essay on the En- iropeon, p. 56.) Mr. Travers informs us, that, in cases of a circumscribed inversion, " produced by ci- catrix from burn or wound," he has found Dr. Crampton's method an effectual remedy. It is^added, that the complete division of the conjunctiva and tarsal cartilage, inclu- ding the inverted portion, and parallel to its border, with the aid of sticking plaster, sometimes proved sufficient. Mr. Travers also sees no objection to the entire removal of that portion of the tarsal edge which is incorrigibly inverted from such a cause, especially when combined with a preterna- tural growth of cilia from the Meibomian border of the tarsus. (Synopsis, fyc. p. 356.) In one inveterate case, which was not effectually relieved by the frequent extrac- tion of the cilia, cauterizing (he edge of the tarsus, the excision of a slip of skin, and smearing die eyelid with concentrated sul- phuric acid, as proposed by Helling, (Hufe- land's Journ. St. 4,p lib) Schreger, with a pair of curved scissors, cut out a triangular piece of the cartilage ofthe eyelid at the place where the cilia were most trouble- some. The great benefit derived from the operation then led the same practitioner to suggest the removal of (he whole of the in- verted edge ofthe tarsus, towards the inner canthus, where some irritation was yet maintained. The plan, though followed by severe pain, appears to have succeeded. (Chir. Versuche, B. 2, p. 253.) Mr. Saunders entertained a favourable opinion of Dr Crampton's operation for the cure of the disease in its early stage; but, he contended, such a vicious bending of the tarsus inward was often the consequence of repeated ophthalmy, attended with ulce- ration of the conjunctiva and inside of the eyelid, so that every endeavour to rectify the wrong position of the tarsus, and restore its original direction, would be fruitless. Hence he believed that its excision vvas de- cidedly indicated; an operation which is said to be followed by no pain nor uneasi- ness, and which is sure in its effect. No particular shortening of (he eyelid ensues; the deformity is materially lessened ; and, unless tbe cornea be already too opaque, perfect vision is re-established. Mr. Saun- ders directs a piece of thin horn, or a plate of silver, having a curvature corresponding to that of the eyelid, to be introduced un- der this part, with its concavity towards the eyeball. On this instrument the eyelid is to be stretched. Au incision is to be made through the integuments and orbicularis palpebrarum down to the tarsus, immedi- ately behind the roots ofthe cilia. The cut should extend from the punctum lachrymale to the external angle. Ihe exterior sur- face of (he tarsus is then to be dissected until the orbital margin is exposed, when the conjunctiva is to be cut through di- rectly by the side of the tarsus, which must now be disengaged at each extremity. The punctum lachrymale must be left uninjured The operation is described as being simple, and if any embarrassment arises, it is from the hemorrhage of the ciliary artery, the blood sometimes obscuring the punctum lachrymale, just when the operator is about to divide the tarsus by the side of it. No dressings are required, it being merely ne- cessary to keep the eye covered for a few days. The skin will continue to be eleva- ted,just as the perfect eyelid was; and, though less completely, yet enough to leave the pupil clear when the eye is moderately directed upward. In all the cases in which Mr. Saunders operated, a fungus grew from the wound. He recommends the excres- cence to be destroyed with caustic or the knife. Respecting this operation I shall merely observe, tiiat it is more severe than that advised by Professor Scarpa, and even than the method of Schreger, and must leave greater disfigurement. Unless, therefore, the lattermethods prove ineffectual,I should consider the practice unjustifiable. Nor is Schreger's method allowable, except in cases which resist ihe milder plan,sanction- ed by Beer, Scarpa, and all the best practi- tioners in ophthalmic surgery. Inversion of the lower eyelid is much Jess* common than that of the upper one. The late Mr. Saunders never saw this disease arise from the same causes which induce it in the upper eyelid, though he acknowledges the possibility of such a case. However,. he met with several instances of the affec- tion, in consequence of encysted tumours, which,as they increased, carried the orbital edge of the terms outwards, and, iu tbe same proportion, inclined the ciliary edge towards the globe of Ihe eye. An inversion of the inferior palpebra is sometimes produced by inflammation and swelling of (hat part of the conjunctiva which connects the eyelid with the eyeball. In cases of ophthalmy this membrane often forms between the' latter parts a distinct fold, which is situated just on the inside of ihe orbital edge of the tarsus, and pushes it outward; while the contraction of the orbi- cularis muscle turns the ciliary edge in- wards, and inclines it between the swelling of the conjunctiva and the eye. In this particular case, Mr. 'Saunders assures us, that replacing the eyelid in the early stage of the disease, and maintaining it so until tlie ophthalmy has been lessened by proper means, will be found effectual. But when the conjunctiva is much thickened and in- durated, Mr. Saunders recommends cutting such diseased part of it away, and the ap- plication of compresses lo keep the orbital margin of the tarsus inward. (See also Travers's Synopsis, p. 234 and 355.) Albinus has recorded a species of trichi- asis which originated from the growth and inversion of one of the hair» upon the ca 502 TRLrfc- runcula lacurytnaiis. The plan of relief con- sisted in plucking out the irritating bair; but it is not mentioned whether the hair grew again. J. Seultelus, Trichiasis Admiranda, sire Morbus Pilaris Mirabilis, 12mo. Norib. 1658. Scarpa suite principali Malattie detzli Occhi. R. Crampton, Essay on the Entropeon, Lond. 1805. Saunders's Obs. on several practical Points relative to the Diseases of the Eye, Edit. 3. Richter's Anfangsgriinde der Wun- darzueykunst, B. 3. G. J. Li er, Lehre von den Augcnkrankeiten, B.2.p. Ill—117,Sro. Wien. IS17. Schreger, Chirurgische Ver- mche, B. 2. Neue Melhode die Trichiasis ~u Operiren, p. 253, 8vo. Nnrnbtrg. 1818. B. Travers, Synopsis of the Diseases ofthe Eye, p. 232—354. fyc. Svo. Lond. 1820. TRISMUS. (from Tg-fa., to gnash the teeth.) The locked jaw. -ee Tetanus. TROCHAR, or Trocar. (from the French, trois-quart, three-fourths, from its point being of a triangular form.) An in- strument used for discharging aqueous fluids, and now and then, matter from different cavities in the body, particularly those of the peritoneum, and tunica vaginalis, in eases of ascites and hydrocele. Trocars are also employed for tapping the bladder, dropsical ovaries, be. A trocar consists of a perforator, or sti- lette, and of a cannula, which latter is so adapted to the first piece of the instrument, that when the puncture is made, they both enter the wound together, with perfect ease, after which the stilette being withdrawn, the cannula remains in the wound, and gives a ready passage for the fluid outward. Such are the uses of a trocar, and the principles on which it should be construct- ed. It would be unnecessary in this work to detail every little particularity in the in- strument. I shall merely observe, that the triangular-pointed trocars seem to retain the greatest share of approbation ; for, al- though those of a flat, lancet-pointed shape enter parts with more ease, their cannula; are not large enough for the ready escape of fluids which are at all thick, gelatinous, or blended with hydatids, and flaky substan- ces. The trocar for puncturing the bladder from the rectum, should be longer than a common trocar, and of a curved form ; but as Mr. Carpue has explained, it should not he passed too high up the rectum, lest the peritonaeum be wounded. Surgeons ought always to bave, at least three trocars ; one of full size, another of middling width, and a third of small dimen- sions. In cases of hydrocele, the latter is often preferable. *TRUSS. (Irousse, French.) Bracherium. A bandage, or apparatus, for keeping a her nia reduced. A truss, which fulfils its in- tention properly, should compress the neck of the hernial sac, and the ring, or external opening of th" hernia, in such a manner, that a protrusion of any of the contents of the abdomen will be prevented with com- plete security. Henee, it is th--* indbnen«a- ble quality oi a good u uas, first to make effectual and equal pressure on the parts in- dicated, without causing pain, or inconve- nience to the patient; secondly, not easily to slip out of its right situation, in the vary- ing motions and positions of the body. Trusses are either of an elastic or non- elastic kind. The latter are composed of leather, fustian, dimity, or similar materials. Tliese cannot be at all depended on, and should, iherefore, be entirely banished from surgery. Since, (as Mr. Lawrence has re- marked) the size of the abdomen varies, according to the different states of the -vis- cera, and to the motions of its parietes in respiration, a non-elastic bandage must vary constantly in its degree of tightness, and keep up either too great, or too little pres- sure. The omentum, or intestine, easilv slips out when the opening is not exactly closed, and the patient who wears such a bandage must be in a state of constant inse- curity. Those who lead an active life, or are obliged to use laborious exertions, will be more particularly exposed to risk. If the patient, after experiencing these defects, endeavours to remedy them by drawing the bandage tighter, he may confine the viscera, but he produces other inconveniences. The. increased pressure injures the spermatic chord, and may affect the testicle: the inte- guments become red, painful, and excori- ated ; and the bandage must be entirely laid aside, until the parts have recovered. Rich- ter has often seen painful tumefaction of the testicle, hydrocele, and even cirsocele, produced from this cause, and entirely dis- sipated by the employment of a proper trus.* (Traiti des Hernies, p. 24.) He also saw the pad of a non-elastic bandage excite, in the region of the abdominal ring, a consider- able inflammation, which terminated aftoi a few days in suppuration. The hernia ne- ver appeared again after the cure of the abscess. The inflammation had extended to the neck of the sac, and obliterated that part.—(Lawrence ou Ruptures, Edit. 3, p. 69, 70.) The spring is a very essential part of every elastic truss, and it consists of a flat long piece of steel, which is adapted tr« the side of the body, on which.the hernia is situated It is not a great many years since the spring used to be made of com- mon iron, and Arnaud and llichter express their preference to a mixture of malleable iron and steel, so tbat (he instrument may be moulded by the hand to any particular shape ; but, as Mr. Lawrence well observes, a truss, which admits of such management, must be more or less liable to the objections. which apply to inelastic bandages, and the only material, which possesses the requisite qualities of firmness and elasticity, is well- tempered steel. The front part of the steel spring has an expanded form, and. when the truss is properly applied, ought to be situated over the mouth of the hernial sac. The spring of a truss has commonly been a semicircle, with the posterior end resting on (he spine. Camper proposed to carry i* nmnd to the anterior ?iinerior spine cti JrFujaS wu-i tue iiiuui ou ihe swuuu eide, a plan, of which Scarpa highly approves. Trusses of this form fit with a degree of steadiness, which cannot be given to others, by tighten- ing the strap. They keep up the rupture better than even a stronger spring of the common kind. Under the back surface of the anterior end of the spring is placed the pad, which should be adapted in shape and size to the passage, which is intended to be shut up. The sleel spring is usually covered with leather, is lined with soft materials, and after being put ou the patient, is fas- tened in its situation by means of a strap, wliich extends from the two ends of the spring, round that side of the body, on which the hernia is not situated. Hare- skin, with tbe fur outwards, is sometimes considered the best cevering for preserving the spring from the ill effects of perspi- ration. Wheu it is necessary to make strong compression, as in large old ruptures, and in persons who cannot avoid labour and exercise, the elastic spring should be made accordingly thicker and broader. But, an object of the first-rate importance is to make the spring press equally upon every point of the ,body which it touches. This is what demands the earnest attention both of the surgeon and the instrument-maker, especially as the hips of some individuals are flat and narrow, while those of other persons are broad and prominent. A thick, flexible, metallic wire, accurately applied round the pelvis, will serve to take the mea- sure and proper shape of the spring, which may afterward be altered a little if found necessary. The wire, however, should be somewhat longer, on account of the length of the spring. The springs of trusses intended for chil- dren, and persons who do not undergo much labour and exertion, need not be made 60 strong as those designed for hard- working, active people. The idea, that children cannot wear steel trusses, is as erroneous as it is dangerous in its practical consequences; a point, on which Mr. Pott has strongly insisted. Trusses are sometimes fabricated with a pad moveable on the spring, instead of being riveted to it. This may be inclined upwards, or downwards, according to the form of the abdomen ; and it is retained at the desired point by a spring fitting into the teetb of a rack. In others, the plate con- tains a screw, by which tbe cushion is pushed further iu ward, or allowed to recede at pleasure. Although there cannot be a doubt, that some of these inventions possess considerable merit, and are in certain in- stances superiorly useful, it must be con- fessed, that, in general, their utility is not »o much greater, than that of common pads, as lo make amends for the want of simpli- city and the increase of expense. I should be sorry, however, to say any thing that would unfairly discourage all such inge- nious endeavours to improve an instrument so difficult lo bi .ng to pertectioa •»=> a truss ; especially as 1 believe there are particular cases, in which pads, witb racks, screws, springs, be. may be employed with great advantage. Notwithstanding every care, sometimes even elastic trusses cannot be hilidered from slipping away from the part, which they are designed to compress. Sometimes they slip downwards, which in fat subjects is generally caused by the projection of the abdomen. Occasionally, the fault consists in the instrument becoming displaced in the direction upwards, which mostly hap- pens in thin persons, and is produced by the flatness of the abdomen. In the first case, the displacement is to be prevented by the use of an elastic scapulary °, in the second, the slipping of the pad upwards is to be prevented by the employment of a thigh strap. When a patient is afflicted with a rupture on each side the two protrusions may be very well kept up by means of a single truss, made with two pads, which are joined together, at the exact distance of tHe rings from each other, by a piece of steel, ap- plied over the convexity of the symphysis ofthe pubes, and proportioned in length to the space between the two openings, through which the viscera descend. In such cases, hovvever, it is absolutely necessary to have the spring stronger, than if there were only one rupture. The truss should also be put on that side of the body, upon which the hernia most difficult to retain is situated. There are some practitioners, however, who give the preference to the use of two single trusses, joined together in front and behind with suitable straps. With respect to the application and use of trusses, the following instructions seem to merit attention. 1. A truss should never be first applied. or changed, except when the patient is iu the horizontal posture, and it is known, with certainly, that all the contents of the rupture are completely reduced. 2. The first applications of a truss should always be made under the superintendency of the surgeon himself; and care should be taken to put on the instrument in such a manner, that the lower third of the pad will compress the neck of the hernial sac against the os pubis, while the upper portion will compress the abdominal ring. The surgeon should also make the patient acquainted with tbe right manner of applying the truss; the principles on which it keeps up the bowels, and affords a chance of a radical cure ; the requisite cautions to be observed,, &.c. When a patient first begins to wear a truss, he should be particularly careful not t» be guilty of any imprudent exertions, and it behoves him to observe most attentively, that the instrument docs not slip from its proper situation It will also be necessary for him to pay attention to the instrumen"t being neither too ti-,ln- nor too lhost iUx. 1'Rl- TUM 3. The patient ought to be provider wiin at least two trusses, which should be chan- ged every morning in bed. In order lo save the truss, especially in fat persons who per- spire a great deal, it is a good plan to lay a soft piece of calico under the pad. 4. All uneasiness about the ring, which always gives rise to a suspicion that a por- tion of intestine, or omentum, is protruded, makes it proper to take off the truss, care- fully examine the parts, aud reduce them if they have descended. 5. When the skin is excoriated by the truss, the part may be cured by sprinkling upon it the powder of acetite of lead, Ful- ler's earth, lapis calamiuaris, oi»r'-. description of the station, at \,iiicu luc 1'siis first protrude irom Ihe ah* domen. TUMOUR. A swelling. In the present article, I intend only to treat of what are usually called sarcomatous and encysted tumours. Mr. Abernethy thinks, that th* manner in which tumours are formed is best illustrated by those which hang pendulous from the membranous lining of different ca- vities. This gentleman adverts to an ex ample noticed by Mr. Hunter, in which, on the cavity of the abdomen being opened, (here appeared lying upon the peritoneum. a small portion of red blood recently co agulated. This, on examination, was found to be connected with the surface, upon which it had been deposited, by means ot an attachment, half an inch long, nnd thb neck had been formed before the coagulum had lost its red colour. (See Trans.for the Improvement of Med. and Chir. Knowledge Vol. 1, p. 231.) Mr Abernethy observes, that if ve*ssels had shot through the slender neck, and organized the clot of blood, thi-? would then have become a living part: it might, have grown to an indefinite magni- tude, 'and its nature and progress would probably have depended on ihe organisa- tion, which it had assumed. He mentions his possession of a pen, found growing from the surface of the peritoneum, and which was undoubtedly formed in the same man- ner as the tumour noticed by Mr. Hunter, viz. by vessels shooting inlo a piece of ex- travasated blood, or lymph, and rendering it a living organized substance. Tumours, in every situation, and of every description, are probably formed in the same way. The coagulating lymph being effused, either ac- cidentally, or in consequence of disease, is afterward converted into a living part, by the growth of the adjacent vessels and nerves into it. Mr. Abernethy remarks, that, when the deposited substance has its attachment hy a single thread, all its vascu- lar supply must proceed through that part: but, in other cases, the vessels shoot into it irregularly at various parts of its surface Thus, an unorganized concrete becomes a living tumour, which has at first no percep- tible peculiarity as to its nature Although its supply of blood is furnished by the ves- sels ol the surrounding parts, it seems to live and grow by its own independent powers, while its future structure seems to depend on the operation of its own vessels. Mr, Abernethy conceives, that the altered struc- ture of an enlarged gland affords no contra- diction to the above account, as, in this latter case ttie suhstance of the gland is the matrix, in which the matter, forming the tumou^or enlargement, is deposited. The structure of a tumour, he observes, is some- times like tbat of the parts, near which it grows. Such as are pendulous in joints, are cartilaginous, or os-eous. Fatty tumours frequently form in the midst of the adipose substance ; and he has seen some tumours (trow ing from tbe palate, which bad a slen- der atta< hineut, and resembled the palate in structure TUMOUR aij.5 However, this resemblance of the struc- ture of a tumour to that of the neighbouring parts, is not always observable. I have in my own possession a completely cartilagi- nous tumour, which I found in the midst of the fat near the kidneys. The pendulous portion of fat, growing from the perito- neum, and mentioned by Mr. Abernethy, serves as another instance of the fact; and, one might add, that every polypus which we meet with, bears no resemblance in struc- ture to the neighbouring parts. Mr. Aberne- thy mentions his having seen b6ny tumours, which were unconnected with bone, or the periosteum, and he observes, that the struc- ture of a tumour is, in general, unlike that of the part in which it is produced. When (he coagulable part of the blood is effused, and the absorbents do not take it away, the surrounding blood-vessels are sup- posed to grow into it, and convert it into a vascular tumour. The effusion of the coa- gulable part of the blood may be the effect of accident, or of a common inflammatory process, or it may be the consequence of some diseased action of the surround- ing vessels, which (diseased action) may in- fluence the organization, and growth ot the tumour. In the former cases, the parts surrounding the tumour may be considered simply as the sources, from which it derives its nutriment, while it grows apparently by its own in- herent powers, and its organization depends upon actions begun and existing in itself. If such a tumour be removed, the surrounding parts being sound, soon heal, and a complete cure ensues. But if a tumour be removed, whose existence depends on the disease of the surrounding'parts, which are still left, and this disease be not altered by the sti- mulus of fhe operation, no benefit is ob- tained. These parts again produce a dis- eased substance, which has generally the ap- pearance of fungus, and, in consequence of being irritated by the injury of the operation, Ibe disease is in general increased by the means which were designed for ils cure. It appears, therefore, that in some cases of tu- mours, the newly-formed part alone requires removal, whilst in others, the surrounding substance must be taken away, or a radical cure cannot be effected. (Abernethy's Surg. Obs. 1604.) This gentleman conceives, that the irritation of the tumour itself, when once the swelling has been produced, keeps up an increased action in the surrounding vessels, so as to become a sufficient cause of the disease continuing to grow larger. As the tumour becomes of greater magnitude, it condenses the surrounding cellular sub- stance, and thus makes for itself a sort of capsule. The close, or loose manner, in which tumours become connected with the surrounding parts, seems to depend very much on the degree of irritation and inflam- mation excited iu the circumjacent parts. When a tumour has been at all lender, pain- ful, and inflamed, it is generally found inti- mately adherent to all tiiencighbouringparts. Mr Abernethy also believe5, that the increa- Vor. ir 671 sed irritation which a tumour creates when it has exceeded a certain size, may explaiu why some tumours, which are at first slow in their progress, afterward begin to grow* with great rapidity. The process by which tumours are form- ed, is commonly thought to be attended with an increased action of the vessels, which supply the swellings, with blood. It is supposed, iu short, to be the same kind of process, which forms all the thickenings and indurations, which, under various circum- stances, occur in different parts of the human body. It has sometimes been named chronic inflammation, to distinguish it from that which is more quick in the production of certain effects, and is often attended with a manifest throbbing in the part affected. This subject of chronic, or passive inflamma- tion is one, about which very little certain is known ; and the very name has commonly been admitted only on the supposition, that some kind of increased action exists in the vessels, though of a slower and less evident kind, than what prevails in acute inflamma- tion. According to Dr. Wilson Philip, the difference between what is called active and passive inflammation seems to depend upon " the degree, in which the arteries supplying the vis a tergo to the debilitated vessels are excited."—(Laws of (he Vital Functions, p. 282, Edit. 2.) If this position be satisfac- torily established, one important step will be made to a knowledge of the differences be- tween acute and chronic inflammation ; but, much would yet remain for explanation be- fore our ideas of the latter process would bo at all complete. In a work of considerable merit, Dr. Baron of Gloucester, offers many considerations against the correctness of the ordinary doc- trines, respecting the formation of tubercles and tumours. By tubercles, he means disor- ganizations composed of one cyst, " what- ever be its magnitude, or the nature of its conten(s," and by tumours, he would under- s(and " morbid structures, that appear to be composed ef more than one tubercle." (On Tuberculaied Accretions of Serous Membranes, fyc. p. 213.) From certain appearances, traced in disuections, Dr. Baron infers, that all tubercles, wherever situated, and of what- ever substance composed, were at their commencement small vesicular bodies, with fluid contents ; hydatids, as he endeavours to prove. " It is impossible to say, how minute they may have been at their origin, nor how large they may grow, before their transfor- mations begin ; nor are we acquainted with the circumstances which occasion such transformations." To these changes in hyda- tids, (according to this writer,) certain tuber- cles owe their existence, and " on the size, relative position, and structure of Ihe tubercles, which are so formed, depend the characters of many of the most formidable disorganisations, lo which the human body is exposed. (P. 215.) A single hydatid, when it is trans- formed (says Dr. Baron) will give rise to one tubercle. " It may be pendulous, or embedded in any soft part, or it mav be aOti if Mou: found between the la)fis ot membranes, and wherever the textures are of such a na- ture as to admit of its growth. It may be so small as to be scarcely visible, or, it may acquire a very great magnitude. Single tu- bercles are often seen in a viscus, while all the rest of the organ is free from disease, and its functions are performed in an uninter- rupted manner. But, it is evident, that the same slate of the system, (whatever that may be,) which calls one tubercle into ex- istence, may generate an indefinite number. Tbey may be diffused through the whole of a viscus, leaving nothing of its original tex- ture, or they may occupy uny proportion of it, or extend to the contiguous parts, and in- volve them in the same form of disease." (P. 216.) When hydatids growing in clusters, and hanging within cavities, become changed into tubercles, Dr. Baron conceives, that the morbid appearances must of course corres- pond in some degree, witb the original dis- tribution of the parts. He has seen tubercles attached in this form to the choroid plexus, to tlie valves of the heart, to the fimbriated extremities of the Fallopian tubes, and to the omentum, and convolutions of the bow- els. In the latter instance, they vvere very minute, the largest not being bigger than the head of a pin, and their number defied all calculation. " Other varieties in the arrangement of the elementary parts of morbid growths, will of course cause corresponding varieties m their appearance. Thus, when hydatids arc enclosed, the one within the other, and are transmitted into solid substances, a section of these substances will exhibit a series of concen- tric lamince." Another variety pointed out by Dr. Baron, is " when an immense number of very small tubercles are generated in juxtaposition, and unite together. Wherever such an event occurs, the original texture of the part is en- tirely lost, and a mass of varying degrees of density and firmness formed. In the earlier stages of its growth, a granulated appearance may be distinctly traced ; but, in process of time, this disappears, the consolidation be- comes more complete, and substances of a gristly, or cartilaginous- or scirrhous texture may be found. I have traced (says Dr. Baron,) the whole' of these gradations in the liver, the lungs, the pleura,the omentum, the peritoneum, and in tumours in other parts.' (P. 219.) " Sometimes, sm-ill hydatids grow from the outer or inner surface of large ones, or float within them. I have seen, (says Dr. Baron,) from a source of this kind, tbe uterus and its appendages converted into an enor- mous misshapen mass, tubercles of the size of the fist growing from it, while these again were surmounted by smaller ones in many gradations. Some had glairy contents, others were in a state of scirrhosity, and ..thers were but little changed, having thin ielicBte cysts, and containing a transparent fluid. " But, perhaps, (remarks Dr. Baron) the most important variety of all, is when tuber- cles, originally distinct irom each otner, ap- proximate as tbejr increase in size, ulti- mately unite, and form tumours, which have received different designations, according to the predominant character of their contents and internal structure. It vvas chiefly to elucidate this part of the subject, tbat I made the distinction between the word- tumour and tubercle, be." (P. 219.) By thus adverting to the primitive arrangement, number, size, &,c. of hydatids, and their sub- sequent mutations, Dr. Baron (ries to ac- count for the^varieties of encysted and sar- comatous tumours, fungus hoematodes, (u- berculated sarcoma, scirrhous swellings, iic. be. The late Dr. Adams, as is well known, referred cancer to the living state, growth, and multiplication of the hydatid. (On the Cancerous Breast, p. 77.) In order to account for tbe various appearances of the disease, he has divided hydatids into a number ot species, as lymphatica, cruenta, and carcino- matosa, zind suspects that there may be others These, be affirms, are lodged in dilferent cavities, or enclosed in a fungus, wbich is occasioned by any individual, or numbers, stimulating the surrounding parts to gene- rate it, for the purpose of dividing the dead from tlie living. This fungus is a nidus, formed altogether for the protection of an- other generation ; by means of it, the living fumilies are separated from the dead, and their preservation is secured. They die, he says, without otherwise affecting the body in which they existed, but by their local stimulus, and he declares, that his object is to prove the animalcular existence of carci- noma. Now, according to Dr. Baron, this main position is the fundamental error of Dr. Adams's book; for, •* in no rational, nor legitimate point of view may cancer be said to have an animalcular existtnes; he- cause admitting, for the sake of argument, that hydatids are animalcules, it has, I trust, been shown, (says Baron,) that it is to tht lost oj' the hydatical character altogether, and the transformations of these bodies, that the mor- bid appearances in this, and many other dis- eases, are to be referred." (P. 276.) Although I consider the evidence and re- marks, which Dr. Baron has adduced, in sup- port of his opinions in many respects inter- esting, the facts brought forward do not ap- fiear to me to justify the conclusion, that the ormation of tubercles and tumours original- ly depends upon hydatids, and their transfor- mation. That hydatids are sometimes found within diseased structures, and tbat cells, cysts, granulated, and tuberculated appear- ances are often noticed in tumours of differ- ent kinds, are facts universally received. But the presence of hydatids in the unchanged state is only an occasional circumstance, whereas, if they were generally a cause of tumours by undergoing some unexplained transformation, it is impossible (o suppose, that some of them, at least, would not be more commonlyfound in adistinct,unaltered form within, or around all swellings,imagined to proceed from clusters of tbera. As the growth of tumours, formed on (hese princi- i'tAiOUR pies, could not, 1 imagine, be accounted for, without supposing a continual multiplication and transformation of hydatids, cither with- in, or around (he swellings, one would ex- pect, that some visible hydatids, previously to their transfiguration, would certainly be apparent en minutely examining tbe interior and the circumference ofthe diseased struc- ture. Yet, I am nol aware, that such fact has been proved to be generally the case, cither by the aid of the scalpel, or the mi- croscope. The observation of eavities, cells, and tuberculated appearances in seime kinds of tumours, is no proof that such modifica- tions of structure are transformed hydatids. Besides, if my limits would allow me to con- sider this topic further, many reasons might be urged against the hydatid doctrine, arising from the consideration of the changes evi- dent in the blood-vessels, supplying parts, in which a considerable tumour is situated. Thus, we often see the trunks of the arteries, running towards such parts, doubled in size, just as is noticed, with respect to the carotid in the natural growth of the stag's horn, and indicating, at least, that the formation and increaseof swellings are effected through the medium ofthe blood-vessels. The sud- den effect of tying the arteries, by which a tumour is supplied with blood, would also be difficult to explain, if the growth of the swelling really depended upon some unde- fined transformation of hydatids. It seems lo be generally admitted, that the growth of all tumours may be retarded, and that sometimes they may even be diminished by means of topical bleeding with leeches, and keeping the parts in a continually cool state, by the incessant application of cold sedative washes. Afterward, when the in- creased action of Ihe.vessels seems checked, and the tumour ceases to enlarge, discu- tients are indicated, such as frictions with mercurial ointment, pressure, electricity, rubefacient plasters, solutions of salts, blis- ters, and issues. Very few sarcomatous or encysted tumours, however, are ever com- pletely removed by these local means. The swelling, on the contrary, generally increas- es, notwithstanding them, and ihe irritation of the disease by stimulants is not altogether unattended with danger of the affection be- coming changed by them into very malig- nant and dangerous cases, sometimes to all appearances cancerous. The most adviseable plan is to recommend the removal of sar- comatous tumours with the knife, while they are small, and in an incipient state. For thus they are got rid of by an operation, which is certainly trivial, compared wilh what might afterward become requisite, if the disease were allowed to proceed, and attain au enormous magnitude. Tumours, Sarcomatous. These have been so named, from their firm, fleshy fuel. They are of many kinds, some of which are simple, while others are complicated with a malignant tendency. Mr. Abernethy has attempted to form a classification of sarco- matous tumours, for the different species of w hirb he* has proposed lmines, deduced from the structure, which they exhibit on diisec- tion. This gentleman has named the kind of swellings, which he first considers, Com- mon Vascular, or Organised Sarcoma. Un- der this title, Mr. Abernethy includes all those tumours, which appear to be com- posed of the gelatinous part of the blood, rendered more or less vascular by the growth of vessels through it. The vessels which pervade this sub-'mice are, in differ- ent instances, either larger or smaller ; and more or less numerous; being distributed in their usual arborescent manner, without any describable peculiarity of arrangement. Perhaps all die varieties of sarcomatous tu- mours arc at first of this nature. The struc- ture under consideration, is met with not only in distinct tumours, but also in the testis, mamma, and absorbent glands. When a common vascular, or organized sarcoma has attained a certain magnitude, the veins of the skin seem remarkably large, and their winding under the integuments excites no- tice. This kiud of sarcoma is not at all tender, so that it may be freely handled, and also electrified, without giving pain. The tumour sometimes grows to such a size tliarthe skin bursts, the substance of the swelling sloughs oul, and the disease is got rid of. However, this mode of cure is at- tended with such terrible local appearances, and so much fever, be. thai tbe removal of the disease wilh the knife is to be preferred. The second kind of sarcomatous tumour, noticed in Mr. Abernethy's classification, is the Adipose Sarcoma. Every one, at all in the habit of seeing surgical diseases, must know, that fatty tumours are exceedingly common. Air. Abernethy believes, that these swellings are formed in the same manner as others, viz. iu the first instance they were coagulable lymph, rendered vas- cular by the growth of vessels into it, and that their future structure depended on the particular power and action of the vessels. According to Sir Astley Cooper, " they are not composed of fatty matter only; but the adipose membrane is increased, and their structure is similar, only somewhat more compact, to that of the fatty membrane in other parts of the body." (Med. Chir. Trans. Vol.11, p. 440.) This fact is very much against the doctrine, which ascribes the ori- gin .of tumours to hydatids and their trans- formation. Adipose sarcomatous tumours always have a thin capsule, formed by the simple condensation of the. surrounding cel- lular substance. It adheres very slightly to the swellings, and, chiefly by means of ves- sels, which pass turough this membranous covering in order to enter tbe tumour. As Mr. Abeinethy has accurately described, the vessels are so small, and the connexion so slight, that, in removing the tumour, no dissection is requisite, "as the operator may easily put his lingers between the swelling and its capsule, so as to break the little vas- cular connexions, aud entirely detach (he disease. The substance of adipose tumours is neve.' furnished with very large blood-vessel-, and ^ -W5 11. MOUR the fear of hemorrhage, which frequently deters surgeons from operating, is quite un- founded. It is an undoubted fact, that there is no species of tumour, that can be removed with so much celerity, with such apparent dexterity, or with such complete security a.ainst future consequences, as those of an adipose nature. However, now and then, when the tumour has been at all in an in- flammatory state, the oqiMile becomes thick- ened, and intimately adinetil to the surface of the -..veiling, so that >uc sep irifom ofthe disease is more difficult, and requires die knife t» be more freely employed. The tu-iour also sometimes becomes, after in- flammation closely adherent to the conti gu vis parts. Adipose tumours often ac- quire nn enormous magnitude. Indeed, there can be no doubt of the fact stated by Sir Astley Cooper, that they acquire a greater magnitude than any other swelling ever reaches. Mr. Aberuetiiy relates an example of one, removed by Mr. Cline, which weighed between 14 and 15lbs., and which I saw myself previously to the opera- tion. Sir Astley Cooper also mentions the successful extirpation of several adipose tu- mours of immense size : one weighing 141b. 102. removed by himself; another weigh- im; lSlbs.'removed by Mr. Cline: and a third, weighing221bs. removed from a lady's thigh by MroCopeland. But the most re- markable case is one, in which Sir Astley Cooper lately removed a fatty swelling which weighed, independently of the blood in it, 37lbs. lOozs., and was situated on the ab- domen of a man, aged 67. (See .Med. Chir. Trans. Vol. 11, p. 440.) Although it is true, that when adipose swellings attain an enor- mous bulk, the immense size of a wound requisite for their removal, must be danger- ous, and is a strong argument in favour of having recourse to the operation at an ear- lier period, yet it is equally true, that large fatty swellings may be taken out, with a greater prospect of success, than any other kind of tumour of equal size. The next species of sarcoma, noticed in Mr. Abernethy's classification, is what this gentleman names pancreatic, from the re- semblance of its structure to that, of the pan- creas. This kind of disease, according to Mr. Abernethy, is occasionally formed in the cellular substance ; but, more frequent- ly, in the female breast, on that side of the nipple which is next to the arm. When a pancreatic sareoma is indolent, aud in- creases slowly, the surrounding parts, and the glands in the axilla, are not affected. i-lut some of these swellings deviate from their common character, and become of a very irritable nature, occasioning severe and lancinating pain, and producing an in- flamnaatory state of the skin covering them, so that it becomes adherent to their surface. The absorbents leading to the axilla are also irritated, and the glands enlarged. Pancre- atic sarcoma does not grow to a very large size ; but, when its progress is unrestrained, the pain attendant on the disease becomes lincinating, and so severe as to make the patients feverish, and Jo«e their health and strength. Mr. Abernethy remarks, that, when the axillarv glands become affected, "one jzencrally swells at first, and is extreme Iv tender and painful; but afterward ihe pain abates, nnd the part remains indurated. Another is then affected, and runs through the same course. To another species of sarcoma, Mr. Aber- rietby applies the epithet mastoid, or mam- mar-;, from the reseml'lain e which this gen- tleman conceives 'ts structure bears to that of the mammary gland. This kind of dig- ease, Mr. Abernethy says he has not oiten seen. In the example which he met with, the tumour was about as large as an orange, ami situated on a woman's thigh. 'Ike swelling vvas removed by an operation; but the wound afterward degenerated into a malignant ulcer, attended with considerable induration of the surrounding parts, and the woman died of the disease in two months. Mr. Abernethy conceives, that the whole of the, morbid part had been cut away, hut that the contiguous parts had a disposition to disease, which was irritated by the ope- ration, and that if the nature of the ca*c could have been known beforehand, it would have been right to have made a freer removal of the substance surrounding the tumour. Mr. Abernethy places the mastoid sareo- ma, between such sarcomatous swellings as are attended with no malignity, and the fol- lowing ones, which have this quality in a very destructive degree. The tuberculated sarcoma is composed of a great many small, firm, roundish tumours of different sizes and colours, connected to- gether by cellular substance. Some ofthe tubercles are as large as a pea ; others equal a horsebean in size ; most of them are of a brownish red colour; but some are yel- lowish. Mr. Abernethy mentions his hay- ing seen this species of sarcoma chiefly in the lymphatic glands of the neck. The dis- ease proceeds to ulceration; becomes a painful and incurable sore, and ultimately occasions death. Another kind of sarcoma, mentioned in Mr. Abernethy's classification of tiiino:>r», is distinguished by the epithet medullary, from its having the appearance of the me- dullary matter of the brain. It appear- to be an exceedingly malignant disease ; com- municates to the lymphatic glands a similar distemper; ulcerates and sloughs, and at last proves fatal. It is particularly apt to make its attack on the testis, and it is treat- ed of in another part of this book. (See Testicle, Diseases of.) Mr. Abernethy includes also in bis classi- fication, carcinomatous sarcoma. (See Can cer.) 1 must refer to another article, (Mamma, Removal of,) for an account of the plan of removing sarcomatous tumours. , Besides many operations, which have of late years been'performed, and are remark- able, on account of the great size of the swellings removed, others, still more inte- resting, claim attention, on account of the nature and Attrition ofthe parts extirpated. Tl'MOlK, SOS Un the excision of the thyroid gland, I need not here dwell, as it is elsewhere noticed. (See Thyroid Gland;) but I feel called up- on to mention some other very bold ope- rations, executed within the last few years- The first is that performed by Mr. Goodlad, of Bury, in Lancashire. The case was an immense tumour, situated on the left side of the'face aud neck, and (he base of which was about twenty-eight inches in circum- ference. The disease extended from (he external canthus ofthe eye above to within three-quarters of an inch of the ^clavicle below, and some idea of the depth of its at- tachments may be conceived, when it is known, that the whole parotid gland was involved in it. For the purpose of obvia- ting all danger of hemorrhage, Mr. Goodlad began with tying the carotid artery. The nature of the operation will be best under- stood by adverting to the appearances after- ward presented by the wound. " The whole sterno-mastoid muscle wns exposed, and its fibres dissected clean, except about half an inch from its insertion into the cla- vicle. The wound extended backwards from behind the mastoid process to the tra- chea anteriorly, but became narrower in the direction of the muscle at the* lower part of the neck. The submaxillary gland was exposed, and about one-fifth of its substance, not appearing healthy, was removed. The digastric and the greater portion of the mylo-hyoideus were exposed. The ramus oi the jaw was only covered by periosteum, except where covered by the masseter mus- cle, part of which, not appearing healthy, was dissected away. The whole of the condyloid process of that bone was laid bare in the same manner, and behind it the pterygoid muscles were also exposed. The membrane of (he cheek was only covered by a cellular substance, which did not ap- pear healthy; but sufficient skin was saved to cover the zygoma. The parolid gland ■was tntirely removed." This enormous wound healed in ten weeks; but unfortu- nately the cure was not permanent; the disease returned, and, fifteen months after ihe operation, the poor woman died. (See Med. Chir. Trans. Vol. 7, p. 112, fyc. Vol. 8,' p. 582.) Itespecling the foregoing severe opera- tion, many surgeons may be inclined to doubt the propriety of tying the carotid ar- tery, as a preparatory step, and, indeed, it is positively condemned in au anonymous note attached to the above case, simple temporary pressure on the exposed vessel being represented as preferable. It appears lo me, however, that Mr. Goodlad s method was justifiable, and on the whole the best, because the application of the ligature to ihe carotid not only removed the dangers of hemorrhage during the operation, but obvi- ated them afterward, and no doubt lessened the necessity for a prodigious number of ligatures, for vessels, which would other- wise have poured out a profuse quantity of blood. Nhv. (he hemorrhage is so profo«e from the main branches of the external carotid, and mere pressure so uncertain of always commanding the flow of blood, that the pa- tient may actually die from sudden loss of blood, as nearly happened in another very interesting case of removal of a large tu- mour involving also the parotid gland, and connected with the transverse process of the atlas, the basis of the skull, the meatus auditorius, mastoid process, and angle of the jaw. The operator, Air. Carmichael, in order to complete the dissection, was obli- ged to divide the trunk of the facial artery : " instantly (says he) an alarming gush of blood, which evidently came from a large vessel, followed the division ; and the dan- ger appeared the more imminent as Ihc pres- sure, which Mr. Todd applied, with all the force he could exert upon the carotid trunk, was actually incapable of repressing the tor- rent. There was not a moment to be lost. Mr. Colles plunged a dry sponge to the bot- tom of the wound, and firmly pressed on the bleeding vessel, while 1 made a horizontal section of the tumour, till I arrived at the cavities occupied by the sponge, with the view of exposing as quickly as possible the mouth of the bleeding vessel. This was accomplished in sufficient time to save the patient's life.' Mr. Carmichael, at the conclusion of the history, remarks, that, if he were called upon to perform such an operation again, he would, in the first in- stance, pass a ligature under the carotid trunk, which might be tightened, or not, as occasion should require. The case here spoken of had a successful termination. One remark- able consequence was a paralysis of one side of the face, brought on by the division of the trunk of the portio dura in the opera- tion. (See Trans, of the King's and Queen's College of Physicians, Vol. 2, p. 101, 8vo. Dublin, 1818.) The next instance which I shall notice, of the removal of an enormously enlarged pa- rotid gland, is that lately recorded by Klein, the eminent operating surgeon at Stuttgardt. The patient was a woman of seventy, and the swelling extended from the ear to the shoulder, in the operation, all the branches of the facial nerve were divided ; a piece of the masseter was left hanging ; the ex- ternal carotid artery and par vagum vvere left quite bare ; the dissected sterno-mastoid lay on on side ; and the temporal, external maxillary, and auricular arteries were of course divided, along with several arteries of the neck, yet the largest of these being tied, the bleeding was very inconsiderable. The event was so successful, tbat at the be- ginning of the third week, the wound was entirely healed. The same distinguished surgeon also re- moved a fatty tumour, extending from the buttock to the ham, and measuring three feet one inch in length, and two feet six inches in circumference. Klein undertook its remo- val, on the supposition, that it was an en- cysted tumour lying above the fascia lata; bul it turned out to be a steutoma coming from beneath it, and reaching to (he thigh- blO J b -> bone, and in every direction among the muscles, nerves, and blood-vessels of the thigh. At length, partly with the fingers, and partly with the knife, the fatty mass was separated from all its important con- nexions. Several vessels were tied, and among them the profunda femoris. How- ever, not more than a pound of blood was lost. The tumour, after its removal, weigh- ed 2716. and three quarters. Tbe patient, a woman 44 years of age, went on very well for eight days; but on the ninth, she was constantly complaining of uneasiness in the foot of the affected limb ; her pulse became weak and intermitting ; and she sunk iu the most unexpected manner. (See Journ. fur Chirurgie herausgegeben von D. L. Graefe und D. P. F. Walther, B. 1, p. 106, fyc. Svo. Berlin, 1820; or Quarterly Journal of Fo- reign Medicine, fyc. Vol. 2, p. 373, fyc.) A question may be entertained, whether, in some morbid enlargements of the parotid gland, and parts extending deeply about the throat, it would not sometimes be better to be content with simply tying the carotid artery, and trying whether stopping this large supply of blood to the diseased parts, would not be followed by an absorption of the tunaour ? Some facts, appertaining to this question, arc noticed in the article Aneurism, where the aneurism by anasto- mosis falls under consideration. It will there be seen, tbat the result of this experi- ment is not sure of permanently repressing the growth of a tumour of this last kind, even when it has this effect at first. This uncertainty will, no doubt, incline many practitioners to prefer the bold method of extirpation. Yet others will perceive, that such an operation, notwithstanding ils suc- cess in a few examples, is dreadfully severe, and must of itself in the generality of cases have fatal consequences. They will also be encouraged, in any similar instance, to try the effect of the ligature, by tbe cure which Sir A. Cooper accomplished, of an enormous cutaneous enlargement of the lower extremity by tying the artery in the groin. Indeed, 1 am sure, tbat as the im- provements in modern surgery advance, the plan of curing tumours by cutting off their main supply of blood, will be much more extensively adopted, than has hitherto been the case. In this way, the surgeon may attempt the dispersion of many tumours, which could not be meddled with in any other manner, and which, if left to them- selves, must have a fatal termination. Tumours E.vcvsteo. These, which are commonly named wens, consist of a cyst, which is filled with different substances. When the contained matter is fatty, it is termed a sleatoma; when somewhat like honey, meliceris; when like pap, atheroma. These are 'the three species, into which writers usually divide encysted tumours. However, some of these swellings do not conform to either of the above distinctions, as their contents are subject to very great variety indeed, and are occasionally of an earthy, bony, or horny nature. Some en- 01 K. cysted tumours of the latter description occasionally burst, and assume the appear- ance of horns, by the gradual projection of the matter secreted within their cysts. (See Sir Everard Home's Obs. on the Grouth of Horny Excrescences, in Phil. Trans, for 1791.) 1 remember seeing an excrescence of this kind removed some years ago from the scrotum of a man in St. Bartholomew's Hospital. Sir James Earle performed tbe operation, and if I am not mistaken, the preparation of the disease is now in Mr Abernethy's museum. But still more re- markable specimens of such excrescences are preserved in the Anatomical Museum of St. Thomas's Hospital; one in particular, which resembles a ram's horn in shape, and was re^noved from a gardener's head at Kingston, by Dr. Roots. A further account of the case is given in Rees's Cyclopaedia, article Horny Excrescence. I suppose every body in London has now seen in the British Museum the horn depo- sited there as a curiosity, and whieb, with another of the same size, grew upon the head of a human subject. What is equally curious,* hairs are not unfrequently found growing in the cavities of encysted tumours, (Delpech Ptecis des Mai. Chir. T. 3, p. 412;) and even teeth, more or less perfectly form- ed, have been strangely met with in the same situations. An interesting specimen of the latter occurrence, in a double encyj- ted tumour in the orbit, was published some time ago by my friend Mr. Barnes, of Ext- ter. (See Med. Chir. Trans. Vol. 4, p. 316.) It is observed by Sir Astley Cooper, that it is when encysted tumours are situated upon tbe temple, and near the eyebrows, and other hairy parts, that they sometimes con- tain hairs: these " have no bulbs, nor ca- nal, and differ therefore from those, which are produced in surfaces of the body, which naturally form hair." In sheep, the cysts sometimes contain wool. (Surgical Essays, Part 2, p. 233.) The manner in which these horny excrescences are produced, is stated to be as follows : " The horn begins to grow from the open surface of the cyst; at first, it is soft, but soon acquires consider- "able hardness ; at first it is pliant, but after a few weeks, it assumes the character of horn." (Vol. cit. p. 235; see also Home in Phil. Trans, for 1791.) Encysted tumours are generally of a roundish shape, and are more elastic than fleshy swellings. However, the latter cir- cumstance depends very much upon tbe nature of their contents, and the thickness of their cysts. As far as my observation extends,, encysted tumours form more fre- quently on the head than any other part; but they are very frequently met with in all situations under tbe integuments, and some- timfes in deeper places. Encysted tumours are also very often seen on the eyelids. Accordingto Sir Astley Cooper, they are in general nearly globular, and when seated on the head, feel very firm, but upon the fo"e thev are attended with a fluctuation 1UM0LA. 51i more or less obscure. The skin covering them, is generally uninflamed ; but it is now and then streaked with blood-vessels, which are larger than those of the surrounding in- teguments. "In the centre of the tumour on the skin, it often happens that in its early state, a black, or dark-coloured spot may be seen, which sometimes continues through the whole course of the disease. In general they are unattended with pain, are never in themselves dangerous, and only require re- moval from the parts in which Ihey occur, and tbe unseemly appearance they produce. Tbey move readily within the cellular membrane, if they are free from inflamma- tion, but the skin in general does not easily move over them." (Surgical Essays, Part 2, p. 230.) The greatest number of encyst- ed tumours, which this experienced surgeon has met with in the same individual, was sixteen, situated upon the head ; and he has seen nine in another patient, as many as which number on one person I have seen myself. Four, five* and six, as Sir Astley re- marks, are not uncommon. The largest, which be has ever seen, was equal in size to an ordinary cocoa nut, and grew upon the head; but in general, they are not more than one or two inches in diameter. He considers them in some degree hereditary, as he has often heard a patient observe ; " I have several spellings upon my head, and my father (or my mother) had several." They also frequently occur in several of the same family. (P. 231.) According to Sir AsUey Cooper, whenen- cysted tumours are dissected, some part of their surface is found firmly adhering to the skin, while other parts are connected to it merely by the cellular membrane. The cyst itself is imbedded more or less deeply in tbe cellular membrane, and its thickness is different in different parts of the body. On the face, or near the outer canthus, the cyst is very thin; but ou the back, it is much thicker, and on the head, it is so thick and firm, that it retains its form after the discharge of its contents, and is so elastic, that after being compressed, it readily ex- pands again to its former size. Within the cyst, Sir Astley Cooper remarks, there is a li- ning of cuticle, which adheres to its interior, and several desquamations ofthe same sub- stance are formed within the first lining. If the vessels of the cyst are injected, they arc found to be numerous, but of small size. The cysts are occasionally met with in an ossified state. (Surgical Essays, Part 2, p. 232,233.) It is the opinion of Sir Astley Cooper, that encysted tumours arise from the enlargement of the.follicles, or glandu- lar pores, in consequence of the obstruction of their orifice. (P. 236.) If this senti- ment were correct, the fact would furnish another consideration against tbe view taken of the formation of the tumours by Dr. Baron. However, itappearsto me, that there are some reasons, which render the adoption of Sir Astley's explanation dim- cult; for, if encysted tumours were only enlarged follicles, they would not be found so far from the skin as they frequently are, as for instance within the orbit, and in other situations yet further from the surface of the body ; and the collections of sebaceous matter, which so often collects, as this gen- tleman observes, in the follicles of the skin of the nose, and may be pressed from them in the form of worms, would, if the cause assigned vvere true, make encysted swell- ings on the nose itself exceedingly com- mon ; yet this part is not so often the seat of such tumours, as other parts of the face. As far also ns my observations extend, pres- sure cunnot be said to bave any share in giving rise to die formation of encysted tu- mours, because 1 have seen (hem chiefly iu situations, where this kind of cause could not be suspected, as for instance, ou the face and about the vertex, and not particu- larly round that part of tbe head, which is compressed by the hat. If also encys- ted swellings were owing lo obstruction ot the cutaneous pores with sebaceous malter, I apprehend few persons would escape the disease. The cure in the early stage would also be as easily effected by the timely re- moval of the alleged obstruction, as the cure of the little tender points on the nose, really caused by the lodgment of the seba- ceous matter in the cutaneous pores. This does not appear to me to be consonant to general experience. How the formation ot steatomatous encysted swellings is to be thus accounted for, I cannot at all conceive. And, lastly, it is to be noticed, tha^ the lit- tle swellings on the nose, arising in the way described, are, when they occur, frequently attended with soreness, from which true encysted tumours, at least in the early stage, are completely free. These, and other reflections, lead me to believe, thar the origin of encysted swellings cannot te salisfaclorily explained upon the principles suggested by the above distinguished prac- titioner. However, as all* his opinions on surgical questions are deservedly valuable, I subjoin the advice which he has- given, founded upon the preceding doctrine. It the follicle- can be seen only as a black spot, filled w ith hardened sebaceous matter, Sir Astley Cooper recommends introducing a probe folo it, and squeezing the sebaceous matter out of the tumour, which is done with little inconvenience. But, if the con- tents cannot lie pressed out without such violence as would create inflammation, he says, tbat the best plan is to make the open- ing larger. Other surgeons have tried to cure encysted tumours by pricking them with needles, and squeezing out their con- tents ; or by applying stimulating and dis- cutient applications to them. However, it is a practice which mostly fails, and, some- times, converts the case into a terrible dis- ease, in which a frightful fungus shoots out from the inside of the cyst, attended with immense pain and irritation, and often pro- ving fatal. (See Abernethy's Surgkal Ob- servations, 1804, p. 94.) Similar dangerous fungous diseases may also arise, whenever the surgeon, in cutting 012 ICMOLf* out encysted tumours, leaves any part of the cyst behind. The most adviseable method, I believe, is to have recourse to the knife, before an en- cysted tumour has attained any considera- ble size. Hovvever, if it is large at the time of tbe operation being done, a portion of the skin must be taken away with the swell- ing, in the manner described in the article Mamma, Removal of. The chief piece of dexterity in the operation consists in detach- ing all the outside of the cyst from its sur- rounding connexions, without wounding it. Thus, the operator takes the part out in an entire state, and is sure, that none of the cyst remains behind. When the cyst is open- ed, some of the contents escape, it collapses, uid the dissection is rendered more tedious and difficult. Such is the common opinion, which has always appeared to me correct. However, Sir Astley Cooper states, that the best man- ner of doing the operation is to make au in- cision into the swelling, and then to press tlie sides of the skin together, by which neans the cyst may be easily everted and removed. If the attempt be made to ex- %-act the tumour whole, "the dissection is nost tedious, and before it is completed, tie cyst is either cut, or burst. So many ncisions. and so much pain, may be readily prevented by opening it freely by one inci- non, raising its edge between the forceps," and dissecting it from its adhesions to the surrounding membrane. (Surgical Essays, Part 2, p. 240.) When the swelling is in the scalp, Sir Astley directs an incision to be made through its centre, from one side to the other, when its contents, which in this situation are very solid, are immedi- ately discharged in a mass of the same shape as the tumour. The cyst being raised with a tenaculum, may then be easily separated. With respect to encysted tumours of the eyelids, the atheroma and meliceris are said by Beer to form only upon the upper eyelid, on the side towards the temple, while he has aiways found the steatoma to be sealed ei- ther in the vicinity of one ofthe eyelids, or sometimes over the lachrymal sac. The athe- roma and meliceris, he says, usually lie in the loose cellular substance directly under the skin of the eyelid, though sometimes more deeply under the orbicularis muscle, or even juke underneath the levator palpebrae supe- rioris, upon the convex surface ofthe tarsal cartilage, (o wliich the swelling is then ge- nerally so firmly adherent, that it is impos- sible to remove this part of the cyst. En- cysted tumours of the upper eyelid are com- monly so moveable, (hat they can be push- ed above the superciliary ridge of the os fronds ; which is regarded by Beer as a very favourable circumstance in the operation. Though tbe atheroma and meliceris of the upper eyelid occasionally become as large as a pigeon's egg, Beer bas never known a steatoma in the vicinity of the eyelids ex- ceed the size of a hazel nut. Encysted tu- mours of the upper eyelid itself sometimes appear moveable, though they mav be nt the same time closely adherent to the ca, tilage. Hence, Beer recommends moving the tumour about for a few days before Ihe operation, and trying to push it above the supercilia'ry ridge ; and if this cannot be done, the circumstance will prove that the swelling is connected with the cartilage, or, at least, is under the orbicular muscle, and the mode of operating regulated according- ly. With the yellow pappy substance, found in the cysts of arethoniatous tumours of (he eyelids, fine short hairs, scarcely one line in length, are frequently blended. Some- times, as Beer remarks, the whole inside of the cyst is covered with (hese Utile short hairs, whieh may all be washed out, and are destitute of bulbs; a fact also notired by Sir Astley Cooper. It merits attention, however, that in tumours of the meliceris kind, formed upon the eyelid, Beer never met with hairs. (Lehre von den Augenkr. B. 2, p. 607—609.) He remarks, lhat whea encysted swellings of the eyelid are let alone, he has never known them produce any injury to the eye itself, excepting the hinderance to the opening of it, when they are large. On the other hand, if they be unskilfully removed, or rashly attacked with caustic, various ill consequences may ensue ; as for instance, fistulae of the lachry- mal gland, entropium from a shrinking of Ihe tarsal cartilage, ectropium from destruc- tion of the skin, and the hare-eye from an actual shortening of the upper eyelid. In consequence of (he inflammation caused by eseharoties, Beer has more than once found the integuments so adherent to the tumour, that in the operation, the removal of a considerable piece of them was una- voidable. But, says he, when swellings of this nature are properly treated in good time, they may be removed without leaving any vestige behind, excepting a trivial scar. Professor Beer joins all the best modem surgeons in considering the entire removal ofthe sac, and the reunion ofthe wound by the first intention, as the safest and most ef- fectual method of curing encysted tumours of the eyelids. He admits, however, that tbe hinder portion of the cysta of some swellings of this nature upon the upper eye- lid cannot be dissected out, because it may be so closely adherent to the cartilage.tbat its excision would injure the latter part too much, and produce either an incurable eu- tropium, or an irremediable shortening of the eyelid. But steatomatous tumours, near the eyelids, may almost always be com- pletely dissected out, the only exceptions being cases in which the swellings happen to be situated between the lachrymal sac and the.orbicular muscle, and so intimately connected with the first of these parts, that the back portion of the cyst could not be cut away, without permanently destroying the functions of tbe excreting parts of the lachrymal organs. However, when the swelling is not too strongly attached to the cartilage of tbe eyelid, Beer sanctions the removal of the whole of the cyst. He par- ticularly insist-- upon the utility of movinc IUMOUK 513 roe tumour a good deal about daily, for a few days before the operation, so as to loosen its connexions, and enable the sur- geon to push it over the edge of the orbit, where it may be steadily fixed during its re- moval. (B. 2, p. 612.) Excepting a few instances, in which the skin was diseased, and firmly adherent to the cyst, Beer has never found it necessary, in the excision of encysted swellings of the eyelids, to, remove any portion of the integuments, and he has cut away some tumours of this kind which vvere as large as a pigeon's, or hen's egg. The incision through the skin, he says, should be longer than the tumour, so as to facilitate the extraction of the distended cyst. (B. 2, p. 613.) When it is not advise- able, for reasons above stated, to attempt to dissect out every particle of the cyst, Beer fills the cavity with lint, lets the wound -suppurate, and if this plan is not sufficient, be applies stimulants and caustic. It is no- ticed by Sir Astley Cooper, that encysted tumours, at the outer canthus, are often dif- ficult of removal, on account of their extend- ing into the orbit, and being adherent to the periosteum. (Surgical Essays, Part 2, p. 241.) Professor Scarpa has strongly recom- mended making the incision for the extrac- tion of encysted swellings of the palpebrae, on the inside of these parts. But, as Mr. Travers correctly remarks, the swellings are often situated superficially, and loosely connected with the tarsus, in which case the operation should be done on the outside of the eyelid. The latter writer admits, however, that the cyst is often formed be- twixt the cartilage and the ligamentary membrane which covers it, and, in his opi- nion, it is only when an intricate adhesion subsists, and tbe appearance of a white cir- cumscribed indentation is seen upon the everted tarsus, that the excision should be performed on the inside of the eyelid, by dividing the cartilage. (Synopsis ofthe Dis- eases of the Eye, p. 357.) I shall conclude the subject of tumours with a few observations, delivered by Sir Astley Cooper, and Professor Langenbeck " The removal of encysted tumours, (the first gentleman observes,) is not entirely unattended with danger. I have seen three instances of severe erysipelatous inflamma- tion succeed the operation of removing these swellings upon the head, and I believe it is owing to the tendon of the occipito- frontalis being wounded in the attempt to dissect them out whole." (Surgical Essays, Part 2, p. 241.) In the extirpation of tumours about the neck, Langenbeck adopts the following rules: he makes a free division of the in- teguments, and dissects the muscles from tbe tumour which lie over it, but he avoids cut- ting through, or injuring them : in this man- ner the swelling is rendered more moveable. By the situation ofthe muscles, he is then enabled to know the place of the chief blood-vessels ; and on this account, he par- ticularly advises young surgeons to study myology with tbe greatest care. As Lan- Vot. If. fir- genbeck remarks, it is indeed an important advantage, after a muscle is exposed, to know what vessels lie atits edges, or under- neath it. Thus, the surtorius is a sure guide to the crural artery, and the sterno- cleido-niastoideus lo the carotid. A surgeon who knows correctly the anatomy of the parts, will not be in danger of wounding unintentionally any large vessel. When the surface of the tumour has been cleared, but the base of it is yet firmly attached, Langenbeck commences the separation on the side which presents the least risk, that is, where the least considerable blood-vessels are, and thence he proceeds by degrees to- wards the most hazardous side. In favour of this method, he offers the following con- siderations : if, by chance, an artery requi- ring a ligature should be cut, it can now be more easily secured, as the base of the tu- mour is already partly detached. The loos- ened swelling may also be drawn away from the large vessels with the hand, or a tenaculum. Langenbeck never introduces the knife deeply, when tlf-ere are large blood- vessels there, but pulls the swelling out- ward, and then divides the cellular sub- stance thus stretched, which is situated up- on the already exposed portion of the tu- mour. In this manner the swelling can al- ways be drawn more and more away from the vessels, until, at last, there is no danger of wounding them. By attending to these principles, Langenbeck has succeeded in re- moving many very large tumours from the neck, where nearly all the muscles of that part were exposed in the dissection, and the carotid denuded. After one of these ope- rations, not only the styloid process could be felt, but all the muscles, originating from it, could be distinctly seen. (Bibl. fiir die Chir. B. 2, p. 312, fyc. 12mo.Gollingen, 1808.) C. G. Stentzel, De Steatomatibus in principio Aorta rcpertis et Cysticis in genere excrescen- tibus. Wittersb. 1723. J. J. Plenck, Novum Systema Tumorum, quo hi morbi in sua ge- nera et species rediguntur. Pars prior. 12mo. Vienna, 1767. Wm. Ogle, Letter concerning the Cure of Encysted and other kinds of Tu - mours without the Knife. Svo. Lond. 1754. Ph. Tr. Walther, fiber die angebohrnen Fel- thaulgeschwulslen und andere Bildungsfeh- ler. fol. Landshut. 1814. ./. P. Weidmann, Annolatio de Steatomatibus. 4to. Maguntiaci, 1817. W. Hey, Practical Observations in Surgery, p. 517, Ed. 2, 8vo. Lond. 1810. Al- lan Burns, Surgical Anatomy of the Head and Neck,8vo. Edin. 1811: this work con- tains much valuable information, respecting the extirpation of swellings about the neck. Schreger Chirurgische Versuche, B.l,p. 297 ; Ueber Lipoma und Extirpatio derselben. Svo. Narnberg. 1811. John Baron, An Inquiry, illustrating the nature of Tuberculated Accre- tions of Serous Membranes, and the Origin of Tubercles and Tumours in different textures of the Body 8vo. Lond. 1819. Sir Astley Cooper, Surgical Essays, Part 2. C. J. M. Langenbeck, Bibl. fur die Chir. B. 2, p. 312. Gott. 1808. Also, Geschichte einer grossen Speckgesrltu-itlst welrher wit dtm Unterkiefer -1-1 ULCERATION. so fesl zasummtuhiiig, doss die Trennung mil .'•*• 6<7ge verrichlet uerdenmusic .- Neue Bibl. S. 1, p. 295. Umo.Hanrver. 1817. B. H. Jacobsen, dc Tumoribus Cyslicis, 4lo. Jena, 1792. C. G. Ludwig Monita de exscinden- ips. dis Tumoribus tunica inclusis. 4to 1758. TYMPANUM. For an account of its dis eases, see Ear. V. "•" fLCERATION; is the process by wliich \J sores or ulcers are produced in animal bodias. In this operation, the lymphatics appear to be, at least, as active as the blood- vessels. An ulcer is a chasm formed on the surface of the body by the removal of parts back into the system by the action of the absorbents. At first, it may be difficult to conceive how a part of the body can be re- moved by itself; but there is not more diffi- culty in conceiving this, than how Ihe body can form itself. Both facts are equally well lonfirmed. Whet-fit becomes necessary lhat some whole living parts should be removed, it is evident, says Mr. Hunter, that nature, iu order to effect this object, must not only confer a new activity on the absorbents ; but must throw the part to be absorbed into a slate which yields (o this operation. The absorption of whole parts in disease, arises Irom five causes; pressure ; irritation of sti- mulating substances : weakness; inutility of parts; death of them. (Hunter on Inflam- mation, fyc. p. 442—446.) Ulceration takes place much more readily fo the cellular and adipose substance, than in muscles, tendons, ligaments, nerves, and blood-vessels. Hence, in the, progress of pus to the surface of the body, ulceration of- ten takes a circuitous course for the purpose of bringing the matter to the skin. The skin itself, also, being highly organized, con- siderably retards the bursting of abscess- es. On the same account, when ulce- ration is spreading, the edyes of the skin bang over the ulcerated surface. (Hunter, p. 447.) -New-formed parts, such us cicatrices, cal- lus, and all adveiiiitious new matter, such as tumours, readily admit of being absorbed. The adventitious matter, indeed, is more prone to be absorbed than that which is a substitute for ihe old. Mr. Hunter explain- ed this circumstance on (he principle of weakness. When ulceration (akes place, in conse- quence of the death of an external part, it occurs first on Ihe outer edge, between the dead and living substance. Abscesses constantly make their way lo (he surface of (he body by ulceration; but as some textures more readily admit of beiug absorbed than others, the matter of- ten follows a circuitous course, before it can arrive al the skiu. (Hunter, v. 448, 449.) A tumour, when it makes equal pressure in every direction around, will only make -.'.! way in »n external course, because what Mr. Hunter termed interstitial absorp- tion happens iu no other direction. (P 449.) v The parts which are situated between an abscess, or any extraneous substance, and the nearest surface, are those which are most susceptible of ulceration. This is one of (be most curious phenomena connected with the process under consideration. It shows (hat there is a principle in ihe human body, by which parts are always prone to free themselves from disease. Slight pressure from without will often produce a thicken- ing of parts, and hence Mr. Hunter remarks, there even appears to be a corresponding backwardness to admit disease. (P. 449.) Both these facts, he observes, are shown in Ihe case of fistula lachrymalis ; for though the malter is nearesl (he cavity of the now, still it makes ils way externally, by means of ulceration, while the Schneiderian mem- brane even becomes thickened, so as to be- come a barrier against the progress of the disease inward. (P. 451.) There is one difference between the ad vancement of an encysted lumour to (be surface of the body, and the progress of an abscess in the same direction, viz. that tbe former does not excite ulceration of the cyst: but an interstitial absorption of the sound parts between the cyst and skin; till the cyst and external skin come into con- tact, at which period inflammation takes place, and absorption becomes accelerated into ulceration. In an abscess, tbe progres- sive ulceration begins in (he cysl, at the same time that the interstitial absorption in the sound part covering the matter is going on. (P. 452—457.) The action of progressive absorption is to remove surfaces contiguous to irritating causes, which Mr. Hunter referred to pres- sure, irritalion, and weakness. In cases of tumours, pressure becomes a cause. The buttocks and hips of persons who lie long on their backs, often ulcerate. The beels of many patients, with fractures, who lie for a great while in the same position, are apt la ulcerate- In (he lader instances, Mr. Hun ter conceived that ulceration is a substitute for mortification, and is at (he same time, a proof of a certain degree of strength ; for if the patient's constitution were very weak, the same parts, would mortify. (P. 453.) That pressure is a frequent cause of ulcera- tion, is also evinced by the occasional ef- fects of chains on prisoners, and harness on horses.. ULCEUS; • lb That irritating substances produce ulcere tion, needs no illustration. Progressive absorption may occur either with or without suppuration. We have in- stances of the latter in cases of extraneous bodies, which (ravel about tbe body with- out producing irritation enough to give rise to the secrelion of pus. In the pro- gress of aneurisms of the aorta, and of fungous tumours of the dura mater to the surlace, the same fact is also illustrated. (P ■ 455.) Absorption with suppuration, in other words, ulceration either happens in conse- quence-of suppuration already begun, in which event the pus acts as pressure; or else absorption attacks external surfaces from particular irritations or weakness, in which- case suppuration must follow. (P. 456.) The production of ulceration requires much greater pressure from without than from within. The process is always dis- posed to take place more quickly, when near the surface of tbe body, and its progress be- comes accelerated in proportion as it arrives near the skin. . The adhesive inflammation precedes the suppurative, and prevents die pus from be- coming diffused, as soon as it is secreted, and when the cyst afterward ulcerates, in order to let the matter approach the skin, tbe adhesive inflammation still continues to go before the ulcerative process, and thus pre- vents the matter from insinuating itself into the interstices of the cellular substance. (P. 457.) The pain of ulceration is, in some degree, proportioned to its quickness. When ulce- ration begins on a surface, or takes place for the purpose of bringing matter to the skin, the pain is always considerable. When ul- ceration take3 place, in order to separate a dead pari, as in sloughing, exfoliations, &c. there is seldom any particular pain. (P. 459.) The ulcerating sore always exhibits little cavities, while tbe edge of the skin is scal- Joped, and thin, at (he same time turning a little out, and overhanging, more or less, the ulcerated surface. The face of the sore appears foul, and the discharge is very thin. When ulceration stops, the edges of the skin become regular, smooth, a little round- ed, or turned in, and of a purple colour, covered wilh a semi-transparent while. (Hunter on Inflammation, fyc. p. 460.) The reader, desirous ot further informa- tion, should particularly consult this last pub- lication, and Professor Thomson's Lectures on Inflammation, p. 349, fyc. ULCERS. Surgeons usually define an ulcer to he a solution of continuity in any of tbe soft parts of tbe body, attended with a secretion of pus, or some kind of dis- charge. In the present part of this Dictionary, there will not be occasion to speak of several kinds of sores, which have been treated of io other articles. (See i.'anccr, Scrofula >rA Vent real Disease.) Ulcers are divided into local and constitu- tional. As Professor Thomson has well ob- served, however, it is only within certain limits,that this distinction is well founded; for an ulcer, which is at first completely lo- cal, may in time affect the system, so as to become constitutional; and ulcers which derive their origin from some general affec- lion of the system, may remain/ifler the re- moval of the constitutional disorder, by which Ihey were originally produced. (Lectures on Inflammation, p. 427.) " Ulcers (says Dr. Thomson) have usually been distinguished from each other by the • causes by which ihey are induced, by the symptoms which they exhibit, and by the parts of the body in which they occur. The wantof a disposition to heal in a suppurating surface may depend upon some specific action iu the cause from which it proceeds, upon something peculiar in the constitution of the patient in whom il exists, or merely upon an improper mode of management: and hence, the distinction that has long been made of ill-conditioned sores, or ulcers, into those which are specific in their nature, and into those which are simple. " Specific sores, or ulcers, may be occa- sioned by specific poisons, or by particular diatheses. The sores or ulcers which arise from specific poisons, may be either local, lhat is, confined, like a primary syphilitic ulcer, to one spot; or constitutidnal, that is, liable to occur in any part, texture, or or- gan, surb as secondary syphilitic ulcers. of diatheses, predisposing to ulcers, we have examples in the scrofulous, scorbutic, and arthritic diatheses, and also in tbe syphiloid diatheses, or that which arises not unfre- quently in those who have had syphilis, from Ihe too free and injudicious use of mercury. " Every ulcer, strictly speaking, is of a local nature; but there are ulcers, which, though necessarily local in their appearance, are connected with, or dependent upon, dis- eases, which affect the general system. These ulcers ought to be regarded as modi- fications of, or forms in which the diseases appear, with wliich they are connected. Considered in this light, it is obvious, that specific ulcers can be treated of with pro- priety, only under the head of the diseases to which they respectively belong. " We call those sores, ulcers, simple, which do not appear to proceed from any specific disease, or morbid diathesis existing in the constitution of those, in whom they take place. They are usually solitary occurren- ces, and the consequences of accidental injuries, and improper modes of manage- ment. They may occur in every part of the body\ but they appear most frequently upon the lower extremities." Professor Thomson afterward remarks, that "the appearances, which different ul- cers exhibit, seem, at first view, to afford an excellent foundation for distinctions among them, and so they undoubtedly da in many respects." 9k> I'LCERs. " But (says he) it is to be regretted, that the characters, upon which the distinctions of ulcers, as well as of many other local diseases, are founded, are neitiier very uni- form in their appearance, nor are very easily distinguishable from one another. Not only are the local appearances which present themselves iu simple ulcers liable to great variations in the different stages of the. same ndividual affection, but tbey are often ap- parently the same w ith, or at least not easily distinguishable from, those which occur in specific diseases, and which require for their cure peculiar modes of treatment. It is this circumstance, which renders it so ne- • cessary for us, in endeavouring to distinguish and to cure ulcers, to avail ourselves of all the information, which we can procure from the history of the ulcer, from the nature of the exciting cause, by which it has been in- duced, and from the effects of the remedies which have been employed, as well as from the particular appearances, which the ulcer itself exhibits." In noticing another ground of distinctions among ulcers, or that derived from the parts in which they occur, Dr. Thomson observes that " every texture and organ of the body possesses physical and vital qualities pecu- liar to itself; and these qualities must neces- sarily modify the appearances, which each texture and organ respectively exhibits in the state of disease. Specific diseases ren- der some parts more liable than others to attacks Of ulceration. Thus, secondary syphilis appears most frequently in the throat; scurvy in the gums ; cancer in the_ lower lip ; and lupous and scrolulous ulce- rations in the upper lip, or in the nose. Cancer seldom or never appears primarily in the upper lip ; but syphilis, when it at- tacks this part, puts on many of the appear- ances of cancer;" a fact, which Dr. Thom- son says he first learned from Mr. Pearson. (See Lectures on Inflammation, p. 427—430 ) In the valuable treatise on ulcers, publish- ed by Sir Everard Home, these complaints are divided into six principal kinds, viz. -. 1. Ulcers in parts, which have sufficient strength to carry on the actions, necessary for their recovery. 2. Ulcers in parts, which are too weak for that purpose. 3. Ulcers in parts, whose actions are too violent to form healthy granulations, whe- ther this arises from the state of the parts, or of the constitution. 4. Ulcers in parts, whose actions are too indolent, whether this arises from the state of the parts, or of the constitution. 5. Ulcers in parts, which have acquired some specific action, either from a diseased state of the parts, or of the constitution. 6. Ulcers in parts, which are prevented from healing by a varicose state of the su- perficial veins of the upper part of tbe limb. Although I have chosen, in the subse- quent columns, to adopt tbis nomenclature, 1 am perfectly aware of its being on some accounts objectionable, but especially be- cause it assumes hypotheses, the truth of which can never be established, nor proved This is one of the considerations, which have induced Professor Thomson to prefer the old names usually applied to ulcers; (Op. cit. p. 435, 438.) and he therefore treats of the simple purulent ulcer ; Inflamed ulcer • Fungous ulcer ; Callous ulcer ; Sloughing ul- cer ; Ulcerative ulcer; Carious ulcer ; and Specific ulcers. OF ULCERS IN PAKTS, WHICH HAVE SUFFICIENT STRENGTH TO CARRY ON THE ACTIONS HE- CESS \RY FOK THF.IR RECOVERY, SIMPLE PURULENT, OR HEALTHY ULCERS. Sir E. Home remarks, that in this "Species of ulcer, the pus is of a white colour, (kick consistence, and readily separates from the surface of the sftre, and when diluted, and examined in a microscope, is found to be made up of small globules, swimming in a transparent fluid. The granulations are small, florid, and pointed at the top. As soon as they have risen to the level of the surrounding skin ; those, next to the old skin, become smooth, and are covered with a thin, semi-transparent film, which after- ward becomes opaque, and forms cuticle. In the treatment of this kind of ulcer, it is only necessary lo keep the surface clean, and prevent the natural processes from beiug interrupted. Sir E. Home observes, that this is in general best done by the applica- tion of dry lint, for the purpose of absorbing and retaining the matter, which serves as a soft covering for the granulations, and by putting over tbe lint a pledget of any simple ointment, in order to hinder the matter from evaporating, by which means the dressings will not become adherent, and may be easily taken off, as often as requisite Although healthy ulcers require no medi- cated application to be made to them, (he dressings must be such as do not disagree with the granulations, or surrounding skin. With some patients, a roller applied with moderate tightness, witb a view of retaining tbe dressings, which cause uneasiness in the part, and make the ulcer lose its healthy appearance. Sir E. Home states, thai he . has seen several such cases, in which the proper appearance of the sore returned as soon as the bandage was discontinued. In some patients, ointment irritates and inflames the neighbouring skin ; and certain superficial ulcers will not heal, while kept in a mobt state, and unexposed to the air; but heal, when allowed to become dry and co- vered with a scab. SirE. Home refers these particularities to constitutional causes, and not disease ; for the ulcers heal as soon as the particular things, which disagree with them, are dis- continued. These peculiarities in certain healthy sores may also attend others of a different description, and should always be discriminated from the effects of disease. Sir E. Home very judiciously recom- mends inquiring of patients, who have pre- viously had sores, what kind of applications they derived most benefit from, and what dressings were found to disagree ULC lKEATtfENT. 1. Applications in the form of vapour, and fomentations, should never be employed, as they render the texture of tbe granulations looser, and diminish the disposition to form skin. 2. With respect to fluid applications, Sir E. Home also very properly condemns poul- tices, as well as fomentations. He speaks of alcohol, as being an application, which promotes the formation of a scab, when this mode of cure is chosen 3. In regard to ointments, their only use, in cases of healthy ulcers, is to keep the matter from evaporating. The mosl simple ointments are the best for the purpose ; par- ticularly the one composed of white wax, and olive oil. Sir E. Home observes, that the great ob- jections to the common simple ointments are, that they sometimes disagree with the skin, even when recent and free from all rancidity. When they have acquired the latter quality, they still more frequently create a greater degree of irritation. 4. With respect to applications in the form of powder, Sir E. Home remarks, that when it is desirable to form a scab on the ulcer, any inert powder may be sprinkled on the sore; but he prefers dry lint. Nothing should touch die powder, or lint; and to prevent this circumstance, Sir E. Home re- commends applying a little bolster on each side of the sore, and over them a roller, which will go from one bolster to the other in the manner of a bridge. For healthy ulcers, dry lint is to be re- garded as being upon the whole the most eligible application. When the sore does not secrete pus enough in twenty-four hours to moisten the lint, the dressings are only to be changed every other day. When a moderately tight bandage is not forbidden by constitutional peculiarities, it is useful both in supporting the muscles and skin, which are often in a flabby state from the unexercised state of the limb, and in de- fending the newly formed parts. (JSee Home on Ulcers.) UT.CKRS IN PARTS WHICH ARE TOO WEAK TO CARRY ON THE ACTIONS NECESSARY FOR THEIR RECOVERY J THE OVERACTING UL CERS OF MR. BURNS; THE FUNGOUS ULCERS OF OLDER WRITERS. This is the second of the classes, into which Sir Everard Home has divided ulcers in general. The granulations of these sores are larger, more round on their external surface, and of a less compact texture, than those formed on ulcers in healthy parts. Sir E. Home has also noticed their semi-transparent ap- pearance. When they have filled up the cavity of an ulcer to a level with the surface of the body, they do not readily form skin, but, rising up in a still higher manner, often lose altogether the power of producing new ughi to be checked in tne early stage of iheir formation, by «ome resistance which they a"* jus' able lo over- come, under whirli circumst ences they de- rive -trC'i^th iio■-. the limited incr-ase of ac- tion which they are obliged to undergo. O • ilie- sh ue principle, according lo Sir E. Home, ihe pres-uie of tight band, g-s is advrin'ageou-t, and ulcer? i\ hit-h he.ef w bile the patient i-> w dking about, are not so apt to In ";tk out again us others healed while the pails are in a slate ol perfect rest In the ireatme-nt of these ulcers, when the granulations haw come to a proper height, and do not form ;-, thin,semi-transparent pelli- cle upon their surface-, ihey aie t- be consi- dered as wenk parti, and ireated according- ly. Sir E. Hume thinks,that in this circum- stau. e, the* best plan, when no particularity of constitution forbids, is pressure, made with a thin piece of lead over the dressings, and supported with a tight bandage. OF REPLICATIONS TO ULCEUS ATTENOEl) WITH WEAKNESS. Although strictly we have no topical ap- plications which can directly communicate strength to granulations, there are certainly some which prevent the granulations from exhausting themseives by luxuriant growth, and stimulate them to draw more blood from the arteries; which effects, as Sir E. Home remarks, render such granulations stronger. 1. This gentleman very properly con- demns, as applications to weak ulcers, ail relaxing fomentations commonly employed ; and recommends, instead of them, the use of spirits of wine, and the decoction of pop pies, in equal proportions, not, however, to be applied hot. 2. Willi regard lo moist applications, the same gentleman expresses his disapprobation of poultices, and mentions a weak solution of the argentum nitratum. as the mosl eligi- ble application in an aqueous form. 3. On the subject of powdered substances, as applications to weak ulcers, Sir E. Home says, he has often tried bark, and the lapis ca- laminaris, without perceiving that the former had any power of strengthening granulations, or the latter any virtue in disposing them to form new skin ; properties commonly im- puted to these applications. Sir E. Home entertains no better opinion of plaster of Paris, or pow dered chalk, em- ployed w ith a view of promoting the forma- tion of skin. Powdered carbon he speaks of as being more adapted to irritable, than wenk ulcers. He praises powdered rhubarb, as particularly applicable to the latter kind of ulcer, because it represses tbe luxuriant growth of the granulations, renders Ihem small and compact, and disposes them to form skin. When, however, the granulations have arisen above ihe level of the skin, it is not powerful enough to reduce them. When 8RS. Ihe rhubarb .s too stimulating, it is to be mixed wilh a fourth part of arude opium in P A piece of lint, a little less than the sore, is always io be put over the powder, and co- vered with a pledget of simple ointment. 4. Ointments, according to Sir E. Home, are particularly apt to disagree with weak ulcers. When other applications fail, how- ever, greasy ones must be tried, and the above gentleman gives a preference to the ung. hydncrg. nitrat. mixed villi hog's ford, in the* proportion of one to five, or else to common cerate, blend- d with a small quanti- ty of the hydrarg. nitrat. ruber. OF ULCERS IN PARTS, WHOSE ACTIONS ARL TOO VIOLENT TO FORM HEALTHY GRclllJ- LAMONs, EITHER FROM THE STATE 01 THE PARTS, OR THE CONSTITUTION : SIM- PLE VIT1ATEO ULCERS OF MR. B. BELL. There are three states of the constitution influencing (he nature of ulcers ; an irrita- ble state, in which all the actions of the ani- mal economy are more rapid than in health; an in,mien! state, in which they are unusual- ly languid; and, lastly, a diseased stale,by which they are affected. An irritable and an indolent ulcer cannot in general be distinguished from each olher by mere appearances, though they may be s . in a few instanc s. Sir E. Home informs us, thai the disposition of an ulcer, like the disposition of a constitution, can only be ac- curately ascertained by determining Ihe ac- tions which arise from the different impres- sions made upon it. The same gentleman notice", that the fol- lowing appearances at once show (he ulcer (o be of an irritable kind. The margin of the surrounding skin being jagged, and ter- minating iu an edge, which is sharp and un- dermined. The bottom of the ulcers being made up of concavities of different sizes. There being no distinct appearance of gra- nulations, but a whitish spongy substance, covered w-Jth a thin ichorous discbarge. Every thing that touches the surface gives pain, and very commonly makes it bleed. The discharge is altered from common pus lo a thin fluid, in proportion lo the degree ot irritability communicated to tbe sore by con- stitutional causes. The pain of an irritable sore in general gradually becomes less. When it is not con- stant, bul comes on in paroxysms chiefly '" (he evening, or nighl-time, wilh great vio- lence, convulsive motions of the limb arc apt to occur, and extend to various olher parts. Sir £. Home refers this symptom to irritation, communicated along the course of the nerves, aud producing an action in them, attended with a violent contraction of the muscles, which they supply- When the above-mentioned signs of an ir- ritable ulcer are not present, we must form a judgment of the nature of (he sore from listening to the history of the case, the effects of various applications. &c. When this kind ULCERS. ■i** oi intorm-Hvioii cannot be obtained, Sir E. Home recommends die treatment lo begin on (he supposition of the ulcer being of au irritable nature. When an ulcer occurs just over the mal- leolus externus, it is geneially of an irritable kind, in consequence of the nature of the pari on which it is situated, quite inde- pendently of any constitutional or local disposition to irritability. Su E Home conceives, that the periosteum, which here lies immediately under the -kin, becomes die seat ol the ulcer, is the cause of its being very difficult lo heal, and gives it the irrita- ble appearance. The fact lhat sores, situa- ted ou the ligament of the patella, and over the periosteum of the anterior surface of the tibia, assume a similar appearance, and are equally difficult to heal, made tbe above gen- tleman more confi unci in his sentiment. In treating ulcers in general, the surgeon will find it exceedingly advantageous to be acquainted with the effects of a great many exlernal applications ; lor a very few cases will continue (o heal beyond a certain time, without some alteration in the treuiment. The necessity ol changing the applications, after they have been continued foracerlain time, is strikingly illustrated by the fact, that leaviug off a powerful applicati >n, and em- ploying one which at first would have had no effect, often does a gieat deal of service. When the change is made to a medicine of powers equal to those of the previous one, the benefit will be more lasting than in the preceding circumstance. Sir E. Home compares the principle of this occurrence witn that by which change of air., even of a very salubrious air, lor one that is less so, often produces an infinite im- provement of the health. OF APP1ICATI0NS TO IRRITABLE ULCEUS. 1. Sir E. Home recommends applications in the form of vapour as being particularly useful, by their quuliiy of allaying irritation aud soothing pain. Tbe steam ot warm water is productive of benefit in ibis way, though seldom Used by itself. Its rood effects are increased when it is mixed with -pints. Sir E. Home speaks also in favour of the benefit derived Irom fomentations contain- ing opium ; such as ihe tincture of opium sprinkled on flannel, wrung «>ut of warm water; or the application of flannels, wet with a warm solution of the extract of opi- um, or with a decoction of poppy heads. A decoction of chamomile flowers, the tops of wormwood, or hemlock leaves, may also be employed for the same purpose. Sir E. Home points out particular irrita- ble ulcers, however, which are rendered rhore painful by warm applications ; and he slate i, that the sores alluded to are generally attended wilh a mottled purple discolora- tion ol (he limb for some way from tiem, and a coldness of Ihe lower part of (he leg, and that Ihey are often disposed to mortify, which event is promoted by wcru-ti* 2. As for moist applications, the poultice made of linseei! meal is the most simple, and mosl easily made ; and as it does not neces- sarily require any addition of oil, is to be preferred, when thii disagrees with ihe sore. Sir E. Home does nol say u.uch in favour of die u-e of the extract of lend in poultices ; for though he allows lhat it often answers very well, he adds, lhat it also frequently disa- grees with the ulcer, and, if long used, is apt to bring on Ihe lead-colic. A decoction of poppy-heads is said to be a very good liquor for making poultices. The carrot-poultice is also found to agree wilh a great many irritable sores. Ihe great objection lo poultices in these cases being the weight of such applications, the limb should always, if possible, rest upon the poultice, and not the poultice upon the limb. When the weight cannot be avoided; and is hurtful, a lighter application should be chosen. If poultices be employed, their use is tc be continued as long as the granulations are small, and the ulcer is rapidly diminishing in size, ,iud this even till (he* cicatrization is complete. When the granulations become large, and loose in Iheir texture, poultices should be left off. When the weight of poultices prohibits Iheir use, Sir E. Home advises the trial of lint, dipped in one of the following lotions, and covered with a pledge t of some simple ointment : » solution of the extract of opi uni; a decoction of poppies ; Ihe .tincture of opium ; a decoction of cicuta ; the liquor plumbi acetatis dilutis; or a weak solution of the argentum nitratum. 3. Powdered applications are generally too stimulating for irritable ulcers. Carbon has been found useful; so has powdered ex- tract of opium, mixed with au equal quantity of carbon, or l.nseed flour. However, opium occasionally affects the coustiluiion, in conse- quence of absorption, and it has been knovvi. to excite violent inflammation, endin-* in mordti-ation. 4. Ointments are not often proper app'.- ca'ions tor irritable uleos, as they are always more or less rancid, and gene* :ily disagree with the skin of persons most subject to such diseases S;r h,. Home* mentions cream as being a very useful application, particularly iu case- in which warmth is found to ULCERS IN PARTS, \t UiJof; AellOfiS \ IU TOO IMIOII t .'O .; nJiM I»),t.tWv <-p a >0 LLcLR-r NULATION-, VV11L rilBK Tlfls INDOLENCE ARISES FROM THE STATE OF THE PARTS, OR OF THE CONSTITUTION : THE CALLOUS ULCERS OF SEVERAL WRITERS. Such is the next division of ulcers adopt- ed by Sir E. Home, in his treatise on the •-ubiect The indolent ulcer forms in its appearance a complete conirast to the irri- table one. The edges of the surrounding skin are thick, prominent, smooth, and rounded. The surface of the granulations is smooth and glossy. The pus, instead of being of a perfect kind, is thin and watery, being composed of a mixture of pus and coagulating lymph. The lymph consists of flakes, which cannot be easily separated from the surface of the sore. The bottom of the ulcer forms quite a level, or nearly fo; and, as Sir E. Home very accurately remarks, the general aspect conveys an idea, that a portion of the skin and parts underneath has been for some removed, without the exposed surface having begun any new action to fill up the cavity When, however, the indolence of the ulcer is not so strondy marked, the sore does not correspond to the preceding de- scription, but resembles iu appearance the ulcer, which possesses an inferior degree of irritability, and can only be discriminated from it by receiving no benefit from smooth- ing applications. The odd circumstance of some indolent sores having the appearance of irritable ones, is, in some degree, explaineclhy ul- cers always being influenced by changes in the constitution, and accidental circum- stances affecting the parts Most of (he ulcers, wliich are to be seen in the London hospitals, are ofthe indolent kind An indolent disposition in the ulcer may proceed altogether from the long ex- istence of the disease ; and hence., .->ir E. Home very justly observes, it is immaterial whether at first it was healthy, weak, or irritable, for, if not cured within a certain time, it becomes indolent, with the excep- tion of a few of the irritable kind, which never change their nature. Indolent sores do form granulations ; but these, every now and then, are all on a sud- den absorbed, and, in the course ot four and twenty hours, the sore becomes as much increased in size, as it had been di- minished in as many days,or weeks, ibis absorption of the granulations arises princi- pally from 'heir not being of a healthy kind ; but the event is promoted by changes in the weather, anxiety, fatigue, be. The object in the treatment of indolent ulcers is not simply to produce a cure, but to render sucb cure as permanent as pos- sible. This can only be accomplished by altering the disposition <»f the granulations, and rendering them strong enough to stand their ground after the ulcer is filled up. When an ulcer, which has existed six months, is dressed with poultices for a w c- , the granulations, at the end of this tfo , ■will partly have filled up the hollow of ii,e sore, bul tbey wm present a large, loose, and glossy appearance. Should the poul- tice be now discontinued, and some proper stimulating application used for another week, (he granulations will be found, at tbe expiration of this time, to have become smaller, more compact, redder, and free from tbe glossy appearance. The ulcer, when healed by the latter application, will not be so likely to break out again,as when healed with large, loose, flabby, glossy gra- nulations. Sir E Home states, that the number of indolent sores, which heal under the use of stimulating applications, and do not break out again, compared with similar cases, treated with mild dressings, are as four lo one. APPLICATIONS TO INOOLENT I LCERS, 1. Medicines in (he form of vapour can not heal indolent sores, so as to accomplish a lasting cure. It is only when these ulcers assume a foul appearance, and are in a tem- porary state of irritation, that such applica- tions can be advantageously employed. In general, patients, on their first admis- sion into hospitals with sore legs, havetheir ulcers in a temporary state of irritation from neglect, exercise, excesses, be. Hence, it is generally found advantageous, for tbe first few days, or even a week, to have re- course to poultices and fomentations. I believe, that any common fomentation, whether of chamomile, poppy-heads, or mere warm water, answers equally well. The time for using it is while a fresh poul- tice is preparing, and this latter application should be changed twice a day. 2. Moist applications, such as poultices, are to be employed when fomentations are proper, and they may be made of bread, oatmeal, or linseed. Sir. E. Home describes a species of indo- lent ulcers, which occur in patients of de- bilitated constitutions which put ou a sphacelated appearance, witbout any appa- rent cause, even after they have made some progress towards a cure, and in this way spread to a very large size. Some of these ulcers, if judged of from (heir appearances, would be ranked as irritable ones; but,as soothing applications do not agree with them, they are not to be classed with the latter kiud of sores. They are said to occur particularly in seamen and soldiers, who have been long at sea. and have been termed scorbutic ulcers. Sir E. Home re- presents them, however, as not being ne- cessarily connected with the scurvy, and being often met with in patients who bave nol been on the sea. He states that they are not of necessity joined with any specific disease ; but are common to all kinds ot p-itier.ts whose constitutions have been im- paired either by salt provisions, warm cli- mates, or drinking. Pro in some trials first made by Dr Har- ass, and afterward by Sir K Home, it appears that tbei-e particular ulcers, when LLC1L1{> &*:i in u sphacelated slate, are benefited by em- ploying the gastric juice of ruminating animals, as an external application. It makes the sloughs fall off, and the sore as- sume abetter appearance. Some pain fol- lows on its being first applied, and it is to be regarded as a stimulating application. Sir E. Home mentions, that in the West Indies such ulcers are advantageously dressed with the fresh root of the cassada, grated into a pulp. Lime-juice has also been found a useful application, and solu- tions of vitriol and alum have been recom- mended. When indolent ulcers are not attended with certain peculiarities, a solution of tbe argentum nitratum is one of the best of the watery applications. It stimulates the gra- nulations, and makes them put on a more healthy appearance, and its strength may be increased according to circumstances. An ulcer, which at first cannot bear this solu- tion above a certain strength without pain, and without the granulations beingabsorbed, becomes able, after the application has been used, about ten days or a fortnight, lo bear it twice as strong, without such effects being produced; a proof ofthe granulations having acquired strength. The tincture of myrrh is often employed as an application to indolent ulcers. Hutie- zowsky has praised a decoction of the walnut-tree leaves, and soft covering ofthe walnut, for the same purpose. (Ada Acad Med. Chir. Vindob. T. 1,1788.) Sir E.Home gives his testimony in favour of both the latter dressings. Diluted sulphuric acid, and the expressed juice of the pod of different species of pep- per in a recent state, are mentioned by Sir E. Home as having been used as applica- tions to indolent ulcers: the latter one in the West Indies. This gentleman recommends also a scru- ple of nitrous acid, mixed with eight ounces of water, as a very useful medicine for ex- ternal use. The strength must be increased or diminished, according to circumstances. Sir E. Home has found that this application promotes, in a very uncommon manner, the progress of the cure. The first application of diluted nitrous acid gives a good deal of pain, which lasts about half an hour, and then goes off. When an indolent ulcer heals with the diluted nitrous acid, the process of skinning is accomplished with more rapidity than wlien other applications are employed ; and the new skin is said to be more completely formed. The acid coagulates the pus as soon as it is secreted. Sir E. Home states, that several patients, who had ulcers dressed with the diluted nitrous acid, were allowed to walk about, without finding Ibe progress of the cure re- tarded, although no bandage (o support (he limb was made use of. This gentleman in- forms us, also, that in ulcers of the leg, at- tended with an exposure of a piece of bone, which retards the cure, because it does not exfoliate, and come aivj»v. the application •Pol If. •*»> of diluted nitrous acid to the bone removes the earthy part, and excites the absorbents to act upon the remaining animal portion. 3. The only application, in the form of powder, adapted to indolent ulcers, is, ac- cording to Sir E. Home, the hydrargyrus nitratus ruber. It may be occasionally used for ulcers ofthe most indolent kind. 4. Ointments are represented as being particularly good applications for indolent sores. The idea of the air having bad effects on sores, which are exposed to it, is now dis- believed. That air has no irritating pro- perty of this kind is proved by the fact, that, when the abdomen of an animal is filled with it, no inflammation is exciled. When the cellular membrane is loaded wilh it, in cases of emphysema, the parts do not afterward inflame. Nor do ulcers in the throat, as Sir E. Home justly remarks, heal less favourably than others, alihough they are of necessity always exposed to the air. Whatever ill effects arise, may probably be explained by the consequences of evapo- ration, which converts the soft pus into a scab. The granulations arc, in all probabi- lity, most favourably circumstanced when they are covered with their own matter, which should only be now and then re- moved, in order that such applications may be made as will stimulate them to secrete a more perfect pus. From what has been just stated, it must be obvious lhat indolent ulcers should not be frequently dressed, and that if they are so, and the dressings are stimulating, the practice w'ill do harm. Changing the dressings once in twenty-four hours is deemed quite sufficient, unless the quantity of matter be very great, which seldom happens. One part of the unguenturn hydrargyri nitrati, mixed with (hree of hog's lard, is one ofthe best applications. Its strength, however, must be increased after being used for some time, as a dressing for the same ulcer. The unguenturn hydrargyri nitrati has the effect "of quickly removing the thickness of (he edges of indolent ulcers, and the sur- rounding dark red colour of the skin. It seems also to have particularly great power in making the granulations become small and healthy, and, of course, the ulcer less likely to break out again. With some ulcers, however 'his ointment is found to disagree. The unguenturn resina*. flavas, and the un- guenturn elemi, mixed with die balsam of turpentine, or that of copaiba, are other common applications to indolent sores. Sir E. Home states, that the resins and turpen- tines are not so powerful as the acids and metallic salts in giving the granulations a healthy appearance, and a disposition to re- sist being absorbed. Cases, attended with a degree of indolent thickening, are such as are most likely to be improved by camphorated ointments. In numerous cases, the applications, what- ever they arCj soon !-"=c theh' effect, and LLCEhs-. others bhou'ti then be substituted tor them, probably never necessary. 1 can safely c>- Thc past and present states of the sore are dare, that all such cases as are described by alwavsto be considered. Although the ulcer Sir E. Home to be cured by this operation. may "be in its nature indolent, it is liable to have readily yielded under the proper ma temporary changes from constitutional uagement of pressure alone." causes; and hence a temporary alteration With respect to Mr. Baynton's mode of in the treatment becomes proper. treatment, while Mr. Whately regards it as 5. Bandages arc undoubtedly of the most a confirmation of the principles insisted essential service in healing many kinds of upon in his own tract, he considers the plan ulcers ; but their efficacy is so great in cur- of making the pressure with adhesive plat- ing numerous indolent sores, tbat they are ter inconvenient, and on several uccounts sometimes considered the principal means objectionable. In every case related by of cure. But among modern advocates for Mr. Baynton, he is sure that the proper ap- rollers Mr. Whately is one of the most zea- plication of compresses and flannel rollers, lous. While this gentleman acknowledges would have produced similar good effects. that the efficacy of pressure iu counteract- The instances of success by this method, ing the effects of the dependent posture was after the supposed failure by the roller, he known to Wiseman, who recommended tbe attributes to the pressure made with the use of Ihe laced stocking for this purpose, plasters, having been applied with Mr. Bayn- he conceives that the effects of pressure, in ton's own hands, whereas that with the roller the cure of ulcers on the extremities, pre- was probably so made, that the effect intend- viously to the appearance of Dr. Under- ed by it could not possibly be obtained. No wood's treatise, were not duly insisted upon surgeon, he observes, who will not be at the by surgical writers. However, he confesses, trouble of applying the roller and compres- Inat there always have been practitioners, ses himself, can be a judge of what may be who were acquainted with the, importance effected by the proper management of them. of this mode of treatment, and adopted it in The following is the calamine cerate, their practice. He then criticises the work which Mr. Whately has usually employed- of Sir Everard Home, in which, it is re- J^. Axung. Porcin. depur. lib. iij. marked, that the effect of pressure is not Empl. Plumbi. lib. iss. much relied upon for the cure of these com- Lap. Calam. praep. ap. lib. j. M plaints. Indeed, says Mr. Whately, it is "To this formula, (says Mr. Whately) I stated in lhat book, not only that no benefit shall add another for making a cerate, which is derived from compression in several spe- nearly resembles the unguenturn tripharmi- cies of these ulcers, but that many ulcers cum of the old Dispensatory, but being less are rendered worse, more painful, and more oily, it makes a much more adhesive plas- unhealthy in their appearance by its use ; ter. It should be spread on rag, or silk, as truths which it would be impossible for Mr. an external covering to the dressing on lint, Whately to refute. They are, 1 conceive, where a tow plaster cannot be conveniently admitted by himself, when be observes that used, as in wounds of the face or hands, a there are certain conditions of an ulcer bubo, or any other sore, where an external which will not bear compression. Whether plaster cannot be readily retained in its si- Sir Everard Home has not given a suffi- tuation by a bandage. This plaster is like- ciently favourable account of the effects of wise so mild, that it never irritates the skiu. pressure in the cure of ulcers of the leg, 1 I have found it also a very useful plaster in will not presume to determine. Perhaps he fractures. The following'is the formula : may not have insisted so much upon this R. Empl. Plumbi. lib. j. treatment as il deserves ; but I can find no Axung. Porcin. depur. une. vj. fault with him for speaking of it as frequent- Aceti une. iv. M." ly injurious, because the fact is notorious. With respect to the proper method of ap- In the cases, published in Mr. Whately's ' plying the roller and compresses, Mr essay, very little variety of dressing was used ; Whately offers the followin j remarks: pressure being the principal means of cure, " The best width for a flannel roller, de- with some exceptions particularly specified signed for those who have slender legs, is in the work. three inches; but for those whose legs are I cannot doubt (says Mr. Whately) that of a lari.e size, they should always be three the practice here recommended must in tbe inches and a half in width. They must end, prevail, notwithstanding it dias this therefore be at first torn a little wider, that great obstacle to contend with, that surgeons they may be of their proper width wheu must condescend, for the most part, to ap- repeatedly washed. It will likewise be ply the bandages with their own hands. The found, that rollers made of fine, soft, and clumsy and ineffectual manner, in which this open flannel, will answer much better than business is too frequently done, can never those made of coarse or hard flannel. be expected to produce the desired effect. I » For those who have full-sized legs, tin am certain, that if the necessary pains be length of six vards is but just sufficient to -.aken, according to the directions here laid answer all the purposes intended by a roller; down, such effects will uniformly follow, as but in those who have very small legs, five must convince the unprejudiced mind, that yards is a sufficient length. Care should be to have recourse to the operation of tying taken that the rollers be washed in very hot ■varicose veins, and the application of a great water, and they should be hung up to drv l,',°'vof remedies, can be » ?ni rarely, most immcdiatelvon being washed. If these ore" I-LCI.'ft? . autions be not attended Unrepealed wash- ing them will, in some kinds of flannel, make them as narrow as tape, by which (hey will be rendered almost useless. They should be often washed, as they are much softer, and of course sil easier, when quite clean than when they are soiled. " In applying a roller, (says this gentle- man) the first circle should be made round the lowest part of the ankle, as near as possible to the heel; the second should be formed from thence round the foot; the third should be passed again round the foot quite to the toes. The roller should then be passed from the foot round the ankle and instep a second time to make the fourth cir- cle. In doing this, it should be brought nearer (but not over) the point of the heel than it was at the first lime of going round (his part. The fifth circle should pass over Ihe ankle again, and not more than half an inch higher up the leg than the fourth cir- cle. The sixth, seventh, eighth, and ninth circles should ascend spirally along the small of the leg, at the exact distance of three- fourths of an* inch from each other. Ha- ving proceeded thus far up the leg, we may begin to increase the distances ofthe circles from each other: they may succeed each other upward to the knee at the distance of from one to two inches, according to the size and shape of the leg. At that part where the calf of the leg commences, it is generally necessary lo let the upper edge of the roller be once, twice, or thrice turned downwards for about half the circumference of the leg, in order to make the roller lay smooth between the middle of the calf aud the small of the leg. When the roller has been thus applied as far as the knee, there will be a portion of it to spare, of perhaps a yard in length ; this remainder should be brought down by spiral windings, at greater distances from each other than those which were made on the ascent of the roller. The windings should in general be completed in the small of the leg, where the roller should be pinned. "In many cases, it is necessary to apply the roller oter the heel. It should be brought as low as possible round the ankle ; as in the former description. From thence, the se- cond circle of the roller should pass from (he instep over one side ofthe heel, and be brought over the other side of the heel to the instep again. The third circle should be passed round the ankle a second time, but still nearer to the heel than the first cir- cle was. The roller should afler this be brought back to the foot, and passed round it to make the fourth circle. A fifth circle should be again made (though it is not iu all cases absolutely necessary) round the foot, to the toes. To make the sixth circle, the roller should be brought back, and passed round the ankle again. The seventh,eighth, ninth, tenth, and eleventh circles should ascend spirally ut the exact distance of three- fourths of an inch from each other; these distances commencing at the sixth circle. The roller should then be carried to the knee, and be brought ctawn again to the small of the leg, as described in the former instruction. " In applying the compresses, it is neces- sary in every instance to put them on one by one,, and not all in a mass, though they be of a proper size and number. They should be crossed in different directions ; the largest of them should in no case be longer than just to meet on the opposite side of the leg to which they are applied. I have in many instances seen the compresses applied by the patients of such a length as to go round the leg like a roller, and be fastened together with pins. This method generally wrinkles and blisters the skin, and by no means answers the purpose of making a com- pression on the part where it is most want- ed. I never suffer a pin to be used in the compresses. If the same compresses in any case be applied two days together, they should always be turned on the contrary side at each reapplication, in order to pre- vent wrinkles on the skin." Mr. Whately notices two objections made by Mr. Baynton to rollers. " The first is, that it is difficult to retain the roller on the parts to which it is applied; the second is, that it gives pain to the patient." Mr. Whately's experience, however, warrants him in saying, that a flannel roller will, in almost every instance, keep the exact posi- tion in which it was first placed, for a much longer time than is necessary. ••* I bave seen these rollers (says Mr. Whately) many hundred times keep their situations without any variation whatever for two days; and that too without the least restraint upon ex- ercise. This has happened in those cases where, from the distance of the patient, or from the circumstance of his being nearly cured, I have wished to dress the leg only every forty-eight hours. I must go a step further, and observe, that I have seen re- peated instances in which these rollers have remained in their situation for three or four days, and even nearly for a week without being applied afresh. In short, it is one of the best properties of a flannel roller, that it i3 easily retained in its situation when well applied. In every instance in which it is necessary to use one, I could pledge myself to apply it in such a manner, as should pfc- vent its altering its position for two days. The method I should use, I have already described ; in addition to which nothing more would be necessary, even in those cases where the shape of the leg is peculi- arly unfavourable to the retention of a ban- dage, than the insertion of a few pins. " In answer to the second objection, I observe, that I have invariably found, that when a flannel roller has been applied in the manner here described, and has not been drawn unnecessarily tight, it gives no pain. It sits nearly as easy as a commorijjtocking, and allows a very free motion and exercise ofthe limb." (See Practical Observations on the Cure of Wounds and Ulcers on the Legs, without rest; by Thomas Whately, 1799.) 6. I shall next introduce an account of nxr.RS. Mr. Baynton's plan of curing old ulcers of the leg, by means of adhesive plaster. Were I to say, that any particular method of dressing such sores is entitled to superior praise, I should certainly decide in favour of this gentleman's practice. I have seen it most successful myself, and I hear it highly spoken of by numerous professional friends, in whose unprejudiced judgment I place much reliance. Mr Baynton acquaints us, that the means proposed by hiin will be found, in most in- stances, sufficient to accomplish cures in the worst cases, without pain or confine- ment. After having been repeatedly disap- pointed in the cure of old ulcers, Mr. Baynton determined on bringing their edges nearer together by means oj' slips of adhesive plaster. To this ne was chiefly led, from having frequently observed, that the proba- bility of an ulcer continuing sound, depend- ed much on the size of the cicatrix which remained after the cure appeared to be ac- complished ; and Irom well know ing tbat the true skin was a much more substantial support and defence, as well as a better co- vering than the frail one, which is obtained by the assistance of art. But when he had recourse to (he adhesive piaster, with a view- to lessen the probability of those ulcers breaking out again, he little expected that an application so simple would prove the easiest, most efficacious, and most agreea- ble means of treating ulcers. Although the first cases in which Mr. Baynton tried this praclice, were of an un- favourable nature, yet be had soon the sa- tisfaction to perceive that it occasioned very little pain, and materially accelerated (he cure, while (he size of the cicatrices were much less than they would have been, had the cures been obtained by any ofthe com- mon methods. At first, however, the success was not quite perfect; as, in many instances, he was notable to remove the slips of plaster, with- out removing some portion of the adjacent skin, which, by occasioning a new wound, proved a disagreeable circumstance in a part so disposed to inflame and ulcerate, ns that in the vicinity of an old sore. He therefore endeavoured to obviate that in- convenience by keeping the plasters and bandages well moistened with spring-water, for some time, before they were removed from the limb. He had soon the satisfaction to observe, tbat tbe inconvenience was not only prevented, but that every succeeding case justified the confidence he now began to place in the remedy. He also discover- ed, that moistening the bandages was attend- ed with advantages which he did not ex- pect : while the parts were wet and cool, the patients were much more comfortable, and the surrounding inflammation was soon- er removed, than he had before observed it to be. ( By the mode of treatment here recom mended, Mr. Baynton found that tbe dis- charge was lessened, the offensive smell -removeJ, and the pain abated in a very short time Bud beside:; these advantages. he also found dint the callous edges were in a few days level with tbe surface of tbe sore; that the growth of fungus was pre- vented, and the necessity of applying-pain- ful escharotics much lessened, if not entirely done away. Mr. Baynton gives the follow- ing description of his method. " The parts should be first cleared of th(> hair, sometimes found in considerable quan- tities upon the legs, by means of a razor, that none of the discharges, by being retain- ed, may become acrid, and inflame Ihe skin, nnd (hat the dressings may be remo- ved with ease at each time of their renew*!, which, bi some cases where the discharges are very profuse, and the ulcers very irrita- ble, may perhaps be necessary twice in flic twenty-four hours, but which I have, in every instance, been only under the neces- sity of performing once in that space of time. " The plnster should be prepared by slowly melting, in an iron ladle, a sufficient quantity of litharge plaster, or diachylon, which, if too brittle when coJd, to adhere, may be rendered adhesive by melting half a dram of resin wilh every ounce of thr plaster: when melted it should be stirred fill it begins to cool, and then spread thinly upon slips of smooth porous calico, of 11 convenient length and breadth, by sweep- ing it quickly from the end held by the left hand of the person who spreads it, to the other, held firmly by another person, wilh the common clastic spatula used by apothecaries; the uneven edges must br taken oil', and the pieces cut into slips abont two inches in breadth, and of a length that will, after being passed round the limb, leave an end of about four or five inches, The middle of the piece so prepared is to be applied to the sound part of the limb, opposite to the inferior part of the ulcer,so that the lbwcr edge of tlie plaster may be placed about an inch below the lower eclse of the soro> and the ends drawn over the ulcer with as mu*ch gradual extension as the patient can well bear; other slips are to be secured in the same way, each aliow and in contact with the other, until the whole surface of the sore and the limb are completely covered, at least one inch he- low, and two or three above Lie diseased part. " The whole of the leg should then be equally defended with pieces of soft calico, three or four times doubled, and a bandage of the same, about three inches in breadth, and four or five yards in length, or rather as much ns will be sufficient to support the limb from (he toes (o the kti"c, should be applied as smoothly as can te- possibly per- formed by the surgeon, and with as much firmness as can be borne by the patient, being first passed round the leg at flic ankle joint, then as many limes round (he foot as will cover and support every part of it, ev ceptlhe toes, and afterward up the limb till it reaches the knee, observing tbat caclt turn of the bandage should have ]'.-< Iiuvc" I'LCERd. edge so placed as to be about an inch above the lower edge of the fold next below. " If the parts be much inflamed, or the di charge very profuse,'they should he well moistened, and kept cool with cold spring- water, poured upon them as often as the heat may indicate lo be necessary, or per- haps at least once every hour. The patient may take what exercise he pleases, and it will be always found that an alleviation of bis pain and the promotion of bis cure will follow as its consequence, though under other modes of treating the disease, it aggra- vates the pain, and prevents the cure. "These means, when it can be made convenient, should be applied soon after rising in the morning, as the legs of persons affected with this disease are then found most free from tumefaction, and the advan- tages will be greater than when they arc applied to limbs in a swollen state. But at whatever time the applications be madte, or in whatever condition the parts be found, I believe it will always happen that cures may be obtained by these means alone, except in one species of the disease which seldom occurs, but that will hereafter be described. The first application will some- limes occasion pain, which, however, sub- sides in a short time, and is felt less sensibly at every succeeding dressing. The force with which the ends are drawn over the limb must then be gradually increased, and when the parts are restored to thefr natural state of ease andsensibility,which will soon happen, as much may be applied as the ca- lico will bear, or the surgeon can exert; especially if the limb be in that enlarged and compressible state which has been de- nominated the scorbutic, or if the edges of the wound be widely separated from each other." Mr. Baynton afterward takes notice of the breaking of tbe skin near the ulcers ; a circumstance which sometimes proved trou- blesome, and arose partly from the mecha- nical effect of the adhesive plasters, and partly from the irritating quality of the plaster. Mr. Baynton, however, only con- siders such sores of serious consequence when they are situated over the tendon of Achilles, in which situation they arc some- times several weeks in getting well. This gentleman recommends, with a view of preventing these ulcers, a small shred of soft leather to be put under the adhesive plaster. Mr. Baynton next adds, " that cures will bo generally obtained without difficulty by the mere application of the slips and band- age ; but when the parts are much inflamed, nnd the secretions great, or the season hot, the frequent application of cold water will be found a valuable auxiliary, and may be always safely had recourse to where the heat of the part is greater than is natural, and the body free from perspiration." (See A Desrriplice Account of a new Method of treating old Ulcers of the Legs, Edit. 2, 175W.) One circumstance, strongly in favour of (he advantages of the foregoing mode ot treatment deserves particular notice: when M. lloux lately visited the London Hospi- tals, he had for the first time an opportunity of seeing this practice, which had never been tried in France. The plan appeared to him so different from every thing which he bad been accustomed to see in his own country, where ulcers were almost always treated by rest in an horizontal posture, and emollient applications, that he left London somewhat prejudiced against the new me- thod. Subsequently to his return to Paris, however, he has given it a fair trial, and experience has now entirely changed his opinion, as he has had the candour to ac- knowledge. (See Rilalion d'un Voyage fait' a Londres en 1814, ou Parallile de la Chi- rurgie Angloise avec la Chirurgie Francoise, par P. J. Roux, p. 150.) OF ULCERS ATTF.NDi;D WITH SOME SPECIFIC DISEASED ACTION, E1TH3P. COSSTITC- TI03JAL, OK LOCAL. 1. Ulcers which yield to Mercury. Here we shall exclude from considera- tion venereal ulcers, as this subject is treat- ed of in the article Venereal Disease. At present we shall only notice such sores as are produced by other diseases of the gene- ral system, or of the parts, and are capable of being cured^by mercury. Perhaps there is no greater source of error in the whole practice of surgery, than the supposition that a sore, when it yields to mercury, must be of a syphilitic nature. Surgeons, however, who run into this ab- surdity, can hardly be imagined to be una- ware that so potent a medicine must have effects on numerous diseases of very differ- ent descriptions. Sir E. Home accurately remarks, that many ulcers unconnected with the venereal disease, which receive no benefit from other medicines, heal under a mercurial course, or yield to mercurial ap- plications. In some cases, the ulcer remains in the same state, while mercury is used ; but begins to look better as soon as the me- dicine is discontinued, in consequence of the beneficial change produced in the sys- tem by the mercurial course. In these cases mercurial frictions are the best, be- cause they occasion least impairment of the constitution, in conscepie.icc of the stomach continuing undisturbed, and capa- ble of digesting well. Another description of ulcers, noticed by- Sir E. Home as deriving benefit from mercu- ry, occur on the instep and font, have a very thickened edge, and are attended with a dis- eased state of the surrounding skin, so as to bear some resemblance to elephantiasis. They are frequently observed affecting ser- vants who live in opulent families in an in- dolent and luxurious way. Sir E. Home states, that fumigations with hydrnrgyrus sulphurates ruber heal these ulcers, and re- solve in a great degree the swelling of the surrounding parts. In some instances, an ointment of calomel and ho!»'<- i^-i-. in b26 ILCElt- others, the camphorated weak mercurial ointment, is the best application. Many diseased ulcers, particularly those of a superficial kind, with a thickened'edge, may be healed when they are dressed with a solution of one grain of ihe hydrargyrus muriatus in an ounce of water containing a little spirit. 2. Ulcers curable by Hemlock. Sir E. Home places more reliance on hemlock as an external than an internal remedy for ulcers. The ulcers which usually receive benefit from hemlock applications, look like those of an irritable sort; but the surrounding parts are thickened in conse- quence of some diseased action. Such sores occur near the ankle, which joint is at the same time enlarged. Sometimes, but not so often, they take place over the liga- ments of the knee. On account of their situation, and the swelling of the joint, they may be suspected to be scrofulous, though tbey are more sensible than stru- mous ulcers usually are. The sores just described are rendered less painful, their diseased disposition is checked, and the swelling of the joint diminished, by hem- lock. Several irritable scrofulous ulcers are also particularly benefited by this me- dicine." Sir E. Home gives the preference to hem- lock poultices, unless their weight should be objectionable, in which case he advises lint to be dipped in a decoction of the herb, und put on the si>re. Ofthe ointment made with the inspissa- ted juice, Sir E. Home says but little in regard to its efficacy. 3. Ulcers curable by Salt-Water. Sir E. Home takes notice of other specific ulcers which yield to this application, alter resisting other remedies. Poultices, made with sea-water, are often employed ; but this gentleman seems to prefer keepi.ig the part immersed in the water in a tepid state, about a quarter of an hour, twice a day. When sea-water poultices bring out pim- ples, in cases of scrofulous ulcers on the legs and feet, Sir E. Home informs us that this disagreeable circumstance may be ob- viated by diluting such water wilh au equal quantity of a decoction of poppies. After a time, tbe stilt water may be tried by ilself again. While each fresh poultice is prepa- ring, die part should also be immersed in such water warmed. When there is a tendency to anasarca, or when there is an unusual coldness in the limb, unattended with any propensity to mortification, tepid salt-water may be used with infinite advantage. 4. Ulcers curable by the Argentum Nitratum. Sir E. Home notices, under this head, an ulcer which does not penetrate more deeply than tbe cutis, but spreads in all directions, producing ulceration on tbe surface of the skin, and often extending nearly tbroagh its whole thickness. The part first affected heals, white the skin beyond is in a state «; ulceration. OI this description are, a leprous eruption, mostly seen in men-impressed in Ireland; a disease of the skin induced by buboes, which have continued a great while after the venereal virus has been destroyed ; and the ringworm. All these diseases are most easily cured by applying to them a solution of the argen- tum nitratum. The leprous eruption is communicated by contact, and makes its appearance in (he form of a boil. This is converted into an ulcer, which discharges a fetid fluid, by which the surrounding skin is excoriated, and the ulceration is extended over a large surface. The pain is the most severe, and the discharge greatest, in hot weather. The parts first diseased heal, while others are becoming ulcerated, and the disease is always rendered worse by spiriluous liquors, salt provisions, and catching cold. Sir E. Home remarks, that tbe disease in the skin, produced by the effects of very irri- table buboes, in constitutions broken down by mercury, is attended with ulceration of a more violent, deep, and painful kind, than the foregoing distemper. The progress of this disorder is, in other respects, very simi- lar to that of the leprous eruption. Although the ringworm only occurs in tbe form of an ulcer in warm climates, a mild species of the affection takes place in sum- mertime in this country. It seems to he infectious; though it often occurs without infection. It commences with an efflores- cence, which is attended with very trivial swelling, and spreads from a central point. The circumference of the efflorescence be- comes raised into a welt, while the rest assumes a scurfy appearance. The welt be- comes covered with a scab, which falls off', and leaves au ulcerated ring, in general, not more than a quarter of an inch wide. The outer margin of this ring continues to ulcerate, while the inner one heals, so that the circle becomes larger and larger. The discbarge consists of a thin, acrid fluid, which seems to have a great share in making tbe disease spread. For all the three preceding diseases, a so- lution of the argentum nitratum is strongly recommended by Sir E. Home. 5. Ulcers which yield to Arsenic. The sores, which come under the definition of noli me tangere or lupus, derive great benefit from this powerful remedy. Sir E. Home observes, that they are nearly allied to cancer, differing from it iu not contamina- ting the neighbouring parts by absorption, and only spreading by immediate contact. From some cases, which fell under Sir E. Home's observation, he discovered, that ar- senic was not only efficacious as an external, but also as an internal remedy. 1 shall not unnecessarily enlarge upon this subject in the present place, as the reader may refer to the articles Arsenic, Cancer, Lupus, Hospital Gangrene, be. for additional information re- LLCERS iative to tbe uses of this mineral in the prac- tice of surgery. Sir E. Home is an advocate for its employ- ment, both internally and externally, for ulcers of untoward appearance on the legs. The fungated ulcer is particularly pointed out by this gentleman as being benefited by arsenic. This ulcer occurs on the calf of the leg, and on the sole of the foot. From its surface, a fungus shoots out, which is entire- ly different from common granulations. The new-formed substance is radiated in its structure, the bottom of the ulcer being the central point,and the external surface, which is continually increasing, the circumference. The substance of this fungus is very tender, and readily bleeds. The first stage of the disease sometimes has the appearance of a scrofulous affection of the metatarsal bones; hut the parts seem more enlarged, and, when the skin ulcerates, a fungus shoots out, and betrays the nature of the case. One species of the fungated ulcer is capa- ble of contaminating the lymphatic glands ; tbe other is not so. The first is represented by Sir E. Home as being incurable by arsenic, or any other known medicine. The second yields to this remedy. Sir E. Home uses a saturated solution made by boiling white arsenic in water, for several hours, in a sand heat. He gives from three to ten drops internally; and, for outward use, dilutes a dram with two pints of water, making it afterward gradually stronger and stronger, till it is of double strength. The application may either be made in the form of a poultice, or of lint dipped in the lotion. The best and safest preparation of ar- senic, both for internal and external use, is (he kali arsenicatum. The mode of em- ploying it may be learnt by turning to the articles Arsenic, Cancer, Potassa, Lupus, be. 6. Ulcers attended wilh Varicose Veins. A certain kiud of ulcer is very apt to oc- cur on the inside of the leg, and is equally difficult to cure, and liable to break out again. It bas the look of a mild, indolent sore; but, (he branches and (runk of the vena saphena are enlarged, and this varix of the veins keeps the ulcer from healing. The sore is seldom deep, usually spreads along the surface, and has an oval shape, the ends of which arc vertically situated. There is a pain affecting the limb rather deeply, extend- ing up in the course of the veins, and exas- perated by keeping the leg a long while iu an erect posture. This is a kind of ulcer, which derives immense benefit from a tight roller, applied from the toes to the knee, although the direct operation ofthe pressure of the bandage on the sore is itself productive of no particular good. Sir E. Home found, however, that many patients could not bear to wear laced stock- ings, or tight bandages, and that others received no relief from them. Hence, this gentleman was led to cr usider what else could be done for the cure of the varicose state of the veins. He represent*, that, in con- sequence of the size of the vena saphena, and its numberless convolutions, the return of blood from the smaller branches is so im- peded, as to retard the circulation in the smaller arteries, and to interfere with their action in forming healthy granulations. The coats', and valves of the veins also become thickened,so that the latter parts (the valves') do not do their office of supporting the weight of the column of blood. These reflections induced Sir. E. Home to think, that some benefit might be obtained by taking off a part of the pressure of this column of blood, by making a ligature round the vena saphena, where this vessel passes over the knee-joint. Thus the cavity of the vein at this part would be obliterated, and a kind of artificial valve formed. This gentleman recommended the follow- ing way of performing the operation : " As the veins are only turgid in the erect posture, the operation should be performed while the patient is standing; and if placed upon a table, on which there is a chair, the back of the chair will serve him to rest upon; and he will have the knee-joint at a very con- venient height for the surgeon. The leg to be operated upon must stand with the inner ankle facing the light, which will expose very advantageously the enlarged vena sa- phena passing over the knee-joint. While the patient is in this posture, if a fold of the skin, which is very loose at this part, is pinched up transversely, and kept in that position by the finger and thumb ofthe sur- geon, on one side, and of an assistant on the other, this fold may be divided by a pointed scalpel, pushed through with the back of the knife toward the limb to prevent the vein being wounded ; much in the same way as (he skin is divided in making an issue. This will expose the vein sufficiently; but, there is commonly a thin membranous fascia con- fining it in its situation ; and, when that is met with, the vein had better be laterally- disengaged by the point of the knife. This is most expeditiously done by laying hold of the fascia with a pair of dissecting forceps and dividing it; for it is difficult to cut upon' parts, which give little resistance, and there is a risk of wounding the vein. After this a silver crooked needle, with the point rounded off, will readily force its way through the cellular membrane connected with the vein without any danger of wounding the vessel', and carry a ligature round it. This part, or.' indeed, what may be considered as the whole of the operation, being finished, the patient had better be put to bed, so as to allow the vein to be in its easiest slate, be- fore the ligature is tied, and then a knot is to be made upon the vein: this gives some pain; but it is by no means severe. The edges of the wound in the skin are now to be brought together by sticking-plaster, ex- cept where the ligature passes out, and a compress and bandage applied, so as to keep up a moderate degree of pressure on tho veins, both above and below the part in- cluded in the ligadire : (Home on Vice,-, „ '296. Edit. 2.^ L _\'(» 1 Nt. It appears that A. Paf6 proposed and per- formed an operation, similar to that des- cribed by Sir E. Home. (The Works of A. Pari, translated by Johnson ; folio, p. 319.) An account of Mr. Brodie's operation for the cure of varicose veins, and some additional remarks on the treatment of uluers accom- panied with varices, will be found in a subrcment article. See Varicose Veins. A description of what has sometimes been called the hospital sore, is given under the head of Hospital Gangrene. For information on the subject of ulcers, consult. Michael Underwood's Treatise on Ulcers of the Legs, fyc. Svo. Lond. 1783, and Surgical Tracts: 3d edit. 1799. B. Bell, A Treatise on the Theory and Management of Ulcers, fye. New edit. Svo. 1791 ; and his System of Sur- gery. J. Mer!:, De Curationibus Ulcerum difficilium praserlim in cruribus obviorum. 4to. Goett. 1776. Baynton's Descriptive Ac- count of a new Method of Treating Old Ulcers of the Legs, 1799, ed. 2. 8vo. Bristol, 1799. Whately's Practical Observations on the Cure vf Wounds and Ulcers on the Legs, wilhout rest, Svo. Lond. 1799. Practical Obs. on the Treatment of Ulcers on the Legs, to which are added, some Observations on Varicose Veins and Piles, by Sir Everard Home, 1801, edit. 2. Principles of Surgery, by John Bell, Vol. 1. 1801. Hunter on Ihe Blood, Inflammation, fyc. C. Curtis, An Account of the Diseases of In- dia, fyc. with Observations on Ulcers and the Hospital Sores of that country, fyc. Svo. Edinb. 1807. Brodie on the Treatment of Varicose Veins of the Legs, in Med. Chir. Trans. Vol. 7, P. 195, fyc. Richerand, Nosographie Chir. T. 1, p. 121, fyc. ed. 4. Boyer, Traiti des Maladies Chir. T. 2, p. 36b. fyc. Paris, 1816. Roux, Voyage fait d Londres en 1614, ou Pa- rallile de la Chirurgie Angloise avec la Chi- rurgie Francoise, p. 142, fyc. Paris, 181b. Dr. John Thomson's Lectures on Inflammation, p. 423, fyc. Edinb. 1813. Dr. Dcwar on the Treatment of Sinuous Ulcers, in Med. Chir. Trans. I ol. 7, p. 482, fyc. The stages of se- veral cutaneous affections,attended wilhulcera- tion, have been excellently described by Dr. Batemun in his valuable Synopsis of Cutane- ous Diseases. UNGUENTUM ACIDI SULPHURICI. —ft. Acidi Sulphurici 3j- Adipis Suillee pra?paruta*. -y.—These are to be well mixed together in a glass mortar. This ointment has been used by Dr. Dun- can, of Edin bur; h, for curing the itch. It has the character also of being efficacious in the reduction of some chronic swellings ofthe joints; and when mixed with a good deal of camphor, it was robbed upon the tu- mour, in cases of bronchocele, by Mr. Nay- for, of Gloucester, with considerable effect. As the sulphuric acid is particularly de- structive of vegetable substances, the parts, to which this ointment is applied, should always be covered with flannel, instead of linen. I NGUEM'UM ANT1MOMI TARTA- KIZATL—ft. Antim. Tart. 3j- Ung.Cetacei '■'<.. Misce. The :i::*iraonial ointment, fre- quently used for exciting irritation of (lie skin, with the view of relieving diseases in the vicinity ofthe irritated part, as is exem- plified in the treatment of some diseases of the eyes aud joints, and a variety of indo- lent swellings. UNGUENTUM CETACEL—ft. Cetaeei 3vj. Cera Albae 3»j- Oliv* Olei. fluid un- cias tres. These are to be melted upon * slow fire, and then briskly stirred (ill cold. This ointment, spread on lint, serves aj n simple dressing for wound% ulcers, etc. UNGUENTUM CER.E (T M ACETO. —ft. Cera Alba? |iv. Olei Oliva* Ibj. Aceli Distillati *f ij. The vinegar is to be gradu- ally mixed with the two first ingredients, after these have been melted together. Dr Cheston recommends this ointment for su- perficial excoriations, cutaneous eruption*, ike. UNGUENTUM CONII.—ft. - Foliorum Conii reccntiura. Adipis Suillse praeparatiB, sing. ^iv. The hemlock is to be bruited in a marble mortar, after which the lard is to be added, and the two ingredients tho- roughly incorporated by beating. They are then to be gently melted over the fire, and after being strained through a cloth, and the fibrous part of the hemlock well pressed, the ointment is to be stirred till quite cold. To cancerous or scrofulous sores, this oint- ment may be applied'with a prospect of ad vantage. (Pharm. Chirurg.) The Pharmacopoeia of St. Bartholomew'! Hospital directs the unguenturn conii, vel cicutafi, to be made as follows:—ft. Folio- rum Cicutae fbj. Adipis Suilla* ifciss. Boil the leaves in the melted hoj-'s-lard until they become crisp. Then strain the ointment. A similar ointment might be more conve- niently made, by mixing tbe extractura conii with anv common salve. UNGUKNT.UM DIGITALIS.—ft. Fo liorum Digitalis Purpurea recentmm. Adi- pis Suillae praeparal-je, sing. |iv. Thh oint- ment may be made in the same manner as the unguenturn conii, and tried in the same » cases. j UNGUENTUM ELEMI CO.MP0SITUM. \ —ft. Elemi ftj Terebinlhinffi -jx Sevi ? Ovilli praeparati ft>ij. Olei Olivse ^ij. Melt the elemi with the suet; remove lliem from the fire, and mix them immediately with ibe turpentine and oil. Then strain the mixture.—Sometimes employed for dressing ulcers, which stand in need of stimulating applications. UNl.UENTUM GALL.E CAMPHORA- TUM.—ft. Gallarum Pulveris SubiilUsirai 3*j- Camphoi ae 3ss. Adipis Suilla; praepa- ratae ^ij. Misce.—This is a very good ap- plication to pib s, after Iheir infljmmatory state has been diminished by (he liq. plumbi. acet. dilut. and leeches UNGUEN1UM HELLEBORI ALBl'- ft. Hellebori Albi pulv. fj. Adipis Suite praeparata* ^iv. Olei Liraonis 3ss. Misce.— This ointment will cure the itch, and st vera other cutaneous diseases. Tinea capitis will sometimes yield to i' UNo UX'j 329 ' UNGUENTUM HYDRARGYRI FOR- TIUS.—ft. Hydrargyri purificali ft'j. Adi- pis Suillae praeparatae ^ixi'j- Sevi Ovilli praeparati "^j. Firsl rub the quicksilver wilh the suet, and a little of the hog'—lard, until the globules disappear; (hen add (be remain- der ol the lard, and make an ointment.— This is the common strong mercurial oint- ment. Of ils uses we med say nothing in this place. UNGUENTUM HYDRARGYRI. CAM PHOR.4TUM.—R. Unguenti Hydrargyri |j. Camphors 3»»- Misce*.—This is often recommended lo be rubbed on thickened. indurated parts, wilh the view of exciting (he action of the absorbents. Rubbed along the. course of the urethre, it is ve*ry serviceable in diminishing and removing chordce. UNGUENTUM HYDRARGYRI MI- TIUS.—ft. Unguenti Hvdrarpyri fori. Jfcj. Adipis Suilla* pra;p«ratae ft,ij- Misce.—Tne weaker mercurial ointment is often rubbed on indurated, thickened pnrts and tumours, when (he object is merely to promote their absorption ; and it is not adviseable to em- ploy the ungnentnm hydrargyri fort, lest a salivation should he induced. UNGUENTUM HYDRARGYRI N1TRA- T13.—ft. Hydrarg. Punficiili Jj. Acidi Nitrosi ^ij. Adipis pisparals ?vj. Olei Oliva* -|iv. Dissolve tbe quicksilver in (he nitrous acid ; and whilst die solution is yet hot, mix with it .(be oil and hog's lard, pre- viously melted, but beginning to concrete, by being exposed to the air. This ointment is a celebrated application to die inside of Ibe eyelids, in cases of chronic ophthalmy, and also to specks on the cornea. When blend- ed with a little olive oil, il also forms a very eligible stimulating dressing for numerous kinds of sores. It is particularly efficacious in curing tinea capitis, and nniuy other cuta- neous diseases. UNGUENTUM HYDRARGYRI NTTRI- CO-OXYDI—ft Hydrargyri nitrico-oxydi •^j. Cerac Albae ^ij. Adipis pracp.ir. -|vj. Misce.—This is a common stimulating ap- plication to indolent ulcers, and sores in ge- neral. UNGUENTUM HYDRARGYRI PILE- CIPITATl ALBI—ft. Hydrarg. Piaecip. Albi 3j- Adipis pruDparata; ^bs. Misce.— An useful application in certain cases of por- rigo, and some other cutaneous diseases. See Porrigo. UNGUENTUM LIQ. PLUMBI ACETA- TIS.—ft. Liquoris Plumbi Acetatis ?v. Adipis Suillie ffej. Ceia*. Alias ?iv. Melt the ingredients together, and continue to stir (hem till cold.— This ointment is em- ployed wilh great advantage as a simple *Tbe preparation of ibis article wilt be greatly expe- dited by rubbing tlie mercury in the first instance, with a (mall proportion ol* Ibe article familiar to us by the appellation of goose-frease; thisri.i lie clone in a glass monar, or even upon a nurlile slab, by a spatula; il bas sucb immediate effect upon tbe mercury. One ounce of Ibis article will lee sufficient, wilh trituraiioi* for tbe space of one minute, to nuke the globules of tbe quick- silver entirely disappear, and render it at once fit for •i 'milture with the proper proportion 4f lard.— Am Ed. VoT II ft? dressing. According to Mr. Dunn, of Scar- borough, it is much improved by pouring Ihe liquified mixture, be-fore the lead has he-en added to it, inlo cold water. It is then to be rubbed iu a morlar, or on a slab with the liq. plumbi acet. The water occasions a fine white cloudy precipitation, which gives to the composition a better ap- pe-a ran (-.--. UNGUENTUM OPHTH \LMICUM.—ft. Adipis SuiHs prsparsiis Zs--. Tutia* praepa- rnta>, Bol Armen. sing. 3'j- Praecip. Hy- drarg. Albi 3j- Misce.—Janiu's celebrated ophthalmic ointment, frequenlly mentioned in the parts of this work, v. hich relate to dis- eases ofthe eye pud eyelids. UNGUENTUM OXYGENATUM, vel ACIDI NITROSI.—ft. Axumsiaj Suillae re- ceittis; nou s.iL-a* unciies stdecim. Lcni culore in vase vitreo lente liqucfuctisaut con- liuua aiMtaiioue iiistiflenlui, Acidi Nitrici uncia? duic. Mussa igni exponatur, donee ebullire ccepil; luiic ab igne icmoveatur, fri- gi-factaeroe tervel ur. In Ibis proce.-s tbe nitric acid is decom- posed, the nitrous gas-escaping, and the oxy- gen combining wilh tbe lard. This oint- ment was particularly recommended by Aly- on, as au application to venereal and herpe- tic ulcers. Its virtues are siiid lo vary con si derahly, according to ibe strength of the acid employed, and it is not generally deemed so efficacious »s the ointment of nitrate of mer- UNGUENTUM PICtS.-ft. Picis, Sevi Ovilli praeparati, sing. ftss. Melt, and then strain them. UNGUENTUM PICIS COMPOSITUM —ft. Unguenti Picis, Unguenti Plumbi Superacelatis sing. "foss. Misce. The two preceding ointments are applica- ble to cases of linea capitis, and some erup- tive complaints. Also to some kinds of irri- table ulcers. UNGUENTUM PICIS CUM SULPHU- RE.—-ft. Unguenti Picis, Unguenti Sul- phuric sing. -|iv. Misce.—This is one of the most common, and, I believe, Ihe most effi- cacious applications for curing tinea capitis, or porrigo. UNGUENTUM PLUMBI«SUPERACE- TATIS.—ft. Plumbi Superacetatis3ij. Cerae Alba.* 2ij. O'ei Ifc-s. The superact-tate of lead, previously powdered, is to be triturated with part of the olive oil. The melted wax nnd rest of (he oil are (hen lo be added. This is a good dressing for cases requiring a mild astringent application. UNGUENTUM RESINS.—ft. Resins Flava*, Cera* Flavac siug. Jbj. Olei Olivae ftj, Melt the resin and wax wilh a slow lire ; then add the oi1, and strain Ihe mixture while h"t.—This is a common application to ul- cers, which stand in need of being gently^ti- mulHted. UNGUENTUM SAMBUCL—ft. Floruni Sambuci, Adipis Suillae, singulorum ftj. The hwg's lard being melted, boil the eider flowers in it till they become crisp, then strain the mixture. UNGUENTUM SULPHU.RIS.—ft. Ad i>,jU 1 lU'.i'HK.' pis Suiilte ti,« Florum Sulphuris ?iv. .\!i>ce. f.NGUF.NTUM TUTI.E.—ft. Tutis pro parats, Unguenti Cetacei q. s. Misce.— Used for smearing the b.irdei-s aud inside of the eyelids, in cases of chronic ophlbaliuy, Sic. UNGUENTUM TUTliE COMPOSITUM. —ft. Tulis prsiiaratai, Lapidis Calaminaris prsparati, sing. 3vj. Camphors 3«j- Un- guenti Sambuci fjjj. Misce. This formula is contained in the Pharma- copoeia of St. Bartholomew's Hospital. It is occasionally,applied to the inside of the eyelids, piles, ulcerations, excoriations, &.c. UNGUENTUM ZINCI.—-R Zinci oxydi 5J. Adipis prspar. ~vj- Misce.— An astrin- gent application in very common use. UNGUIS. (A Nail.) Some surgical au- thors apply this term to a collection of pus, or mntter in ihe eye, when the abscess ap- pears, through the cornea, to be shaped like a finger nail. • UNION BY THE FIRST INTENTION. —When the oppo-ite surfaces of a wound are brought into contact, and grow together nt once, without suppurating, union by the* fiVst intention is said to take place. When wounds heal by suppurating, granulating, be. they are sometimes surgically de-scribed as getting well by the second intention. See Wounds. URETHRA, DESTRUCTION OF PART OF THE.—The attumpts to comp -ti' the canal by operations, performed on theTalia- colian principles, v.i'l be noticed in the arti- cle URINARY FIS1ULA. URETHRA, STRICTURES OF.—A stric- ture of the urelh/a, as a modern ttriier ob- serves, " consists of some morbid alteration of action, or of structure, by whicira purl of ihe canui is iciidt-red narrower ibati ihe res!."" (Wilson on the Male Urinary and Genital Organ i, p. 361.) According io Mr. John Hunter, most obstructions to the pas- sage of ilie urine, if not ail, are attended wilh nearly the same symptoms. Few per- sons lake notice of- the Jir-.t -ymptoms ol" a stricture, till they have eilhpr become vio lent, or other idcouveni tntes have been the consequence. A patient may have, a consi- derable stricture, yet be unconscious lhat his urine does nol freely come away ; aim in consequence of a stricture, there may * v.n be a tendency to inlliiiiimaii»n and suppura- tion in the perinaeum, w bile he feels no ob- struction to the passage of his urine, and does not suspect thai he has any olher com- plaint. There arc three kinds of stricture?; viz. the true permanent one, which arises from an alteration in ihe structure of a pari of tbe ureihra; the mixed case, consisting of a j>er- manent stricture and a spasm; aud, thirdly, the true spasmodic stricture. Whether ihe urethra is a truly muscular canal, and whether a variety of circumstan- ces, remarkalde in its healthy and dieased state, can be accounted for by ils elasticity, the action of the muscles in the perina-um, s-trid .,tii, t principles, without supposing tue canal to be iUelf muscular, are questions on which the writers on surgery entertain dif- ferent opinions. However, the generality of modern practitioners in this country have inclined to lhat view of the subject, which refers the property of muscularity either to the membrane ofthe urethra itself, or to tbe substance immediately surrounding it. The latter is now alleged lo be the real case " From Mr. Bauer's examinations (says Sir Everard Home) we find that the human ureihra is made up of two parts, an intertill membrane, and an external muscular cover- ing. The internal membrane is exceedingly thin., and no fibres are met with thai can give it a power of contraction. When it is put on ihe stretch in a transverse direction, the circumference of the canal is noway; increased; but wln»n stretched longitudinal- ly a small degree of elongation is produced When a transverse section of the urethra is made, while in a collapsed state, the inter- nal membrane is found thrown into folds. pressed together by ibe surrounding parts." It is afterward explained, lhat " the muscii lar covering, by which the membrane is surrounded or enclosed, is made up of fasci- culi of very short fibres, which uppear to be interwoven together, and to be connected by their origins and insertions with '>ne another. They all have a longitudinal direction. There is a greater thickness of this muscular struc- ture upon ihe upper, than the under surfare ofthe ureihra, which is still more evident as it approaches nearer to the* external orifice The fasciculi are united together by an elastic substance of ihe consistence of mucus. Im- mediately beyond the muscular portion of Ihe urethra, is the cellular structure of tbe corpus spongiosum. Formerly " it was believed, that either Ihe lining of the urethra was composed of circu- lar fibres, possessed of a power of contrac- tion, or (hat il was immediately surrounded by such fibres ; and therefore that (he dis ease, commoniy known by the mime of a stricture in the urethra, whs produced hy a contraction of some of tliese circular fibres; aud the permanent stricture was a term ap- plied lo these parts, when in consequence of inflammation they became confined to (hat particular slate. We now find, thai tht lining of Ihe urethra is never met wilh in a contracted slate, but is thrown into folds hy the action of the ela-tic ligamentous cover- ing oi tbe corpus spongiosum, and the swell of ihe longitudinal macular fibres within it. and win,i ihese fibres have, by acting through their whole length, reduc-d tbe urethra to its shortest state, the pressure upon the internal membrane is so great, that there is not room for the urine to pass, till these fibres are relaxed by elongating the whole canal. " A spasmodic stricture is in reality a con traction of a small portion ofthe longitudinal muscular fibres, while the rest are relaxed ; und as this may take place either all round, or upon any one side, itt explains what is met wilh in practice, and could not before be satisfactorily accounted for ; the mark, or impression of a s'ricture sometimes form- LKE1HRA ->3l ibjj a circular depression upon the bougie ; at other times, only on one side. " A permanent stricture is that contraction ofthe canal, which takes place in consequence of coagulable lymph being exuded between the Jasciculi-of muscular fibres, and upon the in- ternal membrane, in different quantities, ac- cording to circumstances ; and, in the same proportion, diminishing the passage for the urine at that part, or completely closing it up. (Sir Everard Home in Phil. Trans. 1820, and Prad. Obs. on Strictures, Voi. 3, p. 26, fyc. Svo. Lond. 1821.) For a particular detail of the arguments and remarks, urged against the doctrine of the urethra being a tube, capable of having its diameter suddenly lessened at every point by the contraction of muscular fibres, I must refer to the writiugs of Mr. C. Bell and Mr. Shaw, whose statements, indeed, have been noticed in my introductory work. (See First Lines of the Practice of Surgery, ed. 4, Vol. 2.) In all obstructions of the urethra, Mr. Hunter remarks, that the stream ot water becomes small in proportion to the stop- page ; but, though this symptom is probably the first, it is not always observed by the patient. In some instances, the water is voided only by drops, and then it cannot escape notice. In other cases, the stream of urine is forked, orscattered Under such circumstances, Mr. Hunter recommends the passage to be examined with a bougie ; and, if one of a common size can be readily in- troduced, the difficulty of voiding the urine is likely to depend on a diseased enlarge- ment of the prostate gland, which should, therefore, be examined. See Prostate Gland. The spasmodic stricture may be known by its being only of temporary duration. This kind of case, and more particularly the permanent stricture, are generally attended with a gleet. The latler complaint is often for a long while suspected as being the only one, and the surgeon finds all his efforts, to effect a cure, fruitless. In diseases ofthe ureihra, and also ofthe prostate gland and bladder, there is com- monly an uneasiuess about the pcrinsum, anus, and lower part of the abdomen. (Hunter.) The first progress of the contraction is, in general, very slow ; but, when once it has so far increased, that the longitudinal fibres are not wholly relaxed by the force of the urine, its subsequent advances are more rapid, and new symptoms are perceived. The urine is voided more frequently, {does not pass without a considerable effort, at- tended with pain Rtid a straining sensation continues, after the bladder is emptied. If the patient accidentally catches cold, drinks a glass of spirituous liquor, acid beverage, or punch, commits an excess in drinking wine, or removes quickly from a warm to a cold temperature, the urine will, perhaps, pass only hi drops, or be entirely obstructed. These causes induce, in the longitudinal fibres at the contracted part, a spasmodic action, by which it is closed. Cold, exter- nally applied to the body, has so great an ell'ect upon a spasmodic stricture, that a patient, who can make water without the smallest difficulty in a warm room, is often quite unable to vqid a drop, on making the attempt in the open air. However, on re- turning to a warm room, and sitting down a little while, he becomes able again to expel his urine. The symptoms of a stric- ture are more frequem in persons who lead a sedentary life, than in those whose pur- suits are active. Strictures in the urethra, being attended with a discharge and pain in making water, especially after any excess, are frequently regarded and treated as a gonorrhoea. These two symptoms often come on a few hours after connexion with women ; the degree of inflammation is very slight; the discharge is the first symptom, and is more violent at the commencement, than at any other periof. The inflammation subsides in a fe.v days, leaving only the discharge, which also frequently disappears in five or six days, whether any means are employed or not for its removal. (Home.) What renders a stricture particularly apt to be mistaken for a gonorrhoea, is the cir- cumstance that, in both diseases, the pain in making water is experienced about an inch and a half from the orifice of the glans penis. In a more advanced stage, the part of the urethra which is the seat of stricture, is always much narrower than the rest of the canal. The stricture is permanent, being combined with a thickening of structure, whereby the diameter of the diseased part of the passage is lessened. However, the diameter of the affected portion of the canal even now varies, according as the spasm and projection of the longitudinal fibres, the spasmodic action of the muscles about the pcrinsum, nnd the effects of inflammation, contribute more or less to a temporary in- crease ofthe obstruction. In the language of Sir Everard Home, the case is now both a permanent stricture, and a spasmodic one ; permanent, because the diseased part of the urethra is always narrower than the rest of this passage; and spasmodic, inasmuch as the stricture may be rendered still more contracted by spasm affecting the muscular structure, adjoining the disease. In the contracted state the passage is closed up ; in the relaxed, the urine can pass through it in a small stream. The spasmodic contraction must act with considerable force, since the urine cannot even pass in a small stream, and a small bougie, which, in a relaxed state of the ure- thra, met with no resistance, can now be scarcely introduced at all. Also, if the bougie be allowed to remain for a few mi- nutes in the stricture, it is not unfrequently grasped so tightly by the spasmodic con- traction, that, when an attempt is made to withdraw it, some force is requisite to sue* ceed. The bougie, when examined, seems as if it had had an impression made round it by a piece of packthread. (Home.) o.-ii URETHRA In old cases of stricture, the muscular coat ofthe blndderbecomes thickened ami stronger lhaii natural, in cc*iir-c,;ueiice of more, force being necessary lo propel the urine through the obstroc.ed pari. The bladder, in this thickened state, docs not admit of the usual dilatation, so that tlie patient is obliged to make water very fre- quently, and he is unable to pass tlie whole night without making this evacuation once or twice. (Home.) A nocturnal emission of the semen is another very common symptom of a stric- ture ; and some patients seem to have no other complaint attendant on the disease of the urethra. A periodical discharge is sometimes brought on by cold, or other occasional causes. When the inflammation extends to the blndder, (he frequency of making water is considerably increased, and the urine very turbid. It is voided for twelve, or twenty- four hours, once or even twice every hour; and, when allowed to stand, it deposits a substance in the form of powder, consisting of coagulable lymph. This is the slightest kind of attack. Sometimes the bladder is inflamed in a greater degree, and secretes pus, which is discharged with the urine. In a still more violent attack, the discharge is similar to the white of an egg,- and particularly adhe- sive. Sir Everard Home states, that it has been discovered by examinations after death, fo be the vitiated secretion of the prostate gland. When the inflammation of the blad- der becomes still worse, the affection some- limes extends to the peritoneum, and the patient dies. As strictures of long standing always im- pede the passage of the urine, the bladder acts with augmented force to overcome the resistance. In this manner, the stricture is kept in a continual state of irritation, and the obstruction becomes more and more considerable. In a few cases, indeed, the diseased part of the urethra is rendered quite impervious ; and the patient's life is preserved by the urethra ulcerating, at some point within the obstruction, and fistulous openings taking place in the perinaeum. See Fistula in Pe- rinao. Strictures are frequently attended with constitutional symptoms, one of the most common of which, in warm climates, is a complete paroxysm of fever. The cold fit is very se\ ere ; this is followed by a hot fit, and then a very profuse perspiration. Du- ring the rigour, nausea and vomiting gene-. rally occur, and at this period the patient bas occasion to make water frequently, sel- dom experiencing at the same time any strangury. When the fit is tolerably com- plete, the patient suffers, in general, only one; in the opposite circumstance, two; but a greater number rarely happen. Such febrile paroxysms are not frequent in cold countries , but do every now and then take place- particularly in consequence of expo- sure to cold, excesses, aud the introduction both of common and armed bougies. According to tho principles of Sir Everard Home, the longitudinal muscular fibres on the; outsido ofthe membrane of the urelhro, are liable to a --nnsmodic contraction, in which state their swell lessens the diamrtev ofthe passage, and they are incapable of becoming relaxed again, until the spasm i.< removed. This spasmodic stricture is only a wrong action ot these longitudinal fibrei; nnd, if the parts could be examined in their relaxed slate, there would be no appearance of disease. When tue contraction is not considerable, it appears, on examination after death, to be merely a narrowing of the urethra; but a permanent stricture, in a more advanced slate, usually consists of a ridge, which forms a projection in the passage. (Home.) Mr. Hunter informs us, that the disease generally occupies no great length of the passage ; at least, that this was the case in most of the instances which he examined In these cases, tbe contraction was not broader, than if it had been produced by surrounding the urethra with a piece of packthread ; and in many it had a good deal of the appearance, which one may fancy such a cause would produce. Mr. Hunter states, however, that he had teen the urethra contracted for above an inch in length, owing lo its coats, or internal mem- brane being irregularly thickened, and form- ing a winding canal. A stricture does not always arise from an equal contraction of the urethra all round; for, iu some instances, the contraction b only on one side ; a fact, which appears to ine to be better accounted for by the con- sideration of the longitudinal arrangement ot the muscular fibres in pockets, on Ihc outside of the membrane of tbe urelbra. than the circular kind of stricture, only oc- cupying as small an extent of the passage, as the constriction which would arise from the application of a piece of packthread round it. The contraction of one side of the canal only throws the passage to the opposite side, which often renders the in- troduction of a bougie difficult. Tbe con traded part '<*• whiter than the rest of the urethra, and is harder in its consistence In some cases there are several strictures. Mr. Hunter mentions his having seen half a dozen in one uiethra, and he observes, that a stricture is frequently attended wilh small tightnesses in other parts of the pas- sage. Mr. Hunter remarks, that every part ot the urethra is not equally subject to stric- tures, the bulbous portion being mucb tbe most subject to the disease. A stricture is sometimes situated on this side of the bulb, but very seldom beyond it, that is, nearer the bladder. Mr. Hunter never saw a stric- ture in that part of the urethra, which passes through tbe prostate gland; nnd the bulb, besides being tbe most frequent seat of this disease, is also subject to it in it** worst forms. (Huufir) URETitllA. 533 Sir Everard Home has measured the ii-ngth of the ureihra in different subjects, ■ nd examined the diameters of the several ,>arts of the passage. Strictures, according to this gentleman, occur most commonly" just behind the bulb of the urethra, the dis- tance from the external orifice being 6 1 2 or 7 inches. The situation, next in the or- der of frequency, is about 4 1-2 inches from the orifice of the gians. Tbe disease does also occur at 3 1-2 inches, ami sometimes almost close to the external orifice. The ttvo parts of the urethra, most frequently affected with strictures, are naturally ihe narrowest. Sometimes the very orifice of the urethra is contracted, and the circum- stance often leads to an erroneous supposi- tion, that the whole canal is naturally form- ed of the same size. The prepuce also is observed lo be particularly often affected with a natural phymosis, in persons who have strictures in the urethra. In almost all the cases which Sir E. Home has met with, there has been one stricture, about seven inches from the exter- nal orifice, whether there were any others, or not. With respect to the causes of strictures, some writers have imputed the disorder to tbe effects of the venereal disease, and often to the method of cure! Mr Hunter entertained strong doubts however, whelher strictures commonly, or ever proceeded from these cames; though he acknowledges, that since most men have bad venereal complaints, a refutation of the above opinion is very difficult. Mr. Hunter was led to think, that strictures did not commonly arise from venereal causes, from reflecting that strictures arc common to most passages in the human body. They often take place in the oesophagus ; the intestines, particu- larly the rectum ; the anus; the prepuce so as to produce phymosis; and in the lachry- mal duct, so as to occasion a fistula lachry- malis. Strictures sometimes take place, when there have been no previous venereal complaints Mr. Hunter mentions his hay- ing seen an instance of this kind in a young man, nineteen years of age, who had had the complaint for eight years, and which therefore began, when he was only eleven years old. He was of a weak scrofulous habit. Mr. Hunter bad also seen a stricture in a boy only four years old, and a fistula in perinso in consequence of it. Strictures happen as frequently in persons, who have bad gonorrhoea in a slight degree, as in others, who have had it in a severe form. It is not an uncommon belief, that stric- tures arise from the use of astringent injec- tions in Ihe treatment ofthe gonorrhoea. »ir Everard Home is of this sentiment, and so is Mr. Wilson. (On the Male Genital and Urinary Organs, p. 370.) 1 he latter gentle- man however, mentions some circninstan- ces, calculated to raise doubts on this point, especially the fact, tbat while injections rarely enter far into the urethra, the most common seat of a stricture is where the membranous part of the canal joins the bulb. M". Hunter himself deemed tbe opin- ion founded on prejudice, and states that ho had seen as many st.ictures idler gonorrhoea, which had been cured without injections, as after cases which had been treated with these latter applications. He rejected also the old doctrine, that strictures are a consequence* of ulcers in t.ie urethra ; for ulcers hardly ever occur in this passage, except when there are stric- tures ;' and it is now generally admitted, that in gonoirhoea, there are no sores in the urethra. Strictures are sometimes produced by external violence, though the passage would appear to be capable of frequently- bearing considerable wounds and other in- juries, without this consequence. Thu^ strictures are not common from lithotomy, and in a modern work, we read the case of a serious gunshot wound of the urethra, where no stricture ensued. (See Annuaire Med Chir. des Hupilaux de Puris, 4lo. 1819.) TREATMENT OF STRICTURES, WITH COMBOS BOUGIES, ON THE PRINCIPLE OF DILATA- TION. Mr. Hunter remarks, that the cure of strir tnres may be accomplished, either by a di- latation of the contracted part, or a destruc- tion of it by ulceration, or escharotics. To these methods are to be added, first the plan of forcing a passage through the stricture with a conical sound, as practised by the French surgeons, when they cannot other wise puss the stricture, and the symptoms are urgent, (isee J. Cross, Sketches of the Medical Schools of Paris, 8vo. Lond. 181,3, p. Ill ; and Pint Lines of the Practice of Sur- gery, Vol. 2, ed. 4;) and secondly, the me- thod of cutting down to obliterated portions of the urethra, and attempting to cure the obstruction by the removal of the diseased parts, tracing the continuation of the pas- sage, and try ing to heal the wonnd over a catheter. Both these practices are attended wilh such difficulties and dnngers, as should make every prudent surgeon very reluctant lo adopt them, except under very urgent circumstances, in which every milder me- thod tails. The dilatation is accomplished by means of bougies or catheters; but Mr. Hunl<*rcoiisidcred,that a cure thus effected. was seldom or never more than temporary. The removal of the stricture by ulceration. may also be effected with bougies. Its de- struction with caustic used formerly to be executed through a cannula, contrived for tiie purpose; but is now performed bv means of caustic or armed bougies. The cure by dilatation is principally me- chanical, when effected by bougies, the powers of which are generally those of a wedge. However, Mr. Hunter conceived, that their ultimate effect was not always so simple as that of a wedge upon inanimate matter: for pressure makes living parts eilher adapt themselves to their new posi- tion, or else recede by ulceration. Bougies of course, either dilate strictures, or makf them ulcerate. •M-H URETHRA The disease bas generally made consider- able progress, before surgical assistance is rec]uired, and the stricture may be so ad- vanced, that a small bougie cannot be made to pass, without a great deal of trouble. If the end of a small bou.-ie, let it be ever so small, can be introduced through the stric- ture, the cure is then in our power. How- ever, a small bou;,-ie frequently cannot pass in the first instance, and even nol after re- peated trials. Ofieu when the stricture is vrry consider- able, a great deal of trouble is ^iven by occasional spasms, which either resist the introduction of a bougie altogether, or only allow a very small one to pass. At other periods, however, a larger one may be in- troduced. In these circumstances Mr. Hunter mentions, that he was sometimes able to make the point of the bougie enter, by rubbing tbe outside of the perinaeum with the finger of one hand, while he pu-h- ed the bougie on with the other. The same eminent practitioner often succeeded by letting the bougie remain a little while close to the stricture, aud then pushing it on. Sometimes the spasm may also be taken off by dipping the glans penis in cold water. Although in cases of permanent stric- tures, the bougie may not pass at first, yet after repeated trials, It will every now and then find its way. In this manner futuie attempts become more certain and easy. However, the success of the subsequent trials to introduce a bougie does not always depend on the instrument having been once or twice passed. Sometimes it can be in '.roduced to-day, but not to-morrow; and in this state the case may continue for weeks, notwithstanding every trial which can be made. Mr. Hunter observes how- ever, that in general, the introduction of Ihe bougie becomes gradually less difficult, and therefore, that we ought not to despair of success in any case. When the passage is very small, it is not* easy to know whether the bougie has enter- ed the stricture or not; for bougies as slen- der as those which must be at first employ- ed, bend so very easily, that the surgeon is apt to fancy, that they are passing along the urethra, while tbey are only bending. Mr. Hunter advises the surgeon first to make himself acquainted with the situation of the stricture, by means of a common-sized bougie; and then to take a smaller one and when its point arrives at the stricture the instrument is to be gently pushed for- ward, but only for a short time. If the bougie has passed further into tbe penis, the surgeon may know how far it has entered the stricture, by taking the pressure off the bougie. For, if it recoil, he may be sure that it has not passed; at least, has not pass- ed far, but only bent. On the contrary, if it remain fixed, and do not recoil, it has cer- tainly entered the stricture. However, the preceding remarks are said not to be so applicable when a very small bougie is employed, which may become bent, without our being an arc of the cii cumstance. A bougie may frequently be introduced a very little way, for instance, only one-tentb 'of an inch, and then it bends, and cannot be pushed further. To determine whether this is the case, Mr. Hunter says, it is necessary to w ithdraw the bougie and examine its end. If the end be blunted, we may hu sure, that tin* bougie has not entered at all; but if it be flattened, for an eighth, or tenth of an inch, be grooved, or have its outer waxen coat pushed up to that extent; or if there be a circular impression made upon the bougie, or only a dent on one side, made by the stricture ; we may be sure that the instrument has passed us far as these appearances extend. It then becomes ne- cessary to introduce another of exactly tlie same size, and in the same manner, and (n let it remain as long as the patient can hem it or convenience w ill allow. By repeti- tions of this plan, the stricture will be over- come. Mr. Hunter remarks, tbat the time which each bougie ought to remain in tbe passage must be determined by the feelings of the patient; for if possible, no pain should ever be given. If ihe patient should experience very acute pain when the bougie is passing, it ought not to be- left in the urethra above five, or at most, ten minutes; or not so long if the pain be exceedingly severe. Each time of application should afterward be lengthened so gradually as to be impercep- tible to the feelings of the patient, and the irritability of the parts. Mr. Hunter affirms, that he has known many patients, who could not bear a bougie to remain in the passage ten, or even live minutes, till after several days, and even weeks, but who in time were able to wear the instrument for hours, and this, at last without any diffi- culty. Ihe best time for keeping a bougie in the urethra, is when the patient has least to do; or in the morning, while he is in bed, if he can introduce the instrument him- self. Mr. Hunter next observes, that the bougie should be increased in size, according to the facility with which the stricture becomes di- lated, and the case with which the patient bears the dilatation. If the parts are very firm, or very irritable, the increase of the size ofthe bougie should be very slow, so as to allow them to become gradually adapted to the augmented size of the instrument. But if the sensibility ofthe parts will allow, the increase of tlie size of the bougie may be somewhat quicker, but never more sud- den than the patient can easily bear. The surgeon must continue to increase the size of the bougie, till one of the largest size can freely pass ; nor should tbe use of this be dis- continued till after three weeks, or a month, in order that tbe dilated part may have time to become habituated to ils new position, and lose its disposition to contract again. However, Mr. Hunter belie*, ed, that the permanency of a cure, effected on fhe prin- UKETHR-V Mb cipie oi ditatatiou, i.ouiu seldom be depend- ed upon. At the present day, many surgeons prefer bougies composed of metal, (lcxiole enough to allow their curvature to be adapted to the bend of the urethra, yet sufficiently firm to retain tlie figure given them, while they are employed. Others very commonly use iron sciuuds, which, in cases where it is necessa- ry to bave an instrument possessing more firmness than a wax bougie, and having a point more unchangeably turned upwards than that of the latter instrument, may have advantages. But, tor all ordinary cases, 1 consider a common bougie a sater aud bet ter instrument; one with which the surgeon is less apt to exert unwarrantable force, so as to occasion, a dangerous degree of irri- tation, or, what is worse, a false passage. CURE OF STRICTURES BT ULCERATION. This is als i accomplished by means of a wax or metallic bougie, and Hie plan may be tried both when the instrument can. or cannot be introduced through the stricture. In the first instance, the method is less pro- per, because the stricture admits of being dilated. In order to cure a stricture by making it ulcerate, the bougie is to be introduced as far through the contracted part as possible, and the size of the instrument is to be aug- mented, as fast as the sensations of tbe pa- tient can well bear. In ttiis manner ulcera- tion will be produced iu the part wliich is pressed; and Mr. Hunter remarks, that tue cure will be more lasting, because more of the stricture is destroyed than when the parts are simply dilated. 1'his eminent surgeon notices, however, that few patients will sub- mit to this practice, and ttial few indeed would be able to bear it, since it is apt to bring on violent spasms in the part, attend- ed with a very troublesome retention of urine. If the smallest bougie cannot be made to pass a stricture, by using some degree of force, dilatation becomes impracticable; and as the stricture must be destroyed, something else must be tried. In many cases, says Mr. Hunter, it may be proper to get rid ot ihe stricture, by making it ulce- rate, or, in other words, be absorbed. Bou- gies, intended to excite ulceration, need not be so small as in the loregoiug cases, as they are not designed to be passed through the stricture; and, in consequence of being of the common size, (hey may be raw.' surely applied to the parts causing the obstruction. The force applied to a bougie, in this case, "mould not be great: for a stricture is ihe hardest part of the urethra ; aud it a bougie U forcibly pushed on, its end may slip off the stricture, before ulceration has com- menced, and make a false passage tor itself in the corpus spongiosum urethras. In trying to cure strictures by ulceration, the utmost attention must be paid ; and if tiie patient does not make water better, not- 'vitbstandirg the bougie passes further, the surgeon may be sure he is lorcing a false passage. When the stricture has so far yielded, as to allow a small bougie to be introduced, the treatment is then to be conducted on the principle of dilatation. Mr. Hunter observes, that whenever a bou-ic oi a tolerable size passes with ease, and the parts a.nd tlie patient bave become accustomed to it, the surgeon need no longer attend for the purpose of introducing .t. The patient may now be allowed to intro- duce bougies himself; and when he can do this with ease, the business may be trusted to bim, as he can make use of the instru- ments at the most convenient times, so that they may be more frequently and longer applied. In the mean while, the surgeon should only pay occasional visits. Mr. Hun- ter adds, thai this practice of the patient; under the surgeon's eye, by which mea. s t;u- former learns the art of .ntroducing bo. - gies, is the more necessary, since strictures are diseases which commonly recur; and, therefore, no man who bas ever had a stric- ture, and is cured of it, should rely on the cure as lasting ; but should always be pre- pared for a return, and always have some bougies by him. He should not go a jour- ney, even of a week, without them ; and the number should be accorditig to the time which he is absent, and the place to which he is going , for in many parts of the world he cannot be supplied with them. To prevent the inconvenience of a bougie slipping out, or the mischief of its gliding into the urethra, a soft cotton thread must be tied round that end of the bougie which is out of the urethra, and then round the root of the glans. This last part of the thread should be very loose. The projecting portion, of the bougie should also be bent down upon the penis, by which means it is rendered less troublesome, and more secure, (See Hunter on the Venereal Disease. When a considerable part of the bougie remains out of the urethra, surgeons usually clip a piece of it off. In many examples, in which a stricture is accompanied with excessive irritability in the urethra, much pain, and a tendency to frequent retentions of urine, when a com- mon bougie is employed, it becomes advisea- ble to alter the plau of treatment, and use either flexible metallic, or elastic gum bou- gies, (see Bougie.) Desault commonly cured all strictures by the skilful employment o! flexible gum catheters, which his patients were directed to w ear a certain length of time every day. These last instruments produce less pain and irritation than any kind of bougie, more especially when the wires are withdrawn ; and were 1 to be my- self afflicted with strictures, I should feel strongly disposed to attempt their removal by the use of elastic gum catheters, which are unquestionably the mildest aud least painful means of cure. 1 have seen cases, however, in wtiich the flexible metallic bou- gie seemed to cause much less irritation than any other kind of bougie ; but in general, t RETHRA those made ot elastic gum give the least pain. Metallic bougies possess the advan tage of retaining the exact curvature of the passage better tnan others ; and, as I bave ^bser-ed, they enable tne s-.-rg-on to e i'loy more force, aud this with more precision than can be done wilh a wax bougie. Vet. as for,*.e is not a principle to be much com- mended in the treatment of ordinary stric- 'ures, I doubt whether such instruments will !ong retain as many employers as they have now acquired, and many of whom use them indiscriminately in all cases. Small catgut bougies are chiefly eligible, when tiie cure by dilatation is preferred, and the smallest bougies of other descriptions cannot be in- troduced through the stricture i HRE OF STRICTURES WITH THE ARGEHTCM NlTRxTCM. Wiseman makes mention of the plan of curing strictures in the uretnra by means of caustic. He observes, that when the oh- stiuction is a caruncle, and you cannot pass il, you may well conclude it is callous: " in which case, you may pass a cannula into ihe ureihra to that caruncle, and, whilst 3 ou hold it there steady, you may convey a grain of caustic into tiie cannul i, and press the caustic to it; and whilst you hold it there, you will perceive its operation, by the pressing forward of the cannula." About tbe year 1752, Mr. Hunter attended a chimney-sweeper, who had a stricture. Not finding that any benefit was derived from the use of common bougies, for a space of six mouths, Mr. Hunter, unaware of the above passage in Wiseman, conceived, that the stricture might be destroyed by e.scharo- fies, and the first attempt, which he made, was with red precipitate. He put some salve ou the end of a bougie, and then dip- ped it in red precipitate. Th" bougie in this -tate, was passed down to the stricture ; but Mr Hunter found, tbat it brought on con- -iderable inflammation all along tbe inside nf the pus-age, as he thought, iu consc- "uence of the precipitate being rubbed off, while the bougie was passing to the stricture. lie then introduced a silver cannula down io the stricture, and aguin passed the bougie wilh precipitate through the tube. As the patient, however, did not make water any better, and the smallest bougie could not be introduced through the stricture, it was . uspected, that the precipitate had sufficient power lo destroy the obstruction. Mr. Hunter was induced, therefore., to fasten a small piece of the argentum nitratum on the end of a piece of wire wilh sealing-wax, and introduce the caustic throug'i the can- nula to tiie stricture. Afler having made the application three times, al intervals of two days, he found that the man voided bis urine much more freely, and on applying the caustic a fourth time, the cannula went through tbe stricture. A bougie was intro- duced for a little while afterward, till the nun had completely recovered. Having experienced this success. Mr. Hun- ter was encouraged ti> apply his mind to Ibt invention of some instrument, better suited to the p.irpose.tban the above contrivance; and an improved instrument was devised, although he acknowledges, that it was not perfectly adapted to strictures in every situ- ation in the '.iretbra. He remarks that (lie caustic should be prevented from hurting tbe unaffected part of the urethra by introducing tbe active substance, through a cannula, down to the stricture ; and that it should be catmhle of protruding a little beyond Ihe end ofthe cannula, by which means it will only act upon the stricture. The caustic should be fiied in a small portcrayon, and it is ne- cessary to.have a piece of silver of the length of the cannula, with a ring at one end, ami a button at the other, of the same diameter as the cannula. The button forms a kind of plug, which should project beyond the end of the cannula in the urethra, so as to make a rounded end ; or, Mr. Hunter says, the portcrayon may be formed with this button at its other end. The cannula, with the button, is to be passed into the urethra, and when it reaches the stricture, the silver plu.; should be withdrawn,and the portrrayon with the caustic introduced in its place ; or, if the plug and portcrayon are on the same instra- inent, then it is only necessary to withdrawthe plug, and introduce the portcrayon-with tbe caustic. The plug, besides giving a smooth rounded end to the cannula, answers ano- ther good purpose, by preventing tbe tube from being filled with the mucus of the ure- thra, when the instrument is passing in- ward, which mucus would be collected iu the end of the cannula, dissolve the caustic loo soon, and hinder its application to the stricture. Wuenthe stricture was beyond the straight part of th- urethra, Mr. Hunter owned, that it was diffi :ult to apply caustic to tbe disease through a cannula. A better mode of applying lunar caustic to strictures was Hftcrward devised by Hunter, nnd has since been extensively introduced into practice by Sir E. Home. This gentle- man directs us to take a bougie of a size that can be readily pas-ed down lo the stric- ture, and to insert a small piece of lunar caustic into the end of it, letting the caustic be e ven witb the surface, but surrounded every where laterally by the sufotance of the bougie. This should be done some little time before it is required to be used; for the materials of which the bou- gie is composed, become warm and soft by being handled in inserting the caustic; and, therefoie, the hold which Ihe bougie has of the ca Ktie, is rendered more secure after ihe wax hi-- be, n allowed lo cool and hard- en. Tne bougie thus prepared, is to be oiled and made ready for u-e ; but before pa-sing it, a common bougie of (he same size is to ne- introduced down to the stricture, in or- der to clear tbe canal, nnd to measure the exact distance of the stricture from the ori- fice 'of ihe urethra. This distance being marked upon the armed bougie, it is to be passed down to the cincture, as soon as the i,Kr-THRA. 337 other is withdrawn. The caustic, in its pas- sage, is scarcely allowed to come into con- tact with any part of tbe membrane, because the point of the bougie, of which the argen- tum nitratum forms the central part, always moves in the middle line ofthe canal ; and, indeed, the quickness with which it is con- veyed to the stricture, prevents any injury of the membrane lining the passage when tbe caustic accidentally touches it. In this mode the caustic is passed down with little or no irritation to the lining of tbe urethra ; il is applied in the most advan- tageous manner to the stricture, and can be retained in that situation sufficiently long to produce Ihe desired effect. The reasons urged in favour of the em- ployment of bougies armed with the lunar caustic, are, that a permanent cure i-effect- ed, which common bougies' cannot accom- plish ; thit the pain arising from the applica- tion of the argentum nitratum to the stric- ture, is very inconsiderable ; and thai nei- ther irritation nor inflammation is found to ensue. The meaning of tliese remarks, however, is to be received as a general one, liable to exceptions. Indeed, Sir E. Home himself has candidly acknowledged, that some inconveniences occasionally follow Ihe use of armed bougies. But what practice, however judicious and eligible, is altogether free from occasional ill consequences? Sir E. Home remarks, that against treating stric- tures of the urethra with caustic bougies, numerous objections have been adduced, and many b-id consequences have been at- tributed to the practice, without any real foundation; "for whatever, a priori, might be supposed the effects of so violent an ap- plication, to a membrane so sensible and ir- ritable as the urethra, nnd I will admiit that it is very natural to conceive they would be very severe, the result of experience, the only (hing to be relied on, e vinces the contrary. The pain that is brought on, is by no means violent; and neither irrita- tion nor inflammation is found to take piece. " That cases do occur, in which strictures bave produced so much mischief, and ren- dered so greai an extent ol the canal dis- eased, that the use of the caustic has proved unsuccessful, is certainly true ; and several of Ihese t a-es have fallen within my own know- ledge. Bul when it is stated tha. none, even of tliese, were made worse by its use; that no bad consequences atlend it; and that no otlwr mode, at present known, is equally efficacious; any occasional want of success cannot be considered as an objec- tion to this mode of practice. ,: But if the apprehension of violent effects from the caustic, however ill-found- ed, cannot be removed, let the alternative be considered; namely, the only operation Kreviously in use, where a stricture cannot a dilated by the bougie. " In those cases we arc obliged to have recourse to means certainly more severe and violent,'laying open with a knife the diseased urethra, and pas-ring through the Vol. II. »;*- divided parts a flexible' gura-calheler into the bladder. This T have done myself, and have frequently seen it performed by Mr. Hunter, and it always succeeded ; neither bringing on so much inflammation as was expected, nor being attended with any symptoms of irritation. " This practice has byolhersurgeons been carried still further; the portion of diseased urethra has been dissected out, and entirely removed ; nor has so severe an operation always brought on untoward symptoms; and patients have recovered. "If the membrane of the urethra, when diseased, is capable of suffering so much injury without any consequent symptoms of irritation, it cannot be doubted that it will bear with impunity to be touched, in a very partial manner, several different times with lunar caustic." Sir Everard afterward proceeds: "Having met with a number of facts, from which a general principle appears to be established, that the irritable state of a stricture is kept up, and even increased, by the use of the bougie, but lessened and entirely destroyed by the application of lunar caustic ; I am desirous to communicate my observations upon Ihese facts, and to recommend the use of the caustic in many cases of irritable stricture, in preference to the bougie. " As the use ofthe caustic tipun this prin- ciple is, I believe, entirely new-, and is con- trary to every notion that has been formed upon the subject, it will require something more than general assertion to gain even the attention of many of my readers, snil more their belief; 1 shall therefore detail the circumstances as they occurred, by Which I conceive the propriety of this prac- tice to be established ; and afterward make some observations upon the principle on which it depends. "My coi nexion in practice with Mr. Hunter afforded me opportunities of attend- ing to cases of stricture in all their different stages; many of them brought on during a long residence in India, attended with great irritability, and exceedingly difficult of dure. " One case of this kind admitted the pass- ing of a small bougie; but, iu the course of three years, very little was gained bv a steady perseverance in the use of that in- strument, either in dilating the canal, or palliating the symptoms of stricture; this made me look upon the bougie as less effi- cacious than I had always been taught to believe it. I was willing, however, to con- sider this a- an uncommon case, depending more on the peculiarities of the patient's constitution th'tn on the nature cf the dis- ease: but I found, on a particular inquiry, that several other gentlemen from India were under circumstances nearly similar; the bougie only preventing the increase ef the stricture, but being unable to dil.de it beyond a certain size ; and when it was left off, the stricture in less than two months returned to its former state of contrac- tion .■35- CRETURA " What plan ou^litto be followed in such cases, I was then unable to determine ; but, that the bougie could not be depended on was evident. During the suspense, the fol- lowing ca*e came under my care. "In August, 1794, a gentleman consulted me for some symptoms which had been considered as indicating the presence of gonorrficxa ; but, as they did not yield tto the common treatment in the usual time, be was induced to take my advice res- pecting the nature of his complaint In the necessary inquiry, to obtain a perfect his- tory of the case, among other things it was stated, that, nineteen years before, there was a stricture which became very trouble- some, and that Mr. Hunter, by the desire of the patient, had applied the caustic, by ■which Ihe stricture was removed, and never afterward returned. He said that he was one of the first persons on whom the caus tic had been used. From this account, I was naturally led to believe that the stric- ture had gradually returned, and was now increased, so much as to produce the pre- sent symptoms ; a discharge being almost always a symptom of stricture when it is much contracted; but, upon examining the canal, a bougie of full size passed on to the bladder witbout the smallest impediment. I therefore took up the case us an inflamma- tion in the urethra; and large doses of the balsam of copaiva, given internally, effected a cure. " The circumstance of a stricture having been removed nineteen years before, and not returning, made a strong impression on my mind, and made me desirous to ascer- tain whether this practice could be employ- ed In cases of stricture in general, and the cure produced by it equally permanent. A short time afterward, I had an opportunity of trying it in the following case. " A captain in the East India Company's -r-rvice, in September, 1794, applied to me for assistance. His complaints were, great irritation in the urethra and bladder, con- stant desire to make water, and an inability fo void it, except in very small quantities. These symptoms had been at first supposed to arise from gonorrhoea, afterward render- ed more severe by catching cold ; but, not yielding to the usual remedies for gonor- rhoea, they were investigated more minute- ly, and a stricture was discovered in the urethra. The mode of treatment was now changed, and the bougie employed ; but its use aggravated all the symptoms, and brought on so great a degree of irritability in the bladder and urethra, that there was jm alarm for the patient's life, which was the reason for applying for my assistance. " Besides the local symptoms, this patient had those of quick pulse, white tqngue, hot and dry skin, loss of appetite, and totul want of sleep, w ith frequent attacks of spasm on the bladder and urethra. A very small flexible gum-catheter was passed, and the water drawn off, in quantity about a pint, "which gave him great relief: this vvas re- pc-ted morning and evening., to keen the bladder in as easy a stale us possible ; In,:, in other respects, lie continued much tbe same. " As the present symptoms were brought on by the use ofthe bougie, little gondwn; to be expected from lhat instrument ; and where the urethra had been so easily irrita- ted, and was disposed to continue in that state, there was no prospect of the use: of the bougie afterward effecting a cure. The-* circumstances I explained to the pafie-nf; and mentioned, in proof of my opinion, tin case in which so little had been effected in three years. " I then proposed to him a trial ofthe caustic, with a view to deaden the edge ot the stricture, us the only probable mean; of effecting a cure. The degree of irritation was already great; I vvas, however, led tu believe that the application of the caustic was not likely to increase it; since, by destroying the irritable part, it might lessen and even remove tlie spasmodic affeclion; but if, contrary to my expectation, the irritation continued, we still should be able to draw off the water, as the slough formed by the caustic would prevent the edge ot the stricture from acting and obstructing the instrument. "The application of the caustic was, upon these grounds, determined on; andit was applied in the following manner. " I passed a common bougie, nearly the size of the canal, down to the stricture, U> ascertain its exact situation, and to make the canal of tbe urethra as open as possible The distance was then marked upon n bougie armed with caustic, of the same* size, which was conveyed down as quickly as the nature of the operation would adroit It was retained upon the stricture with a slight degree of pressure ; at first there was no pain from the caustic, but a soreness from pressure; in less than a minute a change was felt in the sensation of tbe part, it was at first a heat, succeeded by tbe burning pain peculiar to caustic; as soon as this was distinctly felt, the bougie and caustic were withdrawn, having remained in the urethra about a minute altogether. The soreness, he said, was entirely local, by no means severe, vvas unaccompanied by irritation along the canal, and he thought the imeasiness in the bladder diminished by it. He described the pain as resembling very exactly the first symptoms of gonor- rhoea. This sensation lasted half an hour after withdrawing the bougie. " The caustic was applied about one o'clock in the forenoon, and he passnl the day more free from irritation than ho had since the beginning of the attack, which had lasted six days. In the evening, th'*. water was drawn off with more ease th;'*i the night before. lie passed a tolerable night, and, the next day, continued free from irritation. On the- third day, the caus- tic was again applied in the forenoon; the painful sensation whs less tlnui on the for- mer application, lasted a shorter time, and in an hour after the ;«'tnp(l bousrie was wit1'- LRETHRA. oaf drawn, be made water freely for the first time since the commencement of his indis- position. He said the irritation in the blad- der was removed, and he felt very well, his appetite returned, he slept very well, aud continued to void his urine with ease. " In this state, nothing was done till the fifth day, leaving always a day between the applications of the caustic. "" On this day a common-sized bougie went readily into the bladder; it was im- mediately withdrawn, and the cure was considered as complete ; no bougie was afterward passed, lest it might bring back an irritation upon the passage. I met this gentleman twelve months afterward, and he assured me he had continued perfectly well, and 1 have since learned that, in three years, there has been no return. ' " From the result of this case, I was en- couraged to hope that the caustic might be applied to strictures in the urethra wilh more confidence than I had hitherto be- lieved, since it evidently did not bring on or increase the geuoral irritation, but, on the contrary, seemed to allay it " The foregoing case, together with ano- ther which Sir E. Home has related, con- vinced this gentleman that he had disco- vered an effectual mode of treating such strictures as do not admit of being relieved by the common bougie. Hence he adopted the use of armed bougies as a general prac- tice ; but he has not concealed the circum- stances under which the method does not prove successful. Sir Everard informs us, that " in some constitutions, where the pa- tients have resided long in wnrra climates, every time the caustic is applied to a .stric- ture, a regular paroxysm of fever, called by the patient an ague, takes place; and this has been so violent as to render it impossi- ble to pursue this mode of practice. Of this I have met with two instances. I consider this disposition to fever as the effect of cli- mate, and not of any natural peculiarity of constitution; for the brother of one of these eatients laboured under the same disease, ut as he had not been in warm climates, it was removed by the caustic without his ex- periencing such attacks." In gouty constitutions, attacks of the gout iiave in two instances brought on spasmo- dic constrictions, after the stricture had been removed by caustic. This, however, cannot be called a failure of the caustic. It only shows that gout can affect strictures, and reproduce them. " In some patients the strictures are so obdurate, that the use of the caustic is ne- cessary to be continued for a longer time, than the parts can bear its application, or even that of the bougie passing along the urethra; irritation therefore comes on, and stops the progress of the cure, and when the same means are resorted to ugain, the same thing takes place. The cases of failure of this kind that I have met with, some of which may yet ultimutcly be cured, if tho patients will take the necessary steps for that purpose, amount in all to c,\ " In some patients the stricture is readily- removed by the caustic, but, in a few weeks contracts again. The stricture being wholly spasmodic, the caustic, by taking off the spasm, is allowed to pass through, and can- not completely destroy the stricture. Of this kind I have met with one instance* which I must consider as a failure, as I have hitherto been unable to get the better of it. " In those cases where the caustic gradu- ally removes the stricture, and brings the urethra to a size that allows the patient to make water perfectly well, if there is any return, it is not to be attributed to the fail- ure of the caustic, but to the want of proper management, either from the caustic being too small, or its use left off too soon ; but' all such cases are,I believe, within the pow- er of being cured by the caustic, if its use is recurred to when that is found ne- cessary." For the generality of strictures in the urethra, which do not occupy more extent. of the canal than if caused by a piece of packthread being tied round it, bougies, armed with lunar caustic, answer very well, and so, I believe, do common bougies, to which the general preference ought per- haps to be given. For casesf also, in which the urethra is diminished in diameter, for an inch or more, common bougies must be most advantageous, that is to say, when they can be introduced through the stric- t re, so as to cure it on the principle oi dilatation. Whether, in certain cases, where no pro- gress can be made with common bougies, it is better to try caustic, or attempt to force (he obstruction with a sound, is a question on which there is a great deal of difference of opinion. " The practice of pressing firm bougies, or metallic instruments, so as to force the stricture, or lo produce an ulcera- tion of it, (says a modern writer,) so fre- quently has been found to form false pass- ages, fistula?, and gangrene, that I need here make no further observation on the practice, or its consequences. All the advantages that can be gained by pressure, tearing through the stricture, or producing ulceration of it, may be obtained by a careful and judicious U6e of the caustic, which will be found on the whole a safer application, and will be at- tended with less inflammation and pain." (Wilson on the Male Urinary and Genital Or- gans, p.383.) Thi3 gentleman is not, how- ever, an advocate for tbe caustic in every case. "• I consider it," says be, " Ihe safest practice in cases which w ill not yield to the introduction of bougies, and which require a portion of the stricture to be destroyed ; but the symptoms which sometimes attend its use, and the injury which may be done by its improper application, should confine it lo those cases." (p. 385.) I shall conclude this part of the subject of strictures, with inserting some of the general directions given by Sir E. Home how to arm the bougie, and apply the lunar coustic to cf-.r-enrec &40 LKE1HKA. In arming a bougie, it will be difficult to get a piece of caustic of a proper shape and size for the purpose, unless it be cast in a small cylindrical mould. "If these pieces are thicker than the bougie can readily en- close, by putting them in water the outside quickly dissolves, so as to diminish their size as much as is required. The piece of caus- tic, so prepared, is to be cut into small por- tions, about a quarter of an inch in length, and an orifice being made in the end of a bougie, the caustic is to be inserted into it, and the bougie rolled so as to be made per- fectly smooth, taking care that the sides of (he caustic are every where covered, and only the end exposed. " This was the mode (says Sir Everard) in which I armed bougies, when I first took up this practice; but it happened, tbat, in two or three instances, the caustic was left in the urethra; that canal, when in a very irritable state, grasped tbe bougie, and pulled Ihe caustic out; I was therefore led to consider how such an accident might be prevented, and applied to the makers of bougies for that purpose. Mr. Pass, the late beadle of the Surgeon's Company, who dealt in bougies, discovered a very ingenious and effectual mode of securing the caustic. In forming the bougie, a piece of wire, the size of the caustic, is rolled up along with it, passing into tbe substance for half an inch ; when the bougie is nearly finished, the wire is withdrawn, and the caustic inserted in its place *, after this, tbe bougie is rolled again, so that the sides of the caustic become firmly cemented to die linen, by means of the com- position of tbe bougie, and when cold, can- not be separated by any force. In this way bougies are now generally armed. " After the bougie lias been thus prepared, the distance of the stricture from the exter- nal orifice is lo be measured, and the canal eleared by passing a common bougie fully as large as that which is armed. The armed bougie, wi;h the distance marked upon it, is then to be introduced, and applied to the stricture; when it is brought in contact with the obstruction, it is to be steadily retained there; witb a moderate degree of pressure at first, and less as it is longer continued, since the bougie becomes soft by remaining iu the urethra, and readily bends-if the pressure is too great. The time it is to remain depends a good deal upon the sensations of the pa- tient, and (he length of time the parts have been diseased ; but on the first trial it should be less thin a minute, as it then commonly gives greater pain than on any subsequent application. The pain produced by the caustic is not felt so immediately as it would be natural to expect; the first sensation arises from the pressure of the bougie on the stric- ture ; a little afterward, there is tbe feeling of heat in the parts; and lastly, that of pain. " As soon as the caustic begins to act, the i.irgeon who makes the application is made sensible of it by the smaller arteries of the parts beating wilh unusual violence, which is very distinctly felt bv Ihe finger and 'hinfo lhat grasp the penis " The pain that is brought on by Ihe eme- tic lasts for some lime after it is withdrawn , but Ibis period differs in almost every patient, being sometimes extended to half an hour, and sometimes only a few minutes. •■' The kind of pain is. heat and sorenesg, which is not severe, not being accompanied with Ihe peculiar irritation, upon so many oc- casions experienced by patients who bam strictures; an irritation that cannot be de- scribed, which is most insupportable, and is too often brought on by dilating strictures with the bougie." In the vol from which the above directions are taken, Sir Everard Home recommends the patient to make wa- ter, as soon as the armed bougie is with- drawn ; but in a subsequent vol. he explains his chnnge.of opinion upon this point: " | nol only have no wish that the patient should make water immediately after the anplica- tion, but would rather that it be retained some time." (On Strictures, vol. 3, p. bl. Bvo. Lond. 1821.) " It happens not unfrequently," says Sir Everard Home, " that at the first time of making water, some blood passes along wilh it. This is rather favourable ; as, when the parts bleed, the stricture usually proves to be so far destroyed, that at tbe next trial the bougie passes through it. Every other day appears, in general, to be as often a-i it is prudent to apply the caustic. 1 have, how- ever, done it every day in very obstinate cases, where the parts are less sensible, with- out any detriment." In his third volume, lately published, be states, that he now rarely passes the bougie oftener than every third day, and never when the pain from the last application has not entirely gone off. He also never con- tinues any one application beyond Ihe time when the pain begins to exlend further than tho spot to which the armed bougie is ap- plied. (Vol. 3,p. 51.) The bougie which is passed down to pre- pare the way for Ihe caustic, and measure the distance for the armed bougie, must be made of soft materials, that it may readily receive an impression from the part against which it is pressed, and it; colour should be light, so as.to admit of those impressions being more distinctly seen. Wilh ibe assis- tance of such bougies, I am able to discover the size and shape of the orifice of Ihe stric- ture ; lo ascertain wilh accuracy the progress of the caustic upon it; to see whether it is on one side of the canal, or equally ail round ; and to apply the caustic accordingly. " When the soft bougie pastes through the stricture, by leaving it in the canal a few minutes, it can be known whether the stric- ture is completely destroyed or only relaxed; in the last case, there is an impression on the side of the bougie." (Home on Strictures, vol. 1.) V CURE OF STKICTCHES WITH THE I'OTASsJ KLSA. .\ir. Whately, in his publication on stric- '•ues, endeavum-e io coavince -the r-'Atct l/AEYHRA. 641 that they are not merely contracted fibres of the urethra, but really diseased portions of the membrane lining that canal, with a con- tinued disposition lo increased contraction. Hence this gentleman seems to conceive, that the application of a remedy, calcula ed both to remove the diseased affection, and to dilate the contracted part, might perfectly cure the complaint, without putting the pa- tient to the inconvenience of ■*.earing a bou gie. Mr. Whately affirms, that such a reme- dy is caustic, when judiciously used. Hither- to the lunar caustic has been chiefly employ- ed ; but this gentleman states, that it has been his good fortune to discover a more effi- cacious, and at the same lini'- a less painful and hazardous remedy for the disease in ques- tion. The potassa fusn is Ihc application al- luded to, which Mr. Whately says, if used in the manner and with (he precautions about to he described, will be fouud to pos- sess singular efficacy in curing the complaint. He avows, that be bas already had so much experience of it, and tbat be is so perfectly convinced of its superiority over the lunar caustic, as well os over the common bougie, that he now uses it in a considerable number ofthe cases which come under his care. Of its safety he is also as well convinced as of its efficacy ; for if used with circumspection, experience proves that there is little danger of its producing any disagreeable effect. However, if the potassa fusa be applied while the parts are iu a highly inflamed, or irrituble state, or (as Mr. Whately expresses himself) tending to gangrene ; if the habit be bad, and the patient very far advanced in years, ihe most mischievous effects may be expected from the application ; and Ihe use ol any kind ot caustic, under sucb circum- stances, for strictures in tbe urethra, is cen- sured as dangerous in the extreme. Mr. Whately represents, lhat if the patient be affected with fever, or any other acule disease ; if he be much indisposed from any cause ; if, in particular, he have a gonorrhoea, attended with much inflammation aud irrita- tion in the urethra; if the prepuce, glans, or any olher part of the penis, or tbe parts ad- jftining to it, be swelled and inflamed ; if the urethra, and especially the structured part of it, be so irritable as not to bear the touch of a bougie; the use of Ihe caustic is for the present forbidden. Mr. Whalely also en- joins great caution in applying this remedy to persons advanced iti years. Even when no objections of the above kind exist, the caustic should not be resorted to in the first instance. Mr. Whately maintains, lhat in every case of stricture, before venturing to employ the caustic, we ought to be able to pass into the bladder a bougie of at least a size larger than one of the finest sort. This is necessary, both to let the caustic.be applied to Ihe whole surface of the stricture, and to relieve a retention of urine, should it oc- cur during the use of the caustic. When a bougie of the preceding descrip- tion can be introduced, without occasioning pain, faintness, or great dejection of spirits, the ti-e of caustic im: commence- immedi- ately, provided none of tiie above-described objections exist. When the urethra is very irritable, Mr. Whately recommends a common bougie to be introduced every day, and kept in the urethra ; at first, for a few minutes only ; bat by decrees for a longer lime; tilt the irritability of the parts has been sufficiently lessened. | When the urethra is rendered so impervi- ous by a stricture, that a small bougie cannot be passe I into ihe bladder, which viscus is also in a painful inflamed slate, Mr Whately asserts, that caustic, iu any form or quantity, must not be immediately employed; but that the stricture should bp first rendered ca- pable of allowing a bougie a little larger than one of the finest size, (o be-introduced into the bladder. When this is done, the urine is more freely evacuated, and the consequent irritation and inflammation of the bladder lessened, if not removed, together wiih the danger of -e retention of urine. Caustic may (hen be advantageously conveyed into the centre of the stricture. Mr. Whately considers the practice of at once thrusting down, in Ibis sort of case, an armed bougie considerably larger than the narrowest part of the contracted canal, as most dangerous, and horridly painful. For, says this gentleman,, it frequently happens, that nearly the whole of the urethra anterior lo the bulb is so much contracted by nume- rous and uncommonly rigid strictures, that it is impossible, by any act whatever, to di- late the passage to ils natural size. If, (here- fore, the canti!, whilst iu sucb a slate, be rudely torn open by a large caustic bougie, hemorrhage, pain, dangerous suppressions of urine, inflammation, mortification, and death itself, must sometimes inevitably ensue,— even before the caustic can be applied to the principal seat of the disease. In cases like the one just mentioned, the first step prepa ratory to the use of the caustic should be, ac- cording to Mr. Whately, to dilate the strictu- red part of the urethra; for which purpose, he advises the slow and gentle introduction of a fine bougie, with its point inclined to the lower side of the canal, in order to avoid Ibe large lacuna* situated on its upper part When the surgeon, by steady perseverance aud dexterity, has succeeded in gelling a fine bougie through the worst stricture into the bladder, tbe instrument should be worn for u few hours every day, tiil the passage is suffi- ciently dilated to admit a larger one. Mr. Whately, after explaining that caustic potassa ought not to be applied to strictures of the urethra till a bougie of a proper size can be passed into the bladder, pointing out the methods to be taken before applying this caustic, and enumerating certain cases and circumstances in which its employment is interdicted, next proceeds to describe the mode of practice, which it is the particular object of his book to recommend. For the purpose of arming a bougie, Mr. Whately advises us to put a small quantifv of caustic potassa upon a piece of stron°- **?per, t«nd to break the bit of caustic y-it* vL* LTREYHrtA a hammer into small pieces of about the size of large and small pins' heads. In doing this, care should be taken not to reduce it to powder. Thus broken, it should be kept for use in a phial, closed with a ground stopper. The bougie should have a proper degree of curvature given to it, by drawing it several times between the finger and thumb ofthe left h^nd. Mr. Whately next acquaints us, lhat be- fore the caustic is inserted into the bougie, it is necessary to ascertain the exact dis- tance of the stricture (to which the caustic is to be applied,) from the extremity of the penis. For this purpose, the bougie, which should be just large enough to enter the strictbre with some degree of tightness, ought to be gently introduced into the urethra; and when its point stops at the stricture, which it almost always does be- fore it will enter it, a notch is to be made with the finger-nail on the upper or curved portion of the bougie, on the outside of tbe urethra, exactly half an inch from the ex- tremity of the penis. When the bougie is withdrawn, a small hole, about the sixteenth part of an inch deep, should be made at the extremity of its rounded end. A large blanket-pin, two inches and a half in length, with the head struck off, will answer the purpose; the hole being made with the point of the pin. The extremity of the bougie should then be made perfectly smooth with the finger and thumb, taking care that, in doing this, the hole in its centre be not closed. Some of the broken caustic should then be put on a piece of writing paper, and a piece less in size than the smallest pin's head should be selected ; the particle, indeed, says Mr. Whately, can- not be too small for the first application. Let this be inserted into the hole of the bougie with a pocket-knife, spatula, or some such instrument; and pushed into it with the blunt end ofthe pin, so as to make the caustic sink a very little below the margin of the hole. To prevent the potassa fosa from coming out, the hole should then be contracted a little with the finger, and the remaining vacancy in it is to be filled with hog's lard. This last substance (continues Mr. Whately) will prevent the caustic from acting on the sound part of the urethra, as the bougie passes to the stricture. When the bougie is quite prepared, let it be first oiled, and immediately afterward intro- duced, by a very gentle motion, with the curvature upwards as far as the anterior part of the stricture upon which the caustic is to be applied. In doing this, the end of the bougie, held by the finger and thumb, should be a good deal inclined towards the abdomen, on the first introduction of the instrument, in order to prevent its curva- ture. After il has passed about five inches, this end should be gradually brought down- wards, as the bougie passes on, till it forms a right angle with the body. The bougie is know n to have arrived at the stricture by the resistance made to its progress. anterior part of-the stricture, if should fesf. there for a few seconds, that the caustic may begin to dissolve. It should then be pushed very gently forward about one- eighth of an inch ; after which, there should be another pause for a second or two. The bougie should then be carried forward iu the same gentle manner till it has got through the stricture. Tho sense of feeling will generally inform the operator when the point of the bougie has proceeded so far; but the notch in the bougie is to be an ad- ditional guide:, by becoming very near the orifice of the urethra when the end of tne instrument has just got through the stricture. The bougie should now be immediately withdrawn by a very gentle motion to the part at which it was first made to rpst awhile. Then it should be very slowly passed through the stricture a second time; but without letting the bougie stop in its passage. If the patient complain of pain, or be faint, the bougie should be immedi- ately withdrawn; but, if these effects are not produced, we may repeat the operation of passing and withdrawing the bougie through the stricture once or twice more before we finish the operation, which will take up, in the whole, about two minutes. The first application of the potassa fusa, in this manner, gives, according to Mr Whately's account, a very little pain. A slight scalding in making water, and a tri- fling discharge during the first day or two, however, are commonly produced. At the end of seven days the application of the caustic is to be repeated in the same manner. When the first application bas enlarged the aperture of the stricture, which may be known by passing a bougie through it of tbe same size as that by which the caustic was conveyed, the bougie used in the second operation should be a size larger than the one used iii the first; but it must not be too large to pass1 through the stric- ture. If the patient had no pain on the first application, the bit of potassa fusa may also be trivially larger. At the end of seven days more, the armed bougie should be in- troduced a third time. At this, and all future applications, the bougie should be increased in size in proportion as the aperture in the stricture becomes dilated. The quantity of caustic, however, is never to be increased in a ratio to the size of the bougie. In no case3 whatever does Mr. Whately apply more of the potassa fusa at a time than a piece about the size of a common pin's head. Twelve bits of the largest size, which this gentleman ever uses, weigh one grain. When there arc several strictures, the potassa fusa should be generally applied to only one at a time. An interval of seven days is what Mr Whately generally allows to elapse between the applications of the caustic. The rule, however, may now and then be deviated from ; but the potassa fusa ought never to be reapplied till the action of the last ap- plication ha? completely ceased. f'i a fpn LIU'THRA instances, the interval may only be five days ; in some others, it may be eight, nine, or even a longer space. In the above method of using the potassa fusa, Mr Whately represents that this sub- Ln (he ureters or bladder, UKLVAKY ABSCESSED Ao tue patient nas suddenly experienced great relief, without any ofthe urine having been discharged the natural way; when he has at the same instant felt a kind of pricking in the loins, or pelvis; when to tbe ease, which lasted only a few hours, symptoms, more severe than the former ones, have succeed- ed, such as violent fever, hiccough, vomit- ing, be. an internal extravasation is to be suspected. As soon as the extravasation is apparent oxternally,tthe case is announced by symp- toms which hardly ever deceive. The pre- ceding retention of urine ; the sudden ap- pearance of the swelling caused by this fluid ; the rapid progress of the tumour ; the kind of crepitation perceptible in it, like ♦hat which occurs in emphysema; the shi- ning tension and ccdema of the skin ; the diminution of such symptoms as depended entirely upon the retention ; are the first changes which are observable, when the ex- travasation is somewhat considerable. If the patient is not speedily assisted, and the urine continues to be extravasated, the tumour spreads more and more ; the skin assumes a red violet colour; gangrenous eschars are formed, the separation of which gives issue to a very fetid sanies, in which the smell of urine is readily distinguishable. Portions of dead cellular membrane are pre- sently discharged together with the sanies ; the ulcer grows larger; and the dressings are continually wet with the urine. When one of the ureters has given way, and an urinary abscess is formed in the loins, the aid to be derived from surgery is limited to making an opening in the extra- vasation, as soon as it can be felt external- ly. It is then not in the power of art to re- establish tbe natural course of the urine, or to binder this fluid from passing through the wound, and rendering it fistulous. How- ever, there are some circumstances in which a radical cure may be attempted. For ex- ample, if the abscess were produced by a calculus lodged in the infundibulum, or ure- 'er, and it could be felt and taken hold of with a pair of forceps, introduced into the opening, the extraction of the foreign body might promote the healing ofthe ulcer, by rendering the natural channel for the urine free. When the opening, by which the urine has become extravasated, exists in the blad- der or urethra, one indication that does not present itself in the foregoing case, may be fulfilled, viz. the urine may be drawn off by means of a catheter passed into ihe blad- der, and kept there. By this means, we not only immediately stop the progress of the extravasation, but attack the very cause of the malady, by removing the obstacles which oppose the natural course of the urine. The introduction of the catheter then becomes a matter of the most urgent necessity. This operation is often attended with the greatest difficulties. Beside3 the ordinary obstruction of the canal, we have also to surmount the obstacles which tbe urinary swellings situated in the course of "<*L II 159 the urethra, create to ihe passage of the in strument. When these tumours are consi- derable, they ought to be opened before the catheter is employed. The subsidence of the swellings would render catheterism more easy. Besides, Desault was assured by daily experience, that with a little skill, exercise, and patience, the catheter might always be got into the bladder. If, how- ever, the thing could not be done, ought we to puncture the bladder, or have recourse to the operation termed by the French bou- tonniere ? Desault was an advocate for neither of these proceedings: he thought it was a more simple and beneficial practice merely to make an external opening in the collection of effused urine. This measure would both afford an outlet for the urine, and arrest the extension ofthe extravasation. Besides, such an opening is often indispensably re- quisite for the purpose of putting a stop to the symptoms depending upon the effusion and stagnation ofthe urine. But if the ca- theter can be introduced, there may be cases in which an opening would not only be use- less, but hurtful; for instance, when the swelling caused by the urine is of little ex- tent, or when it is situated in the thickues3 of the parietes of the passage, or along ils track, it almost always admits of dispersion by the simple employment of the catheter. But it seldom happens, that this swelling, however small, ends in resolution ; it all- most always suppurates; yet, as it breaks into the urethra, the matter escapes between this canal and the catheter, and renders the making of an external opening needless. Experience teaches us, also, that when the tumour is situated in the scrotum, or be- tween the root of the penis and the 6ymphy] sis pubis, even after the healing of tbe inci- sions made in these situations, a fistula will often remain, which is very difficult of cure. With the exception of these particular cases, Desault vvas an advocate for opening all urinary abscesses. The manner of opening such collections varies according as the urine may be in one cavity, or widely effused in the cellular membrane. In the first case, a simple inci- sion, the whole length of the cavity, will suffice for emptying and healing it. In the second, if the extravasation is extensive, the incisions must be multiplied. It would be absurd to spare the parts; for all those, with which.the urine has come into con- tact, seldom escape mortification. The in- cisions which, are made, hardly ever have the effect of saving them ; but by accelera- ting the discharge of putrid sanies and stag- nant urine, they prevent mischief, which would originate from a further lodgment. At all events, when the operation is at all delayed, the destruction of all the parts in contact with this irritating fluid, is inevita- ble. The approach of mortification i? indi- cated by the crepitation under the bistoury, resembling the kind of noise produced by tearing parchment. The extent and depth of the incisions must be proportioned to J-fo LRLNAKi CALCULI those of the ab.-cc»j. When the extravasa- tion occupies the scrotum, long deep scarifi- cations should be made in that part, as well as in the skin of the penis, and iu every place where the urine is effused. Practitioners, unaccustomed to see such diseases, would be alarmed at the extent of Ihe sore produced by the separation of the eschars. Sometimes the whole scrotum, skin of the penis, and that of the groins, perihamm, and upper part of the thigh, mor- tify, and the naked testicles hang by the sper- matic chords, in the midst of this enormous ulcer. It is hardly conceivable how cica- trization could take place over the exposed testicles; but the resources of nature are unlimited. She unites the testicles and the chords to the subjacent parts, and drawing the skin from the circumference to the centre of the ulcer, she covers these organs again, and furnishes them with a sort of new scrotum. This statement is founded upon numerous cases, in which nature al- ways followed this course. The cicatriza- tion of the ulcer is even more expeditions than might be apprehended, considering its extent. In all this business, what does art do? If the introduction of the catheter is excepted, which indeed is absolutely neces- sary for the radical cure, her assistance is very limited, and almost nothing, in the ge- nerality of instances; for, when patients are no^/texhausted by the tediousness of the disorder, when they are of a good constitu- tion, and in the prime of life, they get well as quickly and certainly with the aid of a good diet and simple dressings, as when they take internal medicines, and use a multiplicity of compound topical applica- tions. The practice of Desault at the H6lel- Dieu, consisted in applying emollient poul- tices, until tbe sloughs were detached. The ulcer was then sometimes dressed with pledgets charged with styrax ; but frequent- ly mere dry lint was used, and continued till the cure was completed. If any com- plication occurred iu the course of the treatment, suitable remedies were prescri- bed for it. Thus, when prostration of strength and tendency to sloughing existed, bark, cordials, and antiseptics were ordered. But in every case, the catheter is tbe essential means of cure ; without it, the treatment is almost always imperfect, and the ulcer will not heal without leaving several urinary fistulae. (See (Euvres Chir. de Desault, par Bicluxl, T. 3, p. 277—267.) URINARY CALCULI. A true explana- tion of the nature of urinary calculi was quite impossible, before chymislry had made considerable progress, and the methods of analysis had advanced a great way towards perfection ; nnd as will ap|K*ar in tin- course of this article, all the valuable knowledge which now exists upon this subject, is in reality the fruit of modern investigations. It is to be regretted, however, (hat our in- formation on many points is far from being st'ttJed, or complete, as any impartial and judicious reader may soon convince himself t>y a reference \0 (he ao|ft .^ 'lnlts. and middle-aged persons, c, uucomnioii unless some extraneous substance happen to enter the bladder and form the nucleus. may furnish a reason for the infrequency ot the disease among soldiers, applicable per haps to such individuals in every country, And th-'tlhe children of soldiers, like thdse of other persons, are not exempt from tin disease, I know very well, having had oc casion myself to operate upon a patient ol Ibis kind during my service with the nrrov The preceding consideration also of IhV general age of sailors iu the royal navy, and ofthe little chance there must be of a boy with sione being sent to sea, or of any sailor being admitted on board of a King's ship with that disorder, unless it be wilfully con cealed by the man himself, furnish to my mind a better explanation of the cause ol so few cases of stone having been met with among seafaring persons, than any of the references to the habits or mode of life of a sailor, made by Mr. C. Hutchison in bis in genious paper. (See Med. Chir. Trans. Vol 9, p. 44:1, fyc.) From this gentleman's ac- count it seems, that out of 86,00 patients, admitted into the Naval Hospital at llaslar, Plymouth, and Deal, in the space of sixteen years, there has only been eight calculous cases, or one in 10,750 patients. Tun of these cases were boys, about fo urt ten years oj age, " who had laboured under symptoms of slone for some years previously to their admis- sion into the service, and into which they had recently entered, expressly for the purpoitof deriving benefit from our magnificent institu- tions; o,;'3 was a marine who had been at sea a few months only ; three were adult seamen, and the seventh a marine ; but their length of service afloat could not be at all as- certained .- the eighth, and last case, was a warrant officer, advanced in years, who had been serving in ordinary, that is, in a ship in harbour for a considerable time previ- ously to the operation." Subsequently lo the period, embraced by the returns col- lected by Mr. C Hutchison, a boy has also been operated upon in Haslar Hospital (Vol. cit. p. 449.) Mr. R. Smith, of Bristol.. has published an interesting statistical in quiry into the frequency of stone in tbe bladder in Great Britain and Ireland, though strictly it is a comparative estimate of tne number of operations for stone in different parts of the kingdom in given spaces ol time, and not of the number of calculous patients. (See Med. Chir. Trans. Vol. 11.) As far as I can judge from the facts sta- led in Mr. Smith's paper, and from what I know about the average number of ope- rations for stone in London, not more than 180 can be fairly reckoned as the an- nual total in Great Britain and Ireland. which is about 1 for each 100,000 of the population, taken at 18 millions. Now, if this fact be recollected, in computing the rarity of stone operations in the navy, and the other circumstances of there being few children and old men in that service, and of every man being examined by a surgeon. rc to the jtafe of his health, before ''"■■ ': pn ORIiNAKY CALCl U #bi tered, I think the reason ot the infrequency of stone in tbe navy will be tolerably clear. However, as sailors live partly in very hot and partly in very cold climates, even if they were of the ages most subject to cal- culi they may perhaps be rather less dis- posed to the complaint, than individuals of the same periods of life, constantly resident iu England In the cold country of Swe- den, urinary calculi are said to be infre- quent. (Richerand, Nosogr. Chir T: 3, p. 528, Ed. 4.;) and, as surgery is there highly cultivated, the uncontradicted statement weighs considerably in favour of the truth of the general belief in the rarity of this disorder iu very cold countries. But, as I have already said, the number of inhabit- ants, to which any particular evidence on this point relates, is an essential inquiry, before a safe inference can be drawn. It is perfectly well ascertained, that the greater number of urinary calculi are com- posed chiefly of lithic, or uric acid, which is naturally contained either in a free or com- bined state in the urine of man, and all other animals, which consume^ great deal of food abounding in azote, as flesh of every kind, fish, shellfish, eggs, be. Whenever the urine will redden the tincture ot turnsol, Magendie infers with the generality of chy- misls, that it contains lithic acid, the pro- portion of which, he says, varies according to the quantity of substances abounding in azote, taken as food. And Magendie further observes, that when animals live altogether ou flesh, their urine is full of uric acid, and even may be entirely composed of it, as is proved with respect to birds, by the experi- ments both of Dr. Wollaston ano Vauquelin. Here Magendie cannot mean free uric acid, but this acid in a state of combination ; for, as Dr. Prout has observed, there is no in- stance known, in which lithic, or uric acid is secreted in a pure state ; birds, serpents, be. always secrete it in combination with ammonia; iq the gouty chalk-stone, it is secreted in combination with soda. (On the Nature, fyc. oj Gravel and Calculus, p. 13.) On the contrary, if animals live on vegeta- bles, as is the case with the herbivorous class, Magendie states that there is no ap- pearance of lithic acid in their urine. In a series of experiments, communicated by Magendie to the Academy of Sciences in 1816, this distinguished physiologist exem- plified, that if a carnivorous animal be de- prived of all nutriment, containing azote, and be fed with sugar, gum, oil, and olher substances considered to be nutritious, and having no azote in their composition, the urine, in three or four weeks, will contain no lithic acid. (See Mini, sur les PropriiUs nutritives des Substance, qui ne contiennevt pas d'asolc Paris, IS 17.) A dog, allowed only sugar, and distilled water, soon began lo grow lean, and died apparently starved on the 32d day from the commencement of his diet. The inference which Magendie Iraws from his experiments, and from some cases which he has detailed, is, that the quantify of uric acid in ll"* t'rinc, aud of course, the tendency to gravel and calculous disorders, depend very much upon the kind of food. Howe\er, he takes n.lo consider- ation the relative proportion ofthe uric acid to the urine itself, because if this be also abundant, Ihe liability to calculi is counter- acted. It would appear also from his obser- vations, that the urine not only becomes impregnated with a great proportion of uric acid in animals, which eat a large quantity of flesh, but is also scanty ; and that, on the other hand, a vegetable diet always pro- motes the secretion of a large quantity of fluid from the kindneys, as well as checks the formation ofthe acid in question. Ma- gendie is also disposed to believe, that the rarity of calculi in hot climates may be partly traced to the kind of food employed. In fact, it is well known, that, in a consider- able pan of Asia, many millions of the inha- bitants never eat flesh. But, though this circumstance must be allowed to have full wei.tit, with respect to the sects whiph re- ligiously decline animal food, the influence ot climate cannot be rejected, because cal- culi are rare in all hot countries, whether^ ', meat be freely eaten or not. At the same time, the tenor of this gentleman's reason- ing tnay be true, that, setting out of the question the influence of climate, a vege- table diet tends to prevent the formation of lithic acid calculi, while eating large quan- tities of such food as contains a greal deal of azote, has the opposite effect. However, Magendie himself is not so par- tial to his theory, as not to confess that it is liable to objections; for, says he, individu- als are met wilh every day, who from their age, manner of living, and habits, appear to be subjected to every condition, calculated to produce the gravel, and yet they remain free from it. Hence he infers, that there must be some unknown causes which some- times keep the uric acid dissolved, even where ils quantity in the urine is copious. On the other hand, he admits that certain persons are met with, whose rtgimen and mode of life ought to exempt them from gravel, aud still they are afflicted. In proof of this fact, he adverts to the poor inhabit- ants of a district in Sussex, mentioned by Dr. Scudamore, (On Ihe Nature and Cure of Gout, fyc. 8vo. Lond. 18lV,) who live almost entirely on vegetable malter and hard beer, and many of whom are much troubled with gravel. Magendie might also have recol- .lected, tbat some birds which live entirely on vegetable matter, as several singing birds kept in cages,-void a good deal of the lithate of ammonia. Magendie refers to examples of gravel being always produced in certain individuals after any unusual exertion, and in other apparently healthy subjects, after any difficulty of digestion, flatulence, the eating of salad, raw fruit, be. With regard to the dyspepsia, frequently attendant on calculous disorders, and other chronic dis- eases, Magendie sets down the complaints of the stomach and of the urinary organs, as probably only iw o effects of the same cause. and not nmfually productive- of cn.ch othe- w.0^ ' KLNAK1 'Sec Rcciierates, \hich Dr. Prout has observed to produce a lithic acid diathesis in per- sons, subject to slight dyspepsia, but in other respects healthy, are, 1, Simple errors in diet. 2, Unusual, or unnatural exercise. either bodily or mental, particularly after eating, and the want of proper exercise at all other times. 3, Debilitating circumstan- ces. (On Gravel, Calculus, fyc p. 113.) An unusually heavy meal, especially of animal food, or bread, he says, is invariably follow- ed by a deposition of the lithate of ammo nia from the urine. Heavy, unfermented bread, and compact, hard boiled, fat dump- lings, or puddings, he finds particularly apt to produce such an effect Crystallised sediments, or gravel, consist- ing of nearly pure lithic acid, Dr. Prout as- cribes to a free acid being sometimes gene- rated in the kidneys, and combining with the ammonia, witii which the lithic acid is previously united, so as to precipitate the . latter in a pure crystallized state. Accord- ing to the investigations ot Dr. Prout, the precipitating acid is not constantly tbe same, though genera'Iy the phosphoric, and sometimes the sulphuric. (P. 1^7, 12S.) The same intelligent writer represents the circumstances, which promote the formation of urinary sediments in general, as being either natural, or acquired. " With respect ta those of the first description, (says he) it cannot I think be doubted, that certain individuals are much more liable to these sediments than others. This tendency is not fotreriuently inherited: tin's ! l.nc"*v a CALCULI. family, where the giandfatnc-i and father have actually lithic calculi in the bladder; and where the grandson, a youth of twelve, or thirteen years of age, has a very strong tendency to the same disease , his urine de- positing frequently very large quantities of lithic acid, both in the form of amorpboos and crystalline sediments. On the olher hand, the disposition to generate these sedi- ments in excess is, like gout, or rather si multaneously with gout, but loo frequently acquired by indolent habits, and excess in eating and drinking. Most frequently, how- ever, the tendency to these diseases is con- nected with some unknown causes, peculiar to certain districts or countries," as, for ex- ample, the district, of which Norwich may be considered as the centre ; in which morn calculous cases occur than in tbe whole of Ireland or Scotland. In such instances Ihe water, diet, temperature, be. of the district has been each accused, in its turn, of being the exciting cause ; bnt, (says Dr. Prout) the circumstance, I believe, still remains unexplained. I have in one or two instan- ces seen a fit of lithic gravel iuduced in fhe predispose©; by sitting on a damp cold seat for some hours. Sometimes also a tenden- cy to lithic calculus is evidently connected with local injury, or disease ofthe kidney." (P. 133.) The difficulty of tracing the causes of the formation of calculi is rather increased, than facilitated, by the fact, that, except when tbe urinary organs are much diseased, the pa- tient may appear to be in perfect health, Indeed, persons of the strongest constitu- tions are often troubled with the stone, quite independently of the entrance of any foreign body, as a nucleus, into the bladder; and it is now universally admitted, that litbii acid itself constitutes by far the most com mon nucleus, even when other calculous matter is deposited round it. (See Prout on Gravel, p. 95.) It is sometimes conjectured that the female is less liable than the male sex, to calculi; but whether tiTis is tbe fact, or whether the circumstance can be satis- factorily explained on another principle, viz. the facility with which any calculi of moderate size are generally discharged through the short and capacious meatus urinarius, are questions perhaps not yet com- pletely settled Infants and children to the age of twelve, or fourteen, are very liable to stone. How- ever, it is asserted by Delpech, that at this period of life, relapses are infrequent; that is to say, an entirely fresh stone is hardly ever formed again ; and, if a return of the complaint happens, the quickness of its re- curronce, and an attentive examination of the calculus, will mostly prove, either that the second stone has formed round a frag- ment of the first left behind, or that it ex- isted when the former one w us taken out, but was not discovered. I am not inclined myself to put much faith in this statement, because it is hardly credible, that the calcu- lous diathesis of childhood can be at all diminished by tbe circumstance of there * LRI.\AftY CALCULI. iiu»t? having already been one calculus, ami of the patient having had the bladder opeued for its removal. Dr. Marcet thinks, that the disorder is frequent only among the children of the poor classes; and that in those of the high- er ranks, or even of the lowest classes, pro- vided they are well fed, the same frequency is not observed. " In the Foundling Hos- pital, for instance, within the last 27 years, during wliich 1151 children have beeu ad- mitted, only 3 cases of stone have occurred, all of which were among children while at nurse in the country. And, in the Military Asylum at Chelsea, which contains about 1250 children, and into which upwards of 6000 of them have been already admitted, no more than one single case of stone has occurred." (See Marcel's Essay on Calcu- lous Disorders, p. 36.) However, supposing that the foregoing statement refers to ope- rations for stone, and that the average number of operations for the population of Great Britain and Ireland, is annually about 1 for each 100,000 inhabitants, the inference drawn by Dr. Marcet, which also does not agree with later statistical reports, cannot be received, because in the total number of children, specified as having been admitted into the above charities, even wheu every allowance is made for the time comprised in the calculation, the proportion of opera- tions is far beyond the average, wilh refer- ence to the population in general. And, that stone cases are more numerous in the children of the poor, than in those of the higher classes, is a fact, which perhaps may be explained by the recollection, that the mass of the population consists of the poor and laborious classes. In the period of life, between the age of twelve, or fourteen, and that of forty, the liability to stone in the bladder, is much less than in infancy, childhood, or old age. And no doubt, many of the cases, which do present themselves in adults, or middle aged individuals, either began at an earlier period of life, or are owing to some extraneous nucleus. According to Delpech, in old men, who are particularly subject to calculi, the dispo- sition to the return of the disease always continues during life; and hence in them, relapses are frequent. (Pricis des Mai. Chir. T. 2, p. 193, fyc.) The following table, collected by Dr. Prout, exhibits the proportion of stone cases before and after puberty, and of their occur- rence in the different sexes: M5* a a *•** ™- U3 — « *>- o o CI (N o !s & -a o <£> ri r- o» o o> -J "o 00 t- •o t- l> m a "■■** CO 5 ** ±< Thus, nearly one half of the whole number of stone cases occur before the completion of the 14lh ifear ; and it appears also from Mr. Smith's valuable reports, that there is an evident increase in the number of cases, about the age of 40 years. (See Prout on Gravel, fyc. p. 210; and R. Smith, in Med. Chir. Trans. Vol. 10.) Dr. Marcet has estimated the comparative frequency of the disease in various coun- tries, and in the different stations of life, and tried to ascertain, whether its frequency be influenced by varieties of climate, or situation, or by peculiarities in our habits and occupations. He instituted inquiries at all the great hospitals of the metropolis, in the hope of getting at some useful records concerning the vast number of patients, on whom lithotomy had been performed in those establishments. In London, he found it impossible to obtain all the particulars of such cases, as no entry of them had been preserved. The Norwich hospital, however, afforded him some details, which are inter- esting. All the calculi, which have been exracted in that hospital for 44 years, viz, from 1772, to 1816, and which amount to 506, have been carefully preserved, with the circumstances annexed to each stone, and the event of the operation distinctly recorded. Dr. Marcet has given the results of these records in the following table : ■>oi,. Ii *,'>j oot LRi.\AR\ CALCULI. CB X 11 - ! o •a fL^ , H On r» 5 "5 »o >0 ?, ] < ■**■ •" ' £ -3 e» -» CO i u / _; X » •o 1^ CM © ..-. 0 ■ —. -3 *- f- CO eft in fc — a CI ci 3 55 U 5 il it a|ipears, says Dr. Marcet, from the above table, that the mean annual number of cases of lithotomy in the .Norwich Hos- pital, during tbe last 44 years, has been 11 1-2, or 23 in every two years ; and that the total number of fatal cases, iu the 506 operations is 70, or 1 in 7 1-4, or 4 in 29. The proportion of females, who have under- gone the operation, is to lhat of males, as 58 to 1000, or about 1 to 17; that the mor- tality from the operation in children was only about 1 in 18; while, in adults, it was 4 in 19, or nearly quadruple. According to Mr. Smith, the mortality from lithotomy at the Bristol Infirmary, has been in the following proportions: Between Age. F :" age and under, 10 and 20 ---- 20 --- 30 ---- 30 ---- 40 ---- Late of Mor-tality, 1 iu 4 1-2 I — b 1—7 1 — 5 40 ---- 50 --- 50 ---- 60 --- 60---- 7o --- 70 ---- SO---- 1—3 1-8 1—4 2-3 1 — 2 1-2 , 1—2 Mean at all Ages 1 in 4 1-4 The following table is also from Mr. Smith's paper, and refers to the Leeds Hos- pital. (See Med. Chir. Trans. Vol. 10.) From Cases- of lithotomy. died 1767 to 1777 24 of which '2 or 1 in 12 1777 ITS- 62 8 1 73-4 ITS? 1797 23 3 1 7 2-3 1797 1807 42 7 1 6 1807 1817 IU o I 5 3-4 Mean at all age.«. I in 7 4-5 In the. Norfolk Infirmary the mortality has been much less in children, than in adults. But at St. r..irthi)b>:new'», th'* propdYlion of deaths in children, during the 20 years that 1 frequently attended operations for stone there, was very great. In the Bristol Infir- mary, the.risk in children seems to have been about equal to what it Inn been in adults. Iu all calculations of this kind, how ever, it is to be recollected, that as opera- tions for the stone are done, not only by surgeons of various degree-? of skill, but in different ways, and even with instruments of great diversity, such computations do not give the fair average of any one method of operating. Now, where the patients are equally favourable, but tbe results of any given number of operations on them are consider- ably different, the skill of the surgeons, the particular methods of operating pursued, the kinds of instruments used, tin* general health- iness ofthe hospital itself, and the treatment after the patients are put to bed,arc consi- derations, by which questions,apparently in- explicable, might sometimes be solved. From the year 1772 to 1816, the Norwich Hospital received ls,S5» patients of all kinds, making an average of 428 annual ad- missions ; and Dr. Marcet observes, that the proportion of 506 operations of lithoto- my, out of 18,859 patients, wliich corres- ponds to about 1 in 38, exceeds in an as- tonishing degree, that obtained from any of the other public institutions, whose records he examined. ( Next to the records of the Norwich Hos- pital, Dr. Marcet derived the most distinct information of this kind from Cheselden, who mentions in his work on anatomy, that during the course of his public practice in St. Thomas's Hospital, a period of about 20 years, he had performed the operation of the stone 213 times, and lost only 20 patients. This was about 2 cases in 21, which is much less than the common average. In St. Thomas's Hospital, during the last ten years, the operation of lithotomyscems to have been done, on an average, 11 times in each two years ; and one case of stone has occurred in each 628 patients admitted. In St. Bartholomew's, lithotomy was per- formed 66 times in the years 1812, 1813 1814, 1815, and 1816. Tile annual average about 11, or 1 in each 340 patients of all descriptions. In Guy's Hospital, lithotomy has been performed, on an average, about 9\>r 10 times annually, during the last 20, or 30 years. The proportion of calculous patients there is ab-o estimated as 1 in about 300 cases of all kinds. Dr.Marcet's inquiries incline him to think, (hat on the whole, lithotomy in the London Hospitals for some years, has been gradually becoming less frequent; and this he con- ceives may be owing, partly to a real reduc- tion in the frequency of the stone, from some alteration in the diet, or habits ofthe people, partly to the use of appropriate ne.bcines : and partly to the circumstance I UlNARY CAr,CULl of calculous patients noi resorting so exclu- sively, as was formerly ihe case, to the great London hospitals for the operation. In the Royal Infirmary at Edinburgh, tbe average number of slone cases annually, during fhe last six years, is said not to have exceeded 2, although about 2000 patients are admitted there every year. Dr. Marcet has been informed by M. Roux, that, in La Charite at Paris, ten or twelve ca*=es of stone occur every year, out of about 2600 patients, and that the propor- tion of deaths from the operation there is 1 in 5 or 6. In the Hopital des Enfans Malades, in the same city, Dr. Marcet states, on the authority of Dr. Biett, that about 6 cases of stone are received every year into lhat establishment, where about 3000 children of both sexes are annually admitted. There have been only 3 cases in females, and what is remarkable, only two deaths from the operation in the course of the last se- ven years. Dr. Marcet was acquainted, thai lithotomy is comparatively rare at Vienna, nol on ac- count of the want of good surgeons, or the unfrequent occurrence of stone cases in that part ofthe continent; but in consequence of the little attention paid to this disease by the mosteminentsurgeonsoftheAusfrian capital. At Geneva, says Dr Marcet, in a popula- tion of 30,000, lithotomy has been perform- ed only thirteen times in the last twenty years, though good surgeons are never wanting in that town to perform the opera- tion whenever an opportunity presents itself. Out of these thirteen patients, seven were not strictly Genevese, though belong- ing to the neighbouring districts, and one vvas an Englishman; so that the disease Would, at first sight, appear to be a rare oc- currence at Geneva. But, continues Dr. Marcet, if the smallness of the Genevese po- pulation be taken into account, this propor- tion of calculous cases may not fall very short of that observed in other places. At Lyons, a populous town, not more than eighty ipiles distant from Geneva, the dis- ease is stated to be rather frequent. With regard to the chymical nature of urinary calculi, there was nothing known until 1776, when Scheele published on the ■subject in the Stockholm Transactions. He there staled, that all the urinary calculi, which he had examined, consisted of a pe- culiar concrete substance, now well known by the name of lithic, or uric acid, which be also showed was soluble in alkaline lixi- via. Scheele further discovered, that the lithic matter was, in some degree, capable of being dissolved in cold water; that this solution possessed acid properties, and, in particular, that of reddening litmus; that it was acted upon in a peculiar manner when boiled in nitric acid ; and lastly, that hu- man urine always contained this substance i" greater or less quantity, and often let it separate in the form of a brick-coloured sediment, by the mere effect of cooling. The discovery made by Scheele; was con- firmed by Bergmann and Morveau, and tbe investigation of the subject was afterward prosecuted by others with redoubled ardour. As Professor Murray observes, experiments continued to be repeated and diversified on these concretions, and on their solvents. At length it was fully ascertained, that there existed others, besides those compo- sed of uric acid; and, latterly, our know- ledge of them has been much extended by the researches of Pearson, Wollaston, Four- croy, and Vauquelin. Several important facts have also been established by the ta- lents and industry of some other distinguish- ed men ; viz. Dr. Henry, of Manchester ; Professor Brande, ofthe Royal Institution of London; Dr. Marcet. late'of Guy's Hos- pital ; and Dr. Prout, of London. The facts and considerations of the latter wriler ren- der it probable, however, that the common opinion of pure lithic arid being contained in the urine is not exactly correct; but that this acid " in healthy urine exists in a state of combination with ammonia, and that, in reality, (his fluid contains no uncombined acid at all." (On the Nature, fyc. of Gravel and Calculus, c. 13.) The credit which is due to Dr. Wollaston for his valuable and original discoveries, respecting urinary calculi, is^'ery consider- able; a truth which I have particular plea- sure in recording here, since, his merits have not been fairly appreciated by the French chymisls. Indeed, as Dr. Marcet observes, it is the more desirable that his claims should be placed in the clearest point of view, as the late celebrated M. Fourcro/, both in his " Systeme des Connoissaiiccs Chimiques," and in his various papers on this particular subject, has, in a most unac- countable manner, overlooked Dr. Wollas- ton's labours, aud, in describing results, ex- actly similar to those previously obtained and published by the English chymist, has claimed them as his own discoveries. Yet Dr. Wollaston's was printed in our Philoso- phical Transactions, two years before Four- croy published his Memoir in the " Annales de Chimie," and three years before he gave to the world his " Systeme des Connoissan- ces Chimiques;" and he discussed in these works a paper of Dr. Pearson on the lithic acid, published in a volume of the Philoso- phical Transactions (for 179S) subsequent to that which contained the account of Dr. Wollaston's discoveries! (See Marcel's Essay on Calculous Disorder.!, p. 60. Also Murray's Syst. of Cliym. vol. 4. p. 616, edit. of 1809.) It would appear then, that Scheele first discovered the nature of those urinary cal- culi which consist of lithic acid ; but tha' Dr. Wollaston first ascertained the nature of several other kinds, some of which have also been described at a later period hy Fourcroy and Vauquelin. On the whole, there are five species of concretions, whose chymical properties were first pointed oul by"Dr. Wallaston, and no less than four be- long to the urinary organs. These nre, 1st. (iouty concretions. 2dly. Th'- fi:-i'*b* (-.',. ■#nt> : til.NARY CALCULI •-ulus. 3dly. The mulberry calculus. 4thly. The calculus of the prostate gland. Sthly. The cystic oxide, discovered in 1810. 1. Is'hie Acid Calculus. Dr. Prout be- lieves that, at least two-thirds of Ihe whole number of calculi originate from lithic acid ; for, as it forms by far the most common nu- cleus, round which other calculous matter is subsequently deposited, if such nuclei bad not been formed and detained, two persons at least out of three who suffer from stone, would never have been troubled with the disorder. (On Gravel, Calculus, fyc. p. 95.) Lithic Ariil forms a hard, inodorous con- cretion, of a yellowish, or brown colour, similar to that of wood of various shades. According to Professor Murray, calculi of this kind are in fine, close layers, fibrous, or radiated, and generally smooth on their surface, though sometimes a little rough. They arc rather brittle, and have a specific gravity, varying from 1,276 to 1,786, but usually above 1,600. One part of lithic acid is said to dissolve in 1720 parts of cold water, and 1160 parts of boiling water; (Marcet, p. 6b.) and Ibis solution turns ve- getable blues to a red colour. When it has he en dissolved in boiling water, smnll yel- lowish .crystals are deposited as the fluid becomes cold, Lithic acid calculi blacken, but are not melted by the blowpipe, emit- ting a peculiar animal smell, and gradually ■ v.iporating, until a small quantity of white ash remain*, which is alkaline. By distilla- tion, they yield ammonia and prussic acid. They are soluble in the cold, iu a solution of pure potassa, or soda, and from the solu- tion a precipitate of a fine while powder is thrown down by the acid. Lime-water likrwi-e dissolves them, but more sparingly. According to "jcheele they remain unchan- ged in solutions of the alkaline carbonates ; a statement which agrees with that of Dr. Front, who accounts for the effect said to be produced by the alkaline carbonates upon calculi in tlie bladder, by their pro- pilly of dissolving the lithate of ammonia. (tgan in Trans, of Irish Acad. 1805, Prout on Gravel, fyc. p. 84.) They are not much acted upon by ammonia. They are not soluble cither in the muriatic or sulphuric acid ; though they are so in the nitric when assisted by heat, and the residue of this so- lution, when evaporated to dryness, as- sumes a remarkably bright pink colour, which disappears on adding either an acid or an alkali. In many of these calculi, the lithic acid is nearly pure ; in others, there w an intermixture of other ingredients, par- ticularly of phosphate of lime,and phosphate of ammonia and magnesia; and, in almost all of ihem, there is a portion of animal matter, which occasions the smell when they are burnt, and the loss in their analy- sis. (See Murray's Chymistry, vol. 4, p. 640 ; end Marcel's Essay on the Chym. and Med. Hist, of Calculous Disorders, Svo. Lond. 1K17 .;• A. :t.~:>t quantity of uric acid is formed in ^'"ity constitutions, and deposited *in the ,r;'. 1 t or soft parts, in tbe state of lithate of ammonia. Sir Everard Home rriuove-d , tumour weighing four ounces from tin- heel of a gentleman, a martyr to the gout and when analysed by Professor Branch*, i' was found to be principally composed of uric acid. (On Strictures, vol. 3, p. :tl3.) 2. Lithate of Ammonia Cnlculur, accord- ing to Dr. Prout, is generally <»f' the colour of clay. Its surface is sometimes smooth ; sometimes tuberculated. It is composed of concentric layers, and its fracture resem- bles lhat of compact limestone. It is ge- nerally of small size, and rather uncom- mon ; but the lithate of ammonia very fre quently occurs, mixed with lithic arid, forming a mixed variety of calculus. Under the flume of the blowpipe it usually decre pitates strongly. It is much more soluble in water than the lithic acid calculus; and always gives off a strong smell of ammonia on being heated with caustic potash. The lithate. of ammonia is also readily soluble in the alkaline subcarbonates, which pure lithic acid is not. (Prout on Gravel, <£-c. p. 83.) 3. Bone Earth, Phosphate of Lnnr Calcu- lus. The presence of pho°pluite of lime in urinary calculi had been mentioned hy Ber-'tnann and others, when Dr. Wollaston first ascertained, that some calculi are en- tirely composed of it. From the investiga- tions of Dr. Wollaston, it appears that this substance sometimes, though rarely, com- poses the entire calculu-, but that in general it is mixed with other ingredients, particu- larly with uric acid, and phosphate of mng- uesia and ammonia. In the first case, the calculus is described as being of a pale brown colour, and so smooth as to appear polished. When sawn through, it is found very regularly laminated, and the lamina* in general, adhere so slightly to each other, as to separate with ease into concentric crusts. It dissolves entirely, though slowly, in mu- riatic or nitric acid. Exposed to the flame of the blowpipe, it is at first slightly char- red, but soon becomes perfectly white, re- taining its form, until urged wilh the ntmont heat from a common blowpipe, when it may be completely fused. It appcr.i* to be more fusible than the phosphate of lime, which forms the basis of bom*; n circum- stance which Dr. Wollaston ascribes to the latter containing a larger quantity of lime. (Phil. Trans. 1797.) 4. Triple Phosphate of Magnesia and Am- monia Calculus. The existence of this cal- culus in (he intestines of animals was first pointed out by Fourcroy; but its being a constituent part of some urinary calcnlT of the human subject, was originally discover- ed by Dr. Wollaston. (Phil. Trans. 1797.) According to Dr. Prout, this species of cal- culus is always nearly white : its surface is commonly uneven, and covered with minute shining crystals. Its texture is not lamina- ted, and it is easily broken and roduced to powder. In some rare instances, however it is hard and compact, and when broken' exhibits a crystalline texture, and is more or Ie<-s transparent. Calculi composed entire !y of the phosphate of magnesia and ammo- QUINARY CALCULI nia are rare, but specimens,in which they constitute the predominant ingredient are by no means uncommon. (Prout, p. 86.) When the blow-pipe is applied, an ammonia- cat smell is perceived, ihe fragment dimi- nishes in size, and if the hea. be strongly urged, it ultimately undergoes an imperfect fu-ion, being reduced to the state ol phos- phate of magnesia. (P. 69.) Dr. Wollaston describes the form ot the ciyslals of this salt, as being a short trilateral prism, having one an^le u tight angle, and the other two equal, terminated by a pyramid of three or six •tides. These crystals, as Dr. Marcet has ex- plained, are but very sparingly soluble in water, but very readily in most, if not all the acids, and on precipitation, they reas- sume the crystalline form. From the solu- tions of these crystals in muriatic acid, sal ammoniac may be obtained by sublimation. Solutions of caustic alkalies disengage am- monia from the triple salt, tbe alkali com- bining with a portion of the phosphoric acid. 5. Fusible Calculus. Mr. *Tennant first discovered, that this substance was different Irom ihe lithic acid, and that, when urged by the blowpipe, instead of being nearly conmmed, a large part of it melted into a white vitreous globule. The nature of the fusible calculus was afterward more fully investigated and explained by Dr. Wollas- ton. (Phil. Trans. 1797.) According to the excellent description lately given ot this calculus by Dr. Marcet, it is commonly whiter and more friable than any other spe- cies. It sometimes resembles a mass of chalk, leaving a white dust on the fingers, and separates easily into layers, or laminae, tho interstices of which are often studded with sparkling crystals of the triple phos- phate. At other times it appears in the form of a spongy and very friable whitish mass, in which the laminated structure is not obvious. Calculi of this kind often ac- quire a very large size, and they are apt to mould themselves in the contracted cavity of the bladder, assuming a peculiarity of form which Dr. Marcet has never observed in any ofthe olher species of calculi, and which consists in the stone terminating, at its broader end, in a kind of peduncle, cor- responding to the neck ofthe bladder. The chymical composition of the fusible calcu- lus is n mixture of the triple phosphate of magnesia and ammonia, and of the phos- phate of lime. These two salts, which. when separate, are infusible, or nearly so, when mixed together and urged by the blowpipe, easily run into a vitreous globule. The composition of this substance, says Dr. Marcet, may be shown in various ways. Thus, if it be pulverized, and acetic acid poured upon it, the triple crystals will be readily dissolved, while tiie phosphate of lime will scarcely be acted upon ; after which the muriatic acid will readily dissolve the latter phosphate, leaving a small resi- due, consisting of lithic acid, a portion of which isalway- found mixed '.'ith the fusi- Ne* calruhi«. It is also remarked jby Dr. Marcet, that many of tbe calculi, which form round ex- traneous bodies in the bladder, are of the fusible kind. And the calculous matter sometimes deposited between the prepuce aud glans is found to be of the same nature. 6. Mulberry Calculus, or Oxalate of Lime is mostly of a dark brown colour, its inte- rior being often gray. Its surface is usually uneven, presenting tubercles more or less prominent, frequently rounded, sometimes pointed, and either rough or polished. Iti-= very hard, difficult to saw, and appears to consist of successive unequal layers: ex- cepting the few stones, which contain a proportion of silica, it is the heaviest of the urinary concretions. Though this calculus has been named mulberry from its resem- blance to that fruit, yet, as Dr. Marcet has observed, there are many concretions of this class, which, far from having the mul- berry appearance* are remarkably smooth and pale-coloured, as may be seen in plate 8, fig. 6, of that gentleman's essay. Accor- ding to Mr. Brande. persons who have void- ed this species of calculus, are much less liable to a return of the complaint, than other patients, who discharge lithic calculi (Phil. Trans. 1808.) With regard to chymical characters (says Professor Murray,) it is less affected by the application of the usual reagents, than any other calculus. The pure alkaline solutions have no effect upon it, and the acids dissolve it with great difficulty. When it is reduced however to fine powder, both muriatic and nitric acid dissolve it slowly. The solutions of the alkaline carbonates decompose it, as Fourcroy and Vauquelin have observed : and this affords us the easiest method of analysing it. The calculus in powder being digested in the solution, carbonate of lime is soon formed, which remains insoluble, and is easily distinguished by the efferves- cence produced by the addition of weak- acetic acid, while there is obtained in solu- tion the compound of oxalic acid with the alkali of the alkaline carbonate. From this the oxalic acid may be precipitated by th« acetate of lead, or of barytes ; and this oxalate, thus formed, may be afterward de- composed by sulphuric acid. Another me- thod of analysing this calculus is by expo- sure to heat: its acid is decomposed, and bv raising the heat sufficiently, pure lime is obtained, amounting to about a third of the weight of the calculus. According to Four- croy and Vauquelin, the oxalate of lime calculus contains more animal matter, than any other. This animal matter appeared to them to be a ""mixture of albumen and uree. 1 he composition of a calculus of this species analysed by Mr. Brande, was; oxalate of lime 65 grains ; uric acid 16 grains ; phos- phate of lime 15 grains; animal matter four grains. 7. The Cystic Oxide Calculus is small, and very rare. It was first described by Dr. Wollaston. (Phil. Trans, for 1810.) In external appearance, it bears a greater re- sfmhlnpe.. (o Hie tnn|(, phosphate* of rna? .jib l RINAK1 CALCULI. nesia, than any other sort of calculus. However, it is more compact, and does not consist of distinct lamina*, but appears as one mass confusedly crystallized throughout its substance. It has a yellowish semi- transparency, and a peculiar glistening lus- tre. Under the blowpipe, it gives a singu- larly fetid smell, quite different from that of lithic acid, or the smell of prussic acid. In consequence of the readiness, with which this species ot calculus unites both with i.cicis and alkalies, in common with other oxides, and the fact of its also containing oxygen (as is proved by the formation of carbonic acid by distillation,) Dr. Wollaston named it an oxide, and the term cystic was added from its having been originally found only in the bladder in two examples. Dr. Marcet, however, has subsequently met wilh no less than three instances of calculi formed of cystic oxide, all of which were unquestiona- bly of renal origin. , 8. Alternating Calculus. Lithic strata fre- quently alternate with layers of oxalate of lime, or wilh the phosphates. Sometimes also the mulberry alternates wilh the phos- phates, and in a few instances, three, or even four species of calculi occur in the same stone, disposed in distinct concentric laminae. On the comparative frequency of these and other varieties of calculi, Dr. Prout's work contains valuable infor- mation. 9. Compound Calculi, with their Ingredients Intimately mixed. Under this title Dr. Mar- ret comprehends certain calculi, which have no characteristic feature, by which they can be considered as distinctly belonging to any of the other classes. He observes, that they may sometimes be recognized by their more or less irregular figure, and their less determinate colour; by their being less dis- tinctly, if at all divisible into strata ; and by their often possessing a considerable hardness. By chymical analysis confused results are obtained. (See Essay on the Chym. and Med. Hist, of Calculous Disorders, p. DO.) 10. Crdculi of the Prostate Gland. Ihe composition of those calculi is said to have been first explained by Dr. Wollaston. (See Phil. Trans, for 1797.) They all consist of phosphate of lime, the earth not being re- dundant as in bones. Their size varies from that of a pin's head to that of a hazel nut. Their form is more or less spheroidal; and they are of a yellowish brown colour. Fpurcroy has described a species of uri- nary calculus, which is characteri-aed by its being composed of the urate or lithate of ammonia. Dr Wollaston, Mr. Brande, and Dr. Marcet did not, however, satisfactorily ascertain the presence of this substance in any of the concretions, which Ihey examin- ed. As also urea and the triple phosphate, both of which afford ammonia, are frequent- ly present in lithic calculi, it is conjectured, that these circumst-mces may have given rise to the analytical results,from which the e\i«;t«*.iie-*»of urate? of ammonia bps been in- ferred. (Brande in Phil. Trans. 1808. Ma eel's Essay, p. 93.) The recent investigations of Dr. Front, however, tend to establish the reality of the lithate of ammonia calculus. Dr. Marcet has met with two specimen! of uriuary calculi entirely different from any wliich have hitherto been noticed. One of these he proposes to name Xanlhic oxide, from £9«f, yellow, because one of ils most characteristic properties is that of forming a lemon-coloured compound, when acted upon by nitric acid. The chymical proper- ties of tbe olher new calculus, mentioned by Dr. Marcet, correspond to those of fibrine, and he therefore suggests the propriety of distinguishing it by the term fibrinous. For a particular description of these new sub- stances, I must refer to this gentleman's Es- say. 11. Carbonate of Lime Calculus. This substance is not enumerated by Dr. Marcet, as entering into the composition of urinary calculi. But, according to Mr. R. Smith, there can be no doubt of the fact. Dr. W. It. Gilby of Clifton, he says, detected it de- cidedly in four instances. " A notice of it will be found in Mr. Tillock's Journ. for 1817, vol. 49, p. 188, in the account of a curious calculus, given to me by Mr. G. M. Burroughs, of Clifton; the nucleus of which is a common cinder, an inch and a half long, and one broad. Since the publication of that paper (continues Mr. Smith,) Mr. H. Sully, of Wiveliscombe, sent me three oddly shaped calculi, which he removed from a lad, together with 15 pea-sized ones previously voided by the urethra, which arc entirely carbonate of lime, held together by animal mucus." (Sec Med. Chir. Trans. vol. 11, p. 14.) Dr. Prout has also seen some small calculi, composed almost entirely of carbonate of lime. (On Gravel, fyc p. 89.) Dr. Prout has investigated with considera- ble talent tbe comparative prevalency of the different forms of urinary deposite, and the order of their succession. flis* data arc taken from the examinations, made by Pro- fessor Brande, of the calculi in the Hunterian Collection ; by Dr. Marcet, of those at Nor- wich and Guy'i Hospital; by Dr. Henry, of those at Manchester; and by Mr. Smith, of others preserved at the Bristol Infirmary. The whole number of calculi examined was 823 ; of tliese, 294 were classed under the name of lithic acid, 98 of which were nearly pure; 151 were mixed with a little of the oxalate of lime ; and *»6 with a little of the phosphates. 113 consisted of oxalate of lime. Three were of cystic oxide 202 were phosphates; of which 16 were nearly- pure ; 84 mixed with a small proportion of lithic acid; eight consisted of phosphate of lime nearly pure ; three of triple phos- phate nearly pure ; and 91 of the fusible or mixed calculi 186 vvere alternating calculi, or thov whose lamina- varied, but consisted of lithic acid, oxalate of lime, and phos- phates: of these. 15 consisted of lithic acid and oxalate of lime, the first being in the greatest proportion : 40 of the oxalate ol LRIiYAi-VY* CALCULI 559 tune iu the greatest proportion, and lithic acid in the least; 51 of the lithic acid and the phosphates ; 49 of the oxalate of lime, and the phosphates; J2 of the oxalate of lime, lithic acid, and the phosphates; one of fusible and lithic; two of fusible, and oxalate of linn; ; and 16, the composition of which was not mentioned. Of compound caleuli, whose composition was not specified, there were tb. (See W. Proul's Inquiry into the Nature and Treat- ment of Gravel and Calculus, p 94.) The proportion of lithic acid calculi is somewhat more than one-third of the whole number. But as this acid is the common nucleus, round which other calculous matter is deposited, Dr. Prout computes the pro- portion of calculi originating from it, to be at least two-thirds of the whole number. According to the experiments of the same physician, the red crystalline calculus is composed of nearly pure lithic acid ; and the earthy, amorphous one, consists of lithic acid, more or less ammonia, generally a lit- tle of the phosphates, and sometimes a small portion of the oxalate of lime. The lighter the colour, the greater in general tbe pro- portion of lithate of ammonia and the phos- phates. (P. 97.) Oxalate of lime calculi form onc-ieventh of tbfi whole number, without any regularity, however, in different museums Cystic oxide calculi art so rare, that the proportion found was only one in 274. Calculi composed of the phosphates, made •about one-fourth of ihe whole number. Alternating Calculi amounted to between one-fourth and one-fifth; but, Dr. Prout otters good reasons for believing, that the data, from Which the estimate is drawn, cannot be depended upon. For additional information on this branch of the subject, I must refer to Dr. Prout's valuable work. The stone being a severe affliction, and the operation extremely hazardous and pain- ful, a variety of experiments have been in- stituted for the purpose of discovering a solvent for urinary calculi. Hitherto, how- ever, all the remedies and plans which have been tried, have been attended with very limited, and by no means, unequivocal **uccess, notwithstanding many persons may have been deceived into a contrary opinion. The dissolution of stones in the bladder has been attempted bylilhontripticmedicines, as they are termed, and by fluids injected into this viscus. At the present day, prac- titioners direct their endeavours very much to the correction of those particular diathe- ses, or states of the constitution, on which the formation of various calculi depend, and more confidence seems to be placed in this aim, than in any schemes for the dissolution of urinary concretions. It is certain, that in the latter project many difficulties present themselves, and among these, some of the most serious arc the great variety in the composition of calculi; the impo*ribility of knowing the exact ingredients of n. stone, while h is concealed in the bladder, though many useful. suggestions for assisting the •udj'inrnt on this point have been recently offered by Dr. Prout, and lastly, if the right solvent were ascertained, as calculated upon chymical principles applied to urinary con- cretions out of the body, it is obvious, that any medicines, taken by the mouth, are lia- blefto so many changes in the alimentary canal, and in tbe lymphatic and vascular systems, that it must be exceedingly difficult to get them in an unaltered state and effect ive quantity into the bladder; while, if this were possible (as it is in the way of injection through a catheter,) the bladder itself might be incapable of bearing the application, and the patient lose his life in the experiment. As Dr. Prout well observes, a calculus in the bladder may be considered a substance placed in a solution of various principles in a certain quantity of water. If any of the more insoluble of these principles exist in this solution in a state of supersaturation, the calculus will afford a nucleus, round which the excess will be deposited. But, if none exist in a state of excess, of course none can be deposited, and the calculus will not increase in bulk. Whoeve;- studies the chymical properties of the urine, says Dr. Marcet, will learn, that " if any alkali (a few drops of ammonia for instance,) be added to recent urine, a white cloud appears, and a sediment, con- sisting of phorphate of lime, with some am- moniaco-ma^iiesian pbdsphate, subsides in - tlie proportion of about two grains of the precipitate from four ounces of urine. Lime water produces a precipitate of a similar kind, which is still more copious ; for the lime, in combining with tbe excess of phos- phoric, and perhaps also of lactic acid, not only precipitates the phosphate of lime, which these aeids held in solution, but it decomposes the other phosphates, thus ge- nerating an additional quantity ofthe phos- phate of lime, which is also deposited. " If, on the contrary (observes the same author,) a small quantity of any acid, either the phosphoric, the muriatic, or indeed even common vinegar, be added to recent healthy urine, and the mixture be allowed to stand for one or two days, small reddish crystalline particles of lithic acid will be gradually deposited on the inner surface of the vessel. -*' It is on these two general facts that our principles of chymical treatmeut ultimately rest. Whenever the lithic secretion predo- minates, the alkalies are the appropriate remedies; and the acids, particularly the muriatic, are the agents to be resorted to when the calcareous or magnesian salts prevail in the deposite." (P. 147,148.) The alkalies taken into the stomach cer- tainly reach the urinary passages through the medium of the circulation ; and it is also strongly suspected that the acids like- wise do so, though this circumstance is still a question. Unfortunately, the quantity of either alkalies or acids, which thus mixes with the urine, is so small, that no imprcs- •sion is made upon calculi of magnitude The experience of Dr. Marcet, Dr. Prout, aud others, however, has clearly asccr- tainec' that such medicine- a:v '>ften capable* vbu 1'rtLVARY CALCULI. of checking a icuaemy to the formation of stone, and sometimes of bringing on a cal- culous deposite depending upon the altered state of the system. Indeed Dr. Marcet ex- presses his decided opinion, that, even sup- posing not an atom of alkali or acid Mter reached the bladder, still it would not tie unreasonable to expect that tliese remedies may respectively produce the desired changes during the first stages of assimila- tion ; in one case, by neutralizing any mor- bid excess of acid in the prima; via*; and in the other, by checking a tendency lo alka- lescence, or otherwise disturbing those affinities, which, in the subsequent processes of assimilation and secretion, give rise to calculous affections. (P. 153.) When muriatic acid is prescribed, from 6 to 25 drops may be given two or three times a day, diluted witb a sufficient quan- tity of water. The best way of taking the alkalies is by drinking soda water as a common beve- rage. It is asserted, however, on the au- thority of Sir G. Blane, that when the alkalies are combined with nitric acid, as in the ordinary saline draught, they also bave the effect of depriving the urine of its acid properties. Dr. .Marcet, with every appearance of probability, refers to carbonic acid itself no solvent power; and he does not even adopt Mr. Brandt's opinion, that this acid passes into the urine, when patients drink fluids impregnated with it. • But, it may be inquired, if no known in- ternal medicine will dissolve a stone already formed, what is the good of merely altering the diathesis, and checking the increase of the calculus, as lithotomy must still be ne- cessary? The reasons for persevering in the aim of correcting any particular state of the system, and the urinary secretion, on which state the increase of a calculus de- pends, are very important; for it is found, that, though medicines may be quite inca- pable of dissolving a calculus, they relieve a great deal of the distress and suffering apparently the effect of the diathesis itself, as will be presently noticed, and sometimes afford such ease that the operation may be postponed until the health is improved, or, in a very old subject, even be dispensed with altogether. The aim is also of high importance, with the view of preventing relapses. As the lithic acid diathesis seems to be concerned in the production of about two- thirds of the whole number of the urinary calculi, the correction of it has been a chief aim among modern practitioners. For this purpose, Magendie, whose experiments tend to prove that tbe lithic acid diathesis maybe lessened and removed by abstinence from animal food, and other nutriments abounding in azote, founds his practice very much upon this alleged fact. His indica- tions, however, are four in number, viz. 1. ;o lessen the quantity of uric acid produced oy the kidneys; 2. to augment the secretion "i urine : a maxim, which leads him to con- sider cutaneous | crspiraliun injuriou . , statement which I think must be rejerti ;<~ quent inability lu uuleiiuino whui juucii' ought to be tried. I'nlil the complete success of litliontript'w is established, therefore, the operation ot lithotomy, severe and hazardous as it is must continue an indispensable practice, whenever the patient's sufferings arc great. and the calculus too large to be voided, or extracted through Ibe urethra. In the curly stage, however, before culculi have exceed ed a certain size, if they cannot be expelled with the urine, they may sometimes be tnkun out by means of an instrument, invented by Mr. Weiss, of the Strand, shaped like a sound, but the eudof which, after its introduc- tion iu lo the bladder, admits of being opened and made to grasp the calculus, which is then to be drawn through the urethra. Tin- urine is first to be discharged through a ca- theter. (Sec an Account of a Case, in which numerous Culculi were extracted without cut- ting Instruments, by Sir. A. Cooper, in Med Chir. Trans. Vol. 11, p. 349.) Consult T. Lobb, a Treatise on Dissolvents of the Slone, Svo. Lond. 1*39. Stephen Hales, kxperimenh and Observations on Mrs-. Sice vens's Midicincs, Sro.Lond. 1741. Morand, in Mem. de I'Acad. ties Sciences, 1740, and 1741. J. Rutty, Neio Experiments on Joamw Sleevens's Medicines, 8vo. Lond 17-12. R Whytl, an Essay on the t irlues of Lime Wa- ter and Soap, in Ihe Cure of Slone, Svo Lttiiib. 1761. D. Hartley, a Vi'.w of the pre- sent Evidence J'or and against Mrs. Sleevens's Medicine, Svo. Lond. 1739 ; and Supplement, 1740. N. Hulme, a safe and easy Remedy for the Slone, fyc. 4lo. Lond. 1778. Wm. Butler, Method of Curefqr the Slone, chiefly by injec- tions, 12mo. Edinb. 1754. B. Langrish, Phy- sical Experiments upon Brutes, in order to discover a safe Method of dissolving Stones in the Bladder by Injections, Svo. Lond. 1746. J Juriu, Effects of Soap-ley, taken internally for the Stone, 2d Edit, with an Appendix, 12mo. Lond. 174b. J. I'. Schrciber, De Mi. dicamenlo, a./. Sleevens, conlracalculum divul gato inefftcaci et noxio, Gott. 1714. Murray Forbes, a Treatise upon Grin el and Gout. wilh ait Examination of Dr. Austin's Theory oj Stone, an Inquiry into the Operation oj Sol- vents, fyc. Set,. Lond. 1793. W. Austin, v Treatise on the origin and component Parts of the Slone, fye. Svo. Lond. 1791. T. Beddqes, on the Niture and Cure of Calculus, fyc. Svo. Lond. ]~'j3 J, S. Dorsey, an Essay on the Lilhonlriplic Virtues of the Gastrin Liquor, Sto. Philadelphia, 18<>2. M. Girardi, D> Ltd Uisina, ejusque et liquet calcis vi lithov- triplica, fyc. Pal(-c. 17"-4. Scheele, in Stock- holm Trans. Fourcroy, in Systeme des Con- noissances Chimiques. I' ollaslon, Pearson, and Brande, in Phil. Trans, and Journal of Science and Arts, Vols. 6 and 8, fyc. A. Marcet, on the Chymical History and Medical Treat- ment of Calculous Disorders, Sro. Lond. 1817; a work full of valuable information. Wilson Piiil'p, in Xedicul Tran*. Vol.6. Dr. llcrij, in ,'ici Chir. Trans. Vol.10. C. Scudamore, on Gout, fyc. Edit. 3. F. Magendie, Recher- dies Phyr.iologiques et M6dicalessurlcs Causes. &-C. dr' '"■ i.rn.vttl'-. Sro. I'-y-ir. t«l«. A MiLs-JKY FiSli)L/L. •>6;-i upland Huicfitson, on the Comparative //•- frequency of Urinary Calculi among Seafaring People, vid. Med. 'Chir. Trans. Vol. V. It. Smith, a Statistical Inquiry into the Frequency of Stone in the Bladder, in Great-Britain and Ireland, rid. Med. Chir. Trans. Vol. IJ. IV. Prout, an Inquiry into the Nature and Treat- ment of Gravel,Calculus, fyc. Svo. Lond. 1821; a work abounding in originalvaluable observa- tions. J. Wilson, on the Structure and Physio- logy of the Male Urinary and Genital Organ , and the Nature and Treatment of their Dis- eases, Svo. Lond. 1S21 ; this publication con- tains an excellent summary of the latest observations on the subject. UKLNARY FISTULAE. By an urinary fistula, strictly speaking, is implied a deep, narrow ulcer, which leads into some of the urinary passages : but, this name is likewise applied to sinuses, which, without having any communication with these passages, termi- nate near some point of their course. Thus. in Desault's works, T. 3, p. 287,) three kinds of fistula?, in respect to the urinary passages, are noticed. The first sort is called a blind external fistula, because it opens only exter- nally ; the second blind internal, because it has only one opening into the urinary pas- sages ; the third, is termed complete, being attended both with an internal opening into the urinary organs, and oiie or more external apertures. Among the blind external fistula?, only such as terminate near the canal of the ure- thra are particularly noticed in Desault's works. All fistulae of this kind are originally owing to an abscess, that has formed in the vicinity of the urethra ; and, in the arti- cle Urinary abscesses, it has been explained, lhat tliese suppurations frequently originate from disease of that canal. Whatever may be the cause of these fistulae, however; it is not unusual to find, that, after the pus has made its way towards the scrotum or perineum, and discharged itself outwardly, the ulcer is converted into a sinus, which resists all the efforts of nature to heal it. One of the chief circumstances, tending to evince, that the sinus has no communication with the urethra, is, that no urine has ever essaped through the opening ; for, with re- spect to the judgment formed from the im- possibility of making a probe touch a catheter in the passage, it must be exceedingly falla- cious, because the winding course of the sinus, or the small size of its communication with the urethra, may prevent the instru- ments from touching each other. According to Desault, the indications in the treatment of these blind fistulae depend upon the nature of their complications. When the sinuses are kept up by a separa- tion ofthe scrotum from the parie es of the urethra, Desault recommends exact com- pression to be made over the part, which method, he says, is sometimes sufficient to accomplish a cure. When this plan fails, he states, that the healing of the sinus may bo promoted by practising an incision on one side of the scrotum, and carrying it as far a* the denuded portion of the nrethr* When sinuses esist, and they depend upon the smallness of the opening, or its un- favourable situation for the discharge of the matter, the aperture should be enlarged, by- making an incision into the main collection of pus. When there are callosities, which resist cataplasms, and the most active re- solvents, Desault advises us to introduce into the fistula, trochees of minium, for.the pur- pose of destroying the indurated parts. When the bones are diseased, exfoliation must be awaited ; and, in every instance, the treatment should vary, according to the cause, upon which the fistula depends. Rlind internal fistulas, or such as communi- cate wilh the urethra, but have no externa! ope;ning, are sometimes produced in conse- quence of the bursting of an absccs1- into this canal; the ulceration, from a retention of urine ; a false passage ; and the healing of the external part of the wound made in lithotomy, while tlie internal part is not united. In these cases, there is a discharge of pu-- from the urethra, before, and sometimes after, the issue ofthe urine ; and one may- feel, in tbe course of the urethra, a tumour, which increases while the patient is making water, and afterward disappears on pressure, attended with a fresh discharge from the penis of a mixture of pus and urine. These internal uriaary fistulae cannot be cured, except by preventing the urine from passing into them and lodging there. The catheters employed should be neither too large norloo.small. If too large, they would exactly fill the canal, and the pus and urine contained in the fistulae could nol be dis- charged. If too small, the urine would in- sinuate itself between them and the sides of Ihe urethra, and enter the fistulas. Their use must be continued till the ulcer is entirely healed. The most frequent urinary fistulae are those which arc termed complete. Their origin may be in the ureters, bladder, or urethra. Those which arise in the ureters, sometimes terminate in the colon, and the urine is dis- charged per anum mixed with the feces. But most commonly, these fistula; make their appcarauce externally, either in the lumbar or inguiual regions. Those which communicate witb tbe bladder, have also dif- ferent terminations. When they proceed from the upper and interior part of this or- gan, they ordinarily pierce the parietes of the tjbttomen above the pubes, and towards the navel. They also sometimes terminate in the groins. When they originate in the poste- rity parietes of the bladder, they sometimes lend into the cavity of the abdomen, where they almost always prove mortal; and some- times into the iniestines, if there should be adhesions between these and ihe blndder, so as to-favour this communication. When the opening in the bladder is near the bottom of this viscus, the fistula sometimes terminates in the rectum of the male, and the vagina of the female subject; but most frequently it ends iu the perineum, in both sexes. With re-jatd fo the fistula*- which originate in the ■ C-i I i* I NARY urethra, they usually open externally in the perimcum, t;ie scrotum, or the penis, and sometimes also in the rectum. Ii ia not un- common to see the external opening of these fistula* at a great distance from tbe internal one, and to find it in the middle, and even the lower pail of the thighs, the groins,, pa- rietes of Ihe abdomen, and us hi^h as ibe sides of the chest. Often ihere is only oue opening in the urethra, while there are -eve- ral situated externally, more or less distant from one another. Most of these fistula* are the consequences of a retention ot urine, and are owing lo the same causes as the diseases of wliich they are a symptom. Those which commu- nicate with the rectum, in the mule s.i'-jeul, sometimes depend upon this intestine having been wounded in Ihe operation of lithoto- my; and those which open into the vag na are otten the effect of a violent contusion, caused by the head of the child in difficult labours, or of ulceration produced by pessa- ries, which are too large, and ihe margins of which are? too sharp and irregular. Carcino- ma of the rectum and viigina atao give rise to fistula?, by eMending into the- bladder. Tbe discharge of urine Irom ihe external oriGce of the fistula, is an unequivocal proof of its communication with the urinary p-\-- SHgc ; when Ihe fisiuta is narrow, and there is no obstruction in th" urethra, the urine some- times escapes more readiiy the bitter way than through the fistula. It may alro be dif- ficult, or even impos-iibls, lo find out the in- ternal orifice ot the fisiula with a probe. When tbe fistula communicates.with the rec- tum or va^ma, a staff introduced through the ureihra may sometimes be felt in those '.art*. H hen fistula of»lhe bladder or urethra are the consequences of a retention of urine, produced by strictures, which still e\ist, or bave even increased since ihe formation of th* fistula, Ihe circumsiancc may render the introduction of the catheter difficult. In this sort of cas**, if the catheter cannot be pass- ed, the surgeon must endeavour to remove the stricture with bougies, on the principles explained in the art.e'e Urethra, Strictures of. " In g<-;r:,-»ral, (as Sir Lveraro Home ob- serves;) wb'S-re fistula; lake place in perinam, iu consequence of a stricture, the removal of the stricture is snricie-tt to give the fi. tula a disposition lo heal. There are, bo .v ever, cases wiiich rei.iro more being done for that purpose, and simply I ay in 5 thc:i open is not sufficient." (See Fistula; in Periiwo.) L • der such circumstances, Sir Eerard Home finds the actual cautery the surest ufoans uf making fhe part heal In one. car-e, he pass- ed a bougie into ihe urethra, and seared the edge, of the fistula wilh a hot wire, introdu- ced as far as to touch the bougie. In another instance, a full-sized silver sound via-, passed into the bladder, and the. direction of the fistula having been ascertained with a probe, a female steel sound was heated to redness, and " at Ihe moment at which il passed bom a red to a black heat, it was hurried down through the fistula (about two inches and a HsiULA*. half) to the sound in Ihe urethra.'' In both these cases a cure wa* effected. (Home, on Strictures, Vol.3,p 262, fyc.) When fistula: terminate in the lower part of the bladder, Desaull advises Ihe utmost care to be taken lo prevent the catheter from being stopped up, and lo hinder the instru- ment from becomiim displaced, or slipping out of the bladder ; for which last purpose, Ihe catheter bracelet described by Sir K. Home seems well calculated. However, when the fistula communicates with Ihe ure thra, Desault believes that no advantaout an inch and a helf !on<, and one-third pi an inch in width, on the left side of the cicatrix. The groove- ttius formed was intended lor the reception of ihe edge of the skin lo be delacbed from the Opposite side. An i,,cision whs then made across the perin. um, above and below, so as to pare away the caibm- edges of thy ure- ihra. The skin was next dissected off from a portion of integument on the right side of t e pi-'-i, euin, about n inch and <. hull in len^ti, aud hait an men broad, leaving a smooth space of rather more Man an .tu.h be- tween th> cut suriaces. The integuments on ihe right side were now dissected up, turned over a catheter, and brought in contact with the opposite groove. The detached portion of ci« at lis bled little during the operation, and before it could be applied to the groove, ils edge had so livid an appearance, as to creale au apprehension that il must perish. Two sutures were employed to assist in re- taining il in ihe de-sired position, and some straps of adhesive plaster and a bandase >6o URINE, INCOIN'TiNkM L Ol uompleleci the dressings. The day after the operation, it was evident that some urine had escaped by the side of the catheter ; and on the third day. when ihe dressings were removed, it was found that Ihe portion of flesh wbicb had been deprived of skin, had sloughed, but that a siiffjcien* quantity had united above and below lo luniacnnul, open at one side, and large enough to in- clude the whole catheter. After the parts had healed, some urine could be made to pass through the urethra, when pressure wa- applied to the left side of 'he remaining fis- tula Various attempts were alterward made to excoriate its edges, and unile them, but without success. A second operation was therefore done in the summer of 1820, and integuments were now borrowed from the opposite side to that from wliich they had been taken in Ihe first operation. " A deep groove was made on the right side, the surface was de- nuded of its cutis to some extent, a consi- derable portion of integument was then de- tached from the left side, and in order to obtain healthy skin (says Mr. Karle) I en- croached a little on the thigh; and laid bare the edge of the fascia lata. Instead of pass- ing any ligature through the detached por- tion, the old quill-suture was employed. which was passed from the two outer cut surfaces. A pad of adhesive plaster was in- .erposed between the ligatures and the flap of skin." The catheter was uot lilt in the urethra, but introduced about three times in 24 hours. By this operation much more was gained, and about two-thirds of the de- ficient part ofthe canal were restored ; but still a small aperture remained at the upper part. This opening could not be closed by touching it with escbarotics, and conse- quently, a third operation on a smaller scale was done, which so nearly completed the cure • as to leave only an orifice large enough to admit a bristle, and this opening subse- quently closed, and the patient remained quite well in March 1821. (See Phil Trans. for 1821.) Here we see the same art .by which new noses and under-lips are formed, extending itself to cases where it may be the means of extricating some individuals from a state in which life is hardly desirable. The sursreon of judgment, however, will never forget, that such an operation is only indicated where the fistula is large, the urethra free from obstruction, and bougies and the ca- theter insufficient. URINE, INCONTINENCE OF. This complaint is quite the reverse of retention of urine ; for, as in the latter affection, the urine is continually flowing into the blad- der, without the patient having the power to expel it; so, in ihe former it flows out, without the patient being able to retain it. According to Desault, children are parti- cularly liable to the disorder; adults are less frequently afflicted with if, and persons of advanced years appear to be still less liable to it. The last observation may seem an error to sue.h practitioners' n« have met with numerous examples, where patients, adv..n ceil in years, were incapable of retainin: Iheir urine. The fact is, that the overflow of this fluid, or, in olher words, its dribhliug away through the urethra, in some cases ol re tention, of which it is only a symptom ha- been too commonly confounded with an incontinence of urine, though the cases are as different in their nature as possible, and require very opposite modes of treatment. In retentions, depending upon weakness and paralysis uf the bladder, the inroluntary drib- bling oj\ the urine is generally only an effect of the other disease, and they prevail to- gether I he distended bladder reacts upon the urine, nnd forces some of it out ofthe urethra, until the- resistance of the sphincter and of the ureihra are procisely equal to tht expelling power. Sometimes the urine even dribbles away incessantly, as is found ti happen when the action of the bladder is entirely destroyed; for being then con- stantly full, it cannot hold imy more of the urine descending to it through the ureter.-.,' unless us much be voided through the ure- thra as is received from (he kidneys, and n= unremittingly as the addition from the lat- ter organs continues to be made. Such ca c rather belongs to the article Urint, Rela- tion iif, than the present subject. It is correctly remarked by Desault, that Ihe causes of an incontinence of urine, strict- ly so called, are the very reverse of those of a retention. The latter case happens whenever the action ol the bladder is weak- ened, and the resistance in the urethra in- creased. On tbe contrary, an incontinence originates, either from the expelling powor ofthe bladder being augmented, while the resistance in the urethra is not proportion ately increased ; or from the resistance be- ing lessened, while the expelling force continues the same. On these principles, Desault thought it easy to explain why the disorder should be most common in chil- dren ; and one reason which he gives for Ihe circumstance is, that in childhood there is more irritability than at any other period of life. The expulsion of the urine, he ob serves, is entirely effected by muscular ac- tion, while the resistance is merely owing to the sphincter vesica?, the levatores ani. and perhaps to a few other inconsiderable fasciculi of muscular fibres ; for the different curvatures of the urethra, and the contrac- tile power of this tube itself, he thought, could make only a feeble resistance to the discharge of the urine. An incontinence happens in children, because the bladder contracts so suddenly and forcibly, that its contents are voided almost before these young subjects are aware of the occasion to make water, and without their being able tj restrain the evacuation. There are also ma- ny children, who, from indolence, or care- lessness, do not make water immediately the first calls of nature invite them, and who afterward, bein^.iirgently pre--ml, wet their clothes. In other young subjects, the sen- sation which makes Ihe bladder contract. ;"id accomnnnte- tbe expulsion of tbe urine, UR1 i\L, 1NCONTi NEM,E OF 567 is so siignt, that the function is performed •without any tormal act ol the will,—with- "ut even exciting an impression sufficiently strong to disturb sleep. This is Ihe case with such children as are troubled only with au incontinence ot urine in.the night-time. Increasing years, by diminishing tbe irrita- bility of the bladder, and making man more attentive to his necessities, usually bring about a cure ofthe infirmity, which'seldom continues till the patient has attained the adult state. It was not, hovvever, the doctrine of De- sault, that no period of life, excepting child- hood, is subject to incontinence of urine. On the contrary, he admits, that other ages are subject to it;. but then it depends almost always upon a want of resistance to the es- cape ofthe urine. Thusj it may be occa- sioned by weakness, or paralysis of the sphincter vesica*, or levatores ani: some- times also by a forcible dilatation of the urethra, and loss of its elasticity, and, fas Desault might have added) its muscular power of contraction, since the microscopi- cal observations of Mr. Bauer, tend to con- firm the existence of muscular fibres on the outside of the membrane of the canal, though, as is elsewhere mentioned, their ar- rangement and mode of action are now re- presented to be quite different from what was formerly supposed. (See Ureihra, Stric- tures of the.) A calculus, a fungus, or any other extra- neous body of an irregular shape, may lodge in Ihe neck ofthe bladder, but not accu- rately filling it, may allow the urine to es- cape at the sides ; or there may even belin the calculus grooves through which the urine may pass into the urethra. A violent contusion, or forcible distention "f the sphincter, is often followed by an in- continence of urine. Formerly, the complaint used to be very common after the mode of lithotomy called the apparatus major, and it is even at present not an unusual conse- quence of the extraction of calculi from fe- males, either by dilatation or division of the meatus urinarius, and neck of the bladder. Women, after difficult labours, and in whom the child's head has seriously contu- sed and weakened the neck of the bladder, are also subject to a species of incontinence of urine; which, However, is in general ex- perienced only when they laugh, or make exertions. Incontinence of urine is stated by many writers to be an attendant on palsy and apoplexy. Here they mistake, what the French urgeons aptly call the " retention d'urine avec regorgement," for an inconti- nence. Tn such cases, the involuntary dis- charge of urine has been referred to paraly- sis of tbe sphincter of the bladder; but it is forgot, that the bladder itself also partici- pates in the paralytic affection ; for the sphincter now being a particular muscle, but only a fa iciculus of fleshy fibres, forni- d, as Desault observes, by the junction of those which compose the inner layer of 'he rjmscula- coat ofthe i'liuM"'.-, it <*«!; only be weakened in the same degree, and at the same time, as the rest of this organ. Be- sides, says Desault, it is proved, and all phy- siologists admit the fact, that the action o». the bladder is absolutely necessary for the exiuLion of the urine, and that when this organ cannot act, a retention always ensues. Although much less danger attends an in- continence than a retention of urine, Ihe in- firmity is a serious affliction ; for. as the pa- tient's clothes are continually wet with a fluid that readily putrefies, the stench whicl be carries about with him, is offensive to himself, and every body who approaches him. In children, the disorder usually gets well of itself; as they grow up and acquire strength. When they wet their beds really from idleness and carelessness, moderate chastisement may be proper, inasmuch as the fear of correction will make them pay more attention to the earliest call to m.ake make water. However, it has always been my own belief, that this doctrine is carried to an unjustifiable extent particularly in schools, and been a pretext for tbe most'ab- surd kind of severity. Nor is it doubted by any man who understands the subject, that in almost all cases, the disorder is a true in- firmity, arising from the causes already in- dicated, and not from indolence; the sup- posed crime taking place, in fact, when the child is asleep, and unconscious of what is happening. If excessive irritability, and coastitutional weakness, be the cause of incontinence ot urine, and a very small quantity of urine forces' the. bladder to contract, the resist- ance of the urethra being involuntarily overcome, an endeavour should be made to lessen such irritability by the use of tht warm, or cold bath, sea-bathing, tonics, chalybeates, good air. be. And in order to prevent the accident from taking place in the night-time, the child should not take any drink for some time before being pu t to bed ; the bladder should be always emp- tied before sleep . and if necessary, the child ought to be taken up in the night for the same purpose. If the infirmity arises from a want of ac- tion in the parts, causing the resistance in the urethra, tonics may be externally and internally employed. However, when the disorder has been of long standing, Desault found that they rarely succeeded. Palliative means are then the only re- source ; viz. instruments calculated either to compress the urethra, and intercept the passage of the urine, or to receive the fluid immediately it is voided. I he first of these plans is more difficult to accomplish in wo- men than men ; but it may be executed Ly means of an elastic hoop, which goes rounci Ihe pelvis, and from the middle of which, in front, a curved elastic piece of steel de- scends, and terminates in a small compress, which is contrived to cover accurately the meatus urinarius. (Sec (Eurres Chir. de De- sault par Bichat, T.3,p. 95, fyc") I.-irgo blisters, applk-d o*ec the os sac-un Mk> t BINE, KE1 CM ION Ol have often cured an incontinence of urine, both when the complaint seemingly arose from excessive irritability of the bladder, and from paralysis and loss of tone in this organ and the parts, which naturally re-ist the expulsion of the urine from it, the case being iu fact a retention " par regorgement," or, as one migiit call it in plain Knglish, a retention, combined wilh incontinence of urine. (See Mid. Obs. and Inq.) As, in some of these cases, the blisters removed also a paralysis ofthe lower extremities, they might have furnished a hint to the prac- tice of making issues for the relief of the palsy of the legs, conuected with the dis- eased vertebra;. URINE.: UK TENTION OF. Il is ob- served by tiie cx-.ierieiicc.-d Mr. Hey, lhat a »■ tention ot tiroie in the bladder, u hen the natural efforts are in< apaule of affording relief, is, in muh subjects, a disease oi great urgency and d-n^er. Persons advanced in years, oe more subject to this complaint, than the young or mi,idle-aged. Il i* of- ten brought on by an incautious resistance lo the calls of nature; ami if uot speedily relieved, generally excite*, some degree of (ever. The distinction, says Mi. Hey, which has sometime-, been made between a SHjiprtssion and retention of urine, i= practical ml judi- ciou- Tue former nvjit properly points out a defect iu the se-ere'ion ofthe kidneys ; the latter, au inability of expelling the uriiu when secrt-ief The retention of urine is an inability, whether total or parti"' of expelling, by the natural efforts, the u....e contained in the bladder. The characteristic symplom of this disease, previous to ihe introduction of '.he catheter, is a distention of the bladder to be perceived by an ex nninalion of the ■ iyp"gastrium,) after ihe patient has di - . harge.d all the urine, which ne i? capable of expelling. As this complaint may subsist, when the How of urine from Ihe bladder is by no means luu.lly suppressed, great caution is required to avoid mistakes. Vioient efforts lo make water are often excited at intervals, and during these strain i;i„s, small quantities of urine are expelled. Such a case may be mistaken for strangury. At other times a morhid retention of urine subsists, when the patient can make water with a stream, and discharge a quantity equal to tbat which is commonly discharged by a person in health. Under this circum- stance, Mr. Hey has known the pain in Ihe !iypoj»as;num, and distention ol the bladder, continue till Ihe patient was relieved by the catheter. And lastly, it sometimes happens, lhat when the bladder has suffered its inmost distention, the urine runs off by the urethra, as fast as it is brought inio the blad- der by the ureters. Mr. Hey has rcpeut- ediy known this circumstance cause a seri- ous misapprehension of the true nature of 'be disease. • fo forntinc a correct judgment of all these cases, it is very neccs-aiy ,o recoiled the important division ol retention* ol urine into the compUtc and incomplete forms ; a distinction which will at once put ibe surgeon on his guard r.^ninst a variety of ci ror*. In every case of retention of urine wliich the late Mr Hey attended, the disease could be ascertained by au examination of (he hy pogoslrium, Iqken in ctnnexion with the other symptoms. The distended bluddo.- forms there a hard and circumscribed tumour, giving pain io tha patient when pressed wilh the liaud. Some obseuriiy may arise upon Ihe examination of a very corpulent |*ersou , but in all doubtful cases, the catheter should be introduced Mr. Hey has not adverted lo the swellinf in ihe rectum, or vagina; nor to case* of contracted bladder, where, of course, Ihc iniurmation, de lived in ordinary instance* Irom (he lumour above the pubes, cunuot be had; but in other respects, bin ohserva- tions on the diagnosis arc practical and correct. M- Hey had seen only a few cases of is- churia rcnalis, or complete suppression of the seen tion of urine. The disease proved fatal in all his patients except one, iu whom il was brought on by the effect of lead, taken into ihe body by working in a pottery It subsisted three days, during a violent at- tack of tbe colica pictouum, and was then removed, together with ihe. original disease. Mr. Hey found no dilfi, ully iu distinguish ing this disorder, in any of the cases, from ibe ischuria vesicalis, though, for the satisfac tion ol some of his patients, he introduced tho catheter. (Practical Obs. in Surgery, p. 374, fyc.) Retention of urine, may be ihe effect of a great many different causes; as paralysis of ihe bladder; inflummuiion of ils neck; the presence of foreign bodies in H ; pressure made on ils cervix by the gravid uterus; en largement ofthe prostate gland, strictures in the urethra; be. Every case of retention of urine demands prompt assistance, but where the disorder presents itself in its complete form, the mis chief of delay is of the most serious nature ; for if (be bladder remain preternaturally dis- lendcd, it not only loses its contractile pow- er, but is quickly attacked wilh inflammation and sloughing. At length some point of it bursts, and the urine is extravasated iu the cellular membrane of tbe pelvis; spreading behind the peritoneum as far up a3 iho loins. and in olher directions, into Ibe perineum, scrotum, and the integuments of ihe penis, and upper part of the inighs. Ibe common result then of the rupture ofthe bladd-r, and the i-ffjsion oi its contents, is tbe speedy death c f ihv patient, from Ihe effects of this irritating fluid upu'. all the parts with which i' comes in contact, a ,otJg which effects is inflammation01 iheperitoncumnudboweW. It apiiears also from the observations, bolhof Desault and Sir Evererd Home, thai a con> plete retention of urit.e after a lime has ihe effect of putting a mechanical topimae ti UKLVE, KEIEMTON Ob. 669 tbe further secrelion oi this fluid in Ihe kid- neys; a circumstance which sometimes has a principal share in producing death, parti- cularly where litis event happens before the urine becomes extravasated. In all cases of retention of urine, the indi- cations are sufficiently manifest; viz. 1st, to adopt such treatment as seems best calcula- ted to procure a discharge of the urine through tbe natural passage,Which object is performed, sometimes by means of fomenta- tions, the warm bath, bleeding, opium, and olher medicines ; sometimes bv the removal of mechanical obstacles to the do iv of tbe urine; but more frequently by the use of the catheter, than any other means. When all tliese phi:*s fail, it then becomes necessary to puncture the bladder. 2ejly. The second indication, or that which presents itself after the immediate dangers of the distention of the bladder, are thus guarded against, is lo remove whatever dis- ease, or olber circumstance, constitutes the still existing impediment to the natural ex- pulsion of the urine'. Witb respect lo the fit manner and time of employing the several means for fulfilling Ibe above indications, and the selection which should be made of them, these are important considerations, which vary in dif- ferent cases, and actually cannot be under- stood, without due reference to the causes and circumstances of each individual case. A part of this subject belongs aiso to other parts of this work, to which, in order to avoid ihe necessity of repetition, I here refer. (See Catheter; Bladder, Puncture of; Prostate Gland, Diseases of; Urethra, Strictures of; ire.) With respect to catheters, we shall find that some cases require (he urine to be drawn off two or three limes n day, and the instrument to be taken out after each evacua- tion ; while in other instances, it is prudent lo keep the lube continually introduced. Here one general caution may be conveni- ently offered, which is, never to let a silver catheter remain in the passage more than a week or ten days, without taking it out and cleaning it; for if this be not done, the instrument becomes coated with deposits from the urine, so as afterward not to admit of being withdrawn through the urethra, without great suffering and irritation. The eye in the beak is also apt to become com- pletely.blocked up; and sometimes the pres- sure which the catheter makes on the part of !he urethra, corresponding to the root of tbe penis, in front of the scrotum, causes in this situation inflammation, followed by a slough as large as a crown piece, and an opening, formed by the loss ot suhstance is left, which may even continue fistulous during the pa- tient's life. These remarks particularly ap- ply to metalic catheters ; but such as are supposed to be made of elastic gum, espe- cially those ordinarily met with in the shops, re apt to spoil and become blocked up with mucus, if not taken out and cleaned, or changed, every five or six days. However, ss I ave mentioned in the article Prostate Vot. IJ. 73 Gland, Diseases of, Mr. Weiss has succeeded in constructing elrstic catheters, which will bear being retained more than a fortnight in the urethra, without becoming obstructed, besides having the advantage of always re- taining a due curve. 1. Ofthe Retention of Urine, to which per- sons of advanced age are liable—This disor- der is so common in elderly persons, that it is generally allowed to be one of the grie- vances to which Iheir period of life is par- ticularly exposed. In them the bladder is less irritable than in younger subjects, and hence, it is not so soon stimufated by the presence of the urine. In fact, it is not un- til a painful sensation arises from the disten- tion ofthe coats of the bladder, that the pa- tient is aware of the occasion to discbarge the urine. The bladder tben contracts ; bet still would not be able to expel its contents, were it not for the powerful action of the abdominal muscles. Nor is (he expulsion of (he urine even now complete; since Ihe bladder no longer retains the power of effa- cing the whole of its cavity. On the con- trary, after each evacuation, some urine is still left undischarged, ond already consti- tutes an incipient retention. The quantity daily augments, and at length, not more than half the fluid contained in the bladder is voided at each evacuation. According to Desault, the complaint par .ticularly attacks old subjects of a plethoric state of body, and of sedentary and studi- ous habits. It also especially afflicts those who, from carelessness or indolence, do not take time enough to expel the last drops of urine ; and others, who are accustomed to discharge their urine into a pot, as they lie in bed, instead of rising for the purpose. In these cases, the urethra and neighbour- ing parts seem to be free from every disease, capable of preventing the issue of the urine ; which has always come away freely, and in a full stream, although it could not be dis- charged with the same force, nor to the same distance, as formerly. At length, in- stead of describing an arch as it flows out it falls down perpendicularly between the legs. Towards the close ofthe evacuation, the patient is also not sensible of the final contractile effort of the badder, of which he used to be conscious in bis younger days. When he is about to make water, he is obliged to wait some time before the eva- cuation commences; and as tbe disorder increases, he cannot make water without considerable efforts ; the quantity of urine, voided each time, manifestly decreases; the desire to empty the bladder becomes more and more frequent; and lastly, the urine only comes away by drops, and an incontinence succeeds a retention. In this state, the patient's sufferings are not very great. The tumour, formed by the bladder above the pubes, is indolent, and, if it be pressed upon with some force, a certain quantity of urine is discharged from the urethra. The retention of urine arising from old age is seldom complete the urine, after l.'RIiNE, REiLMIO.N Oi having lim-Li und distended the bladder, dribbles out of the urethra, sp that the pa- tient voids as much of (his fluid in a given time, as he does in a state of health. Nor is this species of retention of urine com- monly attended wilh very urgent symp- toms. It docs not occasion, like complete retention, a suppression of the urinary se- cretion in the kidneys ; and as the urine escapes through the urethra, after the blad- der is distended to a certain degree, the disorder is less apt to produce a rupture of this organ, and dangerous extravasations of the urine. The swelling of the bladder then continues without any particular suf- fering, except a sense of weight about the pubes and perineum. 'I hese circumstances Have often led lo serious mistakes, and the disease has been set down as an abscess or drops-. Hie indications are to cvncuate the urine, and restore the tone of the bladder. When ihe retention is incipient, the proper action ofthe bladder will sometimes return afler cold applications are made to (he hypogas- tric region, or thighs, and the patient goes from a warm into a cool place in order lo make water. The patient must also be strictly careful lo make water immediately the least indi- cation to do so is felt; for, if this precau- tion be neglected, the bladder grows more and more inert; the desire to make water subsides; and the retention, which al first consisted of only a few drops, very soon becomes complete. It would then he in vain, as Default observes, to try the e\pe- dieuts above recommended. No stimulus will now make the bladder rontrar.l mi'Vi- riently to expel the whole of the urine, cud the catheter is the only thing, by which litis biid can l>e di---charj;cd. This artificial mode of evaluation, however, only affords temporary relief; fnr as the t.ladder is slow in i*t covering its tone, a relapse would be inevitable, it the employment of the cathe- ter were not continued. Hence thisinstru- ment must either be left in the bladder, or in- troduced as often ns (he patient has occa- iim to make water. \Vhen a skilful surgeon is constantly at hated, or when the patient knows how to pa=s fhe cathete r himself, Desault thinks it better to introduce the in- stroment only when the blu-Mer is to be emptied, by which means the incon .enience arising from the continual presence of a fo- reign body, will be avoided. In this cn«c, 'jithcr a silver catheter, or an elastjc gum one, may be used with equal advent;.ne ; but if the instrument is to be kept in the bladder, one made of elastic gum, try it ho can empty tin bladder without this instrument. When he finds that he can expel tbe urine, he should certify himself by means of (he catheter, that the last drops of this fluid are duly \ oided. Should they not be so, he must persevere in the use of Ihe instrument. In Ibis sort of retention of urine, it ha- been proposed lo throw into the bladder as- tringent injections: Desault tried them ; but, he does not give a favourable report of the practice. Warm balsamic, diuretic medicines ; cohl bathing ; and liniments containing the tine- turn lyttse ; have likewise been praised ; but according to Desault, these means frequent ly prove hurtful to persons of advanced years, and are seldom use ful. He restricted his own practice lo the use of the catheter, which, when skilfully employed, often re- stored the tone ol the bladder, and when il failed, other means also were ineffectual A blister over the sacrum niny deserve w trial Parsing over the coses of retention Of urine, relerred by Desault to the effects o< intemperance with women, and the iinmn derate use of diuretic drinks; cases which considerably resemble in their nature and treatment the retention, from the weakened state of the bladder in elderly persons, I proceed to another example of the disnrdei still more interesting to the practical sur- geon. 2. Retention of Urine from an Affeclion oj' the Nerves of Ihe Bladder.—These nerves may be affected either at their origin, or in (he course of their distribution. Injuries of Ihe braiii are seldom followed by a retentioc of urine, but the complaint often accom- panies those of the spinal marrow. A con- cussion of this medullary substance, from blows,, or falls upon the vertebral column ; the injury which it.-uffers in fractures and dislocations of the vertebra-, or from a vio- lent strain of the back ; ils compreshion by- blood, purulent matter, or olher fluid effu- sed in the vertebral canal, and the effects, which a caries of the spine has upon it ; may all operate as so many causes of a re- tention ot urine. This form of the com- plaint may also be the consequence of tu- mours situated" in the track of the nerves, which are distributed to the bladder. VVhetherthe retention of urine-, common in typhus (ever, arises from an affection of the nerves of the bladder, or from the general debility extending itself to the expelling powers, may be a question ;, but the liabili- ty of patients in fevers lo this disorder should never be out of the practitioner's recollection. When a retention of urine arises from in- jury or disease of the spinal mnrrow, an in- sensibility and weakness ofthe lower ex- tremities are almost always concomitant symptoms. The patients suffer very little ; most of them are ignorant of their condi- tion ; and do not complain of any thin-:; being wrong in the functions of the urinary organs. The surgeon, aware that a referj- URINE, RETENTION Ol 57) tion oi urine is common in these cases, should examine, w hether there is any inter- ruption of the evacuation, either by feeling the state of the abdomen just above the pubes, or by introducing a catheter. As this species of retention of urine is only symptomatic, and not dependent upon any previous defect in the bladder, it is not in itself alarming ; but with reference to its cause, il is exceedingly dangerous. Affec- tions of the spine, complicated with injury of the spinal marrow, are often fatal. By means of a catheter, it is always easy to re- lieve the inconveniences, arising from the bladder not contracting, and thus fulfil the only indication, which this sort of retention of urine presents; viz. the evacuation of tbe urine. But this proceeding is merely palliative ; and the bladder will not recover its contractile power, until the causes of its weakness are removed. The last then is the main object in the treatment, which must vary according to the nature and ex- tcut of the disorder. Tbe consideration in detail of all the means, which may be requisite for the relief of the different accidents and diseases of the spine, belongs to other parts of this work. (See Dislocations and Fractures of the Verlebrce; Vertebree, Disease, of.) In shucks and concussions of the spinal mar- row, Desault bad a high opiniou of the be- nefit resulting from cupping. This was done on, or near the part of the back, wbicb had been struck, and the number of scarifica- tions was proportioned to the strength of fhe patient. The plan was sometimes re- pealed the same day, and for several days in succession ; and when the patient could not hear the loss of more blood, dry cupping was employed, which in this country, would be deemed less efficacious, than stimulating liniments or blisters. In diseases of the spine, Desault also preferred the moxa, to caustic issues. 3. Retention of Urine from Distention of Ike Bladder.—Desault thought that this form of the disorder might very properly be call- ed secondary, because it is invariably pre- ceded and produced by a primary retention. Of course, its remote causes are all those cir- cumstances, which may bring on the other forms of the complaint; but its immediate cause depends altogether upon the weakness and loss of irritability in the bladder, occa- sioned by the immoderate distention of its coats. The disorder frequently occurs in persons, who from bashfulness, indolence, or intense occupation, neglect to make water, when they first bave the desire ; or who cannot for a time empty the bladder, in consequence of some temporary obstruc- tion in the urethra Although the impedi- ment to the escape of the urine no longer exists, and the bladder is in other respects sound, yet as this organ has been weakened by tbe excessive distention of its coats, it nmiiot now contract sufficiently to oblite- rate the whole of its cavity, and expel the last portion of urine. The indication is simple *• for there is not here, as in other retentions of urine, anothei disease to be remedied. The catheter, when left in the bladder, generally proves adequate to the restoration of the tone of this viscus. I do not conceive, however, that English surgeons will place any confi- dence in warm diuretics which were com- mended by Desault, though they may join him in the approval of a tonic plan of treat- ment in general. When the urine flows from tbe catheter in a rapid stream, and is projected to some distance, and when it also passes out between the catheter and the urethra, it is a sign that the bladder has re- gained ils power of contraction, and that it can empty itself, without the aid of the instrument. In this circumstance, the ca- theter is to be discontinued, and the patient may gradually resume his usual mode of life. But when the urine passes through the catheter only in a slow stream, the catheter eannot be laid aside, without the bladder becoming distended again, and losing whatever degree of tone it may have re- covered. The titne which the badder takes to re- ain its power of contracting, varies consi- erably in different cases. When the dis- ease is accidental and sudden, it frequently goes off in a few days. When it has come on in a slow manner, it usually lasts about six weeks. However, the cure is not to be despaired of, if tbe paralytic affection of the bladder should continue much longer. Sabatier says that he has seen patients wear a catheter upwards of ninety days, and yet ultimately get completely well. When there is reason for believing, that the urine will come away of itself, the use of the catheter maybe discontinued. When he makes water very slowly; when he is obliged to make frequent attempts; and when he feels a sense of weight about the neck of the bladder; this organ has not- completely recovered its tone, and the em- ployment of the catheter is still necessary When the patient could make water tolera- bly well in the day, but not during the rest of the 24 hours, Sabatier has often seen be- nefit arise from the catheter being worn only in the night-time. When three or four months elapse with- out amendment, Sabatier states bis convic- tion, that the tone ofthe bladder is lost for ever. In this unfortunate case, the patient should continue the flexible catheter, which he should be taught to introduce himself, as often as necessary. (See De la Medicine Operaloirc. T.2.) Among the means deserving of trial, when the,contractile power of the bladder does not return with the use ofthe catheter, I have to mention the tincture of cantha- rides; blisters applied to the sacrum, and kept open with the savine ointment; and cold washes to the hypogastric region. In all cases, where the incapacity of the bladder to contract, whether from weakness, or paralysis, is the cause of retention, and where, though the bladder continues dis- tended, a certain quantity of urine isv 'ider* UKlNE, RETENTION t-»l daily, mistakes are p.i Ocularly liable to be made. Thus, bc-iile-- the chance of the disease being mistaken for an abscess, as Colot states was not uncommon in his time, other errors may take place. Sabatier was consulted about a woman, who had been advised to repair to some distant mineral waters, with the view of dispersing a tumour, which remained after a difficult labour, and was supposed to be in the uterus itself. However, the swelling turned out to be only a retention of urine, as it disappeared as soon as the catheter was introduced. Here no suspicion had been entertained of the real nature of Ihe case, because the pa- tient had voided her urine in a voluntary manner, and in reasonable quantity, for the five, or six weeks, during which the swelling existed. In a thesis by Murray, a case is recorded, in which tbe swelling of the bladder was so considerable, that it was mistaken for drop- sy. The abdomen of a delicate woman began to enlarge, without any particular pain, and the cause was at first supposed to be pregnancy. This idea however, was re- moved by the enlargement increasing too rapidly, attended with a great deal of ana- sarca of the lower extremities, arms, and face. The patient was now considered lo be dropsical ; and a surgeon was sent for to tap the abdomen. The fluctuation in the belly was quite evident. Fortunately, be- fore the operation was done, a trial of diu- retic medicines was determined upon ; and while this plan was goin;^ on, the patient was attacked wilh a total retention of urine for three days; a symptom, which she had not previously suffered. It was now judged prudent to pass a catheter, before tlie tro- car was employed. Eighteen pints of urine were drawn off, and tbe swelling of the abdo- men subsided. The next day, twelve more pintsof urine were drawn off. The anasarca, wbicb was entirely symptomatic, disappear- ed. The application of cold water re-esta- blished tbe tone of the bladder, so that when three pints of urine had been drawn off by means of the catheter, the patient herself could spontaneously expel three or four others, with the aid of pressure on tbe hy- pogastric region. The retention of urine caused by weak- ness, or paralysis of Ihe bladder, and the swelling above the pubes, may continue a long while, without any inconvenience, ex- cepting a sense of weight about the hypo. gastric region, and frequent inclination to make water Sabatier has known patients labour under the complaint more than six months. 4. Retention of Urine from Inflammation of the Bladder.—According to Desault, writers have ascribed different effects lo an inflammation of the neck of the bladder, and to fhe same affection of tbe body of this viscus. They have in fact regarded the first case as a cause of retention ; and the last as a cause of incontinence of urine. An inflamed, highly sensible bladder, instead ■?f beiug weakened, has been supposed to acquire an increase ol energy, and to con tract with greuter vigour. But "if there had not been retentions of urine, which could be referred to nothing but inflammation of the bladder, still analogy might have unde- ceived us; for au inflamed muscle is never found disposed to contract, und if it be compelled to act, its action is alwuy.s fee- ble. Plethoric, bilious subjects, are suid to be particularly liable to this species of reten- tion it is also frequently occasioned hy the abuse of wine, or other spirituous liquors, heating diuretic drinks, or the external, or internal employment of lytta*. This form of the complaint makes its attack suddenly, and may be known by the frequent desire to make water ; the acule pain, iu the re gion of the bladder; pain, which is increusrd by the efforts to make water, and which shoots up to the loins, and along (be urethra to the end of the glans; by the frequency and hardness,of the pulse, and other symp- toms of fever; by the aggravation of the pain, when the hypogastric region is press- ed ; by the easy passage of a catheter into the bladder; by the acute pain, which is excited by the instrument touching the in- side of this organ ; and by the red, inflam- matory colour of the urine. In this case, the most prompt assistance is necessary. The urine, which is a source of additional irritation, should be drawn off. The catheter should be introduced with great gentleness, and merely far enough lo let its eye pass beyond the neck of the blad- der. The inflammation itself is to be counter- acted by the most powerful antiphlogistic remedies, large and repeated venesections ; the application of leeches to the perineum, and hypogastric regions; the warm bath; glysters; fomentations on the abdomen; and cold mucilaginous beverages. When the inflammation extends to the other ab- dominal viscera, attended with hiccough, and vomiting, and continues beyond the sixth day, the patient's life is in extreme danger. 5. Retention of Urine from Hernia of the Bladder.—An inability to discharge the urine is a symptom generally attending her- nia of the bladder. But the weakness of Ibis organ is not always the sole cause of the infirmity; for the urethra itself makes greater resistance than natural to the issue of the urine. As the neck of the bladder is drawn out of its right position by the por- tion of this organ which actually protrudes, the b:.-ginning of the urethra also undergoes an elongation, and a change of its curvature, by being pressed towards the symphysis of the pubes, and its diameter is likewise di- minished. The urine may also be detained in the pouch composing the hernia, iu con- sequence of the communication ^between this and the rest of the bladder being too small, or indirect, or perhaps from the her- nial portion not being compressed by the action of the abdominal muscle, or capable of any contraction itself However, the URENE, RETfibiiK'N Of y,3 rest oi this organ, within the pelvis, can it- self rarely expel the last drops* of the urine. Its complete contraction cannot be accom- plished without great difficulty ; and in the end it almost invariably follows, that the urine is retained both in the protruded and unprotruded portions. When a retention, arising from a hernia of the bladder, is complete, and occurs in both parts of this organ, there is, in addition to the symptoms common to other reten- tions produced by weakness of the bladder, a more or less considerable swelling in the situation ofthe hernia. The tumour is un- attended with any change of the colour of the skin ; is not very tender; and it presents a feeling of fluctuation, sometimes obscure, sometimes very distinct. When the swell- ing is pressed upon, the desire to make wa- ter is excited, or increased, and occasionally a few drops escape from the urethra. As soon as the urine has been drawn off with a catheter, and the patient is put in a pos- ture in which the protruded portion of tbe bladder is higher than the rest of this organ within the pelvis, the tumour subsides, and it is some lime before it becomes large again. When tbe hernia is recent, and the pro- traded portion of the bladder small and re- ducible, the part ought to be returned and kept up with a truss. When the part is ad- herent and irreducible, the swelling ought to be emptied by pressure, and supported with a suspensory bandage. If the hernia could in this manner be made gradually to return into the abdominal ring again, a truss would afterward be requisite. Proposnls have been made to endeavour to excite ad- hesive inflammation in the cavity of the protruded part of the bladder by compres- sion, gradually increased, and thus oblite- rate the pouch, in which the urine lodges. Although Desault thought the attempt cau- tiously made justifiable, he deemed there- with very uncertain. Were tbe retention of urine accompanied with a strangulated state of the protruded bladder, and the contents could not be pressed into the other part of this organ, a puncture of the swelling with a trocar has been advised. But if there were an entero- cele also present, as often happens, this ope- ration would be attended with risk of inju- ring the iutestine. Hence, Desault prefer- red opening the tumour by a careful inci- sion, and he even approved of cutting away the protruded cyst, if the communication betwixt it and the rest of the bladder were obliterated. For additional observations, 1 refer to the 2d vol. of the First Lines of Surgery, Ed. 4. 6. Retention of Urine, caused by displace- ments of the Viscera of the Pelvis.—The dis- placements, here signified, are-a retrover- sion, prolapsus, and inversion of the uterus, and a prolapsus of the vagina, or rectum. When the intimate connexions of the blad- der with the uterus and vagina in the fe- male, and with the rectum in the male sub- ject, are considered, it is obvious that the latter parts cannot be displaced, without drawing along with them the bladder; and that, in this state, whatever may be its con tractile power, it cannot contract so per- fectly as to expel the whole of the urine. To this deficient action of the bladder is necessarily joined an increase of resistance on the part ofthe urethra ; for, the begin- ning of this canal being drawn by the blad- der, changes its accustomed direction, and such alteration cannot be made without the sides of the tube being pressed together. Thus the retroverted uterus draws the os tinea? above the pubes, and the posterior part ofthe bladder is displaced, whfch, in its turn, draws along with it the commence- ment ofthe urethra, pulls it upwards, and increases the curvature, which this canal de- scribes under the symphysis of the pubes'; against which it is forcibly applied. In a prolapsus, or inversion ofthe womb, vagina, and rectum, the back part of the bladder, instead of being drawn upward and forward, is pulled downward and backward, and the curvature of the urethra is totally altered. Below the pubes the bladder forms a convexity, and not a large concavity, as in the instance of a retroversion of the womb. This position of the parts should always be recollected in passing the cathe- ter, as it shows what curvature and direc- tion should be given to the instrument, in order to facilitate its introduction. These retentions of urine are not often followed by any very bad consequences. It is generally sufficient to rectify the wrong position of the bladder, and the commence- ment of the urethra, by the reduction of ihc: displaced viscera, and a cire is then a mat- ter of course, unless the excessive disten- tion should have induced considerable weakness of the bladder, in which event, recourse must be had to the means previ- ously recommended for this state of the organ. The reduction ofthe viscera gene- rally forms the first indication, and the manner of accomplishing it is described un- der the head of Uterus. When tbe reduc- tion is not immediately practicable, or when it fails to remove at once the retention of urine, the catheter is to be used. Frequent- ly, when the urine has been drawn off, the reduction becomes more easy ; but, some- times, the altered direction of the urethra renders the introduction ofthe catheter dif- ficult; nor will the instrument pass, unless it be accommodated to the preternatural state of that canal. Thus, in the retrover- sion of thi*. uterus, a catheter, very much curved, answers better than one nearly straight, like that commonly used for fe- males. A curved catheter, says Desault, also an- swers in cases of prolapsus uteri, &.c.; but with this difference, that, iu a retroversion, the concavity of the instrument must be tinned towards the pubes, but, in the pro- lapsus, towards the anus. Sometimes tbe catheter will not pass unless it be rotated. as it v.i'i-' and uging more properly to midwifery,) there are other conditions of these organs which may give rise to a retention of urine. Thus it sometimes arises from the presence of virions kinds of tumours, or collections of b >od, or other fluid in tbe uterus, or ovary; or the distention of the vagina with the menses, pessaries, be. In such cases, Ihe retention of urine being only symptomatic, the prognosis must de- pend upon the nature of the cause, of which the interruption of the urinary evacuation is only an effect. The latter complaint is here not very dangerous, because its incon- venience may be obviated by means of the catheter. But when the cause of the reten- tion of urine is easily removed, and the tone of the bladder is not impaired, even the catheter is not always necessary, as when tbe complaint is induced by a pessary, or collection of blood iu the vagina. In other examples, in which the cause of the difficulty of making water cannot be imme- diately obviated, as in cases of tumours, the catheter must be employed. In scirrhous and cancerous diseases of the uterus, also, this instrument is the only means of re- lieving tlie retention of urine, as nature and art can do little for the removal ofthe cause. It ought to be known, however, that as these last diseases increase, an incontinence often succeeds to a retention of urine, in consequence of ulceration taking place be- tween the upper surface of the vagina and the lower part of the bladder. 8. Retention of Urine from pressure of Ihe Rectum upon the Neck of the Blwlder. Ab- scesses in the vicinity of this intestine he- morrhoidal tumours, alvine concretions, and the scirrho-contracted state of the guf, be. may bring on a retention of the urine by pressure on the neck of the bladder. The irritation, also, existing in these cases, may rend to produce tbe complaint by exciting a spasmodic contraction ofthe adjacent part of the urethra. Here the relief of the re- tention ofthe urine is to be effected by re- moving or curing the other disorder, which operates as its cause. If this cannot be im- mediately accomplished, the catheter must be used, though, in several instances, it will be belter to avoid even the irritation of the catheter, and try the effects of bleeding, the warm bath, and opium, which will fre- quently enable the patient lo make water. The last means, however, will not suffice, when the cause ofthe retention is likely to ontinue a lone tim*"* 9. Retention of I une from I-orttgn Boon in the li'addtr. Without stopping to con sider the uncommon kinds of retention pro- duced by carcinoma, fungous diseases, nnd hydatids in the bladder, let us pass on to the case, in which tbe urine is obstructed b\ a calculus at the neck of the bladder. Here the patient, by altering his position, fre- quently changes the situation of the stone and is immediately able to make wutei again. However, this expedient will only procure relief while the calculus is loose in the cavity of the bladder; for, after it has become fixed in the commencement of the urethra, it must either be pushed back with a catheter, taken hold of nnd brought out with the* urethra-forceps used by Sir A ' Cooper, or extracted by a kind of operation resembling the apparatus minor. See Li- thotomy. Many instances of various kinds of worm1 in the bladder are upon record. On ibh subject, an interesting paper was published a few years ago, by my friend Mr. Law- rence, who met with an example, in which an undescribed species of worms was abau danlly voided from the bladder. " The ori- gin of those animals (says Mr. Lawrence; which inhabit the internal parts of living bodies, is involved in much obscurity. Al though the intestinal worms appearmauifest ly, from their "peculiar form, consistence, and organs, to be particularly designed for those situations in which they are found ; although they have generative organs, and no similar animals are known to exist out of living bodies, yet it has been generally conceived that the germs, from which they spring, enter from the mouth. The production of hyda- tids in various parts of the body, cannot. however, be accounted for on such a suppo- sition ; neither can we very easily conceive, that ova should enter from w ithout into the urinary organs." The following facts, also stated by Goeze (as Mr Lawrence observes,j entirely overturn this opinion. Professor Brendel, of Gottingen, found ascarides in the rectum of an immature embryo. Blu- menbach discovered taenia; in the intestinul canal of young do^s a few hours after birth, be. ( Versuch einer Naturgeschichle der Ein- geweidewurmer, p. 55.) The case, which Mr. Lawrence has recorded, exhibits an un- questionable instance of peculiar and unde- scribed worms, voided from the urinary passages. This gentleman says, that he knows of no other case, in which a distinc! species of worm has been clearly proved to come from tbe bladder. Most of the cases published were instances of common intes- tinal round worms, which sometimes perfo- rate tbe intestines and are discharged by abscesses, or get into the bladder, after tbe formation of adhesions betwixt this organ and the bowels. In other instances, coag- ula of blood, mucus, or portions of the mu- cous coat of the bladder, have been mista- ken for worms; and as Mr Lawrence fuT- ther observes, some of the descriptions can apply only to larva? of insects. Two spe rimon0 of thi*1 Inst sort, he has ?e*n himself, I K1NL, RETENTION OF. wnich were soul trom u.o country as worms voided from the bladder. (See Medico- Chir. Trans, vol. 2, p. 382, fyc.) In whatever way these animals get info the bladder, a retention of urine may be produced, either when they are numerous, or when there is only one present, but large enough to obstruct the vesical orifice of the urethra. In tbe very curious example rela- ted by Mr. Lawrence, the passage of the urine was obstructed, and the use of the ca- theter continually necessary, 'ihe oil of turpentine was given internally, with some appearance of benefit at first; but, it after- ward brought ou febrile symptoms and ery- sipelas, and its exhibition could not be kept up. It was then injected into the bladder, with an equal part of water. This rather accelerated the discharge of the worms ; but they came away at times, whether the injectioii was used or not, and as this means produced tbe erysipelatous indisposition again, it was left off. Olive oil was after- ward injected; the irritation after it was less, and the fits of pain about the bladder less violent. It was calculated that at the time when Mr. Lawrence was writing the parliculare of the case, from 800 to 1000 worms had been discharged. For a detail of the,symptoms, aud a particular descrip- tion of the worms themselves, we must re- fer to tbe above-mentioned publication. According to tlie observations of Desault, a retention of urine is frequently occasioned by coagula of blood in the bladder. The blood is said sometimes to come from the kidneys, sometimes from the bladder, and sometimes it even regurgitates from the ure- ihra. While fluid, it may be expelled wilh the urine ; but, when coagulated, it is no lougcr capable of being discharged. Il is the blood, w hich passes into the bladder, af- ter wounds, or the operation of lithotomy, lhat is most disposed to coagulate. If the clots were too large to pass through a cathe- ter, the best plan would be to inject into Ihe bladder lukewarm water, for the purpose of loosening and dissolving them. A retention of urine, has sometimes arisen irom the entrance of a piece of bougie into the bladder. Even whole bougies, which had not been properly secured, have been knownto glide into the cavity of that organ. AjDesault observes, the urethra appears to pouess a kind of antiperistaltic action, by which it tends to draw into the bladder whatever substances it includes ; for, says he, it is constantly noticed, that when these bbstances are once within the urethra, if they be not expelled by tbe urine, they al- ways udvancc- towards the blade-r, a cir- cumstance , which cannot be accounted for by their weight. The insinuation of these foreign bodies into the bladder is a serious occurrence both for the patient and surgeon. The for- mer cannot avoid the consequence which will sooner or later originate from the ex- traneous substance, except by submitting to a dangerous and painful operation.: the lat- !-r will be accused of beting the author of all the evil, and will find it difficult to excul- pate himself. In order to obviate the neces sity of cutting into the bladder, in such cases, Desault proposed the use of small spring- forceps, passed into tbe bladder through a cannula, but, although the instrufnent seem- ed to answer on the dead subject, no instan- ces of its doing so on living patients are on record. Were any instrument likely to succeed, 1 think it would be the urethra- forceps, shaped like a sound, employed by- Sir A. Cooper for the extraction of small calculi from the bladder.' (See Lithotomy and Urinary Calculi. 10. Retention of urine from Inflammation of the Urethra. In order to comprehend the mechanism of this case, it is neces- sary to remember, that inflammation never exists, without swelling, and that every tumefaction oi the lining of the urethra, must necessarily lessen its diameter. In- 'flammation of the urethra is most common- ly produced by the external application, or internal exhibition, of lyttae; by gonorrhoea; the unskilful use of the catheter; the em- ployment stimulating injections ; bougies ; be. Together with the lessening of the ca- nal by the effect of swelling, there can also be no doubt, that, in many of these instan- ces, a spasmodic contraction of the urethra and neck of the bladder also contributes to the retention of urine. Although Desault believed that inflamed parts, endued with a contractile power, were not disposed to con- tract in that state, yet, it should be recollect- ed, that even admitting Ibis to be true, the whole length of the urethra is seldom in- flamed, and a part of it may therefore be af- fected with a spasmodic action, without the theory espoused by Desault being at all im- plicated. The effects of opium, tobacco, and other antispasmodics, often evinced in immediately relieving these kinds of reten- tion of urine, seem indeed to leave no doubt respecting the existence of a sort of spasm in the passage. Whatever may be fhe cause of inflammation of the urethra, the diagno- sis is free from all obscurity. Besides the general symptoms of inflammation, the pa- tient complains of a scalding sensation in the passage: he experiences a great deal of smarting, which is sometimes insupportable, when he makes water; the penis becomes in some degree swollen, and more tender; and a very little pressure on the urethra gives acute pain. In the mean time, the stream of urine becomes les ened ; and, at length, this fluid cun only be voided in n very narrow current, or only by drops, and often not at all. The disorder is to be treated on antiphlo- gistic principles. Diluting, cooling, mucila ginous, beverages ; venesection ; leeches to the perineum; the warm bath; opiutn, particularly in the form of clysters, and fo- mentations, are the means which usually give relief. When inflammation exists in the urethra, it is always desirable to avoid, as long as possible, the employment of ca- theters, which create irritation, and of course increase- the e?*usc of the retention. It i« u;o UJR1NK, Kl. particularly, in cases ol this description, and in the'retentions of urine, arising from strictures, that Mr. Larle has suggested the use of tobacco in the form of clysters; a method, deserving adoption when the means above enumerated are unavailing, and it is preferable to the catheter, because it does not cause any increase of iiritati'm and in- flammation in the urethra. (>ce M.-d. Chir. Trans vol. 6, p. 82, fyc.) II. Retention of Urine from Laceration of the Ureihra. The urethra is sometime- nip tured by violent contu-ions on the perinamm; and the rough and un-kinul use of bougie* and oath--t»-rs. The consequences usually are, au extravasation of urine in tin < ellul- rmem- bmnc of the scrotum and penis ; a conside- rable dark-coloured swelling of these parts, often followed by sloughing ; nnd retention of urine. The treatment c insists in in ro- ducing an elastic gum calheter into the blad- der, wth as little delay as possible, Bnd keeping it there until the breach in the* canal is repaired. At the -aim* time, Ihe evils threatened from the effusion of the urine are lo be lessened as much as possible, by ma- king two or three free incisions in a depend- ing part of Ihe swelling, and the employ- ment of fomentations, and antiphlogistic re- medies. 12. Retention of Urine from Tumours situ- ated in the Periiucum, Scrotum, cr Penis. A retention of urine hns been known to arise from phlegmonous swellings and abscesses ; extravasations ot blood; and urinary tu- mours and calculi formed in the perinaeum and scrotum; also from the p.i-ssiire of a sarco- cele ; hydrocele; a very large scrotal her- nia ; un aneurism <>f the corpus caveroosutn ; a ligature on ihe penis; kc. The radical cure ol all such retentions of mine can only be ai omplis-hed by curing the disease, on which they are dependent. However, until the cause can be obviated, the mini* must be dra* n off with a catheter. Elastic gum-catheters u-ually enter more easily than those made of ^ tier, as by th«tir flexibility they .iccommodate themselves bel- ter to any deviation of the. urethra from it- ordinary direction. Desault particularly re- commended a catheter ot middling size to be selected, and introduced, armed with its stilet, until it stops in the canal ; when he advised withdrawing the sti! t for aboui an inch, in order to leave the beak of the in.-.tru- men; quite free, so lhat it may follow the curve ol ihe urethra. Then the tube and the stilet are to be pushed further into the canal, care being take- , however, to keep the «tilet draw.i bnk some distance from the extremi- ty of the instrument By these precaution?, says Desault. the catheter may el>\ays be aot iuto the bUddt-r. Should the introduc- tion prove neither painful nor difficult, De- sault thought it better not to annoy the pa- lient by making him continually wear the instrument 13. Retention of Urine from Disease of lite Prostate Gland. As a grcal deal has been said concernins this cas** in h foregoing a-':"-- It.Nik)A Oi* cle, (see Prostate Gland,) 1 shall not urre de lain the reader long upon the subject. When the swelling of Ihe prostate glanc is of an inflammatory kind, the retention of urine make« its appearance with the same kind of symptoms as attend inflammation about the neck of (he bladder. Here similar treatment to lhat commonly adopted for Ihe retention of urine produced in the latter case, is indicated ; particularly bleeding, fomentations, the w arm bath open- ing medicines, anodyne clysters, the tinctura ferri muriati, and in very obstinate urgent cases, an enema of tobacco. If Ihese means fail, the surgeon may gently endeavour to introduce an elastic j*,um catheter. The symptoms of the retention of urine, caused by chronic enlargement ofthe pros tate gland, and the reason ofthe impediment to the discharge of that fluid in such a case, are explained in another part of this work. (See p.378, fyc. Vol.2.) From (he remarks there introduced, it appears, that when the regular evneuation ofthe urine begins lo be impeded, the catheter becomes indispen- sable, though (he surgeon will often be foiled in his endeavour to draw off the urine with it. unless he be duly acquainted with the morbid changes produced in the parts. And, as Sabatier long ago very correctly observed, the urine may not be discharged though the instrument enter a considerable way, either because its beak becomes en tangled in the prostate gland, or between a swollen portion of this gland and the neck of the bladder, and does not reach the urine Hence Sabatier recommended the employ- ment of a catheter With a very long beak, which'should also be bent considerably up- wards. When, however, all efforts to pass a catheter fail, the only resources are to force a passage with a conical cathel'-r, as explained in Vol. I, or to puncture the blad- der above the pubes. (See Bladder, Punc- ture of.) In this case, the operation should never be done through the perinieum oi rectum, as the great size which the diseased prostate gland sometimes attains, would be au obstacle to making a puncture in either of ti.eae situations. Puncturing the bladder, however, is only a temporary means of re- lief; and until a catheter can be passed quite into the bladder, the cannula of the trocar should not be withdrawn. The objections to leaving the cannula in the wound any considerable time, are tbe irritation of the extraneous body ; the fear of calculous incrustations forming both on the outside and inside of the cannula ; and the hazard of not being able to find the track into the bladder again, if the instru- ment \yere taken out for the purpose of being cleaned. However, Sabatier approves ofthe practice under the foregoing circum- stances. And Colot adduces two instance- in which it proved very serviceable. Sa- batieralso refers to another example of si mi lar success, related in the thesis by Murray When Dr. .Murray saw the patient, the can nula :iad been worn more than a year. The patient was sixty years of a;£e, and enjoyed URINE, RETENTION OF. 677 very good health. He was in the habit of taking a stopper out of the cannula every four hours. The wound had healed very well all round the tube, and was quite free from redness. (Sabatier, Midecine Opira- loire, T. 2, p. 140.) For further observa- tions, see Catlieter and Prostate Gland. 14. Of the Retention of Urine produced by Strictures in the Urethra. From the ac- count, which is given of strictures in ano- ther part of this Dictionary, (see Urethra, Strictures of,) it appears that almost every stricture, bad as it may be, is capable of being rendered still worse, and the morbid part of the urethra more impervious by a spasmodic affection. Going out of a warm into a cold situation, drinking, and other kinds of intemperance, will often bring on an irritable state ofthe canal, attended with a spasmodic action of the strictured part, an increased difficulty of voiding the urine, and even a total retention of this fluid. The patient makes repeated efforts to re- lieve himself; but hardly a drop of urine is discharged. In the meanwhile the bladder becomes filled, and ascends above the pubes; the abdomen grows tense and pain- ful; fever comes on; the countenance looks red ; the brain becomes affected ; and circumstances assume an extremely urgent nppearance. In this case, antiphlogistic means should be adopted without delay. The patient ought to be bled, if nothing in his constitu- tion and age prohibit this evacuation, which it may even be proper to repeat. He should also be pat into the warm bath, and fomen- tations should be continually applied to the hypogastric region. Slightly diuretic beve- rages may be prescribed, and leeches put on the perinamm. The principal means, however, from which the greatest benefit may be expected, is a liberal dose of the tinctura opii, together with an anodyne glvster. This is also another example, for which Mr. Earle has particularly recom- mended the exhibition of tobacco in the form of a clyster; and he has related a •ase in illustration of the efficacy of the plan. (See Medico-Chir. Trans. Vol. 6, p. 88.) The tinctura ferri muriati, which, ac- cording to Mr. Cline, has a specific effect in overcoming spasm of the urethra, seems also worthy of trial. Indeed it should al- ways be tried before tobacco, which being ■-ometimes violent in its effects, ought per- haps to be the last resource in the way of medicines. When such measures fail in enabling the patient to empty his bladder, and this viscus is becoming more and more distended, an immediate attempt should be made to introduce a small flexible elastic ?um-catheter through the stricture or stric- tures into the bladder, which object may **« frequently accomplished, when due care, perseverance, and gentleness, are not ne- glected. Sometimes when a small flexible catheter cannot be introduced, a fine bougie admits °f beinir passed into the bladder, and on ''oj_.Il/ m 73 being withdrawn, the urine follows, and n discharged. When all the preceding plans prove un- availing, and the danger arising from the retention of urine continues to increase, either the stricture must be forced with the corneal sound, an incision practised behind the obstruction, or the bladder punctured. The cannula of the trocar should then be left in the wound till the strictures are either cured, or at least till the urine re- sumes its natural course. 1-5. Retention of Urine from ths Lodgment of Foreign Bodies in the Urethra. That such accident must obstruct the discharge of urine is too plain to need any particular ex- planation. Calculi are the most common substances which bring on this kind of case ; but articles, introduced into the urethra from without, such as bougies, large pins, &,c. are occasionally lodged in the passage ; and I once extracted from a man's urethra' a long black pin, with which he had been examining the passage. The head of it was towards the perinamtu, and the point about two inches from the orifice of the glans. I passed the point through the lower surface of the urethra, and then taking hold of it, drew it further out, turned the head towards the glans, from the orifice of which it was then easily removed. When substances like calculi lodge,oily injections are some- times tried with the view of rendering the passage more slippery; and occasionally the dilatation of the canal with bougies or catheters, followed by a very forcible ex- pulsion of the urine, has answered. The ancients sometimes tried the effect of suc- tion. When the foreign body is closely embraced by the urethra, and it cannot be pushed forward with the fingers, Desault re- commends endeavouring to extract it with the forceps, invented for tbe purpose by Mr. Hunter, and which are contained in a cannula ; or the uiethra forceps, spoken of in the articles Lithotomy and Urinary Calculi might be employed. When, however, the foreign body is too barge to be taken out in this manner, it must be extracted by an in- cision. If an elastic catheter be now kept in the urethra, so as to prevent the urine from coming into contact with the cut part, the wound will heal very well. Some time ago there was published a case of calculus in the urethra, attended with dysury, where almost instantaneous relief was obtained from the exhibition of a tobacco clyster. The patient soon felt a strong desire to void his urine ; and " upon making the attempt, a large calculus came rolling along the urethra, with complete relief of all his com- plaints." (See Edinb. Med. and Surg. Jour- nal. Vol. 12, p. 373.) Fr. M. Colot, Traiti de V Operation de la Taille ; avec des Obs. sur la Formation de la Pierre, et les Suppressions de I'Urine, fyc. 12mo. Paris, 1727. Sabatier, De la Mide- cine Opiraloire, T. 2. C. B. Trye, Remarks on Morbid Retentions of l^rine, 2d Ed. Svo. Gloucester, 1784. Hey's Practical Observa- tions in Surgery. Schreger Chirurgische Ver- UTERI • •■*, INVERsiON oi suchc, p. i.s7, «yc. der Ischuria Calculosa, Sro. Aurnberg, 1811. Desault's Parisian Chirurgical Journal. S. T. Soemmering, Ab- handlung uber die schnell und langsam todt- lichcn Krankheiten der llarnblase und Harn- rohre bey Manntrn in hohen Alter. 4to. Frank. 1809. Richter. Anfangsrunde der Wundarzneykunst, B. 6, p. 210,fyc. CEuvres Chir. dt Desault par Bichat, T. 3. Desanjt et Chopart, Traiti des Maladies des Voies Urinaires, Svo. 1796. Nauchc, Noucelles Re- cherches sur les Retentions d'Urine par Relre- '■issement de I'Urclre, et par Paralysie de la Vessie, fyc. Svo. Paris, 1806. Home's Prac- tical Observations on the Treatment of Stric- tures, fyc 3 vols, and on Diseases of the Pros- lale Gland. 2 vols. 8j*i-». Lond. 1811—1818. //. Earle, in Medico-Chir. Trans. Vol.6, p. S2, fyc. UTEUL'S, INVERSION OF. This case may either be complete or incomplete. When it is incomph-te, only the fundus of the uterus passes through the os tinea*. When the inversion is complete, the uterus becomes entirely turned i;i-ide out, passing through Ihe opciiiu ; in its cervix, dragging along with it a part of the vagina, and de- scending more or less far down, sometimes even between the patient's thighs. The inversion of the uterus mostly arises from the manlier in which the placenta is extracted after delivery. Immediately after parturition, the uterus is not yet contracted, und its cervix is in a widened state. When things are thus disposed, the uterus may pasily follow the after-birth, which is attach- ed to it, and thus become inverted. The event is particularly liable to happen. 1st, When a premature attempt is made to ex- tract the placenta. 2dly, When the funis is pulled outward, without due care'being ta- ken to support the uterus with the fingers of the left hand. 3dly, When the operator draws out the afterbirth ,too roughly and violently. Though the placenta is some- times so adherent that its extraction is diffi- cult, and a risk must be encountered of dragging down the utefus with it, this dis- agreeable accident may generally be avoided by performing the necessary sepaialion of the parts with the fingers introduced into the cavity of the uteri's. The inversion, following delivery, does not always proceed from unskilfulness; but sometimes happens, notwithstanding every precaution, either because the patients themselves make too violent efforts, or be- cause the uterus is enlarged and heavy; or else in consequence of some predisposition, .ome unusual laxity of the organ, which can neither be foreseen, nor prevented. Ruysch saw an inveision of the uterus take place, afler the expulsion ofthe placenta, although delivery had occurred in the most favour- able way. Mr. Windsor believes, that where the uterus and vagina are in a relaxed state, and the female has beeii subject to prolapsus _.t-ri, there is a greater disposition to the -icurrence of inversion, at the time of la- bour, than when sucii condition ol the pan does not exist. (Med. Chir. Trans. Vol. 10, p. 360.) A tendency to the accident is very com- mon in women who have once been afflict- ed with it. Amand mentions a woman, who had nn inversion of the uterus after her first delivery, but the part was reduced. She was attended by Amand again in bet- next confinement; and another inversion of the uterus, quite as bad us the first, » ould have happened, had not he, on perceiving the disposition to the accident, introduced his finger into the cavity of the uterus, and separated the placenta from its attachments, before making any attempt to extract it. Besides causes, connected with parturi- tion, there are others of a different nature. Ruysch, Mauriceuu and Lainotte, supposed an inversion ofthe uterus could only happen at the time when the placenta was extract- ed, or a little while afterward. The acci- dent seemed to (hem impossible al any other period, both on account of the thick- ness of the uterus, and the smallness of the os tinea?. However, many facts prove that the case may also depend on internal causes, and affect women Who have never had children, as well as others who have had them. Thus polypi of the uterus may bring on inversion of the purl. As their pedicle is attached to the fundus of the uterus, they may easily drag it downward when its texture is lax and soft, particular- ly us tbe operation of their weight is conti- nual. (See Denman's Plates of a Polypus with an Inversion of the Uterus. Fol. 1801.) Uterine hemorrhages may also be Conducive to the accident, both because they relax tht; texture of the uterus, and because they are usually attetnV'd with acute pain, wliich makes the diaphragm and abdominal mus- cles act upon the uterus with all their power. Levret speaks of a case of inversion of (he uterus, where the emplacement was not noticed until five years after delivery. In (his example, it is conjectured that the very gradual and slow formation of the disease must have been the reason of its not having attracted earlier attention. (Did. des Sci- ences Mid. T. 23, p. 288. Also liaudelocquc., in Brogniard, Bulletin des Sciences, 2, N. I.) When an inversion of the uterus takes place alter delivery, there are certain symp- toms by which it may easily be known. The uterus, in its natural situation, thicken- ed and swelled as it is at this period, pre- sents itself in the hypogastric region in the form of a round circumscribed tumour ; bin when il has fallen downward, and become inverted, a vacancy is folt in the situation which it ought to occupy. When the in version is incomplete, an e\au..nation with the fingers detects in tbe vagina a tumour, shapen like the segment of a sphere, having a smooth surface, and being surroundeu with the cervix uteri, as with a kind of col- lar, round which tbe finger may easily be passed, either between it and the uterus, or between it and (he vagina. Wh«.n the in- UTERUS, INVERSION OF version is complete, which case is more rare than the preceding, a tumour may be felt in the vagina, from which it sometimes even protrudes, apt to bleed, of an irregu- larly round shape, hanging by a neck, the lower part of which is surrounded by the above circular, thick, fleshy substance, con- sisting of the os uteri itself. The slightest touch makes the swelling bleed. The part has a red colour, which, however, generally diminishes in proportion to the duration of the displacement. In time, indeed, its sur- face becomes less sensible to external im- pressions, and only bleeds at the menstrual periods, the blood oozing from every point ofthe swelling, and not issung from a sin- gle aperture at the lower pari of the tumour, as in cases of prolapsus uteri. In the incomplete inversion, patients feel acute pain in the groins and kidneys, an oppressive sense of heaviness in the hypo- gastric region, and a tenesmus, which, com- pelling them to make violent efforts, forces the uterus further down, and sometimes pro- duces a total inversion of it. Besides these symptoms, more or less copious hemor- rhages also occur. When the inversion is complete, the pain is more acute, the loss of blood more considerable, and the patient often affected with peculiar weakness, fol- lowed by cold sweats, convulsions, and de- lirium. In both forms of the disease, if the reduc- tion be not almost immediately effected, fatal consequences frequently ensue, either very soon after the accident, from the vio- lence of the hemorrhage, or at a more or less remote period, partly from repeated losses of blood, and partly from the constitutional irritation and disturbance incessantly kept up. Happily, as Mr. Windsor observes, the accident admits of remedy, if an intelli- gent person be present to replace the uterus; for if this be done immediately, and the hand of the accoucheur be retained iu the cavity of this organ, until it has contracted, and the patient afterward confined to the recumbent posture, she will generally do well. An unsettled point appears to be, whether the placenta, if still remaining, should be extracted before, or after the re- duction. Mr. Windsor, who appears inclin- ed to prefer the latter method, refers to two examples, in which each plan was followed by a recovery. (See Med. Chir. Trans. Vol. 10, p. 360.) And, in all cases, as the same, author re- marks, the accoucheur, after the expulsion of thejtplacenta, should assure himself by manuapexamiiiation, that the os internum is free, while an endeavour is made to feel the uterus with the hand placed upon the abdo- men. « In consequence of the neglect of this practice (says Mr. Windsor) it is to be feared, that many lives have been lost; the true cause of the succeeding hemorrhage not being ascertained till too late, as hap- pened in the fatal case that occurred to a mid- wife here (Manchester) last winter." Some women perish at once, or within a few hours, and, when they live longer, the re- duction is exceedingly difficult, because the uterus and its cervix are becoming more and more contracted. In the reduction, Sabatier regards (he in- terposition of linen, between the bauds and the uterus, as unnecessary and even disad- vantageous, because it prevents the practi- tioner from having the assistance of a correct feel of the part. The trial should be conti- nued as long as (he patient's strength will allow. However, if the lumour were in an inflamed state, it would be prudent to put* the patient in the warm bath, use emollient applications, and exhibit anodyne and laxa- tive medicines, be. Wheu the reduction cannot be accom- plished, many die, while others survive, subject to an oppressive sense of weight, and frequent hemorrhages, which bring on great emaciation. Sabatier attended two patienfs, who had an inversion of the ute- rus, six months, and yet they vvere able to go about their family affairs. The same author had heard of other women, who had been afflicted with an inversion of the uterus several years. If the reduction cannot be performed, and the patient survive the immediate ef- fects of the injury, "some degree of in- flammatory symptoms, accompanied with fever, ensues. The abdomen becomes full, tender to the touch, and, at its lower part, sometimes rather hard There is costive ness of the bowels, and sometimes retention of urine, requiring for a time the use of the catheter. By the use of fomentations, ene- mata, laxatives, and an antiphlogistic regi- men, the symptoms abate, tbe power of expelling the urine, especially if the uterus is first raised a little in the vagina, is regain- ed, and the patient gradually recovers the full power of this function. Afterward she becomes able to walk about, suckles her infant, and perhaps enjoys apparently even a tolerable state of health ; yet, the sangui- neous discharges generally after a time," return profusely, and her pale countenance, and emaciated appearance indicate the greatest debility. " About the time, when she relinquishes the office of suckling, the menses return more regularly, the discharges of blood are very considerable in quantity, or of long duration ; the mucous discharges are gene- rally copious at other times ; and the con- stitution begins to sink under the reiterated losses it sustains. The pulse becomes fre- quent, the appetite is impaired, a cough, with hectic symptoms sometimes occurs, and the patient is quite unable to pursue her usual domestic duties. In this state pallia- tive means, as the use of astringent and olher remedies, become inadequate to check the exhausted progress of the complaint, and the unfortunate sufferer must soon perish, unless some decisive means be devi- sed for her relief. In this painful extremity, the extirpation of the uterus itself has been proposed as the most efficient means of re- lief, and formidable as the operation nt first b*>0 LTEKLS, INVERSION: OL view seems, it is known to have been al- ready performed with syccess." Windsor, in Med. Chir. Trans. Vol. 10, p. 361—63.) One of the most afflicting consequences of an inversion of the uterus, is so consi- derable an inflammation of the part, as to induce a danger of its mortifying. In this circumstance, the extirpation of the uterus has been also suggested, and even practised; an operation that has had but little success, the majority of patients on whom it has been practised under such circumstances having died. The practice- of extirpating the inverted uterus, through apprehension of the part mortifying, cannot be too strongly repro- bated ; for unless mortification has really happened, the uterus may possibly be brought into a state again, in which the inconveniences arising from its inversion would be very supportable, and the opera- tion altogether avoided. Even supposing mortification were to take place, the Judica- tion would be to appease the bad symptoms, and promote the separation of the sloughs by suitable applications, without doing any injury to the living parts. One example, in which the latter practice was successfully adopled, is recorded byRoussct. That the extirpation of the uterus, when this organ is completely or incompletely inverted,totally irreducible, and attended with the suffer- ings and reduced health, so well described by Mr. Windsor, may sometimes be advisea- ble, cannot now be doubted. Tlie unequi- vocal examples on record of the removal of the cancerous uterus by Osiander,Dupuytren, Langenbeck, and others, and the eases, published by Mr. Newnham and Mr. Wind- sor, where the inverted and irreducible uterus w as successfully extirpated, furnish sufficient evidence in favour of the practice without referring to numerous other cases reported on older authorities, the correct- ness of some of which may be question- able. In fact, polypi, growing from the uterus, frequently attain so considerable a size, that (hey protrude out of the vagina, and are oc- casionally mistaken for the uterus ilself. The surgeon extirpates the tumour with a li- gature ; the operation does not undeceive him about the nature of the part; his patient has a favourable recovery; and the case is published as an instance of the successful extirpation of the uterus itself. Although it is easy to distinguish the in- version of the uterus, which happens soon after delivery, it is not so to make out the nature of such cases, as happen in other circumstances, nolwithslaiidingthe presence of the same kind of symptoms. As cases of the latter kind are uncommon, and, conse- quently, not expected, mistakes are the more liable to be made. A polypus has often been mistaken for an inversion of the uterus, but, it should be recollected, that the upper part of a polypus is always nar- row ; and the tumour, which is not very sensible, is irreducible ; whereas, the uterus, in a state of incomplete inversion, forms a semi-spherical swelling,sometimes a little oblong, but always broader above than be- low. It is very sensible, und may generally be reduced. And, when the inversion is complete, the tumour has a greater resem- blance to a polypus, inasmuch as it seems to have a pedicle, but the impossibility of in- troducing a probe far at the circumference of such pedicle, as can be done in cases of polypi, will generally serve at once as a criterion of the nature of the disease. The greatest obscurity in the diagnosis is said to prevail when the inversion is partial and chronic, because the us uteri then encir- cles the summit of the tumour, just asit does a polypus, and, iu both cases, the finger will pass all round between the parts. (See Newnham's Essay on Inversio Uteri, with a History of the successful Extirpation of that Organ, p. 82, 8ro. Lond. 1818.) However, as I do not believe with (his gentleman, that Ihe neck ofthe polypus isfreejuentiy us large, and sometimes larger, (ban ils inferior por tion, I should yet expect, that the difference in the form ofthe two swellings, perceptible on manual examination, would nere be au important criterion. In general, also, the fact, that inversion of the uterus first hap pens, al or soon after delivery, is a conside- ration, that would tend to a right discrimi nation of the cases? inasmuch as the first protrusion of a polypus directly after delive- ry, is rare, and, when it does happen, under these circumstances, is probably always com- plete, and not partial. Reduction is the only plan, whether the case has arisen from the weight of a polypus or irom uterine hemorrhage. However, this proceeding is generally useless, when the disease originates from obesity. In the latter case, as the cause still continues in full force, the uterus is soon displaced again, and a pessary is the only means to which the patient can resort. Having delivered many additional obser- vations on the subject of inversion of the womb, in the 2d vol. of the First Lines of Surgery, Ed. 4, I shall here conclude with referring to some works, in which the reader will find valuable instruction on the subject. F. B. Wachler, de Prolapsu et Inversionc Uteri, Hala, 1745. Ad. Natura Cur. Vol. 6, Obs. 107, uterus feliciter extir- patus. Nauche, des Maladies de I'Uterus. Sro. Paris, 1816. Osiander, Neue Denkuiirdig keileu, 1 B. p. 307. Sabatier, Midecine Opiraloire, T. 2. Did. des Sciences Mid. T. 23, p. '287. W. Newnham, on /A' Symp- toms, Causes, and Treatment ofiinversio Uteri, with a History of the successful Extir- pation of that Organ, during the Chronic Stage of the Disease, Svo. Lond. 1818. J Windsor, Obs. on Inversion ofthe Uterus,with a Case of successful Extirpation of that Organ, Med. Chir. Trans. Vol. 10, p. 358. fyc. Den- man's Plates of a Polypus, with an Inversion ofthe Uterus, 1801. Dr. Baillie's Series of Engravings, fyc. Ease. 9, Tab. 5. Cleghorn, in Med. Communications, Vol. 2 : a chronic UTERUS, PROLAPSUS OI 581 case. E. h Herzog de Inversione Uteri, 4to. Wirceb. 1817. UTERUS, POLYPI OF. (See Polypus.) UTERUS, PROLAPSUS OF. The womb, situated in the upper and middle part of the pelvis, is but imperfectly se- cured in ils natural place by means of its broad and round ligaments. Hence it some- times descends into the lesser cavity of the pelvis, so as to pass more or less down the vagina, or even protrude beyond the labia. The first case is the incomplete ; the second, the complete prolapsus uteri. In the first form ot the disease, where the uterus bas not passed down so low as to protrude externally, some of the complaints which the patient experiences depend upon tbe pressure of the displaced viscus upon the parts unaccustomed to it, particularly the bladder and rectum ; while other inconve- niences arise from the tension of the liga- ments, destined to retain the organ in its natural positioti. These last grievances are chiefly a sense of heaviness in the pelvis, and a dragging pain in the loins ; symptoms which are aggravated when the patient sits up, or walks about; but diminish when she remains in bed, though as the disease, wheu neglected, scarcely ever fails to grow worse, they rarely subside altogether. However, such amendment actually sometimes hap- pens in consequence ofthe parts becoming gradually habituated to their change of si- tuation. When the disease comes on with great suddenness, the symptoms are re- marked to be much more severe than when itlakes place slowly. In the first case, long- continued syncope, pain over the whole abdomen, tenesmus, uterine hemorrhage, in- flammation of the peritonaeum, and severe febrile symptoms may be excited. With regard to the effects, caused by the pressure of the tumour on the bladder and rectum, they consist of more or less diffi- culty iu voiding the urine and feces. The dysury and constipation increase in propor- tion as the patient continues in an upright posture, and the uterus descends nearer to the inferior orifice of the vagina. Some- times the irritation brings on a consi- derable mucous discharge, which, when the patient suffers little other inconvenience from the prolapsus, is apt to be mistaken for fluor albus, or gonorrhoea. A woman may become pregnant, not- withstanding an incomplete prolapsus of the womb. The displacement may even take place at a more or less advanced period of gestation, (Portal des Accouchemens) while, in other still more uncommon instances, the prolapsus has been remarked to disappear when the period of labour drew near. Cases exemplifying both these facts, are related byLoder, (Journ. far die Chir. B. 2, p. 13,) by Saviard, Portal, (,1/e»i. de I'Acad, de Chir. T.3) in the Journ. de Mcdeciiie. T. 45; and by Chopart. (Traiti des Maladies des Voies Urinaires.) A prolapsus uteri may also happen during parturition. (Garin, Journ. deMid.continui, T.4,p. 265; Du- creux, M'-m de I'Acad. de Chir. T.S.p. 393.) When, in the course of time, a prolapsus uteri changes from the incomplete to the complete state, all the inconveniences de- pending upon the pressure ofthe part upon the rectum and bladder subside : that is to say, the feces and urine are now freely void- ed. But, on the other hand, the symptoms arising from the stretching ofthe peritonae- um become considerably worse. The ute- rus dra-zs down with it the vagina, which becomes doubled on it-elf, and a part of the bladder, connected with the upper part of the lalter tube, is also drawn down. Some of the abdominal viscera may even fall into the cul-de-sac, formed by the vagina, and considerably increase the size of the tu- mour. Ihe swelling, protruding between the thighs, is of au oblong, nearly cylindri- cal form, and terminates below in a narrow extremity, in which a transverse opening, the os tineas, may be discerned, from which the menses are discharged at the periods prescribed by nature. Hovvever, the cylin- drical shape of tne tumour may lead to mis- takes, for the vagina, being doubled on itself, and exposed to the effects of the air, sometimes looks like skin. Hence women. thus afflicted, have occasionally been sup- posed to be hermaphrodites, the tumour be- ing mistaken for a penis. Such a case is recorded by Saviard. The patient is generally troubled with tenesmus, and sometimes feels acute pain in the tumour itself, which is subject to in- flame and ulcerate, in consequence of its depending posture, the friction to which it is exposed, and the irritation of the urine. The direction both of the bladder and the urethra becomes horizontal, so that the urine is thrown forwards, or even upwards, in which latter case it wets the abdomen. Frequently the bladder cannot be emptied witiiout the assistance ofthe catheter; and sometimes the displaced uterus becomes affected with inflammation and swelling. In many cases there are profuse hemorrhages. However, some women become so habitua- ted to the disease that they hardly seem to experience any annoyance from it: when- ever they are in the erect posture, and walk about, the womb falls down, bringing with it the vagina ; and, as soon as they lie down on their backs, the parts as readily return into their natural position again. The incomplete prolapsus is alone sub- ject to any obscurity, which, however, may be dispelled by manual examination. In this, however, some precautions are neces- sary. For instance, as the womb generally returns into its natural situation when the patient lies down, the examination should always be made as she is standing up. For the same reason, if she is in the habit of lying long in bed, the morning is not the best period ofthe day for the examination. The practitioner may also be deceived if he examine tbe parts when the rectum and bladder are distended with their contents, in which state the uterus may ne hindered from descending as low as at other periods. If attention be paid to these circurostan- ''•82 UTERUS, PBOLAPSUs OK ces, an incomplete prolapsus may always be distinguished without risk of error. Hovvever, the records of surgery prove that the case has sometimes been mistaken by the inexperienced, or ignorant, for a poly- pus, and the part extirpated under this sup- position. So serious a blunder will be avoided, if care be taken to remember that polypi are generally softer and less sensible than the uterus; that, in a case of prolapsus, the os tincae is situated at the lower part of the swelling ; and, that if by chance any resembling aperture should be met with upon the corresponding portion of a poly- pus, the prolapsus may still be known by the greater depth to which a probe will en- ter such opening. A polypus ofthe uterus, I believe, is always broadest at that extre- mity, which is nearest the vulva; but the womb, in a state of incomplete prolapsus, forms a tumour which is narrower below than above. With very few exceptions, fhe womb is likewise reducible, and the patient directly afterward feels great relief; whereas a polypus cannot be pushed back, and the attempt, instead of giving relief, only in- creases the patient's sufferings. In a complete prolapsus, no doubt can ever prevail about the reul nature of the case, for whatever uncertainty the feel of tne parts may create, none can ever remain when the swelling is distinctly visible. Although Mauriceau, Saviard, and Monro have recorded instances of prolapsus uteri in maidens, such cases are exceedingly rare. The disease is hardly ever met with, except in women who have had children, and ge- nerally in those who have borne a great many. This particularity is ascribed by writers to the elongation ofthe ligaments of the uterus in women, in whom this organ has been repeatedly gravid. The same con- sideration may also account for the fre- quency of prolapsus uteri during the first months subsequent to parturition, especially as the womb remains for some time after labour more enlarged and heavy than natu- ral. The disease is more common in thin than fat women, and is said often to take place in females when they suddenly change from a fat to a very emaciated state. The displacement is facilitated by a capacious vagina, by a great width of the lesser ca- vity of the pelvis, and the effects of tedious and profuse attacks of fluor albus. Prolap- sus uteri has also been brought on by vio- lent concussions ofthe body; the protracted efforts of vomiting, coughing, or crying, hard labour, and lifting, or carrying heavy burdens. In what has been stated, one may discern the reason why the affliction is so frequent among the lower classes of society, and why women, for a certain time after parturition, should avoid an erect posture, and every kind of exertion. In the treat- ment of prolapsus uteri, there are two indi- cations ; the first is to reduce the part; and the second is to keep it from falling down again. In the incomplete prolapsus, the first in- dication i« verv easv of accomplishment-. and, indeed, when the patient is piaceu on her back, with her pelvis raised somewhat higher than her chest, the uterus often re turns of itself into its natural situation again At all events, the reduction may be imme- diately effected by pushing the uterus up into the pelvis with the fingers. More difficulty generally attends the re- duction of a complete prolapsus Here the same posture is to be chosen as in the for- mer case ; but the legs and thighs should he bent. Tbe rectum should also be first emp- tied with clysters. Sometimes, indeed, every attempt at reduction fails, notwith- standing the adoption of the most vigorous measures, the use of the warm bath, purga- tives, venesection, low diet, fomentations, be. Occasionally, the part is returned after a great deal of trouble; but, owin^ to the long altered slate of parts, the reduction brings on worse symptoms than resulted from the continuance of the prolapsus. Such a case is recorded by Richter. (Bibl. der. Chir. B. 3, p. 141.) The patient's suf- ferings were so much increased by the re- duction, and so obstinate a constipation came on, that it became absolutely neces sary to let the uterus descend again. In any irreducible case, all that can be done is to support the swelling, and prevent its in- crease witb a suspensory bandage, and draw off the urine with a cathelei* whenever re- quisite. In these cases, the altered course ofthe meatus urinarius is to be remember- ed, and the catheter directed horizontally towards the rectum When the displaced uterus is inflamed, and considerably swelled, the attempt at reduction should be preceded by antiphlo- gistic remedies, the patient should be kept in bed, be put on a low regimen, be bled, take purgative medicines, use (he warm bath, and drink diluent beverages, while emollient applications are made to the part it3Plf. This plan of treatment has often been attended with complete success, iu cases of prolapsus uteri, of long standing and considerable size. Ruysch disapproved of making any attempt to reduce the uterus while it was inflamed and swelled. He also thought that the operation should be post- poned when the uterus was in an ulcerated state. However, Sabatier rightly observes, that, as this complication is only accidental, and merely arises from the friction to which the tumour is exposed, and the irritation of the urine, the plan of immediately replacing the part cannot be attended with any dan- ger. On the contrary, since the cause which produces and keeps up the ulceration will cease, as soon as the reduction is ac- complished, the sores will heal after Ihe uterus is put into its natural situation again. When a prolapsus uteri o'ccurs in the early stage of pregnancy, this state should not let the practitioner neglect to reduce the part. Several instances are recorded, in which the reduction was successfully ac- complished in pregnant women ; and one case of this kind is reported by Giraud. >nd symp- toms are tbe consecui'-nee. VAGINA IMPERFORATE 581 Ihe first care ot a practitioner, consult- Mr. B. Bell also strongly recommended it ed in a case of retroversio uteri, should be in gonorrhoea, where the irritability of the (o empty the bladder and large intestines, bladder was excited in a high degree, and and to relax the parts by every possible where the nrine was loaded with viscid means. Then be should immediately pro- matter. In these cases, he directed a scru- ceed to replace the uterus, by placing the pa- pie, or half a dram of the powder, three tient iu a suitable posture, and making me- times a day. thodical pressure in the rectum and vagina. Dr. Saunders orders three drams of uva Should he be so fortunate as to succeed, ursi to be macerated in a pint of hot water, the patient is to be confined in bed, her and two or three ounces of the strained bowels are to be kept open, and she is to be liquor to be given three times a: day. (Pharm. advised always to obey the calls of nature Chirurg.) the first moment she feels any inclination to UVULA,- AMPUTATION OF. The uvula make water. She is also to be enjoined to is subject to several kinds of enlargement, avoid all kinds of exertion, and wait till the in which it becomes both longer and more gradual enlargement of the uterus removes bulky than natural, or is simply lengthened. the possibility of this viscus descending into In consequence of such changes, it becomes ihe pelvis. (Sabatier, Midecine Opiratoire, troublesome in deglutition and speaking, and T. 2.) causes a disagreeable tickling at the root of Some practitioners, of considerable emi- the tongue, frequent retchings, and an an- nence, rather discourage (he manual interfe- noying cough. rence to reduce the uterus, believing tbat When things have attained this state, me- drawing off the urine will generally render dicines are often ineffectual, and the only such interference unnecessary. (Croft, in plan of relief consists in amputating a poi'j Lond. Med. Journ. Vol. 9, p. 63. Denman's In- tion of the uvula. troduclionlo Midwifery, 4lo. Lond. 1801. S. The ancients used to take hold of the Merriman, on Retroversion of the Womb, Svo. uvula with a pair of forceps, and cut off a Lend. Is 10.) piece of it below the blades of the instru (See Lynn, W. Hunter, Garlhshore, Bird, ment. Fabricius ab Aquapendente objected and Hooper, in Med. Obs. and Inq. Vols. 4,5, to this method, because it employed both and 6. Cheston and Cteghorn, in Med. Com- hands, and a third was needed for holding munications, Vol. 2. John Clarke, Practical the tongue and lower jaw. He preferred Essays on the Management of Pregnancy and scissors, and having the left hand at liberty. Labour, Lond. 17t>3. Murray, in Uteri Retro- When the size of the uvula was considera- versionem Animadversiones, Upsal. 1797. ble, and bleeding apprehended, Pare recon- Denman's Introduction to Midwifery, Lond. mended the application of a ligature to the 1810. S. Merriman, on Retroversion of the part, by means of an instrument, composed Womb, fyc. 8vo. Lond. 1S10. John, De Utero of a ring, mounted on a slender handle, and Retroverso, Jen. 1 87. Desgranges, in Journ. formed with a groove upon its convexity. A de Mid. T.66,p.Sb. Klein, Chir. Bemcrkun- ligature is pu( round the ring with a slip- gen, p. 23b. Baudelocque sur le Renverse- knot, which is to be tightened by means of ment; de la Malrice, fyc. Paris, 1803. Cockell, another ring, of much smaller size, mounted Essay on Retroversion of the Uterus Lond. like the preceding one, upon a long slender 1785. Richter, Chir. Bibl. B. 4. p. 61,—70 handle. The ligature i3 to be left in the —2*35—555 : B. 5, p. 132—548; B. 7, p. mouth, and when it does not make suffi- 292; B. 8, p. 715; B. 9, p. 182; B. 11, p. cient constriction, it is to be tightened. 310—328 ; B. 12, p. 45—50.) Fabricius Hildanus subsequently descri- UVA URSI, which was first brought into bed an instrument constructed on the same notice by De Haen, was once considered a principles. Sabatier takes hold ofthe uvula powerful remedy in calculus; but though its with a pair of forceps, made with holes in virtue in lessening the irritation of tbe blad- the blades, like those used for the extraction der, is still acknowledged, its claim to utility of polypi. He then divides the uvula with a on any other principle, is quite rejected, pair of scissors, made with concave cutting Dr. Austin recommended it for lessening the edges. irritability of the bladder, and diminishing Sabatier never saw any bleeding of con the secrelion of diseased mucus, which, he sequence follow this trivial operation. (See supposed, greatly contributed to the aug- Midecine Opiratoire, T.3.) mentation of the stone. V. \7"AG1N\ IMPERFORATE. Female in- before the malformation is discovered. V fants arc often born with different im- Some females are even stated to have be- perforations of the vagina. Sometimes this come pregnant, notwithstanding such ob- passage is not completely shut up, so that struction ; and in these cases, the membrane; die usual evacuations happen in an unintcr- which shut up a part of the mouth of the "tipted manner, nnd it is a considerable time vagina, either was torn by the effects of Voi.U. T" I also VAGINA, PROLAPSUS OF labour, or divided as much as was necessa- ry for delivery. Two membranes, one placed beyond the other, and obstructing the vagina, have also been found. That which is commonly met with is only the hymen, thicker and strong- er than natural. Ruysch describes the case of a woman who had been in labour three days, and could not be delivered Tbe head presented itself, but was prevented from coming oul by the hymen, which shut up the vagina, and was very tense. Ruysch made an incision into the membrane ; but to no purpose, since there was another mem- brane, of a thicker texture, situated more deeply in the passage. As soon as this se- cond membrane was divided, the child was expelled, and the case ended well. When the vagina is completely imperfo- rate, and the time ofthe menses commence, many complaints occur, which afflict the patient with more severity, in proportion as the blood accumulates in the passage, and they may even lead to a fatal termination when the cause is not understood, or not detected till it is too late. These complaints are very similar to those of pregnancy; for instance, rumbling noises iu tbe bowels, loss of appetite, nausea, vomiting, enlargement ofthe mammae, spasms, convulsions, swell- ing of the abdomen, be. Hence, girls in this situation have often been supposed to be pregnan(, although they were not in a state even to become so ; and some young women have been known to die, after dread- ful sufferings. When the malformation consists altoge- ther in the orifice of the vagina being shut up by a membrane, tbe patient may be ea- sily relieved by a crucial incision, or a sin- gle cut, the edges of which arc kept apart by a tent of suitable shape and size. In- stances of the success of such an operation are to be found in numerous writers. Fa- bricius ab Aquapendente informs us, that a female child was born with a membrane which completely shut up the vagina. The girl experienced no inconvenience from it till she was about thirteen, when the period of her menses began. As the blood was re- tained, she became afflicted with severe pons in the loins, the lower part of the ah- d i ;en, and about the upper part of the thighs. Sfee was supposed to be attacked with sciatica, and treated accordingly. Me- dicines w ere prescribed w hich did no good ; and at length she became hectic, and redu- ced to a complete state of marasmus, in which she passed restless nights, lost her ap- petite, and was delirious. A painful, very elastic tumour afterward presented itself in that part of the abdomen which corres- ponds to the uterus. The pains vvere aggra- vated every month, at the period when the patient ought to have menstruated. She was in a dying condition when Fabricius ab Aquapendente was consulted, who, after as- certaining the real nature of the case, per- formed the requisite operation. A prodi- gious quantity of black, putrid blood was discharged from the vagina ;. the bad symp- toms gradually subsided, and tbe patient r< covered. (See also J. C. Loder, Obs. Impei forutionis Vaginai, hone itlustrata, 4to. Je»w, 1800; and numerous olher cases on record.) When the malformation is produced by an extensive accretion of the sides of this passage to each other, the cure is sometimes difficult. The result of the operation is doubtful, because it is impossible to reach the situation of the blood wilhout cutting through a considerable thickness of parl6, in doing which there is some danger of wounding the rectum, or bladder. A lady, twenty-four years of age, after having tried, for eight years, such remedies as seemed best calculated for exciting the menstrual discharge, became affected with a large hard swelling of the abdomen, and a kind of her- petic affection round the body near the na- vel. At length it was discovered, that the imperforation of the vagina was the sole cause of all the bad symptoms which the patient had long endured. An incision was made, which enabled the operator to intro- duce his finger into a large cavity,and which gave vent to a considerable quantity of blood. It was thought that an opening had been made into the vagina; but ibe patient having died three days afterward, it was seen that a mistake had been made, as the cavity, in which the finger had been intro- duced, was that ofthe bladder. The vagina was closed below by a substance of an inch in diameter, aud half an inch thick. The up- per part of this passage, the uterus, and the Fallopian tubes, were exceedingly enlarged, and filled witb a dark brown, sanious fluid. A similar fluid was extravasated in the ab- domen, and it was discovered to have pass- ed there through a rupture which had taken place in the Fallopian tube. The ovaries were in a natural state. De Haen, who has related this case in the sixth part of his work, entitled Ratio Mcdendi, was of opi- nion, that in order to avoid opening the rectum, or bladder, only one oblique cut should be made in the membrane which stops up (he vagina, just as was advised by Meeckren. (Sabatier de la Midecine Opira- loire, T. 1.) VAGINA, PROLAPSUS, OR INVER- SION OF. According to Sabatier and Lev- ret, tbe displaced part does not consist of all the coats of the vagina, in the same manner as the inverted uterus is formed of the whole substance of this viscus. These writers contend that the lining of the vagina is alone displaced, in conseqnence of the swelling and thickening witb which it is af- fected. Upon this point, however, Richter does not accede to the opinion of Sabatier and Levret, but describes the vagina as be- ing liable to two kinds of prolapsus. In one case, all its tunics arc stated to be included in the protrusion, the part becoming invert- ed at the same time that it falls down. In the other example, it is only the relaxed lining of the vagina which descends, and makes the protrusion. The possibility of a prolapsus ofthe whole pf the vagina, losc-ther with all iti coats, VAGINA, PROLAPSUS OF. b37 says Richter, has been doubted by Sabatier and Levret; but without any real founda- tion. If it be possible for the inner coat of the vagina to separate from the external, with which it is intimately connected, (an event which every body admits as happen- ing in (he second kind of prolapsus of the vagina,) why, asks Richter, should it be im- possible for the whole of this tube, together with all its coats, to be separated from the surrounding parts, to which it is less closely adherent? Sometimes the rectum, inclu- sive of all its coats, forms what is termed a prolapsus ani, nnd why may not the vagina be displaced in a similar manner, since it must-be much more liable than the rectum to be propelled downwards in the violent straining at the time of delivery ? Richter •asks, whether every prolapsus uteri is not accompanied with such a displacement of the vagina ? Cases are upon record, where the prolapsus of the vagina happened all on a sudden, in consequence of falls, the start- ing of a horse, be. (Hoin, Levret, Journ. de Mid. T. 40.) Here it cannot be supposed, that the case was merely a protrusion of the inner coat, which can only be gradually re- laxed and elongated. Lastly, some instances, in which the prolapsus of the vagina was several inches in length, have been gradual- ly reduced by means of external pressure. (Hoin.) How can it be imagined,^ays Rich- ter, tbat such cases could proceed from any degree of relaxation to which the membra- nous lining of the vagina is liable ? Richter acknowledges, however, that a prolapsus of all the coats of the vagina is much less common than that arising from relaxation of the membranous lining of this passage ; be states, that when it occurs, it is generally a consequence of a prolapsus of the uterus ; and that it cannot easily hap- pen at all, except about the period of deli- very. (See Anfangsgr. der Wundarzn. B. 7, Kapitel 4.) According to Sabatier, the prolapsus, or inversion of the vagina, appears like a thick, circular substance, irregularly plaited in the middle, and at the bottom of which the cervix uteri is situated, having descended -further down than natural. The displaced portion of the vagina increases, or dimi- nishes, according as the patient sits up, or keeps in bed a certain time. The complaint is accompanied with a sense of heaviness in (he hypogastric region ; tenesmus ; and a difficulty of making water, in consequence ofthe alteration produced in the direction ofthe meatus urinarius. Such is the prolapsus of the vagina in an early state ; but when, it has been of long standing, and the patients have remained for a long while without any assistance, the membranous lining of the passage becomes more and more thickened; and tbe tumour, which it forms, becomes more considera- ble, elongated, and hardened. In this state there still continues, at the lower part of the swelling, an opening, out of which the usual evacuations arc made. The grievances suf- fered are similar to those arising from a pro- lapsus uteri, to which, indeed, the present case bears a great resemblance. The pro- lapsus vagina?, however, differs, inasmuch as the tumour formed by a descent of tbe uterus is very firm, and terminates in a nar- row end, where may be observed the oblong" transverse opening, named the os tincae; while the tumouV, arising from a prolapsus of the vagina, is soft, thicker below than elsewhere, and ends in an irregular aper- ture. Occasionally, a prolapsus of a very limit- ed portion of the vagina is observed. Thi.J case is generally Ihe consequence of an un- common sort ol rupture, termed the vaginal hernia (see Hernia ;) but it should also be known, that in some cases of dropsy, a cir- cumscribed protrusion ofthe vagina, in the form of a cyst, or pouch, filled with fluid, is sometimes noticed. (Richter, Op. et loco citato.) When the prolapsus vaginae is recent, the part may be easily reduced, and kept up witb a pessary. The use of astringent lo- tions will also tend to prevent a relapse. But when tht* case has been of long stand- ing, it is neither easy to effect the reduction, nor to prevent a recurrence of the disorder. Softening, relaxing remedies, in this cir- cumstance, are recommended, and the pa- tient should, in particular, confine herself to her bed, and wear a T bandage, which should be made to press upon, and support a piece of sponge in the orifice of the va- gina. It is reasonable lo expect, lhat after a prolapsus vaginae has continued a long while, the reduction must bo difficult; because the vagina in this state becomes affected with swelling and induration. According to the reports of Hoin and Levret, a large protru- sion of this kind, ten inches in length, was so diminished by keeping the patient inva- riably confined in bed upon her back, that in the course of a month, the rest of the tu- mour admitted of being reduced. Indeed, as Richter observes, there can be little doubt, that the treatment which has been advised by some authors, for the diminution of very old, enormous, omental ruptures, would here be equally applicable ; viz. long confinement in bed upon the back, with the buttocks somewhat elevated ; unremitting, well directed external pressure ; a very low diet; and repeated mercurial purges. During pregnancy, a prolapsus of the whole substance of tbe vagina may cause much embarrassment and even danger. In one case of this description, where the pro- trusion was five inches in length, it became necessary to turn the child, and the displaced vagina was lacerated. The woman, hovve- ver, recovered. (Pielsch, Journal de Mid. T. 34.) In another instance, where the pro- lapsus became, at each return of the labour- pains, as large as a man's head, the practi- tioner succeeded in holding the parts back, while delivery was effected with the aid of the forceps. (See I^dcr's Journ. 1 B. p. 490.) When this is impracticable, it is ne- cessary, according to Richter, to make an VAK VAll incision through both sides ofthe prolapsus ; a measure, says he, to which the practitioner may the more readily make up his mind, inasmuch as the parts have, in some cases, been lacerated, wilhout any ill consequen- ces. A prolapsus ofthe inner membrane ofthe vagina, while small and recent, might per- haps be removed by astringent applications. When, however, it is of long standing, indu- rated, and of large size, much expectation of success from this treatment cannot be en- lertained. Richter sees no reason why, in such a case, (he superfluous relaxed part should not be cut away, especially if the disease be accompanied with ulceration, and other se- rious complaints. As he observes, there can be no doubt, that a prolapsus of the inner membrane of the vagina, when limited to one part of (bis canal, may always be safely extirpated, either with a knife, or a ligature. (Anfangsgr. der Wundarzn. B. 7, Chap. 4.) As the swelling of the membranous lining of this passage is folded back on itself, it sometimes increases in such a degree, that the tumour falls in(o a state of mortification. In this event, some writers have advised the extirpation of the swelling, justifying the practice on the authority of some distinguish- ed practitioners, and the little danger atten- dant on (he operation. Even Sabatier only objects to this pro- ceeding, on thegroundof the danger of mis- taking a prolapsus of the uterus, for one of the vagina. However, no modern surgeons in this country would hesitate about reject- ing such au operation, and leaving the sloughs to separate of themselves. The prolapsus, arising from a hernia in the vagina, can only be ascertained by at- tending to the symptoms which characterize (his sort of rupture. See Hernia. Consult particularly Sabatier, Midecine Opiraloire, T. 2, p. 486, fyc. Edit. 2. Rich- ter, Ansfungsgrunde der Wundar2neykunsl, B. 7, Kap. 4. VARICOCE'LE. (from varix, a distended vein, and x»*aj>, a tumour.) Many writers mean by the term varicocele, a varicose en- largement of tbe spermatic veins, which lat- ter affection I have, with Celsus and Pott, treated of under the name of Cirsocele. Pott remarks, that the varicocel is an enlargement and distenliot blood-vessels of the scrotum) is very iarfdoin an original disease, indep«ga>it^rnny jtber, and when it is, U bWtrly an object of surge- ry. The blood-vessels of the scrotum are of different size in different people ; and like the vessels in other parts of the body, are liable to become varicose; but they are seldom so much enlarged as to be trouble- some, unless sucb enlargement is the conse- quence of a disease, either of the testicle, or spermatic chord. When this is the case, the original disease is what engages our at- tention, and not this simple effect of it; and, therefore, considered abstractedly, the vari- cocele is a disease of no importance. (Pott's Chirurgical Works. Vol. S.~) and I'ott, vursl ocele. Jdcd ele (whicJj**"*Fdesc )n of J0fk man »*>.: :-^r/lr%.n np#*L VARICOSE ULCER. See Ulcer, am. Varicose Veins. "VARICOSE VEINS. The term tarijr, is applied by surgeons to the permanently dilated state of a vein, attended wilh an ac- cumulation of dark-coloured blood, the cir- culation of which is materially retarded in the affected vessel. When veins are vari- cose, they are nol only dilated, they are also evidently elongated ; for besides being irre- gular, and in several places studded wilh knots, they make a variety of windings, and coiling themselves, form actual tumours from the assemblage of their convolutions in one particular place. When the branches of a vein, thus dilated and elongated, are nume- rous, and confined to a certain part of the body, ihey constitute a very distinct swell- ing. Indeed, when the diseased vessels are situated near Ihe integuments, the surgeon can feel, and even see their tortuous course. These things, for instance, are remarkably obvious in Ihe vena saphena interna, in which (be affection is particularly common This vessel may be observed to form in its course several of thess swellings, in the inter- spaces of which it runs in a very serpentine manner. Varices are most commonly observed in the lower extremities, reaching sometimes even as far up as the abdomen. They have, however, been noticed in the upper extremi- ties, and it is probable that the whole venous system is susceptible of the affection. As a well-informed writer observes; " The great venous trunks sometimes become varicose. When the disease is situated near the heart, it is attended will) pulsation, which renders it liable to be mistaken tor aneurism. Mor- gagni observed, tbat the jugular veins were occasionally very much dilated, and pos- sessed a pulsation. (Le/t«r8, art. 9,10, 11.) He also relates a case in which (he vena azygos, for the length of a span, was so much dilated, that it might be compared with the vena cava. The patient died suddenly in consequence of the rupture of Ibis varix into the right side of the chest. (Letter 26,art.29.) Asimifor case is related by Portal, who also mentions an instance in which the right sub- clavian vein was excessively dilated, and burst iuto the chest- (Cours d'Anatomic dedicate, torn. 3, p. 354, 373.) Mr. Cline cribed in bis lectures the case of a wo- who had a large pulsating tumour in her neck, which burst and proved fatal by he- morrhage. A aac proceeded from the inter- nal jugular vein; tbe carotid artery was lodged in a'groove at the posterior part of this sac. 1 ne veins of the upper extremity very rarely become varicose. Excepting cases of nneurismal varix, • such constitutional effects us beloni; to what. he deems the true form of >y phibs, or that in which the use of mercury is the most de- cidedly indicated. It would give me sincere pleasure to find any agreement on this part of the subject among other observers. The reader, indeed, must already know, that the hardened base, which both Hunter and Carmichael have regarded as a distin- guishing character of a true chancre, is not found to be so byr other gentlemen, who have most impartially investigated this point. Thus, Dr. Hennen observes, " we are not in possession of the knowledge of any invariable characteristic symptoms, by which to discriminate the real nature of the primary sore, and we are equally at a loss in many of the secondary symptoms. I am well aware that some practitioners have assumed to themselves the possession of a " tactus eruditus," by which they can at once distinguish a chancre, or a venereal ulcer, or eruption, in which mercury is in- dispensable, from one of n different nature ; but I have seen too many instances of self- deception to give them all the credit that they lay claim to. It would be by no means difficult to show that the high round edge, tbe scooped or excavated sore, the preceding pimple, the loss of substance, the hardened base and edge, whether circumscri- bed or diffused, and the tenaciously adhesive discharge of a very fetid odour, are all ob- servable in certain states and varieties of sores, unconnected w ith a venereal origin. The hardened edge and base, particularly, can be produced artificially by the applica- tion of escbarotics to the glans or penis of a sound person ; nnd if any ulceration, or warty excrescence, previously exists on these parts, this effect is still more easily produced." (On Military Surgery, Ed. 2, p. 517.) Now, if it be asked, whether the chancre with a hardened base, and promi- nent edge, is distinguished by its not admit- ting of cure.without mercury? and by any regularity or peculiarity in the nature of secondary symptoms, when they originate from such an ulcer? modern experience denies the validity of both these criteria. If Mr. Rose's excellent paper be consulted, the reader will see that this gentleman has certainly cured, without the aid of mercury, ulcers, which had a decidedly marked indu- ration of the margins and bases, by which the syphilitic chancre, according to Mr. Carmichael, is easily distinguished. (Med. Chir. Trans. Vol. S, p. 421, fyc. ; also Guth- rie, Vol. cit. p. 576.) And, as for the other points, sufficient evidence has already been defailed in the foregoing columns to satisfy** any impartial mind, that, as far as the eye can teach us, no kind of primary sore bas yet been satisfactorily proved to be the VENEREAL DISEASE. 004 cause ot only one set of peculiar constitu- tional symptoms ; but, on the contrary, (hat a great variety of appearances in the skin, throat, &c. may follow jores, which, as far as externol characlers are concerned, seem exactly alike. The only partial exception to this remark is the great frequency of pa- pular eruptions after superficial sores; a point on which both Mr. Carmichapl and Mr. Rose agree, though the latter gentleman does not represent even this connexion as constant. Mr. Hunter computed, that claps occur more frequently than chancres, in the proportion of four or five to one. 1 am not prepared to offer any opinion on this calcu- lation, in reference either to chancres, as defined by that interesting writer, or under the more comprehensive view of them, to wliich the results of modern investigations would lead. One intelligent writer, how- ever, has observed, that present experience does not justify Mr. Hunter's conclusion re- specting the infrequency of chancre com- pared with gonorrhoea. (J. Bacot, Obs. on Syphilis, p. 64.) Yet, in Dublin, if Mr. Car- michael's statement be correct, the fre- quency of gonorrhoea, as compared with that of what is sometimes termed the true venereal chancre, must be so great as to defy all computation ; for he informs us, that since the descriptions of the success of the non-mercurial practice fell into his hands, he has been anxious to ascertain, by personal observation, whether true syphili- tic chancres did really admit of being cured without mercury ; but, says he, " this dis- ease, as described by Hunter, has diminish- ed in so extraordinary a degree in this country, that, strange to say, I have from that period met with only one case of true chancre." (Observations on the Symptoms, fyc. of Venereal Diseases, p. 14.) As this chancre remained stationary a month, it was thought proper to employ mercurial frictions, and it then soon healed, leaving a callosity which continued two months longer. However, after the above passage was written, Mr. Carmichael met with two cases of " well marked chancre," each of which was attended with psoriasis syphili- tica, scaly from its commencement. No mercury was given. For five weeks, the disease gained ground ; but, in the end, both cases were cured, merely sarsaparilla hav- ing been administered. The following observations, contained in the appendix to Mr. Carmichael's work, do him infinite cre- dit. " Although, (says he,) these two cases cannot fail to make a due impression, yet, if tbey stood alone, their evidence could not be deemed sufficient to establish a be- lief, that true syphilis, like the papular disease, is capable of yielding to the powers ofthe constitution, or to remedies in which mercury does not form on ingredient. But this deficiency seems to be, in a great mea- sure, supplied by the testimony of Mr. Rose, Mr. Hennen, and other equally intelligent surgeons, who had the advantage of serving with our army on the continent; and, if in (he preceding page;-1 appear (o be sceptical with respec( to (he accuracy of their observa- tions, and doubted lha( it was true chancre, and true syphilitic eruption, which y ielded (o (heir prescriptions, unaided by mercury, these (wo cases have satisfied me that every attention is due to tbe exactness and discernment of these respectable individuals ; and if I hesi- tated until 1 saw witb my own eyes, and judged with my own understanding, I claim for my own observations no larger a mea- snre of faith from others." And he after- ward adds," In thus relinquishing my opi- nion, (hat true syphilis differs from other venereal complaints, by always requiring mercury for its cure, it is necessary to reduce the doctrine I hold to this propo- sition : that with respect to (he use of that medicine, it differs from them only in not being injured, but decidedly benefited by it in all its symptoms and stages." (P. 218, 219.) According to Mr. Hunter, there are three ways in which chancres may be produced : first, by the poison being inserted into a wound : secondlv, by being applied to a non-secreling surface; and, thirdly, by be- ing applied to a common sore. A wound, it seems, is much more readily infected (han a sore. To whichever of these three differ- ent surfaces the pus is applied, it produces its specific inflammation and ulceration, at- tended wilh a secretion of pus. The mat- ter produced in consequence of these differ- ent modes of application, he says, partakes of the same nature as the malter which was applied, because, he observes, the irritations are alike. How the alleged examples of very different primary sores being sometimes communicated by the application of tbe matter of chancre, are to be reconciled with the Hunterian doctrines, it is difficult (o suggest, unless Mr. Carmichael's obser- vation about the present excessive rarity of the true syphilitic chancre, can furnish the explanation. However, as far as I can be- lieve my own eyes and judgment, I now see in London tbe same forms of chancre, which used to prevail during my apprentice- ship at St. Bartholomew's Hospital more than twenty years ago. And if any differ- ence can be particularized, it is only that which depends upon their being less rarely converted into worse diseases than mere syphilitic ulceration, by the dreadful effects of immoderate courses of mercury. With respect to the three modes, in which Mr. Hunter speaks of the venereal poison being applied and taking effect, I know not why he should have altogether excluded se- creting surfaces; for of (his nature (as a late writer remarks) are the glans penis and co- rona glandis, (Bacot on Syphilis, p. 55,) and of a similar kind, are the insides of the labia, the surfaces of the nymphae, be. where sores are common enough. Whatever may be (he truth of the impossibility of the forma- tion of chancres within the urethra, the latter considerations certainly tend to prove lhat the secreting nature of ils membrane, is not (he only reason for the alleged fact. I shall not here detain (he reader with o06 VENEREAL DISEASE. descriptions of the primary ulcer with eleva- ted edges, tbe phagedenic, and the sloughing chancre. Such descriptions 1 bave embo- died in the last edition of the First Lines of Surgery, with the sentiments of Mr. Carmi- chael, respecting the (rain of constitutional symptoms, appertaining, as he believes, to each form of ulcer. It is an interesting dis- quisition, but as far as my observations and inquiries go, it has not yet reached any de- gree of certainty or precision ; and as I have already explained, tbe reports published by other gentlemen engaged in this investiga- tion, do not by any means confirm the much desired intelligence, that such progress has been made in the knowledge of all the diver- sified symptoms of the venereal disease, tbat its varieties can now be classed both in re- gard to tbe primary ulcers, and the secondary symptoms connected with each description of chancre. I firmly believe, tbat wilh respect to all the appearances of this disease, both in its primary and secondary forms, a vast deal depends upon constitution, independent- ly of the nature of the virus. And I adopt this opinion, at (he same time that many re- flections, already hinted at in this article, lead me to join in the belief, that syphilitic diseases may depend upon a variety of poi- sons, whereby some of the perplexity of these cases may be explained. The local,-or immediate effects of the ve- nereal disease, are seldom wholly specific; but are usually attended both with Ihe specific and constitutional inflammation. Hence, Mr. Hunter advises particular atten- tion to be paid to the manner in which a chancre first appears, and to its progress. If the inflammation spreads in a quick and considerable way, the constitution must be more disposed to inflarrimation, than natural. When the pain is severe', Mr. Hunter remarks, there is a strong disposition to irritation. Chancres, also, sometimes soon begin to slough, there being a strong tendency to mortification. It is also observed by Mr. Hunter, lhat when there is a considerable loss of sub- stance, either from sloughing or ulceration, a profuse bleeding is no uncommon circum- stance, more especially, when the ulcer is on tbe glans. Tbe adhesive inflammation does not appear lo take place sufficiently to uiiite the veins of this part of the penis, so as to prevent their cavity from being exposed, and the hlood escapes from tbe corpus spon- giosum uietl.iae. The ulcers, or sloughs, often extend as deeply as the corpus cavemosum penis, and similar bleedings are the conse- quence. . With respect to chancres in women, the Labia and nympha?, like the glans penis in men, are subject to ulceration, and the ulce- rations are generally more numerous in fe- males than males, in consequence of the surface on which Ihe sores are liable to form being much larger. As Mr. Hunter observes, chancres are occasionally situated on the edge of the labia; sometimes ou the outside of these parts; and even on the pe- rinaeum. When the sores are formed on the inside of the labia or nymphs, they can never dry or scab; but when they are ex- ternally situated, the matter may dry on them, and produce a scab, just as hap- pens with respect to .chancres situated on Ihe scrotum, or body of the penis. Mr. Hunter remarks, that the venereal mailer from these sores is apt (o run down the perina-um to the anus, and excoriate the parts, especially about (he anus, where the skin is thin, and where chancres may be thus occasioned. Chancres have been noticed in the vagi- na ; but Mr. Huuter suspected that they were not original ones; but that (hoy had spread (o this situation from the inside of tbe labia. Before any ofthe virus has been taken up by tbe absorbents, and conveyed into the circulation, a chancre is entirely a local af- fection. From the Hunterian doctrines, however, it would appear that absorption must generally soon follow Ihe occurrence of the sore ; and all Ihe modern opinions concerning tbe nature of ulceration itself, would lead to the same inference. When no secondary symptoms lake place after the cure of chancre without mercury, I believe few surgeons of tbe present day would at- tempt to account for the fact by the hypo- thesis of (he maKer not having been absorb- ed ; and this observation is made with every disposition on my part to express my assent to the truth of another circumstance, viz. that some persons appear much more sus- ceptible of the effects ofthe venereal disease than other individuals. It is remarked hy Mr. Hunter, tbat the interval between the application of the poison, and its effects upon the parts is uncertain ; but that on Ihe whole, a chancre is longer in appearing, (ban a gonorrhoea. However, the nature of the parts affected makes some difference. When a chancre occurs on (be frtenum, or at the termination of the prepuce in the glans, tbe disease in general comes on earlier; these fiarts being more easily affecled than either the glans penis, common skin of this organ, or the scrotum. He adds, that in some cases, in which both the glans and prepuce were contaminated from the same application of the poUon, the chancre made ils appearance earlier on the latter part. Mr. Hunter knew of some instances in which chancres appeared twenty-four hours afler the application of the malter; and others, in which an interval of seven weeks, and even two months elapsed between the time of contamination, and that when the chancre commenced. However, here, as in almost all other statements about this perplexing subject, we never know with certainty that the writer has sufficient grounds for the as- sumed fact, that il is only one kind of poison which is spokeu of. TREATMENT OF CHANCRES. It was one of Mr. Huuter's opinions, tbat the. ulceration arising from venereal inflera VENEREAL DISEASE. Mfi mation, generally, if not always, continues till cured by art, and his theoretical reason for this circumstance was, (ba( as (he in- flammation in ihe chancre spreads, it is al- ways attacking new ground,so as to produce a succession of irritations, and hinder the disease- from curing itself. L »• as no doubt the foregoing opinion of Mr. Hunter, which formed the authority for tbe position wliich was always forcibly in- sisted upon in the surgical lectures wliich I attended some years ago in London, viz. that all venereal complaints, when notconu- teracted by remedies, invariably grow pro- gressively worse and worse. But modern experience apprizes us, lhat this doctrine is far from being correct. As I have noticed in (he foregoing pages, Mr. Fergusson assures U9, that in Portugal, the disease in ils prima- ry state among the natives is curable without mercury, and by simple topical treatment; lhat the anlisyplwlitie woods, combined with sudorifics, are an adequule remedy for con- stitutional symptoms ; and that tbe virulence of the disease bas there been so much miti- gated, lhat after running a certain course (commonly a mild one) through the respec- tive orders of parts, according lo the known lawsof its progress, it exhauslsitself, and ceases spontaneously. (See Med. and Chir. Trans. Vol. 4, p. 2—5.) In the third edition of the Fir-sr Lines of the Practice of Surgery, it was sufficiently proved, from several conclusions drawn from Ihe writings of Mr. Pearson, (Obs. on the Effects of Various Articles in the Cure of Lues Venerea,) thai venereal sores might be benefited, and even healed under the use of several inert insignificant medicines. And as I have previously explained, the possibility of curing chancres and other ve- nereal complatfi^**, ^without mercury, was long since (ent^-ked by Dr. Clutterbuck, who thence ^sty justly inferred, (hat the healing of a sore without this remedy was no tesl that it was not venereal. (Sen Re- marks on Ihe Opinions of the late John Hun- ter. 1799) But although the whole history of the venereal disease, and of (he various articles of tiie materia .nedica, if carefully reflected upon, must have led to the same conclusion, the truth was never placed in such a view as lu command the general belief of all (he most experienced surgeons in this and other countries of Europe. 1 do not mean to say, Hint (he troth was not seen and remarked by several of the older writers ; for that it ivus hi any man tnay convince himself by refer- ring to several works, quoted in the course »f this article. But it is lo be understood, fill indecision could never be renounced, as long as prejudices interfered with the only rational plan which could be adopted, wilh the view of bringing the question to a fiiibl settlement; I mean experiments on a large and impartial scale, open to the observation of numerous judges, yet under such control *i3 insured the rigorous trial of the practice. N"r could such investigation be so well made by any class of practitioners as the ■iraiv surgecr.?, whose patirr.*.^ are nume- rous, obliged to follow slrictiy tbe treatment prescribed, w ithout any power of going from hospital to hospital, or from one surgeon to another, as caprice may dictate, or of eluding Ihe observation of the medical attendants after a seeming recovery. And here I must lake the opportunity of stating, lhat as far as my judgment extends, the most important and cautious document yel extant on the two questions of the possibility and expediency of curing Ihe venereal disease without mercury, is the paper of Mr. Rose. For let it not be presumed, that because (he army surgeons find the venereal disease curable without mercury, they mean to recommend the total abandonment of that remedy for the distenw per, any more than Ihey would argue (hat possibility and expediency are synonymous terms. At the lime when Mr. Rose publish- ed his observations, he had tried the non- mercurial treatment in the Coldstream Regiment of Guards, during a year and three quarters, and had thus succeeded in curing all the ulcers on the parts of genera lion which he met wilh in that period, to- gether with the constitutional symptoms to which they gave rise. "I may not be war- ranted in asserting, (says this gentleman,) that many of these were venereal, but un- doubtedly a considerable number of them had all the appearances of primary sores, produced by the venereal virus, and arose under circumstances, where there had been at least a possibility of that virus having been applied. Admitting that there is nothing so characteristic iu a chancre, as io furnish in- controvertible proof of its nature, it will yet be allowed, lhat there are many symptoms common to such sores, although not en- tirely peculiar to them, and whenever these are met with, there are strong grounds to suspect, that they are the effects of (he syphilitic virus. In a sore, for in- stance, appearing shortly after suspicious connexion, where there is loss of substance, a want of disposition to granulate, and an indurated margin and base, there is certain- ly a probability of that poison being present. Among a number of cases of such a descrip- tion, (aken indiscriminately, the probability of some being venereal is materially increas- ed, and must at last approach nearly (o a certainty. On Ibis principle some of the sores here referred to, must have been venereal. Tbey were also seen by different surgeons, on whose judgment I would rely, who agreed in considering many of Iheui as well marked cases of true chancre." (Rose in Med. Chir. Trans. Vol. 8, p. 357, fyc.) The men thus trea(ed, were examined almost every week, for a considerable time after their apparent cure, " both that the first ap- proach of constitutional symptoms might be observed, and lhat any deception from au underhand use of mercury might be guarded against." (P. 359.) Sixty cases »f ulcers on the penis were also cured by Mr. Dease, in the Vork Hospital, by means of simple dress- ings,the only general remedy being occasion- al purgatives. The practice was likewise ex- tensively tried by Mr. Whyrnper and Mr 608 VENEREAL DISEASE. Good, surgeons of the Guards, wilh the same kind of success. In Mr. Rise's practrr.e, all idea of specific remedies were entirely laid aside. The patients were usually confined to their beds, and such local applications were employed, as the appearances of the sores seemed to indicate. Aperient medicines, antimony, bark, vitriolic acid, and occasion ally sarsaparilla, were administered. (P. 363.) " tfpon an average (says Air. Rose) one out of every three of the sores thus treat- ed, was followed by some form or other of constitutional affeclion: this was in most instances mild, and sometimes so slight, that it would have escaped notice, if it had not been carefully sought for. The constitu- tional symptoms vvere evidently not such as could be regarded as venereal, if we give credit to the commonly received ideas on the subject. Caries ofthe bones, and some of the least unequivocal symptoms, did not oc- cur. In no instance was there that uniform progress, with unrelenting fury, from one order of symptoms and parts affected to an- other, which is considered as an essential characteristic of true syphilis." (Med. Chir. Trans. Vol. 8, p. 422.) The constitutional symptoms also yielded, without the aid of mercury, and frequently primary sores, cor- responding to what had been called the true chancre, with indurated base, were cured in this manner, yet were followed by no secondary symptoms. We are also in- formed, that " several cases occurred of a cluster of ill-conditioned sores over the whole inner surface of the prepuce, and behind the corona glandis; and also of a circle of 6mall irritable sores, situated on the thickened and contracted ring at the ex- treme margin of the prepuce. These occa- sionally produced buboes." None ofthe sores of this description met with by Mr. Rose, were followed by any constitutional affection. ( Vol. cit. p. 370.) He bears testimony to the ill effects of mercury and stimulants in cases of phagedenic ulcers, and confirms a not uncommon opinion, that they are seldom followed by secondary symptoms, which opinion should be qualified with the condi- tion mentioned by Mr. Guthrie, (Med. Chir. Trans. Vol. 8, p. 565 ) that no mercury be given. Lastly, as I have already stated, Mr. Rose observed, that most of the cases of papular eruptions followed ulcers, which were not very deep, and healed without much difficulty. (P. 399.) Although the fact of the possibility of curing every kind of ulcer on the genitals, without mercury, is now so fully confirmed by the statements of Mr. Guthrie, (Med. Chir. Trans. Vol. 8, p. 558, and 576.) ; Dr. I. Thomson, (Edinb. Med. and Surg. Journ. for January, 1818;) Dr. Hennen, (Op. cit. "Nos. 54 end 55, and Principles of Military Surgery, Ed.2); Mr. Bacot, (On Syphilis, p. 26, fyc.) ; and many other careful obser- vers, and it is of great importance in rela- tion to the removal of an erroneous doc- trine concerning the diagnosis, the expedien- cy of the practice must evidently be deter- mined bv--^h--*-considerations, the princi- pal of which are the comparative quicknes- ofthe cures effected with, and without mer- cury ; the comparative severity and frequcn- cyof secondarysymptoms; and tho generally acknowledged fact, that a syphilitic primary sore is not indicated with any degree of cer- tainty by its mere external charac(cr, or in- deed any other criterion, that I know of. Respecting the comparative quickness of the cures of chancres, or reputed chancres, without the aid of mercury, much disagree- ment prevails in the different reports, even those collected by the same individuals, whose statements must therefore be deem- ed perfectly impartial, though inconclusive. (See Hennen's Military Surgery, Ed. 2, p. 536, fyc.) Some of Mr. Rose's best marked cases of chancre, that is to say, such as were distinguished by the indurated base and cir- cumference, healed in a very short time But even respecting these, or any other kinds of chancre, no regularity on this point can be found. Mr. Guthrie observes, if the " ulcers were not without any marked ap- pearance, and did not amend in the first fort- night,or three weeks, they generally remain- ed for five,or seven weeks longer ; and the only difference in this respect between them and the raised ulcer of the prepuce was, that this often remained for a longer period, and that ulcers, possessing the true charac- ters of chancre, required in general a still longer period for their cure, that is, from six, eight, to ten, twenty, and even in one case, twenty-six weeks, healing up and ul- cerating again on a hardened base. Those that required the greatest length of time had nothing particular in their appearance, that would lead us to distinguish them from others of the same kind, Uut were healed in a shorter time." (Mad.^nir. Trans. Vol. 8, p. 558.) The same wri|-i*rj|tterward ex- presses his belief, that almoiTall the pro- tracted cases would have been cured in one half, or even one-third of the time, if a moderate course of mercury had been re- sorted to. In relation to the question before us, one of the most important documents which I met with, is an official circular, signed by Sir James M'Grigor and Dr. Franklin, from which it appears, that in 1940 cases of pri- mary venereal ulcerations on the penis, cured without mercury, between December, 1816, and December, 1818, (including not only the more simple sores, but also a re- gular proportion of those with (he most marked character of syphilitic chancre) the average period taken up by the treatment, when bubo did not exist, was 21 days,; with bubo, 45 days. (See Hennen's Military Sur- gery, Ed. 2, p. 545.) And it further appears, that during the period above specified, 2827 chancres, a more considerable proportion of which were probably Hunterian chan- cres, were treated with mercury, and that the average period required for the cure, when there was no bubo, was 33 days ; with bubo, 50. As far therefore as a judg- ment can be formed from this official esti- mate, and no calculation is ever likely to be V LNEREAL DISEASE. 609 iurnished on a larger, or more impartial scale, the evidence tends to prove, that pri- mary sores may generally be cured rather sooner without, than with, the administra- tion of mercury. But, as practitioners are not obliged to restrict themselves either to the mercurial, or non-mercurial practice, I am of opinion, (hat the total rejection of mercury is by no means justified by any facts, yet before the public, concerning the time requisite for the cure on either plan, because, as it is universally admitted, (hat some cases are very tedious, unless mercury be given, neither reason nor experience will sanction the exclusive adoption of only one mode of practice, whether the backward- ness to heal exist, or not. On the contrary, as far as the consideration of time has weight, prudence and common sense teach us to diversify the treatment according to circumstances But it may be inquired, since the backward disposition of a sore to heal cannot be known at first by its mere appearance, should the treatment begin with mercury, or not? Now, although late writers dwell very much on the impossibility of judging of the nature of a sore by its look alone, one fact is certain, that some ulcers on the penis have a clean appearance from their very commencement; some cases are simple excoriations ; and others, though ill-condi- tioned, are so small, that a fair chance offers itself of destroying every part of the disease with caustic. In all such cases, I should never commence with mercury. With respect to phagedenic and sloughing chancres, repeated experience has con- vinced me that they are cases, in the first stage of which, at all events, mercury should always be avoided ; and I believe with Mr. Guthrie, that when this is strictly done, secondary symptoms are rare. One sore of (his kind was long ago pointed out by Mr. Pearson as not requiring mercury ; and the attention of surgeons has been of late par- ticularly directed to it by Mr. Bacot. " It is characterized by a great derangement of the general health, by a high state of in- flammation of the part, by great local pain, and proceeds rapidly to the destruction of tbe parts. The situation of this sore is most commonly in the angle between the pre- puce and glans penis -, and those of a full habit of body, the young and the vigorous, are most liable to its attack. The most prompt and vigorous antiphlogistic means are necessary to arrest the progress of this sore; and the blood, taken away in these cases, presents (he usual inflammatory ap- pearances, frequently in a very high degree. Tbe exhibition of mercury in this species of sore is highly mischievous, and productive of the worst consequences; nor does it often happen that secondary symptoms succeed, fee. (On Sy]ihilis, p. 57.) Here, according to Mr. Pearson's observations, made many years ago, mercury is not per- haps necessary for the security of the con- stitution ; but, 1 conceive, it might be more correct to say, that the safety ol the consti- tution actually requires that mercury should Vol. IT ^ be strictly avoided, because there is some ground for believing, that in these in- stances, it is not only injurious to the local disease, but conducive to secondary symp- toms. However, if the latter symptoms should arise, notwithstanding mercury has not been administered during the cure of the ulcer, alterative doses of that medicine may still be useful, as Mr. Carmichael ob- serves, when the disease is in the wane, but not until then ; previously to which pe riod, the best internal remedies are antimo- nials, sarsaparilla, guaiacum, compound powder of ipecacuanha, arseniate of kali, the nitrous acid, and nitro-muriatic bath. (See Obs. on the Symptoms, fyc. of the Vene- real Disease, p. 209.) With respect to chancres, with a hardened base and margin, it certainly appears that many of them have healed tolerably fast without mercury ; but a large proportion of them seem to be tedious when that medi- cine is not employed. (See three cases recorded in the work last quoted.) It may be thought, however, tbat the official docu- ment, circulated by Sir James M'Grigor and Dr. Franklin, tends to prove, that, at all events, these sores heal sooner without than with mercury. But this deduction seems hardly allowable ; because, as these faithful and impartial reporters have sensibly re- marked, tbe 2827 sores, treated with mer- cury, may be fairly presumed to have partaken of fhe character of Hunter's chan- cre, in a greater proportion than the 1940 primary sores treated without mercury. (See Hennen's Military Surgery, p. 545.) Con- sequently, though the sores treated witii mercury seem, on (he average, to have heal- ed more slowly than others treated with it; yet it is to be taken into the account, that a larger number of (he first cases were ulcers with a hardened base and margin, and that if they had not had tbe mercurial treatment extended to them, it is possible their com- plete cure might generally have been still more tedious. As (he evidence now stands, therefore, I conceive it right to employ mer- cury with moderation for all sores on (he penis, having (he characters of the Hunterian chancre, and appearing after a suspicious connexion. > A consideration, however, which ought (o have greater influence than (he slowness or quickness of (he (rea(ment of primary sores, with and wi(hou( mercury, is the question, whether, upon the average, secondary symp- toms are more frequent after the non-mercu- rial practice, than the other ? On this most interesting point, tbe reports vary, as indeed they do on almost every matter in the inves- tigation, excepting the fac(s ofthe possibility of curing all forms of the venereal disease wilhout mercury, Ihe great rarity of any af- fection of the bones, and the general mild- ness of the secondary symptoms, when tbat medicine is not employed. On all these points, the testimonies are strong and con- vincing. But while Mr. Rose found secon- dary symptoms take place in one-third of bis cases treated without merrm-y, 'Med Chi- 610 VENEREAL DISEASE 7Va?w. Vol. S, p. 222,) the proportion in the York, and some olher hospitals, was only about one-tenth. (Vol. cit. p. 559.) In the 1940 cases of primary sores on the penis, treated witbout mercury in the army hospi- tals, between Dec. 1816, and Dec. 1818, there vvere only 96 instances of secondary symptoms of different sorts, or not more than one-twentieth. But the proportion of cases of secondary symptoms in the case of pri- mary ulcers, treated with mercury, was still smaller, and this in an important degree, be- ing only 51 oul of 2827 cases, or about one- fifty-fiftb. Were it not necessary here to make a considerable allowance for the pro- bable circumstance ofthe Hunterian chancre prevailing most in the cases treated with mercury, a point admitted by Sir James M'Grigor and Dr. Franklin, we should here have a powerful and decisive evidence iu favour of the general superiority of mercury for tbe prevention of secondary symptoms. Nor am I certain that the conclusion can be much weakened by the probability of (he difference here alluded (o, becan-e, from (he evidence of la(e brought to light respecting the nature of the class of diseases which go under (he name of syphilis, we have no right to infer, thai what has been called the Irue, or Hunterian chancre, is more disposed than some other primary sores to occasion se- condary symptoms. Indeed, Mr Guthrie declares, in the cases referred to in his paper, that where mercury was not used, (bese symptoms more frequently followed the raised ulcer of the prepuce, than the (rue characteristic chancre of syphilis affecting the glans penis. (Med. Chir. Trans. Vol. 8, p. 577.) On (he whole, as (he reports now stand, and as far as I can judge from cases which I bave seen myself, (he secondary symptoms are more frequent when primary ulcers are promiscuously treated without mercury. But it by no means follows from this fact, that the way to have the smallest possible number of cases of secondary symp- toms, is to employ mercury in all instances of sores on the genitals. This both reason and experience contradict, inasmuch as mer- cury, given in cases which do nol require it for Ihe security of the constitution, is fre- quently itself a source of cutaneous diseases, sore throats, and nodes, which, without its baneful influence, would never have occur- red. The prudent course seems here to be, to exercise our judgment and discretion, and to be guided in some measure by (he ap- pearance and progress of Ihe sore, according to principles already suggested; for though the look of a sore may not, in the present slate of our knowledge, always enable us (o form a certain inference respecting the risk of secondary symptoms, if mercury be omit- ted, it cannot be said, (hat (he danger would be positively obviated by having recourse at once (o mercury in every kind of primary sore, and nol withslandin.; every thing which bas been lately published, I still flatter my- self, tbat surgeons, accustomed to see much of venereal cases, can yet distinguish exco- riations, boils, simple bealthv sore?, and some other similar ailments, (see Evans ov Ulcerations of the Genital Organs, Svo. Lond. 1819.) from ulcers, by which the constitution is liable to be affected. Until further data exist, I cannot venture to lay down other directions about the treatment of primary sores. It is with pleasure, however, that I subjoin the advice of other gentlemen, whose sentiments and talents deserve respect. though their opinion" may nol exactly agree with my own. " In every primary ulcer, (says Dr. Hennen,) I would give up tbe idea of using mercury at first, Irenting it as if it were a simple ulceration, by cleanliness, rest, and abstinence, and applying to it the most simple, and mildest dressings. If (he sore did nol put on a healing appearance in a reasonable time, the extent of which must depend upon the circumstances of (he pa- tient, I should make use of more active dressings- But if, beyond all calculation, it remained open, 1 should certainly not sacri- fice every consideration to n dislike of mer- cury, knowing how many persons have been seriously benefited by a judicious and mild administration of lhat remedy." (On Mili- tary Surgery, Ed. 2, p. 618.) When primary ulcers resist common means a certain time, Mr. Bacot would also have recourse lo mer- cury. (On Syphilis, p. 69.) Like me, how- ever, the laiier author does not approve of invariably postponing that remedy, until Ihe latter criterion, viz. the backwardness ofthe sore to be healed by other melhods, is af- forded. Whenever Ihe employmenl of mercury in (his work is recommended, I am very far from wishing (o be thought an advocate for pushing tha( medicine, ns the phrase is. On the-contrary, experience, has fully convinced me, that in no forms of chancre, nor in any other stages of (he venereal disease, is it proper to exhibit mercury in the unmerciful quantity, and for the prodigious length of time, which cus(om, ignorance, and preju- dice, used to sanction in former days. Vio- lent salivations, at all events, ought (o be for ever exploded. When I was an apprentice at St Bartho- lomew's Hospital, moit of the venereal pa- tients in that establishment were seen with their ulcerated longues hanging e>ut of (heir mouths; their faces prodigiously swelled; and their saliva flowing out in streams. The wards were not sufficiently ventilated, and (he stench was so treat, tbat the places well deserved the appellation of foul. Yet, not- withstanding mercury was thus pushed, (as the favourite expression was.) it was then common to see many patients suffer the niott dreadful of mutilations, in consequence of sloughing ulcer-of the penis; other patients whose noses and palates uere lost ; others who were covered witb nodes and dreadful phagedenic sores. Happily, a( (he present day, this attach- ment to violent salivations no longer pre- vails; simple excoriations and common ul- cers are more attentively discriminated; and even in what are reputed to be true syphili- tic chancres, mercury is seldom given, except VENEREAL DISEASE till in very moderate doses, or such quantities as only gently affect Ihe gums and salivary glands. The surgeon, now no longer blind- ed wilh the continual fear of the rapid and furious progress of syphilis when nol duly unresisted by mercury, avoids the very mode of practice which was itself the cause of all (he aggrava(ed forms of the disease. The consequence is, (hat very bad instances of the ravages of lues venerea are now hardly ever observed in (he above hospital, and the few aggravated cases which are met with, are generally in tbat state previously to their admission. Another benefit, also resulting from modern investigations, which proves (hat chancres, and all other varieties ol the venereal disease, do not absolutely require mercury for their cure, is the safety with which it is now known that the u-e of such medicine may be postponed, where the pa- tient's present state of health would not well bear its exhibition. And I know, that an ig- norance of this fact has formerly caused the death of many a poor sufferer. The greater present mildncs of syphilitic diseases in England, I asc ibe chiefly lo tbe more judicious treatment now adopted, and not to any change or modification in the na- ture ofthe diso.,!er. Thevt- are others, how- ever, who may think ai Mr. Fergusson does with regard to syphilis in Portugal, that the disease has exhausted a great deal of its vi rulence from long continuance among us. But before we are altogether justified in drawing such a conclusion, we must forget all the bad practice wliich prevailed in for- mer days, and cvhich, in my opinion, is suffi- cient to account for the. more severe forms in which syphilis then presented itself. According to Mr. Hunter's ideas, the most simple method oi treating a chancre is to extirpate it with caustic, or the knife, where- by it is reduced to the state of a common lore, or wound, and heals up as such. How- ever, he sanctions this practice only on the first appearance of the chancre, when the surrounding parts are not yet contaminated ; for, he says, it is absolutely necessary to re- move (he whole ofthe dis. ased part, and this object is exceedingly difficult of accomplish- ment, when the disease has spread considera- bly. When the chancre is situated on the glans penis, he thought touching the sore with the lunar caustic preferable to cutting it away, because the hemorrhage from tbe cells of Ihe glans would be considerable after the use of the knife Tbe caustic should be pointed at Ihe end like a pencil, in order that it may only touch sucb ports as are really disease.) ; and ils ap- plication should be repeated till the surface of the sore, after the s**parntion of the last doughs, assumes a red and healthy appear- ance, when it will heal, like any other sore made wilh caustic. When the sore is 0:1 the prepuce, or the common skin of Ihe penis, and in an incipient state, the same practice may be adopted with success. When the chancre is large, how- ever, it cannot be destroyed wilh the argen- tum nitratum, which does not extirpate the increasing sore deeply enough. In such cases, Mr. Hunter thought that the potassa cum calce might answer better. When the caustic could not be conveniently employed, this author sometimes recommended the ex- cision of chancres, a plan which he had adopted himself, and the part afterward healed with common dressings. However, says he, as our knowledge of the extent of Ihe disease is not always certain ; and as (his uncertainly increases with the size of the chancre, (he cure must be in some mea- sure promoted by proper dressings, and it will be prudent to dress the sore with mercu- rial ointment. When a chancre is destroyed almost immediately on its first appearance, Mr. Hunter believes lhat there is little dan- ger of the constitution being infected, as it is reasonable to conclude that there bas not been time for absorption to take place. However, on account of the impossibility of being certain on this point, he recom- mends mercury to be given from motives of prudence, the quantity of which medicine, he says, should be proportioned to tbe dura- tion a,id progress of the sore. When the chancre is large, Mr. Hunter d<*ems mercury absolutely necessary, and he conceives that very little good is to be done by the extirpa- tion. With respect to dressings for chancres, Mr. Hunter seems to have placed a good deal of confidence in those which contain mercury ; bul I do not believe that the same attach- ment to them prevails now which existed (wenty years ago. And the established fact of mercury not being absolutely necessary in any way for the cure of different venereal sores, must have (he effect of removing some prejudices on this part of the subject. As common mercurial oin(men( is always more or less rancid, I have found it in many cases a bad kind of dressing; and now never ap- ply it to ulcerated surfaces. In ordinary cases, I believe astringent lotions made with the sulphate of copper, aceta(e of lead, alum, fee. answer Ihe bes(. Some chancres are in- dolent, and require stimulants, like the hy- drargyri nilrico oxyduin blended with oint- ment, the unguenturn hydrargyri nitrati more or less weakened, or a solution of the nitrate of silver. Mr. Hunter, always partial, even in cases of indolent chancres, to mercurial dressings, expresses his preference to a salve containing calomel, as being more active than common mercurial ointment. In phage- denic and sloughing chancres, the carrot and fermenting poultices, solutions of the extracts of hemlock and opium; but particularly bread and water poultices with opium, and lotions of the arseuiate of kali, nitrous acid, and nitrate of silver, merit trial. In general, Mr. Hunter was an advocate for changing Ihe dressings very often, because the matter separates them from the sore, so as to diminish their effects. He states, that changing the applications thrice a day, will not be found too often, particularly when they are in the form of an ointment. When the venereal nature of a chancre is removed, the sore frequently becomes sta- 612 VT.NEREAL DISEASE. tionary, iii which case Mr. Hunter observes, that new dispositions have been acquired, nnd the quantity of disease in the part has been increased When chancres are only stationary, Mr. Hunter says, they may often be cured by touching them slightly with the lunar caustic. In these cases, no cica trization seems possible, till the contamina- ted surface, or the new flesh which grows on that surface, has either been destroyed or altered. When sores are situated under the prepuce, where they are concealed by a phymosis, some emollient, or gently as- tringent lotion, should frequently be injected under the fore-skin, so as to wash out any malter which might otherwise lodge there, and cause additional irritation. Contrary to the doctrines, which the facts of modern experience have now fully esta- blished, Mr. Hunter believed, that mercury should be given in every case of chancre, how- ever slight, and even when it has been de- stroyed by caustic, or other means, on its very first appearance.^ The remedy, he says, should be continued for some tune after the chancre has healed, in order to hinder (he ve- nereal disposition from forming. Here we find even Hunter himself fulling into some inconsistencies; for, in other parts of his work, he seems to approve of the principle of giving mercury only when actual and visible disease exists, because it cannot cure the disposition to it, even if it exists. Now, though the chancre is cured, no further ab- sorption of the virus from it is possible, and whatever disposition to tlie disease can arise from absorption, must have already been formed, and therefore cannot be prevented, ..iid, according to Mr. Hunter's own theory, the virus has been long ago expelled from the system, together with some of the ex- cretions, mercury is recommended with the view of protecting the constitution. How- ever, if Mr. Hunter's explanations are not altogether satisfactory on this part of the subject, I beli ve the fault is in his theory, because, in cases where mercury is deemed advUeahle, general experience appears to sanction the practice of continuing its use for some time afler the chancre is perfectly healed. Yet many exceptions to this rule present themselves; for, if a chancre is lara;e, and very long in healing, its syphilitic character is generally extinct a good while before cicatrization is completed, and per- severance in mercury under (hese circum- stances would be both an absurd, and a dangerous practice. Hence, in a great measure, the cause of the numerous instances of (he mercurial dis- ease, as Mr. Mathias has named it, and which, in former days, did far more mis- chief than syphilis itself. (See An Inquiry into the History and Nature of the Disease, produced in the Human Constitution by the Use of Mercury, 3d Ed Svo. Lond. 1816.) This part of the subject is noticed by Mr. Hunter, who states, that in very large-chan- cres, it may not always be necessary to continue either the external or internal ad- ministration of mercury till tiie sore is healed ; for the venereal action u just a soon destroyed in a large chancre, as it is in a small one, since every part ofthe sore k equally affected by the medicine, and, ot course, cured with equal expedition. But, in regard lo cicatrization, ciicumstanies are different, because a large sore is lunger than a small one in becoming com red with skin. Hence, according to Air. Hunter, u lar^-e chancre may be deprived of its venereal action, long before it has healed ; while, on the other hand, a small one may heal before the syphilitic affection has been destroyed. In Ihe latter case, he represents it as most prudent, both on account of the chancre and constitution, to continue the employment of mercury a little while afler the sore is healed; advice which, as 1 have ulready stated, is al variance with certain parts of his own theory, however well justified it may be by experience. As Mr. Hunter has explained, chuncrcs both in men aud women often acquire, du- ring the treatment, new dispositions, which are of various kinds, some retarding the cure, and leaving the parts in an indolent thickened state, after the cure is accom- plished. In other instances, a new disposi- tion arises, which utterly prevents the parts from healing, and often produces a much worse disease than that from which it ori- ginated. Sucb new dispositions may lead to the growth of tumours. They are more frequent in.men than women, and generully occur only when the inflammation bus been violent from some peculiarity of the parts, or,constitution. Ihey have sometimes been considered as cancerous. Among the diseases in question, Mr. Hun- ter notices those continued, and often in- creased inflammations, suppurations, and ulcerations, which become diffused through the whole prepuce, and also along (he common skin of (he penis, which beroi.u' of a purple hue, attended with such a gene- ral thickening of the cellular membrane, as makes the whole organ appear considerably enlarged. The same writer observes, that the ulceration on the inside of the prepuce will sometimes increase, and run between the skin and the body ofthe penis, and eat holes through different places, till the whole is reduced to a number of ragged soil-, The glans often shares the same fate, till more or less of it is gone, lieqcently, the urethra iu this situation is wholly destroyed by ulceration, and tiie urine is discharged some way farther hack. The ulceration, if unchecked, at length destroys all the parts. In this acute case, prompt lelief is demand- ed ; but often the proper mode of treatment cannot be at once determined, owing to our ignorance in respect to the exact nature of the peculiar cause of the di-euse. Mr. Hunter states, that tlie decoction of sarsa- parilla is often of service, when given in large quantities; and that the extract of hemlock, and sea-bathing, are sometimes capable of effecting a cure. AccorJing lo my own experience, the omission of mer- cury is here the rao-t essential thim;. VENEREAL DISEASE 618 Sometimes after a chancre has healed, the cicatrix breaks out again, and puts on the appearances of the preceding sore. Occasionally, similar diseases break out in different places from that of the cicatrix. Mr. Hunter believes, that they differ fro in a chancre in generally not spreading so fast, nor so far; in not being so painful, nor so much inflamed ; in not having such hard bases as venereal sores have ; and in not producing buboes. This writer is of opi- nion, that they are not venereal, and he states, that they are very apt to recur. Mr. Hunter does not specify any particular mode of cure for all these cases; but he mentions one instance, which seemed to be cured by giving forty drops of the liquor potassa*, every evening and morning, in a basin of brolh ; and he adverts to another case, which was permanently cured by sea- bathing. In some instances, after a chancre has healed, the parts, as Mr. Hunter remarks, do not ulcerate; but appear to become thickened and indurated. Both the glans and prepuce seem to swell, so as to form on the end of the penis a tumour, or excres- cence, shaped very much like a cauliflower, and when cut into, showing radii, running from its base, or origin, towards the exter- nal surface. It is extremely indolent, and not always a consequence of the venereal disease; for Mr. Hunter has seen it arise spontaneously. No medicine seems to be at all likely to cure the disease ; the only successful means is to amputate a considerable part of the penis, and then to keep a proper catheter introduced in the urethra. Another disposition, induced by the pre- vious occurrence of chancres, is that to ex- crescences, or cutaneous tumours, called warts. These are frequently considered not simply as a consequei.ee of the venereal poison, but as possessed of its specific dis- position, and therefore, says Mr. Hunter, surgeons have recourse to mercury for the cure of them ; and it is said, that such treat- ment often removes them. This eminent practitioner never saw mercury produce this effect, although the medicine was given in sufficient quantity to cure recent chan- cres, and a lues venerea, in the same person. (See Wart.) Mr. Hunter takes notice of sloughs, which occur in the tonsils, from the effect of mer- cury on the throat, and are apt to be mis- taken for venereal complaints. He also mentions that, sometimes, when the original chancre has been doing well, and been nearly healed, he has seen new sores break out on the prepuce, near the first, and as- sume all the.appearance of chancres. When, in the treatment* of chancres, a bubo arises, while the constitution is under the influence of a sufficient quantity of mercury to cure such sores, which medicine has also been rubbed into the lower extre- mity, on the same side as the bubo, Mr. Hunter suspects, that the swelling in the groin is not venereal, but is produced by the mercury. In Ihese cases, he always pre- ferred conveying mercury into the system in some other manner. With respect to the treatment of chancres in women, since it is difficult to keep dress- ings on the parts, Mr. Hunter advises the sores to be frequently washed with some mercurial solution, and speaks of one made with oxymuriate of mercury, as perhaps being the best, since it will act as a specific, and stimulant also, when this is requisite. When the chancres, however, are irritable, they are to be treated in the same manner as similar complaints in men. When the sores extend into the vagina, this passage must be kept from becoming constricted, or closed by the introduction of lint. Sometimes, after a chancre and all vene- real disease are cured,the prepuce continues thickened and elongated, so that the glans cannot be uncovered. Perhaps, the case is often without remedy. Mr. Hunter, bow- ever, very properly recommends trying every possible means, and he informs us, that the steam of warm water, hemlock fomentations, and cinnabar fumigations, are frequently of singular service. When the thickening and enlargement of the prepuce cannot be removed by appli- cations, all the portion, anterior to the glans penis, may be cut away. (See Phy- mosis.) Bubo. The immediate consequence of a chancre, which is called a bubo, and also the remote effects, implied by the constitu- tional, or secondary symptoms, arise from the absorption of recent venereal matter from some surface, where it has either been ap- plied or formed. We are already aware, that Mr. Hunter believed the matter of gonorrhoea to be ca- pable of communicatinj; the venereal dis- ease. Hence, he explains in the following terms, the three ways in which he thought a bubo might arise in consequence of absorp- tion. He observes, that the first and most simple manner, is when the matter, either of a gonorrhoea, or chancre, has only been applied to some sound surface, without having produced any local effect on the part; but has been absorbed, immediately after its application. Mr. Hunter affirms, that he has seen instances of this kind, though he confesses that they are very rare, and that, in most cases apparently of this nature, a small chancre may be found to have existed. The second mode of absorption, or that taking place in a gonorrhoea, Mr. Hunter represents as more frequent. That second- ary symptoms do occasionally follow go- norrhoea is yet commonly admiUed, though whether they differ essentially from those which follow (rue chancres, is a point not yet completely settled. However, as far as Mr Carmichael's experience goes, there is a difference, a part of which consists in the eruptioii*beii'gof the papular kind, as it is also after many instances of simple pri- mary ulcers. (See Obs. on the Symptoms, fyc. of Venereal Diseases, Svo. Lond. 1818.) "»H VENERLAL DISEAH The third mode is the absorption of mat- * Swellings of the absorbent glands may (er from an ulcer, which may ei(her be a originate from other diseases, and should be chancre, or a bubo. This mode is by far carefully discriminated from those which the most common, and it proves, with many arise from the venereal poison. Witb this other circumstances, that a sore, or .ulcer, view, Mr. Hunter advises us first to inquire is the most favourable for absorption. Mr. into the cause, in order to ascertain whether Hunter believed, that absorption was more there is any venereal complaint at some apt to take place from sores on the prepuce, greater distance from the heart, such as than those on the glans. chancres on the penis, or any preceding dis- A fourth mode of absorption from a ease in this situation. He recommends us to wound is also an occasional occurrence. inquire, whether any mercurial ointment Mr. Hunter notices, that what is now has been at all applied to the leg and thigh commonly understood by a bubo, is a swell- on the diseased side; for mercury applied to ing, taking place in the absorbing system, those parts for the cure of a chancre, will especially in the glands, and arising from sometimes cause glandular enlargements, the absorption of some poison, or other which are occasionally mistaken for vene- irritating matter. When such swellings real buboes. This irritation of the inguinal take place in the groin, they are called bu- glands by the mechanical action of raer- boes, whether they proceed from absorption curial ointment, has also been particularly or not. noticed by Professor Assalini, who states, Mr. Hunter regards every abscess in the that he has had frequent opportunities absorbing syslem as a bubo, whether in the of convincing himself of the fact. (Sec vessels, or the glands, when it originates Manuale di Chirurgia, p. 67.) Mr. Hunter from the absorption of venereal matter. reminds us to observe, whether (here has The matter is taken up by the absorbent been any preceding disease in the constitu- vessels, and is conveyed by them into the tion, such as a cold, fever, fee. The quick circulation. In its passage through these or slow progress of the swelling is likewise to vessels, it often affects them with the spe- be marked, and the tumour must be dMin- cific inflammation. The consequence is guished from femoral hernia, lumbar ab- the formation of buboes, which are vene- scesses, and aneurisms of the crural artery. real abscesses. These are exactly similar In particular cases, it would appear, that to a chancre in their nature and effects, the some time elapses ; before the venereal mat- only difference being in regard to size. As ter produces its effects on the absorbent the lymphatic vessels and glands are Irrita- glands after its absorption. Mr. Hunter no- ted by the specific matter, before it has un- tices, that, sometimes, at least, six days dergone any change in its passage, the traispire first; a circumstance, which can inflammation produced, and the matter se- only be known by the chancres having creted, partake of the specific quality. healed 3ix days before the bubo began to Inflammation of the absorbent vessels appear. However, as the last matter of a themselves is not nearly so frequent, as that chancre is probably not venereal, he infers, of the glands. In men, such inflammations, that iu cases of this kind, absorption must in consequence of chancres upon the glans, have taken placeearlierthaiiotherconsidera- or prepucp, generally appear like a cord, tions would lead one to suppose. Accord- leading along the back of the penis from the ing to Mr. Hunter, in general, only (he sores. Sometimes, the absorbents inflame, glands nearest to the seat ot absorption are in consequence of the (hickening and exco- attacked. Thus, when the matter is taken riation of the prepuce in gonorrhoea. The up from the penis in men, the inguinal indurated lymphatics often terminate insen- glands are affected ; and when from the sibly near the root of the penis, or near the vulva in women, (hose glands swell which pubes; while, in other instances, they ex- are situated between the labium and thigh, tend further to a lymphatic gland in the and the round ligaments. groin. Mr. Hunter believed, that this affec- It was one of Mr. Hunter's opinions, lhat tion of the absorbent vessels is truly venereal, only one gland at a time is commonly affect- The formation of a hard cord, he conceived, ed by the absorption of venereal maUcr. If aroseTrom a thickening of the coats of the this sentiment be correct, the circumstance absorbents, and from an extravasation of coa- may be considered as a kind of criterion be- gulable lymph on their inner surface. tween venereal and other buboes. The A cord, of the above kind, often suppu- second order of lymphatic vessels and glands rates, sometimes in more places than one, are never affected; as, for instance, those 60 as to form one, two, or three buboes, or along (he iliac vessels, or back. Mr. Hunter small abscesses in the body of the penis. informs us, that he also observed, lhat Inflammation much more frequently affects when the disease was contracted by a sore, the absorbent glands, than the vessels. The or cut upon the finger, the bubo occurred a structure of the former parts appear to con- little above the bend of the arm, by the sist of the ramifications and reunion of the side of the biceps muscle, and no swelling absorbent vessels. From this structure, ob- of this sort formed in the arm-pit. How- serves Mr. Hunter, we may reasonably sup- ever*, he had heard of a few rare cases, pose, that the fluid absorbed is in some jnea- in which a swelling in the axilla was also sure detained in the glands, and (hus bas a produced. greater opportunity of communicating the When buboes arise from a venereal dis- disease to them, than to the distinct vessels./ease on the penis, they are situated in the VENEREAL DISEASE. 615 glands of the'groin. When a bubo arises from a gonorrhoea, either groin may be attacked. But when the disease originates from a chancre, the bubo most frequently fakes place in the nearest groin. The situation of the absorbent glands, how- ever, is not always exactly the same, and the course ofthe lymphatics Iherefore is sub- ject to some variety. Hence, Mr. Hunter has seen a venereal bubo, produced by a chancre on the penis, situated a considerable way down the thi^h ; he has also often seen buboes as high as the lower part of the belly, before Poupart's ligament; and sometimes near the pubes. At the present day, swell- ings of the femoral glands are never consi- dered venereal. The seat.of absorption is more extensive in the female sex, and the course of some of the absorbents is also different. Hence, buboes in women may occur in three situa- tions, two of which are totally different from those in men. When chancres are situated forwards, near the meatus urinarius, nympha?, clitoris, labia, or mons veneris, the absorbed matter is generally conveyed along one, or both of the round ligaments, and the buboes are formed in those ligaments, just before they enter the abdomen. Mr. Hunter suspected such buboes not to be glandular ones, but only inflamed absorbents. When chancres are situated far back, near or on the perinamm, the absorbed matter is carried forward along the angle, between the labium and the thigh, to the glands in the groin, and often, in this course, small buboes are formed in the absorbents similar to those abscesses which occur on the penis iu men. When the effects of the poison do not rest here, a bubo in the groin may be occasioned in the same manner as in men. Owing to the difficulty of being sure, that women are quite free from infection, it is often more difficult to decide in them, than in men. whether a bubo is venereal, oi not. In men, who have had no local complaint, the bubo can only be venereal, when direct absorption from the surface of the skin has taken place. A bubo, says Mr. Hunter, commonly be- gins with a sense of pain, which leads the patient to examine the part, where a small hard tumour is to be felt. This increases, like every other inflammation, that has a tendency lo suppuration, and unless check- ed, pus forms, and ulceration follows, the ma((er making its way to the skin very fast. The above celebrated writer remarks, however, that there are some cases, which are slow in their progress. This circum- stance he imputes either to the inflammatory process being kept back by mercury, or other means, or to its being retarded by a scrofulous tendency. The inflammation, he says, is at first con- fined to the sland, which may be moved about in the cellular membrane ; but when (he part has become enlarged, or when the inflammation, and suppuration, are more idvain-ni. the s'lrrouud'oig parts become more inflamed, and the tumour is more dif- fused. Some buboes become complicated "with an erysipelatous and cedematous affec- lion, by which they are rendered more dif- fused, and less disposed to suppurate. Mr. Hunter allows, that to distinguish, with certainty, the true venereal bubo from other swellings of the glands in the groin, may be very difficult. He represents the true venereal bubo, in consequence of a chancre, as being most commonly confined to one gland. It preserves its specific dis- tance till suppuration has taken place, and then becomes more diffused. It is rapid in its progress from inflammation to suppura- tion and ulceration. Tbe suppuration is commonly large, considering the size ofthe gland, and there is only one abscess. The pain is very acute, and the inflamed part of the skin is of a florid red colour. Mr. Hunter describes such buboes as arise without any visible cause, as being of two kinds. One sort inflame and suppu- rate briskly. These be always suspected to bs venereal, although he allows there was no proof of it, and only a presump- tion deduced from the quick progress of the disease. The second kind are generally preceded, ami attended with slight fever, or the com- mon symptoms of a cold, and they are generally indolent and slow in their progress. if they are quicker than ordinary, they become more diffused than venereal buboes, and they are often not confined to one gland. When very slow, they give but little sensation ; but, when quicker, the sen- sation is more acute, though not so much so as in venereal cases. They usually do not sup- purate, and often become stationary. When they do suppurate, it is in a slow manner, and frequently in more glands than one, while the inflammation is more diffused, and not considerable, in relation to the swelling The matter makes its way to the skin slowly, and the part affected is of a more purple colour. Sometimes, the abscesses are very large, yet not painful. In considering whether the swellings of the inguinal gl .nds are, or are not venereal, the first thing to be attended to is, whether; or not, there are any venereal complaints. If there are none, Mr. Hunter observes, that there is a strong presumptive proof, that the swellings are not venereal. When the swelling is only in one gland, very slow in its progress, and gives bul little, or no pain, it is probably merely scrofulous. However, when the swelling is considerable, diffused, and attended with some inflammation and pain, the constitution is most probably af- fected with slight fever, the symptoms of which are lassitude, loss of appetite, want of sleep, small quick pulse, and an appearance of approaching hectic. Such swellings are long in getting well, and do not seem to be affected by mercury, even when very early applied. Mr. Hunter mentions his having seen tbe above affection of the groin, together with the constitutional indisposition, take place 616 VENEREAL DISEASE. where there were chancres; and he was puzzled to determine, whether the disease in the groin was sympathetic, from derange- ment of the constitution, or whether it arose from the absorption of matter. He had long suspected, that there was a mixed case, and vvas at last certain, tbat such a case might prevail. He had seen instances, in which the venereal matter, like a cold, or fever, only irritated the glands to disease, producing in them scrofula, to which they were disposed. In such cases, says Mr. Hunter, the swell- ings commonly arise slowly, give but little pain, and if mercury be given to destroy the venereal disposition, their progress is acce- lerated. Some suppurate while under this resolving course ; and others, which proba- bly had a venereal taint at first, become so indolent, that mercury has no effect upon them, and in the end, they either get well of themselves, or by other means. According to Mr. Hunter, buboes are local complaints. TREATMENT OF BUBOES. When a bubo is judged to be venereal, and only in an inflamed state, an attempt is to be made to resolve the swelling. The propriety of the attempt, however, depends on the progress which the disease has made. If the bubo be very large, and suppuration appears to be near at hand, resolution is not likely to be effected. When suppuration has already taken place, Mr. Hunter much doubted the probability of any success at- tending the endeavour, which now may only retard the suppuration, and protract the cure. The resolution of these inflammations, says Mr. Hunter, depends principally on mercury, and almost absolutely on the quantity, ivhich can be made to pass through them. When suppuration has taken place, the cure also de- pends on the same circumstances. Hence, he recommended the mercury to be applied to such surfaces as allow the remedy, when absorbed, to pass through the diseased gland. In this manner, he conceived, (hat the dis- ease in the groin might be subdued, and that the constitution would be less likely to be contaminated. At the same time, he admit- ted, that the situation of many buboes is such, as not to have much surface for ab- sorption beyond them ; for instance, the bu- boes on the body of the penis, arising from chancres on the glans, or prepuce. As venereal buboes are an effect, or conse- quence of chancres, or venereal sores, and glandular swellings in the groin may take place from other kinds of sores, or local ir- ritations, and even from various constitution- al causes, while modern surgeons profess their incapacity always to pronounce the character either of a primary sore, or a bubo, by its first appearance, and progress, it is evident, that the same difficulties pre- sent themselves here, as in cases of primary sores, respecting the principles, by which 'he treatment should be guided. It is like- wise to be remembered, that buboes, when supposed to be decidedly syphilitic, are nol, as Mr. Hunter imagined, absolutely incurable without mercury. The firm confidence also, which Mr. Hunter had in the doctrine of the benefit derived from the practice of rubbing mercury into surfaces, from which it would be conveyed directly to the diseased glands, so as both to resolve the swelling and pre- serve the constitution, is not now regarded as an unquestionable subject. As Mr. Bacot has judiciously remarked, there is some in- consistence in Mr. Hunter's own statements upon this point; for, in one place he affirms, that mercury, applied to the legs and thighs for the cure of a chancre, will sometimes cause, instead of disperse, a bubo. (P. 404.) And Mr. Bacot believes himself, lhat mer- cury as frequently promotes the suppuration of buboes, as their dispersion. (On Syphilis, p 74.) And, respecting the practice of try- ing to make the mercury pass through the diseased glands, Mr. Hunter rather contra- dicts himself in another page, where he con- fesses his own doubts of its utility in suppu- rated buboes. However, Mr. Hunter ad- mits, that mercury alone is not always capa- ble of effecting the cure of such buboes as are deemed venereal; and when the inflam- mation rises very high, he approves of bleed- ing, purging, and fomentations. When the inflammation is erysipelatous, he has a high opinion of bark; and, when it is scrofulous, he praises hemlock, and poultices made with sea-water. He was also aware of the fact of emetics sometimes occasioning the ab- sorption ofthe matter of buboes, after it is distinctly formed. If there is generally great difficulty in pronouncing at first the nature of a primary sore, as to (he question of i(s being syphilitic or not, the same difficulty must occur with respect to judging ofthe glandularswellings, excited by it. And, on this account, and from the encouraging circumstances, that all buboes may be cured without mercury, and tbat the course ofthe venereal disease, unresisted by that mineral, is not so terrible and incurable, as used to be supposed, some surgeons, instead of having immediate re- course to mercury, prefer a little delay, in order to see, whether the swelling will sub- side, or not, under the use of common an- tiphlogistic means. Thus, Dr. Hennen dis- approves of using mercury immediately a bubo presents itself; and he states, that the same principles, which guide him in the pri- mary ulcers, would have tbe same, if not greater force, in the case of buboes. " Iu their irritable state (says he) I consider mer- cury altogether inadmissible." (On Military Surgery, Ed. 2, p. 518.) Although the correctness of some of the principles, by which Mr. Hunter regulated bis practice in buboes, must now be ques- tionable, inasmuch as he calculates too much on the absolute necessity for mercury, and on the usefulness of making it pass through the diseased glands, I conceive, that some of his directions are yet too important to excluded from this work. He says. VENEREAL DISEASE. 017 quantity of mercury, necessary for the reso- lution of a bubo, must be proportioned to the obstinacy of the complaint; but that care must be taken not to extend the employment of the medicine so far as to produce certain effects on the constitution. When the bubo is iu a situation, which admits of a large quantity of mercury being rubbed in, so as to pass through the swelling, and when the com- plaint readily yields to the use of half a drachm of mercurial ointment, every night, the mouth not becoming sore, or at most, only tender, Mr. Hunter"thinks it sufficient to pursue this course, till the gland is redu- ced to its natural size. In this manner, the constitution will probably be safe, provided tbe chancre, which may have caused the bubo, heals at the same time. When the mouth is not affected in six, or eight days, and the gland does not readily resolve, then Iwo scruples, or a drachm, may be applied every night; and, continues Mr. Hunter, if there should still be no amendment, even more must be rubbed in. In short (says he) if the reduction is obstinate, the mercury must be pushed as far as can be done with- out a salivation. When there is a bubo on each side, so much mercury cannot be made to pass through each, as the constitution in general will not bear this method. However, Mr. Hunter sanctions the plan of minding the soreness of the mouth less in this kind of case; though, he adds, that-it! is belter to let the bu- boes proceed to suppuration, than to load the system with too much mercury. When the situation of buboes will not al- low an adequate quantity of absorbed mer- cury to pass through them, (he frictions must be continued in order to affect the con- stitution ; but, according to Mr. Hunter in this case, more mercury will be requisite, than when the remedy can be made to pass directly through the diseased gland ; an as- sertion, which may now be doubted. Many buboes remain, without either co- ming to resolution, or suppuration ; and, notwithstanding every attempt to promote these changes, the glands become hard and scirrhous. Mr. Hunter conceived, that these cases are either scrofulous at first, or be- come so as soon as the venereal disposition is removed. He advises the use of hemlock, sea-water, poultices, and sea-bathing. According to a modern surgeon, of judg- ment and considerable experience, when buboes are in a chronic stationary state, the application of blisters to the swell1 rig is at- tended with the most beneficial effects. And, he rightly observes, that when such tumours are extremely hard and indolent, it is more advantageous to lei the patient have the be- nefit of the open air, exercise, and his ac- customed mode of living, than to confine him in an hospital. (Assalini, in Manuale di Chirurgia, p. 64; Milano, 1812.) Stimula- ting (he skin witii the antimonial ointment. is also sometimes a good practice. The suppuration of buboes frequently can- not be prevented by any known means. They are then to be treated, in some re- Voi II 78 spects,like'any other abscess. Before open- ing buboes, Mr. Hunter conceived it advan- tageous to let the skin become as thin as possible, because a large opening would then be unnecessary, and no measures re- quisite for keeping the skin from closing, before the bottom of the sore had healed. Mr. Hunter was doubtful, whether the ap- plication of mercury should be continued through the whole suppuration. He was in- clined to continue it; but. in a smaller quan- tity. There has been much dispute, whether a bubo should be opened, or allowed to burst of itself, and whether the opening should be made with a cutting instrument, or caustic. On this subject, Mr. Hunter remarks, that (here is no peculiarity in a venereal abscess to make one practice more eligible than another. The surgeon, he says, should be guided in some degree, by the patient. Some patients are afraid of caustics ; others, of cutting instruments. But, when the surgeon has the choice, Mr. Hunter expresses a pre- ference to opening the bubo with a lancet, in which method, no skin is lost. But he observes, that when a bubo is very large, and there will be a great deal of loose skin, after the discharge of the matter, he thinks, that caustic may, perhaps, be better, as it will destroy some of the redundant skin, and occasion less inflammation, than what is caused by an incision. The potassa cum calce is the caustic commonly employed. After the bubo has been opened, surgeons usually poultice it, as long as the discharge and inflammation are considerable, and then they employ dressings, which must be of a quality, adapted to circumstances. In the mean while, mercury is continued, both to make the bubo heal, and prevent the bad effects, which might otherwise arise from the matter being continually absorbed. The mercurial course is to be pursued, till the sore is no longer venereal. But, in ge- neral, since this point is difficult to ascer- tain, Mr. Hunter advises the continuance of mercury till the part has healed, and even somewhat longer, if the bubo has healed very quickly ; for, the constitution is apt to become contaminated. However, he did not approve of this long use of mercury iu all cases; because buboes often assume, be- sides the venereal, other dispositions, which mercury cannot cure, and will even exas- perate. Sometimes the sores, when they are losing, or entirely deprived of the venereal disposi- tion, become changed into ulcers of another kind, and, most probably of various kinds. How far it is a disease arising from a vene- real taint, and the effects of a mercurial course jointly, says Mr. Hunter, is not cer- tain. He suspected, however, that the na- ture ofthe part, or constitution, had a prin- cipal share in the case, and, I believe, few surgeons of the present time entertain any doiibt of the abuse of mercury being a very frequent cause, independently of any other circumstance. (See Malhias on the Mercuri- al Disease. Ed. 3) 6*8 VENEREAL DISEASE, Mr. Hunter observes, that such diseases make the curt ofthe venereal affection much more uncertain, because, when the sore be- comes stationary, or the mercury begins to disagree, we are ready to suspect that the virus is gone ; but, this (he supposes) is not always the case. He had seen some buboes exceedingly painful and tender to almost every thing that touched them, and the more mild the dressings were, the more pain- ful the parts became. In some instances, the skin alone becomes diseased. The ulceration spreads to the surrounding integuments, while a new skin forms in the centre, and keeps pace with the ulceration, so that an irregular sore, which Mr. Hunter compares with a worm- eaten groove, is formed all round. It ap- pears only to have the power of contamina- ting the parts, which have not yet been af- fected ; and those which have, readily heal. According to the same author, when buboes become stationary, and are little inclined to spread, attended with a sinus, or two, hem lock, joined with bark, is the medicine mosl frequently serviceable. Il is to be used both externally and internally. Mr Hunter also speaks favourably of sarsaparilla sea-bath- ing, and sea-water poultices. He states, that at tbe Lock Hospital, gold refiners' wa- ter has been found an useful application ; and that in some cases, benefit has arisen from drinking large quantities of orange- juice, and from the use of mezereon. Lues venerea. Surgeons imply, that a lues venerea has taken place, when the vene- real virus has been absorbed into Ihe circu- lation. Mr. Hunter does not think the epi- thet constitutional strictly proper in its ap- plication (o this form of the venereal disease. By constitutional disease, he observes, he should understand that, iu which every part of Ihe body is acting in one way, as in fevers of all kinds ; but, the venereal poison seems to be only diffused through the circulating fluids, and, as it were, to force certain parts of the body to assume the venereal action, which action is perfectly local. To use Mr. Hunter's phrase, it takes place in different parts in a regular succession of susceptibili- ties. Only a few parts are acting at the same time , and a person may be constitu- tionally affected in this way, and yet almost every function may be perfect. The venereal poison is generally conveyed into the system from a chancre. It may, also, according to Mr. Hunter's doctrine, be absorbed from a gonorrhoea. There is like- wise a possibility of its getting into the cir- culation from the surface ofthe body, with- out any previous ulceration. According to bis doctrine, it may be absorbed from com- mon ulcers, without necessarily rendering them venereal; and it may be taken up from wounds, in which cases, it generally first causes ulceration. Venereal ulcers. In consequence of the blood being contaminated with real venereal pus, it might be expected that the local effects thus produced, would be similar in their nature to those producing them. Mr. Hunter belicvvc', that this is not the- ea-e He notices, that tbe local effects from a constitutional contamination, are all of one kind, viz. ulcers, let the effects make their appearance on any surface whatever, either the throat or common 3kin. But Mr. Hun- ter conceived, that if the matter, when in the constitution, were to act upon the same specific principles, as (hat which is exter- nally applied, a gonorrhoea would arise, when it affecled a canal, and only sores, or chancres, when it attat ked other surfaces. Mr. Hunter found, that even the sores which are caused in the throat are very dif- ferent from chancres. He snvs, that tbe true chancre produces considerable inflam- mation, often attended with a great deal of pain, and quickly followed by suppuration. But the local effects, arising from the virus in the constitution, are slow in their pro- gress, attended with little inflammation, and are seldom or never painful, except in particular parts. However, Mr Hunter allows (hat this sluggishness in (he effects of the poison depends on the nature of the parts diseased ; and he owns that, when the tonsils, uvula, or nose, are alTecied, the progress ofthe morbid mischis.' is rapid, and bears a greater resemblai.ee to a chancre than when it occurs on the skin. Even in those parts Mr. Hunter thought that the ulcers were attended with Ies3 inflamma- tion than chancres which were spreading with equal celerity. Before the time of Mr. Hunter, the matter, secreted by sores which arise from a consti- tutional infection, was always considered to be of a poisonous quality, like the matter of a chancre. At first, one would expect that this must actually be the case, because venereal matter is the cause, and mercury cures chancres, and also ulcers proceeding from a lues venerea. Mr. Hunter remarks, however, that the latter circumstance is not a decisive proof, since mercury is capable of curing many diseases, besides the venereal. He also takes notice, that when pus is ab- sorbed from a chancre, it generally produ- ces a bubo ; but that a bubo is never occa- sioned by the absorption oi matter from a venereal sore, arising from the virus diffu- sed in tbe circulation. For instance, when there is a venereal ulcer in the throat, no buboes occur in the glands of the neck; when there are syphilitic sores on the arms, or even suppurating nodes on the ulna, no swellings form in the glands of the armpit, although these complaints occur when fresh venereal matter is applied to a common sore on the arm, hand, or fingers. No swell- ing is produced in the groin in consequence of nodes, or blotches on the legs and thighs. Some very important experiments are related in Mr. Hunter's Treatise on the Ve- nereal Disease, in order to prove that the matter from a gonorrhoea, or chancre, is capable of affecting a man locally, who is already labouring under a lues venerea, and that the matter from secondary syphilitic sores has not the same power. The parti- VENEREAL DISEASE. 619 culars, however, are too long to be inserted in this book. Paris most susceptible of Ihe Lues Venerea, fyc. Some parts of the body seem to be much less susceptible of the lues venerea than others ; indeed, Mr Hunter observes, that, as far as our knowledge extends, cer- tain parts cannot be affected at all. The brain, heart, stomach, liver, kidneys, and several other viscera, have never been known to be attacked by syphilis. The first order of parts, or those which become affected in the early stage of the lues venerea, are the skin, tonsils, nose, throat, inside of the mouth, and sometimes the tongue. The second order of parts, or those which are affected at a later period, are the peri- osteum, fascia?, and bones. Mr. Hunter conceived, that one great rea- son of the superficial parts of the body suf- fering the effects ofthe lues venerea sooner than the deep-seated ones, depends on the former being more exposed to external cold. He remarked, that even the second order of parts do not all become diseased at the same lime, nor every where at once. But. on the contrary, such as are nearest the external surface of the body are first disea- sed, as, for instance, the periosteum, bones of the head, the tibia, ulna, bones of the nose, fee. Neither does the disease affect these boras, equally on all sides ; but first on that srae which is next to (he external surface. K was Mr. Hunter's belief, how- ever, that the susceptibility of particular bones did not altogether depend upon their nearness to the skin; but upon this cir- cumstance and their hardness together. The foregoing account by no means agrees with the results of modern inquiries into the nature of the venereal disease ; for, unless mercury be given, it appears that the bones are very seldom affected by it. Thus in the cases which were treated by Mr. Rose without mercury, he observes, that " the constitutional symptoms were evi- dently not such as could be regarded as ve- nereal, if we give credit to the commonly received ideas on tbe subject. Caries of the bones, and some of the least equivocal symptoms, did not occur. In\no instance was there that uniform progress, with un- relenting fury, from one order of symptoms and parts affected to another, which is con- sidered as an essential characteristic of true syphilis." (Med. Chir. Trans. Vol. 8, p 423.) We learn also from Mr Guthrie, lhat the bones were not affected in any of the cases, cured entirely without mercury in the York Hospital, though there were several other cases admitted, " in which a few mercurial pills had been taken, and tbe mouth not affected, and in which the primary symp- toms were followed by eruptions both pa- pular and scaly, by ulcers in the throat, by nodes, and, in one case, by inflammation of the periosteum covering the bones of the nose, and ulceration of the septum nasi, although mercury vvas resorted to for its cure." (Vol.cit. p. 560) In the examples treated without mercury, under the superintendence of Dr. Hennen, this gentleman did not see " a single case in which the bones of the nose were affected .- some cases of periostitis, and of pains and swellings ofthe bones of the cranium and extremities were met with ; but, except in two, he never remarked any nodes which could be regarded as unequivocally syphili- tic." One of these yielded to blisters and sarsaparilla; the other,after resisting guaia- cum and sudorifics, was dispersed by mer- cury. (On Military Surgery, Ed. 2, p. 581.) Dr. Hennen's statement on this subject would have been more satisfactory had it comprised his opinion of the characters of an unequivocally syphilitic node. On the whole, it appears tolerably certain that mercury, especially when employed unmer- cifully, and even when employed in mode- ration, and the patient exposes himself to damp and cold, tends to promote the fre- quency of nodes as a sequel of the venereal disease, though as the long and abundant use of the same mineral does not cause the same consequence after other complaints, and venereal ulcers, treated altogether with- out mercury, rarely lead to nodes, it would seem as if these swellings were the product ofthe combined action of syphilis and mer- cury together. The infrequency of nodes in the strictly non-mercurial practice, is one of the most important facts yet esta- blished in its favour, and it is curious to find from some quotations made by Dr. Hennen, that it was well known in former days. Fallopius, in his 96th chap. De Ossium Cor- ruptione, speaking ofthe loss of the bones of the nose and palate, says " et sciatis quod non in omni inveterato gallico hoc fit, sed tantum in iltis, in q\iibus inunctio facta est cum hydrttrgyro?' And Fernelius, in speaking of the injurious effects of mer- cury, observes, " recidiva raro similis est radici, neque iisdem symptomatis exercet, sed fere distillatione, arthritide tophis, vel ossium carie." (Aphrodisiacu* Vol. 3,p. 146.) And Palmarius, in considering the affection of the bones, aa Dr. Hennen has noticed, uses the /""Nowing remarkable words : " sed hoc (is duntaxat contingit, qui plim a Iue venerea hydrargyrosi vindicati putarentur, non qui decoctoguuiacinoetulexipharmaco curati fuissent." (De Morb. ('ontagiosis. Cap. 7, lib. 2, p. 124; Parisiis, 1578.) Dr. Hennen expresses his own conviction, in which I entirely agree, that the carious affections of the bones, which are so com- mon in persons treated by long mercurial courses, proceed not from the disease, but from the remedy rapidly and irregularly thrown in while periostitis exists ; and he has not seen a single case of carious bone in the military hospitals, since the non- mercurial treatment was adopted, except where mercury has formerly been used. (On Military Surgery, Ed. 2, p. 505, 506.) Nor will the results of modern experi- ence and inquiries, made on a very ejften- sive and impartial scale, allow us to consi- der the venereal disease as regularly and 620 VENEREAL DISEASE. unavoidably leading to any secondary symptoms, even though no medicine at all be employed for their prevention. This is fully exempjified in the official reports of the army hospitals. The particulars of 500* i cases, spoken of by Sir James M'Grigor and Dr. Franklin, lead to the opinion, that "the frequency or rarity of secondary symptoms woirfd seem lo depend on circumstances not yet sufficiently understood or explained, although the following fact would tend to the belief, (hat either the constitutions of the men, or the mode of conducting the treat- ment without mercury, are the causes that possess the greatest influence in their pro- duction. In one regiment, 4 secondary » cases out of 24,treated without mercury, su- pervened." In another regiment, 68 cases were treated without mercury, all bearing marks of true venereal disease, (and 28 of them especially selected for their decided characters of chancre) yet no secondary symptoms of any kind had taken place fif- teen months after the treatment had ceased. The same document, founded on the above large number of cases, confirms another fact, that no peculiar secondary symptoms follow peculiar primary sores; a conclusion which is directly adverse to Mr. Carmi- chael's opinions, of which I have taken more notice in another work. (See First Lines of the Practice of Surgery, Vol. 1, Ed. 4.) According lo Mr. Hunter, the time neces- sary for the appearance or production of the local effects, in parts most susceptible of the disease, after the virus has passed into the constitution, is generally about six weeks; but in many cases the period is much longer, while in other instances it is ■shorter. Soufetimes the local effects make their appearance within a fortnight after the possibility of absorption. The effects on other parts of the body, which are less susceptible of the venereal irritation, or slower in their action, says Mr. Hunter, are much later in making their ap- pearance. And when the first and second order of parts are both contaminated, the effects generally do not begin io nppear in the latter iill after a considerable time, nnd sometimes not till those affecting the for- mer parts have been cured. Mr. Hunter, however, refers to instances in which the periosteum, or bone, was affected before any of the first order of parts; but he was uncertain whether the skin or throat would afterward have become dis- eased, as the disorder was not allowed to go on. Venereal Eruptions. The whole tenor of various facts, specified in the foregoing co- lumns, tends to prove, that what is usually called the venereal disease is in reality seve- ral diseases, modified also by constitution,* climate, regimen, and mode of treatment. And hence, perhaps, the chief source of all the perplexity and uncertainty, which are yet so manifest as fully to justify the doubt sometimes entertained, whether any dis- ease, corresponding to the former notions of syphilis, really exists. Were any proof of the (rutii of (his reflection needed, in addition (o (he many o(her proofs of it already premised, the subject of venereal eruptions would at once furnish it ; for herd no kind of regularity can be traced, either in the appearances on the skin abstractedly considered, nor in the connexion between certain kinds of primary ulcers and particu- lar forms of cutaneous disease. Nay, as I have noticed in the preceding pa^es, some- times, hi consequence of a primary vene- real sore, different kinds of eruptions form together, or successively on one individual; and, as far as one can judge by the eye, ex- actly the same kind of chancre may produce very different breakings out in different per- sons, even though treated on precisely the same plan. These circumstances are truly confusing. In Mr. Rose's paper, however, there is a partial confirmation of one part of Mr. Carmichael's theory, viz. the fre- quency of papular eruptions after simple primary ulcers, or superficial sores, which readily heal. According to the latter gen- tleman, this form of eruption may also fol- low gonorrhoea, and is generally preceded by fever, and ends in desquamation. What- ever may be the degree of truth respecting the relation between this kind of eruption and the alleged primary complaints, the practice recommended by Mr. Carmichael for such cases is judicious. Geiuwal blood- letting is recommended when theWis fever, and the medicines praised are antimonials and sarsaparilla. Afterward, when the fever subsides, and the eruption desquamates, an alterative course of antimony and calomel, it is said, will accelerate the cure, though not absolutely necessary. In cases of vene- real pustular eruptions, supposed by Mr. Carmichael to be most frequent after chan- cres with elevated edges, without indura- tion, bloodletting is also advised during the febrile stage, followed by antimonials, sar- saparilla, guaiacum, tar-ointment, baths of sulphurated kali, or tbe nitro-muriatic bath ; and after the pustules have terminated in scaly blotches, alterative closes of mercury, conjoined with sarsaparilla or guaiacum. An eruption of tubercles, or spots of a pus- tular tendency, or of bolh intermixed, pre- ceded hy fever, and terminating in ulcers covered with thick crusts, complaints which Mr. Carmichael considers a sequel rather of the phagedenic than other chancres, he treats at first by bloodletting, followed by antimonials, sarsaparilla, guaiacum, com- pound powder of ipecacuanha, arseniate of kali, nitrous acid, and nitro-muriatic bath. Mercury is said to be hurtful, except in the last stage. To scaly blotches, which he conceives to be a sequel of the true chan- cre, or callous ulcer, he applies the same local treatment as to pustular eruptions, and he deems the question, whether sarsaparilla and guaiacum might here be substituted for mercury, yet unsettled. (See Obs. on the Symptoms, fyc. of Venereal Diseases, Synop- sis, p. 205, fyc) The investigations made in the military hospitals decidedly prove. VENEREAL DISEASE". Ml (hat all kinds of eruptions, supposed to be venereal, may be cured without mercury ; but, I believe, the great and superior useful- ness of moderate quantities of mercury for the removal of the scaly, copper-coloured blotches, is still generally acknowledged. But, even in these cases of copper-coloured spots, Mr. Bacot's advice may be good, viz. when the general health is much deranged, the tongue loaded and furred, and the appe- tite gone, to defer mercury " until, by pro- per evacuations and attention to the general health," the patient has had the benefit of a delay, " which will, in many instances, render all farther medical treatment unne- cessary. It is undoubtedly true that, what- ever plan be pursued, these eruptive symp- toms will eventually disappear ; still, where they continue to linger for a long time, and are attended with4 their usual accompani- ments of great languor, debility, and dis- turbed rest, I neither know, nor can I un- derstand, the advantage of delaying that remedy, which repeated experience has taught me to rely upon," fee. (Bacot on Syphilis, p. 99.) Although Mr. Carmichael's practice seems good, his theory, about the connexion of certain sores with particular eruptions, and other peculiar secondary symptoms, appears to be nearly refuted by the late investigations made in the military hospitals. To some facts, relating to this question, I have already adverted. There is as little certainty, about the essential characters of a syphilitic erup tion, as about the test of every other symptom of the venereal disease, or, rather diseases. While Mr. Hunter describes (he eruption as generally occurring over the whole body, Dr. Bateman states, that syphilitic affections of the skin com- monly make their first appearance on the face, where they are usually copious, and on the hands and wrists. (Prad. Synopsis of Cutaneous Diseases, p. 332, edit. 3.) Their colour, he says, is in general less livid, than that of ordinary eruptions, being of a brown- ish red of different shades ; but that this is not universal; for some of the syphilitic ecthymata have a bright red base in the be- ginning. Exposure to cold accelerates their progress, and increases their extent; while, on the other hand, warmth retards and meliorates them. (P. 333.) According to Hunter, the discolourations make the skin appear mottled, and many of the eruptions disappear, while others continue, and in- crease with the disease. In other cases, the eruption comes on in distinct blotches, which are often not ob- served, till the scurf has begun to form. At other times, the eruption assumes the appearance of small distinct inflammations, containing matter, and resembling pimples, not being however, so pyramidal, nor so red at (he base. Mr. Hunteralso observes, that venereal blotches, on their first coming out, are often attended wilh inflammation, which fiives them a degree of transparency, which is generally greater in the summer, than the winter, --speciidlv, if the patient be kept vvarm. In a little time, this inflammation disappears, and the cuticle peels off in the form of a scurf. "The latter occurrence often misleads the patient and the surgeon, who look upon this dying away of the in- flammation, as a decay of the disease, till a succession of scurfs undeceives them. The parts affected next begin to form a copper-coloured, dry, inelastic cuticle, call- ed a scurf, or scale. This is thrown off, and new ones are formed, which spread to the breadth of a sixpence or shilling; but, sel- dom more extensively, at least, for a consi- derable time. In the mean while, every succeeding scale becomes thicker and thick- er, till at last it becomes a common scab. Then the disposition to the formation of matter takes place in the cutis underneath, and a true ulcer is produced, which com- monly spreads, although in a slow way. When the affected part of the skin is op- posed by another portion of skin, which keeps it in some degree more moist, as be- tween the nates, about the arms, between the scrotum and the thigh, in the angle be- tween the two thighs, on the red part of the lip, or in the arm-pits, the eruptions, instead of being attended with scurfs and scabs, are accompanied with an elevation of the skin, which is swollen with extravasated lymph into a white, soft, moist, flat surface, which discharges a white matter. (Hunter.) Mr. Carlisle has pointed out what ke terms an herpetic abrasion of the cuticle on the breast, or abdomen, having the appear- ance pf venereal blotches. He states, that it is less deep in the skin ; that it has less of an inflammatory base ; and that it is not so distinctly circumscribed, as the true vene- real blotch. It never forms a purulent crust; but is simply a furfuraceous scaling of the cuticle. This form of disease seems to him to be produced by a disordered stomach and liver. (See Lond. Med Reposit. Vol. 7, p. 92.) A venereal eruption often attacks that part of the fingers, on which the nail is formed. Here, the disease renders that surface red, which is seen shining through the nail; and if allowed to continue, a separation of tho nail takes place. When surfaces of the body, covered with hair, are attacked, the hair separates, and cannot be re-produced as long as the dis- ease lasts. It must be allowed, that it is frequently very difficult to say, whether an eruption is syphilitic or not, and an opinion should rather be formed from the history of the case, than from any particular appearance of the eruption itself. As Dr. Bateman has remarked, the cutaneous eruptions, which are the result of the venereal poison, are often the source of considerable embarrass- ment to the practitioner. They assume such a v ariety of forms, that they bid defi- ance to any arrangement founded upon their external character; and in fact,they possess no common, or exclusive marks, by which their nature and origin are indicated. There is perhaps, no order of cutaneous appearan VENEREAL DISEASE. ces, and scarcely any genus, or species of tbe chronic eruptions, which these secon- dary symptoms of syphilis do not occasion- ally resemble. Dr. Bateman admits, hovv- ever, that in many cases, there is a differ- ence, which a practised eye will recognise, between the ordinary diseases of the skin and the syphilitic eruptions, to which the same generic appellation might be given This, says he, is often observable in the shade of colour, in the situation occupied by the eruption, in the mode of its distribution, and in the general complexion of the patient. Hence, to a person conversant with those ordinary diseases, a degree of anomaly in these respects will immediately excite a sus- picion, which will lead him to investigate the history of the progress of such an erup- tion, and of its concomitant symptoms. (See Bateman's Practical Synopsis of Cuta- neous Diseases, p. 331, 332, Edit. 3.) Dr. Hennen in his valuable book, does not pretend to be able to discriminate the true syphilitic eruptions from others, and indeed, by what criterion they are to be known, I am myself entirely puzzled to comprehend, alter the numerous facts, so fully established by recent experimental inquiries. Dr. Hennen generally approves of delaying mercury nt first, in order to see whether these cutaneous affections will yield to other means ; " but (says he) 1 should not very long postpone the employment of the mild- est mercurial alteratives, aided by warm bathing, and sudorifics. (On Military Sur- gery. Ed. 2, p. 518.) Venereal Disease of the Throat, Mouth, and Tongue.—In the throat, tonsils, and in- side of the mouth, the disease is said by Mr. Hunter generally to make its appearance at once in the form of an ulcer, without much previous tumefaction. Consequently the tonsils are not much enlarged. A venereal ulcer in the throat was suppo- sed by the same author to be in general tolerably well marked, though he confesses, that it may not in every instance be distin- guishable from an ulcer of a different na- ture. Several diseases of the throat, he re- marks, do not produce ulceration on the surface. One of these is common inflam- mation of the tonsils. The inflamed place often suppurates in the centre, so as to form an abscess, which bursts by a small opening; but never looks like an ulcer that has begun superficially, like a true venereal sore. The case is always attended with too much in- flammation, pain, and tumefaction of the parts, to be venereal. Also when it suppu rates and bursts, it subsides directly, and it is generally attended with other inflamma- tory symptoms in the constitution. Mr. Hunter then notices an indolent tu- mefaction of the tonsils, peculiar to many persons whose constitutions are disposed to scrofula. The complaint produces a thickness in the speech. Sometimes coagu- lable lymph is thrown out on the surface of the parts affected, and occasions appearan- ces, which are by some called ulcers; by pome sloughs;, and by others putrid sore- throats. The case is attended with too much swelling to be venereal, and with a little care, it may easily be distinguished from an ulcer, or loss of substance. How- ever, when this difference is not obvious at first sight, it is proper to endeavour to remove some of the lymph, and if the surface of the tonsil underneath should appear to be free from ulceration, we may conclude with certainty, that the disease is no( venereal. Mr. Hunter states, that he has seen a chink filled with coagulable lymph, so as to appear very much like an ulcer; but on removing that substance, the tonsil underneath was found perfectly sound. He adds, that he has seen cases of a swelled tonsil, having a slough in its centre, which slough before its detachment, looked very like a foul ulcer. The stage of the com- plaint, he says, is even more puzzling when the slough has come out ; for then the dis- ease has most ofthe characters ofthe vene- real ulcer. Whenever he met with the dis- ease in its first stage, he always treated it as if it had been ofthe nature of erysipelas, or a carbuncle. When (he complaint is in its second stage, without any preceding local symptoms, he recommends the prac- titioner to suspend his judgment, and to wait a little, in order to see how far nature is able to relieve herself. If there should have been any preceding fever, the case is still less likely to be venereal. Mr. Hunter informs us, that he has seen a sore-throat of this kind mistaken for a venereal case, and mercury given till it affected the mouth, when the medicine brought on a mortifica- tion of all the parts concerned in the first disease. Another complaint of these parts, which Mr. Hunter represents as being often taken for a venereal one, is an ulcerous excoria- tion, which runs along their surface, be- coming very broad and sometimes foul, having a regular termination, but never going deeply into the substance of the parts, as Mr. Hunter believes the venereal ulcer does. No part of the inside of the mouth is exempt from (his ulcerous excoriation ; but, according to Mr. Hunter, the disease most frequently occurs about the root of the uvula, and spreads forward along the palatum molle. He remarks, tbat the complaint is evidently not venereal, since it does not yield to mercury. He has seen these ulcerous excoriations continue for weeks, without undergoing any change, and a true venereal ulcer make its appearance on (he surface of the excoriated part He says, that such excoriations were cured by bark, after the end of tbe mercurial course, by which the syphilitic sore was cured. This author describes the true venereal ulcer in the throat, as a fair loss of substance, part being dug out, as it were, from the body of the tonsil: it has a determinate edge, and is commonly very foul, having thick white matter, like a slough,-adhering to it, and not admitting of being washed away. Here, however, as in most other supposed forms of syphilis, some test h wanting, b? VENEREAL DISEASE 623 which the case may be certainly distinguish- ed from olher diseases of (he throat, present- ing similar appearances; for, as Mr. Rose has very truly remarked, "Ihe excavated ulcer of the tonsils, as described by Mr. Hunter, is not, as Mr. Carmichael seems to think, a peculiar symptom of the present*** of Ihe syphilitic virus. I have repeatedly seen it, as well as the scaly blotch,in cases where mercuiy bad been freely employed tor the primary sores, and in which I considered the virus as eradicated, and both have dis- appeared under (he use of sarsaparilla." (Med. Chir. Tians. Vol. 8, p. 421.) In a re- cent work, Mr. Carmichael himself acknow- ledge- the justice of the preceding observa- tion, and owns, that since the publication of bis Essays, he has often noticed ihe exca- vated ulcer of tbe tonsils, either attending the primary phagedenic ulcpr, or Ihe train of constitutional symptom*-which arise from it. (On the Symptoms, fyc. of Venereal Diseases, p. 17.) In affections of the throat. D . Hen- nen states, (hat he " would be more guarded (ban in any others, in the employment of mercury, until all inflammatory disposition was removed." Afterward he has seen (hem yield, " as if by magic, so soon as the local effects of mercury on the parts within (he mouth became obvious." Bul when mercury was given earlier, he has seen a vasl number of instances in which irremediable mischief was done. (On Military Surgery, Ed. 2, p. blS.) According (o Hunter lues venerea some- limes produces a thickening and hardening of Ihe tongue, but frequently ulceration, as in other parts of the mouth. He describes venereal sores on the tongue, as generally more painful than those on (he skin ; but less so than common sore throats from inflamed tonsils. They oblige Ihe patient to speak thick, as if his tongue were (oo large for his mouth, with a small degree of snuffling. Mr. Hunter doubted the reality of a vene- real ophthalmy, (hough he owns that (here are inflammations of the eyes, which yield to mercury. See Ihe subject of irilis in the article Ophthalmy. Symptoms of the second stage of Lues Ve- nerea.—The periosteum, fascia*;, tendons, ligaments, and bones, are the parts which Mr. Hunter enumerates, as liable lo be af- fecled in Ihe second stage of lues venerea. This observation iu ils full extent, however, seems to be rendered rather questionable ; for it would appear from the evidence both of ancient and modern writers, that rVue nodes, or venereal swellings of the bones, and particularly caries, rarely take place from syphilis, unless mercury be employed. It is an observation of Mi. Hunter's, that we can- not always know with certainty what parts may become affected in Ibis stage of Ihe disease. He says he has known the dis- temper produce a (otal deafness, some- times followed by suppuration, and great pain in the ear, and side of the bead. I have already explained, (hat it was one of (his gentieman's doctrines, lhat (he second order of parts were generally deep-seated. When these become irritated by the poison, he observes (ha( the progress of the disease is more gradual, (han in (he first order of parts. I( assumes very much (be character of scrofulous swellings, or chronic rheuma- tism ; only it affects the joints less frequently than the latter affection does. A swelling sometimes makes its appearance on a bone, when there has been no possible means of catching Ihe intection lor many months; and in consequence of the little pain expe- rienced, the tumour may be of some consi- derable size, before it is noticed. Some- times a great deal of pain is felt; but no swelling comes on, till after a long unite. According to Mr. Hunter, Ihese remarks are also applicable to swellings of the tendons, and fascia?. As tumours ol this kind only increase by slow degrees, Ihey are not at- tended with symptoms of much inflamma- tion. When ihey attack Ihe periosteum, Ihey seem like an enlargemenl of (he bone itself, in consequence of being very firm, and closely connei ted with the latter part. Mr. Hunter »bo further observes,that in there advanced stages of the disease, the inflammation can hardly gel beyond Ihe adhesive kind, in which slate, it continues to become worse and worse, and when matter is formed, it is not true pus, but of a slimy description. Some nodes, he says, bo(h of the tendons and bones, las( for years, before (hey form any matter at all. These cases, he considered, as not being certainly venereal, though commonly consi- dered as such. Mr. Hunter found it diflicult lo explain the reason why, when lues venerea attacks the bones, or (he periosteum, the pain should sometimes be very considerable, and sometimes very trivial. Venereal pains in Ihe bones are described by Mr. Hunter as being of a periodic at kind, generally most severe in (he night-time. At ihe present day, when many cases formerly supposed (o be syphilitic, are treated without any mercury, and even (hose which are reputed to be venereal, are cured by much smaller doses of that medi- cine (ban were given in Mr. Hunter's time, nodes have become much less frequent, and I have already in a previous part ot this article expressed my decided belief in the justness of the opinion given by Fullopius and others, that a disposition to nodes is often occasioned by tbe abuse of mercury. Treatment of Lues Venerea.—In Mr. Hun- ter's opinion, the first order of parts, or those which are most susceptible of being affected in lues venerea, are also (he most easy of cure; while the second order of parts take more time (o he remedied. In the class of complaints, arising in (he second stage of ihe lues venerea, Mr. Hun- ter believed, lhat il was unnecessary to con- tinue ihe employment of mercury, till all Ihe swelling had disappeared. For il is ob- served by this distinguished writer, that since these local complaints cannot conta- minate the constitution by re-absorption, and since the venereal disposition and action from the constitution can be cured, white ■'24 VENEREAL DISEAH. the local effects still remain, and this even when the tumefaction, forming nodes on the bones, fasciae, fee. has proceeded to sup- puration, there can be no occasion for con- tinuing the course, after the venereal action has been destroyed. Whatever may be hereafter decided concerning ihe superiority of mercury as a remedy for muny seconda- ry symptoms, one thing appears already well made out, viz. that it should always be employed with moderation, lest it produce worse effects, and more terrible diseases, than those which it is designed lo relieve. For an account of the various ways of exhi- biting it, I must refer to the article Mercury. To the following ingenious reasoning on the operation of mercury, and the principles by which its administration should be regula- ted, surgeons of (he present day will not give more credit than facts warrant, because some of Mr. Hunter's opinions are manifestly in- fluenced by (he supposition, lhat mercury is absolutely necessary for the cure of the ve- nereil disease. In curing the lues venerea, mercury can only have two modes of action ; one on the poison: the other on the constitution. If, says Mr. Hunter, mercury acted on the poi- son only one might conceive it did so, either by destroying its qualities, by decom- posing it,or else by attracting it and carrying it out of the circulation. If mercury acted in the first of these ways, one would expect, that the cure would depend on the quantity of the medicine (aken into the system. If it acted in the second manner, one would infer, that the progress of the cure would be proportionate to the quantity of evacu- ation. But, observes Mr. Hunter, if it act upon the principle of destroying the diseased action of the living parts, and of counteract- ing the venereal irritation, by producing one of a different kind, then, neither quantity alone, nor evacuations, will avail much. He states, that the quickness of the cuie depends on quantity, joined with visible effects. However, it is added, that although (he ef- fec(s which mercury has upon the venereal disease, are in some degree proportioned to the local effecls of the medicine on some of the glands, or particular parts of the body, as the mouth, skin, kidneys, and intestines, yet such effects are not altogether propor- tioned to these other circumstances. When mercury disagrees with the constitution, so as to produce great irritability and hectic symptoms, this action of irritation, as Mr. Hunter explains, is not a counter-irritation to the venereal disease. It was also noticed by the same author, that the effects of mercury on lues venerea are always in proportion to the quantity of the remedy exhibited in a given time, and the susceptibility of the constitution to the mer- curial irritation. He says that these circum- stances require (he mos( minute addition, and that, in order to obtain tbe greatest ac- tion of mercury with safety, and in tbe most effectual manner, the medicine must be giVen till it produces effects somewhere. However, it mnst not be exhibited too quickly, in order that n sufficient quantity may be given, before we are obliged to stop, in consequence of the effects. Mr. Hunter thinks, that when (he local effec(s are pro- duced too quickly, they prevent a sufficient quantity of the remedy from being taken into (he system to counteract the venereal irrita- tion at large. Mr. Hunter mentions his having seen some cases, in which mercury acted very readily locally, and yet the constitution was hardly affected by it, for the disease would not give way. He states, (bat he has met with other cases, iu which the mere quantity of mercury did not answer, till it was given so quickly as lo affect the constitution in such a manner as to produce local irritation, and, conse- quently, sensible evacuations. This, he ob- serves, is a proof lhat tbe local affects of mercury are often the sign of its specific effects on the constitution at large, and it shows that (he susceptibility of the diseased parts (o be affected by (he medicine, is in proportion (o i(s effects on (he mouth. Ils effects, he contends, are not to be imputed (o evacuation ; bu( (o i(s irritation. Hence, be inculcates, (hat mercury should be given, if possible, in such a manner a3 to produce sensible effects upon some parts of the body, aud in the largest quantily (hat can be given, to produce these offects within oer- tain bounds. Mr. Hunter also remarks, that these sensible effects should be the means of determining bow far the medicine may be pushed, so as to have the greatest effect on the disease, without endangering the consti- tution. The practice mus( vary according lo circumstances; and if the disease is in a violent degree, less regard must be had to theconstilnlion,and mercury must be thrown into the syslem in larger quantities ; a very dangerous precept, as far as I can judge, from many cases in which I have seen it acted upon. Mr. Hunter likewise acquaints us, that when the disease is in the first order of parts, a smaller quantily of mercury is necessary, than when (be second order of parts are affected, and the disease has been of long standing, its first appearances alone being cured, and tbe venereal disposition still re- maining in the secondary parts. For the purpose of curing the venereal disease, whether in the form of chancre, bubo, or lues venerea, Mr. Hunter was of opinion, that probably the same quantity of mercury is necessary. He represents, that one sore requires as much mercury as fifty sores in the same person, and a small sore as much as a large one. He thought that the only difference, if there is any, must depend upon the nature of the parts affected, that is, on their being naturally active or in- dolent. He conceived, however, that on the whole, recent venereal complaints are gene- rally more difficult of cure, than the symp- toms of lues venerea, and lhat this may make a difference, in regard to the quautity of mercury necessary. HaviDg"now delivered the principal gene- ral instructions, relative to the exhibition of VENEREAL DISEASE. •62-tj mercury in tbe treatment of (he venereal disease, as given by Mr. Hunter. I must not quit (his subjec( without remarking, (hat even this eminent surgeon appears on (he whole loo partial to (he long use of mer- u- ry, and sometimes to (he intr< duction of immoderate quantities of it into the syslem. In general, however, his observations tend to condemn all violent salivations. It is (o be recollected, lhat in his days, nobody had a suspicion that truly syphilitic sores (if this expression be allowable, while they cannot be defined, nor distinguished by their ap- pearances) would in the end spontaneously heal, and he himself had no dependence upon any medicine, except mercury, for (he cure of the true venereal disease. But mo- dern experience, evinces, that (he disorder seldom now presents itself in forms so bad and intractable as formerly ; that it is even capable of spontaneously ceasing; and tbat we hardly ever see cases in which it is re- quisite to give mercury, except in very moderate quantities. Indeed, such is the change, that many surgeons suspect that the very nature of the disease must have under- gone a material alteration or modification. In England, in my opinion, every thing is lo be referred lo (he improved manner of employing mercury only in moderate doses, and never pushing its exhibition, till tbe constitution is so impaired, that undescriba- ble forms of diseases ensue, which are sometimes the compound effect of mercury and syphilis together; and, in ^)ther in- stances of that description, which surgeons now frequently call syphiloid, or pseudo- syphilitic, not depending upon the venereal poison at all, but upon a state of the system, which mercury is known to aggravate in the worst degree. For additional informa- tion concerning internal remedies for the venereal disease, see Mercury, Guaiacum, Mezereon, Muriatic Acid, Nitrous Acid, Sar- saparilla, Sulphuric Acid, fyc. With respect to the local treatment of (he symptoms of lues venerea, Mr. Hunter thought that none would in general be ne- cessary, «ince the constitutional treatment would commonly effect a cure. However, be admits, that sometimes the local effects will not give way, and the parts remain swollen io an indolent inactive state, even after there is every reason to believe that the constitution is perfectly cured. In such cases, he recommends assisting the consti- tutional treatmeat by local applications of mercury to tbe part, either in the form of a plaster or ointment. The latter applica- tion, he says, is the best. When these are nol sufficient, he advises an attempt to be made to excite inflammation of another kind. He says he has seen a venereal node, which gave excruciating pain, cured by mere- ly making an incision down to the bone, the whole length of the node. The pain ceased, the swelling decreased, and the sore healed up kindly, without the assistance of a grain of mercury. He mentions, that blisters have been applied to nodes with success, remo- ving the pain, and taking away the swelling. Vol. II. ~° -"With regard to these last cases I may add, that, for many years past, the idea of com- pletely dispersing nodes by mercury has been entirely abandoned in St. Bartholo- mew's hospital. In this institution, long protracted mercurial courses for (he cure of such swellings are totally relinquished. When small moderate quantities of mercury have had their full effect, a blister is ap- plied over the swelling, and kef*!*! open, under which plan the tumour generally sub- sides as far as its nature will allow. Diseases resembling the Venereal. Pseudo* syphilis.—Sores on the glans penis, prepuce, fee. in the form of chancres, as Mr. Hunter notices, may and do arise without any vene- real infection, and sometimes they are a consequence of former venereal sores, which have been cured. The symptoms, produced by the venereal poison in the constitution, are such as are common to many other diseases. For in- stance, Mr. Hunter remarks, that blotches on the skin are common to what is called a scorbutic habit; pains are common to rheu- matism ; swellings of the bones, perios- teum, fasciae, fee. to many bad habits, perhaps, of the scrofulous and rheumatic- kind. Thus, says he, most of the symptoms of the vertereal disease, in all its forms, are to be found in many other diseases. Hence, the original cause, and piany leading circum- stances, such as dates, effects of the disorder upon others, from connexion, when only local, the previous and present symptoms, fyc. mu.<6 be considered, before we can determine abso- lutely what the disease truly is. All the cir- cumstances and symptoms, taken together, may be such as will attend no other disease. However, Mr. Hunter confesses, that with all our knowledge, and with all the appli- cation of that knowledge to suspicious symptoms of this disease, we are often mis- taken, calling distempers venereal, which are not so, and sometimes supposing really syphi- litic affections to be of another nature. Mr. Hunter takes notice, that in some constitutions, rheumatism, in many of its symptoms, resembles the lues venerea. The nocturnal pains, swelling of the ten- dons, ligaments, and periosteum, and pain in those swellings, are symptoms both of the rheumatism, and also of the venereal disease, when it attacks such parts. Mr. Hunter, however, did not know tbat he had ever seen the lues venerea attack the joints, though many Rheumatic complaints of such parts are cured by mercury, and therefore supposed to be venereal. Mercury, given without caution, often produces the same symptoms as rheuma- tism. Such complaints Mr. Hunter had seen mistaken for venereal ones, and mer- cury continued. He explains, that some diseases not only resemble the venereal in appearance, but in the mode of contamina- tion, proving themselves to be poisons by affecting the part of contact; then -produ- cing immediate consequences similar to buboes; and also remote consequences si- milar to (he lues venerea 626 VENEREAL DISEASE Mr. Hunter observe?, that it is nearly as dangerous, in some constitutions, to give mercury, when the disease is not venereal, as to omit it in other cases, which are really syphilitic; and had he been ac- quainted with recertt investigations, he would undoubtedly have gone further, and declared that it is in- reality far more dan- gerous« Many of the constitutions, which put on some of the venereal symptoms, when the disease is not really present, he says, are those with which mercury seldom agrees, and commonly does harm. He had seen mercury, which was exhibited for a supposed venereal ulcer ofthe tonsils, pro- duce,a mortification of those glands, and the patient was nearly destroyed. Mr. Abernethy, in his Surgical Observa- tions, 1804, has treated at some length of diseases resembling syphilis, and bas ad- duced several very interesting cases, which I advise every surgical practitioner to read with the greatest attention, as in fact they confirm the views of the subject lately so fully established. " A gentleman (says he) thought that he had infected a slight cut on his hand (which was situated in front of, and just below the little finger,) with the -discharge from a bubo in the groin, tbat he had occa- sion to open. The wound fretted out into a sore about the size of a sixpence, which he showed m%, and which 1 affirmed had not the thickened edge and base, and other characters of a venereal chancre. 1 there- fore recommended.him to try the effect of local means, and not to use mercury. " In about a month, the sore, which had spread a little, became again contracted in its dimensions, and assumed an healing ap- pearance. At this time pain was felt ex- tending up the arm, and suddenly a consi- derable tumour arose over the absorbing vessels, which proceed along the inner edge of the biceps muscle. This tumour became nearly as big as a small orange. As the original sore seemed now disposed to heal, and as there was no surrounding indura- tion, I could not believe if venereal, and therefore recommended him still to abstain from mercury, and apply leeches and linen moistened in the aq. litharg. acet. comp. to the tumour formed over the inflamed ab- sorbents. For it seemed to me, that if the venereal poison had been imbibed from the sore, it would have passed on to one of the axillary glands, and would have caused in- duration and inflammation to take place there more slowly than had occurred on the present occasion. ' " Under this treatment the tumour was discussed, and the sore at the same time healed. About three weeks afterward, the patient called on me, and said that there were venereal ulcers in his throat; and in each tonsil there was an ule^r deeply exca- vated, with irregular edges, and with a sur- face covered by adhering matter-, ulcers, in short, which every surgeon, who de- pends on his sight as his guide, would have pronounced to be. venereal. Shortly after also some copper-coloured eruptions ap E eared on his face and breast. He showed is diseases to several surgeons, on whose opinion he relied, who, without hesitation, affirmed that they were venereal, and that the mercurial course had been improperly delayed " While the patient was looking out for lodgings, in order (hal be might go through the mercurial process, a circumscribed thickening and elevation of the pericra- nium, covering the frontal bone, appeared : it was of the circumference of a half-crown piece ; and was, in short, what every sur- geon, who is guided only by his sight and touch, would, withou( hesitation, have called a fair corona veneris. I now told the patient that I was more inclined to be- lieve his disease was not syphilitic, from the sudden and simultaneous occurrence of this node, with the sore throat, fee. Other surgeons thought differently ; and I believe this very sensible and amiable young man imagined lhat his health would become a sacrifice, if he any longer attended io my opinion. He was preparing to submit to a mercurial course, when very important concerns called him instantly into the country. He went with great reluctance, taking with him mercurial ointment, fee.; and after a fortnight, I received a letter from him, saying that he found his com- plaints benefited by his journey, that busi- ness had^jevented him from beginning the use of mercury for a few days ; that he now found it was unnecessary, for bis symptoms had almost disappeared ; and shortly after- ward he became perfectly well." Mr. Abernethy considers this case as the most unequivocal instance extant of a dis- ease occurring, which could not from ap- pearance be distinguished by surgeons of the greatest experience from syphilis, and which, however, was undoubtedly of a different nature ; (that is to say, it was of a different nature, according to certain cri- teria, then generally believed, but which recent investigations bave proved to be destitute of foundation.) All the tests here alluded to having been spoken of in the foregoing commns, I shall nol here repeat them. Some years ago the nitric acid was intro- duced as a remedy for syphilis. (See Ni- trous Acid.) To the position of its efficacy being as great in venereal cases as was first alleged, many surgeons have not acceded, though, as a sensible writer has observed, it has certainly been allowed, with some other medicines, to remain in a kind of copartnership with mercury, and admitted to be useful in venereal cases under certain circumstances. A great deal of this want of agreement, on the effects of remedies in syphilitic cases, is now explained by the imperfection of the diagnosis, and tbe im- portant fact, that the disease may generally be cured in time, without any medicines whatsoever, though this time is sometimes long. Dr. Scott, who first suggested the use of nitrous acid, has attempted to accoun* VENEREAL DISEASE 627 lor its alleged occasional failures, by ob- serving that the acid, which he employed, was not pure nitric acid, but an impure acid, containing an admixture of muriatic acid. He therefore, some time ago, re- commended the use of a compound acid, containing three parts of nitric acid, and one of muriatic, which he administered inter- nally, and also applied externally, largely diluted, as a bath, until the gums were af- fected and ptyalism produced ; and he con- ceived every trial as quite inconclusive, unless these constitutional effects occurred. " The acid that 1 have used of late (says Dr. Scott) is the nitro muriatic; and it is formed by mixing together equal parts of the nitrous, or nitric acid, and muriatic acid. If these acids be in the state of concentra- tion, that they usually possess in the shops, and if the quantities be considerable, a great volume of gas is evolved on their coming into contact, which taints every fiart of a house, is extremely hurtful to the ungs, and disagreeable to the smell. To avoid this inconvenience, I put a quantity of water, at least equal in bulk to both the acids, into a bottle, and I add the acids to it separately. This method does not only prevent the unpleasant odour, but it tends to retain the chlorine, on which its effects depend. It is well known, that tbe uitro- muriatic acid acts very readily on the metals and earth ; nothing therefore but glass, or extremely well glazed vessels of porcelain, should be used to contain it. Wooden tubs for bathing answer very well, and they should always be made as small as possible, compatible with their holding the body, or the limbs that we wish to expose to the bath. From their being small, we save acid, and are able to heat the bath with ease. In India, I have often exposed the whole body below the head to this bath ; but here 1 have been satisfied, in general, with keeping the legs and feet exposed to it. In order to warm the bath, after the first time, 1 have commonly made a third or a fourth part of it to be thrown away, and the loss replaced by boiling water and a proportional quantity of acid. To save the expenditure of acid, I have occasionally warmed a portion of the bath in porcelain vessels, placed near the fire, but 1 fear this may diminish its effects. " It is no easy matter (continues Dr. Scott,) to give directions, with regard to the degree of acidity of the bath. I have commonly made it about as strong as very weak vinegar, trusting to the taste alone. The strength should be regulated by the degree of irritability of the patient's skin. I may say, that although I like to know that it is strong enough to prick the skin a very little, after being exposed to it from fifteen to thirty minutes, yet I believe that even such an effect as this is unnecessary. " The time too of remaining in the bath, in order to produce the greatest effect, is a matter of doubt. 1 have kept the legs and feet exposed to it for half an hour or more ; but, with more delicate people, not above one-half, or one-third of that time. I have repeated these baths daily, or even twice, or thrice a day. (See Med. Chir. Trans. Vol. S, p. 181.) Dr. Scott adds, that the mere sponging the skin with nitro-muriatic acid, sufficiently diluted with \vater, gives rise to the very same effects as bathing, and is more easily adopted. Fifteen or twenty minutes may be employed in the sponging, though a much less time produces very ma- terial effects. Dr. Scott has found the nitro-muriatic acid particularly useful, even in this coun- try, in that description of syphilis, which is termed pseudo-syphilis; and he attributes the beneficial effects to the chlorine, which is loosely combined in this compound. (See Journal of Science and the Arts, Vol. 1, p. 205—211. Lond. Med. Reposit. Vol. 7, p. 59; and Med. and Chir. Trans. Vol. 8, p. 173, et seq.) The only important conclusion which I venture to draw from Dr. Scott's observa- tions, is a confirmation of the fact of the generally curable nature of syphilitic dis- eases, without the aid of mercury. And I further believe, that though the nitro-muri- atic bath may sometimes be useful, the surest way of bringing it into discredit is to represent it as applicable to all forms of syphilis, for which neither this remedy, nor even mercury itself, will ever suffice. J. de Vigo, De Arte Chirurgica, fol. Lugd. 1518. N. Montesaurus, De Dispositionibus, quas vulgo Mai Franzos appellant, 1497. Ni- col. Massa de Morbo Gallico, Liber, 4to. Ve- nd. 1532, et 1536, audior, 1563. Nic. Leo- nicerus Liber de Epidemia quam Itali morbum Gallicum, Galli'ero Neapolitanum vocant, FoL"'Papia, 1506. Gabr. Faltopius, de Mor- bo Gallico, 4to. Patav. 1563. Nic.de Blegny, Zodiacus Medico- Gallicus, 4lo. Geneva, 1680. ,'Hieron. Fracastorius, Syphilis Poema; et Tradatus de Syphilide; Verona, 1530. Also, De Contagione el Contagiosis Morbis, Venet. 1646, Casp. Torella, Tradatus cum Consiliis contra Pudendagram, Roma, 1497. Also, Dialogus de Dolore et de' Ulceribus in Pu- dendagrat; Roma, 1500. Ant. Francanlia- nus, de Morbo Gallico, 8vo. Patav. 1563. Jul. Palmarius, De Morbis Contagiosis, 4(o. Paris, 1678. Guil. Rondeletius, "de Morbo Gallico, 1576. J. Fernelius, Universa Me- dicina, 4to. Venet. 1564, p. 584, 593, fyc. Ulric de Hutten, de Morbo Gallico, Mogun!. 1531. R. Rostinio, Trattalo di Mai. Fran- cese, \2mo. Venet, 1556.. Al. Luisinus, Aphro- disiacus, Venet. 1566, et in 2 Tom. fol. Lugd. Bat. 1728, one ofthe most valuable collections of the Works of ancient writers on Syphilis. Diaz de Isla, Tratado contra las Bubas. 1527. Wm. Clowes, a new and approved Treatise, concerning the Cure of the French Pockes, by the Unctions, 8vo. Lond. 1575 ; said to be the earliest English book on Syphilis. J. Astruc, de Morbis Venereis; Lutel. Paris, 1740. Le Blond, Obs. sur la Fiivre Jaunc, Chap. 4. Leo Africanus, Descriptio Africa, L. l,p. 86. The last two authors mention the fact of the nature of the Venereal Disease to get well spontaneously in hot climates. Dae. Aber VENEREAL DISEASE eromby, Tula ac "efficax Luis Venerea, sape absque Mercurio, ac semper absque Saliva- hone Mereuriali, Curanda Melhodus, Lond. 12mo. 1684. J. Sintelaer, The Scourge of Venus and Mercury, represented in a Treatise on the Venereal Disease, giving a succinct Ac- count of that Dreadful Distemper, and the fatal Consequences arisinn from mercurial Cures, fyc. with the true Way of curing the Mercurial Pox, found to be more dangirous than Pox ilself, Lond. 1709. Mo.gagni, de Sedibus, fyc. Morborum. John Douglas, Dis- sertation on the Venereal Disease, wherein a Method of curing alt the Stages of that Dis- temper will be communicated, wilhout fhe help of any mercurial drenches, vomits, or fumiga- tions, fyc. and, above all a Salivation in all cases will be avoided, 8vo. Lond. 1737. Lit- dolff, Demonstrate, quod alrocissima Luis Venerea symplomata non sint affedus morbi, sed cura mercurialibus instituta, Erf. 1747. C. Willoughby, The Practice of Salivation shown to be of no Use, Lond. 1723. J. Profity, an Easy and Exact Method of Curing the Ve- nereal Disease, fyc.; to which are added Ex- periments publicly made of an effectual Me- thod of Cure without Salivation or Confine- ment, Svo. Lond. 1748. Wm. Bromfield, Ac- count of the English Night Shade, fyc. and Observ. on the Use of Corrosive Sublimate, Sarsaparilla, and Mercury. Also, of Ihe Cure by the Secretion of Urine, Svo. Lond. 1759. N. de Jansen, Tableau des Maladies Veniri- enncs, consideri par rapport aux diffirentes Manieres de les trailer; avec une nouvelle Milhode de les guirir, exempte de Salivation, fyc. Svo. Paris, 1745, Amsl. 1736. J. Gros- man, A Treatise for the Serpice of Chymistry, fyc.; and Considerations on the Lues Venerea, with its Cure wilhout Mercury, 4to. Lond. 1766. Aslruc, Traitd des Tumeurs et des Ul- ceres, et sur la Nature des Nouveaux Remedes Antiviniriens, 2 Tom. 12mo. Paris, 1759. Gataker, on Venereal Complaints, 1754. C. Hales, Salivation not necessary for the Cure of Venereal Diseases, 8vo. Lond. 1764 and 1772. Dan. Turner, Aphrodisiacus, contain- ing a Summary of the ancient writers on the Venereal Disease, Svo. Lond. 1738. Wm. Becket, History and Antiquity of the Venereal Disease, Lond. 1740. Fordyce, on the Vene- real Disease, 1777. Planck, Doctrina de Mor- bis Venet eis; Vienna, 1779. Chr. Gottfr. &runer% Aphrodisiacus, sive de Luc Venerea, in duas Paries divisus ; quorum una continet ejus vestigia in veteram audorum monumenla obvia; altera, quos flloysius Luisinus temert) omisit striptores, fol. Jena, 1789. Also Pro- grammata Spicileg. Scriptorumde Morbo Gal- lico, Jena, 1799, fyc. J. Arnemann, De Morbo Venerea Analecta ex manuscriptis Musei Bri- tannici Londinensis, Goett. 1789. M. Gautier Dagoly, Exposition Anatomique des Maux Viniriens,fol Paris, 1773. Christ. Girtan- ner, Abhandlung Uber die Venerische Krank- heit, Sro. Gott. 1788. H. Clutterbuck, on some ofthe Opinions ofthe late John Hunter, fyc. Svo. Lond. 1799. S. Chapman, a Trea- tise on the Venereal Disease, being chiefly de- signed as an abridgment of Dr. Astruc's Work, grf Ed.; to which are added, the Improve- ments, with regard to the Use of Sarmipitriliu, Mezereon, and Sublimate : as also an Accoun* of Pie nek's Method of Cure, Svo. Lond. 177* ■ IV. Dease, on the different Methods of treating the Venereal Disease, mo. Dublin, 1783. P. Clare, a New Method of curing Lues Venerea by Ihe introduction of Mercury through the Orifices of the absorbent Vctsclt on the Inside ofthe Mouth, 3 Ld. Lond. 1780 Jesse Foote, Obs on the New Opinions of John Hunter, Sro. Lond. 1786—87; also, Complete Trea- tise on the Venereal Disease, Sro. Lond. C. B. Trye, a Review of Jesse Foote's Obs. on the New Opinions of Hunter,Svo. Lond. 1787. B. Bell, Treatise on Gonorrhoa Virulenta and Lues Venerea, Ed. 3. Lalouette, JYou- velle Mithode de trailer les Malaelics Vcniri- ennes par la Fumigation, fyc. Paris, 1776. John Hunter, a Treatise on the I cnereal Dis- ease, Ed. 2; or with Dr. Adams's Commen- tary. S. Sawrey, an Inquiry into some of the Effects of the Venereal Poison, Svo. Lond. 1802. Jos. Adams, on Morbid Poisons, Ed. 2. J. Pearson, on the Effects of various Articles of the Materia Medica, in the Cure of Lues Venerea, Ed 2, 8t>o. Lond. 1807. ./. Aber- nethy, on Diseases resembling Syphilis in Sur- gical Observations, Svo. Lond. 18(4. P. A. 0. Mahon, Recherches sur la Maladin Syphi- litique dans les Paris, 1804. F. H. Martens et Tilesius, Tableaux des Sympldmes de la Maladie Vinirienne, dessinis d'aprds Nature, 4to. Leipz. 1804. F. Swediaur, Traiti Com- plel sur les Sympt&mes, Femmes enceintes, les Enfans nouveaux-nis, fyc. fyc. des Maladies Syphilitiques, 2 Tomes,7me. Ed. Paris, 1804, Fergusson, Observations on the Venereal Dis- ease in Portugal, as affecting the Constitu- tions of the British Soldiers and Natives, in Med. Chir. Trans. Vol. 4. Wm. Hey, on the Effects of the Venereal Disuse on the Fatus in Ulero, op. cit. Vol. 7, p. 541, fyc. Wm. Blair, Essay on the Venereal Disease, and the Effects of Nitrous Acid, and other analo- gous Remedies, lately proposed as substitutes for Mercury, Svo. Lond. 1808. T. Beddoes, a Collection of Testimonies, respecting the Treatment ofthe Venereal Disease, by Nitrous Jlcid, Svo. Lond. 1799. Alyon, Essai sur les Propriitis Medicinalcs de I'Oxygene, et sur VApplication de ce Principe dans les Mala- diis Vinir'tennes, fyc. 8vo. Paris, an. 7. C. Piatt, an Inquiry into the Efficacy of Oxygen in the Cure of Syphilis, Svo. Lond. 1802. Berlin, Traiti de la Maladie Venerienne chez les Enfans nouveaux-nis, Les Femmes ence- intes, et les Nourrices, fyc. Sro. Paris, 1810. G. Rees, a Treatise on the Primary Symp- toms of Lues Venerea; with a concise, critical, and chronological Account of all the English Writers on this subject, 8t>o. Lond. 1802. J. Rollo, Cases of Diabetes, with the Results of ihe Trials of certain Acids, and other Sub- stances, 8vo. Lond lb06. Lagncau, Expose- des Symplomesr de la Maladie Vincrienne, 4me. Ed. Svo.'Paris, 1816. Bateman's Sy- nopsis, Ed. 6. //. Scott, on the internal and external Use of the Nitro-muriatic Acid, in Med. Chir. Trans. Vol. 8, p. 173; also, in Journ. of Science and the Arts, Vol. I, p. 205, fyc. Schiceigger, on Ihe Cure of Syphilis by VERTEBRAE, DISEASE OF. 629 Abstinence, vid. Hufeland and Harle's Journ. A. Carlisle, on the present unsettled Slate of Opinion about the Venereal Disease, vid. Lond. Med. Reposit. Vol. 7, p. 89. R. Car- michael, Essays on the Venereal Diseases, which have been confounded with Syphilis, fyc. 4to. 1814; also, Obs. on the Symptoms and specific Distinctions of Venereal Diseases, fyc. Svo. Lond. 1818. T. Rose, Obs. on the Treatment of Syphilis, with an Account of several Cases, in which a ( ure was effected, without the Use of Mercury, in Med. l.hir. Trans. Vol. 8. G. J. Guthrie, on the Treat- ment of the Venereal Disease, wilhout Mercu- ry, Vol. cit. A. Mathias, the Mercurial Dis- ease, 3 Ed. Svo. Lond. 1816. J. Thomson, and J. Hennen, in Edinb. Med. and Surgical Journ. Vol. 14 ; also, J. Hennen, in Princi- ples of Military Surgery, Edit. 2, 8vo. Edinb. 1820. J. Bacot, Obs. on Syphilis, principally wilh reference to the use of Mercury, 8vo. Lond. 1821. James Evans, Pathological and Practical Remarks on Ulcerations of the Geni- • tal Organs, Svo. Load. 1819. F. G. Sarfa.ss, » De Methodts alque medicamenlis antisyphiliti- cis,4lo. Berol. 1816. Anonym, sur la Non- existence de la Maladie Vinirienne, fyc. Svo. Paris, 1811. VENESECTION, (from vena, a vein, and sedio, a division.) The operation of opening a vein. Phlebotomy. See Bleed- ing. VERRU'CA. A Wart. See Wart. VERTEBRAE, DISEASE OF. The case, here to be considered, is a disease of the spine, sometimes originating in an ulceration ofthe intervertebral cartilages, sometimes in a morbid condition of the cancellous struc- ture of the bodies of the vertebrae (Brodie on Diseases of the Jjjdnts, p. 259,) followed by a more or less complete loss of the power of using the legs. Formerly, the affection of the limbs was generally called a palsy, and treated as a paralytic affection ; (o which it is in almost every respect perfectly unlike. In the true paralysis, (says Mr. Pott) from whatever cause, the muscles ofthe affected limb are soft, flabby, unresisting, and inca- pable of being put into even a tonic state ; the limb itself may be placed in almost any position, or posture ; if i( be lifted up, and • then let go, it falls down, and it is not in the power of the patient to prevent, or even to retard, its fall; the joints are perfectly and easily moveable in any direction ; if the af- fection be of the lower limbs, neither hips, knees, nor ankles, have any degree of ri- gidity, or stiffness ; but permit the limb to be turned, or twisted, iti almost any manner. In tlie present case, the muscles are in- deed lessened, but they are rigid, and al- ways at least in a tonic state, by which the knees and ankles acquire a stiffness not very easy to overcome. By means of this stiff- ness, mixed with a kind of spasm, the legs of the patient are either constantly kept stretched out straight, in which case consi- derable force is required to bend tbe knees, or they are, by the action of the stronger muscles, drawn across each other, in such manner as to require as much to separate them. When the leg is in a straight position, the extensor muscles act so powerfully, as to require a considerable degree of force to bend the joints of the knees ; and. when they have been bent, the legs are immediately, and strongly, drawn up with the heels to- ward the buttocks. By the rigidity of the ankle joints, joined to the spasmodic action of the gastrocnemii muscles, the patient's toes are pointed downward, in such manner as to render it impossible for him to put his foot flat to the ground: which makes one of the decisive characteristics of the distemper. The majority of those who labour under this disease, are infants, or young children : adults are by no means exempt from it; but Mr. Pott never saw it at an age beyond forty; and Mr. Baynton never met wilh more than three instances, which approach- ed that period of life. (On Diseases of the Spine, p. 4.) In one case, however, recited by ME Bro- die, the patient was forty-five years old. (On Diseases of Joints, p. 268.) By Pott, Baynton, and several other writers, a belief is entertained, that the disease is most dis- posed to happen in scrofulous subjects, in which opinion I am also disposed to join. There can also be no doubt of the fact, sta- led by Mr. Pott, that it most frequently hap- pens in weak and delicate children. According to Mr. Polt, if the patient be a child, the account, most frequently given is, that for some time previous to the incapa- city of using its limbs, it had been observed to be languid, listless, and very soon tired ; that it was unwilling to move much, or briskly; that it had been observed fre- quenly to trip and stumble, although no im- pediment lay in its way ; that when it mov- ed hastily, or unguardedly, its legs would cross each other involuntarily by which it was often and suddenly thrown down ; that if it endeavoured to stand still, and upright, unsupported by another person, its knees would totter and bend under it; that it could not, with any degree of precision or certain- ty, steadily direct either of its feet to any particular point, but, that in attempting so to do, they would be suddenly, and involunta- rily, brought across each other; that soon after this, it complained of frequent pains and twitchings in its thighs, particularly .when in bed, and of an uneasy sensation at Ihe pit of the stomach ; that when it sat on a chair, or a stool, its legs were almost al- ways found across each other, and drawn up under the seat; and that in a little time after these particulars had been observed, it totally lost the power of walking. The same author observes, that if the in- curvation be oS the neck, and to a consider- able degree, by affecting several vertebra*, the child finds it inconvenient and painful to support its own head, and is always desirous of laying it on a table or pillow, or any thing to take off the weight. If the affection be of the dorsal vertebra?, it is soon attended with loss of appetite, hard dry cough, laborious *>30 VEKTEBR.E, DISEASE OF respiration, quick pulse, and disposition to hectic. Mr. Pott states, that an adult, in a case where no violence has been committed or received, will tell you that his first intima- tion was a sense of weakness in his back- bone, accompanied with what he will call a heavy dull kind of pain, attended with such a lassitude as rendered a small degree of exercise fatiguing ; that this was soon fol- lowed by»an unusual sense of coldness in his thighs, not accountable for from the weather, and a palpable diminution of their sensibili- ty. That, in a little time more, his limbs were frequently convulsed by involuntary tvyitchings, particularly troublesome in the night; that soon after this, he not only be- came incapable of walking, but that his power either of retaining or discharging his urine and feces was considerably impaired, and his penis became incapable of erection. The adult also finds all the offices of his digestive and respiratory organs much af- fected", and complains constantly of pain and tightness at bis stomach. The true cause of the disease is a morbid state of the spine, and of some of the parts connected with it; which distempered state of parts wilt, upon careful inquiry, be always found to have preceded the deformity some length of time; in infants, this is the sole cause, and external violence has nothing to do with it. *"* In the adult (says Mr. Pott) I will not assert, that external mischief is al- ways and totally out of the question ; but I will venture to affirm, what is equal, as far as regards the true nature of the case, which is, that although accident and violence may, in some few instances, be allowed to have contributed to its more immediate appear- ance, yet the part in which it show's itself, must have been previously in a morbid state, and thereby predisposed for the pro- duction of it. I do not by this mean to say, that a violent eiertion cannot injure the spine, nor produce a paralytic complaint: that would be to say more than I know ; but I will venture to assert, that no degree of violence whatever is capable of produ- cing such an appearance as I am now speak- ing of, unless the bodies of the vertebrae were by previous distemper disposed to give way; and that no supposable dislocation, caused by mere violence done to the bones of the back, which bones were, before the receipt of the injury, in a sound state, can possibly be attended with the peculiar symp- toms of a curved spine." For some observations, connected with this point, I refer the reader to C. Bell's Surgical Observations, Vol. 1. Mr. Brodie agrees with Mr. Pott, and other writers on the fact, that the actual curvature must be preceded by a disease of the parts, unaccompanied with any visible deformity, and-" cannot take place until the caries has made considerable progress." In the early stage ofthe case, therefore, when, as Mr. Brodie justly observes, the diagnosis is of the most importance, no information can be obtained f-om the appearance of the spine itself, the shape of which is yet un- changed ; and frequently the symptoms, which do take place early, are not unequi- vocal ; they are, according to this writer, " a pain, and some degree of tenderness in that part of the spine where tbe disease has begun; a sense of constriction ofthe chest; an uneasy feeling at the pit of the stomach, and of the whole abdomen ; a disturbed state of the functions of the alimentary ca- nal, and of the urinary bladder; a sense of weakness and aching,and occasional cramps ofthe muscles of the extremities." But, as Mr. Brodie confesses, very similar symptoms may arise from other causes, and sometimes no particular complaints are made previ- ously to the actual discovery of the curva- ture. (On Diseases of Joints, p. 279, 280.). I have already mentioned Mr. Brodie's opinion, deduced from dissection, that, in many instances, caries of the-* spine bas its origin in an ulceration of the intervertebral cartilages, beginning iu their centre, and ex- tending to their circumference, and after- ward affecting the bodies of the contiguous * vertebrae ; but that, iu other cases, the dis- ease has its origin in the bodies of tbe verte- brae themselves, which are liable to the same peculiar disease of the cancellous structure, which is noticed in the articulating extremi- ties of other bones. (Brodie on Diseases of Joints, p. 267.) This gentleman suspects that the disease, which begins in the cancel- lous structure of the vertebrae, is more im- mediately followed by suppuration, than that which commences in the intervertebral cartilages; and that tbe first form of the dis- ease seldom occasions so extensive a des- truction of the vertebrae, as the last. " But (says Mr. Brodie) farther than this, nothing which I have hitherto observed, enables me to point out any circumstances, in which the symptoms of these different diseases differ." (P. 276.) Respecting another state- ment, tbat when the lumbar vertebrae are alone affected, the symptoms dependent on pressure, or irritation, of tbe spinal mar- row, are absent, I cannot say that it accords with several cases which have fallen under my own notice, that is to say, if the affection of the lower limbs is to be received as a test of such irritation or pressure. According to Mr. Pott, the true curvature is invariably uniform, in being from within outward; but it varies in situation, in extent, and in degrees; it affects the neck, the back, or the loins ; it comprehends one vertebra only, or two, or more ; and as few or more are affected, or as these are more or less morbid, and consequently give way more or less, the curve must be different. In these cases, as Mr. Brodie remarks, "the distortion of the spine is usually of a pecu- liar kind, and such as nothing can produce, except ihe destruction of the bodies of one or more vertebrae. Tbe spine is bent for- ward, so as to form an angle posteriorly; and although the destruction of the vertebrae may be the same, it is more obvious in some parts of the spine than it is in others. For example, the spinous processes in the middle VERTEBRA, DISEASE OF. 631 of the back being loug, and projecting downwards, the elevation of one of these must occasion a greater prominence than that of one of fhe spinous processes of the neck, which are short, and stand directly backwards. " Curvature of (he spine, in the direction forwards, may arise from other causes, as a weak condition ofthe muscles, orarickWy affection of the bones. In general, in such cases, (he curvature occupies the whole spine, which assumes (he form of a segmen( of a circle. At other times, however, it occupies only a portion of the spine, usually that which is formed by the superior lumbar and inferior dorsal vertebrae." But here, as Mr. Brodie has found, the curvature is always gradual, and never angular ; a cir- cumstance by which it is distinguishable from the curvature produced by caries. The cases, how'ever, he thinks, have often been confounded, and some speedy and complete cures of carious spine on record, he infers, must have been cases of an entire- ly different nature. (On Diseases of Joints, p. 282, fyc. and Earle, in Edinb. Med. Journ. Jan. 1815.) Lateral curvatures of the spine are alleged generally to incline to the right side ; and the fact is referred (with what correctness I know not,) to the undue power, which is acquired by the more general use of the right arm, and of other muscles, in the per- formance of the voluntary actions." (Bayn- ton on Diseases of the Spine, p. 43.) It is admitted, however, that exceptions are met with, and that the lateral curvature some- times tends to the left, and occasionally resembles the letter S reversed. On this subject, I have also another rare exception fo specify, which is explained by Mr. Bro- die, viz. that though lateral distortions of the spine generally arise from causes inde- pendent of carie3, a slight degree of lateral curvature is, in some instances, produced by the bodies of the vertebrae having been destroyed on one side by caries in a greater degree than on the other. (Brodie on Joints, p. 284.) In general, the lower limbs alone usually feel the effect. Mr. Pott, however, had seen two cases, in one of which the arms only were affected ; in the other, both legs and arms. Mr. Ford showed him a lad, who had lost the use of both arms and legs from a curvature. An account of two simi- lar examples was also communicated to Mr. Pott by Mr. Parke, of Liverpool. Mr. Brodie has never known the paralysis affect the muscles of the arms, when the disease was at the lower or middle part of tbe spine ; but he agrees witb Mr. Cope- land, that the symptoms are not always confined to parts below the disease, and that it is not uncommon for pains in the upper extremities to accompany the para- lytic affection ofthe legs and thighs. (Bro- die, p. 385. Copeland, Obs. on Diseased Spine, fyc.) Very soon after the curvature, some pa- tients are rendered totally and absolutely incapable not only of walking, but of using their legs in any manner ; others can make shift to move about with the help of crutch- es, or by grasping their thighs just above the knees with both hands; some can sit in an armed chair, without much trouble or fatigue ; others cannot sit up with any help; some retain such a degree of power of using their legs as to be able to shift their posture when in bed; others have no such power, and are obliged to be moved upon all occasions. I have been present at the dissection of persons who died of lumbar abscesses, and who, while tbey lived, never suffered the peculiar loss of the use of the lower ex- tremities, so well described by Mr. Pott, though the vertebrae were found to be dis- eased. However, in other instances of such abscesses, attended with caries of the spine, the legs are deprived of their power. But, whether the difference is to be ex- plained by the consideration, that, in some cases, the disease of the bone may be se- condary and the abscess itself the primary complaint, I cannot determine. At all events, suppuration is frequently only an effect, the curvature existing long before the abscess; and, in such cases, the legs are effected. A few weeks ago, Mr. Dunn, of Scarborough, consulted me about a case in which the latter facts were exemplified. Mr. Brodie's opinion, that suppuration takes place at an earlier period in cases where the disease begins in the cancellous struc- ture of the bones, has been already noticed. In having a tendency to excite suppuration, and in producing the weakness of the lower extremities, the present disease of the spine appears to be materially different from the absorption of the vertebra-*, some- times caused by the pressure of aneurisms, and other tumours. (Hodgson on Diseases of Arteries, fyc. p. 80.) Mr. Pott observes:—When a child ap- pears to be what the common people call naturally weakly, whatever complaints it may have are supposed to be caused by its weak state, and it is generally believed, that time and common care will remove them ; but when a curvature has made its appear- ance, all these marks of ill health, such as laborious respiration, hard' cough, quick pulse, hectical heat and flushing, pain and tightness of the stomach, fee. are more at- tentively regarded, and set to the account of the deformity consequent to the curve, more especially if the curvature be of the dorsal vertebrae, in which case the deformi- ty is always greatest; but whoever will carefully attend to all the circumstances of this disorder, will be convinced, that most, if not all the complaints of children, labour- ing under thisMnfirmify, precede the curva- ture, and that a morbid state of the spine, and of the parts connected with it, is the original and primary cause of both. Among many other reasons for thinking, that an effect was mistaken for a cause, Mr Pott enumerates the following : "1 '■ Tbat be did rot remember ever to 6i- VERTEBRA, DISEASE 01 have seen this useless state of the limbs from a mere malformation of the spine, however crooked such malformation might have made it. 2. " That none of those deviations from right shape, which growing girls are so liable to, however great the deformity might be, vvas ever attended with this effect." With respect to the treatment of diseased spine,'! think one principle laid down by Mr. Pott, must receive approbation; viz. that the primary and sole cause of all the symptoms is a distempered state of the parts, composing, or in immediate connex- ion with the spine, tending to, and most frequently ending in a caries of the verte- bra?. Hence, says he, all the ills, whether general or local, apparent or concealed ; ihe ill health of the patient, and in time the curvature. As the disease does not origi- nate in the limbs, no application to them can be of any use, and the great indication must be to stop the progress of the disease in the affected part of the spine. The first suggestion of the probability that issues might prove serviceable in this dis- ease, appears to have been made to Mr. Pott hy Dr. Cameron, of Worcester, who told him, that having remarked in Hippo- crates, an account of paralysis of the lower limbs, cured by an abscess in the back, he had in a case of useless limbs, attended with a curvature of the spine, endeavoured to imitate this act of nature, by exciting a pu- rulent discharge, and that it had-proved very beneficial: which was confirmed to Mr. Pott by Mr. Jeffreys, of Worcester, who had made tbe experiment with the same success. The practice which Pott recommends, consists merely in procuring a large dis- charge of matter from the integuments on each side of the distempered bones forming the curvature, and in maintaining such dis- charge until the patient shall have recovered his health and the use of his limbs. They who are little conversant with matters of this sort (says Mr. Pott) will suppose the means very inadequate to the proposed end ; but they who have been experimen- tally acquainted with the very wonderful effects of purulent drains, made from the immediate neighbourhood of diseases, will not be so much surprised at this particular one; and will immediately see how such kind of discharge, made and continued from the distempered part, checks the fur- ther progress of the caries, gives nature an opportunity of exerting her own powers of throwing-off the diseased parts, and of pro- ducing, by incarnation, an union of the bones (now rendered sound,) and thereby establishing a cure. Mr. Pott considers it a matter of very little importance towards the cure, by what means the discharge be procured, provided it be large, that it come from a sufficient depth, and tbat it be continued for a suffi- cient length of time. He tried setons, issues by incision, and issues by caustic, and found the hst in general preferable, being least painful, most cleanly, most easily ma- nageable, and capable of being longest con- tinued. The caustics, he observes, should be ap- plied on each side of tbe curvature in such a manner as to leave the portion of skin, covering the spinal processes of the protru- ding bones entire and unhurt, and so large, that the sores upon the separation of the eschars, may easily hold each three or four peas, in the case of the smallest curvature ; but in large curves, at least as many more. The issues which modern surgeons usually majte, for the relief of the symptoms arising from diseased vertebra?, are larger than such as Mr. Pott himself was in the habit of forming. They now commonly prefer making an issue on each side of the spinous processes, about three or four inches long, and half an inch broad. The size ofthe issue intended to be made being determined, the place where it is to be made should be accurately marked out with ink. All the skin immediately around should then be covered wi(h adhesive plaster, in or- der that it may be protected from the action of (he caustic. Let the surgeon next take a piece of caustic potassa, or of potassa cum calce, and wrap a little tow round one end of it, so that he may take hold of it with safety and convenience. The other end of the caustic should then be moistened a little, and rubbed very quickly on the portion of the integuments, which is to be converted into an eschar. The caustic is to be rubbed in this manner, till the part turns of a dull brown colour, when the caustic should be carefully washed off with a little wet tow, and a poultice applied. As soon as the eschars admit of being re- moved, a row of peas, or beans, connected together with thread, should be laid on the sore, and confined there with sticking plas- ter. A compress, containing a piece of pasteboard, or sheet-lead, is then to be bound over the peas or beans with a roller. In consequence of the continued pressure, the peas or beans soon form little hollows for themselves, in which they should be regu- larly placed every day. When the pressure is not duly maintained, the granulations are apt to rise so high, that the peas cannot be well kept on the part. In this circumstance, the surgeon must try to repress the high surface of the sore, by sprinkling on it a little savine powder and subacetate of cop- per, mixed together in equal proportions. When this plan is unavailing, the reappli- cation ofthe caustic becomes indispensable. Whatever time maybe requisite to restore the health, as well as the use of the limbs, Mr. Pott thinks, that the issues should be kept open until these objects are completely fulfilled; and even longer, especially in growingchildren. He owns that nothing can be more uncertain, than the time required for the cure. He has seen it perfected in two or three months ; and he has known it require two years; two-thirds of which time passed before there was any visible amend- ment VLRTEBIE-E, DISEASE OF. o3o ■ -VlUul^e discijargft has been made some ' tmfi, the patient is found to be better, in all general respects, and if of age to distinguish, will acknowledge, (hat he feels himself to be better in health ; he begins to recover his appetite, gets refreshing sleep, and has a more quiet and less hectical pulse ; but tbe relief which he feels above all others, is from having got rid of that distressing sen- sation of tightness about the stomach ; in a little time more a degree of warmth, and a sensibility are felt in the thighs, which they had been strangers to for some time ; and generally much about the same time the power of retaining and discharging the urine and feces begins to be in some degree exerted. The first return of the power of motion in the limbs, says Mr. Pott, is rather disa- greeable ; the motions being involuntary, and of the spasmodic kind, principally in the night; and generahy attended with a sense of pain in all the muscles concerned. •At this point of amendment, if it may be so called, it is no uncommon thing, espe- cially in had cases, for the patient to stand some time without making any farther pro- gress ; this, in adults, occasions impa- tience, and in parents, despair ; but in the milder kind of case, the power of voluntary motion generally soon follows the involun- tary. The knees and ankles, by degrees, lose their stiffness, and.the relaxation of the latter enables the patient to set his feet flat upon the ground, the certain mark that the power of walking will soon follow; but those joints having lost their rigidity, be- come exceedingly weak, and are not for sometime capable of serving the purpose of progression. An attentive examination of the morbid appearances, and their effects in dilferent subjects, led Mr. Pott to conclude, among other things, that the disease which produ- ces these effects on the spine, and the parts in its vicinity, is what is in general called scrofula. That ulceration or caries of the bodies of the vertebra? affected, is the common morbid change, and not enlargement. That when the attack is made upon the dorsal vertebra?, the sternum and ribs, for want of propea^support, necessarily give way, and deformity, additional to the curve, is produced. That this kind of caries is always confined to the bodies of the verteba?, seldoigp^or never affecting the articular proc-Jsses. Two cases were seen by Pott, in which the bodies of the vertebra*; vvere complete-^de- tached from their processes, so as to leave the membrane of the spinal marrow per- fectly bare. That without this destruction ofthe bodies ofthe vertebrae, there can be no curvature of the*kind here treated of; or in other words, that erosion is the sine qua non of this disease ; that although there can be no true curve without caries, yet there is, and that not infrequently, caries without curve. That the caries with curvature and useless "".-*:. H *° limbs, is most frequently of the cervical or dorsal vertebra?, the caries without curve, of the lumbal, though this is by no means constant or necessary. That in Ihe case of carious spine without curvature-wit most frequently happens, that internal abscesses, and collections of matter are formed, which matter makes its way outward, and appears in the hip, groin, or thigh ; or being detained within the body, destroys the patient: the real and immedi- ate cause of whose death is seldom known, or even rightly guessed at, unless the dead body be examined. That what are commonly called lumbal and psoas abscesses, are not infrequently produced in this manner, and therefore, when we use these terms, we should be understood to mean only a description of (he course, which such matter has pursued in its way outward, or the place where it makes its appearance externally, the terms really meaning nothing more, nor convey- ing any precise idea of the nature, seat, or origin of a distemper subject to great varie- ty, and from which variety its very different symptoms and events in different subjects, can alone be accounted for. That contrary to the general opinion, a caries of the spine is more frequently a cause, than an eft'ect of these abscesses. That the true curvature of the spine from within outward, of which the paralytic, or useless state of the lower limbs, is a too fre- quent consequence, is itself bul one effect of a distempered spine ; such case being al- ways attended with a number of complainls, which arise from the same cause : the gene- rally received opinion, therefore, that all the attending symptoms are derived from the curvature, considered abstractedly, is by no means founded in truth, and may he pro- ductive of very erroneous conduct. That when two or more vertebra? are af- fected, forming a lar e curve, however per- fect the success of the (realment may be with regard to the restoration of health and limbs, yet the curvature will and must re- main, in consequence of the union of the bones wilh each other. That the useless stale ofthe limbs is by no means a consequence of tbe altered figure of the spine, or of the disposition of tbe bones with regard to each other, but merely of the caries: of (his truth there needs no other proof, than what may be drawn from Ihe cure of a large and extensive curvature, in which three or more vertebrae were con cerned : in this the deformity always remains unaltered and unalterable, notwithstanding the patient recovers both*health and limbs. Polt contends, that u morbid state of the parts, previous to deformity, caries, or curve, must be allowed. All the general complaints of persons afflicted with this disorder, ho says, will, upon careful inquiry, be found to have preceded" any degree of deformity , to have increased as the curve became appa- rent, and to have decreased as (he means used for rolief toedc place; the pain and tightness about the stomach, the indigs-itio??,, VERTEBRA], DISEASE OF. the want of appetite, the disturbed sleep, fee. fee. gradually disappear, and (he marks of returning health become observable before the limbs recover the smallest degree of their power of moving. On the other hand, is admitted to be as true, that when from extent, orTOgree, or inveteracy of the caries, the issues are found to be unequal (o the wished-for effect, (he general complaints receive no amendment; but increase until the patient sinks under them. If all this be true, says Mr. Pott, and it be found that the* issues are capable of ef- fecting a perfect cure, even after a caries has taken place, and that to a considerable degree, is it not reasonable to conclude, that the same means, made use of in due time, might prove a preventive ? Besides the forms of disease of the spine treated of in this article, the observations of Mr. Wilson prove, that the distemper may sometimes begin within Ihe theca vertebralis, and thence extend to the bones. He also demonstrated, at the College of Surgeons, scrofulous tumours in the spinal marrow. Such diseases would create a loss of power in the parts below them, without any curva- ture of ihe spine. (Lectureson the Skeleton, fyc. p. 397.) In France, tbe same indication is followed as (hat on which Mr. Pott lays stress, viz. lo endeavour to arrest the disease of (he spine by means applied in (he vicinity of the mor- bid.parts. But instead of employing caustic issues, (be moxa is used, and sometimes re- peated cupping near the affected bones; both which means were particularly re- commended by Desault. Another practice, which yet has partisans, though it was strongly disapproved of by Pot(, is that of supporting the spine with ma- chinery. Perhaps Ihe latter aulhor may have carried his objections to this method beyond all reason, and with tbe exception of Dr. Harrison, (see Lond. Med. and Physical Journ. Nov. 1820,) I believe no modern practitioner now ever advi-i.--i it on t e -lip- position of there being any dislocation; an error which formerly prevailed. As Mr Brodie observes, certainly no machines ought ever to be employed for the purpose of elon gating the spine and correcting the deformi- ty : but if they be used simply to take off the weight of the head, chest, and upper ex- tremities, from the diseased part of the spine, they may sometimes be of service. The late Sir James Earle had a very favourable opinion of their utility. I believe, with Mr. Brodie, that they ought never in the first in- stance to supersede tbe constant mainte- nance of tbe horizontal position ; but thai they may be advantageous, wheii circum- stances make it desirable that tlie patient he- gin to sit up a pari ofthe day. (On Diseases cf the Joints, p. 291.) From Mr. Pott's own account, it will be seen, lhat he never pretended that issues, kepi open in the vicinity of the disease, were infallible; and a late eminent surgeon has actually referred the go»d which Pott thought accrued from them, to the long ob- servance of the horizontal posture. Mr. Baynton, the gentleman to whom 1 allude, also mentions, that M. David is the only writer who has suggested that rest would affect the cure of diseases of the spine. On Ibis point, however, Mr. Baynton was en- tirely mistaken, as, about eighteen years ago, Loder wrote some remarks, particularly directed to the object of recommending quie- tude in the present disease, as Ihe best means of promoting anchylosis. (See Med. Chir. Beobachtungen, p. 251; 8io. Weimar, 1794.) Now, although I fully concur in ihe pro- prie(y of keeping (he patient hs quiet as pos- sible in the recumbent position, inasmuch as motion must be hurtful to the diseased part of the spine, it does not follow, that be- cause (his admission is made, tbat issues should be rejected, and tbat rest must do every thing. In one part of Mr. Baynton's reasoning, an erroP prevails, which I shall here notice, as it seems greatly to have influ- enced his opinions; and as far as 1 know it has not been remarked by (be critical exa- miners of that gentleman's book. The mis- take is in supposing, that the process by which tbe diseased part of the spine is to be restored and united, should be conducted exactly on tbe same principles as the union of bones free from disease. In facl, there is an additional indication, wliich is to stop the progress of the disease, for which purpose, experience proves that issues, aided by rest, are the means affording the best chances of success. I have attended several children myself, who, from Ihe effect of issues, reco- vered the use of their lower extremities, even though they could not be kept constant- ly at rest I must also give my testimony to (he truth of Mr. Bodies statement, that many patients are benefited almost immedi- ately the issue's are made, or uniformly And themselves better after each application of Ihe caustic. (On Diseases of Joints,p. 282.) In some cases, howeve-i, caustic i^iuet fail to affosd relief; and when they are of no use, rest in the- horizontal posture, below ground, I believe- must soon be the patient's doom. Whether the occasional failure of issues is to be ascribed to the advanced pro- gress which tbe disease has mnde, or to i(s having begun in the cancellous structure of the vertebrae, as suggested by Mr. Brodie, future observation must decide. Consult Pott's Chirurgical Works, Vol. 3. G. Gebb, Select Cases of the Disorder, com- ma^fi termed Paralysis of the Lower Extre- mities, Svo. Lond. 17*3:2. C. H. Wil.inson, Essaiikon Distortion of the Spine, fyc. Svo. Lonhr\l9S. Loder Med. Chir. Beobachtun- gen, B. \,p. 247, fyc. Svo. Weimar, 1794. J. C. Frank, Oratio de Vertebralis Columna in Morbis Dignitatc; Patter, 1791. C. Van Roy, De Scoliasi, 4lo. Lugd. 1774. Sir J Earle, Observuions on the Cure of Curved Spine; m which the effect of Mechanical As- sistance is considered. 8vo. Lond. 1803. Gius- eppe Bergamaschi, Osservazioiii sulla Inflam- mazione dello Spinale Medollo e delle sue Membra** ' 4!n. Par 1P10. T. Baynton. A' WAR WH1 63b Account of a Successful Method of Treating Diseases of the Spine; 8vo. Bristol, 1813. H. Earle, in Edinb. Med. and Surg. Journ. for January, 1815. J. L. Choulant, Decus Pelvium Spinarumque Deformatarum ; 4lo. Lips. 1818. G. Malseh de nova Machina Graefiana Distortiones Spina Dorsi ad Sanan- das, nernon Disquisilio Defor mi latum ista- rum; 4lo. Berol. 1818. Abercnmibie, in Edinb. Med. and Surg. Journ for January, 1818. Kapeler, in Annuaire Med. Chir. des Hdpilaux de Paris, T. 1, p. 390 , 4to Paris, 1819. T. Copeland,' Obs. on the Symptoms and Treatment of Diseased Spine ; 8vo. B. C. Brodie, Pathological and Surgical Observa- tions on the Joints, p. 257, fyc. Svo. Lond. 1818. James Wilson, Lectures on Ihe Struc- ture and Physiology of the Skeleton, and on the Diseases of the Bones and Joints; p. 39b, 8vo. Lond. 1820. VINEGAR. (See Acetic Acid.) VINUM OHII. Take of extract of opium ^i, cinnamon bark bruised, cloves bruised, of cae:h 3j i wine a pint. Macerate for eight days, and filter. The thebaic tincture, or liquid laudanum of Sydenhnm. In sur- gery, il is often preferred to the common tincture of opium, as* an application to the eye. VIPER, BITE OF. See Wounds. VOLVULUS, (from rolvo, to roll up.Y See Intussusception. w. WART. Mr. Hunter observes, that a wart appears to be an excrescence from the cutis, or a tumour formed upon it, by which means it becomes covered with a cuticle, which is either strong and hard, or thin and soft, just as the cuticle is which covers the parts,, from which the excres- cence arises. Warts are radiated from their basis to their circumference. The surface of the radii appears to be pointed, or granu- lated, like the surface of healthy granula- tions, with the exception of being harder, and rising higher. The surface on which tbe wart is formed, seems only to be capa- ble of producing one; for the surrounding and connecting surface does not throw out a similar substance. Thus, when a wart has once begun to grow, it rises higher and higher, without becoming larger at its basis. Such excrescences seem to have within themselves the power of growing; for, as Hunter remarks, after they have risen above the surface of the skin, on which their basis cannot grow larger, they swell out into a round thick substance, which becomes rougher and rougher. In consequence of this structure, warts are very liable to be hurt by bodies rubbing against them, and from such a cause, they often bleed very profusely, and are rendered sore and painful. (On the Venereal Disease, p. 250, Edit. 2.) As warts are adventitious substances, and not any part of the original structure of the body, their powers of life are weak. Hence when stimulated, they generally become smaller, and at length altogether disappear, or drop oft". On this principle, warts may frequently be cured by the application of the sulphate of copper, or a powder, composed ofthe powders of savine leaves and the subace- tate of copper, in equal proportions However, the employment of stronger escharotics, like the nitrate of silver, or the concentrated acetic acid ; the removal of such excrescences with a knife, or pair of «cis<=ors; or tying their necks with a liga- ture, is a mode frequently preferred, be- cause the cure is sooner accomplished. The two last methods are eligible, when the wart has a narrow neck; but after the removal of the excrescence, it is still proper to touch the root with the caustic, or the acetic acid ; for unless the whole be com- pletely destroyed, the wart will inevitably grow again.\ Warts on the pudenda, and about the anus, scarcely ever withstand the effect of the powder of savine, and subacelale of copper, though they will sometimes resist a course of mercury, adequate to cure lues venerea ; a consideration, which led Mr. Hunter to believe them not to be syphilitic. In this opinion, I believe all the best sur- geons of the present day concur* WHITLOW. (Panaris, Onychia, Pana- ritium, Paronychia.) A whitlow' is an in- flammation, about the end of the finger, exceedingly painful, and very much disposed to suppurate. The toes are also sometimes the seat of the disease. Writers usually divide whitlows into four kinds. In the first, or mildest, a vesicle, filled with matter, commonly arises near the root, or side of the nail, after a superficial inflammation of trivial extent. The matter is situated immediately under the cuticle. Sometimes the abscess takes place under the nail, in which case, ihe pain is severe, and not unfrequently shoots upward, as far a« the external condyle. * The ligature is ns effectual and coiive?nic»nt as any method recommended, for the removal of warts. But as warts have selilom necks -ufficienl to retain the thread, I have been in the habiHif resorting to a plan wliich 1 have always found successful, to the emire removatof warts. Take a fine sewing needle, armed with strong silk, and pass it through the centre of the tumour at its base, taking care to go deep enough, that the whole d^ease n^ay be included, then hy lying this ai each side.ot sufficient tightness to interrupt the cir- culation, the wart will drop off within tbe week, wiihoiit inconvenience to the patient. from ihe manner in which the ligatures are applied, there is no possibility of their coming off, until the disease come with it. In this way, I have freed a hand from a dozen at one- time, to the great satisfaction of the iudividual ; ami when removed in this mrmier. I hav never found them recur. Am. Ed. 63d W HlTLuW The second kind oi whitlow is chiefly situ- ated in the cellular substance under the cutis, nnd, for the most part, occurs at the very end of the finger. In this sort of c.i's, the inflammatory symptoms, especially the pain, are far more violent than in other common inflammations of not'grcaterextent. However, although the pain is thus severe, it does not in general extend for from the part affected. Writeis usually impute the violence ofthe pain, and the considerable degree of inflammation attending the com- plaint, to the hard and unyielding nature of the skin on the finger, lo the same cause they also ascribe the difficulty of perceiving any fluctuation after mailer is formed ; and the slowness with which Ihe pus makes its way outward. The third kind of whitlow is distinguish- able from the others by the following cir- cumstances. With the most excruciating pain, there is very little swelling in the affected finger, but a vast deal in the hand, particularly about the wrist, und over the whole fore-arm. The pain extends to the hand, wrist, elbow, and even the shoulder. When suppuration takes place, a fluctuation can never be fell in the linger, though it may very often be distinctly perceived in the hand, at the wrist, or even somewhere in the fore-arm- The case is frequently ac- companied with considerable fever. The disease is seated in the tendons and their sheaths, and the power of moving the fin- gers, and even the whole hand, is lost. Authors describe the fourth kind of whit- low as arising principally from an inflamma- tion of the periosteum. The case is attend- ed with one peculiarity, which is, that, how- ever violent the pain may be, it never ex- tends to (be hand and fore-arm, nor is there any exlernal swelling of the affected finger. Suppuration generally follows very soon, the usual consequence of which is a caries, or rather a necrosis, ofthe subjacent finger-bones. Whitlows commonly begin on the inside of the fingers; but they do occasionally commence on the back of these parts, and even on that of the hand. Though pain about the wri?t is usually the effect of in- flammation in the finger, Acrel mentions a case in which the disorder was altogether confined to the hand itself. (Vorfalle, 2 B.p.\91.) Mr. Wardrop bas favoured the public with an account of a particular species of whitlow, -which, from its malignant cha- racter, he has denominated the onychia ma- ligna. "The commencement of this dis- ease is marked by a degree of swelling, of a deep red colour, in the soft parts at the root ofthe nail. An oozing of a thin ichor afterward takes place at the cleft formed between the root ofthe nail and soft parts, and at last the soft parts begin to ulcerate. The ulcer appears on tbe circular edge of the soft parts at the root of the nail; it is ac- companied with a good deal of sw elling, and the skin, particularly that adjacent to the ulcer, has a«deep putple colour The appe arauce of (lie ulcer is very uuhcallir.. the edges being thin and acute, and its sin face covered wilh n dull yellow, or brown coloured lymph, nnd attended with an ichor- ous and very fetid discharge. The growth tithe nail is interrupted, and loses its na- tural colour, and at some places appears to have but little connexion with the soft parts. In this state (siys Mr. Wardrop) I have seen the disease continue for several years, so that the toe, or finger, became a deform- ed bulbous mass. The pain is sometimes very acute . but the disease is more com- monly indolent, and accompanid w ilh lit- tle uneasiness. The disea-e a»ii'cj-j bolh the toes and the fingers. I have only observed it on the great toe, and more frecpienlly on the thumb,than any ofthe finders, hoc-curs, too, chiefly in young people ; but I have also seen adults affected with it." (War- drop, in Med. Chir. Trans. Vol. 5, p. \3b, 13b.) The causes of whitlows are generally of it local nature. Writers enumerate the fol- lowing a* the most common : a contusion : suddenly warming the finger when it is ex- ceedingly cold; pricks with needles, or other sharp instruments ; and the iiiMiiua- tiou of irritating mailer into scratches on the finger. A surgeon, in operating for a fistula in ano, has been known to cut his finger, and have, in consequence ofthe accident, a very severe and dangerous kind of whit- low. Richter also mentions a person who had a most obstinate whitlow, iu conse- quence of a slight wound on the finger, in examining the head of a horse that had the glanders. Sometimes the cause of a whit- low depends on a splinter, or thorn, which continues lodged iu the part. Very often, no particular cause whatever can be a.>sign- ed for the complaint. • The first case, which occurs about the root of tbe nail, ought to be opened as soon as possible. When this plan is not adopted, the matter is apt to penetrate more deeply, reach tbe root of the nail, and occa- sion a loss of this part. When an effectual opening is nol made, the matter collect again. In general, a detachment of the cu- ticle takes place as far as the abscess extends. When the inflammation has been very vio- lent, and the matter has made its way as far as the root ofthe nail, the nail itself is in general gradually detached, while the denu- ded portion of the root of the nail acts on the sore as a foreign body, and hinders it from healing. Hence the surgeon should repeatedly cut away as much ofthe lower edge of the nail as he can, and insinuate a little soft lint between the margin of the nail and the sore, in order to keep the latter from being irritated by the former. In pro- portion as the old nail gradually separates, a new one makes its appearance. When matter lie.; under tbe nail, an open- ing should be made through the part as speedily as possible, for the discharge ofthe abscess. In order to perforin this operation, Richter advises the surgeon to scrape the nail with a piece of glass, till it is as thin a- WHITLOW. G37 dean well be, when it may he cut through with a bistoury. In the second species of whitlow, suppu- ration may sometimes be prevented, and the inflammation be resolved, by the timely employment of proper means. When the pain is violent, and acute fever prevails, it may be adviseable to bleed the patient. In a few severe cases, the application of three or four leeches to the affected finger has been known to procure prompt relief (Schmucker.) Theden thinks, th^at applying a roller round the finger, hand, and arm, and frequently wetting the first two parts with a lotion, the. most certain means of resolving the inflammation. Platuer advi- ses the finger to be for some time immersed in water as warm as the patient can bear. Some recommend the external use of cam- phorated spirit, or the volatile alkali; while others advise the affected finger to be plun- ged in a warm solution of soap, or kali. When the whitlow is occasioned by a prick, particular care must be taken that no extra- neous substance remain in the puncture. When the symptoms do not lessen by the fourth day, Richter recommends an open- ing to be made. Even when no fluctuation is discovered, he approves of making a cru- cial incision in the seat of the pain, and lie states, (hat although no matter may be dis- charged, the patient always derives infinite relief from the operation. The benefit, he says, may either be imputed to the bleeding, or to the division of the hard tense skin wliich compresses the subjacent inflamed parts. Sometimes the collection of matter can be plainly felt, and, in this case, there can be no hesitation about the place where the opening should be made. However, it may be proper to remark, that the opening should always be made sufficiently large. When Ihe surgeon makes a small puncture, it soon closes again, and a repetition of the operation becomes necessary. When open- ing the abscess is delayed, the theca of the flexor tendons easily becomes affected, or (he matter may spread to a considerable ex- tent under the skin. Sometimes it makes its way through the cutis by ulceration, and raises up the cuticle. In this case, as soon as the cuticle has been opened, a director should be introduced into the aperture in the skin, and the latter opening be enlarged with a bistoury. The third species of whitlow seWom affects the last phalanx ofthe fingers; but, generally, the second or third. In this case, Richter enjoins us never to defer making an opening longer than the third day. If we wait till suppuration happens, we shall wait till the tendons are destroyed, and the use ofthe finger lost. In the wise under consi- deration, the matter is always of bad qua- lity, and very small in quantity. A fluctua- tion in the finger can seldom be felt. How- ever, in a few instances, the matter is per- ceptible at the extremity of the finger, or about the finger-joints, but, more often, in the palm of the hand, or near the wrist. In these circumstances, the tendons arc in general already destroyed, and a stiffness ofthe finger and hand is to be apprehended. When the complaint is the consequence of a puncture, the best plan, according to Richter, is at once to enlarge the wound; for, in this sort of case, all other methods are unavailing. It is not enough, however, to cut through the skin ; the tendinous theca itself must be laid open. When a collection of matter forms to- wards the wrist, attended with violent pain in that situation, an opening must also be made there. If an opening should have been already made in the hand, a probe may be introduced into the wound, and ano- ther aperture made in an eligible situation, by cutting on the end of the instrument. In the same way, Richter advises an open- ing to be made in any part of the fore-arm, where great pain, or the symptoms of sup- puration, may indicate its propriety. In the fourth kind of whitlow, early inci- sions, made down to the bone, are Ihe most certain means of obviating the danger. When such incisions are not made early enough, suppuration takes place and the bone becomes carious. The cut is to be made in the place where the pain is most severe. When the first phalanx is affected, the incision may be made in front of (he finger ; but when the second or third is the seal of (he complaint, the opening should be made on one side. However, in order that the opening may be useful, it is absolutely necessary to make it down to tbe bone. When the incision is delayed too long, a small quantity of unhealthy matter is usually detected, and the bone is found in (he state of necrosis. As 'an exfoliation can hardly be expected in this situation, it is best to remove at once the diseased piece of bone. When the last phalanx alone is affected, the finder retains its form, with the exception of its end being a tittle shorter and flatter. When the disease, however, is situated in the third phalanx. Richter thinks it better to amputate the finger than remove the diseased bone, as the finger, if left, would always remain stiff and unserviceable. (See Anfangsgr. der Wundarzneykunst, Vol. 7.) With regard to the treatment of the spe- cies of whitlow, named by Mr. Wardrop, onychia maligna, all local applications have, in many instances, proved quite ineffectualj £nd the part been amputated. The only local treatment, which Mr. Wardrop has ever seen relieve this complaint has been tbe evulsion of the nail, and afterward the occasional application.of escharotics to the ulcerated surface. I have myself seen a similar plan occasionally succeed, and the applications which appeared to answer best were arsenical lotions, Plunket's caustic, or a very strong solution of the nitrate of sil- ver. Nothing, however, will avail, till the nail is removed, and ils (otal separation sometimes takes up a good deal of time, unless the patient submit to the great pain of having it cut away. Mr. Wardrop tried with success the e\h\ 63b WOlixND- bition of mercury in four cases of the ony- chia maligna. The medicine was given in small doses at first, and afterward increa- sed, so as to affect the gums in about twelve or fourteen days. When the system was in this state, the sores in general soon assumed a healing appearance, and the bulbous swelling gradually disappeared. (See Med. Chir. Trans. Vol. 5, p. 138.) WOUNDS. A great deal of the subject of wounds has been already considered in the articles, Gunsliol Wounds; Head, Inju- ries of; Hemorrhage; Hydrophobia; Paro- tid Duct; Sutures; Tetanus: Throat; be. A wound may be defined to be a recent solution of continuity in the soft parts, sud- denly occasioned by external causes, and generally attended at first with a greater or lesser degree of hemorrhage. Wounds in general are subject to a consi- derable variety in (heir na(ure, degree of danger, facility of cure, and the consequen- ces which are to be apprehended from them. Some wounds are perfectly trivial, not extending more deeply than the skin and cellular membrane; while others are more serious, penetrating the muscles, ten- dons, large blood-vessels, and nerves, of im- portance. There are also certain wounds which are not confined to (he soft parts, but injure even the bones ; such are many sabre-wounds, which frequently separate at once both a portion ofthe scalp and the subjacent part of the skull. Many wounds of (he head, chest, and abdomen, injure the organs contained in those cavities. In short, the varieties, and the degree of danger, at- tending wounds in general, depend very much upon some of the following circum- stances. The extent of the injury ; the kind of instrument with which it has been inflict- ed ; the violence which the fibres of the part have suffered in addition to their divi- sion ; the size and importance of the blood- vessels and nerves which happen to be in- jured ; the nature of the wounded part in respect to its general power of healing favourably or not; whether the operations of the system at large, and life itself, can be well supported or not, while the func- tions of the wounded part are disturbed, interrupted, or suspended by the accident; the youth or old age of the patient; the goodness or badness of his constitution; and the opportunities which there may be of administering proper surgical aid, and assist-1 ance of every kind. Wounds are distinguished by surgical wri- ters into several kinds ; viz. incised, punc- tured, contused, lacerated, poisoned, and gun- shot wounds. They also make another equal- ly important division into Wounds of the Head, Thorax, Abdomen, fyc. Of gunshot wounds, and wound3 of the head, an account has already been given. (See Gunsho( Wounds^ and Head, Injuries of.) The other cases I shall now proceed to consider. Incised Wounds. As a general observa- tion, it may be slated, thai, cateris paribus, a wound, which is made with a sharp culting instrument, which is, iu short, a mere inci- sion, is attended with less hazard of danger- ous consequences, (ban any other kind of wound whatever. The fibres have only been simply divided ; Ihey have suffered no con- tusion nor laceration ; consequentiy, (hey are less likely to inflame severely, or lo sup- purate, or slough ; and they commonly ad- mit of being united again in a very expedi- tious manner. Generally simple incised wounds bleed more freely, (hen contused and lacriated ones, which at first rometimes scarcely pour out any blood al all, although considerable blood-vessels may be injured. But this cir- cumstance, apparently diminishing the- dan- ger of contused and Ian riiti d wounds, is deceitful, and serves rather lo render the case in reality more perilous, by inducing the inexperienced practitioner to be off his guard against hemorrhage. Thus, in gun- shot wounds, it often happens, (hat on (heir first occurrence, the bleeding is trivial; but the side of some large artery having suffer- ed great violence at (he time ofthe accident, il may ulcerote or slough, a week or ten days afterward, and an alarming aud even fatal effusion of blood be the result. In cases of simple incised wounds, the bleeding which at once takes place from all Ihe divided vessels, is a source of very use- ful information to the surgeon, inasmuch as it enables him to judge, what danger is to be apprehended from the hemorrhage, whe- ther the cut vessels are large enough to de- mand the ligature, or, on the contrary, whe- ther they are such as will cease lo bleed, either by slight pressure, or of Iheir own accord. In a recent simple incised wound, there are three objects which the siiKgeon should endeavour to accomplish, wilhout the least delay. The first, and thai which requires his immediate interference, is Ihe bleeding, which must be checked. The second is the removal of all extraneous matter from Ihe surface of the wound. Tbe third is the reunion of the opposite sides of the injury. When the divided vessels are not above a certain size, (he bleeding soon spontaneous- ly ceases, and no surgical measures need be taken on this particular account. When the wounded vessels are even somewhat larger, and their situation is favourable for com- pression with a bandage, it is often advisea- ble to close the wound and apply compresses and a roller, rather than have recourse to ligatures, which always create a certain de- gree of irritation and suppuration. How ever, (hough I have made this observation, I should be exceedingly sorry to appear at all against the general preference to ligatures, whenever tbe wounded arteries are above a certain magnitude. In this circumstance, tying the bleeding vessels is the only safe mode of proceeding. When the artery is of considerable size, and it3 mouth can be readily seen, the most proper instrument for taking hold of it is a pair of forceps. In applying the ligature, the surgeon must take WOUNDS 639 care to pull its ends in such a manner, (hat (he noose will not rise above the mouth of the vessel, and for the purpose of altering the direction of the force employed in tightening the ligature, the ends of (he thumbs are generally made use of. Tbe tenaculum is commonly employed for ta- king up arteries, which are nol large and distinct. Very fine ligatures, of sufficient strength, are at present often applied, as well to large as small vessels. One half of each ligature should always be cut off, before the wound is closed, and there are some surgeons, who prefer the method of cutting off all the liga- ture, except what forms the noose immedi- ately round the artery. (Delpech, Mim. sur la Pourriture d'Hopilal, p. 29; Lawrence in Med. Chir. Trans. Vol. 6, p. 156.) To the latter plan, however, a few surgeons have addu- ced objections, particularly Mr. Guthrie, who only admits tbe utility of it in cases where the wound will not unite by the Grst intention ; (On Gunshot Wounds, p. 94.) nnd Mr. Cross, of Norwich. (See the London Medical Repository, Vol. 7, p. 353.) The experiments of Mr. Cross tend lo the following conclusions : First, If the wounds do not unite by the first intention, the ligatures may escape with the discharge, without any inconvenience. Secondly, If common ligatures of Iwinc are cut short, the wound may unite over them, and they may be found in abscesses after an interval of many weeks. Thirdly, If the finest dentist's silk be era- ployed in the same way, and Ihe wound unite over it, the ligature may be detached from tbe vessel, and remain buried in an ab- scess, where it will be found at different pe- riods, from one to seven months; and this tnay happen, whether the vessel be firmly compressed with u single ligature, or divided between two ligatures, so as to imitate the circumstances under which vessels are tied after operations. Fourthly, If Indian silk, fine as hair, be put round a vessel -o as to diminish its dia- met*i r, or to effect its obliteration, by just compressing ils sides together, it may remain in this situation, without ex<;iting abscess, or producing any inconvenience. The ligature may be thus applied to compress an artery for the cure of aneurism ; but not to secure vessels divided in operations. If a thin liga- ture be drawn sufficiently tight upon a ves- sel on the face of a stump to be secure, Mr. Cross is persuaded, that the extremity of the vc.-el which becomes insulated, as it vvere, must die. (See Lond. Med. Rcposit. Vol. 7. p. 363.) It deserves attention, ilia: the preced- ing inferences are- chiefly founded on v hich may attend the endecivoiir to bring about such an union. Experience also fully proves the frecru"nf roccess which attends nn en- deavour to unite a purl, which retains only Ihe slight connexion of a small piece of flesh, or even a few fibres. My friend, Mr. Law- rence, lately had a case which illustrates the (ruth of (his statement. A man on the (op of a stage-coach,vc a-; carried underagateway which did not leave sufficient room for bim to pass wilhout injury, and his head was so much wounded, that one of his ears was entire- ly separated, wilh (he exception ot an attach- ment by a trivial piece of integuments. Mr. Lawrence assented lo the man's wish of not having the separation completed, and fixed ihe part in its situation with a few su- tures. The consequence was (hat (ho ear soon united again, and the patient escaped all disfigurement. Ofthe knowledge of ihe disposition of living cut surfaces (o grow together with considerable expedition, sur- geons, both of ancient and modern times, have availed themselves not only in (he treatment of accidental wounds, but also in (he removal of deformity, ns exemplified in Ihe cure of fissures in the palate or lips, (see Harelip,) but most particularly in the curi- ous and interesting art of forming new under lips and noses, and closing large defi- cienccs in the urethra wilh flaps of flesh, raised from tho adjacent parts, shaped ac- cording to circumstances, and laid directly down upon a fresh-cut surface, purposely prepared, where it is steadily confined for a certain time with sutures, or simple adhesive plaster and pressure, as the nature of (he case may indicate. Nay, sometimes, the flesh for the formation of the organ to be restored has even been taken from a distant part, as for instance, from the arm for Ihe restoration of parts of (he face. When (his was done, the limb was confined in close contact with the raw surface formed on the face, until a union between ihem had been effected; a division was now performed with the scalpel, and (he opportunity taken to shape the portion of the limb which was to be left behind, according as tbe part to be restored might be the ear, nose, or tip. At the present day, the flesh is usually taken from the adjacent parts; a connexion of the flap with ihe rest of the body is retained, so as to ensure some circulation of blood in it, and it is turned into any position which tbe circumstances may demand. (See Gas- par Taliacotius, Chirurgia Nova de Narium, Aurium, Labiorumque Defedu,pcr insilionem cutis ex humero sarciendo, fyc. Svo. Francof. 1598. J. C. Carpue, an Account of Two successful Operations for restoring a lost Nose from the Integuments of the Forehead, 4to. Lond. 1816. Giuseppe Baronio, Degli Innesti Animali, Svo. Milan. C. F. Graefe, De Rhi- noplastice, sive Arte curium Nasum ad Vivum restituendi, cemm entatio, qud prisca illius ratio ilerum experimentis illustratur novisque me- thodis ad majorem perfedionem pcrducilur, 4/o. Berol.1818. Sir A.Cooper, on Unnatural Apertures in the Urethra; Surgical Essays, Part 2. H. Earle, on the Re-establishment of a Canal in the place ofaportion ofthe Urethra, in Phil. Trans, for 1821. A Case of restored Nose, by Mr. C. Hntch'son. A Case of artificial Aw VWL-MAa. 6A[ Wed by o. t. Cotti<.r,in Med. uud Physical Journ. for June, 1820. Mr. John Bell describes the process of adhesion to be this: either the arteries of the opposite surfaces inosculate mouth to mouth, orjrather each cut-surface throws out a gluten; the gluten fills op the intermediate pace; into that gluten the lesser arteries of each cut-surface extend themselves, and it is thus, perhaps, by the generation of u new intermediate substance, that the con- tinuity and entireness of the part arc so quickly restored. If any one point fail to adhere, there the wound must run into suppuration ; because, says Mr. J. Bell, at that point there is a separation of parts, which is equivalent to a loss of substance. The same writer observes, that there are, no doubt, accidents, both of the constitution and the wound, which will prevent adhesion. If the patient be of a bad habit of body; if he be lying in a foul hospital, in the midst of putrid sores, and breathing a contagious air; if he be ill of a fever, or flux, or any general diseuse; then the properties of the body being less perfect, the wound will not ad- here. Mr. J. Bell also notices, that, if the wound be foul, made with a poisoned weapon, or left with foreign bodies lodged in it; or if a considerable quantity of blood be poured out into the cavity of the wound, or if there be a wounded lymphatic, or a wounded salivary duct, a wounded intestine, or a bleeding artery or vein, the immediate adhesion of the whole of the wound may be prevented. Hovvever, I cannot help re- marking, that, though Mr. John Bell, in imitation of most surgical writers, sets down the wound of a lymphatic as preventive of (be union of wounds, I cannot say, that I ever saw such an effect imputable to the cause just mentioned. Also, when an artery or vein is cut, and requires to be tied, the adhesion of the wound would be prevented only just where the ligature lies, aud at no other point. There is no wound, observes Mr. John Bell, in which we may not try with perfect safety to procure this adhesion ; for nothing •ran agree better with one surface of the wound, than the opposite one, which has been just separated from it. They may immediately adhere together, and even if they should not do so, no harm is done, and the wound will yet suppurate as favourably, as if it had been roughly dressed with dry caddis, or some vulnerary balsam, or acrid ointment. If one. part should suppurate, while one half adheres, then, says Mr. John Bell, one half of our business is done. In short, this simple duty of immediately closing a wound is both natural and 6afe. (Discourses on the Nature and Cure of Wounds, Vol.1.) Upon Ibis interesting topic of the advan- tages of union by the first intention, the most enlightened surgeons of all Europe now begin to entertain only one opinion. The practice is generally adopted both in the treatment of accidental cuts, and of the wounds resulting ffom surgical operations. •',*. II. "1 Thus Assaiini, one of tiie iiesi modern sur- geons in Italy, begins his Manual of r-»urger,y with the following axiom : " Wounds and injuries of the soft parts, produced by cOt- ting instruments, from the trifling wound oi a vein, made for (he purpose of discharging a few ounces of blood, to the incision in the uterus for the extraction of the feetus, inclw- rively, should all be united by the first inten- tion. (See Manuale di Chirurgia; Discorso Primo. Milano, 1812.). British surgeons have, indeed, been ac- cused by M. Roux of indiscriminate par- tiality to the plan of uniting all incised wounds by the first intention, and his coun- tryman Baron Larrey has wished the me- thod to be discontinued after ampliation, in order (as he sta(es) to lessen the chance of tetanus. But the exceptions which these surgeons wish to make, are few, and few as they are, they are not likely to be establish- ed, since several of the circumstances, al- leged as reasons for limiting so beneficial a practice, are hypothetical, and far from being clearly proved. (See Roux, Mivioirc. et Obs. sur la Riunion immediate de la Plaie aprts TAmpulation circulaire des Membres, 8vo. Paris, 1814. Larrey, Mim. de Chir. Mil. Tome 4, Svo. 1812—17.) Sometimes the attempt to procure union by the first intention fails, even in cases of incised wounds : but, in this circumstance, no harm arises from tbe kind of practice which has been followed. The case, in fact, now falls into nearly the same state, as would have occurred, bad no attempt at union been made at all. The patient has taken the chance of a quicker mode of cure : but he has not been successful, and he must now be cured by a process, which on ac- count of its slowness he at first wished to avoid. It is to be observed also, that union by the first intention, if not spoiled by sutures, rarely fails so completely, that there is not a partial adhesion of some points of tiie wound. The moment when we observe pain, inflammation, and swelling of the wound, a separation or gaping of its lips, the stitches tense (when these have been used,) and the points where the stitches pass parti- cularly inflamed, Mr. John Bell advises us to undo the bandages, draw out the sutures, and take away every thing, which acts like a stricture on the wound. These prudent measures, he observes, may abate the rising inflammation, and prevent the total separa- tion of the skin, while an endeavour may still be made to keep the edges of the wound tolerably near each other by the more gentle operation of sticking-plasters. Hovvever, when the inflammation rises still higher, and it is evident, that a total separation of the sides of the wound cannot be avoided, Mr. John Bell wisely recom- mends leaving the parts quite loose, and ap- plying a large soft poultice; for, says he, should you in this critical juncture, persist in keeping the parts together with sutures, the inflammation, in the form oferysipelas, would extend over the w hole limb, attended with a fetid and bloody suppuration, ^fter'titr S * wound iiaa been brought into a favourable -.(ate, another attempt may be made to bring the edges near each other, not with -titures^ but strips of adhesive plaster, or the gentle-application ofajmndage. Mr. John Bell concludes with remarking, that the suppuration, production of granula- tions, and all that follows, are the work of nature. The only thing that the surgeon tan usefully do, is to take care of the health. When the wound does not suppurate favour- ably, tbe discbarge generally becomes pro- fuse, thin, and gleety. This state is to be amended by bark, wine, rich diet, and good air. I shall conclude this subject of union by the first intention, with an extract from the writings of Mr. Hunter, who observes, (hat " It is with a view to this principle of union, that it has been recommended to bring the sides (or lips) of wounds together; but, as the natural elasticity of the parts makes them recede, it has been found ne- ■ **ssary to employ art for that purpose. This necessity first suggested the practice of sew- ing wounds, and afterward gave rise to va- rious inventions iu order to answer this end, such as baudages, sticking-plasters, and liga- tures. Among these, the bandage common- ly called the uniting bandage is preferable to all the rest, where it can be employed; but its application is very confined, from being only adapted to parts where a roller can be used. A piece of sticking-plaster, which has been called the dry suture, is m<>re general hi ils application than the uniting bandage, and is therefore preferable to it on many oc- casions. " I can hardly suppose (says Mr. Hunter,) a wound, in any situation, where it may not be applied, excepting penetrating wounds, where we wish the inner portion of the wound to be closed equally with the outer, as in the case of hare-lip. But even in such wounds, if the parts are thick, and the wound not large, the sides will seldom recede so far as to make any other means necessary. The dry suture basan advantage overstitches by bringing a larger surface of the wound to- gether, by not inflaming the parts to which it is applied, and by neither producing in ihem suppuration nor ulceration, which stitches always do. When parts, therefore, can be brought together, and especially where some force is required forthat purpose, from the skin not being iu large quantity, t«n*. sticking-plaster is certainly the best ap- plication. This happens frequently to be lh« case afler the removal of tumours, in amputation, or where the sides of the wound are only to be brought together at one end, as in the hare-lip ; and I think the difference between Mr. Sharp's cross-stitch, after ampu- tion, ns recommended in his Critical Inquiry, and Mr. Allanson's practice, shows strongly tbe superiority pf-khe sticking-plaster (or dry suture.) In tfttte parts of the body where • ie skin recede* more than in others, this *.-.!.-rint et becoui-* •';•<■-! r!**ce>«s»ify : and as rV-1 sr-jeJn !•■ ibaM-v Tmrf-•'''*<•. ?<^ '-''tic :r* anv. it is therefore seldom iieee-.-ary to appiy usy thing in wounds of that part ; the practice will certainly answer best in superficial wounds, because (be bottom is in these more within its influence. " The sticking-plasters should be laid on in strips, and these should be at small dis- tances from each other, viz. about a quarter of an inch at most, if the part requires close confinement; but when it does not, they may be at greater distances. This precaution becomes more necessary if the bleeding is not quite stopped ; there should be passages left for the exit of blood, as its accumula- tion might prevent the union, although (bis does not always happen. If any extraneous body, such as a ligature, should have been left in the wound, suppuration will take place, a'nd the matter should be allowed to vent at some of these openings, or spaces. between the slips of plaster. I have known a very considerable abscess formed in con- sequence of this precaution being neglected, by which the whole of the recently united parts has been separated. " The interrupted suture, which bas gene- rally been recommended iu large wounds, is still in use, but seldom proves equal to the intention. This we may reckon to be the only one that deserves the name of su- ture ; it was formerly used, but is now in a great measure laid aside in practice, not irom the impropriety of uniting parts by* this process, but from the ineffectual mode of attempting it. In what manner better methods could be contrived, I bave not been able to suggest. It is to be understood, tbat. the above methods of'.bringing wounded parts together, in order to unite them, are only to be put in practice in such cases as will admit of it; for if there was a method known, which in all cases would bring the wounded surfaces into contact, it would, in many instances, be improper, as some wounds are attended with contusion, by which the parts have been more or less deadened; in such cases, as was formerly observed, union cannot take place accord- ing to our first principle, and Iherefore it is improper to attempt it. " in many wounds, which are not attend- ed with contusion, when we either know, or suspect, tbat extraneous bodies have been introduced into the wound, union by tbe first intention should not be attempted, but they should be allowed to suppurate, in or- der that the extraneous matter may be ex- pelled. Wounds which are attended with laceration, although free from contusion, cannot always be united by the first inten- tion, because it must frequently be impossi- ble to bring the external parts, or skin, so much in contact, as to prevent that inflam- mation which is naturally produced by ex- posure. But even in cases of simple lacera- tion, where the external influence is but slight, or can be prevented fas we observed in treating of the compound fracture,) we find that union by the first intention often takes place : the blood, which fills up the ■"..(t^rctif.*-*; of Hie lace-rntcd part*-, having pre- UOUNi*? vented the stimulus of imperfeciion in them, and prevented suppuration, may afterward bo absorbed. "Many operations may be so performed as to admit of parts uniting by the first in- tention ; but (he practice should be adopted with great circumspection : the mode of operating with that view, should in all cases be a secondary, and not a first considera- tion, which it bas unluckily been too often among surgeons. In cases of cancer, it is a most dangerous attempt at refinement in surgery. " In the union of wounded parts by the first intention, it is hardly or never possible to bring them so close together at the expo- sed edges, as to unite them perfectly by these means; such edges are therefore obliged to take another method of healing. If kept moist, they will inflame us deep be- tween the cut surfaces as the blood fails in the union, and (here suppurate and granu- late ; but if the blood be allowed to dry and form a scab between, and along the cut edges, then inflammation and suppuration of those edges will be prevented, and this will complete (he union, as will be descri- bed by and by. " As those effects of accidental injury, which can be cured by the first intention, call ap none of the powers of the constitu- tion to assist in the reparation, it is not the least affected or disturbed by them ; the parts are united by the extravasated hlood alone, which was thrown out by the injury, either from the divided vessels, or in conse- quence of inflammation, without a single action taking place, even in the part itself, except the closing or inosculation of tbe vessels : for the flowing of the blood is to be considered as entirety mechanical. Even in cases where a small degree of inflamma- tion comes on, it is merely a local action, and so inconsiderable, that tbe constitution is not affected by it; because it is an opera- tion, to which the powers belonging to the parts themselves are fully equal. The in- flammation may produce a small degree of pain, but the operation of union gives no sensation of any kind whatever." (Hunter on the Blood, Inflammation, and Gunshot Wounds.) Contused and Lacerated Wounds.—Lace- rated wounds are those, in which the fibres, instead of being divided by a cutting instru- ment, have been torn asunder by some vio- lence, capable of overcoming their force of adhesion. The edges of such wounds, in- stead of being straight and regular, are jag- ged and unequal. The term contused is applied to those wounds which are occasioned by some blunt instrument, or surface, which has violently struck a part of the body. These two species of wounds greatly re- semble each other, and as they require nearly the same kind of treatment, writers usually treat of them together. Lacerated and contused wounds differ from simple incised ones, in appearing, at first view, mnch les*? alarming than the lat- ter, while, m reality, tney ere niiiiiiteb. more dangerous. In simple cut wounds, th- retraction ofthe parts, nnd (lie hemofrhiig^ arc generally much more considerable than in a lacerated wound of the sami* si/" However, notwithstanding these r.ircun: stances, (hey commonly admit of be-in'; healed with far greater ease. It is worthy of particular notice, that lacerated and con- tused wounds are not in general attended with any serious efiusion of blood, even though large blood-vessels may be injured. I say in general, because in the year 1813, I saw a soldier, whose death vvas occasioned by a sudden effusion of a very large quan- tity of blood from the internal jugular vein. which vessel had been injured by n musket- ball, that first entered the integuments be- hind the mastoid process, and passed ob liquely downwards and forwards toward the sternum. The blood did not issue er*.- ternally; but formed betwixt the inlegu ments and the trachea, a large dark-coloured swelling, which produced almost immediate suffocation. At tlie memorable siege of Saragossa, Professor Assalini saw a surgeon whose left carotid artery had been injured by a musket-ball, perish of hemorrhage in a few seconds. (See Assalini's Manuale di Chirurgia, p. 32, Milano, 1812.) In most cases, hovvever, there is little or no hemorrhage from lacerated and contused wounds, and it is a circumstance, which often leads inexperienced practitioners to commit great mistakes, by inducing (hem to promise too much in (he prognosis which (hey make. Stu^eons versed in practice, however, do not allow themselves to be de- ceived by the absence of hemorrhage, and. in proportion as there is little bleeding, they apprehend that (the violence done to the fibres and vessels has been considerable. What is it, but the contused and lacerated nature ofthe wound, that prevents hemor rhage from the umbilical arteries, when ani- mals divide the navel-string with their teeth ? Whole limbs have frequently been torn from the body, without any hemorrhage of con- sequence taking place. In the Phil. Trans. Cheselden has recorded a very remarkable case, in which a man's arm was suddenly torn from his body. Samuel Wood, a miller, had round his arm a rope, which got entangled with the wheel of the mill. He was lifted off the ground, and then stopped by a beam, which pre- vented his trunk from passing further; at this instant, the wheel, which was moving with immense force, completely tore, and carried away, his arm and scapula from his body. The appearance of a wound, occa- sioned in this manner, must of course be horrible, and the first idea, thence arising, must naturally be that the patient cannot possibly survive. Samuel Wood, however, escaped with his life. The limb had been torn off with such velocity, that he was un- aware of the accident, till he saw his arm moving round on the wheel. He immedi- ately descended by a narrow ladder from the mill, and even walked some paces •"-.'th W'Ol.Mte. a view ol seeking abstain-.*. He now fell down from weakness. The persons who first came to his assistance, covered the »•.oundvvlth powdered sugar. A surgeon, \vno afterward arrived, observing that there vyas no hemorrhage, was content with bringing down the skin, which was very loose, so as to make it cover the surface of the wound. For this purpose he used two cross stitches. The patient vvas conveyed the next day to St. Thomas's Hospital, and put under the core of Mr. Fern. This prac- titioner employed the usual means for pre- venting the bad symptoms most to be ex- pected in this sort of case. The first dress- ings came away without any bleeding; no alarming consequences ensued ; and the patient, in two months, completely reco- vered. When the arm was examined, it was found, that the muscles, inserted into the scapula, were torn through near their inser- tions; while other muscles, arising from (his bone, were carried away with it. The skin, covering the scapula, had remained in its natural situation, and seemed as if it had haen divided precisely at the insertion of the deltoid muscle. In La Mode's Traili des Accouchemens, may be found an account of a little boy, who, while playing near the wheel of a mill, got his hand, fore-arm, and arm, suc- cessively entangled in the machinery, and the limb was violently torn away at the shoulder joint, in consequence of the lad's body not being able to pass in tbe direction in which tho arm was drawn. The bleed-. ing was so trivial, that it was stopped with a little lint, and the boy very soon reco- vered. In tbe fifth vol. ofthe Edinb. Med. Com- mentaries, may also be perused the history of a child, throe years nnd a half old, whose arm was torn off by the wheel of a mill. Mr. Carmichael, who saw the child about an hour after the accident, found it almost in a dying state, with cold extremities, small faltering pulse, and all the right side of the body convulsed. However, there was nardly any bleeding. The arm was broken about an inch and a half above the elbow; the stump had a dreadful appearance ; all the soft parts were in a contused and lace- rated state, and the humerus was laid bare as high as the articulation, which was itself exposed. The skin and muscles were lace- rated to a much greater extent, and in dif- ferent directions. The remainder of tbe humerus vvas removed from the shoulder- joint by amputation, only as much skin and muscle being left as was sufficient to cover the wound. In two months the child was well. In tbe Mim. de I'Acad. de Chir. T. 2, is an account of a leg being torn away at tbe knee joint by a cart wheel. The pa- tient was a boy, about nine or ten years of age. This accident, like the foregoing ones, was accompanied with no hemorrhage. The lower portion of the os femoris, whieh w;a« expo-art d. was aronntated, together with such portion ot the soil parts, us u&-> in t< contused and lacerated state. The patient experienced n perfect recovery. The preceding cases strikingly confirm tho observation, which 1 have already made, in regard to the little bleeding, which usu- ally arises from contused and lacerated wounds. In these instances, (he pain is also in an inverse ratio to the cause of the accident; it is generally very severe, when the wound is only moderately contused : and, on the other hand, the patient scarcely suffers any pain ut all, where there has been so violent a degree of contusion, us at once to destroy the organization of the part. When the bruised fibres have not been injured above a certain degree, the part suppurates ; but such portions ofthe wound as have suffered greater violence, inevitably die, and are cast off in the form of sloughs. Granulations are afterward formed, and the breach of continuity is repaired by the process of cicatrization. (See this word.) When a still greater degree of violence has been done, and, especially, when arte- ries of a certain magnitude have been in- jured, a mortification is too frequently tht consequence. However, if the constitution be good, and the mischief not too extensive, the case may still end well. But, in other instances, the event is alarmingly dubious ; for the mischief is then not limited to the wounded parts, which have suffered the greatest degree of contusion ; but, (oo fre- quently, extends over such parts as were not at all interested by the wound itself. The mortification arising directly from (he impaired organization of ports, is not what is (be most alarming circumstance. A still more dangerous kind of mortification, is that which is apt to originate from the violent in- flammation occasioned by the accident. This consequence demands the utmost attention on the part of the surgeon, who must let no useful means be neglected, with a view of diminishing the inflammation before it has attained too high a degree-, and very danger- ous symptoms have commenced. In Ihe first instance, he should not be afraid of let- ting the wound bleed a little, if it should be disposed to do so. The edges of (he wound should then be gently drawn towards each other with a few strips of sticking-plaster, so as to lessen the exlenl of (he exposed sur- face : bu( no sutures are proper. Indeed, (he plan of diminishing the exposed surface of a contused wound with strips of adhe- sive plaster, is not invariably right; because their application creates a hurtful degree of irritation. The method is chiefly adviseable when there is a large loose flap of skin, which can be conveniently brought ovi-r the wound. In other cases, it is best to leave the parts free, uncompressed, and uncoiilinid wilh any adhesive plaster, because if it were applied its irritation would do harm, and could not possibly procure any uniou of the parts. Under Ibe most favourable circum- stance*, hardly any part of the wound can be expee-md to unite by (he fii«s( intenlron : * W&UNDb Wo Ine whole orthe gi.ater ^ttof it will neces- sarily suppurate, after (he detachment of the sloughs. The surface wil.l then granulate, new skin will be formed, and the part heal just like n common wound. Perhaps, until the sloughs separate, the best application is a soft poultice, which should be put on cold, lesi it bring on too great an oozing of blood. Nothing, indeed, is so proper for checking any tendency to hemorrhage as cold applica- tions, which are also the most effectual in preventing and diminishing the great degree of inflammation, which is one of the most "dangerous consequences of this description of wounds. No surgical writer, I think, has given more rational advice, respecting contused wounds, than that published by Professor Assalini. In general, says he, the treatment of contused wounds, whetherthey be simple and slight, or complicated and severe, re- quires the active employment of debilitating means in order to prevent inflammation. Cold water, and ice ; and general and topi- cal bleeding, are the things usually resorted to with success. Vulnerary lotions, campho- rated spirit, and other spirituous applications, are improper, and if their pernicious effects are not always very evident, it is only be- cause the contused injuries have been trifling, and in their nature perfectly easy of cure. In these cases, as well as in those of extravasa- tions and glandular swellings, Assalini gives a preference to cold applications. The in- ternal remedies and regimen, (says he) should also be adapted to tbe condition of the patient. A cannon-ball, at the end of its course, may come into contact with a limb, and fracture the bones, while the inte- guments have the appearance of being unin- jured. Such cases are often attended with dreadful mischief in the soft parts around the bone, which generally sphacelate. This is an accident for which immediate amputa- tion is mostly indispensable (see Gunshot Wounds;) but if any thing be capable of pre- venting inflammation and gangrene, it is an active debilitating plan of treatment, assisted with cold applications to the injured part. In such cases, the internal and external use of stimulants is approved of by many sur- geons. But, Assalini prefers considering the state ofthe injured limb, just like what it is when affected with frost; and he thinks that the employment of stimulants will neces- sarily produce the same effect as caloric prematurely applied to parts deadened with cold. On the contrary, from the outward employment of ice and cold lotions in these cases, and in contused injuries in general, he bas seen the greatest benefit derived. Assalini conceives, that reason will be found to support this pructice. The opera- tion of cold, he says, retards the course of the blood, which meeting with only dama- ged vessels, augments the extravasation as it continues to flow. By lessening the tem- perature of the part, cold applications like- wise diminish the danger of inflammation ind sphacelus, at the same time that they have the good otlect ol rendering tlie suppa ration, which must ensue, less profuse, than it would be, were not extravasation of blood, and violence of the inflammation, lessened by such applications, and a lowering plan of treatment. Why, says Assalini, should not this me- thod, which is generally adopted to prevent the effects of concussion of the brain after blows on the head,be, for analogous reasons, employed in examples of extravasation and commotion in other parts of the body r (Manuale.de Chirurgia, Parte Prima,p 17.) Cold applications, however, in cases of con- tused wounds, are chiefly to be preferred, for the first day or two, in order to check the increase of extravasation and inflammation. After this period, 1 give a decided preference to an emollient linseed poultice, which will be found the most easy dressing during (hose processes, by which (he sloughs are detached, the surface of the wound cleansed, and the origin of granulations established. When these changes have happened, the remaining sore is to be treated on the same principles as ulcers in general. See Ulcers. Punctured Wounds.—A punctured wound signifies one, made with a narrow-pointed instrument, the external orifice ofthe injury being small and contracted, instead of being of asize proportionate to its depth. A wound, produced by a thrust of a sword, or bayonet, affords us an example of a punctured wound. Wounds of this description are in general infinitely more dangerous than cuts, notwith- standing (he lalter have the appearance of being by far the most extensive. In cases of stabs, the greatest degree of danger al- ways depends on the injury, and rough vio- lence which the fibres have suffered, in ad- dition to their mere division. Many ofthe disagreeable consequences are also to be imputed to the considerable depth, to which these wounds extend, whereby important parts and organs are frequently injured. Sometimes the treatment is rendered per- plexing, by the difficulty of removing ex- traneous substances, as for instance a piece of the weapon, which has been left in the wound. Lastly, experience proves, that punctured wounds and stabs are particularly liable to be followed by a great deal of in- flammation, fever, deep seated abscesses, si- nuses, &c. A strange notion seems to pervade tbe writings of many systematic authors, that all the danger and disagreeable consequences of punctured wounds are entirely owing to the narrowness of their orifices, which pre- vents suhable applications from being made to their bottom. Hence, it is absurdly re- commended to dilate the opening of every stab, with the view, as is generally added, of converting the accident into a simple inci- sed wound. Some of these writers are advo- cates for making the dilatation with a cutting instrument, while others, with equal absurdi- ty,propose to enlarge the opening with tents. Certain authors regard a punctured wound, as a recent sinus, and in order to make the* inner surfaces unite- they recommend •*?***' u>'-h> WOUMjj citing a degree of inflammation in them, either by means of setons, or injections. In the" earliest edition of The First Lines of ihe Practice of Surgery, I have taken parti- cular pains to expose the folly and errors, which prevail in most writings on this part of practice. In the above work, I have re- marked, that if the notion vvere true, that an important punctured wound, such as the stab of a bayonet, could be actually chan- ged into a wound, partaking of the mild nature of an incision, by the mere enlarge- ment of its orifice, the corresponding prac- tice would certainly be highly commenda- ble, however painful But the fact is other- wise : the rough violence, done to the fibres of the body by the generality of stabs, is little likely to be suddenly removed by an enlargement of the wound. Nor can the distance, to which a punctured wound fre- quently penetrates, and the number and na- ture of the parts injured by it, be at all altered by such a proceeding. These, which are the grand causes ofthe collections of matter, that often take place in the cases under consideration, must exist, whether the mouth and canal of the wound be enlarged or nol. The time when incisions are pro- per, is whevn there are foreign bodies to be removed, abscesses to be opened, or sinuses to be divided. To make painful incisions sooner than they can answer any end, is both injudicious and hurtful. They are sometimes rendered quite unnecessary,.by the union of the wound throughout its whole extent, without any suppuration at all. Making a free incision in the early stage of these cases, undoubtedly seems a reasona- ble method of preventing the formation of sinuses, by preventing the confinement of matter, and were sinuses an inevitable con- sequence of all punctured wounds, for which no incisions had been practised at the moment of their occurrence, it would un- doubtedly be unpardonable to omit them. Fair, however, as this reason may appear, it is only superficially plausible, and a small degree of reflection soon discovers its want of real solidity. Under what circumstances do sinuses form ? Do they not form only where there is some cause existing to pre- vent the healing of an abscess? This cause may either be the indirect way, in which the abscess communicates externally, so that the pus does not readily escape ; or it may be the presence of some foreign body, or carious bone ; or lastly, it may be an in- disposition of the inner surface of the ab- scess to form granulations, arising from its long duration, but removable by laying the cyst completely open to the influence of the air. Thus it becomes manifest, that the occurrence of suppuration in punctured wounds is followed by sinuses only when the surgeon neglects to procure a free issue for the matter, after its accumulation; or when he neglects to remove any extraneous bodies. But as dilating tbe wonnd at first can only tend to augment the inflammation, and render tbe suppuration more extensive, it ought never to be practised in timse l»j.-*_ except for the direct objects of giving free exit to matter already collected, and of being able to remove extraneous bodies palpably lodged. I shall once more repeat, that it is an erroneous idea to suppose the narrowness of punctured wounds so princi- pal a cause of the bad symptoms, with which they are often attended, that the treatment ought invariably to aim at its re- moval. Recent punctured wounds have absurdly- bad the same plan of treatment applied to them as old and callous fistula?. Setons and stimulating injections, which in tbe latter cases, sometimes act beneficially, by exci- ting such inflammation as is productive of the effusion of coagulating lymph, and of fhe granulating process, never prove ser- viceable when the indication is to moderate an inflammation, which is too apt to rise to an improper height. The counter-opening, that must be formed in adopting the use of a seton, is also an objection. However. what good can possibly arise from a seton in these cases ? Will it promote the dis- charge of foreign bodies, if any arc present P By occupying the external openings of the wound, will it not be more likely to prevent it P In fact', will it not itself act with all the inconveniences and irritation of an extra- neous substance in the wound P Is it a likely- means of diminishing the immoderate pain. swelling, and extensive suppuration, so often attending punctured wounds P It will un- doubtedly prevent the external openings from healing too soon ; but cannot this ob- ject be effected in a better way? If the sur- geon observes to insinuate a piece of lint into tbe sinus, and pass a probe through Us track once a day, the danger of its closing too soon will be removed. The practice of enlarging punctured wounds by incisions, and of introducing se- tons, is often forbidden by the particular situation of these injuries. In (he firs( stage of a punctured wound, the indication is to guard against the attack of violent inflammation. When no con- siderable quantity of blood has been lost, general and topical bleeding should be prac- tised. In short, the antiphlogistic plan is to be followed. As no man can pronounce, whether such wounds will unite or not, and as no harm can result from the attempt, the orifice ought to be closed, and covered with simple dressings. In such cases, cold appli- cations are also highly commendable. Whe- ther gentle compression might be made to promote the adhesive inflammation or nol, may be doubtful : I confess, that I should not have any reliance upon its usefulness. Perfect quietude is to be observed. When the pain is severe, opium is to be adminis- tered. Sometimes under this treatment, the sur- geon is agreeably surprised to find the con- sequent inflammation mild, and the wound speedily united by the first intention. " Nu- merous are the examples of wounds, which penetrate the large cavities, being; healed bv WOUND.*? ii-i; the iin-.i intention, thai is, w iinout any sup- puration. Even wounds of (he chest itself, with injury of the lungs (continues an ex- perienced military surgeon and professor,) ought to be united by the first intention. (Assalini, in Manuale di Chirurgia, parte Scconda, p. 13.) More frequently, hovvever, in cases of deep stabs, the pain is intolera- ble; and the inflammatory symptoms run so high as to leave no hope of avoiding sup- puration. In this condition, an emollient poultice is the best local application ; and when the matter is formed, the treatment is like that of abscesses in general. See Sup- puration. Poisoned Wounds: Bile ofthe Viper.—If we exclude from present consideration the bites of mad dogs, and other rabid animals, which subject is fully treated of in the ar- ticle Hydrophobia, wounds of this descrip- tion are not very common' in these islands. hi dissections, pricks of the hand sometimes occur, and tbey are in reality a species of poisoned wound, frequently causing consi- derable pain and irritation in the course of the absorbents; swelling and suppuration of the lymphatic glands of the arm or axilla; and severe fever and constitutional irrita- tion. An instance of the fatal consequences of such an injury must still be fresh in the recollection of "the profession; and some others of yet more recent date have taken ■place iu this metropolis. (See London Me- dical Repository,- Vol. 7, p. 289.) In many instances, however, surgeons wound Iheir fingers in dissecting bodies, and no particular ill consequences ensue. The healthy and robust are said to suffer less frequently after such accidents, than persons, whose constitutions have been weakened by hard study, excesses, pleasure, or previous disease. It is remarked, also, that pricks of the fingers, met with in open- ing the bodies'of persons who have died of contagious diseases, and where a virus or infectious matter might be expected to exist in such bodies, do not communicate the in- fection. Doubtless (observes Richerand) Ihe activity of certain animal poisons, from which the venereal and several other dis- eases arise, is extinguished with life. (No- sographie Chir. T. I, p. 102, 103. Edit. 4.) Wilh regard to the treatment of the pricks of dissecting scalpels, the surgeons of tbe continent recommend the immediate cauterisation of the little wounds with a ;,rrain of caustic potassa, orthe liquid muri- ate of ammonia. Tonic remedies, particu- larly wine, is prescribed, and great atten- tion paid to emptying the bowels. The stings of bees, wasps, and hornets, are also poisoned wounds, though they are seldom important enough to require the assistance of a surgeon. The hornet is not found in Scotland ; but it is an inhabitant of -neral of the woods in England. Ils sting, which is more painful than that of a bee, or wnsp, is not, however, often the occa- sion of any serious consequences. The -,tin<*= of all these insects are attended with •v <'vjrp pain in the pv* very .juirklv suc- ceeded by un inflammatory swelling, which. after a short time, generally subsides of it self. When the eye is-stung, as sometimes bas happened, the effects may be very se- vere, as is elsewhere noticed. (See Ophlhal my.) It has been lately observed, that (he pain ofthe stings of venomous insects, like (he bee, depends less upon the introduction ofthe sting iuto the part, than upon that of, the venomous fluid. The experiments of Professor Dumeril tend to prove, that when Ihe little poison bladder, situated at the base ofthe sting, has been cut off, a wound with the sting then produces no pain. The poison flows from the vesicle through the sting at the instant when this passes into the flesh. The exact nature of this venomous fluid is not known. When applied to rau- cous surfaces, or even to the surface of the conjunctiva of the eye, it causes no dis- agreeable sensation ; but when it is intro- duced into the skin, by means of a needle, it immediately excites very acute pain. Oil, honey, spirits of wine, the juice of the plantain, and a variety of other local applications, have been extolled as specifics for the relief of the stings of insects. Mo- dern experience, however, does not sanc- tion their claim to this character. In fact, none of these applications either neutralize the poison, or appease with superior efficacy the pain ofthe sting. These cases should all be treated on com- mon antiphlogistic principles, and the mosl rational plan is to extract the sting, taking care, in the first instance, to cut off the little poison vesicle with scissors, lest in the at- tempts to withdraw the sting more of the virus be compressed into the part. The stung part should then be immersed for a time iu ice-cold water, and afterward co- vered with linen, wet with (he liquor plumbi acetatis dilutus. Were the inflammation to exceed the usual degree, leeches and aperi- ent medicines would be proper. In short, as there is no specific for the cure of these cases, they are to be treated with common antiphlogistic means. With regard to the bites of serpents, those inflicted by the rattle-snake of Ame- rica, and the cobra di capello of the East Indies, are the most speedily mortal. In- deed, this is so much the case, that some- times there is scarcely an opportunity of trying any remedies; and even when the patient is not destroyed thus rapidly, there is such general disorder of the nervous sys- tem, with repeated faintings and sickness. that medicines cannot well be retained iu the stomach, at least for some time. Mr. Catesby, in the Preface to his Natural History of Carolina, informs us, that the Indians, who, by their constant wanderings in the woods,, are liable to be bit by snakes, know, as soon as tbey receive the injury, whether it will prove mortal or not. If it be on any part at a distance from large blood-vessels, or where the circulation is not vigorous, they apply their remedies; but if any vein of considerable magnitude ••»** hnrf. 'h' •>■ quietly n*-ig;n *,ien'^<*'vpnly on account of the shape of the fangs, the wound might be attended with very un- pleasant effects; but it is certain of being so, by reason of the species of inoculation which complicates it, and of which the mechanism is as follows: When a viper is about to bite, it opens its mouth very wide. The two curved fangs, which bad previously lain flat down in the cavity of the membrane attached to their base, now project, and become perpendicu- lar to the lower jaw. When the bite takes place, the poison is propelled through the fangs, by the contraction of the muscles, ?Pfi ,|?(. r!(,^,i:-p cf the month, and is in- jected into tht* wound wuu a lorce propur tioned to its accidental quantity at the time, and (he vigour of the animal. The bite of a viper is quickly followed by severe effects, some of which are local, and the others general; but it is with the former that (he disorder invariably commences. At (he ins(ant of tbe bite, the bitten part is seized with an acute pain, which rapidly shoots over the whole limb, and even affects the viscera and internal organs. Soon after ward the wounded part swells and reddens. Sometimes the-tumefaction is confined to the circumference of the injury; but most frequently it spreads extensively, quickly affecting every part of the limb, and even the trunk itself. A sanious fluid is often discharged from the wound, around which phlyctenae arise, similar to those of a burn. After a short time, however, the pain abates considerably; (he inflammatory tension changes info a doughy, or cedematous soft- ness ; (he part grows cold; and the skin exhibits large livid spots, like those of gan- grene. The general symptoms also cottir on with celerity; the patient is troubled with anxiety, prostration of strength, diffi- culty of breathing, and cold profuse sweats Vomiting frequently occurs, and sometimes copious bilious evacuations from the bowel? These symptoms are almost constantly at- tended with an universal yellowness, and excruciating pain about the navel. The effects occur in the same way iu nearly all subjects, with some difference? depending upon the particular irritability and constitution of the patient; the high or low temperature of the atmosphere; the greater or lesser anger of the viper; the number of its bites; the size of the reptile itself; (he depth to which the fangs have penetrated ; and whether the bitten part happens to be one of great sensibility, or was naked or not at the time of the acci- dent. In general, weak, pusillanimous persons, of bad constitutions, and loaded stomachs, suffer more sudden and alarming ill consequences, than strong, healthy sub- jects, who view the danger without fear. Several bites are, of course, more danger- ous than a single one; and, lastly, it has been remarked, tbat the venom of the viper is more active in summer than the spring. A year or two ago, however, tbe news papers recorded the death of a servant, from the inadvertent application of the poi- son to a scratch on his hand, as he was exa- mining the fangs and venomous organs of a viper perfectly torpid iu the winter season. Severe, however, as the effects of the bite of a viper may be, they are far from being so perilous as they are commonly supposed to be. Indeed, the injury rarely proves fatal to an adult,even when inflicted by a viper in the middle of summer, the period when the animal is mo3t active and vigorous. Exceptions to this common be- lief, however, are upon record. Thus in the year 1816, a woman, in France, aged sixty-four, was bit on the thigh by a viper, and died in thirty-'eve-n hours, notwltl • WOUNDS w4i» standing the internal use of the liquor am- monia?, and the enlargement of the wound. and cauterization of it with this fluid. In this case, il is to be observed, that an hour elapsed before any thing was done. (See Annates du < ercle Medicate, T.l, p. 43, 810. Paris, 1820.) Fontana, therefore, was not exactly cor- rect in concluding, lhat the bite of an ordi- nary viper will not prove futal to a full- grown person, nor even to a large dog, though it does so to smaller animals. Five bites from three strong and healthy vipers were not able to kill a dog weighing sixty pounds; and as this dog was little more than a third part of the weight of an ordi- nary man-, Fontana supposed that a single bite could never be fatal (o an adult. He says, that he had seen a dozen cases himself, and had beard of fifty more, only two of which ended fatally. Concerning one of these cases, he could get no information ; the olher patient perished of gangrene, twenty days after the bite. The mortifica- tion began three days after the accident, the bitten place having been deeply scarified almost as soon as the injury was received. Fontana believes, that much of the faint- ness, be. which ensues upon the bite of a viper, are the mere effects of terror " Upon a person's being bit (says hei the fear of its proving fatal terrifies himself and the whole family. From the persuasion of the disease being mortal, and that not a mo- ment is to be lost, they apply violent or hurtful remedies. The fear increases the complaint. I have known a person thai was imperceptibly bit in the hands or feet, and who, after seeing the blood, and ob- serving a viper near him, suddenly fainted away; one, in particular, continued in a swoon for upwards of an hour, until he was accidentally observed, and. recovered out of it by being suddenly drenched in cold water. We know that death itself may be brought on by very violent affections ofthe mind, without any internal disease. Why may not people, that are bit, die from a dis- ease, produced entirely from fear, and who would not otherwise have died from any complaint produced by the venom ?" Al- though it must be owned, that Fontana be stowed a great deal of attention upon this subject, the above reasoning is hypothetical and inconclusive. If it were to be granted, that some very timid, delicate, or nervous people, die from fear alone, it could not be admitted, that the generality of people, bit by snakes, perish also from the violent effect of mental alarm. Whenever the patient dies, the catastro- phe is always ascribable to the quantity of venom inserted in the wound ; the number of bites . their situation near important or- gans ; and the neglect of proper means of relief". In ordinary cases of a single bite upon the extremities, the patients would get well even without any assistance ; but the symptoms would probably be more severe, and the cure slower Vol II TO From some facts, recorded by Sir Everard Home, and observations made on the opera- tion of the poisons of the black spotted snake of St. Lucia, the cobra di Capello, and the rattlesnake, it appears, that " the effects ofthe bite of a snake, vary according to the intensity of the poison. When the poison is.very active, the local irritation is so sud- den, and so violent, and its effects on the genera! system are so great, that death soon takes place. When the body is afterward inspected, the only alteration of structure met with, is in the parts close to the bite, where the cellular membrane is completely destroyed, and the neighbouring muscled very considerably inflamed. When the poi- son is less intense, the shock to the general system does not prove fatal. It brings on a slight degree of delirium, and the pain in Ihe part bitten is very severe : in about half an hour, swelling takes place from an effusion of serum in the cellular membrane, which con- tinues to increase, with greater or less ra- pidity, for about twelve hours, extending, during that period, into the neighbourhood of the bite. The blood ceases to flow in the small vessels of the swollen parts ; the skin over them becomes quite cold; the action of the heart is so weak, that the pulse is scarcely per- ceptible, and the stomach is so irritable that nothing is retained by it. In about sixty hours, these symptoms go off'; inflammation and sup- puration lake place in the injured parts; and when the abscess formed is very great, it proves fatal. When the bite has been in the finger, that part has immediately mortified. When death has taken place, under such cir- cumstances, the absorbent vessels, and their glands have undergone no change, similar to the effects of morbid poisons, nor has any part lost its natural appearance, except those im- mediately connected with the abscess. In those patients, who recover with difficulty from the bite, the symptoms, produced by it, go off more readily, and more complete- ly, than those produced by a morbid poi- son, which has been received into the sys- tem." (Sir E Home, Case of a Man who died in Consequence of the Bite of a Rattle Snake, in Phil. Trans. 1810.) Numerous remedies for the bites of com- mon vipers have obtained celebrity. Ac- cording to certain writers, each of these re- medies has effected wonderful cures; and yet, as Boyer well remarks, every one of them has been in its turn relinquished for another, the sole recommendation of which has frequently consisted in its novelly. Any of these boasted medicines, though of oppo- site qualities, cured, or at least seemed to cure, the patients, and the partisans of each considered, that he had a right to extol his own remedy as a specific, when the patient, to whom he administered it, was seen to re- cover perfectly, after suffering a train of se- vere symptoms. But the reasou of this pre- tended efficacy becomes obvious, when one kuows that the bite of a viper is of itself rarely mortal to the human subject, and that the severity ofthe symptoms materially de- pends upon the quantity of the venom tu the vfr W'Oli.NDS. wound. (Boyer, Trade des Maladies Chir. T l,p. 428.) The treatment of the bite of a viper is di- vided into local and general means. The local treatment has for its principal object the destruction of the venom ; the prevention of its entrance into the vessels, or the removal of it from the wound. Of scarifying the wound, I shall only say, that it promises no utility, if it be practised with a view of letting such dressings be ap- plied, as are extolled as specifics ; for we know, that there is no local application, which is entitled to this character. Fontana was an advocate for applying a ligature round the limb, in order to check the ingress of the venom into the circulation ; and he thought, that he had seen much good result from this practice. Sir Everard Home is also of opinion, that " the only rational lo- cal treatment, to prevent the secondary mis- chief, is making ligatures above tbe tumefied part, to compress tbe cellular membrane, and set bounds to the swelling, which only spreads in the loose parts under the skin ; and scarifying freely the parts already swoln, that the effused serum may escape, and the matter be discharged as soon as it is formed. Ligatures (he says) arc employed in Ameri- ca, but with a different view, viz. to prevent the poison being absorbed into the system." (Phil. Trans, for 1810, p. 87.) At all events, if compression be employed, it should be so regulated as not to create any risk of gangrenous mischief, by its interruption of the circulation. Suction of the wound has been proposed, and seems founded on reason : but experi- ence, I believe, has determined little in its favour. A cupping-glass might be employed, but, probably, no mode of suction would succeed in extracting the whole of the poi- son. The most certain method of removing the virus consists in the excision of the bitten part. This operation,however, would hardly be proper, unless done immediately after the injury, before much inflammation had come on. It is likewise a practice to which many patients would not assent, and even some surgeons may deem the proceeding too se- vere, in relation to the bite of the viper of this country. The bite might also be incon- veniently situated fpr the excision of the parts. Another plan, more commonly preferred is, that of destroying the envenomed part with caustic, or the actual cautery. When this is done in time, the poison is prevented from extending its irritation over the ner- vous system, through the medium of which all the worst symptoms are usually excited. The caustic and cautery may also have the effect of chymically destroying the venom itselt, while they must tend to hinder its passage into the circulation, inasmuch as they destroy the neighbouring absorbent vessels. The caustic, which Fontana pre- ferred, was potassa. But, as Boyer sensibly remarks, every caustic, of equal strength, must infallibly have the same effect, as its mode of opeiaung is that ol destroying tht' poiut of irritation, viz. the seat of the vc nom. Iu France, liquid caustics are pre - ferred, the fluid muriate of antimony, the liquor ammonia;, or the sulphuric, or nitric acid, because their action is quicker, and they more certainly penetrate to the bottom ofthe wound. (Traiti des Mai. Chir. T. 1, p. 429.) Either of these liquids mav be applied by means of a slender pointed bit of wood, which is to be dipped in it, aud then introduced into the punctures, made by the fangs of the reptile. The piece of wood should be withdrawn, wet once more, ami applied again. If a drop of-the caustic can be inserted, so much the better. When the bite is very narrow and deep, the caustic can- not well be introduced, before the mouth of the wound is somewhat enlarged with a lan- cet. A little bit of lint may then be wet in one of the above fluids, aud be pressed deep- ly into the wound. After the caustic has produced an eschar, (he best application is an emollient poul- tice. It is not, however, every bite of a viper that requires local treatment, even of this degree of severhy. As Boyer observes, when the wound is superficial, the viper benumbed with cold ; its poison considera bly exhausted by its having previously bit- ten other animals ; the swelling inconsider- able ; and the patient neither affected with prostration of strength, nor pain about the praecordia ; a few drops of ammonia may be introduced into the wound, and a small compress wet with the same fluid applied. Formerly, olive oil was considered, iu Eng- land, one of the best applications for the bites of snakes, and its virtues were after- ward extolled in France by Pouteau ; but, says Boyer, it possesses no specific efficacy, as the experiments of Hunaud and Geoffroi have decidedly proved. (Traiti des Mala- dies Chir. T.l,p. 431.) With respect to the general treatment, if we exclude emetics, of which Dr. Mead had a high opinion, when the patient was much jaundiced tbe favourite medicines are cor- dials, ammonia, and arsenic. The ancients employed theriaca, Mithridates, salt, and the carbonate of ammonia. Of all stimulants, however, the liquor ammonia; is that which now obtains the greatest confidence; or else, the eau de luce, which only differs from the fluid ammonia, iu containing a small quantity of the oleum succinatum. In France, this remedy is even at the present time regarded, as having the best claim to the title of a specific for the bite of a viper. (Boyer, op. cit.) In France, Bernard de Jussieu first tried ammonia in the year 1747 (see Hist, de I'Acad. des Sciences, 1747;) sinee which time it has been extensively employed for the cure of the bites of vipers, both as an inter- nal and external remedy. It bad, however been highly praised by Dr. Mead at a much earlier period. A few drops of the remedy are to be ex- hibited every two hours : but. au it ia very WOUNDS 00 i po wenui, it must always be diluted with tea, or some other drink, or the mistura cam- phorae. The dose, however, must depend upon the age and constitution of the patient, and^ the intensity of the symptoms. Four or five drops suffice for a person of weak, delicate, irritable habit; but twelve or fif- teen may be given to stronger subjects, when (he symptoms are violent. With am- monia, some practitioners order wine. In St. George's Hospital, (he man who was bit by the rattle-snake, kept for exhibi- tion, took aperient medicines, the liquor ammonias, aether, the spiritus ammonias, comp. opium, and other stimulants; but without any apparent benefit. The disease followed that course which Sir K. Home has described as usual when the shock on the system is not directly fatal, and the mischief in the arm ultimately produced the man's death. (See Phil. Trans. 1810.) From the following passage, in relation to the bites of snakes iu general, it seems that Sir Everard Home, in 1810, had no confidence in any medicines which had then been duly tried. "* The violent effects, which the poison produces on the part bit- ten, and on the general system, and the shortness of their duration, where they do not terminate fatally, (says he) have fre- quently induced the belief, that the recove- ry depended ou the medicines employed ; and, in the East Indies, eau de luce is con- sidered as a specific. There does not appear to be any founda- tion for such an opinion ; for when the poi- son is so intense as to give a sufficient shock to the constitution, death immediately takes place, and where the poison produces a lo- cal injury of sufficient extent, the patient also dies, while all slighter cases reco- ver. The effect of the poison on the con- stitution is so immediate, and the irritability ofthe stomach so great, that there is no op- portunity of exhibiting medicines till it has fairly taken place, and then there is little chance of beneficial effects being produced. (Sir E. Home, in Phil. Trans. 1810.) Fontana also had little faith in reputed antidotes; but it is to be noticed, (hat his observations refer only to the bites of vipers. "In no country (says he) through which I passed, could I ever find any two people or persons, bit by the viper, either in the moun- tains or valleys, that used (he same reme- dies. Some used theriaca alone, either ex- ternally or internally applied ; others com- mon oil ; a third set used stimulants, such as the strongest spirituous liquors; whilst others, on the contrary, tried every different kind of sedative. In short, there is hardly any active kind of medicine that has not been tried as a cure in this disease ; while, at the same time, it is certain that, under all the varieties of application, none of the pa- tients died." Hence. Fontana concluded, lhat none of the remedies had any effect in curing the disease. Later observations, however, tend to raise our hopes, that a medicine is now known which really seems to possess consi- derable efficacy against uie bite, even of a very formidable kind of snake. From some facts recorded in Dr. Russell's History of In- dian Serpents, on the authorities of Mr. Duf- fin and Mr. Ramsay, it appears that the Tan- jore pill, of which arsenic is the chiefingre- dient, is exhibited with considerable success in India afterthe bites of venomous serpents: this information led Mr. Chevalier to pro- pose the fair trial of arsenic. Mr. Ireland, surgeon to the 60th regt. had formerly heard Mr. Chevalier recommend the trial of arsenic, and be was resolved to make the experiment whenever an oppor- tunity offered. On his arrival in the island of St. Lucia, he was informed that an officer, and several men, belonging to the 68th re- giment, had died from the bites of serpents, supposed to be the coluber carinatusof Lin- naeus. The reader will find some interesting ac- count of the serpect here alluded to, in a tract, which I have lately read, entitled Mo- nographic du Trigonociphale des Antilles, ou Grand Viperc Fer-dc-Lance de la Martinique, par A. Moreau de Jonnes, 8vo. Paris, 1816. Mr. Ireland also learnt, that every thing had been tried by the attending medical men to no purpose, as all the patients had died, some in six, and others in about twelve hours from their receiving the wound. A case, however, soon came under Mr. Ireland's own observation, and as nothing that had been done before, seemed to have been of any service, he was determined to give arsenic a full trial. " Jacob Course, a soldier in the York light infantry volunteers, was bitten in the left hand, and the middle finger was so much lacerated, that I found it necessary to am- putate it immediately at the joint with the metacarpal bone. " I first saw him about ten minutes after he had received the wound, and found him in a torpid, senseless state ; the hand, arm, and breast of the same side were much swelled and mottled, and of a dark purple, and livid colour. He was vomiting, and ap- peared as if much intoxicated. Pulse quick and hard : he felt little or no pain during the operation. " The wound being dressed, and the pa- tient put to bed, I ordered a cathartic clys- ter, and the following medicine to be taken immediately. r\ Liquor Arsenic. 3>j- Tinct. Opii, gt. x. Aq. Menth. Pip. j|iss. which was added to half an ounce of lime-juice, and as it produced a slight effervescence, it was given in that state; th;s remained on his stomach, and was repeated every half hour for four successive hours. In the mean time, the parts were frequently fomented with common fomentations, and rubbed with a liniment composed of 01. Terebinth. -|s8. Liquor Ammon. "|ss. and 01. Oliv. *^iss. The cathartic clyster was repeated twice, when the patient began to be purged ; and the arsenical medicine was now disconti- nued. He had become more sensible when touched, and from that time he gradually 653 WOUNlfe. recovered his faculties; he took some nou- rishment, and had several hours sleep. " The next day he appeared very weak, and fatigued ; the fomentation and liniment were repeated. The swelling diminished gradually ; the natural colour and feeling returned, and by proper dressings to the wound, and attention to the state of his bowels, he soon recovered and returned to his duty." Mr. Ireland recites about four other ex- amples, in which arsenic was exhibited with similar success. It deserves particular notice, that the li- quor arsenici employed by Mr. Ireland, was prepared according to Dr. Fowler's pre- scription, which directs sixty-four grains of arsenic, and as many of the fixed vegetable alkali, to be dissolved in a sand beat, and the solution to be made an exact pint, so that two drachms contain one grain of arse- nic in solution. (See Med. Chir. Trans. Vol. 2, p. 393, fyc.) Wounds of the Thorax.—The thorax is a cavity of an irregularly oval figure, bounded in front by the sternum, laterally by the ribs, posteriorly by the vertebra? ofthe back, above by the clavicles, and below by the diaphragm, a very powerful muscle, which forms a kind of partition between the cavity ofthe thorax, and that ofthe abdomen. The diaphragm is not stretched across, in a straight direction, from one side of the chest to the other; but on the contrary, descends much further in some places than in others. If the cavity of the thorax be opened by a transverse section, about the middle of the sternum, the diaphragm ap- pears, on examination, to be very promi- nent and convex towards its centre, while it sinks downward at its edges, towards all the points to which the muscle is attached. At its anterior, and most elevated part, it is fixed to the ensiform cartilage, whence, de- scending obliquely to the right and left, it is inserted, on both sides, into the seventh rib, all the lower ribs, and lastly, into the lower dorsal vertebra*. According to this descrip- tion, it is obvious, that the cavity of the thorax has much greater depth and capacity behind, than in front; a circumstance which surgeohs ought to be well aware of, or else they will be liable to give most erroneous opinions concerning wounds of the chest. For instance, a practitioner deficient in ana- tomical knowledge, might imagine that a weapon, pushed from above downward into the front ofthe chest, could never reach the lungs, after having penetrated the cavity of the abdomen. It is a fact, however, that no instrument could pass in this direction, even some inches below' the highest part of the abdomen, without entering the chest. The whole cavity of the thorax is lined with a membrane named the pleura, which is every where adherent to the bones which form the parietes of this cavity, and to the diaphragm. Each side of the thorax has a distinct pleura. The two membranes meet in the middle ofthe chest, and extend from tiie sternum to the vertebra;. In this man- ner two cavities are formed, whicu u;ive th' sort of communication vv ith each other. By the two pleura?, touching and lying against each other, a middle partition is formed, called the mediastinum. These twe membranes are intimately adherent to each o(her, in front, (he w hole length of the ster- num ; but behind, where they approach the vertebrae, they separate from each other, so as to leave room for the aorta, i.ropha- gus, be. The heart, enclosed in the peri- cardium, occupies a considerable space ou the left ofthe mediastinum, and all the rest ofthe chest is filled with the lungs, except behind, where the large blood-vessels, nerves, thoracic duct, and oesophagus, are situated. In the perfectly healthy state,the lungs dc» not adhere to the pleura; but in the majority of subjects, at least in thin climate, who are examined after death, such adhesions are found iu a greater or lesser degree. The disease may probably be oc casioned by very slight inflammation ; and as the surface of the lungs is naturally des- tined (o be always iu close contact with the pleura, and patients arc frequently not sus- pected to have any thing wrong in the tho rax, this morbid change being often acci dentally discovered after death,in looking for something else ; it may be concluded, that it doft3 not produce any serious effects. The thorax is subject to all kinds of wounds ; but their importance particularly depends ou their depth. Those which do not reach beyond the integuments do not differ from common wounds, and. when properly treated, are seldom followed by any bad consequences. On the contrary, those which penetrate the cavity of the pleura, even by the slightest opening, may give rise to alarming symptoms. Lastly, wounds injuring any ofthe thoracic viscera, are always to be considered as placing tho patient in a state of considerable danger. From what has been said, it appears that wounds of the thorax are very properly di- visible into three kinds; viz. 1. such as affect only the skin and muscles ; 2. such as enter the cavity of the chest, but injure none of the viscera ; 3. others, which in jure the lungs, or some other viscus. Superficial Wounds of the Thorax.—Im mediately a surgeon is called to a recent wound of the chest, his first care should be to ascertain, whether the weapon has pene- trated the pleura or not. In order to form a judgment on this circumstance, surgical writers recommend, 1. Placing the wound- ed person in the same posture in which he was wheu he received the wound, and then carefully examining with a finger, or probe, the direction and depth ofthe stab. 2. Tho examination, if possible, of the weapon, so as to see how much of it is stained with blood. 3. The injection of fluid into the wound, and attention to whether it regur- gitates immediately, or lodges in the part. 4. The colour and quantity of the blood, discharged from tbe wound, are to be no- ticed, and whether any is coughed up. 5. We are to examine whether air escape8 UOUNDr 6b'o Irom the wound in res,uratiou, and whether there is any emphysema. 6. Lastly, the state of Ihe pulse and breathing must be considered. !n wounds of the chest, however, sur- geons should not be too officious with their probes, merely for the sake of gratifying their curiosity, or appearing to be doing something. No judicious" surge-on can doubt that authors have dwelt too much on the subject of probing wounds of the abdo- men and thorax ; for they would really lead their readers to believe, that, until the wound has been traced with the finger or probe, to its very bottom and termination, surgeons are not qualified to institute any mode of treatment. The only advantage of knowing that a wound penetrates tbe chest, is, that the practitioner immediately feels himself justified in having recourse to bleeding and other antiphlogistic means, with the view of preventing inflammation of the pleura and lungs, which affection, if not controlled in time, often proves fatal. However, there can be little doubt, that if the nature and depth ofthe wound cannot be readily detected with the eye. the finger, or a probe, or by the discharge of air, or I blood, it is much safer to bleed the patient than to put him to useless pain with the probe, and waste opportunities of doing good, which too frequently can never be recalled. In short, generally speaking, it is better, and more advantageous for all pa- tients, that some of them should lose blood, perhaps unnecessarily, than that any of them should die in consequence ofthe eva cuation being omitted or delayed. Almost all writers, who have taken pains to direct how wounds of (he thorax should be probed, conclude with remarking, that, however advantageous a knowledge of the direction and depth of the wound may be, much harm has frequently been done by pushing the attempts to gain such informa- tion too far. It is, perhaps, of greater im- portance to learn, by some kind of exami- nation, the extent of a wound, which does not reach beyond the integuments, or in- lercos(als, than to know whether the wound extends into the cavity of the chest. For, even w hen the pleura is found to be divided, if the wound be attended with no urgent symptoms, the information is of no practical use, if we make it a rule to adopt, without the least delay, a strict antiphlogistic plan of treatment, in all cases in which there is any doubt or chance of the parts within the chest being wounded, and likely to inflame. Besides, frequently, tbe symptoms are more urgent and alarming than they could be were only parts on the outside ofthe thorax injured ; and, under such circumstances, it is manifest that a probe cannot be neces- sary for discovering that the wound extends into the chest. W'ith respect to the injection of luke- warm water, or any other fluid, and the cir- cumstance of it's regurgitation, as a criterion of the wound being only superficial, the plan is more objectionable than the employ- ment of a probe ; tor, it the liquid be pro pelled with force, it may be injected into the cellular substance, and seem to be pass- ing through the track ofthe wound into the chest, while, in reality, not a drop does so. Besides, is it a warrantable proceeding to try to insinuate any quantity or kind of liquid whatever between the pleura and lungs, into a situation in which it must neces- sarily obstruct the important function of respiration, and cause serious inconve- nience ? When air issues from the wound in expira- tion, (here is ground for suspecting that the lungs are wounded. But I believe, that such authors as represent this circumstance as an infallible criterion ofthe nature ofthe accident, labour under a mistake ; for when there is simply an opening in the chest, with- out any injury of the lungs whatever, the same symptom may occur. The air, which is discharged through the wound in expira- tion, has previously entered the bag of the pleura through the same wound in inspira- tion. In order to remove all doubt, the pa- tient should be requested to expire,as strong- ly as he can, so as to force out whatever air may have accumulated in the Chest. At the end of each expiration of this kind, care must be taken to bring the skin closely over the orifice of the wound, and to keep it thus applied, during each following inspiration, for the purpose of preventing the external air from entering. In this way, if there be no wound of the lungs, all the air will soon be expelled; but if it still continues to be dis- charged in expiration, the lungs must be wounded. Sometimes, an emphysematous swelling takes place round wounds of the thorax, in consequence of a quantity of air diffusing it- self in the cellular substance. In wounds, which are straight and ample, this symptom is very uncommon ; but, in cases of narrow oblique stabs, and where the lungs are wounded by the points of broken ribs, it is by no means unfrequent. (See Emphysema.) When a considerable quantity of blood flows from the wound, there is reason for conjecturing, not only that the weapon has penetrated the cavity of the thorax, but that some of the thoracic viscera are injured. Excepting the intercostal arteries, which run along the lower edges of the ribs, and (he trunks of the thoracic arteries, all the other vessels, on the outside of the chest, are very inconsiderable The effects of com- pression will indicate, whether the blood escapes from an artery on the outside of the cavity of the pleura ; and sometimes, the situation and direction of a wound at once denotes, that the hemorrhage cannot pro- ceed from the trunks of the thoracic ar- teries. Even the appearance of the blood, which conies from the wound, may lead to some conjectures, concerning the depth of the injury. The blood, which flows from wounds of the lungs, is of a brighter scarlet colour, and more frothy, than ti*af. vhirh i" <'!- 6b4 WGLNDa. charged from the vesoeis of any other part. There can be no doubt of the lungs bein<» wounded, when the patient is observed to spit up blood ; but, the absence of (his symp- torn is no( a positive proof of (heir be'mer untouched, though unquestionably, a very important circumstance in the "diagnosis, and, generally speaking, a correct criterion of the lungs having escaped injury. At all events, when no blood is spit, or coughed up, the lungs can never be deeply pene- trated. The state of the pulse, and that of respira- tion ought to be particularly attended to by the practitioner. Neither one, nor the other, seems altered, at least at first, w hen wounds do not reach more deeply than the integu- ments; but those which penetrate the cavity of the thorax, and especially' such as injure the viscera, may frequently be distinguished, from the very first moment of their occur- rence, by their effects on the sanguiferous -ystem, and the function of respiration. When the lungs are wounded, at a point where they adhere to the pleura, no air can he effused in tbe thorax, and the functions of those organs may, on this account, suffer less disturbance than would be the conse- quence of an equal degree of injury at some other unadherent portion of the lungs. Experience proves, that when either air or blood insinuates itself between the lungs and the pleura, the lungs become immedi- ately oppressed, the* breathing is attended with great difficulty, the pulse is weak, con- 'ra. ted, and intermittent. Wounds of the integuments and muscles of the thorax, are not attended with any particular danger; they heal with the same readiness, and by the same means, as com- mon superficial wounds iu any of her part of the body. When the case is a punctured, or a gun- shot wound, some writers are advocates for laying open the track of the injury from one end to the other^if its course should not be too extensive, and they then recommend dressing the cavity down to its bottom. When the track of the wound was too exten- sive, a seton was sometimes introduced. The aim of such exploded practices vvas to prevent the outer part of the wound from healing too soon, and thus give time for (he whole of it to heal in an equal degree. When a seton was used, the thickness ofthe skein was gradually diminished, and, after the whole of it had been removed, a slight compression was kept up for a few days, with the view of completing the cure. The French surgeons have the discredit of having brought setons into fashion in this branch of surgery, and I am particularly glad, that a late writer has well exposed the absurdity of the practice. ** We find (says Mr. John Bell) the history of it to be plainly this : that as Guy de Chauliac, Pare, and atl the older surgeons, did not know how to dilate gunshot wounds, they found these same setons useful in bringing the eschar -ooner away, and in preserving an open wound ; and, as they believed the v.-juijus Lo he poisoned, they took the opportunity of conducting, by these setons, whatever acrid medicines might, according to the prevailing doctrines of that time, have any chance ot correcting the poison." Mr. J. Bell notices, how surprising it is to see the cruelty, aud per- severance, with which some modern prac- titioners, particularly French, draw these cords through wounded limbs; and when the roughness of such a cord, or the acri- mony ofthe drugs conveyed hy it, produces a copious suppuration, these men are de- lighted with such proofs of their success The setons have been introduced by (he French surgeons, across the thickest parts of (he limbs, along the whole length of the fore-arm, and, at (he same time, frequently through the wrist-joint. The setons have also been covered witb stimulating applica- tions. Profuse suppurations, and dreadful swellings of course ensued; still, as Mr. J. Bell has remarked, these cruelties were con- tinued, till the wound healed almost in spite of (he pain ; or (ill the coming on of very dreadful pain, great suppurations, convul- sions, &c. made the surgeon discontinue the method, or even amputate the limb. The French have become so familiarized to setons, that they do not restrict their use to flesh wounds, they pass them quite across the thorax, across the abdomen, and even through wounds of the knee-joint. When we wish to excite inflammation, in the cavity of the tunica vaginalis, for the purpose of radically curing a hydro- cele, we either pass a seton through the part; lay it open with an extensive inci- sion ; cram a tent into it; or inject some irritating fluid into it. While the animal machine continues the same, says Mr. John Bell, the same stimuli will produce the same effects, and a seton, injection, or long tent, if they produce pain and inflammation in the scrotum, will not be easy in the chest; and, unless we can use them in the chest, with the same intentions with which we use them in the hydrocele, (in other words) un- less we are justified in inflaming the chest, and causing an adhesion of all the parts, we cannot use them with any consistency or good sense. With regard to the cases which the French.adduce in confirmation of the good effects of their plans, I am entirely of opinion with Mr. J. Bell, that the facts only prove, that the patients recovered in spile of the setons. " It is like (adds this author) what happened to a surgeon, who was dab- bing in the thorax with a piece of caustic which fell directly into the cavity of the chest, where it caused very large suppura- tions, and yet the patient was saved. The patient recovered, in spile of the caustic, jusl as M. Guerin's patient, and many other poor unhappy souls, who lived in spite of the setons. One would think, that people took a pleasure in passing setons across the eyeball, the chest, the knee-joint, be. merely to make fools stare, when the busi- UNDS Guu aciS might be u.3 effectually done wilh -in abscess lancet." Mr. John Bell, in his usual lively style, makes the employment of tents, in wounds of the chest, seem equally ridiculous and improper. Indeed, he says, he knows of no occasion in all surgery/in which tents can be useful, except in the single one of a narrow opening, which we desire to dilate, in order to get at the bottom of the wound; and where cither, on account of some great artery, or the fearful temper of our patient, we dare not use the knife. (See J. Bell on Wounds. Dis- course 2, Vol. 2.) Having hitherto been engaged, rather in pointing out what ought not to be done, than what ought, I shall next make some re- marks on the line of conduct, which should be adopted, in cases of wounds of the pa- rietes of tbe chest. When the wound is a common cut, the sides of the division are to be brought into contact, and maintained in this position with strips of adhesive plaster, compresses, and a bandage, until they have grown toge- ther. If the surgeon take care to relax such muscles as happen to be cut, or to be situated immediately under the wound ofthe integu- ments, there will rarely be any need of sutures. As cut wounds seldom or never penetrate *.he chest, and there is generally no reason why they should not unite by the first inten- tion, without being followed by extensive inflammation and abscesses, antiphlogistic means should be employed with moderation. Bleeding will not often be requisite. The grand objects arc, to keep the patient in a quiet state, on rather a low diet, and to hin- der him from taking wine, porter, spirits, or any other stimulating beverages. If the wound, instead of healing favoura- bly, should inflame, the treament should be regulated by the principles laid down in the article Inflammation. If it suppurate over its whole surface, but without a great deal of surrounding swelling and inflammation, one or two strips of sticking-plaster, may still be used with advantage ; for, in this way, the cavity, which must now be filled up by gra- nulations, will be rendered much smaller than it otherwise would be. Some very soft lint may be laid in the cavity of the wound, which the sticking-plaster does not entirely remove, and over the whole a pledget of some mild, unirritating ointment. No pres- sure is now proper, until the inflammation diminishes; and if the discharge riiould be profuse, or the surrounding inflammation considerable, the best application would be an emollient poultice. In this state of things, the patient should also be bled, and leeches be applied near the inflamed parts. When the case is a stab, or punctured wound, the fibres of the divided parts are not simply cut, they are also considerably stretched, bruised, and otherwise injured. Hence, generally they will not admit of being united so readily, as the sides of a clean incision, made with a sharp instru- ment. However, the possibility of uniting (be opposite sides of punciureu wounds mus! depend very much on the shape of the weapon, and the suddenness, roughness, and v iolence, with which it was driven into the part. A prick wilh a needle is a punctured wound ; so is that often made by surgeons with their lancets ; yet, these injuries do not frequently bring on violent inflammation and abscesses, as other wounds Irequentiy do, which are inflicted with bayonets, and pikes. Let us suppose a man to have received a thrust of a bayonet, which has run into the skin and muscles, covering one side of the thorax: what plan can the surgeon follow, with the greatest advantage to his patient ? Instead of laying open the whole track of such a wound with a knife, as is barbarously recommended in many of the principal works on surgery; instead of drawing a seton through its whole course, or of cram- ming into the part a hard, irritating tent; the practitioner should take whatever chance there may be of uniting the wound without suppuration. For this purpose, he should recollect (hat the great degree of violence done to the parts in punc(ured wounds is the reason why they are so apt to inflame and suppurate. Hence the expected inflam- mation is to be counteracted in the very first instance ; and immediately the wound is dressed, the patient should be freely bled, and take some saline purgative medicines. With regard to the dressings, the orifice of the wound may be lightly closed with sticking- plaster, or covered .vith any mild superficial applications. Over and around these, the surgeon may apply linen, kept continually wet with cold water, or the liquor plumbi acetatis dilutus. As, however, many pa- tients have a strong dislike to cold applica- tions to any wounds upon their bodies, it is often necessary to dispense with this prac- tice. The dressings are to be retained with a roller; but it is not to he tight, as pressure is more likely to do harm, than good. Thus the inflammation of the wound will be moderated ; the extravasa- tion of blood prevented; the chance of union by the first intention taken ; and all painful operations avoided. And, nothing is more certain than the fact, that, if antiphlogistic means be strictly employed, many stSbs heal without abscesses, or any very severe symp- toms, when no hope could be entertained of their doing so under other treatment. But, if suppuration should happen, and a col- lection of matter take place, would the patient suffer more, or be put into greater danger, by having a proper depending opening, of just sufficient size, now made into the abscess in an eligible place, than if he had submitted to bave the formidable operation of laying open the whole extent of a stab, performed in the first instance ? In short, will he sutler half so much, be half so long in getting well, or have to encounter half the danger ? With all this advantage, he will have taken a certain chance, which attends all these case", if the wound be u.>o WOLN In- coming united by whal is called the first intention, that is to say, without any suppu- ration. I need not enlarge upon this subject, but refer the reader to what lias been ad van- tage vvbicb he partly ascribes to the seton, the pain of drawing which across the chest deadened every lesser pain, and, consequent- ly, tbe patient could not feel the trifling pricking of the bone, (ill his greater suffer- ings from (he seton were allayed. '* in short, (says Mr. John Bell,) M. Guerin passes a a great strap of coarse linen across the cavi- ty of the chest, and when it causes inflam- mation, he thinks to subdue it by bleeding ; when M. Guerin continued for thirty days drawing a coarse selon through the breast every morning, and bleeding for the cough every night, what did he do bul raise inflam- mation with his left band, to show how welt he could cure it with his right ?" (See John Bell on Wounds, Vol. 2, p. 36—38.) The liability of wounds of the chest to be complicated with the lodgement of foreign bodies, is a circumstance of which the prac- titioner should ever be mindful. " In the examinations of the bodies of soldiers who have died from these injuries, (says Dr Hennen,) I have frequently found pieces of wadding or clothes, spiculae of bone, und balls, and, in one case, some charpie used as a dressing ; either loose in various parts of the lungs, or lying in sacs, which the exer- tions of the constitution to free itself had thrown round them by tbe medium of the coagulating lymph. In the more fortunate few who have recovered, these matters have been discharged from the wounds, or ex- tracted from them by the surgeon. In some lucky case3, (bey have been ejected by the convulsive efforts to cough, which their irri- tation has occasioned." (On Military Sur- gery, Ed. 2, p. 367.) For an account of Ihe dexterity with which Larrey has sometimes traced balls in the chest, rtnd extracted them by bold operations, I must refer to his valua- ble writings. (See Mem.de Chir. Mil. T. 4,p. 250, fyc.) Balls have sometimes lodged anil remained encysted in tbe lungs for upwards of twenty years, wilhout the health being at all disturbed by iheir presence. (See Percy, Manuel, fyc p. 125; Boyer, Traiti des Mai. Chir. T. 7, p. 310, fyc.) j 2. When one ofthe intercostal arteries is wounded by a narrow oblique stab, the ac- cident canuot at first be known. In this case, the blood commonly makes ifs way 65S woun ns into the cavity of the chest, where it causes a more or less considerable extravasation. But when the wound is ample, and direct, the effused blood, which has all the charac- ters of arterial blood, leaves no doubt con- cerning the injury of an intercostal artery. However, if any uncertainty prevail, it may easily be dispelled, by introducing a finger into the wound, and making pressure with it on the lower edge of the rib, which cor- responds to the vessel suspected to be in- jured. Gerard proposed to stop hemorrhage from the intercostal artery, by means of a liga- ture. His plan was to enlarge the external wound, as far as the upper edge of the rib, corresponding to the wounded intercostal artery, and then to introduce into the chest a common curved needle, armed with a ligature, to which was attached a dossil of lint. The needle was passed behind the rib, rather higher than the superior edge of tbe bone. The point ofthe instrument was then pushed from within outward, and brought out through the external wound, together with the ligature. When the dossil had come into contact with the artery, the two ends of the ligature were tied over a thick compress, placed ou the outside of the rib. In this man ner, the bone was sur- rounded with (he ligature, and the artery compressed. Goulard, of Montpelier, having found dif- ficulty in passing a common needle, whose shape little corresponded to the track, through which it bad to pass, being curved towards its point, and straight towards the eye, invented one expressly for this opera- tion. He also objected to the common bent needles, as he conceived tbat they might wound the lungs with their sharp points and edges. Goulard's needb; formed three-fourths of a circle, and was fixed on a long handle, which facilitated its introduc- tion. The eye, in which the ligature was put, was situated near the point, which was a little blunted, and the ligature lay in a groove, in the convexity ofthe instrument. When the needle had passed through the intercostal muscles, and its point had made its appearance over the rib, which was above the artery, the ligature was untied, and held, while the needle was withdrawn at the place where it had entered. The ji_-ature was then tied, as in Gerard's me- thod. It was afterward thought, that com- pression mi^ht answer better than the fore- going use of tbe ligature. Lottery, professor of anatomy in the university of Turin, con- structed, for this purpose, a steel plate, which is described, and engraved in the second volume, 4to. of the Memoires de I'Acad. de Chir. This plate was narrow at «ne end; broad at the other ; and curved in two directions at its narrow part, where there were some holes, by means of which a compress for the artery was fastened on the instrument. The broad end of the plate had ""vo long parallel slits, through which a riband was passed, with which the instru- ment was secured. When the wound,, corresponding to the intercostal artery, was sufficiently extensive in the transverse direction, the narrow, bent end of the instrument was so introduced, that the lower edge of the rib above was placed in the concavity of the curvature, while the compress acted on the edge of the bone, and, of course, on the artery. The rest of the instrument applied itself to tbe side of the thorax, in which situation it was fastened. When the wound was not ample enough, a sufficient dilatation of i( was first made for (he introduction of the instrument. Quesnay employed a piece of ivory, which he covered with lint, be. and then intro- duced within the chest. The instrument was then drawn from within outward, by means of a riband, and thus the necessary compression vvas produced. Quesnay's plan is somewhat like that in- vented by L6ttery. But, to have introduced the compress entirely into the thorax, to- gether with the ivory, which was the basis of it, and then to have drawn the contri- vance from within outward, as vvas probably intended, a very large wound would have been indispensable. This was also one of the many strong objections to Lottery's instrument, which, in fact, could only be employed when there was a free and ample opening. Belloque, seeing the inetficacy of all the compressing means used before his lime, and their inconveniences, invented an in- strument, which, he says, is calculated for making proper pressure and following the motion of (he ribs, without hindering the escape of extnivasatcd blood. The machine is engraved, and described, in 2 T. of Mem. de I'Acad. de Chir. 4to. It is composed of two plates, which are wadded, and capable of being brought towards each other by means of a screw. This instrument, as Sa- batier observes, may indeed answer; but it is complicated and awkward, and its utility is founded on the supposition ofthe wound being larger, than wounds are, which are made with common weapons. Justly averse to any unnecessary multi- plication of surgical instruments, modern practitioners reject all particular contrivan- ces for stopping hemorrhage from the inter- costal arteries. Indeed, as the accident is very rare, it is probable, that, if the best in- strument possible were devised, it would hardly ever be at hand, when required. A common dossil of lint (says Sabatier,) fastened to a strong ligature, and introduced between the two ribs, or even quite into the chest, and then drawn, from within out- ward, like Quesnay's compress, would fulfil every desirable purpose. The external wound should then be covered with simple dressings, and a bandage applied round the body. The patient should be freely and repeatedly bled, and treated on the most rigorous antiphlogistic plan. Professor Assalini joins all the best mo, WOUNDS. 039 oern surgeons in reprobating the introduc- tion of the preceding contrivances and ex- traneous substances into tbe chest, in order to stop hemorrhage from the intercostal ar- tery. All these methods, he remarks, are calculated to excite a dangerous degree of inflammation in the chest. Hence he pre- fers simply cutting the artery across, so as to allow it to retract, and if this plan fail, he recommends the wound to be closed. Should the blood find its way into the chest, it is true, the consequences will be serious, but not fatal; and, if the symptoms require it, the operation of empyema may after- ward be done. A small quantity of effused blood, however, may be absorbed, and no such proceeding be requisite. (Manuale di Chirurgia, p. 58, 59.) Dr. Hennen conceives, that whenever the tenaculum can be used for an injured inter- costal artery, the practice should be adopted. He states, that cases are reported in which the vessel was thus secured ; but that he has never seen the method adopted himself. " Unfortunately, (says he) we but too often are disappointed in finding the source ofthe hemorrhage, and here judicious pressure is our only resource. In some very slight cases, I have used the graduated compress with success; but if the sloughing is exten- sive, nothing but the finger of an assistant, relieved as often as occasion may require, and pressure direct upon a compress placed along the course of the vessel, or so dispo- sed as to operate upon its bleeding orifice, will be of any avail. (Military Surgery, Ed. 2, p. 377.) 3. The protrusion of a portion of the lungs, in consequence of wounds penetra- ting the ehest, is a very unusual case : but there are some instances recorded by wri- ters : and one case I attended myself after the battle of Waterloo. Schenckius relates an example, taken from Rolandus. The latter was called to a man, who had been wounded in the thorax, six days before. A portion of the lungs protruded in a state of mortification. Rolandus extirpated it, and the patient soon recovered. Tulpius has recorded a similar fact. A man received an extensive wound, just be- low his left nipple. His naturally gay dis- position, however, led him to neglect the injury; and on the third day a piece of the lungs, three inches in length, protruded. The patient went to Amsterdam, whence he was distant two days' journey, for the pur- pose of receiving succour in one of the hos- pitals of that city. The protruded piece of lung, which was already mortifying, was tied, and cut off with scissors. It weighed three ounces. The wound healed in a fort- night, and the patient experienced no com- plaint afterward, except a slight cough, with which he was occasionally troubled. He survived the accident six years, leading a wandering, drunken life. After death, no- thing particular was observed in the thorax, except that the lungs had become adherent to the pleura, in the situation of the wound. Hildanus relates another case : a man was wounded with a knife, belu-een the fifth and sixth ribs, near the sternum. As apiece of lung protruded through the opening, and had a livid colour, it vvas extirpated with the actual cautery. The wound vvas then dilated, and the ribs kept apart, with a wooden wedge, under which plan, (he por- tion of lung, girt by the opening, shrunk within the chest. The patient was soon completely well. A fourth example of a protrusion of a piece of lung through a wound in the tho- rax, is among the cases recorded by Ruysch. The servant of a seafaring man was wound- ed in the anterior and inferior part of the chest, and was immediately attended by a surgeon, who mistook the protruded piece of lung for a portion of omentum, and ap- plied a tight ligature round it. Ruysch, who was consulted, soon detected the mistake which had been made, but he delivered his opinion, that the wound would heal very- well, as soon as the tied piece of lung was detached. The event justified his prognosis, and Ihe patient recovered. When the protruded portion of lung is sound, the reduction ought to be made without the least delay. It should be done on the same principles as those on which protruded pieces of intestine, or omentum, are reduced. (See Wounds of the Abdomen.) A recurrence of the accident is to be pre- vented by closing the wound, and placing a compress over it. But when the piece of lung is already in a mortified state, in con- sequence of the constriction which it has suffered, or when its large size prevents re duction, Sabatier is of opinion, that the only resource is to extirpate the part, after apply- ing a ligature round its base. If the latter step were not taken, a dangerous hemor- rhage might follow, or even au extravasa- tion in the thorax. (Midecine Opiraloire, Tom. 2, p. 224.) However, the practice recommended by Sabatier appears ques- tionable in the instance of mortification, be- cause the dead part will naturally be thrown off by a spontaneous process; and when the wound is too small to allow the part to be returned, its dilatation might be more adviseable than the removal of a consider- able portion, or even any, of the lung. After the battle of Waterloo, I had a pa- tient with a protrusion of a piece of lung, four or five inches in length. The part waa much bruised, and could not be easily re- duced. I therefore applied a ligature round its base, and cut it off. Previously, how- ever, I made an incision in i(, in order to ascertain whether it would bleed freely, which being the case, induced me to use a ligature. I was afterward informed by my friend Mr. Collier, that the man died. 4. Emphysema is another symptom with which penetrating wounds of the chest are frequently complicated, especially when they are small, and indirect. When such wounds are small, and not straight in their course ; wheu their track is rendered im- pervious either by change in the situation of the muscles, the swelling of the parts, 660 WolADs clots of blood, or any extraneous substan- ces ; air may insinuate itself into the cellu- lar substance, so as to cause a great deal of tumour and distention. Emphysema is easily distinguishable by the tumefaction of the part affected, without any pain, or change of colour in the skin, and by the crepitation which is perceptible on pressing the air from one part of the cellular sub- stance into another. Emphysema may take place, where the lungs are not wounded, but in this case it can never be of much ex- tent. Here the emphysematous swelling is caused by the air, which insinuates itself into the cavity of the thorax through the wound, during the first inspirations which follow the accident, and the same air is expelled in the subsequent acts of expira- tion. But when the lungs are wounded, the emphysema arises from the escape of air from those organs, during inspiration, first into the cavity of the thorax, and thence, through the inner opening of tbe external wound, into tbe cellular substance. I should bave deemed it unnecessary to have said any thing in this part of the work, on the present subject, and have contented myself with referring to the article Emphy- sema, were nol the cause of this symptom rather perplexing, and did I not hope that Ihe following extract from Sir A. Halliday's publication will (end to facilitate the com- prehension of these cases. This gentleman mentions (he following circumstances, under which air may escape from the lungs, or emphysema arise. ls(. " An injury or disease of tbe pleura pulmonalis, causing a wound or ulceration of that membrane, and thus allowing the air to escape from the lungs, as in oblique ex- ternal wounds, where the outer opening, and that of the pleura costalis have healed, or closed up, and in ulcers of the surface of the lungs. 2dty. "The pleura pulmonalis, and pleura costalis, may be wounded or ulcerated when there is no external opening, as when the ends of fractured ribs penetrate through both into the substance of the lungs; and it is from this accident, &.c. tbat emphysema most commonly takes place. 3dly. "The common integuments of the parietes ofthe chest, the intercostal muscles, and the pleura costalis may be wounded, while the plura pulmonalis and the lungs remain uninjured, so that the air admitted from without, and collected in the cavity of the (horax, may be pressed into the cellular membrane, so as to occasion emphysema." The same writer remarks, •■*• that the lungs in tbe thorax have often, and not unaptly, been compared to a bladder in a close pair of bellows; bul if we suppose Ibe bellows to be divided into (wo compartments, and each of these to contain a bladder, which mutually communicate with each other, and with the external air, by means of a tube which is exactly adapted to tbe nozzle of the bellows, and which admits the air only into the cavity of the bladders, and not into the ^pace betwixt the bladders and bellows, we shall then have a perfect representation of the mechanical structure of the thorax The bellows will represent the thorax, divi ded in the middle by the mediastinum ; (he bladders will represent the lungs of tbe right and left sides; and the tube, which com- municates wilh the bladders and with Ihe external air, wili represent the trachea. The only thing which is wanting to render this mechanical representation perfect, is, that Ibe bladders should exactly fill (he bellow*, so as to leave no air betwixt them and the bellows." It is explained by Sir A. Halliday, (hat when the handle of the bellows is lifted up, the bladders become filled by the external air, which rushes in through the (ube which communicates witb both of them. When the handle is depressed, the air is expelled again. Iu the like manner tbe lungs are filled with air, and emptied again when the capacity of (he chest is enlarged by the inspiratory mus- cles, and then diminished by the expiratory ones. When emphysema nrises from a wound, or ulceration of (he pleura pulmonalis, on one side of the thorax, the case is nearly Ihc same as if an opening were made in one of (he bladders, which opening would form a communication, as tbe same gentleman ob- serves, with the bellows and bladder on one side. If this should happen while the handle of the bellows is depressed, no sooner is the handle raised, than air rushes into the space betwixi the bladder and bellows, and on keeping up (he handle a little while, the bladder will become quite collapsed, and (be place which it occupied, while distended, will now be occupied by the air. If now, says Sir A. Ifolliday, " we attempt to force out the air, by depressing the handle of the bellows, we shall find tbat (his cannot be done ; for there is no direct communication between the bellows and the external air; and as the effused air presses equally on all parts of (he collapsed bladder, it cannot es- cape through it." When (be thorax is expanded in inspira- tion, the pressure is taken off the surface of the wounded lung, and Ihe air which now enters this organ, instead of distending its cells, passes through its wound into the space between the pleura pulmonalis, and pleura costalis. The lung will, indeed, be partially expanded, as long as inspiration on that side goes on ; tbe more so, Ihe smaller its wound is. Al every expiiation, however, when the thorax is diminished, the effused air will be compressed against the wounded lung; but none of the air which has escaped can re-enter the lung again ; " because (as the preceding writer accurately remarks) tbe whole of (he air contained in tbe lung, must be forced out, and then the pressure (of (he air) against every pari of (he collapsed lung being equal, will prevent its separating any part, so as to make a passage, for itself into tbe trachea." Thus fiesb air accumulates at every inspiration in (he space between (he pleurae, while none can escape from the same situation during expiration, and the quantity WOUNDS 661 •accumulated will, at last, equal that which is received into (he other lung, during the most powerful inspiration. When the pleura pulmonalis, and pleura costalis are both wounded, the. same effusion of air between them continues from the above-mentioned causes, till the lung collap ses. When an attempt is now made to ex- pire, the injured side of the thorax must con- tinue distended, notwithstanding every el- fort of the patient. In this expiratory act, however, if the capacity of the thorax be diminished, and the air compressed, a part of it finds its way through the wound in the pleura costalis, into the common cellular substance of the parietes of the chest. The passage of air into the cavity of the thorax during (he inspiration is, as Sir A. Halliday observes, now more easy than the return of (hat aliendy effused in (he cellular membrane, and consequently, the subcuta neous emphysema continues to increase with a rapidity which is remarkable, as long as tbe putii-nl lives. To explain ihe origin of emphysema, in cases of wounds, which only enter Ibe chest, and do not injure the lungs ai alj, this writer has recourse to Ihe simile ot the bellows and bladders. Were an opening made into the bellows, without injuring ihe contained bladders, and Ihe access of air by this open- ing more free than thn/. WOl'M)-. matter -<•> situ.-ncil, and the caviiy of the abdomen, the abscess after a time mostly points 'Ntcrnally. The proper treatment of this case is to prevent the surprising accumulation of mat- ter, and rapid increase of mischief, by- making a depending opening, sometimes at (he very lowest part of the sheath of the rectus muscle, and this, as soon as the lodge- ment of matter is clearly ascertained. If ever there be a case- in which it is ad- vantageous and justifiable to make an early dilatation of a punctured wound, in order (o prevent the above-described ill conse- quences, il is unquestionably the present one. Such practice, indeed, is particularly recommended by Callisen, in addition to the strictest antiphlogistic means. (See Syst. Chir. Hodierna, Vol. 1, p. 698, edit. 1798.) Sometimes (he matter is formed between the external and internal oblique muscles, and spreads to a great extent. The pus may even insinuate itself into ihe abdomen, and the case end fatally. Such an example is recorded by Dr. Crowther, of Wakefield. In (his ins(ance, however, the disease pro- ceeded from a contusion, not a wound. (See Edinb. Mid. and Surgical Journal,Vot. 2, p. 129.) Superficial wounds of the abdomen arc to be treated on the same principles as simi- lar wounds in other situations. The indica- tions are to prevent inflammation as much as possible, and, if suppuration should be inevitable, to let out the matter by a de- pending opening as soon as the abscess ^ known to exist. The inflammation is to be checked by general and topical bleeding, low diet, emollient clysters, diluent beve- rages, quietude, opening medicines, cold applications, or fomentations and poultices, and the mildt-st and most simple dressings. (See Inflammation.) Whenever the abdominal muscles are wounded, they should be relaxed, and the patient kept quiet in bed. A very impor- tant point in the treatment of wounds of the parietes of the abdomen, is to afford a degree of support to the wounded parts, so that the pressure of the viscera may be re- sisted. The sides of the abdomen are almost wholly composed of soft parts, which'easily yield. Pro part of (he front, or sides of the abdomen, is supported by a bony structure, and as tlie viscera are for the most part, more or less moveable, and closely com- pressed by the abdominal muscles, and dia- phragm, they are liable to protrude, when- ever the resistance of the containing parts i3 not sufficiently powerful. Hence all wounds of the abdomen, especially those, in which both the integuments and muscles have been cut, demand strict attention to the precau- tion of supporting the wounded part, and this, though the peritoneum itself should not happen to be divided. The patient ought to keep as much as possible in a horizontal position, and suitable compresses and bandages should be applied. And, in order to guard against berniae, the parts should be supported, iu this way, n con.*-: dnrable time after the wound is healed. 'J heprritoneumbeingconnectcd by mean*< of cellular substance* with the inner surface of the abdominal muscles, there is bIwhv some risk of the inflammation of these parts extending to^that membrane. The danger must be averted by ihe rigorous em- ployment of antiphlogistic treatment. What renders the event still more dangerous, is, that when one point of the peritoneum is* affected, the inflammation usually sprends with immense rapidity over iN whole ex- tent, and too often proves fatal. As superficial wounds of the abdomen are to be treated on the general principles, ap- plicable to all resembling wounds in other situations, it is hardly necessary to state, that union by the first intention, if possible, is always to be attempted. Of Wounrls penetrating the Cavity of the Abdomen—The first thing which the surgeon is generally anxious to know, when he is called to a wound of the belly is, whether the wound penetrates the cavily of (he ab- domen, and whether any of the viscera arc injured. When the wound is extensive, and the bowels protrude, the first part of the ques- tion is jf once decided. But when the wonndJs narrow, and the viscera do not protryfle, it is more difficnK (o know, whe- (her the cavity of the abdomen is penetra- ted or not. An opinion, however, may be formed, by carefully examining the wound with a finger or a probe ; by observing, if possible, how much of the weapon is stain- ed with blood ; considering the direction in which it was pushed ; the quantity of blood lost, the state of the pulse, and whether any bile, feces, or other fluids, known to be na- turally contained in some of the abdominal viscera, have been discharged from the ori- fice of the injury. When the wound is sufficiently large to admit the finger, a surgeon can always learn, whether the injury extends into the abdo- men, because the smooth lining of that cavity, and the contained bowels, may be easily felt. There is onc%chance of decep- tion, however, arising from the possibility of mistaking the inside of the sheath of the rectus muscle for the cavity of the perito- neum ; and when the examination is made with a probe, particular caution should be used in forming a judgment of the nature of the case ; for the parts are so soft and yield- ing, that a very little force will make tbe instrument pass a considerable way inward. Every examination of this hind should always be undertaken, if possible, when the patient is exactly in the same position, in which he was at the time of receiving the wound. Formerly, injections were some- times employed as tests of the penetration of the cavity of Ine abdomen. This absurd experiment is now very rightly exploded. It is well known to the moderns, that the space, termed the cavity of the abdomen, i.», in fact, completely filled with the various viscera, and that in general, an injected UOLMJS. 667 fluid would not so easily find its way into ihe bag of the peritoneum, as an unreflect- ing person might suppose. And if it vvere propelled with much force, it would be quite as likely to insinuate itself into the cellular substance of the parietes of the abdomen, or perhaps, into the sheath of the rectus muscle. The least tortuoshy of the wound, or a piece of bowel, or omentum, lying against the internal orifice of the injury, would also completely prevent an injection from passing into the abdomen. When a considerable quantity of blood issues from a wound of the abdomen, we may pronounce, almost with certainty, that some large vessel, within its cavity, is inju- red. Excepting^he epigastric artery, which runs on the forepart of the abdomen, along the inner surface of the rectus muscle, no large vessel is distributed to the muscles and integuments. At the same time, it is deserving of particular notice, that a large artery may be opened in the abdomen, and not a drop of blood be discharged from the wound. In such cases, the consequent symptoms quickly lead to a suspicion of what has hap- pened. The patient complains of extreme debility and faintness; his pulse falters; he has cold sweats; and if the bleeding should not speedily cease, these symptoms are soon followed by. death. Sometimes, the extension of the wound into the cavity of- the abdomen, is from the first quite manifest, being indicated by (he escape of chyle, bilious matter, feces, or other fluids. The vomiting up of a consi- derable quantily of blood, or its discharge by stool, affords also the same information. The urine however, may flow from a wound, which does not actually penetrate the abdo- men, for the kidneys, ureter, and bladder may be said to be out of the abdomen, be- cause tbey are really on the outside of the cavity of the peritoneum. When none ofthe above symptoms occur; whea neither the finger nor probe can be introduced; when none of the fluids, known to be contained in the various receptacles in tbe abdomen, are discharged from ths wound; when the pulse remains natural, and the pain is uot excessive ; there is rea- son to hope, that the wound has not injured parts of greater consequence, than the in- teguments and muscles. (Encyclopidie Mithodique, Partie Chir. Art. Abdomen.) I have now taken a survey of the criteria,- commonly noticed by writers, for the pur- pose of enabling surgeons to discriminate a wound, which penetrates the abdomen, from one which is more superficial. My next duty is to warn the practitioner, that too much solicitude to determine this point, is very frequently productive of serious harm. It may be set down, as an axiom in surgery, that in general, whenever the probing of a wound is not rendered absolutely neces- sary by some particular object in view, it may be judiciously omitted. A narrow, oblique wound may enter the cavity of the abdo- men, without there being any particular method of ascertaining, whether it has done so, or not. However, this want of positive information is of no practical importance ; for, when there are no urgent symptoms, evincing the nature of the case, the treat- ment ought obviously to resemble that of a simple wound ; and whether the wound be deep, or superficial, antiphlogistic remedies are indicated. The edges of a wound, penetrating the abdomen, but unattended wilh injury of the viscera, are to be brought together wilh sticking-plaster, in the same way as common wounds. Sutures are not generally neces- sary. Numerous cases may be found in the records'of surgery, proving that wounds of the abdomen may be easily united without sutures, provided the surgeon take care to avail himself of the assistance, which may be derived from a suitable position and a proper bandage. But such cases are less decisive, than relations of the Cesarean operation, the extensive wound of which admits of being healed by the same simple means. It is not my intention to assert, that in the majority of these examples, sutures were altogether dispensed with; but, the ligatures frequently cut their way through the skill and muscles, and the ap- plication of others was impossible, either on account of the particular state of the case, or the patient's aversion to them. Still the union of such wounds vvas accomplish- ed. A bandage, made on the same plan, as (hat with eighteen tails, would be extremely convenient for longitudinal wounds of the abdomen. (See Pibrac in Mim. de I'Acad. de Chir. T. 3,4to.) In the treatment of wounds of the abdo- men, sutures may generafly be relinquished, not only without harm, but with benefit; for their employ mentis sometimes the cause of bad symptoms. In one instance, the hic- cough and vomiting could not be appeased by any remedy which vvas tried. On the fourth day, the wound was inflamed and painful, and it vvas judged proper to cut away two sutures, and employ only simple dressings, with the view of diminishing the pain and swelling. The symptoms quickly abated, and in a week, were entirely cured, the wound healing up very well. (Op. cit.) However, there are circumstances, iu which it would be impossible to dispense with sutures. If, for instance, the belly were torn open from one side to the other with a bullock's horn ; or if it were exten- sively divided with the tusks of a wild boar, a stag's horn, a razor, be. and the inflated intestine could not be kept from protru- ding ; some stitches would be absolutely necessary, but even then, they should be as few as possible. (Sabatier, Midecine Opira- loire, T. 1, p. 214, edit. 2.) " Our good old surgeon Wiseman (observes Mr. John Bell) has said with great simplici- ty, as a great many have said after him, ' it frequently happeneth, that a sword passeth through the body, without wounding any considerable part.' He means,that a rapier, or ball, often passes quite aciOi.- the belly, 61'-- UulMJa in at the navel, anu out at foe back, and that surrounding parts would uave been required wilhout one bad sign, the patient recover?, for an outlet; and if the internal surface of and as has very often happened, walks the irritated bowel had tended to form ad- abroadin good health, in eight days; which hesions, the canal would have been in con- speedy cure has been supposed to imply a ' stant danger of obliteration." (Travers on simple wound, in which all the bow-els have Injuries of the Intestines, fyc. p. 10.) escaped. But we see now, how this is to be That collections of matter, however, do explained ; for we know, that in a thrust sometimes take place in the cavity of the across the abdomen, six turns of intestine abdomen, in consequence of wounds, is a may be wounded,—each wound may ad- fact, of which there are too many proofs on here; adhesion, we know, is begun in a record for the possibility of the case to be few hours, and is perfected in a few days ; doubted. At this moment, be it sufficient to and when it is perfect, all danger of inflam- refer to two examples of the occurrence, as mation is over; and when the danger of in- related by Mr. B. Bell. (System of Surgery, flammation is over, the patient may walk Vol. 5, p. 256.) abroad; so that we may do, just *as old If the abscess were in any other part of Wiseman did in the case here' alluded to, the body, and did not rcVlily point, the (P. 98, the case of a man, who was wound- wisest practice would undoubtedly be to cd across the belly, and well and abroad in make an opening sufficient for the evacua- seven days,) ' Bleed him, and advise him to tion of tbe matter. But suppuration in the keep his bed and be quiet.' In short, a man, abdomen can seldom be known with cer- thus wounded, if he be kept low, has his tainty in an early stage of the case : for the chance of escaping by an adhesion of the abscess is so deep, tbat no fluctuation, nor internal wounds." (Discourses on the Nature swelling, is perceptible, until the quantity and Cure of Wounds, p. 329, 330, edit. 3.) - of pus is considerable. Nor would it bo The truth of these observations is well judicious to expose the patient to the hazard, illustrated in a case mentioned by Dr. Hen- which might arise from making an opening nen, in which a soldier recovered, whose into the abdomen, merely for the sake of abdomen was pierced with a ramrod, which discharging a small quantity of matter. stuck so fast in the vertebra?, that some Many writers impute much of the danger force vvas required to disengage it. (On of wounds of the abdomen to the entrance Military Surgery, p. 402, ed. 2.) of air into the cavity of the peritoneum. When a man is stabbed or shot in the belly, In inculcating such opinions, hovvever, they and none of the bowels protrude, the wisest betray an inaccuracy of observation, which plan is to keep the patient as quiet as possible, a very little reflection would have set right. have recourse to copious and repeated bleed- Too much stress has long been laid on the ing, prescribe anodynes, and the lowest fluid introduction of air into the abdomen, as diet, and apply light superficial unirritating being a cause of inflammation. The fact dressings. In the event of severe pain and is, the cavity of the belly is always so cora- sWelling ofthe belly coming on, leeches, pletely occupied by the several viscera, that fomentations, the warm bath, and emollient the whole inner surface of the peritoneum poultices, will be necessary, and nothing is invariably in close contact witb them, will now avail, except the most rigorous and therefore, air cannot easily diffuse itself employment of antiphlogistic remedies. As from the wound, throughout the abdomen. Dr. Hennen observes, the best means of After tapping, in dropsical cases, inflamma- emptying the bowels are oleaginous clysters, tion seldom arises, though here the air has and if any internal medicine be given, as a quite as good an opportunity of entering purgative, it should be of the mildest nature, the abdomen, as in auy case of wound. (On Military Surgery, p. 402, ed.2.) Castor The peritoneum in animals has been infla- oil is perhaps tbe best; but, on tbe whole, ted, without any inflammation being exci- for some few days, I would hardly venture ted. In cases of tympanitis, the peritoneum beyond the use of clysters for procuring is distended with air, and yet both this evacuations from the bowels. membrane and the bowels are quite unin- Suppurationin the Abdomen, in consequence flamed. In the human subject, it seems of Wounds.—Abscesses within the bag of probable, that if a wound vvere made in a the peritoneum are far from being common, vacuum, the breach of continuity itself As a late writer well observes, " the con- would be an adequate cause of inflamma- taining and contained parts of the abdomen (ion. It may also be remarked, that collec- present to each other an uniform and con- tions of matter in the abdomen are almost tinuous surface of membrane. This mem- always completely circumscribed, and sepa- brane is of the serous class, and the species rated from the general cavity of the perito- of inflammation, to which it is especially neum,by the adhesion of the viscera to each subject, is that, wliich has been denominated other, and to the inside of the peritoneum. the ^adhesive. The membrane, lining the I am of opinion, that no surgical writer intestinal canal, is of the mucous class, and has succeeded so well, as Mr. John Bell, in the ulcerative inflammation is the species, exposing the absurd apprehensions, not un- to which this class is liable. This benefi- commonly entertained by practitioners, re- cent provision is an irresistible evidence of specting the entrance of air into tbe abdo- the operation of a salutary principle in dis- men and other cavities of the body. He ease. If the inflamed peritoneum had run inquires, 1st. Whether air can really get into directly into suppuration : ulceration of the the cavity of the abdomen? and, 2dlv VYOUNL-S Gtit' Whether, if it were tiiere, it would produce the dreadful effects ascribed to it ? Upon the first question, his arguments run thus:—"Suppose a wound of an inch in length .—suppose the bowel to have ^unk, in some strange way, into the pelvis, for example, so as to have left a mere vacuum ; vyhat should happen with the flexible pa- rietes of the abdomen ? Should they stand rigid, while the air rushed into the cavity to fill it ? No, surely. But, on the contrary, the walls of the abdomen would fall toge- ther, and the pressure of the outward air, far from making the air rush in by the outward wound, would, at once, lay the belly flat, and close the wound. But, since the walls of the abdomen are not flaccid, nor the ca- vity empty, but the abdomen full, and tbe flat muscles, which cover it, acting strongly, the effect must be much more particular ; for, the moment that the belly is wounded, the action of the muscles would force out part ofthe bowels ; the continuance of that action is necessary to respiration : the re- spiration continues as regular after (he wound as before ; and the continual pres- sure of the abdominal muscles, nnd (be diaphragm, against all the viscera of the ab- domen, prevents the access of air so effec- tually, that though we should hold such a wound open with our fingers, no air could pass into the abdomen, further than to that piece of gut which is first touched with the finger, when we thrust it into the abdomen. Nothing is absolutely exposed to the air, ex- cept that piece of intestine which is without the abdomen, or that, which we sec, when we expose a small piece of the bowels, by holding aside the lips of the wound. The pressing forward of that piece, and the pro- trusion of a portion of the gut, proportioned always to the size of the wound ; the pres- sure from behind keeping that piece pro- truded, so that it is with difficulty we can push it back with our finger; this incessant pressure, in all directions, is an absolute se- curity against the access of air. The intes- tine comes out, not like water out of a bottle, the place of which must be supplied by air entering into the bottle, in proportion as the water comes out; but, the gut is pushed down by the action of the muscular walls of the abdomen, and that action follows the intestine, and keeps it down, and prevents all access of the air, whether the gut con- tinue thus protruding, or whether it be re- duced ; for, if it be reduced, the walls of (he abdomen yield, allowing it to be thrust back, but admitting no air. Those, who want to know tho eifect of air, diffused within the cavity of the abdomen, must make other experiments, than merely cutting open pigs' bellies ;—they mnst give us a fair case, without this unnecessary wound. We will not allow- them to say, when they cut open the belly of any creature, with a long inci- sion, that tbe inflammation arises from the air; much less shall we allow them lo say, when they open the belly with a smaller incision, that, by that little incision, the air gets into the abdomen, and that rdl the bowels are exposed to the air.' (Discourses on the Nature of Wounds, p. 343,344.) In adverting to the question, whether ait is so irritating to the cavities of the body as many have supposed, Mr. John Bell critici- ses with much spirit and success, the opi- nions, published on this subject by Mr. A. Monro, in his account of the Burstre Muco- sa;, as the annexed quotations will show. " That the vulgar should believe, the first superficial impression that strikes them, of air hurting a wound or sore, is by no means surprising; but it is not natural that men, bred to philosophy, should allow so strange an assertion as this, without some kind of proof. That the air which we breathe, and which we feel upon the surface so bland and delightful, should have so opposite a relation to the internal parts, that it should there be a stimulus, more acrid and more dangerous than the urine, is not to be believed upon slight grounds. I do affirm (says Mr. John Bell) that it remains to be proved, that this fluid, which seems so bland and pleasant to all our senses, and to the outward surface, is yet a horrible stimulus when admitted, as a celebrated author grandly expresses ii, ' into the deep recesses of our body.' "— (Monro's Bursa Mucosa.) With how much reason Mr. John Bell objects, that this doctrine is unfounded, will be manifest to every man of any discern- ment, or impartiality. " The air, for instance, escapes from the lungs, in a fractured rib, and first goes abroad into the thorax ; then into the cellular sub- stance ; then the emphysematous tumour appears; but often without any scarifica- tions, with very little care and assistance on our part, the air is absorbed, the tumour disappears, and, without inflammation of the chest or any particular danger, the man gets well. Here then is the air, within the cavity of a shut sac, filling the thorax, and oppressing the lungs, without any danger- ous inflammation ensuing. " That the air may be pushed under the cellular substance all over the body, withou: causing inflammation, is very plain, from the more desperate cases of emphysema, where the patients, after living eight or ten days, have died, not from inflammation, but from oppression merely, the body being so cram- med witb air, that even the eyeballs have, upon dissection, been found as tense as blown bladders. We have also many ludi- crous cases of this kind, which prove this to our perfect satisfaction. Soldiers and sailors sometimes touch the scrotum with a lancet, introduce a blowpipe, and blow it up to an enormous size, imitating her- nia?, by which they hope to escape from the service. The old story of a man, who was so wicked as to make a hole in his child's Head, and blow it up, that he might show the child in the streets of Paris for a mon- ster, is well authenticated ; and I have lit- tle doubt, lhat a fellow who knew how to do this, would blow it up every morning, and squeeze it out when he put the child to bed at nighf. Some villtnons bn< c'*er=. hav- 670 * WOUND:*. ing a grudge at a soldier, found him lying situation ofthe abscc.-s be very distinct, drunk under a hedge; they made a little and the quantity and pressure ofthe matte- hole in bis neck, and blew it up, till he was clearly productive of inconveniences. Un like a bladder, or, as Dr. Hunter describes the der these circumstances, the surgeon should disease of emphysema, like a stuffed skin." make a cautious puncture with a lancet. (P. 388, 389.) Protrusion of the Viscera.—The omentum ki At'L;eijm*ny otlier pertinent observations, and small intestines are tbe parts most liable blended with appropriate satire on the ex- to protrusion ; but, in large wounds, the travagant notions professed by Monro, on great intestines, the stomach, and even the the bad effects of the air in lithotomy, liver and spleen, may project through the operations for hernia and hydrocele, the opening. The general symptoms, indicating Cajsarian section, l±c. Mr. John Bell most a protrusion of the parts, are sufficiently ob- justly holds up to ridicule the propositions vious; but, it deserves attention, that, in fat ?*' "Aitken to Ptrform Ihis last operation subjects,, the adipose membrane may project under the cover of a warm bath, in order to from the wound, and put on somewhat of exclude the air. " This, though it may seem the appearance of omentum. The special to be a scurvy piece of wit, vvas really pro- symptoms are to be collected from a know- posed in sober serious earnest. But (adds ledge of the natural situation of the parts, Mr. John Bell) the admission of atmospheric and reflecting what region of the abdomen is air, as a stimulus, when compared with the wounded. (Callisen, Syst. Chir. Hodierna, great incisions of lithotomy,of heruia.of hy- T. l,p. 702 and 703,edit. 1798.) drocele, of Caesarean section, of the trepan, From penetrating wounds considerable is no more than the drop of the bucket to portions of the bowels, or omentum, somc- the waters of the ocean. And it is just as times protrude, and though these viscera may poor logic to say, that after such desperate not have received injury, yet their being operations, these cavities are inflamed by displaced, is sometimes productive of fatal the admission of air, as it would be to say, consequences. (as Monro did) that when a man is run The best mode, of preventing such mis- through the pericardium with a red-hot po- chief, is to return the viscera into the cavity ker, that the heart and pericardium are iu- of the abdomen as speedily as possible. flamed by the admission of the air." (P. 847, Almost all authors recommend fomenting Edit. 3.) the displaced parts, previously to the attempt Enough, I conceive, has been said, to dis- at reduction ; but in giving this advice, they pel all the idle fear and prejudices, which seem to forget, that while time is lost in this have prevailed concerning the bad effects preparatory measure, the protruded bowels ot the air in wounds of the abdomen, as well suffer much more harm from exposure, that. as several other cases. When so justly erai- is to say, from the very circumstance of ncnt a man as Dr. Alexander Monro, senior, their being out of their natural situation, was disturbed by such apprehensions, it is than they can possibly receive good from not wonderful that many a poor ordinary any application made to 1hem. No kind of member of the profession should have been fomentation can be half so beneficial, as the terrified nearly out of his wits upon the sub- natural warmth and moisture of the cavity ject; and for quieting this alarm, and expo- of the abdomen. In order to facilitate the sing its absurdities, I really think Mr. John return of a protruded piece of intestine, or Bell deserving particular praise. omentum, the abdominal muscles should be In general, in all cases of wounds of tbe relaxed by placing the patient in a suitable abdomen, it is an excellent rttle never to be posture, and the large intestines emptied officious about abscesses which may take with a glyster. In mentioning the last place, nor to exhibit a partiality to such ex- measure, it is not meant, that the surgeon periments as have been devised for learning should delay the attempt to reduce the part, precisely what bowel is wounded. It is until the glyster has operated. No, this quite time enough to interfere, when the means is only enumerated as one that may urgency of the symptoms confirm any sus- become serviceable, in case the surgeon can- picions which may be entertained. A great not immediately accomplish the object in deal of harm is frequently done by hand- view.—The mesentery ought always to bo ling and disturbing the wounded parts more reduced before the intestine ; the intestine than is necessary, and it is well known that before the omentum ; but, the last protruded wounds, at first Attended with alarming portion of each of these parts ought to be symptoms, frequently Ijave a favourable ter- the first reduced. tnination. Swords, balls, and other wea- It is only when the intestine and omen- pons, sometimes pass completely through turn are free from gangrene and mortifica- the body, without the patient suffering after- tion, that they are invariably to be returned ward any threatening symptom, or, indeed, into the cavity of the belly, without hesita- any effects which, abstractedly considered, tion. Also, when the protruded parts are would authorize the inference, that the vis- covered with sand, dust, or other extraneous cera had been at all injured. Severe inflam- matter, they should be tenderly washed with mations may not end in suppuration, and a little tepid water. wheu pus is formed, it is sometimes absorb- For the reduction of the parts, (he fore- ed again. Nothing then indicates the ne- fingers: arc the most convenient, and it is a cessity for the discharge of purulent matter rule to keep the portion first returned, from in the abdomen, unless the fluctuation and protruding again, by one finger, until it has WOL'Nb; '■71 been followed by another portion, introdu- ced by the other finger. The second piece is to be kept up, in the same way, bv the finger used to return it; and so on, till the displaced parts have all been put into their natural situation. In attempting to reduce a piece of pro- truded intestine, the patient should be placed in the mo3t favourable posture : the head and chest should be elevated, and the pelvis raised with pillows. Nothing can be more absurd, than the advice to put the thorax rather lower than the pelvis, in order (hat the weight of the viscera may tend to draw inward the protruded parts. This is another erroneous idea, arising from (he ridiculous supposition, that a great part of the abdomen is actually an empty cavity. The relaxation of the abdominal muscles'is a much more rational and useful object. When this is properly attended to, and the above directions observed, and the wound is not exceedingly small, in relation to tha bulk of the protruded viscera, the parts may generally be reduced. But in addition lo what has been already stated, it is neces- sary (o remark, that tbe pressure should be made in a straight direction into the abdo- men ; for when made obliquely, towards (he edges of the wound, the parts are liable (o suffer contusion, without being reduced, and even to glide between the layers of the abdominal muscles, and become strangula- ted. When the wound is in the front of the abdomen, pressure made in this unskilful way may force the viscera into the sheath of the rectus muscle, and cause the same perilous symptoms as arise from an incarce- rated hernia. (See Hernia.) When the reduction seems complete, the surgeon should assure himself of it, by in- troducing his finger into the cavity of the "ibdomen so as to feel that the parts are all actually reduced, and suffer no constriction between the edges of the wound and the viscera in the abdomen. A difficulty of reduction may arise from •lie protruded intestines being distended with feces or eir. In this circumstance, the contents of the gut may frequently be made to pass by degrees into thm-sfigrtion of the intestinal canal, which is within (be abdomen. In order (o accomplish (his pur- pose, the surgeon must press (he contents of the bowel toward the wound ; and, if he succeeds in emptying the part, he will com- monly experience equal success in his next attempt to replace it in the abdomen. Sometimes, in cases of narrow stabs, considerable pieces of intestine protrude, and cannot be reduced without doing im- prudent violence to the bowel. Under these circumstances, the dilatation of the wound is indispensable. However, when the reduction seems almost a matter of im- possibility, on account of the smallness of the wound, if the surgeon be careful to re- lax the abdominal muscles, draw a little more intestine out ofthe wound, and gently press (he contents ofthe bowel through the constriction into the abdomen, he will fre- quently succeed in reducing the parts, with- out using the knife. When such operation is unavoidable, the dilatation should be made in a direction which will not endanger the epigastric ar- tery, and, if possible, in the same line as the muscular fibres. We are also advised to make the incision upward rather than downward, when it can be done with equal convenience, be- cause it is supposed the first direction will be followed by less danger of hernia. (Sa- batier, Midecine Opiraloire, T. 1, p. 220, Ed. 2. Callisen, Syst. Chir. Hod. T.l, p. 70b.) If, however, the upper angle of the wound correspond to the direction of the suspensory ligament of the liver, writers advise making the dilatation at the lotfer angle, in order to incur no risk of hemor- rhage from the umbilical vein. In the adult, this vessel is generally obliterated, and turned into a ligamentous substance ; though it would appear tbat, in a few in- stances, it remains pervious to tbe navel. Hildanus saw a young man die instantly in consequence of a stab in the belly between the false ribs and the umbilicus; and, on opening the body, he found blood effused from a wound ofthe umbilical vein. It has been feared, also, that cutting the suspen- sory ligament of tbe liver might give rise to such a displacement of that viscus as would interrupt the freedom of respiration, or obstruct the circulation of the blood in the vena cava. But the apprehension is un- founded ; for Riolan found this ligament ruptured and retracted toivards the liver in a nimble Ethiopian female dancer, whose respiration had not suffered any particular disturbance during her lifetime. (Sabatier, Me'd. Opiraloire. T.l, p. 220, 221, Ed. 2.) The incision should never be larger than absolutely requisite, as hernia is much dis- posed to occur wherever the peritoneum has been divided. The operation may be done with a curved bistoury and a director, much in the same way as is done in cases of strangulated ruptures. (See Hernia.) , After the battle of Waterloo, many cases presented themselves in which the bowels and omentum protruded, and in several of these examples the reduction could not be effected before the wounds had been en- larged. So tightly also vvere the parts girt, that the operation was sometimes far from being easy. Instead of enlarging wounds ofthe abdo- men, it has been proposed to let out the air from the protruded intestines, by making small punctures with a needle, so as to lessen their volume sufficiently to make them reducible. The suggestion first origi- nated with Pare, who declares that he has practised the method with success. Rousset, his contemporary, also informs us tbat the plan vvas adopted by another surgeon in an instance where the epigastric region was wounded, and a large portion of the intes- tines protruded in a strangulated state. Pe ter Lowe, an English surgeon, likewise- assures us, that he frequently adopted (he <>;2 WOUNDS practice, when olher means failed. Garen- geot, Sharp, and Van Swieten, are all ad- vocates for Pare's proposal; but they recommend the employment of a round needle, which will merely separate the fibres of the intestinal canal, without cutting them, as a flat, triangular, sharp-edged needle would unavoidably do. These last writers, however, only sanction the practice when the quantity of protruded intestine is great, and the bowel is so enormously distended with air, that it would be impossible to re- duce the part, though the wound were en- larged, and every thing else put in practice, likely to bring about the reduction. But, as Sabatier remarks, the punctures must be entirely useless, if made with a fine needle, since they will be immediately stopped up with tbe mucous secretion, with which the inside of the bowels is constantly covered ; and if the punctures are made with a broad triangular needle, or a very large round one, as Desault and Chopart advise, they must be highly dangerous, inasmuch as they are likely to give rise to inflammation, and even to extravasation, within the abdomen. (Midecine Opiratoire, T. l,p. 10.) Tbat small punctures in tne bowel would not answer the purpose, but be obstructed by the villous or mucous coat, is a fact, which has been for a long time well known to surgeons. Callisen, among others, has particularly noticed it: " Acu punctura** enim flatibus exitum parare nequeunt, siqui- dem tunica villosaforaminula obstruit," be. (Sys. Chir. Hod. T. 2, p. 704.) It was the circumstance of small punc- tures being unavailing, that led Desault and Chopart to recommend the use of a large round needle : "pour que louverture ne soit point bouchie par les mucnitis dont les intes- tines sonl enduits." But they vvere also aware of the danger of employing such an instrument, since they give us directions how to proceed in order to prevent extra- vasation and inflammation: On pri vien- dra I'epanchement des matiires stercorales en passant, avant de reduire I'intrstin, une anse dc fil dans la portion de mesentlre qui ripond a la piqure pour la fixer conlre les berds de la plaie extirieure et Von combatlra par les rembdes ginlraux Tinflammalion que eel pi- qure peut atlirer." (Traiti des Maladies Chirurg. T. 2, p. 135.) Richerand is still an advocate for puncturing the bowel, for which operation he boldly recommends a small hydrocele trocar. (Nosogr. Chir. T. 3, p. 336, Ed. 4.) Mr. Travers, one of the latest and best writers upon this subject, most properly joins in the condemnation of the plan of pricking the protruded bowels. •' Blancard and others protested against this practice on the very sufficient ground of its ineffi- cacy. La Faye very truly says, it is a use- less as well as dangerous practice ; for the openings made by a round needle cannot give issue to the contained air." Mr. Tra- vers then cites two cases, showing that even small stabs in a bowel will not prevent its becoming distended with air "A man was brought to St. Thoeia-. s hospital, on Saturday, the 30th of June last, (1811)who had been slabbed iu the direc- tion ofthe epigastric artery, on the left side ofthe abdomen, by a case knife. He died in eighteen hours, apparently from the sud- den and copious hemorrhage, which had taken place within the belly. About half a yard of ileon was protruded. The gut was highly discoloured, and so much distended, notwithstanding it was pierced in three places, that the wound of the integuments required to be freely dilated before it could be returned. The apertures were in fact obliterated by the mucous coal." '■* It appeared upon the trial of Captain Sutherland (Ann. Reg. June 1809), for tho murder of bis cabin boy, that (he intestines had been extensively protruded through a wound near the left groin, and had lain ex- posed for four or five hours ; that the dirl: had pierced through one fold of intestine, and entered another; that the wound of the intestine was half an inch long; (hut the reduction could not be accomplished until the parietal wound was dilated ; and that the intestine was then returned, and the integuments sewed up." (Tracers on Injuries of the Intestines, p. 17-1, 176.) With respect to this last case, however, I must observe, that it does not satisfactorily prove what the author intends, namely, that the bowel was distended with air, though there was a wound in it half an inch long, for the evidence does not inform us that the difficulty of reduction was owing to this cause. I have seen a very small portion of omentum protrude through a wound, nnd baffle all endeavours to reduce it for nearly an hour. The first case adduced by Mr. Travers, however, is more explicit and in- teresting ; and we are to infer from it, and the observations of Haller, Callisen, &.c. that the punctures made in an intestine are not closed by mucus, as Sabatier and De- sault have asserted, but by the mucous coat itself. As the above expedient had been recom- mended by writers of some weight, I tiought tha( (he subject should not be passed over residence, and without a caution to the reader, never to put any confirtence in the method. The plan does not facilitate the business of the operator. There is not even this solitary reason in favour#of the practice ; and though it may have answered when large needles were used, and some patients so treated may have recovered, every person, who has the least knowledge of the animal economy, will easily compre- hend how even tbe smallest opening, made in parts so irritable and prone to inflamma- tion as tbe bowels, must be attended with greater danger than would result from en- larging a wound of the skin and muscles. Besides, the air may frequently be pressed out ofthe intestine in a safer way, as I have already described. A wound of the abdomen, attended with one ofthe most considerable protrusions of ev,«> viscera that I have ever read of. is re- uncommon. The treatment, is explained iu (he article Hernia. When the protruded intesliueis in a state of inflammation, its imtnedinte reduction is, beyond all dispute, the means most likely to set every thing right. Even when the in- flammation is considerable, a timely reduc- tion of the displaced part, and the employ- ment of antiphlogistic means, will often pre- vent gangrenous mischief. The dull, brown, dark red colour of the intestine may induce WOUND.-. u73 corded by Mr. Hague, surgeon at Rippon '• August 30th, 1808 (says this gentleman) I went to Norton Mills, about four miles from hence, to see John Brown, a*t. 12 years, who had received a wound in the abdomen by a wool shears. On my arrival, which was little more than an hour after the accident, I found the poor lad in a very distressing situation; the great arch of the stomach, and the whole of the intestinal ca- nal,(duodenum excepted,) contained with- . JH™*«*it"'- :!™£ Protruded though tiie practitioner to suppose, either that the part is already mortified, or must inevitably become so, and consequently, he may delay returning it into its natural situation. But notwithstanding this suspicious colour of the intestine, its firmness will evince, that it is not in a state of gangrene. The ultimate recovery of a portion of intestine, so cir- cumstanced, is always a matter of uncer- tainty ; but the propriety of speedily repla- cing Ihe part in its natural situation, is a thing most certain. "Panes egressa? sana; (observes Callisen) citissime sunt reponenda"*, neque obstat mutalio coloris nativi in rubrutn the wound. The incision vvas on the left side of the body, commencing at about two inches below the scrobiculus cordis, and extending in a straight line near four inches in length, distant from tbe navel two inches, and he was quite sensible, and had vomited so as to empty the stomach ; very little blood was lost. I immediately proceeded very carefully to examine the protruded viscera, none of which were wounded, and reduced them as quickly as possible, begin- ning with the stomach, and following the regular course-of the intestines, in the latter portion of which I distinctly felt feces of subfuscum." (Syst. Chir. Hod. T. 1, p. 703^ rather firm consistence. He complained of some pain during the reduction, though not much; and expressed great relief when the parts were completely returned. I now desired an assistant to lay the palm of his hand over the wound, and make some pressure upon it; for I found, that, without this, the parts would soon have protruded again by the action of respiration, which was oppressed and laborious. I brought the sides of the wound together by five su- tures, beginning from above downwards, and passed the needle on each side, quite through the integuments with the perito- neum, &c. The wound was also dressed with adhesive plaster, and covered with a bandage." (Vide Edinburgh Medical and Surgical Journal, Vol. b,p. 129,4^.) This case is interesting; for notwith- standing so unlimite'd a protrusion of the viscera, and the circumstance of the parts being left unreduced for more than an hour, a recovery ensued, under the judicious em- ployment of bleeding, purging, anodynes, he. In la Caserne de St. Elizabeth at Brussels, after the battie of Waterloo, the number of protrusions of (he viscera, which fell under my notice, were much more considera- ble, than what I previously had any idea of ever meeting with. 1 well remember, in my edit. 1798.) In case the bowel mortify after its reduction, all hopes of tbe preservation of life are not to be abandoned; as I have no liced in the articles Anus, artificial, and Her- nia, in which last part of the book, many things, necessary (o be known, concerning (he mode of reducing protruded omentum, will also be found. When a piece of intestine cannot be re- duced, granulations and new skin sometimes grow over it, and a cure follows, as the ex- perience of Callisen confirms. (Op. cit. p. 706.) The protruded viscera having been re- duced, the next object is to retain them iu the abdomen, until the wound is completely healed. When the wound is small, (his is a malter of no difficulty ; for i( is enough to put the patient In a position which will re- lax the fibres of the wounded muscles, while (he edges of Ihe^gtound are maintained iu contact with sticking-plaster, and supported by a compress and bandage. Costiveness is to be remored by the mildest purgatives, such as the oleum ricini, or by laxative clys- ters, which are still preferable. But in case-j of extensive wounds, even when tbe treat- ment is conducted with all possible judg- ment, it is occasionally difficult, and even impossible, to hinder the protrusion of (be bowels by common dressings and a ban- dage. In this circumstance the edges of own part of the hospital, two protrusions of the wound must be sewed together. (See a large portion of the stomach ; three of the bladder ; and ten or twelve of tbe mesente- ry, omentum, or intestines. Whether a suture should be used, when the protruded intestine is wounded, is a subject which will be noticed in considering wounds of the intestines. Some of the exposed intestine may have mortified before (he arrival of surgical assisl- ance. In cases of wounds, (his event isjrare ; but in those of strangulated hernia? it is not Vor. H Q"' Gaslroraphe.) In modern times,however, su- (ures are much more seldom employed than formerly, and in tbe above article, some re- marks are.offered, proviug that the generality of wounds of ihe abdomen do not require the practice.. When (be omenluin protrudes, and is strangulated by the narrowness of the open- ing, it soon contracts adhesions to it, unless speedily reduced. Should such connexion be already formed, when tbe surgeon is firs': consulted, we are advised to cut off (he nor- 1674 WOUNDS- tion which exceeds tiie level of the inteo-n- ments. and to leave the rest in the wound. The latter will block up the opening, and have the good effect of preventing hernia. (Richerand, Nosogr. Chir. T. 3, p. "39, edit. 4.) When ibe protruded omen- tum is sound and free from adhesions, it ought lo be reduced without delay. But, when the hro'rusion is large, and there is reason to fear, from the vomiting* and the pains shooting from (he wound to the episras- tric region, that the stomach is dragged^the displaced part must be made free, and if Found, reduced. Should it be in a mortified state, the dead part must be previously cut away, and any vessels which bleed,' lied separately with a piece of fine thread, or silk, both ends of which may either be cut off close to the knot, and (he part then reduced; or one end ofthe silk may be left out of the wound, and Ihe other cut away. Practition- ers who apprehend ill effects* from leaving within the abdomen so small a particle of extraneous matter, as the little knot of fine thread, will prefer the las! method, and with- draw the IjgatUre altogether, as soon as it becomes loose. Extravasation in the Abdomen.—Wounds of (he abdomen may be complicated with extravasations of blood, chyle, excrement, bile, or urine. None of these complica- tions, however, are half so frequent, as an inexperienced practitioner would apprehend. The employment of the phrase cavily of the abdomen has paved the way to much er- roneous supposition upon this subject, and has induced many absurd notion.*, which even the sensible observations, long ago pub- lished by J. L. Petit, have scarcely yet dis- pelled. As a modern writer has observed: " There is not truly any cavily in the human body, but all Ihe hollow bowels are filled wilh their contents, all tbe cavities filled wilh (heir hollow bowels, and thp whole is equal- ly and fairly pressed. Thins, in tbe abdomen, all the viscera are moved by the diaphragm and Ihe abdominal miisffas upwards nnd downwards, with an equable-continual pres- sure, which has no interval; and one would be op( to add, (he intestines have no repose, being kept tin*-* in continual motion ; but though Ihe action ofthe diaphragm, and (he reaction of the abdominal muscles are alter- nate, Ibe pressure is continual; the motion which it produces, (tbey produce) ia like that which ihe bowels have, when we move (hem forwards in walking, having a motion, with respect to space, but none with regard (o each olher, or to the part of the belly which covers (hem ; the whole mass of tbe bowels is alternately pressed, to use n course illustration, as if betw i.\t two broad boards, which keep each turn or intestine ih Its right place, while the whole mass is regularly moved. When (he bowels are forced down by (he diaphragm, (he abdominal muscles recede : when (he bowels are pushed back again, it is (he reaction of (he abdominal mus- cles, thatforces thembackand follows them; there is never an instaii' of interrupt ton of ibis pressure., nev or a moment, in which tlie bow els do not press against the peritoneum *, nor is there the smallest reason lo tfoubl that the same points in each un* continually opposed. We see that (he intestine s do not move, or. at least, do not need to move in performing (heir functions: for in hernia, where large turns of intestines are cut off by gangrene, the remtuning part of Ihe same intestines is closely fixed to the groin, and yel Ibe bow- els are easy, and their functions regular. We. find (he bowels regular, when Ihey lie out of (he belly, in hernia, as w ben a certain turn of intestine lies in the scrotum or (high, or in a hernia of (he navel ; und where yel ihey are so absolutely fixed, that the piece of intestine is marked by (he strailness of (he rings. We find a person, after a wound ofthe intestine, having free stools for many days ; and what is it that prevents (he feces from escaping but merely this regular and universal pressure ? We find a person, on Ihe fourth or fifth day, with feces coining from the wound ! a proof, surely, that (he wound of the intestine is s.till opposite or nearly opposite (o (he exlernal wound. We find the same patient recovering without one bad sign ! What heller proof than (his could we desire, lha( none of the feces have exu- ded into (he abdomen ? " If in a wound of (he stomach, the food could gel easily ouif by thnt wonnd, the sto- mach would unload itself thnt way, there would be no vomiting, the patient must die; but so regular and continual is this pressure, that the instant a man is wounded in the stomach, he vcmifs, he continues vomiting for many days, while no( one particle es- capes into (he cavity of the abdomen. The outward wound is commonly opposite to (hot of Ihe stomach, and by that passage, some part of the food comes out; hint when any accident removes tbe inward wound of the stomach from tbe outward wound, the ab- dominal muscles press upon Ihe stomach, nnd follow it so closely, that if there be not a mere laceration extremely wide, this pres- sure closes ihc hole, keeps the food in, ena- bles tbe patient to vomit, and not a particle, even of jellies, or soups, is ever lost, or goes oul into Ihe cavity of the belly. " How (proceeds Mr. J. Bell) without this universal and continual pressure, could the viscera be supported ? Could its ligaments, as we call them, support the weight of (he liver ? Or wha( could support the weight of the stomach when filled ? Could the mesen- tery, or omentum, support the intestines; or could its own ligaments, as we still name then, support the womb? How, without this uniform pressure, could these viscera fail (o give way and burst ? How could tbe cir- culation of (he rehdomen go on ? How could Ihe liver and M.leeu, so turgid as (hey are with blood, fail to burst ? Or what jujssihlv could support the loose veins and arteries of Ihe abdomen, since many of them, e.g. the splenic vein, is (are) two feet in length, is (are) ofthe diameter of the thumb, and has (have) no other than the common pellucid and delicate coats ofthe vein8 3 How could WOUNDS 07" the viscera of the abdomen bear shocks and tails, if not supported by the universal pres- sure of surrounding parts? In short, the acci- dent of hernia being forced out by any blow upon the belly, or by any sudden strain, ex- plains to us how perfectly full the abdomen is, and how ill it is able lo bear any pressure, even from its own muscles, wilhout some point yielding, and some one of its bowels being thrown out. And the sickness and faintness, which immediately follow the drawing off of the waters of a dropsy, explain (o us, what are the consequences of such pressure being even for a moment relaxed. But, perhaps, one of the strongest proofs is this,that the principle muslbe acknowledged, in order to explain what happens daily in wounds; for though in theory we should be inclined to make this distinction, that the hernia, or abscess of the intestines will ad- here and be safe, but that wounded intes- tines, not having time lo adhere, will be- come flaccid, as we see them do in dissec- tions, and so, failing away from (he exlernal wound, will pour out their feces into the ab- domen, and">prove fatal; though we should settle this, as a fair and good distinction in theory, we find that it will never answer in practice. Soldiers recover daily from the most desperate wounds; nnd the most likely reasons, (hat we can assign for it, are the fulness ofthe abdomen, (he universal, equa- ble, and gentle pressure ; and the active dis- position ofthe peritoneum, ready to inflame with the slightest touch. The wounded in- testine is, by the universal pressure, kept close to the external wound, and the perito- neum and tbe intestine are equally inclined to adhere. In a few hours, thnt adhesion is begun, which is to save ihe patient's life, and the lips of the wounded intestine are glued to the lips of the external wound. Thus is (he side of the intestine united to the inner surface of the abdomen ; and though (he gut cas(s ou( its feces, while the wound is open ; though it often casts them out more freely, while the first inflammation lasts; yet the feces resume their regular course, whene- ver tbe wound is disposed to close." (John Bell's Discourses on Wounds, p. 323, 327, Edit.3.) The foregoing extract, though drawn up in a careless style, contains such observa- tions as are well calculated to make the reader understand, that the abdomen is in reality not a cavity, but a compact mass of containing and contained parts; that the close manner, in which the various surfaces are constantly in contact most powerfully oppose extravasations ; and lhat, in fact, it often entirely, prevents them. The passage cited impresses us with the utility of that quick propensity to (he adhesive inflamma- tion, which prevails throughout every peri- toneal surface, and which not only often has the effect of permanently hindering effusion of the contents of the viscera, by agglutinating the parts together, but which, even when an extravasation bas happened, benefioially confines (he effused blood in one mass, and •ajr-ounds it with such adhesions ot the parts to each other, as are rapid in their formations, and effectual for the purposes of limiting the extent of the effusion, and preventing the irritation of the extravasa- ted mutter from affecting the rest of the ab- domen It is to Petit that surgeons are indebted for more correct modes of thinking upon the foregoing subject, and it is with great plea- sure that I here refer to his valuable obser- vations. (See Mem. de I'Acad. de Chir.) But notwithstanding the reciprocal pres- sure of the containing and contained parts against each other, and the useful effect ot the quickly arising adhesive inflammation, in all penetrating wounds of the belly, com- plicated with injuries of the viscera, we arc not to suppose, that, extravasation never happens ; but only lhat it is much less fre- quent, than has been commonly supposed. Mr. Travers, with much laudable industry, has endeavoured to trace more minutely, than any preceding writer, the particular circumstances, under which effusions in the abdomen are likely or unlikely lo hap. pen." It being admitted (says he) that there are cases in which effusion doe3 lake place, it is easy to conceive circum- stances which must considerably influence Ibis event. If, for example, the stomach and bowels be in a state of emptiness, the nausea which follows the injury will maintain that state. If the extent of the wound be con- siderable, (he ma((er will more readily pass (hrough (be wound, than along the canal. A wound of the same dimensions in the small and large intestines, will more readily evacuate the former than (he latter, because it bears a larger proportion to the calibre. Incised and puntured wounds admit of the adhesion of the cut edges, or the eversion of the internal coat of the gut, so as to be in many instances actually obliterated; where- as lacerated, or ulcerated openings, do not admit of these salutary processes. Again, in a transverse section of the bowel, contrac- tion of the circular fibre closes the wound, whereas in a longitudinal section, the con- traction of the fibre enlarges it. Such (says Mr. Travers) are the circumstances, which combined, in a greater or less degree, in- crease or diminish the tendency to effu- sion." (On Injuries of Intestines, fyc. p. 13, 14.) After the details of some experiments and cases, the preceding author makes, among other conclusions, the following : 1. That effusion is not an ordinary conse- quence of penetrating wounds. 2. That if the gut be full and the wound extensive, the surrounding pressure is over- come, by the natural action of the bowel tending to the expulsion of ils contents. 3. That, if food has not recently been taken, and the wound amounts to a division of the gut, or nearly so, the eversion and contraction ofthe orifice of the tube prevent effusion. 4. That if the canal be empty at the time of the wound, no subsequent state of tbe bowel will cause effusion, Because the v.-per- liiC WOLNUtv *?ening inflammation agglufmates the sur- rounding surfaces, and forms a circumscribed sac; nor can effusion take place from a bowel at'the moment full, provided it retains a certain portion of its cylinder entire, the wound not amounting nearly to a semidivi- sion of the tube, for then the eversion and contraction are too partial to prevent an extravasation. 5. That, when however air has escaped from the bowel, or blood has been extrava- sated in quantity within the abdomen at the time of the injury, the resistance, made to effusion, will be less effectual, although the parietal pressure is (he same, as such fluids will yield more readily, (ban (he solids na- turally in contact. (P. 25, 26, 100.) " That, though extravasation is not com- mon in penetrating wounds, it follows more generally in cases, where the bowel is ruptured by blows, or falls upon the belly, while the integuments continue unwounded. (P. 36.) 7. That when the bowels are perforated by ulceration, (here -is more tendency to effusion, than in cases of wounds. (P. 38, &c.) Mr. Travers attempts to explain the reason of the greater tendency to effusion, in cases of iniestine burst by violence, than in those of ulceration, "by the difference in the na- ture of tbe injury, which the bowel sustains, when perforated by a sword or bullet, as in the one case, or burst or ulcerated in the other A rupture by concussion could only take place under a distended state of the bowel, a condition most favourably to effu- sion, and from the texture of the part, a rup- ture so produced would seldom be of limited extent. The process of ulceration, by which an aperture is formed, commences in tbe in- ternal coat of the bowel, which has always incurred a more extensive lesion, than the peritoneal covering. The puncture, or cut, is merely a solution of continuity in a point, or line; the ulcerated wound is an actual loss of substance. The consequence of this ditterence is, that, while the former, if small, is glued up by the effusion from the cut ves- sels, or, if large, is nearly obliterated by (be full eversion of the villous coat, the latter is a permauent orifice." (P^46.) How much Mr. Travers and Mr. John Bell differ in opinion, upon (hese latter points,'will appear from the following pas- sage : after adverting to the adhesion, which takes place between the viscera and the peritoneum, under a variety of circumstances attending disease, Mr. John Bell observes : " This it is, which makes the chief difference, in point of danger, betwixt an ulcerated and a wounded intestine ; for, in a wound, there is, as we should suppose, no time for adhe- sion, nothing to keep tbe parts in contact, no cause, by which the adhesion might be pro- duced. But, in an ulcer, there is a slow dis- ease, tedious inflammation, adhesion at first, and abscess, and bursting afterward; some- times a fistula remains discharging feces, and sometimes there is a perfect cure. If a nut- shell, a l»rge cofo. a bom?, or any dangerous tiling be swallowed, it slops in the stomach ■ causing swelling and dreadful pain ; at last, a hard firm tumour appenrs, and then it sup- purates, bursts, the bowel opens, the food is discharged at every meal, till the fistula gradually lessens, and heals at lust. But where the stomach is cut with abroad wound of a sabre, the blood from the wounded epiploic vessels, or the food itself, too often pours out into Ihc abdomen, and the patient dies, be." (Discourses on Wounds, p. 321, edit. 3.) The author afterward proceeds to explain, how in cases of penetrating wounds, the compact state of the containing and con- tained parts, and the incessant and equable pressure, which the viscera sustain, fre- quently hinder effusion. Which of these gentlemen is most correct, I cannot pretend to determine, and whether Mr. Travers's cases are deviations from what is most common, can only be decided by a comparative examination of a greater num- ber of facts. When the intestines ulcerate, and thus rid themselves of foreign bodies, the general tenor of the cases on record un- doubtedly aflbrds us little reason to be ap- prehensive of extravasation.. \et, with re- spect to ulceration of the intestines from other causes, circumstances may be very- different. Audit is but justice to state, That Mr. Travers's opinions have received some confirmation from an interesting case, pub- lished by Dr. J. Crampton, of Dublin. It is an instance of rupture of the stomach, and fatal effusion of its contents into the cavity of the abtlomen. The patient was a young lady, aged 29. She.vv as suddenly taken ill with spasm in her stomach, and other severe symptoms, aad died iu about twelve hours. " On opening the abdomen, the stomach was observed to he pale, flaccid, and empty. Its contents, among which were recognized oat- meal and castor oil, had escaped into the cavity of the abdomen, through a round aperture situated on its anterior surface, at tbe union of the cordiac and pyloric portions. This perforation of the stomach was perfectly circular, about the size of a pea, and appeared to be the result of an ulcer on the mucous surface, which had gradually penetrated the other coats. This ulcer was hollow and circular, nearly the size of a shilling, und had the appearance, as if it had been made with caustic, with the orifice in its centre." (J. Crampton, Med Chir. Trans. Vol. 8, p. 230.) To the prece- ding, Mr.Travers has apnexed some addition- al facts : one is an example of a rapidly fatal effusion of the intestinal contents, through an ulcerated opening about a finger's breadth below the pylorus. The foramen had a peritoneal margin, and proved to be- (he centre of an irregular superficial ulcer of the mucous coat. Another case is that of a similar ulceration ofthe smalllnlestines, and fatal extravasation of their contents. In another example, a circular aperture of the peritoneum, large enough to admit a crow's quill, was found after death at the junction of the duodenum and stomach. It also was the cenfre of an ulcer. ?b*t had destroye-ct 1>0U.V»t-. 611 me villous and muscular cbats oi the bowel to the extent of half an inch. For many other ingenious observations, I must refer the reader to Mr. Travers's paper, who con- cludes with remarking, that the chief diag- nostic symptoms of these hopeless cases ap- pear to be : 1. Sudden, most neute, and unremitting pain, radiating from the scrobiculus cordis, or the navel, to the circumference of ihe trunk, and even to the limbs. A peculiar pain, the intensity of which, like that of par- turition, absorbs the whole mind of the pa- tient, who, within an hour from the enjoy- ment of perfect health, expresses his serious and decided conviction, thai if the pain be not speedily alleviated, he must die. 2. Coeval w ith the attack of pain, remark- able rigidity and hardness of the belly, from a fixed and spastic contraction of the abdo- minal muscles. 3. A natural pulse for some hours, until the symptoms are merged in those of acule peritonitis, and its fatal termination in the adhesive stage. (Mtd. Chir. Trans. Vol. 8, p. 231, et seq.) Blood is more frequently extravasated'in (lie abdomen, than any other fluid, but, it does not always take place, unless the wounded vessels be above a certain magni- tude. The compact state of the abdominal viscera, in regard to each other, and their action on each other, oppose this eft'ect. The action alluded to, which depends on the abdominal muscles and diaphragm is rendered very manifest by what happens in consequence of operations for hernies, at- tended with alteration of the intestines, or omentum. If these viscera burst, or suppu- rate, after being reduced, the matter which escapes from them, or the ptis which they secrete, is not lost in the abdomen ; but is propelled towards the wound in the skin, and there makes its exit. Tlje intestinal mat- ter effused from a mortified bowel, has been known to remain lodged the whole inter- val, between one time of dressing the wound and another, in consequence of the surgeon stopping up the external wound with n large tent. When the above-mentioned action or pressure of the muscles, is not sufficient to keep the blood from making its escape from the vessels, still it may hinder it from be- coming diffused among the convolutions of (he viscera, and thus the extravasation is confined in one mass. The blood, effused nnd accumulated in this way, is commonly lodged at the inferior and anterior part of the abdomen, above the lateral part of the pubes, and by tbe side of one of the recti muscles. The weight of the blood may propel it into this situation, or perhaps, there mav be less resistance in this direction, than in others. In opening the bodies of persons, •who have died with such extravasations, things may put on a different aspect, and the blood seem to be promiscuously extra- vasated over every part of the abdomen. Hut, when such bodie^fcus examined with care, it will be founo^^Bt the blood does not ir'sintrnte itself amWr^ the viscera, till the moment when the abdomen is opened* and the mass previously lies in a kind of pouch. This pouch is frequently circum- scribed, and bounded by thick membranes, especially when the extravasation has been of some standing. (Sabatier Midecine Opi- raloire, T. 1, p. 28—30.) Every practical surgeon should remember vyell that all the abdominal viscera closely touch either each other, or the inner surface of the peritoneum. This is one grand reason, why extravasations are seldom extensively diffused ; but, commonly lie in one mass, as Petit, Sabatier, and all the best moderns have noticed. The pressure of the elastic bowels, diaphragm, and abdominal muscles, not only frequently presents an obstacle to the diffu- sion of extravasated matter, but often serves to propel it towards the mouth of the wound. The records of surgery furnish numeVoas instances, in which persons have been Stab- bed through the body, without fatal conse- quences, and sometimes without the symp- toms being even severe. In Mr. Travers's publication manyjecses,exemplifying this ob- servation, are quoted from a' variety of sources: Fab. Hildan. Obs. Chirurg. Cent. 5. Obs. 74. OCuvres de Pare, liv. 10. Chap. 35. Wiseman's Surgery, p. 371. La Motte's Traite Complet de Chirurgie, be. be. In such cases, the bowels bave been supposed to have eluded the point of the weapon, and, perhaps, in a few instances, this may actually have been the fact; but, in the generality of such examples, the bowels must have been punctured, and the extravasation of intes- tinal matter prevented by the pressure ofthe viscera against each other. The pouch, or cyst, in which the extrava- sated blood, or matter, lies, as mentioned bv Sabatier, is formed by fhe same process, which circumscribes the matter of abscesses. (See Suppuration.) Iris, in short, tho adhe- sive inflammation. All the surfaces in con- tact with each other, and surrounding the extravasation, and track of the wound, ge- nerally become so intimately connected to- gether by the adhesive inflammation, that: the place, in which the extravasation is lodged, is a cavity entirely destitute of all communication with the cavity of the peri- toneum. The track of the wound leads to the seat of the effused fluid, but has no distinct opening into the general cavity of the abdomen. The rapidity, ijith which the above adhesions frequently form, is almost incredible. It should be known, however, tbat extra- vasations are occasionally diffused in various degrees among the viscera, owing to the patient being subjected to a great deal of motion, or affecled vvith't-iolent spasmodic contractions of the intestines. Urine and bile are also generally dispersed to a great extent. As for blood, its disposition to coagulate must often tend both to stop fur- ther hemorrhage, and confino the extravasa- tion in one mass. Symptoms and Treatment of Extravasation in the Abdomen. I. Blood—Wounds of the spleen, une! of very large veins and art Tie'. I'uij WOL>D^ in tlie abdomen, almost always boon prove fatal from internal hemorrhage. The blood generally makes its way downwards, and accumulates at the inferior part of the ab- domen, unless the presence of adhesions happen to oppose the descent of the fluid to the most depending situation. The bt-lly swells, and a fluctuation is perceptible. The patient grows pale, loses his strength, is affected with syncope, and his pulse be- comes weak, and scarcely distinguLhable. In short, the symptoms usually attendant on profuse hemorrhage ore observable. As the viscera and vessels in the abdomen are compressed on all sides by tbe surrounding parts, the blood cannot be effused without overcoming a certain degree of resistance ; and unless a vessel of the first magnitude, like the aorta, the vena cava, or one of their principal branches, has been wounded, the blood escapes from the vessel slowly, and several days elapse, before any consi- derable quantity accumulates. In these cases, the symptoms, which per- haps had disappeared under the employ- ment of bleeding and anodyne medicines, now recur. A soft fluctuating tumour may be fell at the lower part of the abdomen ; sometimes on the right side ; sometimes on the left; but occasionally on both sides. The pressure made by tbe effused blood, on the urinary bladder, excites distressing inch nations to make water ; while the pressure, which the sigmoid flexure of the colon suffers, is the cause of obstinate constipa- tion. In the mean time, as the quantity of extravasated blood increases, the perito- neum inflames. The pulse grows weaker ; dobility ensues; the countenance becomes moistened with cold perspirations; and according to some writers, unless the sur- geon practise an incision for the discharge of tbe fluid, the patient falls a victim to the accident. In the year 1733, Vacher adopted this treatment with success. Petit afterward tried the same plan, though it did not an- swer, (as is alleged) in consequence of the inflammation having advanced too far before the operation was performed. Long before the time of Vacher and Petit, a successful instance of similar practice was recorded by Cabrole, in a work which this author pub- lished, under the title of A*f recent date. (See Hennen's Military Surgery, Ed. 2, p. 438 ) As the latter author observes, wounds of the stomach not unfrequently become fistulous and remain open. In u cuse, re- corded by Richerand. the fistula continued open nine years'; and in another instance, related by F.ttmuller, ten years. (De Vul- nere Venlriculi Programma, Lip. 1730.) And Wencker has detailed a case, in which the opening continued twenty-seven years. (See Halleri Dissert. Chir. Vol. 6, art. 19.) For farther information, connected with this subject, the reader may also consult, Jungen, de Lethalitate Vulnerum Venlriculi, Helmst. 1751; and Ludov. Horn, de Ventri- culi Ruptura, Svo Berol. 1817. Also Med. Chir. Journ. Vol. 5, p. 72. Wounds of the Intestines.—The vomiting of blood, or discharge of it by stool; the escape of fetid air, or of intestinal matter, from the mouth of the wound ; an empty collapsed state of a portion of bowel, pro- truded nt the opening in the skin, are the common symptoms attending u wound of this kind. When the wound Is situated in the protruded portion, it is obvious to the surgeon's eye ; but when it affects a part of the intestinal canal within the abdomen, the nature of tbe case can be known only by a consideration of other symptoms. In addi- tion to such as I have already described, there are some others, which ordinarily accompany wounds of the bowels ; as, for instance, oppression about the praecordia, acute or griping pain in the belly, cold sweats, syncope, be. But, unle-33 tbe wounded intestine protrude, there is no practical good in knowing whether the bowel rs injured or not, since, If it be in f h+ WOUND? lihi suuo-men, the treatment ought not to be materially different from tbat of a simple penetrating wound of the belly, unattended with a wound of any of the viscera. Large wounds of the small intestines, particularly of the duodenum and jejunum, are attended with acute fever, anxiety, paleness of the countenance syncope, cold perspirations, a small, intermitting, tremulous pulse, and they frequently prove fatal. Injuries of the small intestines are also more often, than those of the large ones, followed by extra- vasation. A total division of the upper part of the intestinal canal, towards the pylorus, will deprive the body of the nourishment requisite for its support. If the chyle escape from the wound, the patient will die of a slow marasmus : and if it become ex- travasated, it will be likely to excite such irritation as will prove fatal. The escape of excrement, or of fetid air from the wound, indicates an injury of one of the large in- testines. In these cases, the symptoms are generally milder, and the passage of the intestinal contents outward through the wound more easy, on account of the bowel being less moveable. For the same reason, the wounded intestine more readily con- tracts an adhesion to the adjacent parts. (Callisen, Syst. Chirurgia Hodierna, T.l, p. 717.) A wounded intestine is said to present some particular appearances, to which the generality of writers have paid no attention : " If a gut be punctured, the elasticity ofthe peritoneum, and the contraction of the muscular fibres, open (he wound, and the villous, or mucous coat, forms a sort of her- nial protrusion, and obliterates the aperture. If an incised wound be made, the edges are drawn asunder, and reverted so that the mucous coat is elevated in the form of a fleshy lip. If the section be transverse, the lip is broad and bulbous, and acquires tume- faction and redness from the contraction of the circular fibres behind it, which produces, relatively to the everted portion, the ap- pearance of a cervix. If the incision be according to the length of ihe cylinder, the lip is narrow, and the contraction of the ad- jacent longitudinal fibres, resisting tbat of the circular fibres, gives the orifice an oval form. This eversion and contraction are produced by that series of motions, which constitutes the peristaltic action of the in- testines." (Travers on Injuries of the Intes- tines, p. 85.) According to this gentleman, some of these appearances were described by Haller, in Element. Physiol, lib. 24, sect. 2; and Opera Minora, f. 1, sect. lb. Having witnessed the facility, with which considerable injuries of the intestinal tube were repaired, Mr. Travers was desirous of ascertaining more fully the powers of na- ture in the process of spontaneous repara tion, and of determining, under how great a degree of injury it would commence, as well as the mode of its accomplishment. For these purposes, he divided the small intestine of several dogs as far as tbe mesen- Vor,. IL 9(i terry. AH these animals died, in conse- quence of the intestinal matter being extra- vasated, if they had been lately fed, or if they had been fasting in consequence of in- flammation, attended with a separation of the ends of the divided bowel, eversion of the mucous coat, and obliteration of the cavity, partly by this eversion, and partly by a plug of coagulated chyle. Iu one particular instance, in which Mr. Travers made a division of th* bowel, half through its diameter, a sort of pouch vvas formed round the injured intestine. " A pouch, resembling somewhat the diverti- culum in these animals, was formed opposite to the external wound, on the side ofthe pa- rietes, by the lining peritoneum, on the other side, by the mesentery of the injured intes- tine, that intestineitself,aiidanadjacentfold, which had contracted with it a close adhe- sion. The pouch, thus formed and insula- ted, included the opposed sections of the gut, and had received its contents, be. The tube, at the orifices, was narrowed by the half eversion, but offered no impediment to the passage of fluids." (P. 96.) Whether, under these circumstances, the functions of the alimentary canal could have been con- tinued, Mr. Travers professes himself inca- pable of deciding. Among the inferences, which this gentleman has drawn from the experiments, detailed in his publication, the tendency of the two portions of a divided bowel to recede from each other, instead of coalescing to repair the injury, merits no- tice, inasmuch as it tends to show, that the only means of spontaneous reparation con- sist in the formation of an adventitious canal, by the encircling bowels and their appendages. The everted mucous coat, which is (he part opposed to the surround- ing peritoneum, is also indisposed (o the ad- hesive inflammation. When, however, the wound of the intes- tine is smaller, the obstacles to reparation are not absolutely insurmountable. Here, retraction is prevented, and the processes of eversfon and contraction modified by the limited extent of the injury. If, therefore, tbe adhesive inflammation unite the con- tiguous surfaces, effusion will be prevented, and the animal escape immediate destruc- tion. But, union can only take place through the medium of the surrounding parts. According to Mr. Travers, it is the re- traction, immediately following the wound, that is a chief obstacle to the reparation of the injury ; for, if the division be performed in such a way as to prevent retraction, the canal will be restored ia so short a time, as but slightly to interrupt the digestive func- tion. In confirmation of this statement, a ligature was tightly applied round the duo- denum of a dog, which became ill, but en- tirely recovered, and was killed. " A liga- ture, fastened around the intestine, divides the interior coats of the gut, in this effect resembling the operation of a ligature upon an artery. The peritoneal tunic alone maintains its integrity. The inflammation, 682 WOUNDb which (He ligature induces ou either side of it, is terminated by the deposition of a coat of lymph, which is exterior to the ligature, and quickly becomes organized. When the ligature, thus enclosed, is liberated by the ulcerative process, it falls of necessity into the canal, and passes off with its con(en(s." (P. ue, 104.) It appears also from Mr. Travers's experi- ments and observations, that longitudinal wounds of tiie bowels are more easily repair- ed, than such as are transverse In a dog, a longitudinal wound, of the extent of an inch and a halt, was repaired by the adhesive inflammation. Here the process of eversion is very limited ; the aperture bears a smaller proportion to the cylinder of the bowel; and tbe entire longitudinal fibres resist the action of the circular, which are divided, and can now only slightly lessen tbe area of the canal. (P. 108.) We come now to the consideration ofthe treatment of wounds of the intestines; a subject, in which much difference of opinion has prevailed ; principally, however, con- cerning the circumstances in which sutures are necessary, and the most advantageous way of applying them. When the wounded bowel lies within the cavity of the abdomen, no surgeon of the present day would have the rashness to think of attempting to expose the injured intestine, for the purpose of sewing up tiie breach of continuity in it. In fact, the sur- geon seldom knows at first what has hap- pened ; and when (he nature of the case is afterward manifested, by the discharge of blood per anum, an extravasation of intes- tinal matter, be. it would be impossible to get at the injured part of the bowel, not only because its exact situation is unknown, but more particularly on account of the ad- hesions, which are always formed with sur- prising rapidity. But, even if the surgeon knew to a certainty, in (he firs( instance, lhat one of the bowels was wounded, and the precise situation of the injury, no suture could be applied, without considerably en- larging the external wound, drawing the wounded intestine out of the cavity of the abdomen, and handling and disturbing all the adjacent viscera. Nothing would be more likely, than such proceedings, to ren- der the accident, which may originally be curable, unavoidably fatal. I entirely agree upon this point with Mr. John Bell, who says, " When there is a wounded intestine, which we are warned of only by the pass- ing out of the feces, we must not pretend to search for it, nor put in our finger, nor expect to sew it to the wound ; but we may trust that the universal pressure, which prevents great effusion of blood, and col- lects the blood into one place, that very pressure, which always causes the wounded bowel and no other to protrude, will make the two wounds, the outward wound and the inward wound of the intestine, opposite each other, point to point; and if all be kept there quiet, though but for one day, so lively is the tendency to inflame, that the adhesion will be beguu, which is lo save the patient's life." (Discourses mi Wounds, p 361, Edit. 3.) When the extravasation, and other symp- toms, a few days after the accident, show the nature of the case, a suture can be of no use whatever, as the adhesive inflamma- tion has already fixed the part in its situ- ation, and the space in which the extrava- sation lies is completely separated from the general cavity of the abdomen by the sur- rounding adhesions. When (he bowel does not protrude, and the opening in il is situated closely behind the wound iu the peritoneum, a suture is not requisite; for the contents of the gut not passing onward, will be discharged from the outer wound, and not be diffused among (he viscera, if care be (aken to keep the exlernal wound open, lhere is no dan- ger of (he wounded bowel changing ils situation, and becoming distant from the wound in the peritoneum, for the situation which it now occupies is its natural one. Nothing but violent motion or exertions could cause so unfavourable an occurrence, and (hese should always be avoided. Tbe adhesions, which (ake place in the course of a day or two, at length render it impos- sible for the bowel to shift its situation. Things, hovvever, are far different when tbe wounded part of the bowel happens to protrude. Here we have the authority of all writers in sanction of the employment of a suture. No enlargement of the outer wound is requisite to enable trie practitioner to adopt such practice ; there is no disturb- ance of the adjacent parts; there is no doubt concerning the actual existence of the injury . no difficulty in immediately finding out its situation But, though authors are so generally agreed about the propriety of using a suture in tbe case of a wounded and protruded bowel, they differ exceedingly both as to the right object of the method, and the most advantageous mode of sewing the in- jured part of the intestine. Some have little apprehension of extravasation, advise only one stitch to be made, and use the li- gature chiefly with a view of confining the injured bowel near the external wound, so that in the event of an extravasation the effused matter may find its way outward. Other writers wish to remove the possibi- lity of extravasation, by applying numerous stitches, and attach little importance to the plan of using the ligature principally for the purpose of keeping the intestine near the superficial wound. When the wound of a bowel is so small that it is closed by the protrusion of the villous coat, the application of a suture must evidently be altogether needless; and since the ligature would not fail to cause irritation, as an extraneous substance, the employment of it ought unquestionably to be dispensed with. Supposing, however, the breach in tbe intestine to be small, yet sufficient to let (he feces escape, what method ought fo be WOL.NDb 083 riopled r The following practice seems rational. As Sir Astley Cooper vvas ope- rating on a strangulated hernia, at Guy's Hospital, an aperture giving issue to the in- testinal contents was discovered in a portion of the sound bowel, just when the part was about to be reduced. The operator, inclu- ding the aperture in his forceps, caused a fine silk ligature to be carried beneath the point of the instrument, firmly tied upon the gut, and the ends cut off close to the intestine. The part was then replaced, and the patient did well. Mr. Travers, who has related this fact, approves of the plan of cutting away the extremities of the ligature, instead of leaving them hanging out of the external wound. It appears, that, when the first practice is followed, the remnant always makes its way into the intestine, and is discharged with the stools without any in- convenience. But when the long ends are drawn through the outer wound, and left in it, they materially retard the process of heal- ing. (On Injuries of the Intestines, fyc. p. 112, 113.) Let us now inquire what ought to be the conduct of a surgeon, should he be called to a patient, whose bowel is divided through its whole cylinder, and protruded out of the external wound. Various have been the schemes and pro- posals for the treatment of this sort of acci- dent; and since experience has furnished few practitioners with an opportunity of seeing such a case in the human subject, a variety of experiments have been made on animals, in order to determine what treat- ment would be the most successful. Ram- dobr, indeed, is stated by Moebius to have had occasion to try on the human subject a plan, of which a vast deal has been said and written. He cut off a large part of a mor- tified intestine, and joined the two sound ends together, by inserting the upper within the lower one and fixing them in this posi- tion with a suture, (he ligature being also employed (o keep (hem al (he same time near (he external wound. The patient re covered, and the feces continued to pass entirely by the rectum in the natural way. (See Hallen Disput. Anat. Vol. 6, Obs. Med. Miscellun. 18.) About a year after the operation, the patient died, when the anatomical prepara- tion of the parts was sent to Ramdohr by Heister. They were preserved in spirits of wine, and exhibited, according to the latter author, an union of (he two ends of the bowel together, and their consolidation with a part of the abdomen. Now it has been questioned by a late writer, whether the union here spoken of ever really happened. When the upper end of the bowel is intro- duced into the lower, the external surface of the former is put in contact with the inner one ofthe latter; a serous membrane is placed in conlac( with a mucous one. These heterogeneous structures, he alleges, are not disposed to unite The mucous membrane, when inflamed, more readily secretes a kind of mucus, which would be an invincible obstacle to adhesion. He thinks it therefore more than probable, that, in the case related by Heister, the invagi- nation was maintained by the union of the intestine with the corresponding part ofthe abdominal parietes. Several experiments on living animals have convinced bim that this happens, and that the mucous mem- brane will not unite with the external peri- toneal coat. This impossibility of produ- cing an immediate union between the mu- cous and serous membranes may of course be urged as an objection to Ramdohr's practice. (Richerand, Nosographie Chir. T. 3, p. 344, 345, Edit. 4.) Another equally strong objection is, that the upper end of the bowel cannot be put into the lower one, unless it be separated from a part of the mesentery. Here the division of the mesenteric arteries may cause a dangerous bleeding. In vain did Boyer tie seven or eight of these vessels : his patient died with an extravasation in the abdomen. (Riche- rand, T 3, p. 343, Edit. 4.) Moebius attempted to repeat Ramdohr's operation upon a dog; but he could not succeed in insinuating the upper part of the divided bowel into the lower one, on ac- count of the contraction ofthe (wo ends of the intestinal tube, and the smallness of the canal. Moebius, therefore, was obliged to be content with merely bringing the ends of the bowrel together with a suture : the ani- mal soon afterward died of an extravasa- tion ofthe feces. Dr. Smith, of Philadelphia, also tried to repeat Ramdohr's method, but could not succeed. He divided the intestine of a dog transversely, and having inserted a piece of candle into that portion ofthe bowel, which was supposed to be uppermost, he endea- voured to introduce the superior within the inferior; but the ends became so inverted, that it was found utterly impossible to suc- ceed. The scheme vvas therefore given up, and only one stitch made, the ligature being then attached to the external wound, in the manner advised by Mr. John Bell. The dog died, and on examination there was found a considerable quantity of feces and water in the abdominal cavity. Twro more trials were made of Mr. John Bell's plan, by Dr. Smith, on the intestines of dogs. In both instances the animals died, the intestines being much inflamed, and feces effused in the abdomen. (See Dr. Smith's Thesis.) Mr. Travers likewise tried the same ex- periment. " I divided the small intestine of a dog, .which had been for some hours fast- ing, and carried a fine stitch through the everted edges, at the point opposite to their connexion with the mesentery. The gut was then allowed to slip back, and the wound was closed. The animal survived only a few hours. Examination. The pe- ritoneum appeared highly inflamed. Adhe- sions were formed among the neighbouring folds, and lymph vvas deposited in masses upon the sides of the wounded gut. This presented two large circular orifices. Among 684 WOL.ND^. the viscera were found a quantily of bilious fluid, and some extraneous substances, and a worm was depending from one of the apertures. By the artificial connexion of the edges in a single point of their circum- ference, and their natural connexion at the mesentery, tbey could recede only in the intervals, and here they had receded to the utmost." In another experiment, Mr. Tra- vers increased the number of points of contact, by placing three single stitches upon a divided intestine, cutting away the threads, and returning the gut. The animal died on the second day. Examination. Similar marks of inflammation presented themselves. Tbe omentum was partially wrapped about the wound ; but one of the spaces between the sutures vvas uncovered, and from this the intestinal fluids had esca- ped. On cautiously raising the adhering omentum, the remaining stitches came into view. Here again the retraction was con- siderable, and the intervening elliptical aperture proportionally large. On the side, next to the peritoneum, however, the edges were in contact and adhered, so as to unite the sections at an angle. From such experiments, the conclusion drawn by Mr. Travers is, lhat apposition at a point or points, is, as respects effusion, more disadvantageous than no apposition at all; for it admits of retraction and prevents contraction, so that each stitch becomes the extremity of an aperture, the area of which is determined by the distance of the stitches. (P. 116, 119.) This gentleman therefore maintains, that the absolute contact of the everted surfaces of a divided intestine, in their entire circumference, is requisite to secure the animal from the danger uf abdominal effusion. (P. 121.) The species of suture employed (says Mr. Travers) is of second- ary importance, if it secures this contact. (P. 134.) Aud among other observations, I find " wounds amounting to a direct divi- sion of the canal are irreparable, and there- fore invariably fatal." (P. 133.) These inferences do not appear to me satisfactorily established. We are told, that apposition at a point or points is, as respects effusion, more disadvantageous than no ap- position at all, and that the absolute con- tact of the divided surfaces, in their entire circumference, is requisite to secure the animal from the danger of abdominal effu- sion. The foundation of these unqualified conclusions is five experiments made on dogs, in four of which experiments the di- vided bowel was brought together witb one stitch, on Mr. John Bell's plan, while in another three stitches were made; and yet, in all these instances, the animals died with the contents of (he bowels effused. So far the inferences seem established. Unfortu- nately for their stability, however7, Mr. Travers immediately afterward proceeds to relate other experiments, instituted by Sir Astley Cooper, Dr. Thomson, and Dr. Smith, which, though Mr. Travers seems snaware of the fact, tend most completely to overturn the conclusions, which he had been previously making. " Sir A. Cooper repealed the experiments of Duverger, who had succeeded in uniting by suture, the divided intestine of a dog, in- cluding in it a portion of the trachea of a calf. In place of the uninterrupted suture, three distinct stitches were inserted. On (he six- teenth day tbe animal was killed, aud (he union vvas complete." (P. 123.) Here are two facts, proving iat a wound- ed intestine may be united, though (he suture vvas nol such as to maintain the divided sur- faces in contact, in the whole of their cir- cumference. Sir Astley Cooper then made (he experi- ment, without including the foreign sub- stance. The animal recovered, being a third fact, (ending (o prove, (bat the absolute contact of every point of the ends of the divided bowel is not essential to the cure. (See. A. Cooper on Inguinal and Congenital Hernia, Chap. 2.) After dividing the small intestine of a dog, Dr. John Thomson, of Edinburgh, applied five interrupted stitche.*,'at equal intervals, the ends of the ligatures were cut oft", and the external wound was closed wilh a su- ture. This animal did not die of the opera- tion, and when he was afterward killed, it appeared that the threads bad made (heir way into the interior of the intestinal canal. Dr. Thomson repeated lhi> experiment, and did not kill (he animal*till six weeks after- ward, when the same tendency of ligatures to pass into the bowels, and be thus dischar- ged, was exemplified. These two last cases make five, in proof lha( (be absolute contact of every part of (be ends of a divided bowel is not essential to prevent effusion, or the consequences of the wound from proving fatal; and several other experiments were made by Di. Smith, of Philadelphia, who employed four stitches with similar success. As far then as the majority of such facls ought to have weight, we are bound to re- ceive the conclusions of Mr. Travers as in- correct, and unestablished. I am only sur- prised, that Mr. Travers himself, who has cited (he particulars of all these last experi- ments, did not perceive, that they struck di- rectly at his own inferences. They are not only irresistible arguments against Mr. Tra- vers's conclusion, that the union of a divided bowel requires the contact of the cut extre- mities in (heir entire circumference; but Ihey are a plain denial of another position advanced hy ibis author, viz. that wounds amounting (o a direct division of the canal, are irreparable, and, therefore, invnriably fatal. With respect to the species of suture be- ing of secondary importance, provided it secure the complete contact of every part of the everted ends of the divided bowel, I regret, (hat Mr. Travers bas omitted to insti- tute experiments, in order to show that any such suture can be practised, and if he has the ingenuity to apply it, whether the result would be for or against the conclusion;. WOUNDS. 686 which be has formed. The fact of the su- tures always making their way into the cavi- ly of (he bowel, and being thus got rid of, appears lo me highly interesting, since it shows the safe(y of cutting away the ends instead of leaving them hanging out of the external wound, so as to create the usual ir- ritation and inconveniences of extraneous substances. It seems that Mr. Benjamin Bell first recommended cutting the ends ofthe li- gatures away, and reducing the bowel in this state into tne abdomen, as, be says, a con- siderable part of the remainder of the liga- ture will fall into the cavity of the gut (Sys- tem of Surgery, Vol. 2, p. 128, edit. 7.) We have seen that the experiments of Dr. Thom- son confirm the observation, and those insti- tuted by Mr. Travers, tend to the same con- clusion. According to tbe latter writer, the follow- ing is the process, by which a divided intes- tine is healed, when sutures are employed. "It commences with the agglutination of the contiguous mucous surfaces, probably by the exudation of a fluid, similar to that which glues together the sides of a recent flesh wound, when supported in contact. The adhesive inflammation supervenes, and binds down the everted edges of the peritoneal coat, from the whole circumference of which a layer of coagulable lymph is effused, so as to envelope the wounded bowel. The ac- tion of tbe longitudinal fibres, being oppo- sed to the artificial connexion, the sections mutually recede, as the sutures loosen by tbe process of ulcerative absorption. During ibis lime, the lymph deposited becomes or- ganized, by which further retraction is pre- vented, and the original cylinder, with the threads attached to it, is encompassed by (he new tunic. " The gut ulcerates at the points of the ligatures, and these fall into its canal. The fissures left by the ligatures, are gradually healed up ; bul (he opposed villous surfaces, so far as my observation goes, neither ad- here, nor become consolidated by granula- tion, so (hat the interstice, making the divi- sion internally, is probably never obliterated." (Travers on injuries of the Intestines, fym p. 12S.) Notwithstanding I have carefully read all the arguments adduced by Mr. Travel's in favour of stitching a divide d bowel at as many points as possible, I still remain un- convinced of the advantage of such practice, for reasons already suggested. If a case were to present itself to me, in which a bowel, partly cut through, protruded, I bbould apply only a single suture, made with a small sewing-needle, und a piece of fine silk. If the bowel were completely cut across, I should have no objection to attach its ends together by means of two or three Btitches of the same kind. I coincide with Mr Travers, respecting the advantage of culling off the ends of the ligature, instead of leaving them in the wound, as I believe he is ri-ht, in regard to the little chance (here is of the injured intestine receding far from the wound- and if ri "■ ends of the ligature are then of no use in keeping the bowel iu this position, (hey must be objectionable, as extraneous substances. As confirming some of the foregoing ob- servations, I would refer to the valuable wri- tings of Scarpa, and those of Dr. Hennen. The parts of ihe former, to which I allude, being contained in tbe last edition of the First Lines of Surgery, need not here be re- peated. " Tbe older practitioners, (says Dr. II. nnen,) were very much averse from leav- ing any thing to nature in cases of abdomi- nal injuries, although their universal em- ployment of sutures ough( to have convinced them, how much she could bear with impu- nity; for there can be very little doubt, that their uniform performance of the operation of gastroraphe vvas at least superfluous, if not positively hurtful. In tbe course of a very extensive practice, two cases only have come under my notice, where it was required to a wounded intestine, though frequently it may be needed for injuries to the parietes." (On Military Surg, ed 2, p. 411.) When the protruded intestine is mortified, which must be a very rare occurrence in cases of wounds, the treatment should be the same as that of a mortified enterocele. (See Hernia.) As Dr. Hennen observes, in the treatment of wounds of the abdomen, the violence of sypmtoms is to be combated more by gene- ral means, than by any of tbe mechanical aids of surgery. The search for extraneous bodies, unle-s superficially situated, or they can be felt with <\ probe, is entirely out of the question. " Enlargement, or contrac- tion of the wound, as the case may require, for returning protruded intestine, securing the intestine itself, and promoting the ad- hesion of the parts, is all (hat the surgeon must do in the way of operation; and even in this, Ihe less he interferes the better." (On Military Surgery, ed. 2 p. 401.) The principal indication is to prevent a dangerous degree of inflammation. Hence bleeding and the antiphlogistic treatment are hi.hly indispensable. Let not (he sur- geon be deterred from such practice by the apparent debility of the patient, his small concentrated pulse, and the coldness of his extremities, symptoms common in acute in- flrttnmatioti of the bowels, and, in fact, them- selves, indicating the propriety of repeated venesection. Wounds of the small intes- tines are attended with more dangerous symptoms than those of the large ones. All flatulent, stimulating, and solid food, is to be prohibited. The bowels are to be daily emptied with -dysters, by which means, no matter will be -uffered to accumulate in the intestinal canal, so as to create irritation and distention. When excrementitious matter is discharged from the outer wound, it is highly necessary lo clean and dress the part very frequently. Gentle pressure should also be made with Ibe fingers, at the circumference of the wound, at each time of applying the dress- ings, for the purpose of promoting the e? 686 W0LM1S. cape of any extravasated mailer. For Ihe same reason, the patient should always lie, if convenient in a posture that will render the external opening depending. After a day or two, the surgeon need not be afraid of letting the outward wound heal up; for the adhesive inflammation, all around (he course of the wound, will now prevent any extravasated matter from becoming dif- fused among the viscera. If the case should end well, the intestine generally undergoes a diminution in ils diameter at the place where the wound was situated. When this contraction is considerable, the patient oc- casionally experiences colic pains at the part, especially after eating such food as tends to produce flatulence. As these pains usually go entirely off after a certain time, and no inconvenience whatsoever remains, the in- testine may possibly regain i(s wonted capa- city again. A more considerable corislric- (ion of the above sort has been known to occasion a fatal miserere. Even the intes- tine itself has been known to burst in (his situation, after ils contents had accumulated behind Ihe contracted part. Patients who have recovered from wounds in the intes- tines, should ever afterward be particularly careful not lo swallow any hard substances, or indigestible flatulent food. On (his sub- ject the writings of Scarpa are particularly interesting. In some instances, intestinal malter con- tinues .to be discharged from the outer wound, either in part, or entirely, so that either a fistula, or an artificial anus, is the consequence. A fistulH is more apt to fol- low, when an intestine has been injured by a hall, has been quite cut through, or has mortified. Bul numerous cases prove, (hat (bis is not invariably the consequence, and tbat a perfect cure h;is frequently followed each of Ihese occurrences. (See Anus, Arti- ficial.) When an intestine is completely cut through, and tbe lower portion of tbe canal lies inaccessibly concealed in the abdomen, writers insist upon (he necessity of promoting (he formation of an artificial anus. In this particular case, they recommend fixing the extremity of the intestine with a fine suture, to the edges of the outer wound. Iu order lo distinguish Ihe upper end of the intestine from the lower, (he proposal is sometimes made to give the patient a little milk, and to observe whether ibe fluid, after a (ime, issues from (he moutii of the protruded gut. In (he mean while fomentations are employed. If (he upper end of the intestine be in the abdomen, ihese speculative authors even deem il justifiable, when the accident is quite recent, lo dilate the outer wound, search for the hidden continuation of the bowel, and then sew the (wo ends together. Practical surgeons, I believe, are right in attaching little value to such directions. " Indeed, (says a modern writer,) Ihe surgi- cal world have long since dismissed their fears about the intestine falling inwards, and about the difficulties of distinguishing be- ' iveen tbe right and the wrong end of it. The apprehensions of abdominal effusion^ are now all pretty well subdued. The occur rence is extremely rare, and when it does happen, we leave the poor wretch (o die in peace, without searching after effused fluids, the nature of which cannot be known, or if known, (he information cannot in the most remote degree lead (o recovery. I have never witnessed a case where any possible good effects could follow the paracentesis; for peritonitis, iu its most exquisite form, has always preceded the symptfrn-s wliich would lead to the performance of (hat ope- ration." (Hennen on Military Surgery, Ed. 2, p. 411.) In some instances, musket-halls pass into tlie abdomen, lodge there a considerable (ime, and are then voided through the in- testinal canal; while, in other examples, they become encysted, and continue lodg- ed the rest of the patient's life, without producing much, or, indeed, any inconve- nience. Contusions and other Injuries of the Ab- domen.—A violent contusion of the abdo- men may injure the contained viscera, wilh- out Ihe occurrence of any external wound. It was in thi« way, that the liver or gall- bladder was ruptured in the boy mentioned by Mr. Fryer, (Med. Chir. Trans. Vol. 4;) and (ha( tbe vena cava was lacerated in the case which fell under (be observation of Richerand, where a carl-wheel passed over child's belly. (Nosoirraphie Chir. T. 3, p. 353.) , Iu olher instances, the mischief is done to the intestines; and still more fre- quently, the viscera, as well as the parietes of the abdomen, have only suffered a more or less forcible contusion. The effects of such violence, are inflammation of the in- jured bowels, aud their adhesion to (he in- side of the peritoneum. Thus the stomach and intestines, the liver, and the gall-blad- der, when inflamed from a blow upon the front of the belly, contract adhesions to (be corresponding portion of the parietes, which has been also bruised, and is ilself inflamed. When such inflammations suppurate, (and, according to Richerand, it is (heir mosl usu- al tjourse,) on opening the abscess, the pus is found blended with tbe matter, which the viscera contain or secrete. Thus the alimen- tary matter, aud even intestinal worms have been discharged with the pus on opening certain abscesses, which communicated wilh (he cavily of the stomach or bowels ; and bile has been found blended with the mat- ter of abscesses in (he right hypochondri- um. When in consequence of a blow upon the anterior part of the belly, the patient expe- riences in the situation ofthe injury a deeply- seated pain ; when a tumour forms, and the symptoms indicate violence done to some of the adjacent viscera ; the inflammation is to be opposed by every possible antiphlogistic means. But when, notwithstanding such treatment, the swelling increases and suppu- rates, the abscess is not to be opened until it is perfectly mature. The inflammatory symp- toms, which preceded its formation, indicate WOUND? 687 that there ji.-, an adhesion between the in- jured organ and the parietes of the abdomen. Without this adhesion, opening the abscess would be attended with more risk, because the pus, or other matter, might become ex- travasated in the cavity of the peritoneum. For the same reason, iu the examples of tu- mours, caused by bile in the gall bladder, J. L. Petit recommends deferring the opera- tion of opening them, until the inflammatory symptoms evince, that an adhesion has taken place between the fundus of the gall bladder, and the corresponding point of the parietes of the abdomen. An adhesion of the abdominal viscera to the inner surface of tbe peritoneum may be induced by other causes, besides the action of contusing bodies. A knife, a tork, a shoemaker's awl, a needle, and other extra- neous substances incapableof passing through- out the alimentary canal, have been known to irritate the stomach, or bowel, and to bring on adhesion of them to the parietes of tbe abdomen, where a tumour has formed, which, on being opened, has discharged the foreign body. The records of surgery abound in facts of this kind. A fistula suc- ceeds the opening of the abscess; the ali- mentary mailer escapes; and if the aper- ture admit not of being healed by methodi- cal compression, the intestinal canal between the fistula and the anus contracts ; most of the contents of the bowels pass out at the preternatural opening, and the patient falls into a state of marasmus, the more quickly fatal, the nearer the injury of the intestinal canal is to the stomach. A long-continued pressure on the epigas- tric region may cause an adhesion of the stomach to the peritoneum, and suppuration taking place at the part, a fistula, communi- cating with the cavity of that organ, may be formed, and allow the victuals to escape ex ternally. (See Richerand, Physiologic, T. 1.- Chymificalion : Aosographie Chirurg. T. 3, p. 353—350, Ed. 4.) I shall conclude, with repealing, that in the generality of injuries of the abdomen from external violence, whether wounds or contusions, the principal danger depends upon inflammation of the peritoneum. In the treatment, therefore, the most necessary thing is to prevent and oppose this perilous affection. Copious and repeated venesec- tion, the application of leeches, mild ape- rient clysters, a low fluid diet, perfect rest, fomentations, and the warm bath, are among the most effectual antiphlogistic remedies, which, in such cases, are entitled to praise and confidence. For information on wounds of the abdo men, see Flajani, Osscrvazioni, fyc. T. 3. A. Malaval Quastio, &,c. an tenuium intesti- norum vulnus lethale ? Paris, 1734 Wencker, Virginis per viginti septem annos ventriculum perforatum habentis, Historia el Sedw, Ar- gent. 1743. Haller, Disp. Chir 6—19. Callisen's Systema Chirurgue Hodiema, T.l, » 697, fyc. Edit. 1798, Hafnia. Richerand, Nosogr. Chir. T. 3, p. 327, 4c Edit. 4. Med. Clrir: Trans. Vol. 4. p. 330. J. Cramp- ton's Case of Rupture of the Stomach and Escape of its Contents, fyc. with Obs. by B Travers, in Med. and Chir. Trans. Vol. 8, p- 228, fyc.Jlichter, Anfangsgrunde der Wun- darzneykunsl, B. 5, Kap. 1. Discourses on the Nature and Cure oj' Wounds, by John Bell, Edit. 3. L. Nannoni, De Similium par- Hum humanum corpus conslilutentium rege- neratione, Mediolani. 1782. Encyclopidie Mithodique, Partie Chir. Art. Abdomen et Intestins. Dr. Smith's Inaugural Thesis. B. Travers, an Inquiry into the Process oj' Nature, in repairing Injuries of the Intes- tines, Svo 1812. J Hunt ci on Gunshot Wounds. Sir A. Cooper's work on Inguinal and Conge- nital Hernia, Chap. 2, fol. 1804. Sabatier, Midecine Opiraloire, T.l. Petit, Essai sur les Epanchemens, fy Suite de I'Essai sur les Epanchemens, in Mim. de I'Acad. de Chir. For information on wounds in general, see Cas. Magatus, De Rara Medicatione Vul- nerum, seu de Vulneribus raro traclandis, fol. Ven. 1616. A. Read, his Works, containing, 1. Lectures on Tumours and Ulcers. 2. A Treatise ofthefirsi Pari of Chirurgery, which teacheth the reunilion of the parts of the Body disjointed, and the methodical doctrine of Wounds, fyc. 2d Edit. 8vo. Lond. 1650. Wer- ner, De Vulneribus absolute et per accidens le" thalibus, Regiom. 1650. J. Bohn, De renun- cialione Vulnerum ; seu Vulnerum Lcthalium Examen, 12mo. Lips. 1689. P. Ammannus, Praxis Vulnerum lelhalium, fyc. l2mo Fran- cof. 1690. ./. Lolbatch, New Light of Sur- gery, showing a more saj'e and speedy way of curing Wounds, than has hitherto been prac- tised, 12mo. Lond. 1095. Ph. Conr. Fabri- cius, Programma quo causa infrt quentia vul- nerum lethalium, prce minus lethiferi sexfab- rica corporis humani auatumica, et silupartium pracipue eruuntur, Helmstad. 1753. John Hunter, a Treatise on the Blood, Inflammation, fyc. John Bells Principles of Surgery, and his Discourses on Hounds. W. Balfour, Ob- servations on Adh considerable a number of the bitten and calamitous beings could not be ac- crimmodated in any house that could be procured. I was therefore obliged to separate them into three divisions ; and send each division to a distinct house. I attached to the first division, nine men; to the second, eleven women ; and to the third, six children. In each of the houses I stationed a Hebrew surgeon, to prepare the decoction of the Genista lateotinctoria, to administer it to them regularly, and to report to me every thing that happened. The result was, that, in the1 first divi- sion, five persons hud swellings under the tongue; in the second, all had them ; and in the third, only three of the child- ren. Among these individuals, they who had the deepest and most numerous wounds, experienced the tumours on the third day. The rest on the fifth, spventh, and ninth days. In one. woman, these sub lingual swellings did not manifest themselves until (he twenty-first day after the bite. This woman had received a slight bite in the right leg. The seven persons who had no tu- mours nevertheless drank the decoction for six weeks, and were then set at liberty with the rest, excepting those whose wounds were not healed. They remain- ed in charge until their entire restoration to health. 1 have employed, as an excel- lent detergent, the residue of the decoc- tion of the herb Genista, as an applica- tion to the wounds, in the form of a poul- tice. It is not unfrequently necessary, to give a gentle purgative, once* a week, or at least a simple clyster prepared from a decoction ofthe marsh-mallows of the shops, in which a small quantity of Astrakan salt is dissolved. By either of these means, costiveness is prevented. There is a matter which merits (he greatest attention This is the succession of forerunning symptom*, observable during the formation of the -mall pus- tules, whose discovery is the offspring of a most lucky observation. Towards that stage, the pupil of the eye is dilated and fixed; the look is sad; uneasiness is complained of; and there is a small pain in the head. These are the only symp- toms 1 have been able to detect. The simple and easy method of treating per- sons threatened with hydrophobia, is that which has been practised upon about fbrtv individuals with complete success. The little girl, who fell a sacrifice to ruy experiment, affords a piece of evident! quite as strong. Henceforward a regi- men can be adopted, of which I will war rant the salutary result. By way of conclusion, I remark, thai at different times and places, 1 have treated six persons in the same manner; among others, a peasant who had been bitten by a mad wolf, as he was going from one village to another. His cries brought other men. who assisted in killing Ihe ferocious henst, vv ho had been already marked as hydrophobic. The only dif- ference between this and the radical cure, was, that this man, among other wounds, had been bitten on the forepart of the ahkle; and that the tendons and liga- ments were so lacerated, that all the sur- gical means which vvere applied, could not prevent a great deformity ofthe foot. He was confined to his bed for two months. After the disclosures I have made con- cerning (he hydrophobic virus, I consider the disease* us a local evil, of which it is possible to prevent the consequences, by a seasonable removal of the morbific matter. For after the reabsorption has been made, there are no means of arrest- ing its terrific effects. I think it may be (henceconcluded, that the known symp- toms of hydrophobia, such as constriction of tbe breast, violent pain in the head, dilatation ofthe pupil, occasional palsy of the tongue, convulsions, dread of liquids, all nervous symptoms, are produced by the reabsorption of the hydrophobic poi- son. Tiie nerves from the fifth pair, those which go to the tongue, the inter costal and corvical nerves, furnish diiect evidence; of the manner in which the virus exerts its deleterious action through the medium of the nerves leading from the sublingual and submaxillary glands. Without taking into consideration the complicated distribution of these nerves, their connexions and sympathies, 1 en- tertain the hope, that Physiology will, one day, give us more satisfactory details on this subject. It only remains for me, gentlemen, to state my sole and particu- lar desire for the publication of a me- moir, useful to humanity, and the chief object of my researches and of my exer- tions. Accept, respectable president, and m»-rubers, who have had the goodness to receive me as a colleague and fellow- labourer, the observations which I offer you, in the most philanthropic spirit; add thereto yourown intelligence, and aid me vvith your practical experience. I shall be overjoyed if I should be happy enough to limit the disasters caused by bydro- phobia. (Signed) MAROCHETTI appt.: Since the receipt of the foregoing, the Doctor has had forwarded to him a communication, which, when read, will be found in affinity with the preceding. Remarks on Hydrophobia, more particu- larly as it occurs in Dogs ; in a letter from a gentleman of observation and experience in JYew-Jersey, dated March 15, 1822. Sir—I lately read with much plea- sure, in the New-York Spectator of the 1st instant, Mr. Middleton's letter to you accompanying Dr. Marochetti's very interesting report on the symptoms and cures of hydrophobia. * As I consider it the duty of every member of the human race, to commu- jicate any thing that may in any way tend to elucidate or corroborate (bis wonderful discovery, (the grealest that has yet been made in medical science,) I beg leave to submit to your considera- tion two cases, which within these eighteen months have fallen within- my personal knowledge fend information, and may be depended on. On the morning of the eighteenth of December, 1820, while living in Canada, a favo.urite dog, belonging to me, of the Setter breed, showed what I imagined to be symptoms of madness, on which I immediately directed ray servant to tie him up in an out-house, and to give him some salt and water, as he appeared from scratching; his neck and throat until it absolutely bled, to have something sticking in it; this made him in a short time throw up a quantity of yellow frothy matter, and seemed to relieve him very much, so that at 12 o'clock he ap- peared free from every species of com- plaint. Soon after, the servant gave him some water, which he hipped freely, and immediately threw up a large quantity of the same yellow frothy matter, some of it in large lumps. From these symp- toms, 1 was induced to think that he had swallowed some poisonous substance, on which account I gave him some milk and water and fat mutton broth, which he took freely, and appeared as if sensi- ble of the attention paid him, and as usual wagged his tail, and readily obe}'ed every order I gave him. Next day his appearance was more unfavourable : his eyes appeared glazed and heavy, his tail drooped, his stomach and bowels were contracted, his back raised in a circular form, and his neck raw from continual scratching. At this time 1 had him and the barrow in which he lay removed to a warmer plate, which I did without any difficulty, as lie knew and obeyed me as usual; yet, soon after, when 1 held out my stick towards him, ho laid hold, and left the marks of his ili'l'V oflp teeth in it. in tlie evening I gave him some more milk and water, and mutton broth, wliich he took freely and went to rest. About midnight I was awakened by his incessant and apparently painful harking, which he continued without in- termission until daylight, when be exhi- bited what appeared to me such un- doubted signs of violent madness, that I was under the painful necessity of shoot-' ing him. My servant then told me, that the day 1 desired him to be tied up, he made a snap at his thigh, and gave it a pinch, but having on ihick pantaloons, and drawers, he did not break the skin, and no bad consequences have ensued from it. When staying last August with my friend, Mr. Grant, at Montreal, I happen- ed to mention all these circumstances to him, when he, pointing to a favourite dog, lying at his feet, told me, that about two years ago he was in so similar a situation, that he left orders with his servant to shoot him, and as he could not do it himself, or be in the way when it was done, he went into the country for some hours. On his return home, the, first question he asked was, " bave you disposed of the dog ?" to which, to his great surprise, the servant answered, "No, sir, 1 could not find in my heart to kill the poor dumb brute, and as he seemed by his violent scratching to have something in his throat, or «motith, that caused his illness, I got a friend to assist me, who held him down while I opened his mouth for the purpose of examining it, and his throat, when under his tongue, I observed a large Blob or Tumour, which I opened with a penknife, and out of it came a great deal of nasty matter, whicii the dog threw out of his mouth, imme- diately leaped up, frisked about the room as if sensible of the cure that had been effected on him, and he is now as well as ever he was." Mr. Grant could hardly believe the story ; but tht* entrance of the dog into the room, in his usual man- ner, to his great joy, confirmed the truth of it. On Mr. G's relating tliese circum- stances to me, I mentioned to him, that I thought the matter of so great conse- quence, that he ought to draw up a state - ment, and communicate it to some medi- cal friend, as it might, perhaps, be the means of finding out a cure for the dis- temper in dogs, which I then thought it was, though vvas convinced, from Dr. M.'s report, that it vvas the real hydro- phobia. As I soon after left that country, 1 do not know whether or not Mr. G. follow- ed my advice ; but in case he has not, I now give you all the circumstances of both cases, well convince! thi\* they can- 6&, APPENDIX. not be placed in better hands; leaving you at liberty to make such use as you may think proper of this information. As Dr. M. mentions having the hands properly covered when examining the m Hrths of patients, I would beg leave to suggest your publishing what material you deem a proper and necessary cover- ing for the hand; with which, and a lan- cet, at least one person in each village, or large family, ought, in case of accidents, to be provided, as there are many parts of this extensive country, where medical aid cannot be procured, or the patient unable to pay the expense of the long attendance necessary. And I would also beg leave to suggest the propriety of having this report of Dr. M.'s promulga- ted throughout the country in general, through the medium of newspapers or cheap pamphlets, with the addition of such remarks as you may think proper or necessary to make to it. When 1 was a boy, at school in the North of England,! learnt to worm dogs, which, it was said, did not prevent their going mad ; but in case they were infect- ed, occasioned a relaxation or paralysis in the lower jaw, which disabled them from biting any thing, and under that idea, I afterward wormed n number of dogs, but cannot, at this distant period, say what were the consequences or effects of it; but as the custom was ge- neral, (here, must have been something in it, and peihaps might have proceeded from the idea that the tongue was some- how afflicted. That the saliva of a mad dog will not communicate the disease, unless carried into the circulation through a wound in the skin, I am perfectly con- vinced, as a lady, a friend of mine, had her fact licked all over by a favourite grayhound, which had been tied up on account of being supposed to be infected, but got loose, and immediately after be- ing again tied up, got loose a second time, and ran ofi, and, before he was killed, bit a number of dogs and cattle, all of which went mad, yet the lady never felt any bad consequences from it. With real esteem, I have the honour to be, Sir, your most obedient, Humble Servant, W. ARMSTRONG. S. L. Mitchill, M.D. March 26, I8£2. LITHOTOMY. What I have to say at present upon this article, is founded upon two lately-discovered anatomical facts, which, in my opinion, will become ofthe first consideration in regulating the operation of lithotomy. The first of them has reference to the particular ex- tent, thickness, and connexion of the triangular l'gament of the urethra ; and the second to the peine partition, or d> minutes, and vvas refreshed, but was sick at stomach, and had made an effort to vomit ; ordered not to attempt to speak. 10 P M.—Had coughed -.me*, which was followed by a discharge of fresh blood from the mouth, as well as from the wound, so as to come through the bandage, and run upon the neck. Pulse 88 : had taken a little cold water by tea- spoonsful 31*/, 10 A. M.—Had a good night, but coughed hard several times, yet no more bleeding ; felt much refreshed from sleep ; pulse 92; skin tiatmal; took 10 drops tmct. opii to allay cough, but nausea be- ing the effect, vvas not repeated: to have cold barley water instead of common wa- ter, by the tea-spoonful. April 1st.—Passed an uncomfortable night, owing to cough ; pulse 92 ; was ordered enema communis, which was re- peated in tUe afternoon with good effect. Five P. M. pulse 120 to 13b; articulates a little, though indistinctly ; vvas ordered a cough mixture. SLd—More, comfortable; pulse 88; all symptoms favourable. No tumefaction about the eyelids ; cough less. 3d.— Felt refreshed ; countenance good; no tumefaction of the face ; articulated distinctly; pulse 88 ; complained of hun- ger. 8 P. M. pulse 80; cough was trou- blesome forepart of the day. mixt. ex- pect, cont. 4th.—Said with a distinct and audible voice that she- was better than at any other time since the operation ; felt no pain in the wound ; coughed less ; but from the state ofthe bandages, the wound was cleaned and dressed. The parts vvere found to look well; pulse 92; felt hungry ; vvas ordered some, thin broth. 5th.—Had a comfortable, night; took some chicken tea with much relish ; pulse 104 ; no appearance of tumefaction. Had an enema this morning which operated well; cough much relieved. 6th-—Dressed : removed from the up-' per wound the sutures, and all the liga- tures except one; parts looked well. The lower wound looked well; but there was little union there by adhesion, proba- bly owing to cough ; pulse 80. 7th.— Has been sitting up in bed a lit- tle ; pulse 32 ; was ordered sulphate of soda in divided doses. 8th.—Improving daily ; wound-- doing well; the last ligature from the upper wound was removed ; pulse 120. The increase of pulse probably owing to the operation of salts, which had just then taken place -•«- APPENDIX. 12//t.—While the wound was dressing this day the ligaturp from the carotid came away; patient doing well; pulse 104. 15/L—The fcetorand disagreeable taste in the mouth very much g«>ne, from the daily use of a weak spirit and water lo- tion. She was permitted to nurse her babe a little to-d»y. for the first time since the operation. 16th.—Wounds almost closed. 17th.—She felt satisfied that the wound within the mouth was completely healed. 210th.— H.td been down stairs. 2Sti.—Was permitted to chew some animal food on the right side of the mouth. 2Rth, Mid-day.— Suppuration was ob- served in the course of the cicatrix ofthe upper wound. Upon opening the part with a lancet, the noose of one of the li- gatures came away which had been left in the wound, the thread having been taken off before close to (he knot." May C.—Left the city this day, com- pletely recovered, for her residence on Long-Mand. The last case, though not by any means the least, I have now to commu- nicate. Prince, a coloured lad, aged 18 years, Was sent to Dr. Mod, from Middletown Point, Nevv-Jersej, having an osteo-sar- comatous tumour, embracing the lower jaw-bone from the articulation of the right side, as far round as the alveolar socket, supporting the first molar tooth on the left, presenting in size an appear- ance equal to that of his head. In giving his history, he stated that, at the age of twelve, an enlargement of the bone showed itself at the right side, op- posite the situation of the second molar tooth, which was at first considered a gum-bile, but, gradually increasing, dis- lodged, one after another, the teeth in its neighbourhood. When it had arrived to the size of a walnut, a lancet was put into it, but no pus or fluid issued In 1818, (then as large as a goose's egg) it was -'.gain open- ed, and a small quantity of hlood and matter was discharged. Lately, two or three small openings had taken place within the mouth, attended with a dis- charge of pus and ichor, at which places also were denuded several bony spiculae, clearly characterizing the disease. Ex- ternally, and near the most depending part, an ulceration of the skin had shown itself, from which the tumour afforded a daily discharge of an ounce or two of matter; and this had been kept up for fche several last weeks. By this opening, a probe could be passed for some dis- * Tbe reader may apply this fact to what bas been said in the Appendix e>f ^ol. I upon leaving ligatures iindCT tbe skin for Absorption, after amnntation. tancc into the substance of the enlarge^ ment. From the great emanation which was Firesent in this lad's case, there could be ittle hope entertained from the formida- ble operation which would be required to relieve him from such a mass of disease. Still, as he was about to perish, and being on bis own part very desirous to take what little chance the means might pro- mise, it was thought right to operate. Having assisted Dr. Mott in this opera- tion also, 1 had opportunity to observe the different steps of the performance. May lbth, 1842.—At noon this day the doctor co ..menced by tying the right ca- rotid artery, a little above the clavicle. This the patient bore well, being little exhausted; and after resting and refresh- ing himself wilh a little wine, he. express- ed his wish lhat the operation might be continued. An incison was now begun opposite the jugum lemporale, cairied in a semicircu- lar course over the most prominent part of Ihe swelling, and terminated opposite Ihe first molar tooth of the left side. Another cut of the same form, but of less extent, below this, left insulated a large piece of integument, in which was situated the ulceration. The flaps being then dis- sected from the tumour, the second bicuspis tooth of the left side was extract- ed, and the bone sawed through at this sound part, by the same instrument which had been devised for the other cases. Now raising with an elevator, and then by the thumb and finger, the hone, where sawn through, the diseased mass was cautiousl} dissected from the tongue, palate, and pharynx, until the joint upon the right side was exposed. The capsu- lar ligament was then cut into, at the in- ner side of the joint; after which, the bone was easily removed from its articu- lation. In the course of this operation; very little blood was lost, it being neces- sary only to apply four ligatures. The patient was much exhausted, as the operation, from the great extent of the disease, necessarily occupied a con- siderable time ; and this was also favoured by his previous state of debility. After he recruited a little, the flaps of the parts vvere brought together by seve- ral interrupted sutures, and upon apply- ing adhesive straps wjth the double-head- ed roller, he was sent to bed. This tumour weighed twenty ounces. 3 P. M.—Has continued to recover gradually from the shock of the opera- tion. 5 o'clock.—Had a sleep of half an hour ; awakened relieved ; pulse regu- lar and distinct. 8 o'clock.—Pulse 140, and regular; skin cool and moist; signified bv a nrnl APPENDIX *7Qo that he was more comiortable lhan he expected to be ; had spoken pretty dis- tinctly for several things, contrary to par- ticular orders ; swallowed some water from Ihe spout of a teapot, but taken with much difficulty. 16th, 10 A.M.—Has slep( quietly for the most of the night, and only took a little cold water oncl*: skin of natural tempera(ure; pulse 120, and stronger than last evening ; nodded lha( he felt comfortable; was ordered a little cold water occasionally, but to take it as sel- dom as possible. 10 P. M—Pulse 124, and fuller ; skin pleasantly warm; articulated that he felt refreshed from slepp ; swallows well, the fluid being conveyed into the poste- rior fauces by means of an elastic tube and bottle. Contrary to orders, rose from his bed to have an evacuation from his bowels, and pass urine ; all which he ac- complished without difficulty. 17th, 10 A. M.—Had a good night. Pulse 120 ; skin natural: swallows with more difficulty ; and some of the liquid passes through the wound. Bandage was removed, and all the dressings ad- justed anew ; slight cough. 9 P. M.—Said he was as comfortable as in the morning. Pulse 124. Has slept considerably during (he day, and ex- pressed himself as much strengthened by it. l&th, 10 A.M.—Passed a goodnight; is quite as well as yesterday ; swallowed better; pulse 130. 10 P. M.—Was not so well as in the morning. Pulse fre-m 135 to 140. Coughed more frequently, with hurried respiration ; was restless, and felt faint at times; in the course of the afternoon, during a very heavy lightning-storm, he suddenly fainted, and appeared threaten- ed wilh immediate dissolution : but after a short inteival, revived by the use of volatiles and fanning ; said he felt consi- derable pain in his left side, which pre- vented him from taking a full inspiration ; he described every breath as painful to him, which was also evinced by the dis- tress of his countenance; was ordered a blister immediately to his side. \9th, 10 A M—Relieved by the blis- ter; slept considerably during the nighl; had fainted once during the night. Dress- ed the wound ; more than two thirds of it had united by adhesion. Breathing better. Pulse from 132 to 140. Cough less troublesome ; swallowed some cho- colate. ... In the course of this day, however, his breathing became more troublesome, with great anxiety and restlessness; and at 4 o'clock in the afternoon, after two or three faint turns, he expired. Anxious to be satished «>f the cause ot big sudden death, I examined the body. 1 found tiie wounds, the result of the operation, healthy, and united by adhe- sion throughout (he most of their course. Upon raising the sternum, I found id (he anterior mediastinum a massy depo- sit of coagulable lymph, seemingly of recent exudation ; this was of a yellowish hue, having the exact appearance of pus, but wanting* fluidity. In the cavity of (he pericardium vvas contained a pint of yellow serum ; and each lung exhibited marks of high inflammation ; Ihe surface of both lungs vvas of a florid, and in some places a deep purple hue. There was, however, in no place any adhesion be- tween the lung and the side of the chest. The conclusion I have drawn from this examination, coupled with my acquaint- ance wi(h the metre particular circum- stances of this man's case is, that his death was to be attributed to inflamma- tion of both lungs, caused by lightning. As 1 am informed these cases are yet to apppar before the public in a more de- tailed state, I shall content myself with this one remark :—I believe an important practical fact has been confirmed by these operations; namely, that the tying ofthe common carotid previously to any other part of the operation in these individual cases, did prevent hemorrhages during the performance, which would have so interrupted the surgeon that he might have been unable to proceed. But more- over, that tying these arteries low down in the neck before the other part of the ope- ration, and not their branches, as they might ha»e been from time to time cut in (he course ofthe operation, did prevent an excess of inflammation during the cure; which, as can be imagined, might have extended to the brain and its mem- branes, and been the cause of death. At all events, might have protracted the cure, by effecting a long-continued puru- lent discharge, w ith emaciation, and much loss of slrength to the patients. About three weeks after Prince's death, an old gentleman came from Westches- ter, with a similar disease of the right side of the jaw, of considerable extent; but as he was of an irritable constitution, bad habit, and upwards of sixty years of age, he was advised to go home, and not think of an operation. ( have been (yesterday. December 11,; shown another case hj Dr. Mott. in a fine- looking boy of about nine years of .ige, from the neighbourhood of Corlaer's Hook, on whom it is purposed to operate in the course ol (he week. The disease is of three years' growth, and extends from the angle at the left side of the jaw to the chin. [t is probable, that had it not been for the successful issue ot Catharine Buck- lew's case, we should never have heard ofthe remaining four; proving that csteo :o4 APFEMdX. sarcoma in that situation, is not a novel disease.; nor so rare as may have been hitherto supposed. PESSARY. I have lately had pre- sented me, by Dr. Barker of this city, a newly-construcled pessary for prolapsus uteri; for which he has just now ob- tained a patent. That there was room for*improvement in these instruments, no practitioner, to whose lot it has fallen to direct ihe ap- plication of those hitherto in use, can deny; and it will be admitted, that the common boxwood pessary, to say the least against it, is calculated to excite and keep up a debilitating discharge from the vagina. Dr. Barker's instrument is a pyriform gum-elastic bag ; having connected wilh its neck a valvular mechanism of ivory, for retaining such air as might be intro- duced to fill it, after it had been passed up the vagina. The pressure induced by such an instrument must be one as will most effectually answer the com- manding indication; and can never be unpleasant or injurious to the patient. There is attached to it a contrivance, by which tbe patient herself can fill it with air, and by which also she may empty it when it may be her wish to have it withdrawn. That this part of it, however, may not be improved upon, I am not so well convinced ; but, as re- gards the instrument itself, it is undoubt- edly the best, under the name of pessary, that has yet been submitted to the pub- lic ; proved by the assurances of the nu- merous patients who have already put it to test. PROSTATE GLAND. What I have to say upon this articje, is, that 1 have never seen any thing like a third lobe, as described by Sir Everard Home to this gland in its healthy state: yet I have seen something like it behind the veru- montanum, while the prostate was gene- rally enlarged, although not tumefied in any other pi.ri.ii.r situation. And I will venture this * xplnnaiion for the occur- rence. The prostate gland is surrounded by a tunic, derived from the posterior surface of the triangular ligament, and which, after strengthening the urethra at the membranous part, pas-es on to this gland, affording a covering equally dense with the tunica albuginea of the testis. But the prostate is not lined with any thing like this where it is pierced by the ure- thra : yet the verumontauum gives firmness to the anterior part of that groove. As the effect of a general in- flimmatioi: of this gland, its vvhole sub- stance will at first become gradually en- larged, and (hen, if the disea-**-* continues, a special tumefaction or elevation will chow itself, projecting towards the cavity ofthe bladder n< hind the veiuinoin.h.uu''. or in other words, at that part of tht: prostate which is wanting support from lite dense tunic just spoken of. And when inflnnimalioii exists iu that part of the gland exclusively, this peculiar eleva- tion,oi third lobe, may show itself without any general enlargement of the prostate gland, TiC DOULOUREUX. Upon the opt ration lor this disease I have had fre- quent conversations with my friend Pro- fessor Mott, who, as far as I can learn, has had more to do vvith it than any me- dical man in the country. He informed me that he had operated for neuralgia about fifty different times, with varied success ; and has among other facts ob- serv id, that in cases wherein he had operated more than once, the interval of relief became less, in proportion as the operation had been often performed. The inaugural dissertation of the late J. W. B. Murray, M. D., which contains a summary of Dr. Mott's experience up to 1816, the lime of its publication, hav- ing fallen into my hands, 1 shall copy as much of it, as has reference to the opera- tion for tic douloureux. "The most strenuous advocate for the operation, in this country, is Professor Mott. His success has been so unequi- vocal, and his opportunities of witnessing the disease so comparatively numerous, that his unqualified opinion in all cases of Neuralgia, is ' divide the nerve;' then, if necessary, employ the other remedies to destroy or diminish the susceptibility to return, which will be accomplished most certainly hy hemlock and other narco- tics. Dr. Mott has operated on five pa- tients. He has divided different nerves on Dr. Jones's face eleven limes, but the disease seems so rooted in the old gen- tleman's constitution, as to require fre- quent repetition of the operation. He has become so accustomed to it, that whenever the inveterate tormentor deve- lopes itself, he sends for his surgeon with- out delay, knowing that from his hands he shall receive relief. Mr. George G. Graham, practitioner in Orange County, while a student of medicine, divided the infra orbilar nerve with success ; and Dr. Post,associated with Dr. Mott, operated lately on a gentleman, whose left cheek was diseased, and he instantly arrested the spasms. Thf degree of certainty promised by the operation, as resulting from the phy- siology of nervous reunion, becomes an interesting question. Dr. Haightou's masterly and conclusive experiments on tlie reunion of divided nerves, have com- pletely established that point: and it is a settled dogma in physiology, that by the growth of fresh matter, or by the ap- proximation of the divided ends, the APPENDIX ;■>•> -. unctions of a nerve are restored. Mr. Abernethy, however, arguing from the renewed sensibility and mobility of the ring finger, on which he operated, thought that the anastomosing branches had be- come enlarged, and, officiating in lieu of the original trunk, rendered a complete cure impracticable. Had that learned surgeon removed a portion of the trunk of the ulnar nerve, and then been baf- fled in his anticipated cure, his apprehen- sion would be well founded. There is some difference between the effects of a divided trunk and of its branches. Ner- vous influence can readily be recommu- nicated by the preservation of the for- mer, should theflatter be effectually ope- rated upon. Moreover, as the nerve of the opposite side of the finger was deri- ved from the radial nerve, the difficulty of solving the mystery is diminished. In opposition to the utility of operating, the uncertainty of immediate relief from a division of the nerve has been particu- larly urged. For, say they, the reunion is so speedy and so certain, that nature will commence her countervailing pro- cess before the desired object is com- pletely attained; thus tantalizing the pa- tient still more, and adding unnecessa- rily to his sufferings. The author of a thesis* supported before the Faculty of Medicine of Paris, expresses his doubts of the success of the operation ; he pre- tends that it was repeated five times on one patient* and asserts lhat he finally owed his cure to the warm baths of Plom- bieres. In the same dissertation are the histo- ries of two other patients, on whom a Parisian surgeon practised without suc- cess the division, and afterward the cau- tery on the supra and infra-orbitar nerves, the malar branches of the portio dura, and the mental nerve.f The preceding remarks on the success of the operation are a full reply to such objections. Wherever a considerable portion of Ihe nerve can be abstracted, a greater dura- tion will assuredly be given to the cure. This cannot be attempted on many of the nerves of the face; because the ra- mification is so immediate and extensive, as to preclude a successful endeavour to remove much of the frontal, infra-orbital, or mental nerves. The branches of the pes anserinus are intimately connected with the parotid gland and duct; also by some very beautiful and extraordinary anastomoses with the other facial nerves, so that a similar hinderance occurs here. The only nerve about the head which affords the slightest chance for effectual and final division is the portio dura, in * Utrum in pertinacibus capitis ct faciei doloribus alic-uid prodesse pe.^it, sectin ramorum ncrvi qu nil Jsf proponebat Vcllart, 1768, *?**«*<>.'"*«"£ i kicherancl Noio^jriipliic «.*l:i-urgiea!c, r. II- P »•»■ 'Vol »! *'° its passage between tue stylo-mastoid hole, and the angle of the lower jaw. When the disease is in any other part of the system, if half an inch of the princi- pal trunk supplying the affected spot could be removed, there would be little dread of its return. A repetition of in- cisions through a nerve, by insulating se- veral portions, would be another means of protracting a renewal of the disease: and in the sub-orbitar nerve, this has been done by Dr. Mott, when operating on Dr. Jones.J This improvement, I be- lieve, is attributable to Dr. Mott, and its application must be productive of deci- ded and happy consequences. It is a curious circumstance connected with the operation, that although the nerve shall be completely divided, from some cause, the chain of morbid actions will not be interrupted for several, per- haps twelve or fourteen, days. This has induced some to pronounce hastily, that the operation has failed. Any attempt satisfactorily to explain this occurrence, 1 think would be fruitless. Operation on the infra-orbitar nerve.— The participation of this nerve in neural- gia, may be detected by the course of the pain up the side of the nose, some- times following an arched direction be- tween the eyebrow and upper lid, or in either the brow or lid, and extending along the zygomatick arch: or it may be confined to the muscles passing between the os mala; and the angle of the mouth, involving the buccinator and masseter. Pressure may be applied to the infira-ot bitar foramen, during which the pain will be arrested, provided the disease depends on that nerve. A tremulous motion of the upper lip on one side, most commonly attends this variety of neuralgia. To Dr. Haighton we are indebted for an excellent view of this nerve, and a delineation of the point for division. " He measured the space between the inferior edge of the orbit and the superior edge ofthe foramen in thirty skulls, and found the distance in sixteen skulls 1-4 of an inch, which he considers the me- dium distance from the upper part ofthe foramen ; and if we allow 1-8 of an inch for the breadth of the foramen, and 1-8 below its inferior part, half an inch from the lower edge ofthe orbit will be a pro- fier place for performing the operation. laving endeavoured to establish a rule for determining its distance from the orbit, it may be proper to ascertain its situation with respect to a line drawn from the inferior part of the internal an- gular process of the os frontis, obliquely across the orbit, to the centre of the os mala:. The measurement of this line ri tniity skulls, did not vary more than M> t JM' al I'.ofi- toty.'neu series) V?"!. I!. V"*-" 70ti vPPKM)l.\ of an inch, ai.u it was foiled that a line lrawn downward perpendicular to this oblique line, at the distance of 7-8 of an inch from the internal angle of the eye, passed across the orifice ofthe sub-orbi- tar foramen.'' This point being settled, Dr. Haighton's direction for operaling, is " to make an incision of S-4 of an inch in length, car- ried obliquely downwards, (on account of the oblique course which many of these nerves take, in their passage from the foramen to the ala nasi,) the centre of which must correspond with the fora- men, only 1-4 of an inch below it. The incision must be made duwu to the bone, otherwise we cannot be certain of divi- ding the nerves, as they are situated very deep." The deformity produced by a large cicatrix, in this method of operaling, ex- poses it to objection. Professors Post and Mott have employed the following mode with the happiest success, and per- fect facility. The only instrument required is a sharp-pointed bistoury, or phymosis knife, either in a stiff handle, or well secured. Having ascertained the situation ofthe infra-orbitary foramen, by Dr. Haighton's rule, and also by the depression which can be distinguished in most subjects, let the nose be held aside by the assistant who secures the patient's head. Intro- duce the bistoury about midway between the nose and the nasal margin of the foramen ; carry it down to the bone, and pass the point close to the bone, in order to get it under the nerve. The point must then be elevated a little, though it must not pass through the skin from be- neath; by a little rubbing motion vvith one finger upon the point ofthe knife, at tiie same time cutting gently with the knife, the nerve will be divided. As a considerable branch of (he inter- nal maxillary artery accompanies the in- fra-orbital nerve, its division will be shown by a copious arterial hemorrhage ; and a peculiar acute pain accompanies the sec- tion of the nerve, in addition to the dif- ference, perceptible to (he operator, be- tween cutting a nerve, and «ny other soft solid. The upper lip must now be exa- mined by touch. If the patient acknow- ledge a destruction of sensibility, the sur- geon may withdraw his bistoury ; other- wise, the cutting must be repeated, until from numbness, he is satisfied that the nerve is divided. By asking the question previously to withdrawing the knife, (he patient has no reason to conceive that any dis. ppointmcnt attended the first at- tempt, and the repetition of incisions be may suppose to belong regularly to the operation. c Being certain that the nerve is tho- roughly divided at the lirst point of s-cc tion, make two or three incisions thrbtigh it lower down ; and thus endeavour, a-j Dr. Jones expresses it, to " insulate a portion of it, (included as it were in a pa- renthesis,; with respect to the common sensorium." Since Ihe infra-oibit.iiy nerve as it leaves the foramen expands immediately like a fan, and distributes its branches to (he surrounding parts, Ihe incisions last mentioned may be exten- sive, retaining the knife slill underneath the skin. The knife is then lo be with- drawn through (he first opening, and the lips of this diminutive external wound can he drawn together^and secured by- adhesive plaster. The only obstacle to a free section to- wards the nose, is the facial vein, which, beginning at the inner angle of the eye, holds a diagonal course towards the angle ofthe jaw. A wound of this, howpver, will not be attended with any serious con- sequences: it will only add (o the ecchy- mosis already arising from the artery, and ran be compressed by a slight force applied to the spot. The suffusion of blood will be removed by absorption in a few days, and its removal may be aided by any moderately stimulating lotion. The great advantage of this method over Dr. Haighton's, will be apparent from the impossibility of any large cica- trix being the consequence. Operation on the Frontal nerve.—This final distribution of a highly useful and important branch of the trigemini, after it has entered the orbit through the fora- men lacerum, appears to cling to the roof of the orbit, passing between the bone and the periosteum,* of course above the le- vator muscle of the upper eyelid. It leaves the oi bit through the supra-orbitar foramen, which in many skulls is only a notch, closed below by a ligament. The situation of this hole or notch may be ascertained, with tolerable precision, by finding the sub orbitar foramen ; as it is about 1-4 of an inch within a perpendi- cular line drawn from Ihe latter, and con- tinued -up (he forehead. Pass a bistoury or knife about S-4 of an inch within ihe orbit, immediately beneath the superciliary ridge of the os frontis, and divide the nerve ouJwardly. A numbness must be felt on the forehead and eyebrow, and down the nose, before the knife is withdrawn. The connexion between the nerve and the bone is suffi- cient to impress the necessity of keeping the point ofthe bistoury as close as pos- sible to (he bone, and the dense perioste- um affords additional resistance while di- viding the nerve. The ophthalmic artery will bleed profusely for a few minutes, " Meckel. Traclatus Anatcniico-pliy<.iolo;icu^ c' qiip.to pare u*?rvoru xi cerebri. ?■»«-. xsjirr. APPENDIX. 707 and when its flow outwardly is repress- ed, it will produce so much ecchymosis as to blacken the eye to a considerable extent. Operation on the Mental nerve.—The foramen through which emerges the in- ferior-maxillary branch of the fifth pair, is situaled generally about midway be- tween the alveolar processes of the -jaw and its base, in a line belween the cu'spi- datus and anterior bicuspid teelh. The nerve may be divided by turning down the lip, and introducing (he bistoury about the first bicuspid tooth, with the back towards the angle of the jaw. Keep the knife close to the bone, and hy fol- lowing the excavation of (he jaw, the nerve will be divided by a cutting mo- tion rather from the bone. In the aged edentulous subject, from the absorption of the alveolar processes, no reference can be made to ihe teeth, in finding (he mental foramen. It is situated generally in the same line with the'supra orhitary hole, and consequently can easily be discovered. Operation on ihc Portio Dura.—A mere description of the complicated and oxtensivt* distribution of this nerve, will be sufficient to justify a doubl of any operation being so devoid of danger, or troublesome consequences, as to author- ize its performance. When neuralgic* sensations are traced from just above (he angle of (he jaw, in transverse lines across the face, upwards through the temples, downwards along the base to (he symphysis of the chin backwards behind the ear ; exciting es- pecially a profuse discharge of saliva,* and frequently, from their severity, ab- sorbing all perception of distinct linear direction, but communicating the idea of the whole cheek being in a paroxysm of neuralgia, a surgeon may pronounce the portio dura to be the affected nerve. A brief display of the organs contained in the side ofthe face, seems necessary for the purpose of conveying a distinct view ofthe embarrassment and difficulty attending any projected operation on the portio dura. The parotid gland, whose agency in furnishing saliva is superior to any olher destined for that use, occupies (he whole space from the mastoid process of the temporal bone, penetrating to the "very root of the external auditory sinus, almost lo the internal carotid artery and jugular vein ;"f it is sunk behind the lower jaw, and adheres to the pterygoideus interims muscle, while it reaches inruardly, by * I have not uoticeel this in nny description of Neu- kideia; bul a moment's reflection. 1 ihink, will show, mat a diseased nerve pas-an- tbrou;!li the parotid ■land, imbedded in its substance, musl afiVjt the flow ?,(' saliva from that irlmid. < Suri'ical Anat«nn of the Ile-.'l anil :Wk. 1>> Mr. •.tin'ii !t"n>« of ninSfcCiv means ofthe sdcia parotidis, nearly to the anterior edge of the masseter muscle, and upwards to the zygoma. The ducts from its numerous lohuli unite, and are conti- nued in one trunk to the buccinator mm cle, which it perforates nearly opposite the second or third dens molaris. " It- course will generally be defined, by a lint: extended from the junction of the lobe of the ear and figured portion, to midway between the root of the nose, and the angle ofthe mouth." The arteria transversalis faciei "is generally placed midway between (he parotid duct and the zygoma. At this part it lies between (he socia parotidis and the masseter muscle." "The portio dura, when passing from the foramen stjlo-mastoideum, lies be- hind the parotid gland; but it immedi- ately dips into its substance. It conti- nues a single and undivided trunk, for about half an inch of its course. This part of (he nerve runs in a slanting di- rection, downward and forward, imbed- ded in the gland. Where the portio dura is escaping from the skull, it is deep- seated, and nearly in contact with (he arteria posterior auris, and where that artery and the occipital arise by a com- mon trunk, the latter vessel is quite in the vicinity of the portio dura. By the styloid process," (which is the bar- rier between the external and internal carotids,) "the nerve is separated from the internal carotid artery, and jugular vein. About midway between the ascending plate ofthe jaw-hone and the mastoid process, the portio dura is nearly opposite to the posterior facial vein, and the exlernal carotid artery. " It is at this point, at a place where the nerve is still deeply covered by the glandular substance, that it divides into its branches, which separately perforate the gland, to reach the cheek, and other parts on whicii they are to be distributed. The largest of these branches inclines upward and forward, and while still im- bedded in the gland, it subdivides into a numerous set of twigs, which cover as with a net-work} the zygoma and the ar- teria transversalis faciei. The largest of these twigs runs nearly midway between the zygoma and the parotid duct. The. other divisions of this nerve ramify over the face, and about the throat. *' The trunk ofthe nerve can be reach- ed, with safety, only by an incision be- ginning at the very root of the mastoid pre-cess, and continued downward and forward, aiong the anterior margin of the sterno-mastoid muscle. The dissection, no doubt will require to be deep; but in performing it the surgeon will not expe- rience much difficulty. The lobe of the ear will require, to be pulled upward, and held forward, while prosecuting this dis- •*08 APPKNTHV section. In performing the dissection, the ncrvus sunerficialis colli will necessa- rily be divided, whereentering the lower angle of the parotid. The glandular substance itself will be injured, and the arteria posterior auris will he cut across."* In this manner, Mr. Burns has been in the habit of removing half an inch of the nerve on the dead subject; and Professor Molt, since the inestimable Surgical Anatomy ofthe Head and jYeck made its appearance, has exhibited to his class of surgery the mode of performing the ope- ration. It has never been attempted in this complete and radical manner on (he living subject; although many incisions have been made in the cheek, for the purpose of dividing the branches of the pes anserinus. The outline that has been given ofthe anatomy ofthe face, exhibits the difficulty attending that procedure, and the infallible consequence must be troublesome, perhaps perpetual, salivary fistulas. Should it be necessary, however, to divide any of the facial branches of the portio dura, it has been suggested by Dr. Mott, that it might by effected by in- troducing a bistoury, as in (he other ope- rations, and making the incisions in vari- ous directions beneath Ihe skin. The prospect of an unpleasant result will be thus considerably diminished, and the fistula would probably admit of a more rapid cure. A few observations on the propriety of employing caustic applications, will close the subject. If the object be lo destroy every -prospect of a recurrence of neural- gia, and if the patient will consent to an experiment, which, if successful, must effectually annihilate the nerve, the pre- cedents afforded by the French surgeons will authorize the attempt. It has been objected, that the proximity of some of the nerves to fhe bone must necessarily involve exfoliation. This consequence depends, very probably, on the manage- ment ofthe caustic, which should not be left so long in contact with ihe bone as to endanger its continuity. After the nerve has been divided by the operation, it may answer a good pur- pose to interpose caustic between the extremities of (he nerve, and thus com- bine both expedients. The tediousness of reaching the nerve from (he surface by caustic, besides the torture it would in- flict, possibly producing tetanus, seem to interdict any proceeding different from that proposed. Dr. Jones declined the use of caustic, from dread of tetanus, nor was his fear without foundation. We should, hovvever, repose someconfidence in the practice ofthe French, and admit this method of destroying a nerve to an "tir-i" -il AiwuTtv of (he Head ond N>"1 equal rank with the knife, in those ca=e-> where its employment is feasible, and unattended with danger to the bone. Following this iB a letter by the Pro- fessor to Dr. Murray, from which some additional information can be collected. Esteemed Pupil,—Since a doubt has been expressed by some, as to the even- tual result of the operation of dividing the nerve in Neuralgia, allow me to avail myself of this opportunity, to state the success which has attended it in my practice. In a confirmed case of neuralgia, in a lady about 60 years old, in 1810, I divi- ded the infra-orbital nerve on the right side ; the relief was instantaneous. Be- fore the knife was withdrawn, she ex- claimed, " I am relieved, I can now speak, blow my nose, and swallow,'" which had been almost impossible for some days, owing to the unspeakable agony ofthe disease. There were slight neuralgic symptoms for about ten days, then she became perfectly free from the slightest trace of it, and has never since had a return severe enough to induce her to resort to the operation, the pain of which she by no means dreads: for all attest that a single paroxysm far sur- passes the smart from the incision. For about four months she was entirely fret from the disease. A gentleman, aged about fifty, having had neuralgia for four years, applied to me, in the beginning of the year 1811, for surgical relief. Palliative means having tailed, and the disease increasing in violence, I recommended the opera- tion as the best and only remaining re- source. I divided the infra-orbital nerve of his right cheek. The paroxysms con- tinued for a day or two as frequent and violent as before the operation: but in a week it entirely left him. In about four months, the pain began to return, and increased in violence from time to time. but did not equal its former severity till about six months since, when it be- came rnore severe than ever. About three months ago I repeated the opera- tion on the same nerve: the pain went off" gradually in about a week, and he says the last operation is by far the most successful. In 1811,1 divided the right infra-orbi- tary nerve for a lady, who had been labouring under severe neuralgia for two or three years. She experienced no immediate relief; on the contrary, the paroxysms appeared to be increased in frequency, and aggravated in violence, for several days: they then began to de- cline, and had entirely left her about the twelfth day. / believe the disease bar vevr-r returned AF-PKMlIX. I'D*-* On that highly respectable physician, and victim to neuralgia, Dr. Jones, of this city, I have operated about eleven times, and in every instance with the most per- feet success. i Afer ^.avinS bpen afflicted with this horrible disease for seven or eight years u 5?Vlng exhaus,ed a» the resources of the Materia Mediea to no purpose, the doctor at last yielded to my frequent and earnest importunities, and allowed me to divide the right infra-orbital nerve, at the -advanced age of sixty-seven years. His pains were increased for several days, but about the twelfth they abated gradu- ally, arid in a few days completely left him. He continued for four or five months free from pain ; but afler exposure to cold, he felt now and then alarming touches of the disease, which at length became very violent. Every subsequent operation on the infra-orbital and mental nerves, has been followed with complete relief; but the intervals have been mostly shorter than the first; (hey do not, how- ever, gradually shorten; several of the last operations have varied very little in the interval of ease, it being of from three to four months duration. The violence of the paroxysms has se- veral times been augmented for a day or two after the operation, and as the addi- tional irritation of the division of the nerves subsides, the pain gradually dimi- nishes. The disease always leaves him in from seven to twelve days after the operation. From the last division, how- ever, of the infra-orbitary, about three weeks since, he received immediate ease, having scarcely a single pain afterward. Last winter, I divided the right infra- orbital nerve for Major B----, aged about fifty, who had been labouring under a regularly increasing neuralgia for about four years. The operation increased his disease in every respect for several days; it then abated, and gradually went com- pletely off in. about the usual period of twelve days. Four months and more have now elapsed, and the disease has not returned. About three weeks since, I attended, in conjunction with Dr. Post, a Colonel K-----, aged about sixty, who for five years had been afflicted with severe neu- ralgia of the left infra-orbital nerve. Dr. P. divided this nerve, and it vvas fol- lowed with immediate relief. He expe- rienced little or no pain afterward. Hoping that all the miserable victims of neuralgia may be encouraged to resort to a surgical operation, either in (he form of a simple or double division ; by a sin- gle external incision, or, where practica- ble, the removal of a portion of the nerves, I am, with sentiment** of high regard and esteem, VALENTINE MOTT. r> mo. (May) 1st. linn. TOURNIQUET. Notwithstanding all the encomium justly paid to the screw tourniquet of M. Petit, that instrument seems superseded by one of American invention. 1 could never bring myself to believe, that a sufficient pressure could be obtained against the artery by Ihe pad of that instrument, while applied as di- rected in the text ; viz. the tourniquet itself being upon the extremity in an op- posite direction, without producing much more general eonstric(i<>n of (he limb than was to be desired. On this account. I havt- been in (he habi( of dispensing wilh the ordinary pad, and substituting a small and firm single-headed roller under the base of the instrument, and placing the whole over the artery. Whe- ther it was merely ideal or not, I will not pretend to answer; but certainly patients were much better satisfied by this method of applying the instrument. The tourniquet invented by Dr. Moore, of Massachusetts, appears to an-wer in a most excellent manner this design. It is made of brass, and intended to be ap- plied over the ariery. It has a pad of metal, of an oval convex form, that can be projected from the under part of the instrument by the operation of a male and female screw, which is morticed in a frame, aho of brass, for (he purpose of its support, and for giving it a proper di- rection. There may h-2 a linen compress between this pad and^lhe limb, or the brass pad may be covered by a piece of shamois leather, gathered around it for the lime, after the manner (hat tailors cover buttons. The strap of this instru- ment is intended to buckle on the outside ofthe limb ; and to prevent the skin from any unpleasant sensation, there is a piece of leather placed under the buckle analo- gous to that for the under part of Petit's screw tourniquet. TRUSS. J am at a loss to divine why Mr Cooper has altogether omitted the mention of the truss of Messrs. Salmon.. (*ddy, &, Co. of London, w hich does ap- pear lo me as infinitely superior to any now in use, or likely to be contrived. There are two very formidable objec- tions that I think must obtain again.-'t all the trusses, with that exception, and they are the following : \\ hen the pad is firm- ly connected with the steel strap, it is clear, that in the different positions of the h'dy, and constantly during progressive motion, pressure is made alternately by the one edge tf (he pad. then by Ihe cen- tre, or (he other <-dge ; and in proportion as Ihe truss has been at first well appli- d, tha^ is, with the more convex par( of the pad against (he ring, so the same centre of the pad n ay be the cau-e of strangulation of a portion of iniestine <.•**■ omentum, that should have been permit- ted to peep through the opening in the abdominal parietc^. at a time when pve«- 510 APPENDIX. sure was made by the edge of the truss. In this way I would explain the evils at- tributed to trusses. The truss I speak of provides against this accident, by ha* ving a ball and socket joint between the p.«d and steel strap, by which contrivance no other part of the pad can at any time make pressure but the very centre ; and which, if in the first instance properly ap- plied to the ring, must continue to make a fair and an equahle pressure. The other objection applicable to trusses in general, is derived from the cir- cumstance of the strap which passes by the pelvis being in close contact with the body at that part; so that in progressive motion, when the mu*-cles at the upper part of the thigh and outer part of the pelvis contract, the parts become for a time swollen, so tbat th» pad is neces- sarily drawn from immediately over the ring. The consequence of this is, a pro- trusion of the hernia ; against which the ball and socket joint, I have just alluded to, will not protect. The truss, however, I would recom- mend, has a provision by which this occurrence camot take place. The strap is not in contact with the pelvis, but takes a free course by its side, and can, for convenience sake, be laid against the soft abdominal muscles above the spine of the ilium ; while from having a free motion with the pads by virtue of the ball and socket joint, it preserves at the same time a sufficient and most uniform pressure. VARICOSE VEINS. From wh«t 1 have seen in this country, the practice of Mr. Brodie seems to have been impro- ved upon, by one more in conformity with that of the ancients. I have reference to the excision of about an inch of the trunk of the princi- !>al superficial vein, which receives the ilood from those in the varicose state. Last year, I witnessed this operation at the Philadelphia Hospital, on a man with extensive varices of the superficial veins below the knee. The vein in the ham, or the branch in that situation which was to become the saphena, was cut upon with a scalpel, and about an inch of its length extracted. The integuments were brought together hy adhesive plaster, and in about Three weeks all the varices disappeared. I have been in the habit of puncturing these veins witb a lancet, in several situa- tions at the same time ; and after they had bled freely, of dressing the limb with a compress and bandage, very systemati- cally applied, moistening the whole three or four times within the first twenty-four hours with the rectified spirits of wine. By this treatment, the disease was very generally removed, provided it was not dependent upon constitutional circum- stances. fv\l> OR* THR SJ'COVf) voruivtF. ,;iN7 m j/te NLM041391729