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A
SYSTEM
O F
SURGERY.
       EXTRACTED FROM THE WORKS OF



    BENJAMIN BELL,

         OF EDINBURGH:


                   V
 By NICHOLAS B. WATERS, M. D.


FELLOW OF THE COLLEGE OF PHYSICIANS OF PHILADELPHIA, AND
 ONE OF THE SURGEONS OF THE PHILADELPHIA DISPENSARY.
Illustrated with Notes and Copperplates.
              ■■A
THIRD EDITION.         ^
         PHILADELPHIA:


      PRINTED BY ARCHIBALD BARTRAM,

FOR THOMAS DOBSON, AT THE STONE HOUSE,

    NO. 41, SOUTH SECOND-STREET.
1806. 
,   *
'"V
K
t&qH&jrm.                                            __./ ijM -J**
                            No. 21.

   Diftrifr of Pennfylvania,  to wit:

     BE it remembered, that on the  nineteenth day of Auguft, in the
fixteefith year of the Independence of the United States of America, Tho-
mas  Dobfon, of the faid diftrift, hath depofited in this office the title of
of a Book, the right whereof he claims, as proprietor, in the words follow-
ing, to wit:
  " A Syftem of Surgery, extracted from the works of Benjamin Bell,
" of  Edinburgh: by Nicholas B. Waters, M. D. Fellow  of the  College
" of Phyficians  of Philadelphia,  and one  of the Phyficians and Surge-
" ons to the  Philadelphia Difpenfary—Illuftrated with Notes  and Cop-
" perplates."
  In conformity to the aft of the Congrefs of the United States, intituled,
" An aft for the encouragement of learning by fccuring the copies of Maps,
Charts, and Books,  to the Authors and Proprietors of fuch copies, during
the times therein mentioned."

                       SAMUEL CALDWELL,  Clerk
                              of the District of Pennsylvania. 
PREFACE.
QURGERY  teaches us  the  knowledge of  all thofe
^ difeafes which require manual operations  for their
removal;  their caufes;  and  the  methods of preventing
and of curing them.
   For fome years paft it has been a fubjc£b of regret with
the medical part  of the  public,  and particularly among
ftudents,  that we have had no  work on  this important
branch of medicine,  which gives  a view  of  the prefent
ftate  of the art, In a moderate compafs :  Mr. Bell's fyf-
tem, although a  mofl valuable production, being extend-
ed to fo  great  a length,  as to be not only expenfive, but
exceedingly inconvenient.
   To fupply this defect, I have  repeatedly heard a wifli
cxpreffed, by fome of the  mofl  eminent of  the profeffion,
that a feleclion  of the more effential parts ■ of Mr. Bell's
treatife were made ;  in  which, however,  nothing ufeful,
immediately relating to Surgery,  fhould be omitted.
   Although well aware that I might not execute a work of
this kind in fuch a way as to obtain the approbation of the
critical reader,  yet the belief,  however  miftaken, that  it
might be done by  any perfon tolerably acquainted with the
fubjedt, if not in the beft manner with  refpecT: to lan-
guage, at leafl in fuch a manner  as to  be highly ufeful;
the late Dr. Jones, formerly profeffor of furgery in King's
College, New-York, cheerfully engaging to look over the
manufcript, and add  occafional  obfervations,*  furniflied
by his  own experience;  Dr. William Shippen, profeffor
of anatomy and furgery, alfo obligingly  promifing to de-
                                                   vote

  * Thefe will be readily diftinguilhed. from fuch as I have given myfelf,
which confift chiefly in extrafts from different authors of merit. 
iv
PREFACE.
 vote a part of his leifure to the perufal of the work ; I de-
 termined to rifle the  undertaking.  How far  I have fuc-
 ceeded in the attempt, mufl be left to the decifion of my
 medical  brethren.
   Thofe  who  cannot readily  conceive  that  the  effential
 parts of a performance of feven volumes can be comprifed
 in a fingle one of the feme fize, will pleafe to confider, that
 this one  volume, from the manner in which it is  printed,
 contains at leaf} as much as any two of the original; and
 that the anatomical deferiptions, defcriptions of operations
 and practices, which are,  at prefent, feldom if ever employ-
 ed,  theoretical   difcuflions, and  repetitions, which, taken
 together,  occupy no  fmall part  in the work of Mr. Bell,
 are entirely omitted.
   As Mr. Bell  expreffes  his opinion  fomewhat differently,
 on  the fame fubjecT:, in different places, I may fometimes
 appear to have juftly incurred the cenfure of mifreprefenta-
 tion; but I beg that  in fuch inflances,  a judgment may
 not be formed without a previous attention to  every thing
 that is delivered  on the fubjecT in queftion.
  Following the general  plan  of the  original treatife, I
 have attempted  no fyflematic arrangement of  the  difeafes
 to be confidered ; becaufe thefe  have feldom much con-
 nection in their  general  fymptoms, or in their refpecTive
 mode3 of cure.   When, indeed, the  different fubjecTs ap-
 peared to be connected, or illuflrative  of each other, they
 are generally treated of in immediate fucceffion.
  After noticing the appearance  or fymptoms of the  dif-
eafe, its ufual and known caufes are confidered;  its pro-
bable confequences; and  the befl method of treatment:
And when  an operation  of importance  is defcribed,  the
parts  which  fliould be avoided,  as well as thofe that  are
to be divided, are particularly pointed out. 
CONTENTS.
CHAP. I. Of Inflammation and its Confequences, CHAP. II.	Page. I
On the Theory and Treatment of Ulcers, CHAP. III.	*7
Obfervations on White Swellings of the foints, CHAP. IV.	66
Of Sutures, CHAP. V.	74
Of the Ligature of Arteries, and other artificial means of stopping Hemorrhagies, CHAP. VI.	79
Of Blood-letting, CHAP. VII.	84
Of Aneurifms, CHAP. VIII.	100
Of Hernia, CHAP. IX.	ll5
Of Hydrocele, C H A P. X.	J34
Of the Hematocele,	'51
CHAP. XI.	
Of the Varicocele, Cirfocele, Spermatocele, and Pneumatocele,	'54
C H A P. XII.	
Of the Sarcocele, or Schirrous Testicle,	156
CHAP. XIII.	
Of Difeafes of the Penis,	161
C H A P. 
vi          CONTENTS
               CHAP.   XIV.           Page.
Of the Stone,                                 166
                CHAP.   XV.
Of Incontinence of Urine,                       187
               CHAP.   XVI.
Of a Suppreffion of Urine,                     189
               CHAP.   XVII.
Of Obstructions in the Urethra,                 192
               CHAP.   XVIII.
Of the Fistula in the Perinaum,                198
               CHAP.   XIX.
Of the Hemorrhois or Piles,                    202
                CHAP.   XX.
Of Condylomata, and other fimilar Excrefcences
    about the Anus,                           204
               CHAP.   XXI.
Of a Prolapfus Ani,                           206
               CHAP.  XXII.
Of an  Imperforated Anus,                      207
               CHAP.  XXIII.
Of the Fistula in Ano,                         209
               CHAP.  XXIV.
Of the Paracentefis of the Abdomen,            215
               CHAP.   XXV.
Of the Paracentefis of the Thorax,              219
               CHAP.  XXVI.
Of Bronchotomy,                              228
               CHAP.   XXVII.
OfOefophagotomy,                             230
              CHAP.  XXVIII.
Of the Amputation of Cancerous Mamma,       233
                                      CHAP. 
CONTENTS.
vn
              CHAP.   XXIX.           pagC.
Of Affeclions of the Brain from external Vio-
    lence,                                     235
               CHAP.  XXX.
Of Difeafes of the Eyes,                       257
              CHAP.   XXXI.
Of Difeafes of the JNofe and Fauces,             304
              CHAP.   XXXII.
Of Difeafes of the Lips,                        318
              CHAP.  XXXIII.
Of Difeafes of the Mouth,                     324
             CHAP.  XXXIV.
Of Difeafes of the Ears,  and Operations prac-
    tifed upon them,                           354
              CHAP.   XXXV.
Of the Wry-neck,                             360
             CHAP.  XXXVI.
Of Difeafes of the Nipples,                     361
             CHAP.  XXXVII.
Oflffues,                                     362
             CHAP.   XXXVIII.
Of the Inoculation of the Small-Pox,             364
             CHAP.  XXXIX.
Of Wounds,                                   365
                CHAP.  XL.
OfBurns,                                    417
               CHAP.   XLI.
Of Tumors,                                  420
               CHAP.   XLII.
OfFraclures,                                  464
                                      CHAP. 
viii         CONTENTS.
              CHAP.  XLIII.            Page.
Of Luxations,                                 494
              CHAP.  XLIV.
Of Distorted Limbs,                           5 21
              CHAP.   XLV.
Of Distortions of the Spine,                     524
              CHAP.  XLVI.
Of Amputation,                               S27
              CHAP.   XLVII.
Of Removing the Ends of Bones, in Difeafes of
   the Joints,                                554
             CHAP.  XLVIII.
Of preventing or diminifning Pain in Chirurgi-
   cal Operations,                             55J
              CHAP.  XLIX.
Of Midwifery,                                558
                CHAP.  L.
Of opening Dead Bodies,                        563
                CHAP.   LI.
Of Embalming,                                565
               CHAP.   LII.
Of Bandages,                                 567 
                        A

SYSTEM  of  SURGERY.
              CHAP.    I.




   On Inflammation and its Consequences.

                SECTION  L

  Of the Symptoms, Terminations, and Caufes of Inflammation.

    EVERY organized part of  the body is liable to in-
     flammation ; but  as the treatment of this affection,
when feated in the internal  parts, belongs to the province
of medicine ; we propofe in this place, merely to confider
the complaint, with its confequences, as it is mofl frequent-
ly obferved to occur externally.  And as the greater part
of the phenomena  which in  general  attend it, will be
underflood from the  confideration of Phlegmon, we fhall
confine onr  obfervations  more particularly to that fpecies
of the difeafe.
   Phlegmon  is a circumfcribed  tumor, attended with
heat,  rednefs, tenfion,  and  a throbbing pain ; and, if ex-
tenfive, with fever.
   When thefe fymptoms are removed,  and leave the part
unaltered in its ftructure, the difeafe is faid to terminate
by refolution.
   If however, in a  fhort time all the fymptoms are aug-
mented, and the tumor becomes foft, fomewhat prominent
                       A                       in 
in the middle, or towards the mofl depending part,  ac-
quires a clear, fliining appearance, and becomes lefs pain-
ful ; the different fymptoms of fever then abate, and upon
preffure a fluctuation  is perceived ; the  inflammation is
then faid to end mfuppuration.
   But if all the fymptoms, general as well as topical, ex-
cept the fwelling, continue to increafe, there will be reafon
to apprehend that gangrene will foon take place.
   Gangrene,  or mortification, is  firft  indicated  by a
change of colour in the part affected, from a bright red to
a livid or leaden cafl, while fmall veficles, containing a thin
acrid ferum, are difperfed over its furface—the pain abates
and the pulfe finks—but continues frequent—the tumor at
lafl lofes its tenfenefs—turns  black  and flaccid—and the
part is entirely deprived of its  vital properties.
   Thefe are the mofl common terminations of inflamma-
tion ; but fometimes,  though very rarely,  it ends in fchir-
rus.
   The general exciting caufes of inflammation, are what-
ever tend to produce irritation and pain.   They are either
external or internal.  The  external caufes are, wounds of
all kinds; bruifes ;  burns, whether  by the actual or po-
tential cautery;  corrofive  and ftimulating applications,  as
ftrong acids, cantharides, and rubefacients;  ligatures, and
tumors that act as ligatures ;  violent exercife of a particu-
lar part; and  cold partially applied.  The internal caufes
are morbid matters of various kinds ; as thofe of fyphilis,
fmall-pox, meafles,  fcrophula,  and  fevers.
   Thofe circumflances which feem to give a predifpofition
to inflammation are,  a full plethoric habit of body, indu-
ced by a very  nourifhing diet, or by want of exercife ;  or
perhaps by a combination  of  both—Inflammation occurs
alfo more frequently in young than in old people,  and  in
men than in women.
   The proximate caufe of inflammation feems to eonfift in
an increafed aftion of the arteries  of the part;  and when
                                                    the 
                       C   3  ]
the difeafe does not originate from the application of irri-
tating fubflances, this,  as  well as the increafed action of
the heart when it occurs, feems to be fupported by a fpafm
or conflriction of the extreme veffels,  either of the parti-
cular part or of the general fyftem.   See  Cullers PraEl.
Phyfic. vol.  I.
   In almofl every cafe of external inflammation, the prog-
noflick may be favourable.  For if refolution, which is the
eafiefl and mofl defirable  mode of termination, is not ef-
fected, fuppuration will mofl readily be the confequence;
and the danger attending that, if the conflitution is other-
wife healthy,  is feldom great:—When, however, the dif-
eafe is extenfive, and the fymptoms very violent, there is
much danger to be feared ; for, independent of the rifk from
the fever itfelf, if the fymptoms continue high  for any
length of time, without fhewing a tendency to refolution
or fuppuration, gangrene will pretty certainly follow: and
in what manner that may terminate is always uncertain.

                    S  E  C T.  II.

      Of the Treatment of Inflammation by Refolution.

   In the cure of phlegmon, the firfl indication in general
is to promote refolution.   There are, however, fome cafes
in which this is  not to be attempted.  Thus inflammato-
ry fwellings, that fucceed to fevers, and other internal dif-
orders, fhould always be brought to fuppurate as early as
poffible : as  it is generally fuppofed, that nature by thefe
points out  an outlet for  fome fuperabundancy of fluids;
and that it might be attended with danger to give her any
interruption.   And in  phlegmons occurring in fcrophula,
we fhould trufl entirely to the operations of nature; for
if they are repelled, bad confequences might enfue ; and if
brought to fuppuration they produce fores very trouble"-
fome to heal.
                                                     In 
                       [  *   ]
   In cafes of incipient phlegmon, where the general fyf-
 tem is not affected, topical remedies merely, with a pro-
 per attention to regimen, will often accomplifh a refolution.
 But when the effects of the difeafe are in any confiderable
 degree extended to the whole fyflem, it becomes neceffary
 at the fame time to pay attention to thefe.
   The firfl circumflance to be attended to  in every cafes
 is the removal of all exciting caufes that continue to ope-
 rate.  Of applications to the part, thofe of a fedative nature
 are  chiefly  to be depended on;  and next to thefe, emol-
 lients.  Of the former may be confidered the preparations
 of lead diffolved  in vinegar, and the vegetable acid.  Of
 the  latter, all the bland expreffed  oils, alone, or joined
 with  wax, in form of a foft ointment.
   With refpect  to  fedative applications, it  is not meant
 to recommend the whole clafs  in external inflammation.
 Thus opium, one of the mofl  powerful fedatives, when
 applied  externally, always  produces fome degree  of irri-
 tation ;  and although it perhaps may have been very ufe-
 ful in fome fpecies of inflammation ; yet  it  will probably
 never become of general ufe in fuch difeafes.
  Warm  emollient  fomentations  too,  although more
 powerful, as fedatives,  in removing tenfion and pain, than
any other remedy; yet from  experience, I am well  con-
vinced they  always  tend  to produce  fuppuration; and
when this is  not occafioned,  they leave fuch a relaxation
in the parts, as renders the complete removal of the dif-
eafe exceedingly tedious.
  Similar objeftions may be made to mofl fedative ap-
plications.  They do not, however, operate againft  the ufe
of the preparations of lead ; which we may  affirm,  from
the experience of a  great many praaitioners, to be by far
the mofl  ferviceable remedies as difcutients,  that have yet
come into general ufe.  They have been faid  to produce
deleterious effeas in fome inflances; but thefe have  been
                                                  very 
                        C   5  ]
very rare; and I have known the greater part of the fur-
face of the body to be covered with them for weeks, with-
out any bad confequences being occafioned by them.
   Saccharum faturni,  or the  fugar of lead, as  being
the  preparation whofe ftrength can  be  mofl  exactly
afcertained,  fhould be  preferred to any of the others.
It is mofl conveniently applied in the form  of a watery
folution; for  the  preparation  of which the following
proportions  in  general  anfwer  very  well:  R. Sacch.
Saturn,  ffs  folve in aceti .§iv.  & adde aq. fontis diflillat.
ibij.   The addition of vinegar renders the folution  more
complete.
   Mr.  Goulard's  vegeto-mineral water is  preferred by
fome to  this  preparation : it is made by adding two tea
fpoonfuls of  the ExtraBum Saturni to a quart of water,
and four  tea  fpoonfuls of  brandy.  The  quantity  of
extract or brandy to be diminifhed or increafed accord-
ing to the nature of the difeafe, or fenfibility of  the part.
Cataplafms made  of  thefe preparations and crumb  of
bread, fhould be conflantly applied, as cold as the patient
can bear them without uneafinefs, and be renewed when
ever they become hard. When the inflamed part is not ve-
ry tender, or  lies deep, the vegetable acid inflead of the lead
anfwers very  well; and an alternate ufe of this and the lead
has, in fome inflances, appeared to  be  more ferviceable
than a continuance of either feparately.   If,  however, the
fenfibility of  the part does not admit of poultices, doubled
pieces  of foft linen, moiflened with the faturnine folution,
fhould be fubflituted to them.
   Emollients tend greatly to remove inflammation :  but as
they are  lefs  efficacious than the  preparations  of lead, and
always blunt the aaion of thefe,  they  fhould  never
be employed except the tenfion, irritation, and pain are
very confiderable :  when any  of the mild expreffed oils
may be gently rubbed over the  inflamed parts two or
three times a-day.
                                               Topical 
                       C  6   ]
   Topical  bleeding fhould  always be  employed  when
the inflammation is extenfive: and the blood  fhould  be
drawn from  a part as  near as poffible  to  the difeafe.
Reft fhould be enjoined—and the ufe of animal food, and
of  fpiritous  and   fermented  liquors,   ftriaiy  forbid.
And,
   When a confiderable  degree of fever comes on, it will
be  proper  to  order general bleeding, gentle laxatives, and
cooling diaphoretics.  We  fhouid then procure eafe to the
patient by  the exhibition of opium in large dofes.
   By thefe means, in the courfe of a few days, refolution
of  the tumor will gently begin  to take place.   The
fame plan fhould then be purfued,  but  with caution ; be-
caufe,  if fuppuration fhould at lafl be  produced, its pro-
grefs will be rendered flow and uncertain by debilitating
the fyftem, and the patient  will not be capable of fupport-
ing the confequent  difcharge, fhould it be confiderable.
  Although we  may generally determine, in the courfe
of three  or four days, whether the difeafe will end  in
refolution or not;  yet it mufl  be obferved, that inflam-
mations  in tough  membranous parts, often  continue a
confiderable time without {hewing any tendency to ter-
mination : In fuch cafes, we fhould never be deterred from
a perfeverance in the ufe of refolvents, unlefs the fymp-
toms of fuppuration commence, gangrene  is threatened,
or an incurable obftruaion  is feared;  when  fuppuration
fhould always be encouraged as much as poffible.


                   SECT.  III.


                    Of Suppuration.

   Suppuration is that procefs by which the con-
tents of tumors and ulcers  are converted  into a  whitifh,
                                                 thick, 
                       C  7   ]
thick, opaque,  and fomewhat foetid matter, termed Pus.
This, by many, has been fuppofed to be effeaed entirely
by a natural exertion of the fyflem ; but experience teach-
es us, that art is capable,  in all cafes, of giving confider-
able afliftance.
   With  refpea to  the  formation of pus, various opini-
ons  have been  entertained.   By  fome, pus has been be-
lieved to confift in a diffolution of the blood-veffels, nerves,
and other folids, in the fluids of inflamed parts.  Others,
have fuppofed  it to be formed  in the  blood; and that
it is from thence fecreted into abfceffes, wounds,  and
ulcers.   But the mofl probable opinion  is, that  pus  is
produced by  a certain degree of fermentation upon the
ferous  part  of the blood,  after its feparation into the ca-
vities of ulcers and abfceffes; and this, in confequence  of
the  natural heat of the part, or of heat artificially appli-
ed.  And  it is further rendered probable by experiment,
that as the ferum is  depofited more  or lefs free from fat,
red  globules,  &c. it will yield a pus more or lefs pure  or
vitiated.   Vide Cullen and Pringle.
   When fuppuration  is  to be promoted, all the means  of
producing refolution mufl be laid afide.   But as a certain
degree  of inflammation  is found neceffary for the forma-
tion of pus, it will be  improper to let the inflammatory
ftate fubfide fuddenly.  The diet of the patient fhould there-
fore be regulated by the circumftances of phlogiftic diathe-
fis,  or of debility which feem to prevail; and, fuch applica-
tions fhould be made  to the inflamed parts as tend to pre-
ferve in them a proper degree of heat.  This lafl is a cir-
cumftance  of the utmoft  importance—And  the  experi-
ments of Mr. Gaber and  myfelf on ferum out of the body,
and of  myfelf on inflammatory tumors in the body, have
made it evident to me, that the greater the heat  is, to a
certain  extent, the  fooner fuppuration  will  take  place.
From  hence it probably  happens, that fwellings near the
heart fuppurate in much lefs  time than thofe more diftant
                                                  from 
                       [   8   3
 from it; and the want of a due degree of heat, perhaps,
 prevents the greater part of  foft fwellings from coming to
 fuppuration;  which  then  form  atheromata,  fleatomata-,
 and melicerides.
   Warm fomentations and  cataplafms  are  the  means
 generally ufed for the application  of  heat   to  phleg-
 mons :  and  when they  are  frequently  renewed,  they
 anfwer  the purpofe very effeaually.   But if they are not
 applied  more  than once  or twice a-day,  it is probable
 they do more  injury than good.   For as foon as the heat
 they at  firft poffeffed is diflipated,  the moifture they fup-
 port,  with the confequent  evaporation,  muft always  ren-
 der the  part colder than if it had been merely wrapped up
 in flannels.
   In order to  receive advantage from thefe  remedies,  the
 parts  affeaed  fhould  be  well  fomented  with flannels,
 preffed  out of  fome emollient decoaion, and  applied, a3
 warm as the patient  can  bear them, continued half an
 hour at  once, and renewed four or five times a-day.   Im-
 mediately after the fomentation, a large emollient poultice
 fhould be applied warm, and renewed every two or three
 hours.  Bread  and milk,  with a  little butter or oil,  in
 common,  forms the mofl eligible poultice.
   When there is a defea of inflammation in  the tumor,
 roafled onions, garlic,  &c. may be  added to the poul-
 tices ; but ftrained galbanum, or fome other of the warm
 gums, diffolved in the yolk of an egg, or a fmall portion
 of cantharides, are  much  more elegant  and  efficacious
 additions.  Plaflers of the warm  gums  are ufeful, and
become  neceffary fubftitutes to the poultices, if  the patient
cannot be confined within doors.
   Dry cupping, i. e. cupping without fcarification, upon,
or as near as poffible to the affeaed  part, in cafes  where
inflammation is defeaive, is alfo eminently  ferviceable.
Thefe 
                       [  3   ]
  Thefe applications  fhould be continued, until fuppUfa-
tion takes place ;  which  feldom fails to be the  cafe, in
a longer or fhorter time,  according to the circumflances
of the difeafe—The formation of  matter  is indicated  by
a remiffion of all  the  fymptoms.  The  throbbing pain
goes off,  and a more dull and conflant  pain fucceeds;
the tumor becomes pointed at fome particular  partj gene-
rally near the middle,  where, if the matter  is not contained
in a cyfl, or very  deep-feated,  a  whitifh-yellow  appear-
ance is obferved ;  and a fluauation of fluid is plainly per-
ceived upon preffure.  In addition to thefe  local fymptoms,
whenever a large colfeaion of pus  is formed,  frequent
fhiverings almoft  conflantly occur.
   In the treatment of colfeaions  of matter or abscesses,
it is  a general  rule never to  open them, until a tho-
rough fuppuration has taken place ;  for if it  is done  be-
fore, they never heal  kindly.   An exception to this  rule
occurs in the treatment of critical abfceffes that  are pro-
duced in  malignant  fevers,  and in the  plague—Thefe
fhould  be opened  as foon as  it  can be  afcertained  that
there  is a depofition of fluid.   And colfeaions of matter
on the joints, or  over the cavities  of the  breafl or belly,
efpecially if  they run deep, ought to be difcharged as
foon as any fluauation can be perceived.   Becaufe, when
the refiflance on every fide is equal, they may as readily
pour out their contents internally  as externally ;  and  the
confequence  of a large abfcefs, burfting into either of the
large cavities, is  commonly fatal.
   Abfceffes have ufually  been opened either by Caufiic or
Incifion.  With refpea  to the  caufiic, it is not  attended
with any fuperior advantage  to  a  fimple incifion : It gives
much more pain; it  is more flow in its effeas;  and it is
impoffible  always to  confine its  operation to thofe parts
which  were  alone intended to be affeaed.   On account
                          B                         of 
                       [   10  ]
 of thefe inconveniencies,  incifion with a lancet or lcalpel,
 is very generally preferred to it.
    When the fwellings are  not very large, they are com-
 monly opened by an incifion, extending two-thirds of their
 length,  and terminating  at  their lower  extremity : but
 abfceffes of confiderable  extent  fhould be laid open their
 whole length.  It has been advifed by fome, to take away
 a part of the teguments, when they are very much ftretch-
 ed ; but this can very feldom be neceffary or proper—
 never indeed, unlefs the parts are completely dead.
   The inconveniencies of opening abfceffes with the knife,
 arife from the fuddennefs of the difcharge of their con-
 tents, and the admiffion of  air to the ulcerated furface.
 The firfl occafions faintings, and other difagreeable fymp-
 toms, and the latter often induces an  aftonifhing  change
 in the difcharge, from a well digefled pus to a thin fanies ;
 and that fometimes within fo fhort a  fpace as  forty-eight
 hours ; and afterwards, if the tumor has been very large,
 a  heaic fever,  which either proves fatal  in a fhort time,
 or terminates in confirmed phthifis. It feems probable that
 the air produces thefe effects  by  its irritation; by ftimu-
 lating the veffels to a greater abforption, and by rendering
 the matter to be taken up more putrid.
  None of thefe bad confequences of incifion and caufiic,
 follow the ufe of the feton.   It therefore,  with propriety,
 claims a preference to both of them. , When the  feton is
 employed in opening abfceffes, there is little or no furface
 of the  fore expofed to the  air ; a gradual difcharge is occa-
 fioned; it is attended with very little pain and inflamma-
 tion ; produces a very fmall cicatrix ;  and  generally com-
 pletes a cure in half  the time neceffary  to accomplifh it
when incifion or caufiic are ufed.
  The feton is  to be formed as  follows:—An opening
fufficiently large for  the cord, being made with -a lancet
in the fuperior  part of the  abfcefs,  a  director,  flightly
curved, and  having  an  eye  at one  end,  threaded with
                                                      a 
                        [   u   ]
 a  cord  of  candle-wick  cotton,  or of foft  filk, propor-
 tioned in thicknefs to the fize  of the tumor,  is  then to
 be  introduced,  and  its point to  be pufhed downwards
 until it is felt externally, exaaiy oppofite to the moft de-
 pending part of  the fwelling.   The direaor being kept
 firm by  an affiflant, an incifion is to  be made with a fcal-
 pel upon its lower end, fomewhat larger*  than the open-
 ing  firft made.   The direaor is now to be  withdrawn
 downwards, with fo much of the cord  as will  leave two
 or three inches  of it hanging  out of  the lower orifice.
 In  about twenty-four  hours after the introduaion  of the
 cord, and daily  afterwards, fo much of it  fhould be drawn
 downwards  as  will  admit  of all that   part  of it  be-
 ing cut off which had been lodged in the abfcefs.  In order
 to  make the cord pafs  eafily, the part to be ufed fhould
 always be rubbed with fome emollient ointment.
   By this method of cure, the gradual difcharge produced,
 admits a gradual contraaion of the fides of the cavity, and
 the flight inflammation fupported on their furfaces, by the
 irritation of the cord,  induces a firm and  fpeedy union of
 them.   As   the difcharge diminifhes, the feton fhould be
 leffened  by degrees,  by withdrawing a  thread  of the cot-
 ton once in two or three days. At length,  when little more
 matter  is produced  than may be fuppofed to arife from
 the irritation of the cord, it may be altogether taken out;
 and a gentle preffure fhould then be made on the parts by
 a roller,  until the completion of the cure.f
                                                   Every

  *  This will hinder an inconvenient tranfuding of matter above.  B.
  f Several objections may be offered to Mr.  Bell's method of opening
abfceffes with the feton : In the firft place, it does not appear to be an eafy
matter to pafs a feton in the mode  he directs, through  a  large or deep
abfcefs, or that it fhould anfwer the purpofe he propofes by it.
  In the large deep abfceffes frequently formed in the breads of fat women,
fuch fmall  openings do not difcharge the matter contained fufficiently to
prevent new and troublefome  finufes,  and many women are too timid
                                                       to 
                       [   12  ]
   Every thing  that  has  been faid refpeaing the  cure of
 abfceffes from recent inflammation, applies with equal pro-
 priety, to all tumors which contain a purulent  matter,  or
 a fluid not much thicker than pus.

                    SECT.   IV.

                     Of Mortification.

   A complete mortification, or the laft flage of gangrene/
 is known by the difeafed part becoming black, by its lofing
 all pain and fenfation, and by its emitting a confiderable
 fcetor.—A foftnefs, and  entire diffolution  of  the different
 parts of the organ affeaed, alfo in common take place.
   There  is a fpecies of gangrene called the dry, in which
 the parts continue hard and conneaed a confiderable time
 although  entirely mortified.  This feems to  be produced
 from an obftruaed  flow  of blood to the parts, by the pref-
 fure of tumors, ligatures, &c.; and is never a  confequence
 of inflammation.  With refpeft to the difeafe termed the
 white gangrene, and in which the parts preferve nearly the
 natural colour, it is very  doubtful whether it can with
 propriety be confidered as a gangrene—We mean, in this
 place, to confine our  remarks more  particularly  to  that
 fpecies which fucceeds inflammation.  They are, however,
 in general, applicable to all the varieties.
   Eryfipelasf is the fpecies  of inflammation mofl apt to
                                               terminate

to permit of one opening, inftead of two which muft be made by the fe-
ton—nor does frefh good air appear  to be fo injurious to wounds as Mr.
Bell feems to think.   Upon the whole, further experience feems neceffary
before  this new mode can be generally preferred to that in common prac-
tice.

  * See what has been already faid on gangrene.
  f See Seel, on inflammatory tumors. 
                       [   13  ]
terminate in gangrene ;  and when joined with phlegmon,
as it frequently is, it gives that the fame tendency.
   In fome inflances, mortification comes on almofl before
an inflammation is completely formed.   This occurs mofl
frequently in  carbuncles.  In  thefe,  there  is feldom  any
evident fwelling; and the parts often become gangrenous
in the  courfe of twenty-four hours.  The  rapid progrefs
ufually made in thefe cafes renders  them extremely dan-
gerous, when very extenfive, or feated on any of the large
blood veffels or nerves.  If this is not the cafe, the patient
frequently recovers,  with the lofs of the affeaed part.
   Carbuncles commonly appear without any evident exter-
nal caufe ; and probably depend, in general, on a fcorbutic
or putrefcent flate of the fluids.  They  are ufually a fymp-
tom  in peftilential difeafes;  but fometimes, although very
rarely,  they happen as idiopathic affeaions.
   Gangrene feems to be  produced from a putrid fermen-
tation in blood effufed by the violent action of the  veffels
in an inflamed part; and to be propagated, by the affimila-
tory  power of the gangrenous ferment.
   The feparation of the difeafed  part is occafioned by an
inflammation,  and fucceeding fuppuration,  of fome irrita-
ble part to which the mortification is extended; and the
general fymptoms are readily accounted for from the debi-
lity induced by the putrefcent flate of the fluids.  See Cul-
len,  Pr. Ph. vol. I.
   We  fliould  never make a pofitive prognoflic in  the be-
ginning of gangrene : for patients are fometimes carried off
fuddenly,  without previoufly appearing in  any imminent
danger.  When, however, the difeafe originates from ex-
ternal inflammation,  is not deep or extenfive, and has be-
come flationary, the prognofis may generally be much more
favourable than when it is produced from an internal caufe,
is confiderable in extent, and continues to increafef  For,
                                                    in 
                          [  14  ]
  in this cafe, there is always the greatefl danger to be fear-
  ed ; and, even in any confiderable mortification from an
  external caufe, the patient cannot be pronounced free from
  danger until the entire feparation of the" gangrened parts.
    As  there have been many inflances in which death has
  fuddenly enfued after the ceffation of the progrefs  of the
  difeafe,  and before any general putrefcency has appeared,
  we conclude that the fatal termination is then produced,
  not from abforption of the putrid matter,  as may be with
  probability fuppofed in long continued cafes, but from the
  deleterious  effeas of  the gangrened part on the nervous
  fyftem.
    In  the treatment  of gangrene,  whenever the general
 fymptoms of inflammation continue to a  confiderable  de-
 gree, it will  be  proper to order blood letting,  laxatives, and
 acidulated cooling drinks.  But evacuations, and particular-
 ly blood letting, fhould be ufed with the greatefl  caution;
 and never to a  greater degree than feems abfolutely  necef-
 fary for moderating the violence of the fymptoms.
    When, however, as is mofl frequently the cafe  if  the
 difeafe has made any confiderable progrefs,  the patient is
 much debilitated,  the indication is, to give the fyftem fuf-
 ficient  vigour  to  free  itfelf from  the mortified parts.*
 This is accomplifhed by a generous diet, and a liberal ufe
 of tonic  cordials,  and particularly of good wine.  When
 very great debility and languor occur, volatile alkali, con-
 feaio  cardiaca, &c.  may be given with advantage.   But
 of all  the tonic remedies  of mortification,  the f common
                                                 Peruvian
  * Mr. Pott defcribes a fpecies of mortification incident to the toes and
feet, in which opium is a very effectual remedy, and nothing elfe is of any
material benefit. B.
  f Befides the advantages derived from the internal ufe of the bark, we
may, froTn the experience of many practitioners in this  city, with confi-
dence recommend it as one of the mofl powerful external applications in
this formidable difeafe. 
                       [   15  ]
Peruvian bark* is the  mofl efficacious.  It fliould be giv-
en as foon as the fymptoms of  inflammation are  abated,
and in as large quantities as the flomach will bear—As a
great irritability of this organ is very commonly a confe-
quence of gangrene, it will be bell to exhibit the bark, ve-
ry finely powdered, in combination with fome of the fpi-
rituous  waters.  The  vitriolic  acid  may alfo  be  given
with advantage:  and  may  be mixed with  the patient's
common drink.
  These are  the internal remedies that  can be with mofl
certainty depended on.
  There has been a great variety of external applications
recommended; particularly all  the  warm  gums  and
balfams, ardent fpirits, and even  alcohol; and  to admit
of a nearer application of them  to the found parts, deep
fcarifications through  the  difeafed,  and  into  the heal-
thy  parts, have conftantly been advifed.   But it is proba-
ble   that thefe ftimulating  fubflances,  by  exciting too
ftrong irritation,  do more harm than good.  And the in-
cifions alfo  may  do material injury, not only by wound-
ing  blood veffels, nerves, tendons,  &c.  but alfo,  by ad-
mitting a free entrance  of  the putrefcent fluids into the
found parts.  For thefe reafons, and becaufe I have never
known them produaive  of  good effeas,  I have long been
of opinion that they might be  entirely laid afide.—Mr
Pott concurs with me in fentiment—It  will, however, be
proper  to remove a portion of the mortified parts, when
the difeafe is extenfive ; in order to leffen the fcetor, and
contribute to render the healthy parts capable of throwing
off the remainder : but the  fcarifications  fhould  never ex-
tend to the parts  unaffeaed by the complaint.
                                              Theriaca


  *  The red bark, from many experiments, appears evidently much infe-
rior to the common bark.  B. 
                       [  16   ]
   Theriaca has long been, and  is now with fome, a ve-
ry common application ; but I never faw any evident good
effeas from its ufe.
   All  the  advantages to be derived from the common ap-
plications in  gangrene,  are generally  obtained with more
eafe and certainty, from gently ftimulating embrocations.
A weak folution of crude fal ammoniac in vinegar and wa-
ter anfwers exceedingly well—a drachm of the fait to two
ounces of  vinegar and fix of water,  form a mixture of a
proper ftrength in common cafes; but the  degree of fli-
mulus may be eafily increafed or diminifhed according to
eircumftances, by ufing a larger or fmaller  proportion of
the fait.
   When a flight inflammation commences  on  the verge
of the living parts, we  may generally with  certainty ex-
pea a feparation  of thofe mortified: but after  fuppura-
tion is perceived, this, without doubt, will very foon follow.
When the  feparation is accomplifhed, the wound is to be
treated as  a fimple purulent ulcer;  while  at  the fame
time,  proper  attention is to be paid to the general ftate of
the fyftem.
   It fometimes  happens, that  mortifications  deftroy  fo
much of the foft parts in the extremities, that amputation
becomes  abfolutely neceffary.  In  thefe cafes, the opera-
tion fhould never be performed until we are fatisfied that
the progrefs  of  the difeafe  has entirely ceafed.   When
this is determined, the limb fhould be removed as foon as
poffible.  See chap, on Amputation.
CHAP. 
[  17   ]
             CHAP.     II.

On the Theory and Treatment of Ulcers.
                    SECT.   I.

            Obfervations on Ulcers in  general.

      AN ulcer, is commonly defined a folution of continu-
       ity in any of the fofter parts of the body, difcharg-
 ing either pus, fanies,  or any other vitiated  matter.  But
 it muft be evident, that every caries attended with lofs of
 fubftance might with propriety  be termed an ulcer : how-
 ever, to avoid making diftinaions which are not abfolutely
 neceffary, we fhall confider caries as an accidental fymp-
 tom of ulcer, and treat of it under the general denomina-
 tion of carious ulcer.
   Ulcers have received various appellations, derived from
 their appearances,  caufes,  and  other eircumftances; but
 we fhall make fuch diflinaions  only as appear to be  of
 real ufe in direaing the proper treatment.
   Ulcers may be divided into  two general claffes.   In
the firft may be comprehended all thofe that are entirely
 local, and do not depend upon any diforder of the fyftem
 at large.  In the fecond clafs all are included that are the
 confequence of, or that are  conneaed with, any difeafe  of
 the conflitution.   The utility of fuch a claffification muft
be evident from the difference of treatment neceffary in ac-
complifhing the  cure of the fpecies arranged under each
divifion.   Thofe  of the  firft clafs requiring none but to-
pical remedies; while in the latter, medicines that affea
the whole fyftem are alfo abfolutely neceffary.
                         C                        The 
                      [  18   ]
   The topical ulcers are,  1. The fimple purulent ulcer.   2.
 The fimple vitiated ulcer.  3. The fungous ulcer.  4. The
 finuous ulcer. 5.  The callous ulcer. 6. The carious ulcer.
 7. The* cancerous, and 8. The cutaneous ulcer.
   The  ulcers conneaed with an affeaion of the whole
 fyftem, are, 1. The venereal ulcer.  2.  The fcorbutic, and
 3. The fcrophulous ulcer.
   The general caufes of ulcers, are,  1. Occafional or ex-
 citing.   2.  Predifpofing;  or,  3. A combination of both
 thefe.
   Under the firft head may be ranked wounds in general—
 bruifes ending in  fuppuration—burns—and inflammation
 which terminates in gangrene or fuppuration.
   The fecond divifion includes all fyftematical affeaions
 attended with topical determinations ; fuch as fevers that
 terminate in abfceffes—lues, fcrophula—and fcurvy. And,
   In the third,, are comprehended the fores produced by a
 concurrence of the  caufes above enumerated.    Thus  a
 flight wound,  in a habit contaminated  by the abovemen-
 tioned difeafes, will occafion a troublefome fore, which,
 in a healthy conftitution would have healed without diffi-
 culty.
   The prognofis in ulcers muft depend,  1. Upon their
 caufes.   2. Their fituation;  and, 3.  On  the time of life
 and habit of body of the patient.
   The occafional  caufe muft evidently  have a very confi-
 derable influence on the nature  of the complaint, e. g.  An
 ulcer  produced by a wound infliaed with a fharp inftru-
 ment,  will, every other circumftance  being  alike, heal
 much more eafily, than one confequent to a bruife, or a
 wound from a ragged  inftrument.   Punaured wounds
 are likewife  more  difficult of cure than  fuch as have large
 openings ; this feems to originate, 1.  From the want of a
 free exit to the matter ; which, in confequence, caufes  it
to form finufes between the integuments and mufcles,  &c.
                                                and, 
                       [   19  ]
 and, 2. To the pain and inflammation which fo particularly
 occur in wounds of this kind.
   2dly.  The  fituation, whether with regard to the na-
 ture and organization of the parts affeaed, or their being
 feated on  the trunk or extremities.  Thus  it has been
 long  known that ulcers in the flefhy parts give lefs pain,
 afford a better-conditioned difcharge, and heal much more
 readily than thofe fituated on tendons, glands, the periofle-
 um or bones.   And  experience has taught us, that fores
 on the head and trunk heal much more eafily than thofe
 on the extremities, and particularly when the lower extre-
 mities are affeaed.
   This difference feems to arife principally from the de-
 pending fituation of the latter ;  for the fluids in the veins
 and lymphatics having here to proceed in a direaion con-
 trary to their own gravity, and the former receiving but lit-
 tle aid from the  aaion of the heart; whenever any of the
 parts lofe their tone, or are deranged by accident, fwellings
 and efpecially of the ferous kind, muft be produced.  And
 when thefe fwellings  arife in the vicinity of ulcers, by oc-
 cafioning too  great an  afflux of matter to the fore, they
 at length vitiate the difcharge, and thus protraa the cure.
   The fituation of ulcers  with  refpea to the neighbour-
 hood of large blood veffels and nerves, or any of the larger
 joints or  cavities, from the rifk of the matter penetrating
 to them, muft alfo confiderably influence the prognofis.
   And, laftly, The age and conftitution of the patient muft
 be taken into confideration.   Thus, in young healthy peo-
 ple, ulcers will heal much more kindly than in the old and
 infirm.
   With refpea to the treatment of ulcers, the firft circum-
 ftance to be determined is the propriety of attempting a cure
 or not.  In recent fores there is no room for doubt;  but
when  ulcers have been of long  continuance, or appear to
have had any  effea,  either in carrying  off or preventing
                                               difeafes 
                      [   20  ]
difeafes to which the fyftem has formerly been fubjed, it
has always been confidered as dangerous  to  heal  them ;
and inftances have  often happened of the fatal effeas of
the fudden floppage of long continued and large dischar-
ges.   From experience,  however, we  may  now  affirm,
that the cure of any ulcer may be attempted, provided a
difcharge of matter, equal in quantity to  that produced by
the ulcer, be kept up by any other means.  This difcharge
is mofl conveniently furnifhed by an iffue.
   An iffue being introduced, and made to difcharge  nearly
as much as the ulcer, the cure of the latter may then fafe-
ly be carried on ; and if the fore has not been of very long
Handing, the fize of the iffue may be gradually leffened, till
it contains only a fingle pea; and it will then  give but lif-
tle trouble.  But when the ulcer  has been of long dura-
tion, and particularly if it  has  apparently prevented any
dangerous  difeafe, the iffue fhould be  continued  of  the
fame fize  for life.   Its fituation may be determined by the
conveniency of the patient.
   This circumftance obviates one objeaion that has been
made to the praaice, viz. that an iffue is as troublefome and
difagreeable in its management as an ulcer;  for the fitua-
tion of ulcers, independent of the  nature of the difcharge
they occafion, and  of the bad effeas of abforption of the
matter on the fyftem at large, often renders them exceed-
ingly inconvenient, and fometimes dangerous.
   It has been  alfo objeaed to the fubftitution of a dif-
charge by iffue to that by ulcers, that the matter produced
is not  fimilar ;  that iffues  conflantly afford  a bland pus,
while the  difcharge from ulcers is often very acrid, and
thus may free the fyftem from a matter highly pernicious
to it.   But that the effeas of all thefe drains on the body
at large, arife more from  the quantity than  the quality of
the difcharge, is  clearly evidenced by the following,  as
well as a variety of other eircumftances, viz. that the fame
                                                   bad 
                      [   21  ^
bad effeas ate produced from the floppage of a difcharge
from  iffues, as from the  healing of the worft fpecies of
ulcers.
   And it is very clear from many faas, that the variety of
matter afforded by ulcers originates, except in fome cafes
in which  a great degree  of putrefcency  prevails, and the
blood runs off in form of a thin ichor, from  the  degree of
inflammation or peculiar conformation of the veffels  in an ul-
cerated part;  from  the  heat fupported; and from the
remora of the fluids for a longer or fhorter time in the ca-
vity of the fore.  Thus it cannot be proved, by any analyfis
of the blood, that the acrid matter which is fometimes dis-
charged,  previoufly  exifted in it; and by  varying the
degree of external  heat, the applications to the fore, and
the interval of the dreffings,  we can vary the nature and
appearance of the difcharge.


                     SECT.   II.


               On the fimple Purulent Ulcer.

   The fimple purulent ulcer, is entirely a topical affeaion,
is attended by an inconfiderable degree of pain and inflam-
mation, and affords a difcharge of mild pus.  The granu-
lations which arife in it are of a firm, red, healthy appear-
ance, and if no accident occurs, in general,  the cure goes
on regularly until a cicatrix is produced.
   This ulcer is firft treated of, becaufe it is  the mofl fim-
ple that is produced, both in its fymptoms and method of
cure.   And, as it is to the ftate of fuch a fore that every
other fpecies  muft be reduced, before a cure can be ob-
tained, we fhall be particularly minute in our obfervations
with refpea to it; and, when treating of the other varieties
                                                     of 
                       _  22  ]
of ulcers, we fhall  occafionally refer to what is here ad-
vanced,  in order to avoid repetition.
   The caufes of purulent ulcers,  are, all wounds that do
not unite without the formation of matter—burns, whe-
ther produced by fire, aquafortis,  fcalding liquids, &c.;
bruifes;  and  every  external accident that terminates in
fuppuration, with an opening as a confequence  of it.
   The prognofis may generally be favourable ;  and more
or lefs fo as there is a lefs or greater lofs of fubftance—fa-
vourable or unfavourable  fituation  of the  fore,  and good
or bad habit of  body of  the patient.
   Before proceeding to a particular  inveftigation  of the
means to be employed in the cure of the fimple ulcer, it
will be proper to make a few obfervations on the manner
in which nature, as well as art, operates to accomplifh the
healing of fores in general.
   In the progrefs of ulcers to a cure, there is generally a
growth of new parts, termed from its appearance granu-
lations, that tends to diminifh any vacancy produced. This
fubftance is formed in larger or fmaller quantity,  as the pa-
tient is young or old, healthy or otherwife ; and to fo con-
fiderable  a degree  in young plethoric people, as often to
rife above the level of the neighbouring integuments.
   When the lofs of parts is thus as far as poffible fupplied,
the cure  is then  perfeaed by the formation of  a cicatrix,
either by a natural exficcation,  forming a kind  of cuticle
or fcarf fkin, or by the application of aftringents.  Granu-
lations fecm to confift, in every cafe, merely in an extenfion
of the fmall blood veffels that have been divided, with a
confiderable proportion of  inorganic cellular  fubftance,
probably  fecreted from thefe veffels, and which  ferves to
connea and fupport them; for it does not appear that or-
ganical parts are ever reproduced.
  But although granulations  contribute very much  to  lef-
fen vacancies occafioned by lofs of fubftance in ulcers, and
                                           particularly 
                       [   23  ]
particularly in young people; yet this effea,  in  all cafes,
is evidently  chiefly produced by a diminution of the parts
that remain.   And cures, even of large ulcers  are often
obtained, efpecially  in  old people,  without  any  evident
growth of parts whatever.
   This part of nature's procefs, is to be remarked even in
the fmallefl fores; but is much more evident in the larger,
and more particularly in thofe induced  by amputation of
the thigh.  In ulcers produced by amputation,  there is
never any confiderable formation of new parts; and  the
cure advances only in proportion to the contraaion of the
fkin caufed by  the  decreafe of the parts which it  fur-
rounds—This wafting takes place  in every  part  but  the
bones;  and  is fully evidenced by diffeaion: for  this
teaches  us,  that  even  the largeft as well as the fmaller
veffels, are  entirely obliterated to  a certain extent,  and
appear only  as cords : the fibres of the mufcles are greatly
diminifhed,  and there is often hardly any trace of cellular
fubftance.
   From what has juft  been faid, it muft be plain, that
compreffion,  by the laced flocking  and  bandages,  produce
beneficial effeas in ulcers; not only by preventing (Ede-
 matous and  other fwellings in their vicinity, but  by  con-
 tributing to  the diminution of the adjoining parts.
   I have conftantly found more  benefit to arife from
 compreffion, than from any other remedy; and as the laced
 flocking is not always well made,  and  is  difficultly appli-
 ed, I prefer the roller to produce it.   The rollers fhould
 be made of  thin flannel, and ought to  be about two and a
 half inches wide.—If  the member is cedematous, they
 fhould be applied from its extremity to a little above the
 difeafed part; but if there is no cedematous fwelling,  they
 fhould extend only from  two  or three inches below to  as
  much above the fore.
    In the application of the bandages,  they fhould always
  be fo managed as to fupport the fkin,  and bring  the edges
                                                      of 
                        C  24   ]
  of the fore as near together as poffible: for, as new fkin
  is never re-produced, or even an  elongation of the old,
  all thofe parts which remain uncovered by  it, will  have
  nothing for their future proteaion, but a thin fcarf  fkin.
   It is to be obferved,  however, that compreffion  is  ne-
  ver to be employed while any  confiderable  degree  of in-
  flammation remains in wounds ;  as foon, however,  as this
  has a good deal fubfided, it will  contribute exceedingly to
  expedite a cure by approximating the fides of the fore, and
  at length producing their coalefcence.
   The produaion  of granulations in fores, is an  opera-
 tion of the fyftem  itfelf: and all the affiftance art can af-
 ford, confifls in removing the obftruaions which  nature
 meets with in her progrefs.  Thefe obftruaions may be
 reduced to two general heads,  thofe of an internal nature,
 and thofe which operate as external or local caufes.
   Of the former kind are, every general diforder to  which
 the conftitution is  liable;  as we find, from  experience,
 that  a healthy ftate of the body only is capable of pro-
 ducing proper  granulations.   Thus the  cure  of  ulcers
 that occur in fyphilis, fcrophula and fcurvy, can never be
 properly effeaed, unlefs the general affeaion be firft cor-
 reaed.
   A low emaciated flate of body, alfo, either from  a very
 poor diet, or from immoderate evacuations, is very  preju-
 dicial to the growth of new parts.   In general,  the pati-
 ent fhould be fuffered to  live fo as that he may be kept in
 a fituation at  leafl not much more reduced than that of
 his common health.  But as a variety of treatment in this
 refpea muft be neceffary in different cafes, the proper
 diet muft be direaed by the judgment of the furgeon.
   The local obftruaion to the granulation of ulcers, may
be reduced to thofe  that aa mechanically,  and thofe of  a
corrofive nature.  As inflammation and pain contribute
much to prevent the healing of  fores, every thing, which
                                                   by 
                      C   25  ]
by  irritating,  tends  to excite them  fhould be avoided—
All flimulant  extraneous  bodies  fhould  be taken away,
and the dreffings fhould be mild and fimple, and changed
but feldom.
  The corrofive fubflances that impede the cure of ulcers
are chiefly the vitiated difcharges from them.  Thefe are
fometimes fo acrid,  as not only to prevent the rifing of
granulations, but  even to corrode the neighbouring parts.
They fhould be correaed, and if poffible, by the means
hereafter to be pointed out, converted into pus.
   When the vacancies in fores are properly filled up, the
remaining part of the cure confifls in the formation of a
cicatrix.  This is  frequently, in a great meafure, a work
of  nature;  but it  may  often be  confiderably  expedi-
ted by the application of mild flyptic powders and wafheg.
Thefe,  by corrugating the ends  of the veffels, and  ex-
ficcating the cellular fubftance in which they are envelo-
ped, tend very much to form that delicate covering term-
ed cicatrix ;  which though at  firft very thin, by fubfequent
depofitions of  inorganic fubftance, commonly acquires at
length no inconfiderable degree of ftrength and firmnefs.
  The  indications  of cure  in  the fimple purulent ulcer, are,
1. Todiminifh, as much as poffible, any vacancy the ulcer
may have occafioned: and, 2.  To promote the formation
of a cicatrix.   For the accomplifhment  of the firft, it is
neceffary, as before explained, not only to have new gra-
nulations  formed, but alfo to produce a decreafe of the
parts contiguous to the fore.
   In order  to effea  a produaion of new parts, we muft
avoid the application of every  thing that may occafion pain
or irritation, as the  warm gums, balfams, and fpirituous
tinaures, which  have been fo indifcriminately ufed in all
fores, remove all corrofive matters, and make  ufe of mild,
bland unguents as dreffings.   The  following is  one of
the mofl ufeful of this clafs—&.  of wax, |iv. fpermaceti,
                            D                      §"i. 
                      [  26  .]
 |iii. oil ffcj.   Goulards  cerate is alfo  a very good mild
 application.   It is thus made : Take 4 oz. of refined wax,
 and ftj. of oil; keep them over a flow fire, until the wax
 is  melted, ftirring them gently.   Having previoufly mix-
 ed |iv. of extraa of lead with ft>vj. of water, add it gra-
 dually to the  wax  and oil,  now cooled.  Let them  be
 well incorporated together with a wooden fpatula ; always
 taking care  to  let the quantity  of water firft put in, be
 entirely abforbed before any more is added.  This  oint-
 ment,  as well as every other, fhould be made in fmall
 quantity at  a time, as it is  of confequence to have them
 free from rancidity.
   The  frequency of dreffing ulcers muft principally de-
 pend on the  quantity of matter difcharged ; but in general
 they fhould  be dreffed once  in twenty-four hours.   The
 ointment fhould be fpread on pledgits of lint, and  fhould
 be  applied immediately after the removal  of the preceding
 dreffings, in  order to prevent the bad effeas which often
 follow expofure of the fore for any time to the air.  Some
 furgeons have  advifed the renewal of  the applications to
 fores but once in five or fix days.  By this method, how-
 ever, and particularly in hofpitals, the air muft neceffarily
 be rendered impure.
  Ointments have beert fuppofed by fome to render the
 granulations  lax and flabby :  but this I have never been
 able to perceive.   Such effeas are, indeed, produced by a
 long continued ufe of emollient  fomentations  and poul-
 tices—Lint applied immediately to fores, except the dif-
 charge is very great, gives too much irritation, and indeed
 always aas more or  lefs as an efcharotic.
  The next circumftance requiring attention in this part
 of the  cure,  is to preferve the matter difcharged in a pro-
per purulent  ftate. This, in  the fimple purulent ulcer, is
chiefly produced by the prefervation of a proper degree of
heat—Whilfl any inflammation remains, this is befl  ef-
                                                feaed 
                      .   27  ]
feaed by warm emollient poultices, renewed every three
hours; but as foon as the  inflammatory fymptoms have
abated, they fhould be laid afide.  The fame purpofe may
then be better anfwered  by  applying  over  the  dreffings
thick quilted coverings of wool, cotton,  or any fuch fub-
ftances as retain heat mofl effeaually.
  The other mofl material part of the firft  indication in
the cure of  ulcers is to be anfwered by compreffion.  This
is to be employed in the  eircumftances, and in the man-
ner mentioned when we treated of ulcers in general.
  When the lofs of  fubftance in ulcers is fully  fupplied,
the fecond indication is to be attended to, viz. the formation
of a cicatrix.
  This is frequently effeaed by nature alone ; but, in  ma-
ny inftances, it is a matter of confiderable difficulty.  The
emollient ointments  muft be now laid afide,  and the  fore
fhould be dreffed with fome flyptic drying ointment, as the
unguent album  prepared with cerufs, and  wafhed once
or twice a-day with lime-water or ardent fpirits.  Thefe
will often fucceed.
   On fome occafions, cicatrization is prevented  by  the
granulations rifing above the furface of the  neighbouring
parts. It is then neceffary to have recourfe to aftringent, or
even efcharotic applications.   One of  the beft of the mild
efcharotics is blue vitriol; if this is  not fufficiently ftrong,
nothing weaker than the common caufiic flone will be ef-
feaual; and in  flight cafes of this kind, lint, and a pretty
tight bandage will frequently produce a cicatrix.
   When every  previous part  of the  cure  has gone on
very  well, it often  happens, that the granulations  con-
tinue raw, and fhow no tendency to heal for fome time;
in thefe cafes, when the means we have recommended do
not accomplifh the cure, compreffes wet with ardent  fpi-
rits, being applied  under the  roller,  will often anfwer;
                                                    or 
                       [   28  ]
or thefe may be alternated  with tinaure  of myrrh,  or a
folution of blue vitriol in water.
   Befides local applications, there  are  fome general eir-
cumftances very neceffary  to be attended to in the treat-
ment of ulcers.
   Reft of body, and particularly of the part  affeaed,  is
very requifite :  and, in all  fores on  the lower extremities,
nDtwithftanding what has lately been faid to the contrary, I
am fully convinced by  long experience, that a more per-
manent and fpeedy cure will  be effeaed, if the patient
can keep the limb  in a horizontal pofture  generally, than
if he is permitted to take much exercife.
   The diet fhould be fo regulated,  that the patient  may
be kept in his ufual habit of body.   All exceffes in eating,
as well as in drinking,  fhould be carefully avoided.
   Internal medicines appear to be entirely unneceffary for
the cure of the fimple   purulent ulcer,  except when the
.difcharge is uncommonly large and  thin; in  which  cafe
the peruvian bark  is often a very ufeful  remedy.


                    SECT.   III.

               Of the Simple vitiated Ulcer.

   The vitiated ulcer differs only from the fimple purulent
fore in the nature  of the difcharge.
   The matter afforded is either, 1.  A  thin, limpid,
fometimes greenifh difcharge, termed fanies.  2.  A fome-
what red-coloured, thin, and generally very acrid matter,
termed ichor;  or,   3.  A more vifcid,  glutinous kind  of
fluid,  called  fordes.  This  laft  is  alfo frequently  of a
brownifh  red  appearance,  fomewhat refembling  the
grounds of coffee, or grumous blood mixed with  water.
They are all more  foetid than pus, and  none of them free
                                                  from 
                      [  29  ]
from acrimony—What has been termed ichor, is often fo
corrofive as to deftroy large  quantities  of  the  neighbour-
ing parts.  In confequence of the nature of the difcharge,
the granulations wafle away, and have a  dark brown  or
black appearance.  The pain is often confiderable, and
is proportioned to the acrimony of the matter.
   The caufes of this ulcer  are the fame as thofe produc-
ing the  purulent ulcer;  and. that fpecies eafily degene-
rates  into this  from negfea or improper treatment; and
particularly when the tendinous  parts are  the  feat  of the
difeafe.
   The prognofis in the vitiated ulcer,  may be favourable
when the complaint is not  extenfive or is local,  has not
been of long duration, and  occurs in young, healthy fub-
jeas ; b.ut, in oppofite eircumftances,  it fhould always be
very doubtful.
   The quality  of the difcharge in ulcers has been above
fhewn to depend chiefly on the different degrees of inflam
mation in the part;  and this is  further confirmed by the
nature of the remedies that  are mofl effeaual in relieving
thefe diforders, which are principally of that kind which
remove pain and  irritation.   Thus warm  emollient cata-
plafms and fomentations often give great  eafe, and meli-
orate  the  difcharge within  twenty-four  hours:  thefe
fhould be ufed  as formerly recommended to promote fup-
puration, and  the  dreffings  applied immediately  to  the
fore fhould be mild, like thofe advifed  in the fimple puru-
lent ulcer, while too great a degree of inflammation  con-
tinues.   When the pain is  very   confiderable,   opiates
fhould be  given,  and repeated according  to  eircum-
ftances.
   The diet muft be regulated  by the habit of body;  if
weak, it fhould be nutritious ; if full,  the regimen fhould
be low.   In the former cafe, the peruvian bark is a very
                                                effica- 
                       [  30  ]
efficacious remedy, and fhould be given  in  dofes  of 3j.
fix1 or eight times a-day.
   When the abovementioned eircumftances  are  attended
to, and the part affeaed is kept at reft in a  proper  pof-
ture, the  fore is  commonly fooner or later reduced  to
the ftate of the fimple purulent ulcer; and then requires
the fame method of treatment.
   I have never feen any evident good effeas produced by
the exhibition of nitre; although I have frequently given
it in large dofes for a confiderable length of time.*


                    SECT,  rv.


                  Of the Fungous Ulcer.

   By fungus, or as it is fometimes termed  hyperfarcofis,
is meant fuch preternatural rifings in fores  as are com-
monly more foft  and fpongy than healthy granulations.
Thefe, in fome inftances, arrive at a very confiderable fize;
and now and then acquire very great degrees of hardnefs.
The pain attending them is feldom confiderable;  and the
difcharge afforded varies according to the fpecies of  fore
they happen to be  conneaed with  while they  are recent;
but after fome continuance, this, as well as other eircum-
ftances  become fo  changed, as to form very  different
fores from thofe which originally exifted.
   Thefe excrefcences are often owing to  the negfea of
repreffmg the granulations when they  fhew a difpofition
to advance beyond the furface of the found parts.  They
are alfo produced  in various fores that are  not  healed at
bottom, before granulations are fuffered  to  proceed  any
                                               length.

  * It has, however, in a few  inftances,  been attended with very happy
effe-ts in the cure of old habitual ulcers of the leg. 
                      [   31  ]
length.   Thefe inftead of cicatrizing when they are on a
level with the found parts, continue to  advance until the
caufe is removed.
  With refpea to the cure of fungi, when it is found that
they are produced merely by an over-growth  of parts,  if
they are not of any confiderable breadth, and  efpecially if
they are not very high, we fliould have  recourfe to efcha-
rotics.—By many, we are direaed to ufe the aaual caute-
ry, and by others the fcalpel; but few  patients will fub-
mit to either of thefe,  and particularly as the diforder may
juft aseffeaually, though not quite fo expeditioufly, be re-
moved by means more gentle.
   Of all the  caufiic preparations,  the lunar caufiic is the
befl  for this purpofe.   It aas more quickly, and does not
give more pain than the milder forts ; it never  fails to pro-
duce the proper effea as many others do; and it is not fo
apt to run, and to  fpread over the neighbouring parts,  as
fome of the other cauflics.
   The cauflics fhould be liquefied, and then  applied by a
fmall brufh or  pencil, daily or every other day—A ftrong
folution of verdigreafe, fal ammoniac, blue or white vitriol,
will alfo commonly prove effeaual.  But folutions of fil-
ver or mercury in nitrous acid  form the  mofl powerful
applications of this kind.  In making the laft we muft ob-
ferve, that one ounce of ftrong fpirits of nitre will diffolve
no more than  about  fix  drachms  of quickfilver.  Thefe
cauflics fhould never be  applied to an extenfive furface at
once.  After  their ufe  the part fhould be covered with
lint,  as ointments leffen their aaivity.
   When the  bafe of the excrefcence is  narrow and its
height confiderable, it fhould be removed by a ligature ap-
plied at its root, and  tightened daily.   If, however, toge-
ther with great height, the tumor has  a broad bafe,  this
method will not fucceed; and the following  muft be put
in praaice.
                                                      A 
                      [   32  ]
   A ftrong flraig'ht needle fixed in a handle,  with an eye
near the point, being pufhed through the tumor at its bafe,
and two ftrong waxed threads being introduced at its eye,
it is to be again drawn back, leaving the threads with their
ends hanging out at each fide of the fwelling.  A firm liga-
ture  is then to be formed round each half of the fwelling by
the threads,  and tightened from time to time.
   The fungus being by either of  thefe methods removed,
the fore is then to be treated as  a fimple purulent ulcer.
   The other fpecies of fungous excrefcence which proceeds
from the granulations not being raifed on a good founda-
tion,  is generally eafily diftinguifhed from the preceding
fpecies: It rifes  with greater rapidity, and is not fo firm
as healthy granulations.
   As foon 3S the caufe is difcovered, any confined matter
beneath fhould have vent given to it by a proper  open-
ing ;  after which, by taking care that the fore fills up from
the bottom, the cure will go on  eafily in the common way.
There is feldom then occafion for efcharotics, as the fungus-
commonly wafles away of itfelf.


                   SECT.   V.


                 Qn the Sinuous  Ulcer.

   By finuous ulcer is meant a fpecies  of fore communi-
cating with  one  or more openings or  cavities,  which are
commonly feated in the cellular membrane, between  the
interftices of mufcies, or between the mufcles and integu-
ments.   By long continuance,  or by the ufe of aftringent
applications, a  finus  often  becomes hard and  callous in
its internal furface;  and in fuch a ftate, from its fuppofed
refemblance to a pipe, it is termed  a fiftula.
                                                  The 
   The mofl frequent caufe of finufes, is  the  want of a
free difcharge of matter  formed in ulcers and abfceffes;
which, falling to the mofl depending fituation of the part,
if it does not there find  a ready  paffage  by an opening
made to it, readily infinuates itfelf into the cellular mem-
brane, and proceeds gradually onward till  it finds a vent.
Very tight bandages applied immediately over a fore, and
not made to  aa on the parts above  and below for fome
diftance,  are alfo a frequent caufe.
   In healthy conftitutions, when there is eafy accefs to
the finus, a favourable prognofis may generally be made;
but when the difeafe has been of very long continuance,
and particularly if the finufes open into any of the joints,
or are beyond the reach of ah operation,  a cure  is diffi-
cult,  and doubtful.
   The intention of cure,  in every cafe of finUs, is to pro-
duce a coalefcence of  its  fides, fo as to deftroy any vacui-
ty that may have been occafioned.
   To effea this, it is neceffary  firft to make a depending
orifice for a free exit  to  the matter; and then, by a gen-
tle irritation,  to induce  on  the  internal  furface  of the
fore,  a  flight degree  of  inflammation,  and   confequent
adhefion of the fides of  the finus.   Both thefe intentions
are anfwered by the introduaion of the  feton, from the
orifice in the ulcer along the courfe of the  finus to  its
other extremity, where an opening fhould  be made in the
manner we formerly direaed in  abfceffes.   The treatment
is then to be  fimilar to that of abfceffes in which a  feton is
ufed.  Vide chap. I.  fea. iii.  A cord fhould be intro-
duced into every finus.
  This method is entirely free from danger, and is admif-
fible in  almofl every cafe  that can occur.  It   is  particu-
larly proper in  finufes in  the perinseum: for the  cicatrix
formed there  after the opening a  large finus by the knife,
                            E                       is 
                       C  34   ]
is often more inconvenient and painful than  the  original
difeafe.
   The  finufes being by this means filled up, the ulcers
with which  they have been conneaed,  are then to be
treated  by the method adapted  to the fpecies to which
they belong.
   By many writers, ancient as well as modern, we are di-
reaed,  in recent finufes to ufe healing injeaions;  and
when their fides have become  callous, efcharotic injec-
tions and  powders have been recommended.  None of
thefe,  however,  produce any permanent good  effeas;
and often convert fimple finufes into the callous.   Others
advife  to lay  open the  different finufes,  and cut out the
whole  of the callofities.  This  will often effea a cure;
but the  pain, and  often the danger attending it, muft
induce a preference of the mode above recommended.
  When, however, incifion is preferred,  unlefs  all the
parts are  evidently callous;  in  which  cafe extirpation
may be neceffary,  mere divifion  of the  parts forming
the finus fhould  alone  be ufed.  The free vent thus giv-
en to the  matter, and the fuppuration fupervening, will
frequently remove very confiderable callofities.


                SECT.   VI.


                 On the Callous Ulcer.


   An ulcer is faid to be callous when its edges,  inftead
of contraaing and  diminifhing the fize of the fore, keep
at a diftance, turn ragged, and at laft,  by acquiring  a
preternatural degree of thicknefs, often rife  confiderably
above the level of the  neighbouring parts—the difcharge
                                              afforded 
                       [  35   ]
afforded by it, is commonly a thin vitiated matter.   Vari-
cofe veins alfo occur as a fymptom, and particularly  when
the difeafe is feated in  the  lower extremities ; hence the
name of varicofe ulcer, which this fpecies has acquired,
from a fuppofition that it was produced from matter fup-
plied by thefe veins, which frequently have the appearance
of opening into the fore.   The varices feem to originate
chiefly from an  obftruaed return of blood, by the pref-
fure of the callous parts  on the veffels.
   The caufes of callofities in ulcers may be all reduced to
neglect and mifmanagement.  When, from thefe eircum-
ftances, the fmall veffels of the edges of ulcers are prevented
from proceeding in a proper  direaion, are forced to pufh
upwards,  and  even fometimes  backwards,  they,  by the
preffure  of bandages,  will  neceffarily acquire at  length
a morbid hardnefs or  callofity.
   In the cure of  this  difeafe, the caufes originally produ-
cing it are firft to  be  removed; and the callofities may
then be taken away.
   Recent cafes are often cured merely by the repeated
Application of  warm emollient  cataplafms—and  alfo by
gum-plafters;  but  when the parts  have acquired much
hardnefs,  the  only remedies are the cauftic,  or fcapel.
And as the firft is equally certain with the other, it  fhould
as the  eafiefl  method,  be  always  employed.   For the
reafons  formerly  given, the lunar caufiic  fhould here
likewife be preferred.  The  folution of filver or of mer-
cury in nitrous acid, may be alfo ufed to advantage.  Ei-
ther of thefe fhould be applied to the callous edges every
two days, while the  cataplafms are  ftill  continued as
long as any degree  of foulnefs remains in the fore.
   For the cure of  the varices,  it is not only neceffary to
remove   their  primary  caufe,  the  callofity,  but  like-
wife to reftore the tone of the veffels weakened by their
                                             iiftention, 
                         [  36  3
  diftention,  by the application of the laced flocking, or a
  roller.*
    A confiderable fwelling of the adjacent parts very com-
  monly oc curs ; when this does not go off  after the hard-
  nefs  is removed,  the ufe of a flannel bandage will ufually
  prove effeaual in diffipating it.


                     SECT.   VII.

                   On the carious Ulcer.

    By the term carious ulcer we underfland  that fpecies of
 the diforder only which is conneaed with a  local affeaion
 of a bone: whether the difeafe of the bone may have been
 always confined to the part, or exifts  after  a general dia-
 thefis which originally gave rife to it has been removed.f
   When a bone is at firft laid  bare, it is impoffible to de-
 termine whether it will become carious ; as  in a great ma-
 ny inftances this does not follow even a removal of part of
 it.  A cure fhould, however, never be attempted until this
 can be afcertained.
   If at the end of  the fourth day after the denudation of a
 bone, it retains its natural appearance,  we may  conclude,
 with tolerable certainty, that a caries  will not fucceed. For
 when this is to happen, it generally begins in three days or
 four at fartheft.  The bone begins to lofe  its natural heal-
 thy appearance, turns firft of a pale white,  and then of a
 pale  yellow.  It fometimes remains  in this  ftate  for fome
                                                    days,

  • The growth of varices may be retarded by the ufe of the roller or
laced flocking judicioufly applied; but I never was able  to cure old exten-
five varices by thefe or any other means.
  f Caries appears evidently from its fymptoms, caufes, and method of
cure, to be a difeafe exactly of the fame nature with  a  fphacelus er gan-
grene of the foft parts.  B. 
                       [   37   ]
 days, and by degrees gets a more deep tallow-like appear-
 ance.   It continues thus  for a longer or fhorter time, ac-
 cording to  the  degree  of violence with which the injury
 has been done; and afterwards goes through the differ-
 ent ftages of brown and black, until it has acquired a black
 of the deepefl dye.
   The  difcharge  from ulcers of  this  kind, is generally
 thin; and of a moft difagreeable fcetor, which  always be-
 comes more confiderable  as  the  diforder  advances;  at
 laft it acquires a blackifh hue, and  often a confiderable de-
 gree of acrimony.   As the feveral  degrees of blacknefs
 go  on, fmall holes appear in the bone,  and  increafe
fo as at length to  render it quite fpongy.  The carious
 part then generally becomes  loofe,  and when preffed, a
 large quantity of a fattifh, intolerably  foetid matter is forced
 out.  This  taints the whole  difcharge ; and the fmell of
 it is  fo very peculiar, as to afford one of the moft charao-
 tereftic marks of caries.
  The granulations in this ulcer are foft and flabby, fpring
 up in clufters, and have a dark brown, together with fome-
 what of a glaffy appearance.   They ufually advance very
 fall, and if not carefully  attended to, will be apt to form
 large and troublefome excrefcences.
   All the phenomena abovementioned, occur in greater or
 lefs degree,  whether one lamina, or the whole fubftance of
 a bone is affeaed.
   When the bone has not been bared, it is often a matter
 of confiderable difficulty to difcover a  caries.  If we are
 able to introduce a probe, and by that means find a rough-
 nefs on the furface of the bone, we  may, with certainty,
 conclude it  to be carious.   And when it is impoffible to
 reach the difeafed part with an inflrument, we may com-
 monly afcertain the exiftence of a latent caries,  by the ap-
 pearance of the fore and the nature  of the difcharge.
                                                  The 
                       [  38   ]
   The caufes of caries may be, in general, whatever de-
 flroys the circulation in the whole or any part of a bone :
 as wounds which affea  either  the  periofleum or bones;
 violent contufions  and inflammations of the  periofleum,
terminating in abfcefs or gangrene ; the acrid matter of ul-
cers penetrating to, and deftroying the periofleum ; and
the improper application  of fharp acrid fpirits and  pow-
 ders to bones merely laid bare.
   It is to be remarked, that deftruaion of the periofleum,
or even the removal of part of a  bone is not always follow-
ed  by caries; and this is feldomer a confequence of fuch in-
jury to the cranium than to  any other part of the body ;
 probably  from  the  greater number of blood-veffels diftri-
 buted to that part.
  The prognofis in  caries muft  depend principally on the
following eircumftances :  The fituation of  the difeafed
parts; the nature of the  affeaed bones ; the nature and
degree of the caufe ; the fize of the caries; the age and
habit of the patient.
  Thus a caries in any of the bones of the  fkull, ribs, or
vertebra, from  their fituation near the vital organs,  muft
be attended with more  rifle than when it affeas the bones
of the extremities.   And a caries near a joint, from the
danger of this  becoming difeafed,  is always more  to be
feared than when it is confined  to the middle of the bone.
The texture of  a bone fliould  have alfo confiderable influ-
ence in the prognofis;  as well as the nature of the caufe:
exfoliations being much  more  tedious  in  the hard and
compaa,  than  in the more foft and vafcular bones, and a
wound with a fharp  inftrument, does not generally produce
fo deep or extenfive a caries as that which commonly fuc-
ceeds to violent  contufions.  The cure is likewife produced
in a  longer or fhorter time  as the caries is extenfive or
not.
  And, laftly, the habit and age of the patient muft have
                                           confiderable) 
                      C   89  ]
confiderable weight in making a prognofis.  For the cure
of caries generally proceeds fo flowly, that few can fupport
the difcharge it produces, if they have not previoufly been
perfeaiy healthy.
   The healing of an ulcer attended with caries fhould ne-
ver be attempted, until the difeafed bone is removed.   For
if the foft parts above fhould be united, an abfcefs would
be produced by the irritation of the bone beneath,  and
force them open.
   In a healthy ftate of the body, the feparation of the cari-
ous bone is produced, as in gangrene, by the intervention of
a  flight degree of inflammation excited on the extremity of
the found  parts—Suppuration follows, and this, together
with the rifing of granulations, foon detach the dead from
the living  parts.   If we fuffer ourfelves to be  direaed by
this procefs of nature, we may often accomplifh in a few
weeks what would otherwife require many more months
to effea.  The principal indication  of cure  therefore, it
is evident, fhould be by repeated and judicious applica-
tions to excite fuch a degree of inflammation, in the adjoin-
ing found parts  of the bone, as may be requifite for the
feparation  of thofe mortified.
   If the bone is not bared,  it fhould  be expofed to view
either by  laying open the foft parts or removing fome of
them.  The fafeft and eafieft mode of  exciting the necef-
fary inflammation,  is by making a number of fmall perfo-
rations in  the difeafed part, with the pin or perforator of a
trepan fixed in its handle, to  fuch a depth as to give a lit-
tle pain, every third or fourth day.    When the caries is
very deep  and extenfive, it will fhorten the procefs to ufe
the fmall head of a trepan.—As foon  as  any  part  of me
bone  becomes  loofe at the  edges,  its feparation will
be  much  haftened, by daily   infinuating  below  them
 the end of  a fpatula or levator, fo as to prefs them up-
                                                 wards 
                       [  40   ]
wards.  During the  feparation  of the bone, in order to
obviate  the fcetor, the fores fhould be wafhed with a de-
coaion of bark, of walnut leaves, camphor diffolved  in
fpirits, or lime-water.   The latter I would advife to be al-
ways ufed, as it not only correas the fcetor, but likewife
diffolves the cohefion of the bony matter.   Pledgits of lint
dipped in thefe fhould be laid on the bone, while the reft
of the fore is dreffed in the ordinary way.
   After the  feparation  of the caries,  the ulcer is to  be
treated as a fimple purulent fore.
   When  a very large portion, or the whole circumfer-
ence of a bone is carious, the fhorteft procefs is to take out
all the difeafed parts by the head of a trepan, or a flraight
or circular  fpring-faw.  This may be done in all cafes
where the difeafe is  confined to the  middle of a bone,
except, perhaps, when the thigh  bone is affeaed-  There
are many inftances of the regeneration of whole bones;
hence we fhould never defpair of a cure where the part
difeafed can  with  fafety be removed.   When  the thigh
bone is extenfively  affeaed, or when the ends of the larger
bones forming joints, are carious,  amputation is almoft the
only  remedy  to be depended on.   See chap, on Ampu-
tation.
   During the treatment of caries, the fame attention is re-
quifite to the patient's habit of body, diet, and regimen in
general, as we have recommended in other fpecies of fores.
   The  bark is almoft the  only  remedy  that  fhould be
ufed  internally;  but when  the  foft parts  become very
painful and inflamed, flight fcarification, or bleeding with
leeches, fhould be employed, and opiates fhould be given
freely.
SECT. 
[   41   ]
                      SECT.   VIII.


                    On the cancerous Ulcer.*

    Cancers have generally been divided  into the occult and
 open.    By the former are meant fuch hard fchirrous fwel-
 lings  as are attended with  frequent fhooting  pains, and
 which generally terminate at length in the  latter.    By  the
 open, or ulcerated  cancer, we underfland that fpecies of
 fore which commonly  fucceeds  to  hard fwellings of  the
 glands, although in fome inftances, it occurs  without any
 previous hardnefs.   The edges of this ulcer are hard, rag-
                                F                          ged,

   * The following obfervations on Cancers, arc the refult of the  expe-
 rience of Mr. Berchien, a Swedifh furgeon  of eminence ; and who, in
 confequence of having purchafed Mr. Guy's remedy for twenty years,
 had a very great number of patients with cancerous complaints  under his
 care from all the northern parts of Europe. They were publifhed in the
 Swedifh language by Mr. Berchien, and by him fent to Dr. Adam Kuhn,
 the prefent profeffor of the practice of  phyfic in the univerfity of  this
 place, who has favoured me with a translation of them.
   There are three fpecies  of  cancers: the cancer genuinus, fungofus,  and
fcrophuUfus.  The cancer genuinus, or  genuine cancer, is the moft common.
 It ufually appears firft in the form of a very fmall, hard, and  moveable
 tumor or fchirrus:  this  is ufually  fmooth and round:  but in fome in-
 ftances, it feels like a fmall tendon or firing.   After fome increafe of  fize,
 it often retains its  fmoothnefs;  but in other cafes, it becomes rough
 and angular, affumes the  form  of a cone,  an  almond, &c.  It  often
 continues of the fame fize for a number of years ; but it alfo frequently
 continues conftantly to increafe in  magnitude from its  firft  appearance.
 The tumor is at firft moveable, but after it  has  made  fome  progrefs,  A
 becomes attached to the adjacent parts.   When it advances near to  the
furface,  it becomes very perceptible  to the eye,  and the fkin contracts a
 wrinkled appearance.
  A pain,  in fome inftances, is felt before any evident tumor,  particularly
 in the cord-like cancer.  In other cafes, there  is no pain  until the tumor
appears; and in others again, which is  moft frequently  the  cafe,  the
                                                             pain 
                          [   42   ]

ged, and unequal, very painful  and  reverfed  in different
direaions.   The  furface  of the fore  is  commonly  very
unequal.   The  difcharge is  for the  mofl part a thin foe-
tid  ichor;  and  is often  fo acrid  as to excoriate and even
deflroy the neighbouring parts, and by this means it fome-
times  produces confiderable  hemorrhagies.   There  is a
confiderable  fenfe of heat  over the whole ulcerated fur-
face, which is the moft tormenting fymptom of the  difeafe,
and violent, fhooting, lancinating pains.
   Thefe are the mofl frequent  fymptoms of  cancer,  but
                                                           they

pain does not come on until the tumor has  acquired  a  confiderable fize;
but after the pain begins, the fwelling conftantly increafes in magnitude.
Sometimes a momentary fhooting pain only is  felt during the  menftrual
flux, or upon changes of weather ; but in other cafes it is continual.
   Not long before the cancer becomes ulcerated, the fkin changes to  a
red colour, and is painful to the touch; it foon after  becomes chapped,
and a thin fanies iffues from the fiffures.  The edges of the fore foon be-
come hard and uneven, and are reflected in various directions.  There  is
never a  good pus afforded, but  the  difcharge  is a thin fanies  or ichor,
which often deftroys the contiguous parts.
   This fpecies of cancer attacks various parts of the body; but particu-
larly the lips, nofe, and breaft.
   The cancer fungofus chiefly occurs in fat women of a lax habit of body
and who have large breads.  It begins like the genuinus, with a fmall
moveable hard tumor; but it is more fpongy, elaftic, like  a  clufter  of
fmall tumors, and  not fo hard.  Its progrefs is aftonifhingly rapid:  in
fome inftances  it  has grown from the fize of a nutmeg, to the bignefs
of a man's head, in  the  courfe of eight ot ten months.  Little blue or
reddifh  fpots, often appear over the furface  of  the tumor;  which, when
opened, difcharge blood, or a bloody ferum.
   When the cancer ulcerates, it difcharges  fuch quantities of a  bloody
fcrous matter, often all at once, that no dreffings can keep it  dry.  From
one  or  more of the openings, arife large fpongy lobe-like excrefcences,
which fometimes have a refemblance to fheep's liver, and at other time*
have the form of the head of a cauliflower ; and  are hard and cartilagi-
nous to the touch.  Thefe often fpread over the whole  breaft, and are,
 in fome inftances, ftrangulated at their bafe by the fkin.
   This fpecies affects not only  the breaft,  but alfo the  neck, fhoulders,
 arms, and legs.
                                                             Thf 
                           [   43   ]

they are often fo varied, that it is not always eafy to diftki-
guifli the difeafe.   When however, two, three, or more
of thefe  concur,  we may always be pretty certain of the
ulcer being  cancerous.
   We  may be  affifted in the diagnofis by the fituation  of
the fores: thus they generally  affea  glands, or  parts  in
which glands are numerous.   Hence a  far  greater num-
ber  occur  in  the  lips and in  the breafts of women than
in every other part of the body.
    Various eircumftances  have been affigned for the pro-
                                                        duaion

   The cancer fcrophulofus begins  fometimes like the  two  other  fpecies
with a fingle fchirrus; but in  moft inftances, there are feveral  near each
other,and which  often feem connected:  Thefe are not fo  hard as in
the genuinus, and give little or no pain until they become  open fores,
and even then but little.  In the advanced  ftages, the  breaft appears  co-
vered with reddifh blue fpots, and is flat and  hard.  The integuments
and fubftance of the breaft being drawn in, fo as to produce a furrow in
the middle, and firmly fixed to the mufcles and ribs.   This attachment
often occafions  a confiderable  impediment  to  refpiration.   The fubcuta-
neous lymphatic glands become  hardened in every part  of  the breaft,
and particularly thofe towards the axilla.
   There are many openings formed ; fome of thefe often dry up in a little
time, and get a thick white fcab :  others continue open—fome of them
difcharge pus, others a thin foetid black  ichor.   The edges  of the  ulcers
are frequently  red and fungous; and  the difcharge  often penetrates at
length to the ribs and fternum, and even into the thorax.
   In this fpecies, there are ufually indurated lymphatic  glands in  various
parts of the body,  and other marks of  fcrophula; and it  evidently  de-
pends on a general affection.
   Tumors in the breaft from milk, have been accufed of terminating in
cancer; but there is no good evidence  of this;  and  where  it has  appa-
rently been the cafe, I have no doubt that  there  has, at  the  fame time,
been a fchirrus  in the breaft, which has become cancerous  from  the ir-
ritation produced by the milky tumor.
   The general exciting caufes of cancers, are paffions of  the  mind, parti-
cularly grief or  terror,  and external  violence.  In  the  cancer  genu-
inus and fungofus, thefe  operate locally  by  producing,  probably  an
obftruction  in the  lymphatic ve.Tels,  and a confequent  fchirrus from
a gradual accumulation of lymph, and abforption of its thinner parts;  but
in the cancer fcrophulofus  there is a general  difeafe connected with  the
                                                           topical 
                            [   44   ]

 duaion  of cancers ; and at leafl an equal  number  of re-
 medies have been  propofed for the  cure of  them ;  but our
 little fuccefs in the treatment  of the difeafe fhows clearly,
 that the ideas adopted,  and  the remedies  offered,  have
 been  more founded  on  theory, than on  obfervation and
 praaice.
                                                                It

 topical affe&ion.  From hence it is evident, that the  cure of the latter can
 only be effected by conjoining the general  remedies  of fcrophula with
 proper applications to the cancerous  part; whilft the genuine and fun-
 gous cancers may  be  effectually  removed by timely, topical  remedies a-
 lone.  The fcrophulous cancer may fometimes be cured by an  early and
 judicious ufe of mercury, general and topical, and by hemlock; but both
 of thefe are injurious in the other fpecies; for the cure  of which,  we can
 with fafety, only  depend on early  extirpation, or Guy's powder.-----
   As a  confirmation of the accuracy  of this interefting  account  of can-
 cers, I am happy to give the teftimony of  Dr. Jones, of this  city, whofe
 long experience has afforded him an ample opportunity of afcertaining
 its agreement with the phenomena, nature, and proper method of treat-
 ing thefe dreadful difeafes.
   The Doctor thus expreffes his opinion on the fubject:—Mr. Berchien's
 obfervations on cancers, appear  to be the  refult of  accurate  obferva-
 tion, and great experience; from  which alone any genuine improvement
 can be made in the  cure of difeafes.
   His diftindtion  of cancers  into the three   general  fpecies  of  genui-
 nus, fungofus, and fcrophulofus, is  well founded,  and  merits  the  fe-
 rious attention of  all  thofe who wifh to treat  this  terrible difeafe with
 propriety.   The two firft may be radically cured by extirpation with the
 knife or cauftic, as they appear to be  local  difeafes:  but  the  cancer
fcrophulofus requires the aid of internal medicine, to correct  the  vitiated
habit; though very few inftances occur of perfect cure.
   The cancer fungofus appears to be more liable to  relapfe than the ge-
 nuinus ; and inftances have been known,  where  the  cancer fungofus has
 broke out after it  appeared to be perfectly cured by  Guy's powder, and
 remained found above ten years.
   The fame fpecies of cancer has been frequently clofed by the  ufe of
 arfenic; but has often broke out again,  and  at  laft baffled all remedies.
 Similar confequences have  attended a quack  noftrum, which has been
 much boafted of in this city for two years paft.
   From thefe  inftances, it  appears  to be a  melancholy truth,  that there
 are cancerous ulcers which baffle  all the remedies hitherto difcovered. 
                       [  45   ]
   It however  appears  evident  to me,  that cancer is ge-
nerally a local  affeaion, not originally conneaed with any
conftitutional  complaint;  and that a  general cancerous
taint, feldom, or perhaps never occurs, but in confequence
of the cancerous virus being abforbed into the fyftem from
fome local affeaion.   This opinion is  more  particularly
rendered probable, by the fuccefs of extirpation in curing
cancers.   From  a  ftatement  of Mr.  Hill,  furgeon in
Dumfries, it  appears  that of eighty-eight cancers he had
extirpated  before the   year  1768,  in  1770  there  were
two  of the patients not  cured : in nine  they had broke
out  again ; one  was threatened with a relapfe ; and about
forty remained  alive  and found.  From thefe and many
other authenticated faas,  we  think ourfelves warranted
in drawing the above mentioned conclufion.   The ill fuc-
cefs  of fome  furgeons, and particularly of hofpital prac-
titioners, may more juftly be attributed to the inveteracy
of the cafes in  which they have been ufually confulted than
to any thing really incurable in the nature of the difeafe.
   Cancers fucceed to external accidents: to tumors of the
breafts in nurfes and lying-in  women mifmanaged ; to fe-
vers  and other internal diforders, of which  they feem to
be the terminations:  and  they  happen to  women about
the time  of the ceffation of the menfes.
   All thefe eircumftances probably operate in bringing on
cancer, by firft  inducing a preternatural determination of
fluids to the  part,  which neceffarily diflend and ob(lru6l
its veffels : from the fmall degree of irritability  in thefe, the
part  affeaed being ufually glandular, an indolent tumor or
fchirrus is thus gradually produced by the accumulation of
fluid : this, at  length, either from increafe of bulk or from
external  violence is excited to inflammation ; which, at a
longer  or  fhcrter period, finally terminates in the forma-
tion of the cancerous virus.
   This explanation will perhaps be admitted as agreeable
                                                    at 
                          [   46   ]
 at leaft to probability, if we confider that glandular parts,
 which are almoft always, if not  in every  cafe,  the feat of
 cancer,  never  afford  a  good  difcharge:  and, from the
 analogy  of many other fores which often  produce  a mat-
 ter nearly as acrid as the cancerous virus, we may certain-
 ly be  allowed to infer,  that fome peculiar affeaion of
 thefe parts may induce the formation of a matter as  acrid
 as that of cancers: and when the virus is thus formed it
 may in time be  abforbed  and  produce a  general  cance-
 rous diathefis.
   There is  no remedy to be depended on in cancers but ex-
 tirpation ; and it fhould be had recourfe to immediately on
 the difcovery of the difeafe.  With refpea to the parti-
 cular modes  of performing this operation, we muft  refer
 to what will be  faid hereafter;  and  fhall  only  obferve in
 this place-, 1. That cauflics, on  account of the  irritation
 and inflammation they  produce, fhould never be preferred
 to the fcalpel.    2. Wherever the diforder is fituated, eve-
 ry part that  has the  leaft  appearance of difeafe,  every
 indurated gland in the neighbourhood fhould be always
 taken off,*  otherwife  the  cancer  will certainly return ;
 but no more of the  integuments fhould be removed than
 is abfolutely neceffary :  for  the fmaller the cicatrix that
 remains, the lefs will be the confequent irritation ; and from
 this, perhaps, the chance of the difeafe returning may be
 leffened.   The teguments fhould, as far  as  poffible, be
 brought to  cover the wound by  the  employment of the
                                               interrupted
  " From a circumftance which occurred in a cafe  of occult cancer of
the mamma extirpated by Dr. Hutchinfon, of this city, and  of which 1
was a witnefs, I fhould think it very proper, in every  inftance, to avoid
cutting the tumor.  After the operation, the Doctor's pupil wifhing to
examine the whole fubftance of the cancer, made an incifion into it, and
there immediately iffued forth a confiderable quantity of a  thin icho-
rous matter.  The patient very foon recovered;  which, perhaps, might
not have been  the cafe had this matter  been difcharged into the
wound.  For it is very well known that cancerous fores have  been fome-
times prodaced from the application of the virus,  even to parts covered
W ith the integuments. 
                       [   47   ]
interrupted  or twifted  future.  3.  After the removal of
the cancer, if the  teguments  do not entirely cover the
wound, and a hemorrhagy  enfues,  dry lint fhould  be
ufed as a drefling ; but if there is no difcharge of blood,
the lint fhould be  fpread with fome emollient ointment.
The  fore  fhould   afterwards  be  treated  as  a fimple
ulcer, and healed as foon as poffible.  4. Some little time
before the healing of the fore, an iffue fhould be introduc-
ed—and  this is  probably done with greatefl advantage,
if made  within  the vicinity of the cancer.  Iffues feem
particularly neceffary in cafes of cancer that proceed from
fuppreffed evacuations, and have  continued a long time;
and we have  no doubt,  but that  they  often prevent the
return of the difeafe.
   The eircumftances that fhould prevent the extirpation
of cancers, are,  in  general, 1. The appearance of cance-
rous ulcers and  fchirrous glands  in  feveral parts of the
body at the fame time.  2. The conneaion of them with
Dther  parts  that cannot  be  removed  without danger.
Thus cancers adhering  to the trachea, or to the coats of a
large artery, can  never, without the greatefl rifk, be extir-
pated.  But large  portions  of mufcles  and tendons have
been taken away with cancers without  producing  much
inconvenience.   And there have occurred many inftances
of cancerous mammae, in  which there were  adhefions to
the periofleum of  the ribs, to the clavicle, and fometimes
a chain of indurated glands, extending to  the bottom  of,
the  arm-pit,  and yet all the difeafed parts were with per-
fea fafety removed.
   3.  An operation can   never be advifable, where  the
parts affeaed are fo fituated, as to prevent  their being to-
tally extirpated ; as is the  cafe in cancers  of the uterus and
reaum.  The indication  then, is to palliate the different
fymptoms,  fo as to render the difeafe as tolerable to the
patient as poffible.  As, for this purpofe, the great objea
                                                     is 
                        C   48   J
is  the abatement or  prevention  of pain, nothing  fhould
be exhibited internally, or applied externally, that can have
the  leaft effea  in  producing irritation or inflammation.
A diet of milk, and  the lighteft vegetables fhould be or-
dered :  no  animal food, fermented  or  fpirituous liquors,
fhould  be  allowed;  and  all violent exercife  fhould  be
carefully avoided.
   The  fcetor of  cancers is considerably correaed  by the '
ufe of hemlock.  This may be taken internally in powder
or extraa,  and  applied  externally  with  emollient  poulti-
ces in powder,  if the juice cannot be had.   It commonly
alfo  mends the difcharge ; and this much fooner than the
carrot-poultice  that has been fo much recommended in
foul fores.*
   When a good difcharge is obtained the fore fhould be
treated  as a fimple purulent  ulcer—and particular atten-
tion (hould be paid to avoid long expofure of the ulcerat-
ed  furface  to the air.  The  violent fhooting pains are re-
lieved fometimes by cicuta—and  fometimes by emollient
fomentations—when  neither  of thefe  fucceed, we muft
have recourfe to opiates.
  Befides a variety of other  remedies, cicuta, belladonna, and
arfenicf, externally as well as internally, have been much
employed and recommended for the cure of cancers; but we
                                                      have

  * Similar good confequences have fucceeded the ufe of common  poke
—the ley-poultice—and of fixed air.
  f Arfenic has been probably the bafis of moft of the  quack medicines
for cancer ; fuch as Guys, Plunket's, and  others.   Dr. Rufh has proved,
by a  chemical analyfis,  that Martin's remedy contained  this fubftance.
It has been obferved to occafion various fpafmodic affections in  fome  in-
ftances, and particularly to aff ct  the mufcles of the eyes.  We have good
evidence of its producing beneficial effects in  many inftances, and of ef-
fecting cures in fome.
  If it is propofed to apply arfenic to an occult cancer,  it  will be necef-
fary to deftroy the cuticle by the  lunar cauftic or fome other fubftance, or
                                                         by 
                         [   49   ]
have never feen any of them produce any permanent adv an-
tage. Mr. Juftamond has fpoken highly of an efcharotic me-
dicine compofed of fteel and fal ammoniac, infufed in fpirit
of wine, with a certain proportion of oil of tartar and fpirit
of vitriol.   The edges of the cancers, as well as the Jiard
excrefcences that occur in them, are to be conftantly moift-
ened with this liquid ; and during  the  ufe  of it, he like-
wife advifes  the internal  ufe  of flores martiales.   From
the  trials  I have made of thefe remedies,  I have not ex-
perienced any real advantages.


                     SECT.   IX.


                 On  the  Cutaneous  Ulcer.


   There are  few difeafes lefs underflood than thofe of the
fkin.  The defcriptions given  of them are fo confufed ;
and they are  fo varioufly named by different writers, that
it is difficult to colfea any thing on the fubjedt fatisfaaory.
We fhall here  confine ourfelves  to fome general obferva-
tions on thofe topical complaints of the fkin  that are apt to
produce troublefome ulcers.  Thefe, as well as fome others,
have all been included under the general term of  Herpes,
from their being apt  to fpread from one part to another.
   The chief varieties of herpes may be comprehended in
the four following fpecies, viz.  the Herpes farinofus, pufiu-
lofus, miliaris, and exedens.
                             G                        The

by a knife, previous to its ufe.  Mr. Juftamond does not think it neceffary
in any cafe to apply it over the  whole furface of the tumor, but merely to
its circumference.  He is of opinion that arfenic operates  in feparating
the cancer by exciting an inflammation, and confequent  fuppuration, of
the found parts connected  with thofe difeafed.  The arfenic is ufually
applied either in  form of a watery folution, as ftrong as it  can  be made,
or mixed with fome unguent, or powder. 
                       [  50  ]
   The herpes farinofus, or what may be termed the dry tet-
ter, is the mofl fimple of all the fpecies both  in its nature
and  treatment.   It appears indifcriminately in  different
parts of the body ;  but mofl commonly on the face, neck,
arms, and wrifls, in pretty broad fpots of exceeding fmall
red pimples. Thefe are generally very itchy, but not other-
wife troublefome ; and after continuing a certain time, they
at lafl fall off in form of a white powder, fimilar to fine
bran ; leaving the fkin below  perfeaiy found ; and  again
returning in form of a red efnorefcence, they fall off, and
are renewed as before.
   The  herpes  pufiulofus  appears in the form of puftules,
which are originally feparate, but afterwards run together
in clufters. At firft they feem to contain nothing but a thin
watery  ferum, which  afterwards turns yellow ;  and ex-
uding over the whole furface of the part affeaed, it at lafl
dries  into a thick cruft or fcab.  When this falls off, the
fkin below frequently appears entire, with only a flight de-
gree of rednefs on its furface ; but on fome occafions, when
the matter has probably been more acrid, upon the fcab
falling off, the fkin is found  flightly excoriated.   Erup-
tions of this kind appear moft frequently on the face, be-
hind the ears,  and on  other parts of the head ;  and they
occur moft commonly  in children.
   The herpes miliaris breaks out indifcriminately over the
whole body ;  but more frequently about the loins, breaft,
perinseum, fcrotum and  inguina,  than  in  other parts.
It generally appears in clufters, though fometimes in dif-
tina  rings  or circles, of very  minute  pimples, which
from their refemblance to millet, have given the denomina-
tion to the fpecies.—The pimples are at firft, perfeaiy fe-
parate ;  and  contain nothing but a clear lymph, which, in
the courfe of the difeafe is excreted upon the furface; and
there forms into  fmall diftina fcales ; thefe  at  lafl fall
off, and leave  a confiderable degree of inflammation be-
low, that ftill continues to exude frefh matter, which like-
                                                   wife 
                       C  51   ]
wife forms into cakes, and fo falls off as before—The itch-
ing in this fpecies is always very troublefome :  and the
matter difcharged from the pimples is fo tough  and vifcid,
that every thing applied to the part adheres in fuch a man-
ner as  to occafion a great deal of uneafinefs on its being
removed.
   The  different  fpecies of herpes are in common known
by the names of tetteryfhingles, and ring-worm ;  but the lafl
is mofl frequently applied to the herpes miliaris.
   The  herpes exedens, fo called from its deftroying or cor-
roding  the  parts  which  it attacks, appears commonly at
firft in  the form  of feveral fmall painful  ulcerations, all
colfeaed into large fpots of different fizes, and of various
figures,  with always more or lefs of an eryfipelatous-like
inflammation.  Thefe ulcerations difcharge large quanti-
ties of a thin, fharp, ferous matter ; which fometimes forms
into fmall  crufts that in a fhort time fall off; but moft
frequently  the difcharge fpreads along the neighbouring
parts, where it foon  forms ulcers of the fame kind.
   Although thefe excoriations or ulcers do not, in general,
proceed  further than the  true  fkin ;  yet  fometimes the
difcharge is  fo  corrofive as to deftroy  the fkin,  cellular
fubftance,  and on fome occafions, even the mufcles them-
felves.  It  is this fpecies  that fhould properly be termed
the depafcent or  phagedenic ulcer;  but ulcers  of the
herpetic kind have,  with  great impropriety, been  com-
monly  fuppofed  conneaed with fcurvy, and thence have
been  termed fcorbutic: Whereas it is  very  certain, that
herpes  is a  complaint  generally  joined with a ftate  of
the body entirely oppofite to  that  which takes place  in
fcurvy,  viz. the plethoric and inflammatory, is  very differ-
ent in its appearance  from fcorbutic ulcers,  and requires
very oppofite remedies.
   This fpecies of herpes appears at different times in  every
part of  the  body, but  moft frequently about the  loins,
where it often fpreads fo as to furround the whole waift.
                                                     It 
                      [  52  ]
It feems to be eafily communicated by contagion ;  that is,
by  the  application of the virus,  by the intervention of
clothes and other fubflances.   I have known even the dry
fpecies of the diforder communicated thus.
  There is as much confufion and uncertainty among au-
thors refpeaing the cure of cutaneous difeafes, as with re-
gard to their defcription.   It has  always  been fuppofed,
till lately, that thefe complaints originated from fome ge-
neral morbid affeaion of the fyftem.  And it was even be-
lieved to be unfafe to attempt their cure in any other way
than by  correaing the difeafe of the fluids which it was
fuppofed produced them.   But it is  ftrange that this opi-
nion fliould not have been rejeaed  when it was  known
that they could be  cured  by  topical  applications.   It  was
formerly the praaice to direa long debilitating courfes of
medicines—but whenever internal medicines are now di-
reaed, it is with a view to reftore the diminifhed difcharge
of perfpirable matter ; which,  from want of cleanlinefs, and
from Come other caufes, being long retained on the  furface
of the body, and there turning acrid, may often, it is pro-
bable,  give  rife to many cutaneous affeaions.   And, ac-
cordingly we find, that  all fuch remedies prove more or
lefs effeaual as they keep up a more or lefs free perfora-
tion.   And what  puts  it beyond a  doubt that they pro-
duce their good effe els in this manner is that warm bath-
ing and cleanlinefs alone, in many inflances, will cure thefe
difeafes effeaually.
   In the treatment of all the fpecies of herpes, the firft and
principal circumftance  to be attended to is, that not only
the parts affeaed, but even the whole furface of the body,
be kept as clean and perfpirable as poffible; for which pur-
 pofe nothing is of fo much importance as the frequent ufe
of warm bathing, together with gentle friaions, with clean
linen cloths; this laft, in the dry fpecies, may be applied
over the difeafed parts.  When  thefe eircumftances are
                                               properly 
                       [   53  ]
properly attended to, few or  no internal remedies are ne-
ceffary in the flighter degrees of herpes.
  Of external applications, the feveral drying and  aftringent
remedies are  moft to be depended on—lime-water, decoc-
tions  of  the  different kinds of boles, and of the aftringent
earths, often remove flight cafes of thefe complaints.  A
watery folution of faccharum faturni, applied in cataplafms,
or on foft linen rags, is fomewhat more powerful—But in
inveterate cafes, a folution of corrofive fublimate of mercu-
ry in  water is more to be depended on than any of thefe. {
About 10  grains to  Ibj.  of water is in general a proper
proportion,
   Ointments prepared with thefe fubftances are not more
effeaual than the  watery folutioas ;  the latter are more
cleanly, and therefore claim a preference.
   When the difeafe has been of long flanging, and efpeci-
ally if large quantities of matter are difcharged,  it becomes
neceffary to have recourfe to other remedies.
   The more obftinate  and  virulent fuch complaints are,
the greater attention becomes requifite to the promotion of
a  free difcharge by the fkin ; for which purpofe,  together
with warm bathing, warm  diluent drinks  fhould be  plen-
tifully allowed.  New whey anfwers in this view very well.
Although farfaparilla and  mezereon have been much re-
commended for this purpofe, I never knew  them to pro-
duce more beneficial effeas  than the common decoaion
of the woods.   This may be rendered occafionally  more
diaphoretic by adding  fifteen or twenty drops of tinaure
of antimony to  each cupful.   A  free perfpiration may in
common be kept up by taking two or three  pounds of  the
decoaion in the courfe of every twenty-four hours.
   Crude antimony, to the quantity of two drachms in  the
 day,  is alfo  a ufeful and gentle diaphoretic.   Its efficacy
is often rendered greater by conjoining a fmall  quantity of
                                                  gum 
                       [  54   ]
 gum guaiacum with  it, by which means it proves gently
 purgative.
   In plethoric patients, laxatives often prove ferviceable.
 Thofe of the cooling kind only fhould  be ufed.   Sea-wai-
 ter anfwers  very  well,  when  the  patient's ftomach will
 bear it; but cream of tartar made into an efeauary with
 an equal quantity of fugar, and fome mucilage of gum ara-
 ble, forms a much more agreeable laxative.
   An iffue is always neceffary in the more  inveterate fpe-
 cies  of herpes,  and fhould be one of the  firft remedies ;
 without which, as in ulcers, the difeafe is very apt to re-
 turn after being cured.
   As confiderable  inflammation fometimes attends herpes,
and particularly the herpes exedens, the faturnine applica-
tions become very neceffary.   Warm poultices and fomen-
 tations almoft conftantly tend to increafe the difeafe, by
 fpreading the humour.
   When the ulcers penetrate deep, it is neceffary to drefs
them with ointments, compofed either  of zinc, faccharum
faturni, or white precipitate  of mercury, and hog's lard.
The proportions of zinc and axunge may be  3ij.  in  fine
powder of the former to  3vi.  of the latter.
   When thefe remedies do not fucceed in the  cure of her-
pes, which is feldom the cafe, there  will be reafon to
fufpea that fome other difeafe fubfifts  at the fame  time__
This, on accurate examination,  will  frequently be  found
to be the lues venerea. In this cafe, mercury muft be add-
ed to  the remedies already advifed.
   A combination of fcabies or the itch  with herpes  fome-
times occurs, and produces a tertium  quid, almoft as
loathfome as the leprofy.  In this cafe, the  treatment ne-
ceffary for fcabies muft be joined with  that ufed  for the
removal of the herpes.   Mercury will frequently cure the
itch, and often removes  herpes ; but as it fometimes fails
                                                    in 
                           [  55   ]
    in the former difeafe, and  fulphur hardly ever does,  the
    latter fhould be preferred.
       In every herpetic eruption to which  children are liable,
    fulphur  feems  the mofl  effeaual remedy;  and  when
    others have failed it fhould always be tried.  The fulphur
    vivum is  much  ftronger  than the flores fulphuris,  and
    fhould therefore be ufed in preference.
       There is a variety of herpes, which frequently affeas
    the face, and occurs  more particularly in  females,  ex-
    ceedingly diftreffing and  difficult  to  remove—All  the
    common remedies are often ineffeaual in curing it.   I have
     fucceeded in many fuch cafes by the ufe of  the following
     preparation : 1$,.  lac.  fulphuris  5ii. facchar.  faturni $j.
(Tie aq- rofar. gviii.  m-  The  eruption is to be bathed with
     this, morning and evening, firft fhaking the  vial.   When,
     however, it  is thought proper to ufe mercury,  the  un-
     guentum citrinum, prepared with a lefs quantity of  acid
     than is  ufually employed, is the moft effeaual preparati-
     on of it I have ever ufed.
        The tinea capitis and crufta laaea of children, belong to
     the fpecies of herpes puflulofus, and require the fame ge-
     neral treatment.   In the former, it is of great confequence
     that the  hair fhould be  cut  fhort; and the  folution  of
     fublimate fucceeds remarkably well.
        Iffues feem particularly ufeful in curing and preventing
     herpetic  difeafes  in children; and they may, with the
     greateft fafety, be healed  up after the fifth or  fixth year of
     their age.  As the quantity of fluids  which, before  that
     period,  appears to  be difcharged by  different eruptions
     upon the furface, feems  then neceffary to  be applied to
     the fecretions of the body.
SECT. 
C  56   ]
                   SECT.  X.

                On the  Venereal Ulcer.

  We now come, in order, to  confider the  ulcers con-
neaed with a general affeaion of the fyftem;  and fhall
firft treat of the venereal  ulcer.
  Although,  by the term venereal ulcers, is  generally
meant thofe which are a  part of fyphilis;  yet  chancres,
which are not always conneaed  with any general difeafe
are alfo included under it.  They may therefore be divid-
ed into thofe  that  appear as primary fymptoms of the
difeafe, and fuch as  may be more  properly  confidered as
fymptomatic.
  Of the former kind are chancres  in general,  wherever
fituated, whether upon  the parts of  generation,  the nip-
ples, or lips.  Thofe ulcers may alfo, in fome  cafes, be
reckoned primary, which remain after the burfling of bu-
boes that have arifen from an infeaion  lately communi-
cated, and before  there is a  probability that the  whole
fyftem is affeaed.
  Such ulcers are confidered  as fymptomatic, as arife in
ftonfequence of a general  taint of the habit.   Of this kind
are all thofe which fucceed to old  buboes,  and fuch as
appear along with other venereal fymptoms  a  confiderable
time after infeaion ; the moft  common fituations of which
are, the throat, palate,  nofe,  the parts immediately above
the bones of the cranium, tibia, humerus, and other hard
bones thinly covered with flefh.
  In  many cafes, it is difficult to make this diflinaion in
venereal fores; but unlefs it is always done, we cannot di-
rea the proper mode of treatment.   The principal means
of diflinaion are obtained either by information from the
                                               patient 
                      [   57  ]
patient, or from the  appearance of the different fores
themfelves.
  If, foon after expofure to infeaion, an ulceration appears
upon  the part to which the virus  was immediately appli-
ed,  together with fwellings of any  of  the  glands  in  the
courfe of the lymphatics,  we may be almoft  convinced that
thefe  are only  local  affeaions.    Such ulcerations  are
termed chancres.   They  appear  at  firft,  as  fmall miliary
fpots, which  foon rife and form little veficles ;  thefe upon
burfting, difcharge fometimes a  thin watery fluid, and on
other  occafions, a more  thick yellow matter.  The edges
of fuch fores are generally hard and painful; and as well
as the  glandular fwellings already defcribed, are common-
ly attended with more or lefs inflammation.
  The fymptomatic  venereal ulcers are  in general, more
troublefome  than chancres.    They  are  diftinguifhed, 1.
By  information from the patient.   2.  By their fituation ;
and,  3. By  their appearances.   Thus if  a patient  who
has fymptoms of infeaion in his conftitution, is attacked
with one or more ulcers,  whether in confequence of exter-
nal  injuries or not:  and if  they  refill the common  me-
thods of cure,  there can be little doubt of  their being in-
feaed by the general taint.    But when  it cannot be af-
certained that the patient is  affeaed, by his own informa-
tion,  we muft endeavour to form a judgment from the fi-
tuation and  appearances of the ulcer itfelf.
  Venereal  ulcers from  an  old infeaion generally appear
immediately  above the bones, and particularly above fuch
as are  but thinly covered with mufcles.    They  firft ap-
pear in the  form of a red,  and fomewhat purplifh efflo-
refcence, confiderably diffufed.   This foon riles into  a
number of very fmall puftules,  which  ooze  out a  thin
fretting ferum.   At  firft, thefe puftules  when obferved
through a glafs, appear perfeaiy diftina; but they at laft
run together, and form  one large ulcer,  whofe edges are
                      H                     commonly 
                      [  58  ]
commonly ragged and fomewhat callous; and there is ge-
nerally a light red  appearance,  extending  a confiderable
fpace beyond the fore and efnorefcence.
  Sores of this kind have frequently the form  of a cup,
with the narrow part at  the bottom.  But when carious
bones lie  at the  lower part, they  are generally filled up
with fungous excrefcences.   They are feldom attended
with much pain.   The  difcharge from  them  is at  firft
thin, but  at lafl puts on  a very charaaeriftic appearance ;
being of a confiflence rather more  vifcid  and tough than
good pus, with a  very loathfome, though not the ordinary
fetid fmell, and a  very fingular greenifh yellow colour.
  The diflinaion of venereal fores into primary and fymp-
tomatic, is of confequence in direaing the proper treatment.
For  the former might be cured merely by deftroying the
venereal matter with cauftic, if attended to before any ab-
forption had taken place.   But as it is impoffible to ascer-
tain  whether the virus has entered the fyftem or not, when
we  are applied to,  the  cure of chancre fhould never be
trufted to  topical applications; but, together with thefe,
mercury fhould be always ufed internally;  and to prevent
a further  abforption of  matter, the healing of  the  fore
fhould be accomplifhed as foon as poffible.
   This diflinaion  points out  to us likewife,  that in ul-
cers from  an old pox, we  ought  never to  make  ufe  of
fuch dreffings as have a tendency to heal them foon ; but
fhould rather truft entirely to the internal ufe of mercury,
and to fuch  applications  as merely keep them clean and
 eafy.   For the healing  of fuch fores then affords the fur-
 eft index  of the removal of the general difeafe.
   As  we  are feldom called early enough to deftroy the
 virus in chancres by cauftic, and indeed until  it would be
 fomewhat dangerous to  attempt  it, after wiping the fores
 clean, I generally fprinkle them with finely  powdered red
 precipitate of mercury, and over  this  apply lint fpread
                                                   with 
                      [  59  ]
with common ointment.   This anfwers very well in all
cafes unattended  by inflammation.  It feldom occafions
much pain or irritation: and produces a flough, which in
the courfe of a dreffing or two, generally comes away, and
leaves the ulcer perfeaiy clean.  When in this ftate,  the
fore  would probably heal if nothing more than cerate was
applied to it, but for fear any venereal matter fhould  flill
remain, I commonly then drefs it with the ftrong mercurial
ointment.   In this manner chancres are in general eafily
cured, and with much lefs mercury given internally than
if allowed to remain open a confiderable time.
   By long continuance however, and the negfea of proper
remedies, thefe ulcers put on the appearances and nature of
thofe that depend on a general infeaion ; and confequently
require the fame method of treatment.   They are very apt
to become inflamed and very painful;  and more efpecially
when  feated on the penis.   Where this is the cafe,  it is
fometimes neceffary to order bleeding : but in general, the
faturnine poultice will be fufficient to moderate the inflam-
mation.  After the removal of the inflammatory fymp-
toms,  the beft application is common wax ointment.
   There are two modes of throwing mercury into the fyf-
tem ;  the one by giving it internally by the mouth, and the
other by introducing it into the body  through the abfor-
bents  on the fkin by means of friaion ; but, as the laft me-
thod is  by much the mofl  troublefome and  inconvenient,
and is not attended by any peculiar advantages, the former
is now, I believe, generally preferred.
   Thofe preparations in which the mercury has undergone
 no other operation than triture, as the quickfilver pill,  P.
 Edinb. are in general the beft.   When this is not found to
 anfwer, the mercurius corrofivus fublimatus, or mercurius
 calcinatus, may be tried; and it is fometimes neceffary to ufe
 a variety of preparations before a  cure can be effected. 
                       [  60  ]
   But, in  whatever form  mercury is employed,  it fhould
 always be continued  until a forenefs of the mouth is in-
 duced, as that is the only certain indication of its  having
 entered the  fyftem.   This forenefs in  very flight degree
 fhould be fupported until the cure is perfeaed.
   In order to guard againft the mercury's running off too
 quickly by the mouth, and producing troublefome faliva-
 tion, which it is very apt to do, it has been recommended
 to determine the operation of the medicine in fome  degree
 to the fkin by the ufe of warm bathing—not only during the
 ufe of the mercury, but previous to its being begun—This
 effea may, in fome degree, be obtained with lefs rifk from
 cold, by the  ufe of a flannel fhirt, by drinking plentifully
 of decoaion  of the woods or farfaparilla :  and by  avoid-
 ing cold.  Where the warm bath can conveniently be ufed
 it fhould,  as  being more powerful in its effeas, without
 doubt be employed.   It  alfo has  a good influence in  pre-
 venting the operation of the mercury on the bowels.
  By the ufe of thefe different remedies, venereal  ulcers
 will  commonly foon be  removed.   The mercury fhould
 be continued  for  a longer or a fhorter time after the difap-
 pearance of the  fymptoms, according to  the inveteracy or
 ftanding of the difeafe.
  It fometimes happens that after a long exhibition of mer-
 cury, and when there is reafon to fuppofe that the venereal
 taint  of the habit is altogether eradicated, the ulcers can-
 not be brought to heal.   In this  cafe  there will be room
 to fufpea  that  fome  other difeafe may have fubfifted in
the conftitution  together with the lues venerea, and  that
 both may have had fome fhare in the  produaion of the ul-
 cers.   When  the nature of this  diforder is afcertained,
proper remedies to correa it muft be conjoined with thofe
before given.
Venereal 
                       [  61   ]
  Venereal ulcers are fometimes rendered  obflinate by a
caries of fome bone, independent of any other difeafe. This
is to be fufpeaed when they are feated upon or near any of
the bones,  and particularly if there occur fungous excref-
cences.   To the  remedies for the venereal affeaion, we
muft then add the treatment proper for caries.  See feaion
on the carious Ulcer.
   When  neither  caries nor  any conftitutional affeaion
feem to prevent the healing of fuch ulcers, and they appear
to grow worfe ; and particularly when the fyftem  feems
much debilitated by the confinement  and effeas of the re-
medies, the beft and moft effeaual mode of treatment is, to
order a light nourifhing diet, with  frefh air and exercife.
This by invigorating  the  body  often produces furprifing
cures.  The Peruvian bark is here alfo of fervice.
   Old  fores of this kind, on account of the  floughs with
which  they  are  ufually covered, require  flimulant dreff-
ings.  The following  ointment  is very  proper,  ]£, ung.
bafil. flav.  I]. mere. pnec.  rubr.  3ij. M.   When  they be-\
come clean, they are to be treated in the ufual way.
   When  the glands are the  feats of venereal ulcers, it is
fometimes neceffary to deftroy the whole, or a confiderable
part of fuch as are much hardened, by cauftic,  before a
cure can be obtained.
   Although venereal  ulcers are  in general to be cured  by
proper treatment, yet fome  inftances have  occurred, in
which  they  have refilled all the  efforts  of nature,  and
art,  and   at laft  have carried  off  the patient in great
mifery.—* Such cafes probably are  only  to be met with
in hofpitals.
                                               SECT.

  * They are fometimes met with in private practice, and after refilling
all the methods recommended by different writers, have been known to
recover folely by the  ufe of a free  diet and  exercife. 
[  62   ]
                   SECT.  XI.

                On the Scorbutic Ulcer.

  The charaaeriftic marks of ulcers that occur in fcurvy,
are as. follow:—They never afford  a good pus;  but  a
thin foetid fanious  matter, mixed with  blood; which at
length has the appearance of  blood coagulated,  and is
with difficulty feparated from the furface of the fore.   The
flefh beneath this is foft, fpongy, and very putrid.—Efcha-
rotics to remove the floughs anfwer no good purpofe, for
they certainly appear again  at the  next dreffmg—Their
edges are generally  of a livid  colour, and puffed up by
excrefcences beneath the fkin.   If compreffion is employ-
ed to  keep the fungus from rifing, it generally produces
a gangrenous difpofition, and  always renders the member
cedematous, painful,  and for the moft part fpotted.
  As the difeafe increafes, they fhoot out a foft  bloody
fungus,  refembling boiled  liver ; which often  rifes  in a
night's time  to a  monftrous  fize ;  and  if deftroyed by
cauftic or the knife,  bleeds plentifully, and returns again
by the next dreffing.   They  continue a confiderable time
in this condition,  without affeaing  the bones—and are
produced by the  flighteft  wound or bruife, in  fcorbutic
perfons.
  This defcription is only applicable to  fcorbutic ulcers
that accompany very great putrefcency in the fyftem at
large ; for  fuch inveteracy is not often met with,  except
in long fea-voyages ; but in Scotland, flighter degrees of
the fame kinds  of  fores are often feen, and fometimes ac-
companied  with the moft charaaeriftic  mark of fcurvy,
viz. foft  fpongy gums.   They generally appear  among
the loweft clafs of  people, and  feem to originate rather
from  want of food in general, than from confinement to a
                                             particular 
                       [   63   ]
particular kind.   They feldom are produced in parts pre*
vioufly  found ; but  ulcers already formed,  and  wounds
infliaed during the prevalence of a fcorbutic  affeaion,
always  degenerate  into fores of  this  kind.   Moft of
the  ulcers of the  poor in Scotland partake of a  fcor-
butic taint.
   The immediate or proximate  caufe of fcorbutic ulcers,
as well  as of every other fymptom of fcurvy, may  be re-
ferred to a  certain degree of putrefcency  in the  fluids.
This may be induced by a variety of caufes, the moft ma-
terial of which are, living conftantly upon  fait provifions ;
a total want  of vegetables; with expofure to a cold, moift
atmofphere.   See Pringle,  Lind,  and Huxam, on the
Scurvy.
   The cure of fcorbutic ulcers muft depend chiefly on the
correaion of the putrid diathefis of the fyftem ; for which
purpofe, vegetables of  all kinds, but efpecially thofe of an
acefcent nature,  with milk and whey, are found to be cer-
tain remedies.   The different fecretions, efpecially thofe
by the  kidneys  and fkin,  and  more particularly the  laft,
which is in common almoft entirely obftruaed, fhould be
gently promoted.    Laxatives, as tamarinds, manna  and
cream of tartar,  are alfo very ferviceable—-Thefe remedies,
joined with total abftinence from  faked  food, and  atten-
tion to  avoid all the other exciting caufes, commonly re-
move all the fymptoms of fcurvy.   The ulcers fhould be
dreffed  with  powerful  antifeptics.   Lind  recommends
ung. aegyptiac. and mel rofarum acidulated with fpirits of
vitriol.
   In the fcorbutic ulcers  that  occur in  Scotland, it  is
feldom  neceffary to confine  the patient  to  an antifcor-
butic courfe.  And they are  more  effea ually removed
by  the  gradual  allowance  of  a  generous diet, with a
moderate  proportion  of  good  wine, or  perhaps what
is  better,  of porter  or  ftrong  beer.    Peruvian bark
                                             internally 
                       [   64  ]
internally, and applied to the ulcers in decoaion, is a very
ufeful remedy in thefe cafes ;  but the beft external appli-
cation while much putrefcehcy remains, is the carrot poul-
tice ; when this is removed,  the  ulcer is to be dreffed as
in other cafes.  Iffues are alfo to be ufed occafionally.

                   SECT.  XII.

                On the  Scrophulous  Ulcer.

   By fcrophulous ulcers are meant thofe  fores which  are
confequent to fwellings, fymptomatic of fcrophula or king's
evil.
   Scrophula begins with  indolent, fomewhat  hard,  co-
lourlefs tumors; which at  firft chiefly  affea the conglo-
bate glands of  the neck; but  at length attack the cellular
fubftance, ligaments and bones.—Thefe fwellings are more
moveable than fchirri,  fofter,  and  feldom  much painful;
they are tedious in coming  to fuppuration ; very apt to
difappear fuddenly, and again  to rife in fome other part of
the body.  There is a  remarkable  foftnefs  of fkin in  this
difeafe, a kind of fullnefs in the face,  and generally large
eyes and a very delicate complexion.
   Scrophulous ulcers feldom  yield a good difcharge;  af-
fording upon their  firft appearance, a  vifcid, glairy,  and
fometimes a whitifh curdled matter, that afterwards chang-
es to a more thin watery fanies.  The edges are frequently
painful: and always much tumefied.   As long  as there is
any fcrophulous diathefis  in  the  fyftem, fuch fores often
remain for a great length of time, without fhewing any
difpofition either to heal or  grow worfe : at other times
they heal very  quickly,  and again break out in fome other
part of the body.
   A variety of caufes have been mentioned as  tending to
produce fcrophula, viz. a crude indigeftible food; bad wa-
                                                    ter; 
                        [  65  ]
 ter ; living in low damp  fituations ;  its being an heredi-
 tary difeafe, and in fome countries  endemic,  &c.  But,
 whatever may be the exciting or predifpofing  caufes, the
 difeafe itfelf either' depends upon, or at leaft is much con-
 neaed with a debility of the conftitution in general,  and
 probably of the lymphatic fyftem in particular: the com-
 plaint firft fhewing itfelf by affeaions of the latter.  This
 is evident from the nature of many of the caufes, and from
 fuch remedies as are found to prove mofl ferviceable in the
 cure.
   Gentle mercurials  are fometimes of ufe as refolvents in
 fcrophulous fwellings* ; but nothing has fuch good effeas
 as the large ufe of peruvian bark.  Chalybeate and fulphure-
 ous waters too, have frequently proved  ferviceable :  and
 a long ufe of mild faline aperients have been found benefi-
 cial.   Cold bathing, and particularly in  the  fea, together
 with moderate exercife, is often of fingular fervice;  as
 likewife change of air, efpecially to a dry climate.
   Until the general  fcrophulous taint  is removed,  it is
 dangerous to heal  the  ulcers;  all that  fhould be done,
 therefore, fhould be, to give as free a vent to the matter as
 poffible, and to prevent the formation of finufes.
   The beft  applications are  the faturnine preparations:
 thefe remove that inflammatory complexion  they affume
 when relaxants are employed; and tend much  to prevent
 the fpreading of the fores.,
   When, however, the ulcers become fwelled  and pain-
 ful, and difcharge a very corrofive matter, we may fufpea
 a caries to be at the bottom of the fores.   Nature muft then
 be aflifted, where it is praaicable, by the removal of fuch
 parts of the bones as are mofl difeafed, and have  become
 loofe.   But this cannot be done when the large joints are
                           I                   affeaed:

  * Compreffes dipped in a folution of fal ammoniac, in vinegar  and wz-
ter, and applied to the tumors before  any inflammatipn appears, have
been found ufeful, 
                      [   66  ]
affeaed : In that cafe, as amputation is not always advifa-
ble, for fear of the difeafe returning, we muft  truft to na-
ture for a cure.   Here the general remedies, formerly men-
tioned, fhould be diligently employed.   I think I have feen
cicuta have very good effeas in mending the difcharge from
the ulcers,  when joined with the bark.
   When it will be fafe toJieal the ulcers, iffues fhould al-
ways be introduced.   Gentle compreffion has uncommonly
good confequences in fores  of this kind.
CHAP.     III.
                    SECT.   I.

Of the  Symptoms and  Caufes  of White  Swellings of the
                      Joints.

rT,HE term white fwelling has  commonly  been  ap-
 •*■    plied to fuch enlargements of the joints as are not
attended with difcolouration of the integuments ; the only
fymptoms which at firft take place, being a greater or lefs
degree of fwelling, with a deep feated pain.   In the pro-
grefs of the difeafe, however, inflammation affeas  all the
adjoining parts, as well external as internal; and when this
terminates in fuppuration, it is not uncommon for openings
to be formed all  around the difeafed joints.
   There -feem to be  two fpecies  of  this difeafe, entirely
different in nature from each other.  In the one, a cure is
often in part, and fometimes wholly obtained; whereas the
other is always beyond the reach of art.
                                             Swellings 
                       C   67  ]
  Swellings of this kind occur  more  frequently  in  the
large  than in the  fmaller joints; thus, at  leaft  twice as
many are met with in the  knee  and ankle  joints, as in
all the reft of the body befides.

      $ 1. Of the Rheumatic fpecies of White Swelling.

  This difeafe begins with an acute pain, which feems to
be diffufed over the whole  joint, and frequently  even  ex-
tends along the tendinous expanfions of the mufcles. There
is from the beginning, an uniform fwelling of the whole
furrounding teguments in greater or lefs degree ;  but is al-
ways fo confiderable as to occafion an evident difference
in point of fize between the difeafed, and the found joint of
the oppofite  fide.  A confiderable tenfion generally prevails;
but there is  feldom, in this period of the diforder, any ex-
ternal difcolouration.
  The patient from the beginning, fuffers much pain from
the motion of the joint; and, finding it  eafieft in  a relaxed
pofture, keeps it generally bent; this often produces a rigi-
dity in all  the flexor mufcles, which is often afterwards
with difficulty removed.  If the  difeafe is not now carried
off, the fwelling augments gradually ; and has fometimes ac-
quired thrice the natural fize of  the  part.  The  cuticular
veins become turgid and varicofe : the limb below the tu-
mor decays confiderably in its flefhy fubftance, at the fame
time that it  frequently acquires an equality in point of
thicknefs, by becoming cedematous; the pain now begins to
be more intolerable,  efpecially when the patient  is warm ;
and abfceffes form in different; parts of  the  fwelling,  and
run in various direaions, but frequently without inter-com-
munication.  In thefe a, fluauation  is generally evident up-
on preffure___Thefe fwellings have a peculiar elaftic feel.
  When the colfeaions of  matter have an opening formed
to, them, they difcharge at  firft  a  pretty good  pus :  this,
                                              however, 
                       [   68  ]
 however, foon degenerates into a thin foetid  ill-digefled
 fanies; and has never any remarkable influence in reducing
 the fize of the fwellings. If the fores are not kept open by
 art, they foon heal up, and others are formed by colfeaions
 in different places ; fo that in fome cafes, the furrounding te-
 guments are entirely covered with cicatrices remaining after
 fuch ulcers.
   Long before this period, the patient's health fuffers con-
 fiderably: firft from the pain, which is often fo violent  as
 to take away both fleep and appetite, and  afterwards from
 the abforption of the matter.
   When the difcharge of matter commences, the effeas  of
 its abforption begin to appear; thefe are quick pulfe, night
 fweats, and weakening diarrhoea, which generally  at laft
 carry off the patient, unlefs the difeafe is cured.
   I have had feveral opportunities of examining limbs af-
 fected with white fwellings, that were  amputated in very
 early  periods of the difeafe, on account  of the  intolerable
 pain,  and an apprehenfion of the complaints being incura-
 ble.   In  all thefe inftances the  only morbid appearance,
 was a preternatural thicknefs of the furrounding ligaments,
 without any difeafe of the joint whatever.   The degree  of
this enlargement did not appear always proportionate  to
 the duration of the complaint.  In an  advanced ftage,  it
 always was confiderable ; and was generally attended by an
 effufion of a thick glairy matter  into the furrounding cel-
 lular fubftance, which probably caufes the peculiar  elaftic
 feel of the fwelling.
  The different abfceffes run in various direaions through
 this matter, without feeming to mix with it.  A great ma-
ny fmall hydatids are alfo obferved in fome inftances,  in dif-
 ferent parts of the tumor—And, in the farther progrefs  of
 the difeafe, all thefe together form a confufed mafs.
   All thefe appearances I have met with, without any con-
 comitant affeaion of the bones  of  the  joint.  When the
                                             complaint 
                        [  69   ]
 complaint, however, has continued very long, the ligaments
 are deftroyed by the acrimony of the matter, which in con-
 fequence abrades the cartilages, and  then renders the bones
 carious. The  tendons are neither enlarged nor hardened.

   § 2. Of the Symptoms of the Scrophulous White Swelling.

   In this fpecies the pain is generally more acute than  in
 the other; and inftead of being diffufed, is more confined
 to a particular fpot, moft frequently to the middle of the
 joint.   The pained part appears fometimes to be no larger
 than a dollar.  The fwelling is at firft commonly very in-
 confiderable.  The leaft motion gives pain ; hence a con-
 traaion of the limb is at length produced as in  the  other
 fpecies.   As the difeafe advances the pain and fwelling in-
 creafe ; and an evident enlargement of the ends of the bones
 takes place.
   In procefs of time the tumor acquires the fame elaflicity
 as occurs in the rheumatic fpecies; varicofe veins appear—
 abfceffes are formed—On examination the bones are found
 carious,  and parts of them are difcharged at the fores that
 are produced___By the farther continuance of the difeafe,
 the conftitution fuffers in the fame manner, as in the vari-
 ety firft  defcribed.
   When joints are diffeaed in the  firft flages of the  dif-
 order, the foft parts feem to  be very little affeaed;  but
 in all that I have examined, there was conftantly obferved
 an enlargement either of  the whole  ends of  the  bones,
 or of their epiphyfes; frequently  of thofe on one fide
 of the joints only ; but  in  fome, both bones have  been
 difeafed.  This enlargement fometimes is the only morbid
 appearance ; but generally,  and always  in  the  advanced'
 flages, the foft fpongy parts  of  fuch bones are  found to
 be diflblved into a thin, fluid,  foetid matter;  and that in
 fome cafes without the  cartilages  being  much affeaed.
Thefe,  however,  are at  length  diflblved ; and  then the
                                              different 
                       [  70   ]
 different hard and foft parts intermixing, exhibit an incon-
 ceivably confufed mafs.
   In the advanced ftage of the complaint the foft parts are
 generally affeaed.  The ligaments become thickened, and
 the cellular membrane is filled with the fame glairy matter
 that is produced in  the  rheumatic white fwelling.

          § 3.  Of the Caufes of White Swellings.

   The caufes of the rheumatic fpecies may be, fprains that
 particularly affea the ligaments of the joints, bruifes, lux-
 ations, and whatever can tend to produce inflammation of
 the ligaments.  A rheumatic  diathefis or difpofition is pro-
 bably alfo a principal caufe of this difeafe.  Forrheumatifm
 is known to attack particularly the ligaments, or other deep
 feated membranes, and more  efpecially  affeas  the larger
joints—Hydarthrus  or white fwelling alfo occurs in the
 fame habits that are moft fubjea to rheumatifm, viz. the
 young and plethoric.
  That it is the ligaments that  are  firft affeaed in this
 difeafe is evident from the hiftory and diffeaions.  From
 thefe we may conclude, that this complaint is  at  firft al-
 ways occafioned by  an inflammation of  the  ligaments  of
 the joints. And we may confider  the different matters that
 are formed, to depend on the difference of parts affeaed in
 the Courfe of the difeafe.
  The other fpecies of the diforder,  from the  fymptoms
enumerated, and the appearances on diffeaion, feems evi-
dently to be originally an affeaion of the bones ; the foft
parts feeming only to fuffer in the progrefs of the difeafe
from their conneaion with and vicinity  to thefe.   It fel-
dom is the confequence  of any accident; and the patient
is feldom able to account for it.
  This difeafe is generally attended with  known fymptoms
of fcrophula; or the  patient has had  them at an earlier pe-
                                                  riod 
                       C   7i  ]
riod of life, or at leaft is of fcrophulous parents.   From
thefe, and the above defcribed eircumftances, it is probable
the diforder is of a fcrophulous nature.


                    SECT.  II.


           Of the Treatment of White Swellings.


   In the rheumatic  white fwelling, as it is always at firft
 of an inflammatory nature, confiderable advantages are ob-
 tained in common, by the ufe of an  antiphlogiftic courfe.
 The firft remedy which fhould be employed  is blood-let-
 ting—This is moft effeaual if the blood is drawn immedi-
 ately from the affeaed part,  by  cupping, performed on
 each fide of the joint.   At leaft eight or ten ounces fhould,
 if poffible, be  difcharged at each  time, and this  fhould
 be repeated according to  eircumftances.   When a  fuffici-
 ent quantity of blood  cannot thus  be obtained, leeches
 fhould be had recourfe to.
    A fmall blifter fhould be immediately applied on the an-
 terior part of the joint; and the part afterwards kept run-
 ning until the wounds from which the blood was difcharg-
 ed, are fo far  healed,  that a  veficatory may  be laid  on
 one fide and as foon as this is nearly healed another fhould
 be placed on the oppofite fide  of the joint.   By  thus ap-
 plying them alternately to each fide, a conftant ftimulus is
 kept up ; which, in deep-feated  inflammations,  feems to
 have  a greater effea  than the  difcharge  produced from
 them.
    Cooling laxatives, at proper intervals, are alfo of ufe;
 and the patient fhould, in every refpeB, be kept upon a ftri<3
 antiphlogiftic  courfe.   From an  attention to all thefe eir-
 cumftances the difeafe has frequently been removed.
                                                   The 
                        [   72  ]
    The inflammatory  fymptoms being moftly gone,  and
  while  there  are  yet  no  appearances of the formation
  of matter, mercury, not given fo as to falivate, but merely
  to affea the mouth gently and to keep it fomewhat fore
  for a few weeks,  I have fometimes known of ufe.   The
  beft form of employing it in this cafe  is by  way of  unc-
  tion—3ij. of a weak mercurial ointment fhould be rubbed
  into the part three times a-day; and as  the friaion may be
  very ferviceable, it fhould be continued an hour each time.
  By the French writers, falls of warm, and of cold water, on
  fwellings of this kind  are much recommended.  There  is
  the greateft reafon to fuppofe,  from  the  known  relaxing
  powers of moifture when joined with heat, that a proper
  application, and particularly of warm emollient fleams may
 prove more ufeful than any other  remedy.  The friaion
 in the ufe both of warm and cold  water  has probably a
 confiderable influence ; and the chief effea I think,'can be
 attributed to that only in the latter  cafe.   I have  fome-
 times feen it employed with advantage.
   Although by  the ufe  of thefe remedies, the difeafe is
 often entirely removed ; yet, in many inftances, when the
 pain and fwelling are chiefly or entirely  gone, it frequently
 happens, from the  bent pofition in which the limb  has
 been kept, that the ufe of the joint is  entirely loft, and
 it contraas fuch a rigidity, that very great pain attends any
 attempts to move it.
   It has unfortunately  happened that this contraaion  has
 been generally attributed, either to an union of the ends of
 the conneaed bones, or to an infpiffation of the fynovia ;
 both of  which are  incurable.   But from diffeaions  we
 may confidently conclude, that except in the moft advanced
 ftate of the difeafe, the firft does not occur in one cafe in
 twenty ; and that it is very doubtful whether  the lafl  is
 ever produced.
                                                 The
i 
                        [   73  ]
   The immobility of the joint is confequently to be  confi-
 dered as the effea of a contraaed ftate of  the flexor muf-
 cles, and tendons ;  which, in  feveral  inftances, fome  of
 which were thought to be of the worft  fpecies of anchylo-
 fis,  I have feen totally removed by the application of  emol-
 lients.  See chap, on ContraBions of the Limbs.
   After the formation of matter, no confiderable advantages
 can be expeaed from any of the remedies  we have  above
 recommended. In that cafe, the difcharge of the colfeaions
 fliould be made as foon as poffible, by the  employment of
 the  feton—This can eafily be effeaed,  and fometimes has
 been the means of faving many  fuch difeafed joints.
   Amputation fhould never be had  recourfe to unlefs the
 patient's conftitution is fo much reduced, that there would
 be confiderable rifk from any farther delay.
   When the difeafe  has deftroyed the ligaments, and per-
 haps the cartilages and bones of the  joint, amputation  is
 the only refource.   See chap, on Amputation.
   All the above remarks, relate  particularly  to the  rheu-
 matic white fwelling.  With refpea  to  the more fatal fpe-
 cies, the fcrophulous,  we  can offer  nothing fatisfaaory.
 When the fmall joints are affeaed,  and the difeafed parts
 of the bones begin  to  caft off, a cure may be fometimes
 promoted by affifling the efforts of nature  ; but in all the
 larger joints, it is not probable that any other -refource than
 amputation  will ever afford much relief.   And even the
 effeas of this  can feldom be  depended on as lafting ; for
 while the fcrophulous taint fubfifls in the conftitution, the
 diforder will mofl probably appear  again  in fome  other
 part.  On account of the violence of the pain,  it is  how-
 ever neceffary fometimes to run the rifk of this.
   When it  does not appear advifable to perform the ope-
 ration, we muft truft to palliatives.   Of thefe, opiates in
 large dofes,  by  moderating the pain  and procuring  fleep
 are generally the moft ufeful.   The  general remedies and
diet proper in fcrophula, are alfo to  be  recommended.
                         K                 CHAP, 
[  74   ]
C H A  P.    IV.

   Of Sutures.
     THE intention of futures,  is to unite parts that have
      been divided.  The futures  in  prefent ufe are dif-
tinguifhed into the true or bloody, and  the falfe  or dry.
The true futures are the interrupted, the glover's, and  the
twifled; thefe are  performed by the needle.   The  union
of parts produced by the medium of adhefive plafters has
been termed the dry future.

                   SECT.  I.

                Of the Interrupted Suture.

   This is the fpecies of future that has generally been made
ufe of in deep wounds; but  we fhall endeavour to make it
appear hereafter, that it is not fo well adapted to fuch cafes
as the twifled future.
   In order to a proper retention of the parts, in forming
futures in general, it has ufually been  confidered neceffary
to carry the  needle to the bottom  of  the  wound, fo as to
give no room for the accumulation of  matter ; and this has
commonly been done by  introducing it from without in-
wards, and then from the wound to the fame diftance on
the oppofite  fide.   But, the interrupted  future  is more
neatly and eafily performed, by paffmg both  ends of the
thread from  within outwards, by  means of a needle fixed
on each.  When they are carried through, the needles are to
                                                     be 
                       [  75   ]
be removed, and  the threads remain untied, until all that
are found neceffary are paffed.
   The number of ligatures muft depend chiefly on the ex-
tent of the divided parts.  One future has generally been
faid to be fufficient for an inch of wound, but when muf-
cular parts are cut tranfverfely,  a greater number in  pro-
portion to  the extent of ,the  fore will be neceffary.  A li-
gature  fhould be introduced at every angle of a wound,
however inconfiderable it may be.
   In paffing  the ligatures it has been a rule to pierce the
fkin at a diftance from the edges of the wound equal to its
depth,  in order to prevent them from cutting through the
parts.   But it is very feldom proper to make the fpace more
than an inch, or lefs than half an inch.   The form of the
crooked needle proper  for  forming  the  interrupted future
is delineated in plate vii.  fig. 6.   The fize of the needle, as
well as the ftrength of the ligature,  muft  always be pro-
portioned to the depth of the wound, and the retraaion of
the parts.  The ligatures ought nearly to fill the eyes of the
needles ; and in order to make  them pafs eafily,  to render
them durable, and eafily fufceptible of a flattened form,
by which they are lefs liable  to cut through the  contained
parts, they fhould be well waxed.   While the ftirgeon is
tying the threads, the  lips of the wound fhould be preffed
together by an affiftant.   The  ends  of  the ligatures are
ufually carried twice through the firft  noofe, to prevent
them from flipping. This forms the furgeon's knot. The in-
fertion of lint beneath or between the knots, as recommend-
ed by fome, prevents them from being well made, and has
little good  effea.  It is neceffary to tie  the threads  imme-
diately  above the wound, in  order to give an equable fup-
port to each edge of it.
SECT. 
[  76   ]
                    SECT.   IT.

                  Of the  Quilled Suture.

   The quilled future is formed by a quill, or piece of plaf-
ter, rolled up into the form of a quill, and placed on each
fide of a wound, one of which is included in the doubling
of the  ligature, and the  other is preffed by the knot.
   This future  has been ufed in very  deep wounds,  and
fuppofed to give better fupport than ligatures alone, which
fometimes cut through the parts ;  but it is evident that the
threads muft make as great a  preffure when the quills are
ufed, as when they are not; and confequently, that this fpe-
cies of future might with propriety be entirely laid afide.


                   SECT.   III.

                 Of the Glover's Suture.

  The glover's future confifts in a feries of flitches connea-
ed with each other, and continued in an oblique  fpiral di-
reaion along the courfe of the divided parts.   The ufe of
this future has been confined to wounds of the inteftines :
but even thefe may be more perfeaiy united by the inter-
rupted future.  See chap, on Wounds of the Inteflines.
  It will therefore follow, that  the  glover's flitch is en-
tirely unneceffary to a furgeon.
SECT. 
[  77   ]
                    SECT.  IV.

                  Of the Twifled Suture.

   In making the twifled future, we unite divided parts by
 means  of threads twifled  around pins or needles pufhed
 through their edges. This future has feldom been employed,
 except in the hare-lip; but it is preferable to any other fpecies
 in all wounds that are not more than an inch and a half in
 depth,becaufe better calculated to retain the parts in contaa.
 In very deep wounds the interrupted future muft neceffari-
 ly be ufed, on account of the difficulty and pain that would
 attend the introduaion of pins to form the twifled future.
   The  pins made ufe of  for twifting the threads upon,
 fhould be flat, as in plate ix. fig. 7.; as the whole preffure
 falls upon them, and when thus made they are not fo apt to
 divide the parts as  ligatures.  Thofe ufually employed are
 of filver, with fteel points ; but as gold pins are not fo lia-
 ble to acquire a cruft by immerfion in  fluids, and require
 no fteel  points, they fhould be preferred.   They ought,
 in general,  to be from an inch to  an inch and an half in
 length,  of a  proportionate  breadth, and have heads  for
 the fingers to prefs upon.
   In performing this operation, the divided parts muft be
 brought nearly into contaa by an afliftant, leaving only fuch
 a fpace as will allow the furgeon to fee that the pins are car-
 ried to a proper depth.  A pin is then to be introduced on
 one fide externally, pufhed inwards to within a little fpace of
 the bottom of the wound, and carried through the oppofite
 fide, to the fame diftance from its edge that it was made to
 enter at on the other fide.  The diftance at which the pin
fhould be  entered  from the edge muft be determined by
the depth of the  wound, and the degree  of retraaion of
its fides,  as in making the interrupted future.   If the pins
                                                    do 
                       [  78   ]
do not pafs eafily, the  inftrument  termed porte-aiguille
may be ufed to pufli them forward.
  The firft pin being thus paffed  very near one  end of
the wound, and the  parts  ftill fupported, a firm  waxed
ligature fhould be  carried three or four  times around and
acrofs it, fo as to defcribe the figure of 8, and fufficiently
tight to draw the  lips of the wound  into  clofe contaa.
The thread fhould  then be fecured by a loofe  knot, and
another  pin  introduced.   The  ligature  is  now to  be
loofened, and applied to  this pin as direaed for the firft,
and others paffed at proper diftances, the whole length of
the wound, all being  conneaed by the fame ligature.
   A pin fhould always be  placed  near each end of the
fore, to prevent the feparation of its extremities.  In large
wounds  the pins fhould be three-quarters of an inch dif-
tant from each other; but in the fmaller, a greater num-
ber in  proportion to the extent of fore will be neceffary.
When the futures are all  formed, the  wound fhould be
covered by lint wet with mucilage, to exclude the external
air.  The introduaion of lint beneath the ends of the pins
has  a  tendency to make them cut the parts.  When they
give uneafinefs, a  piece of thin linen fpread with adhefive
plafter will be  better.  I have  never known  the appli-
cation of a bandage  after this  operation  produaive of
good effeas, but  have often feen it occafion troublefome
inflammation.
   In general, the  pins fhould be fuffered to remain from
five to feven days, according to the depth of the wound.
But when the patient is unhealthy, a longer time  may be
neceffary.*

                                                     As

  * 1ft yoting healthy fubjects the union is often  completed in half the
time; but  perhaps the fafeft  way is to leave the pins in the parts till a
fmall degree of digeftion appears. 
                     [   79  ]
  As foon as they are removed, a bandage  may  be  ufed
with advantage, to fupport the newly-united parts.   But
perhaps ftrips of leather fpread with glue, applied to each
fide of the cicatrix, and conneaed by ligatures, would be
preferable.
  Of the dry future we fhall treat hereafter.
                CHAP.   V.

Of the Ligature of Arteries, and other arti-
  ficial means of stopping Hemorrhagies.
  IN every wound, the firft circumftance to be attended
   to is the hemorrhagy.   This is either produced  from
the large arteries, or by a  general oozing from the fmaller
veffels.  In the firft cafe,  a temporary  ftoppage  of the
difcharge  fhould be  immediately  attempted by  com-
preffion, until  the  permanent fecurity of  ligatures can
be obtained.   In the head  and trunk, the eafieft  method
of preffure is formed by lint or foft linen retained firmly on
the mouths of the veffels by  the hand or a bandage; or if
the fuperior part of the veffels can be compreffed it anfwers
better, as ligatures can then be applied with more  eafe.
   When the wound is in the extremities, and compreffion
can be made  on the fuperior part of the artery, it fhould
immediately be done by means of  the tourniquet.  Plate
iii. fig. 5.
                                             Previous 
                       [  80   ]
  Previous to the application of the tourniquet, a cufliion,
three inches in length, and one  and a half  in  breadth,
fhoi.ild be placed immediately above  the principal artery,
and  well  fecured  by two  turns  of  a roller.   Over  this
roller the ftrap  of the tourniquet is to be firmly fixed, the
fcrew being on the fide of the limb oppofite to the cufhion :
One turn of the fcrew  is generally fufficient.    See plate
and explanation.
  As the ancients were ignorant of the ufe of the tourniquet
and of ligatures, they endeavoured to  remove hemorrha-
gies by applying aaual cauteries or  hot irons  to the large
veffels, and lint covered  with  ftyptic powders, to  the
fmaller.  But thefe often failed.   Even lately,  agaric, cha-
lybeate folutions, and  the  mineral acids have been much
recommended.   Thefe in many cafes  do not produce the
defired effea.   When ligatures can  be well applied, they
invariably  fucceed; and in  the larger veffels fhould alone
be depended on.
  Various methods have been  ufed  for  tying  arteries.
The common praaice at prefent is, by means  of a curved
needle to pafs a ligature of fufficient ftrength  around the
mouth of the veffel, including a quarter of an inch of the
contiguous parts: but, as tying the nerves and mufcles often
produces not only partial but general  fpafms,  and always
a great deal of pain, it  is advifable to include the  artery
only in the ligature, by employing forceps, or rather the te-
naculum,  Plate vii. fig. 5.   In very deep wounds the
needle may be neceffary ; but fuch cafes rarely  occur.  Ex-
perience  from  repeated comparative trials has convinced
me, that the mode recommended is as fecure as that by the
needle; and when it is ufed the ligatures come  away much
fooner, generally at the  third or fourth dreffmg;  which is
often of very great advantage.   I have  feen  inftances of
the ligatures remaining for weeks  when  the needle was
employed,  ^and fome cafes in which they were at laft cut
away by the furgeon.
                                                  The 
                      [   81  ]
  The forceps do not anfwer  well in tying fmall arteries;
they might therefore, Math  propriety,  be entirely  laid
afide, as the tenaculum or hook is equally applicable to the
large and fmall arteries.  The manner of ufing it is as fol-
lows :
  In order to detea the arteries to be tied, the  tourniquet
muft be loofened, and as foon  as the iargefl artery is dis-
covered, the furgeon fixes his  eye upon it, and immediately
again tightens the tourniquet.  An affiftant then  forms a
noofe in the ligature, and placing it over the end of the vef-
fel, the operator pufhes the point of the tenaculum through
the fides of the veffel, and pulls as much of it  out as he
thinks fhould be included in  the furgeon's knot now to be
made by the affiftant.   For greater fecurity a fecond knot
fhould alfo be formed.  In making the knots, a very fmall
addition to the force requifite  for reftraining the hemor-
rhagy, is fufficient.
  In this manner all the arteries that can be diftinguifhed
fhould  be  fecured: for  fatal  hemorrhagies have  fome-
times  been produced from very  inconfiderable veffels,
when the patient has become  warm in bed.   Lofs of blood,
fear, or cold, often occafion  fuch a retraaion of the fmall-
er arteries, that it  is difficult to detea them :—To effea
this, the tourniquet fhould be loofened, and the wound
well wafhed with a fponge and warm water ;  and if the
patient is faintifh,  a glafs of wine  or  fome other cordial
fhould be given.
  As in fome  inftances we are unable to  tie arteries by
means of the tenaculum,  we fhould be provided with nee-
dles of various forms and fizes.   Thofe ufed in  forming
the interrupted future  are very well adapted to the tying
of arteries.  In ufing the  needle, it fhould be introduced,
armed with a  ligature, at the diftance of a fixth or eighth
of an inch from the artery, pufhed to a depth fufficient for
retaining the thread, and  carried one half round the veffel.
                      L                             It 
                       [  82   ]
 It muft now be withdrawn, and being again pufhed for-
 ward till it has encircled  the mouth of the artery, is then
 to be pulled out,  and a knot formed on the ligature as al-
 ready direaed.
   Hemorrhagies to an alarming degree are frequently pro-
 duced in extenfive wounds by  a general oozing  from  the
 furface of the fore; and fometimes it is with difficulty they
 are fuppreffed.   They feem to proceed from two very dif-
 ferent eircumftances :  1ft. In robuft habits, either from too
 great a quantity of blood, an excefs of tone in  the veffels,
 or a combination of both; or  2dly. And more frequent-
ly, in relaxed debilitated habits, from a diflblved  ftate of the
 blood, a want of tone  in  the veffels, or a concurrence of
both thefe.
   In healthy conftitutions, the difcharge of blood from the
 fmaller veffels of wounded parts is commonly foon remov-
 ed by the contraaion  of  thefe veffels, and the difcharge
 of a glutinous fluid from them, which is diffufed over the
furface of the wound :  but when it continues in fuch de-
 gree as to fhew a morbid ftate,  it is to be attributed to one
of the  caufes abovementioned.    In  robuft habits relief is
to be obtained  by  opening a vein; or perhaps  more  ef-
feaually by untying  one of the principal arteries of the
part and fuffering it  to  difcharge freely;  by keeping the
patient cool; giving him cold acidulated drinks ;  obliging
him to avoid motion, particularly  of the  part;  covering
the wound  with lint; and by applying  a bandage over
it.   In all thefe cafes, and particularly when violent fpaf-
modic  affeaions fupervene, a large dofe of opium  is one of
 the moft effeaual remedies, and  fhould  be exhibited  as
 foon as the patient has been bled and put to bed.  When
we have  reafon to fuppofe the difeafe is fupported by the
fecond fet of caufes mentioned,  a generous diet, and a free
 ufe of Port, Madeira,  or other good wines, fhould be  al-
                                               lowed ; 
        >                [  83   ]
lowed; the patient fhould be  kept cool; mineral  acids,
particularly the vitriolic,  muft be given; reft of body en-
joined ; and opiates, to obviate  pain or  fpafm, liberally ad-
miniftered.
  Together with thefe general  remedies, particular dreff-
ings,  adapted  to the ftate of the fyftem, fhould be applied.
Dulling the parts with ftarch or wheat flour, or gum arabic
in fine powder, has been ufeful in all ftates of the body, but
particularly in that of debility.   In this cafe, lint moiften-
ed with tinaure  of myrrh, traumatic balfam, and other fti-
mulating  applications, are very ferviceable.   When thefe
do not prove effeaual, an equable preffure by a bandage,
or the hand applied over the dreffing, will feldom fail.*

  * This laft mode of preffure is much  the beft, and has fucceeded in fome
aneurifms, where it could be made immediately upon the orifice of the
wounded artery.
CHAP. 
[  84-   ]
CHAP.     VI.

  Of Blood-letting.
                    SECT.  I.

                Of Blood-letting in general.

   IN all general affeaions where blood-letting is confider-
    ed  neceffary,  the blood is difcharged  by an opening
made in an artery or vein.   The former operation is call-
ed arteriotomy ; the latter phlebotomy.   In local  affeaions,
particular  benefit  is  often  afforded by dividing a number
of the fmaller veffels  of the part difeafed ; this is termed
topical bleeding.
  We fhall firft confider phlebotomy.  The choice of a vein
in this operation,  muft be  determined by  the  particular
eircumftances of  the patient.  The  veins from  which
blood  is  ufually  drawn,  are  thofe of the  arm at the
flexure of the cubitus or fore arm, the jugular veins, and
thofe  of the ankles and feet.  On certain occafions,  blood
is alfo taken from the veins of the hands, tongue, and
other parts.
  In blood-letting in general,  as the pofition of the  pati-
ent has  fome  influence on the effeas of the operation, it
fhould be precifely fixed.    When fainting  is likely to  be
induced, and we do not wifh to rifk it, an horizontal pof-
ture is to be preferred;  but if we expea advantages from
the fainting, the patient fhould  be placed erea.   The part
                                                     to 
                         C  85   ]
 to be  operated  upon fhould be fo fituated, as that the
 principal  light of  the  apartment  may fall direclly up-
 on it:  and the  furgeon ought  always to be feated ; as he
 will then bleed with much more fleadinefs and nicety than
 if he ftands.*  When the patient is properly fixed, a ban-
 dage fliould be applied to the member to be operated upon,
 to produce an accumulation of blood in the veins; but not
 fo tight as to obftrua its paffage in the correfponding ar-
 teries.
   Various inftruments have been invented to bleed with ;
 but there  are  only two now  in ufe: the lancet and the
phleme.
   The phleme  is  placed immediately on the part  to  be
 cut, and  by means of a  fpring  is ftruck fuddenly into the
 vein.   Its inconveniencies are, that we  muft regulate the
 depth  to which it is to go, before we apply it; on which
 account,  if the vein  lies deeper  than fuppofed, we may
 not reach it; and there is danger of its wounding arteries,
 or other parts beneath the vein,  if  it fhould go too far.f
 Thefe difadvantages do  not  attend the  ufe of the  lancet,
 and therefore it  certainly ought  to be preferred.
   The lancet  fhould be fpear-pointed—it then  enters
 the integuments with little pain ; and forms an opening in
 them very little larger than the  orifice in  the vein,  which
 renders it an  eafy matter to flop the difcharge.—Thefe ad-
 vantages  are  not derived from the broad-fhouldered lancet
 in common ufe.
   The  ligature having been made for a  fhort time to pro-
duce fome fwelling  in the veins,  that vein is to be fefeaed
                                                   which

  * This depends upon habit—thofe accuftomed to operate  ftanding will
perform with more eafe to themfelves, than if they were feated.
  f Notwithftanding  thefe obvious objections, the phleme  is very uni-
verfally ufed  here, among  the bleeders, in preference to the lancet;  and
even fome medical practitioners employ  it.  I have very feldom heard of
any material bad effects from its ufe—never  but of one cafe of aneu-
rifm. 
                       [   86  ]
which rolls lefs than the others on being preffed with the
finger, even if it  fhould be  fomewhat  deeper than thofe
near it—Veins that lie contiguous to arteries and tendons
fhould; if poffible,  be avoided ; although a dexterous ope-
rator may often open them with perfea fafety.
  When a vein is  made choice of,  the furgeon, if he is to
ufe the right hand, grafps firmly the member, an inch and
an half below  the  part to be  operated upon v/ith his left,
and makes  fuch a preffure on  the vein, with the thumb, as
will interrupt the communication between the inferior part
of it, and  the part above the thumb, and will render the
teguments fomewhat tenfe.   The lancet being bent to ra-
ther more  than right angles, is then to be taken between
the thumb  and fore-finger of the right-hand of the opera-
tor, and leaving one half of the blade uncovered, he refts
his  hand on the  remaining  fingers, and then pufhes the
point of the lancet into the vein, and carries it forward in an
oblique direaion, until the orifice is fufficiently large.  The
point ought neither to be raifed nor depreffed, left it fhould
wound parts unneceffarily.  The inftrument is now to  be
withdrawn, and the left hand removed as foon as the cup
for  receiving  the  blood is applied.  While  the blood is
flowing, the member fhould be kept in  the pofition it had
when the incifion was made;  otherwife the fkin may flip
over the orifice in the vein, obftrua the difcharge, and
produce ecchymofis.
  If the wound is made longitudinally,  it does not admit
of a free difcharge  ; and if  acrofs the vein, it is difficult to
heal.  The fize of the orifice  muft depend on the eircum-
ftances of  the difeafe for which the bleeding was ordered.
In  general, when the  fpear-pointed lancet  is  ufed,  an
eighth of an inch will be fufficiently large; but when we
employ the common lancet, a quarter of an inch will not
be too much.
                                                    It 
                       [  87   ]
   It  fometimes happens that the blood is not freely dif-
 charged, either from faintifhnefs, or from the opening in
 the fkin receding from that in the vein.   In the firft cafe,
 it will be  proper  to admit  a ftream of air into the apart-
 ment, to  give  fome wine  or other cordial, and have the
 patient placed in a horizontal pofture.  If the blood does
 not then flow as we wifh it, the part fliould be put into  a
 variety of pofitions, the mufcles fliould be thrown into ac-
 tion by moving fomething in the hand, if the arm is ope-
 rated upon ;  and if the pulfe is feeble in the inferior part
 of the member, we fhould loofen the ligature.
   As foon as a fufficiency of blood is drawn,  the com-
 preffion fhould  be  taken off, and if the difcharge does not
 then  ceafe, the thumb fhould be applied above, and the
 fore-finger below the orifice, and it being well wafhed and
 cleared of blood,  its fides fhould be brought exaaiy to-
 gether,  and  there retained  by a ftrip of adhefive plafter.
 This will generally be fufficient; if it is not, it will be pro-
 per to apply a linen comprefs over the plafter, and fecure
 both with a roller.
  The wound will commonly heal by the firft  intention,
 or without the formation of pus; but  troublefome confe-
 quences fometimes enfue.  Of thefe the moft material are
 thrombus  or ecchymofis; wounds of arteries, nerves, or
 tendons contiguous to the vein ;  and inflammation of the
 internal coat of the vein operated upon.


                   SECT.   II.

             Of a Thrombus or Ecchymofis.

  A thrombus is a fmall round tumor  produced by extra-
vafated blood infinuating itfelf into the cellular membrane.
When this fwelling is more diffufed it is  termed an ecchy-
                                                mofis. 
                      [  88  ]
inofis.   In bleeding, it is commonly induced by the orifice
in the fkin receding from that in the vein.  Immediately
on the appearance of fuch fwellings the ligature fhould be
removed, and again applied, as foon as the limb is brought
into the pofition it had during the operation.   Should not
this fucceed in difperfing the tumor, or  at leaft in pro-
curing a free difcharge of blood, the ligature muft again
be taken  off, and  if the neceffary quantity of blood has
not been drawn, another vein fhould be opened.
   Thefe fwellings  in  general go off of themfelves ;  but if
they do not, they may often be difperfed by the applica-
tion  of compreffes  wet  with brandy, or a folution of fal
ammoniac in vinegar.   If thefe have not the defired effea,
the tumor fhould be laid open, the blood  taken out, and
the wound then healed in the ufual mode.


                   SECT.  III.

               Of Wounds of the Arteries.

   The only certain  method  of knowing whether an  ar-s
tery is wounded through the  vein, in bleeding,  is to com-
prefs the vein above and below the orifice ;  if the artery is
wounded, the difcharge will then continue, or be increafed;
if it is  not, it will ceafe.   The flow of blood being per
faltum, is  a fallacious criterion, becaufe it  may happen from
a vein lying immediately  above an artery.
   As foon as we are certain of an artery being thus wound-
ed, as much blood fhould be fuffered to flow as the ftate
of the body will admit of,  and the wound fhould then be
clofed by adhefive plafter;  reft fliould be  enjoined, and
the body  kept cool;  gentle purgatives muft be given, and
blood-letting repeated occafionally.   By thefe means, the
fyftem will be relaxed.   And we fhall have  fome chance of
                                                healing 
                       C  89  ]
healing the wound.  If this is not accomplifhed, the effu-
fion of blood forms a fpecies of aneurifm.
   It has been the common praaice  in wounds of the ar-
teries, to apply immediate and ftrong  compreffion, by
means of compreffes and bandages;  but it is evident that
this, from the obftruaion it gives  to the  paffage  of  the
blood, according to its  degree, muft either increafe the he-
morrhagy by producing an increafed aaion in the  artery,
or caufe a gangrene in  the parts below.


                   SECT.  IV.

   Of Wounds in the Nerves and Tendons from Bleeding.

   These accidents arife from carrying the lancet through
the back part of the vein ; and may be avoided by keeping
the point of the inftrument in  a ftraight  direaion,* in
ftead of depreffing it after it has entered the cavity of the
vein.
   If immediately on the introduaion of the lancet the  pa-
tient complains of exquifite pain, we may reft affured that
either a nerve or tendon has been wounded.
   In fome cafes, by proper management, the pain will gradu-
ally go off entirely without any bad confequence whatever.
At other times,  however, the pain foon increafes, a fmall
degree of fwelling takes place; the lips of the fore become
fomewhat hard and inflamed ;  and in the courfe of about
twenty-four  hours from the operation, a thin watery ferum
begins to be difcharged  at the orifice.
  If relief is not foon obtained, thefe fymptoms generally
continue nearly in  the  fame ftate for two  or three days
longer.   At this time,  the pain becomes greater, and in-
                      M                         ftead
* See Section I. 
                       [   90  ]
 ftead of being acute as before, is now attended with a burn-
 ing heat, which gradually augmenting proves,  during the
 whole courfe of the difeafe, exceedingly diftreffing.   The
 fulnefs and hardnefs  in the lips of the wound begin to in-
 creafe, and the fwelling by degrees extends over the whole
 member; from the foot, if the operation has been perform-
 ed there, over the whole lower extremity; and from the
 elbow, if the bleeding has been done  in  the  arm, down
 the fore-arm,  and along the humerus  over the  peaoral
 mufcle and other contiguous parts.
   The parts at lafl become  exceedingly hard  and tenfe ;
 an eryfipelas frequently appears over the whole member ;
 the pulfe  becomes generally very  hard and quick ; the
 pain intenfe, and the  patient very reftlefs ; twitchings of
 the tendons occur, on fome occafions,  a locked jaw  and
 other convulfive affeaions fupervene ;  and  all thefe fymp-
 toms continuing  to increafe, it moft frequently  happens
 that the fufferings of the patient are  only terminated by
 death—All the inftances of  accidents of this kind that I
 have feen have ended fatally.
   By  fome,  the  fymptoms  we  have  enumerated have
 been attributed to wounds of the tendons; others fup-
 pofing  tendons  to be deftitute of  fenfibility,  have  im-
 puted them,  in all cafes,  to  wounds of the nerves:  and
 Mr. Hunter of London,  is entirely  convinced  that  they
 are the confequence of an inflammation of the  internal
 coat of  the  vein  operated  upon—He  has  traced  this
 inflammation  in  horfes,  and even  in  the human  fub-
jedt, to a confiderable extent in  the  vein, and in fome in-
 ftances, even to the heart. The matter formed in confe-
quence, Mr. Hunter fuppofes to produce death, by being
carried to the heart in the  courfe of the circulation.   But
although  there  can  be  no  doubt that  this  inflamed
ftate of the vein may often occur, yet we are clearly of opi-
nion, that  the  violent pain experienced immediately af-
                                                   ter 
                     [  91   ]
ter the punaure,  cannot be occafioned by the  wound of
the vein ; and that the inflammation of its internal furface
ought rather to be confidered as fymptomatic of the pre-
vious affeaion of  a nerve or tendon, than as the fole and
primary caufe of  the fymptoms which we have  above de-
fcribed as confequent to bleeding.
  In order to obviate the ufual  confequences of  this  acci-
dent, a confiderable quantity of blood fhould be immedi-
ately  difcharged at the  orifice, the  limb fliould be kept
perfeaiy at reft, for fome  days,  care being at the fame
time taken  that the mufcles of the part be all preferved in
as relaxed a ftate  as poffible;  the patient fhould be kept
cool, and on a low diet; and if neceffary, laxatives fliould
be adminiftered.
  By this  treatment we may  frequently prevent all bad
fymptoms; and when thefe  do  occur, from injudicious
management, they prove  fatal as much from  negligence
in the fubfequent  treatment, as from any thing peculiarly
bad in the  nature of the accident.
  When,  however,  notwithftanding the employment of
the means recommended,  the  lips of  the wound  grow
hard and inflamed, the pain increafes, and efpecially if the
fwelling becomes more confiderable, we muft  have  re-
courfe to other remedies.  Topical  bleeding,  by leeches
applied as  near as poffible to  the lips of the wound, fre-
quently affords much relief: and when the pulfe is full and
quick, it is neceffary to employ general bleeding to a very
confiderable extent.
  As  applications  to the  part, warm emollient poultices
and  fomentations have been  ftrongly recommended.   I
have ufed them ;  but never with good effea—And it is
probable,  that as  the membranous  parts affeaed are in-
capable of  yielding  a good pus,  to  produce  which, has
been  the  objea  of their ufe, they prove hurtful by the
heat they communicate. 
                       [   92   ]
  By Heifter and others, inflead of emollients, oil of tur-
pentine, tinaure  of myrrh, and other heating applications
are  advifed.   But fufpeaing that they would increafe the
fymptoms, by irritating parts rendered already exquifitely
fenfible by difeafe, I have never employed them.
  I can,  however,  from  repeated  experience affert, that
cooling aftringents, and  particularly  the faturnine pre-
parations, afford much more eafe and effeaual relief than
warm emollients.   In all fuch cafes, therefore, immediately
after bleeding, the fwelling ought to be covered with foft
linen moiftened with the faturnine folution ; and this being
kept conftantly wet for a few hours, the part fhould then
be  covered by pledgits fpread with the faturnine  or Gou-
lard's cerate.  Thefe   preparations  fhould be alternately
ufed till the tumor entirely fubfides.
  The febrile fymptoms muft be moderated by keeping the
patient cool; on  a low diet;  preferving a lax ftate of the
bowels ;  and if neceffary, by repeating  blood-letting.
  For the violence  of  the  pain, which often  prevents the
patient altogether from fleeping, opiates  fhould be freely
exhibited ; and when twitches  of the  tendons and other
convulfive fymptoms occur; medicines of this  kind become
ftill more  neceffary; but it is to be  obferved that unlefs
they are given in  large dofes, they certainly  aggravate in-
flead of leffening the  difeafe.
  When every thing we have  advifed  proves ineffeaual,
and the life of the patient appears to be in imminent danger,
the only remedy from  which much advantage is to be ex-
peaed, is a free and extenfive divifion of the parts in which
the orifice producing the mifchief was at firft made.
  In performing this  operation, in order to prevent an in-
convenient difcharge of blood from the fmaller veffels, or
a dangerous hemorrhagy from the larger, it will be neceffa-
ry to have a tourniquet applied on the fuperior part  of the
limb.  When this is done, a large tranfverfe incifion fhould
                                                     be 
                      [   93  ]
be made through the teguments of the parts chiefly af-
feaed, and carried acrofs the original  orifice  in  the vein.
The furgeon muft then, by cautious diffeaion, wiping the
blood away frequently with a fponge, and avoiding the ten-
dons, larger  arteries,  and  veins, endeavour to  difcover
the wounded  nerve;  if  he cannot  accomplifh  this,  he
fhould ftill continue the incifions till he gets to the periof-
teum.   The tourniquet fhould then be loofened ; and if the
wounded part has been divided, the pain will ceafe.  If the
pain continues, the  adjacent tendons,  and particularly that
which lies beneath the vein, fhould be accurately examined;
and the one in  which a wound or inflammation is difco-
vered fhould be entirely divided.   If neither wound nor
inflammation appears, the tendon which lies moft contigu-
ous  to  the vein fhould be  cut through ;  and if  one  or
two others fhould be liable  to  fufpicion from their fitua-
tion, we fhould not hefitate to  divide them  all.   When
this is done, it feldon happens that relief is not immediate-
ly derived from it.
   The tourniquet muft now be flackened as much as pof-
fible, and fuch arteries as have  been wounded muft be fe-
cured.  The parts are then  to be covered with foft eafy
dreffings, and the wound is to be treated as in other cafes.
   The  mode of treatment here recommended, I  have feen
praaifed with the greatefl fuccefs.


                    SECT.  V.

              Of Blood-letting  in the Arm.

   It appears to me, that the fixing on the  fore part of the
arm at the elbow, as the  ufual place for blood-letting, is  a
very capital error, on account of the rifk we run of wound-
ing  the nerves, tendons, and  arteries  contiguous to the
                                                veins ; 
                       [  94   ]
 veins;  and efpecially  as  it can  be performed with equal
 eafe, and with  much lefs danger, in the neck, the lower
 part of the legs, the ankle, and the feet.   The only rea-
 fon that can be given for the praaice is that the veins ap-
 pear here more confpicuous than in other places.
   In applying the ligature previous to bleeding in the arm,
 we fhould place it  about an inch or an inch and a half
 above the joint of the elbow, and  the knots fhould be made
 on the outfide of the arm, that they may not interfere with
 the lancet.
   As the  median bafilic vein appears in general more con-
 fpicuous than any of the reft, and is  lefs covered with cel-
 lular fubftance and the tendinous expanfion of the biceps
 mufcle, it fhould be preferred.  The incifion alfo gives
 lefs pain on account of thefe eircumftances.
   The  operation is more neatly performed,  if the right
 hand is ufed in bleeding in the  right  arm, and the left in
 the left arm of  the  patient, than if the right hand is ufed
 in both cafes.
   In  very corpulent people, it fometimes  happens that
the larger veins  cannot be feen ;  but  when  they can be
fenfibly felt, they may  be opened with perfea fafety.  In
fome cafes again, the veins of the arm  can neither be feen
 nor felt.  The ligature may then be applied to the middle
 of the fore-arm,  and a vein  of the wrift  or back of the
hand, may generally be opened  with eafe.


                   SECT.   VI.

          Of Blood-letting in the Jugular Vein.

   This operation is fometimes judged neceffary in inflam-
mations of the throat, diforders of the eyes, and other af-
feaions of the head.
■There 
                      [   95  ]
  There is no branch of the  external jugular vein that
can be  opened with propriety, but its principal pofterior-
ramification ;  and even  this lies  fo  deep,  that a  confi-
derable  degree of preffure  is neceflary  to  bring  it well
into view.  In order to produce this, it is commonly advif-
ed to place the  thumb  upon the vein, about  an  inch, or
an inch and  an half  below where the opening is to be
made.  This, however, is feldom fufficient;  for the blood
on being flopped in this branch, paffes off by others com-
municating with it: fo that unlefs the vein  on the other
fide of the neck is alfo comprefled, the vein  to be  opened
can never be  fully diftended.   In order to do this, a com-
prefs, fhould be applied over it, and a ligature carried above
this, and knotted under the oppofite arm-pit.
  The  patient's head  being fupported, the operator fhould
then make a  firm preffure on the vein with his thumb, and
with a  lancet penetrate at once into the veffel, making an
opening fomewhat larger  than that advifed  in bleeding in
the arm, on account of the greater difficulty of procuring
a fufficient quantity  of  blood.    Adhefive plafter alone
commonly reftrains the difcharge.
  It has been direaed to make an  incifion down to the
vein with a fcalpel, and to ufe the lancet merely for opening
the vein : but this precaution is entirely  unneceffary, and
fometimes may injure the operator in the opinion of the
patient.

                   SECT.   VIL

          Of Blood-letting in the Ankles and Feet.

  In thefe cafes, the ligature being applied jufl above the
ankle joint,  all the  branches-of the vena faphena, both
in the infide  and outfide  of  the  foot, generally come into
view ; and wherever a proper vein appears, it may be open-
ed with fafety.
                                                   The 
                      [   96  ]
  The ufe of warm water prevents  us from  afcertaining
the quantity  of blood difcharged,  and is  perfeaiy un-
neceflary.
  The bleeding generally  ceafes immediately on the re-
moval of the ligature, fo that nothing more than a ftrip of
adhefive plafter is neceffary to be applied to the wound.
  When  it is  found neceffary  to difcharge blood from
the penis,  the veins can eafily be  brought into view by the
application of a ligature ; but in  the tongue, in the exter-
nal  hemorrhoidal veins, and other parts  where compref-
fion cannot be applied, all that the furgeon can do, is  to
make an orifice in the moft evident part of the vein, and
if a fufficient difcharge is not thus produced, to immerfe
the parts in warm water, where this is praaicable.


                  SECT.   VIII.

                    Of Arteriotomy.

  Arteriotomy feems hardly in any cafe, to have better
effeas than opening  a vein ; and is always attended with
much  hazard,  notwithftanding   what has been  faid  by
theorifts to the contrary, when praaifed  on the larger
veffels.  The  different branches of  the  temporal artery
are thofe only  from which blood is taken  in  ordinary
praaice;  but any of the fmall arteries that lie fuperficial,
or contiguous to bones, and admit eafily  of compreffion,
might be  opened with perfea  fafety ; as thofe of the fin-
gers at the middle of the laft phalanx.  The  opening may
be made as in common phlebotomy ; but if the  artery is
deeply covered with cellular fubftance, it will be neceffary to
                                                expofe 
                      [   97  ]
expofe it to view by the fcalpel, before making the orifice
with the lancet;  for if the veffel fhould be entirely divid-
ed, it would retraa and put a flop to the evacuation.
   If  the  blood fhould not flow  freely,  it will  be  pro-
per to comprefs the artery immediately above the orifice;
and when a fufficient quantity is obtained, we  may com-
monly reftrain the evacuation by applying a comprefs and
roller as direaed  in venaefeaion.
   If this does not flop the difcharge, it may with tolera-
ble certainty be  fuppreffed, either by cutting the artery
entirely acrofs at the orifice ; by taking it up with a needle
and ligature ;  or by obliterating its cavity by a gradual and
conftant compreffion.  For this laft purpofe, a fmall femi-
circular ftrip of fteel covered  with leather, to reach from
temple to temple, with a comprefs of linen, anfwers much,*
better than a cpmmon bandage.


                   SECT.  IX.

                Of Topical Blood-letting.

  "Topical  bleeding is  performed either  by means of
leeches; by flight fcarifications with the fhoulder or edge
of a lancet;  or by the inftrument termed a  fcarificator.
When the laft mode is employed, it is neceffary, in order to
produce a fufficient difcharge of blood, to apply cupping
glaffes over the divided parts.   Thefe promote the evacu-
ation by having the air contained in them rarefied immedi-
ately previous to their application.
   With a view to produce this rarefaaion and  confequent
fuaion, heat is  now  ufually  applied to  the cavity of the
glafs  either  by fupporting the mouth of it  for a  few
feconds above  the flame of a  taper, or  by throwing in-
to it a piece of bibulous paper impregnated with fpirits of
                         N   •                    wine, 
                       C  98   _]
' wine, and fet on  fire.   The laft is. the eafieft and beft
 mode—by the former we are very apt to crack the glafs if
 the flame be fuffered to touch it.  The cup  fhould be ap-
 plied  direaiy upon  the  part, when the paper  is nearly
 extinguifhed.
    As foon as this is done, the fcarifications, if well made,
 begin to difcharge freely; and  as foon as the glafs is near-
 ly full of blood, it fhould be taken away ; which may be
 eafily done by railing one fide of it.   When more blood
 is wifhed to be taken, the parts fhould be bathed in warm
 water, then dried,  and another glafs exaaiy of the fize
 of the former, inftantly applied—and thus, if the fcarifica-
 tions  have  been fufficiently deep, almoft  any  neceffary
 quantity  of blood may  be drawn ;  but  when this cannot
 be obtained from one operation, the trial  fhould be  repeat-
 ed as near as poffible to the parts already cut.
    When it  is wifhed to difcharge  the  blood as quickly
 as poffible, two  or more cups may be applied  at once,
 and previous to the fcarifications, for a few feconds, as well
 as afterwards.—The  wounds  made by the  fcarificator
 fhould be  well  cleared of blood, and  dreffed with foft
 linen or lint dipped in milk  or cream.
    Dry cupping confifts in  the mere  application  of the
 glaffes, without any fcarification.   This may be very ufeful
 where we wifh to determine a quantity  of blood to a par-
 ticular fpot.
    When cupping cannot be ufed, we generally  have re-
 courfe to leeches  for  the  topical evacuation of blood.   In
 order  to make thefe animals fix  on a particular fpot, they
 fhould be fuffered to creep  upon a dry cloth or board for
 a  few minutes previous to their application ;—the part
 fhould be moiftened with milk, cream or  blood :—and they
 fhould be confined to it by a fmall wine glafs.   As foon as
 the leeches  have feparated, the  bleeding is in  common
                                              promoted 
                       [  9-9   ]
promoted  by  covering  the parts with  linen  wet with '
warm water;  but  the application of  cupping glaffes  an-
fwers the purpofe much better.
  Scarification with  the edge or fhoulders of a lancet is
fometimes neceffary,  and particularly in inflammations of
the eye-ball, where it often proves a very effeaual remedy.
  In  performing this operation, the  upper eye-lid being
fupported by an  affiftant, and the lower by the left hand of
the furgeon,  a  number of flight  fcarifications fhould be
made through  the veffels that feem moft turgid on the tu-
nica conjunaiva.  The eye fhould then be bathed in warm
water to encourage the difcharge.
  It has been  recommended to  ufe a fpeculum in  order
to keep the eye fleady ; but this  is  totally unneceffary,
and by its preffure it may perhaps be injurious.
  The beards  of barley, drawn over the furface of the eye
in a direaion contrary to their fpiculse, have been much
extolled to  produce a difcharge  of blood—but this gives
fuch exquifite  pain that it is now going out of ufe.
CHAP. 
C  100  ]
CHAP.     VII.

     Of  Aneurisms.
                    SECT.   I.

             General Remarks on Aneurifms.

     ANEURISMS are tumors formed either by the dila-
      tation of the  coats of arteries; or by blood effufed
from arteries into the contiguous parts.  The firft fpecies
has ufually  been denominated the  true aneurifin;  but it
may with greater propriety be called  the encyfled.  The lat-
ter  fpecies has been  generally termed  the falfe ;  but from
its appearances, I think it ought to have the appellation of
the diflfufed aneurifm.
  In the true or encyfled aneurifm, when externally fitu-
ated, the tumor,  when firft obferved, is commonly very
fmall and circumfcribed ; the fkin retains its natural  ap-
pearance ;  when preffed  with the  fingers, a  pulfation
correfponding  with that  of the  artery below is evidently
diftinguiflied ; and with very little force,  the tumor may
be made to difappear entirely.  If it is not removed when
in this ftate, after fome time the fwelling  gradually in-
creafes, and becomes more prominent; but the fkin for
a confiderable time retains  its natural appearance.   The
tumor  is not painful, even on preffure; continues of an
equal foftnefs ;  and  its ^contents may  generally ftill be
made to difappear  by preffure.  At  length,  when  the
                                               fwelling 
                             \
                      [   101  ]
fwelling becomes very large, the fkin grows pale, and in
the more advanced ftage of the difeafe, oedematous ;  the
pulfation ftill continues ; but the tumor, now in fome parts
foft, in others hard, does not yield much to preffure.''"
  The fwelling continuing to increafe, becomes gradually
exceedingly painful; the fkin turns livid, apparently verg-
ing to a gangrenous ftate ; at lafl  a bloody ferum  oozes
from the teguments ;  and if a mortification  does not take
place,  the  fkin  cracks in different parts, and the  blood
burfts forth from the artery. In the large  veffels of the
trunk,  this  generally produces almoft inftant death;  but
in the extremities, the hemorrhagy  may  be  reftrained by
the tourniquet.
   In aneurifms of the larger arteries, the contiguous parts
fuffer confiderably.   The bones appear to be particularly
affeaed: and in different cafes are much deranged,  and
fometimes  entirely  diflblved.   Thefe  confequences have
even occurred in the thigh and arm.
   Various  caufes  may be fuppofed neceffary to the pro-
duaion of  encyfled aneurifms.
   1. As we know of no reafon why partial debility fhould
not  occur  in  arteries as  well as in other parts,  we may
confider this as one of the moft frequent  caufes of the dif-
eafe, when  it cannot be traced  to any external accident;
as is commonly the cafe  in aneurifms of the aorta,  and
other internal arteries.  And when  weaknefs is produced in
the  fmalleft degree, a dilatation mufl neceflarily' follow,
and be conflantly increafed, from the aaion of the blood.
   2. The  external coat of an artery being deftroyed by a
wound, the inner tunic will be incapable of refifting  the
impulfe of the  blood ; and thus an aneurifm will be rea-
dily induced.  Such cafes  are moft frequently produced
by blood-letting in the arm.
   3. The  external coat of an artery is fometimes deftroy-
                                                    ed 
                       [  102   ]
 ed by the matter of abfceffes  and ulcers,  and occafions
 aneurifmal fwellings in the manner juft explained above.
   4. As arteries receive, in  many fituations,  confiderable
 fupport from the adjoining parts, aneurifms may be  pro-
 duced from a removal  of thefe  parts.   This appeared to
 be the only caufe  of  feveral  aneurifmatic tumors that oc-
 curred  in a cafe of gangrene which  deftroyed a part of
 the thigh.
   5. In blood-letting in the arm, it fometimes  happens
 that the artery is wounded through the vein when it  lies
 in contaa with it: a communication being thus formed,
 the arterial blood, by its impetus, produces  a dilatation of
 the coats of the vein, and thus forms what has been term-
 ed  the varicofe  aneurifm.   This may with propriety be
 confidered as encyfled, becaufe  the  blood  is  confined to
 the cavity of  the vein.  Soon  after the injury, the vein
 communicating with the wounded artery, begins to fwell,
 and gradually acquires a large fize : and when any confi-
 derable  anaftomofis  occurs near to the part affeaed,  be-
 tween  it and  the contiguous veins, thefe alfo become
 much enlarged.   By preffing  upon the fwelling, it may be
 made to difappear entirely;  and if it is of confiderable
 fize, the blood  on being forced out of it, makes a very
fingular, hiffing  kind of noife.  This, when it occurs, is a
 very charaaeriftic fymptom ;  but it is not always met with.
   There is a very fingular tremulous motion difcovered in
 the  dilated  vein, attended with a perpetual hiffing noife,
 as if air was paffing into it through a fmall aperture.   If
 a ligature be applied immediately  below the  fwelling,  and
 made fo tight as even to flop the pulfation in the limb, the
 fwelling in the  veins  does not feem affeaed,  and  when
 removed by preffure, inftantaneoufly returns on the preffure
 being taken off.   If the fwelling is removed, and a flight
 preffure  be made on the orifice in the artery by the point
 of the finger, the veins will remain perfeaiy flaccid, until
                                                   the 
                       C   103   ]
 the removal of the compreffion from the orifice ;  and this
 happens even if the circulation in the  artery is not entire-
 ly obftruaed below.
   In the fame manner, if the artery be  compreffed above
 the orifice, fo as to flop the  paffage of  the blood,  that tre-
 mulous motion and hiffing noife in the fwelling ceafes in-
 ftantly ; and if the veins are now emptied as before, they
 will remain fo until the preffure upon the artery is remov-
 ed.   In fome inftances, it  happens that if a ligature be
 applied an inch  or two above the fwelling, and another as
 much below it, fo tight as to prevent the circulation in the
 tumor,  by compreffion, all  the blood contained in it may
 be  made to pafs into  the artery; from  whence it imme-
 diately returns on  the preffure being removed.
   When  this difeafe  has continued  for any  length of
 time, and the fwelling has become confiderable, the trunk
 of the artery  above  the orifice generally grows preterna-
 turally  large,  while the branches below become propor-
 tionably fmall.  Hence the  pulfe of the inferior part of
 the member is always more  feeble than that in the found
 limb.
   The diminution of  the branches of the artery  may be
 readily accounted for from the direa paffage of fo great a
 part of  the arterial blood from the  trunk into the corre-
 fponding vein ; but no fatisfaaory reafon has yet been given
 for the enlargement of the artery above  the fwelling.
   The  diffufed  or falfe aneurifm occurs in various parts
 of the body; but we fhall here confine our defcription to
 that fpecies  which we  know to be  moft  frequently occa-
 fioned by a wound made  direaiy into  an artery, and
 which it is commonly in the  power of art to relieve.
  This difeafe is frequently  produced by  a wound of the
artery in  blood-letting  in  the arm ;  and indeed  when
the artery is thus  wounded, an aneurifm  is almoft always
                                                   th«- 
                      [   104  ]
the confequence.   The following is the ufual progrefs of
the complaint.
   A fmall tumor, about the fize of a  horfe-bean, gene-
rally rifes juft at the orifice in the artery, foon after the
difcharge of  blood  has been  flopped: at firft it is  foft,
has a ftrong pulfation,  and yields  a little upon preffure ;
but it foon acquires a firm confiftence by the coagulation
of the contained blood.
   If the fwelling is not  now  improperly treated by com-
preffion, it generally remains  nearly of the fame fize for
feveral weeks, when it begins gradually to increafe ; and if
feated in the ufual place of blood-letting in the arm, it pro-
ceeds rather farther up than the orifice, and extends more
inwardly than towards  the outer part of the arm, probably
on account of the expanfion of the biceps mufcle being there
lefs firm than in the external and under part.  The enlarge-
ment of the  tumor proceeds with much more quicknefs,
and  is much more diffufed  in fome inftances  than in
others; this  feems to depend chiefly on the degree of lax-
ity of the parts into which the blood is effufed.  Thus, in
fome inftances, fwellings  of  this kind have  been many
months, and even years in arriving at any confiderable
fize; whilft  in others the blood has been diffufed over the
whole arm, from the elbow to the  fhoulder, in the courfe
of a few hours after the artery was wounded.
   I am convinced that the compreffion commonly advifed
in wounds of the arteries, has alfo a confiderable influ-
ence in producing  a diffufion of the blood.  If the preffure
 could be applied over the orifice alone, it might be advan-
 tageous ; but by every  mode yet recommended, the refluent
 blood is  much obftruaed in its paffage ; and this muft
 evidently diftend the wounded artery in an equal propor-
 tion,  and  increafe the quantity of blood which efcapes by
 the orifice.
                                                 When 
                     '[   105  ]
   When compreffion has not been applied to fuch tumors,
unlefs  there is a very unufual degree of laxity in the fur-
rounding  parts, the fwelling  increafes in a gradual man-
ner ;  but it does not  become  much more prominent,
rather  diffufing itfelf among the adjacent parts; by de-
grees it acquires  a very firm confiftence and the pulfa-
tion, which  was at firft  confiderable, always diminifhes in
proportion to  the hardnefs and fize  of the tumor, info-
much that it is fometimes fcarcely perceptible.
   In the  firft  flages, if the  blood thrown out  lies very
deep, the fkin  preferves  its natural appearance,  and does
not change its colour till  the  diforder is  much advanced.
It frequently happens however,  that  the blood is thrown
out at  firft with  fuch violence,  as to get into immediate
contaa with the  fkin,  and change it to a  livid  colour;
and in fome inftances,  either  from the  quantity extrava-
fated, improper  treatment, or negligence, a mortification
has been induced.
   As the tumor increafes, the  patient,  who  in the firft
ftage did  not  complain  of much uneafinefs, is  diftreffed
with fevere  pains, fliffnefs, want  of feeling, and immobi-
lity of  the whole member;  and thefe fymptoms continuing
to augment, if the tumor is not  previoufly operated upon,
the teguments  at laft burft; and when the artery is of con-
fiderable fize,  and we do not have immediate recourfe  to
means  to prevent it, death muft certainly be the confe-
quence.
   A variety of caufes may  be  produaive  of the  diffufed
aneurifm.
   1. Violent bodily exertions may  be confidered as the
mofl frequent  origin of  the rupture of arteries internally
fituated; but thefe cafes do not  come properly under our
confideration in this  place.
   2. The corrofive matter  of fores and abfceffes by en-
                        O                       tirely 
                    [   106  ]
tirely deftroying the coats of arteries, may occafion this
fpecies of the difeafe.
  3. The fharp fplinters  of  a fraaured bone being pufh-
ed into a neighbouring artery, have produced aneurifms.
  4. Violent blows  have been known to bring on aneu-
rifms.  This can  fcarcely happen  in  any other fituation
than on the head ; on account of the arteries being there fo
particularly expofed, and lying fo near a firm bony fubftance.
  5. It has been affirmed by refpeaable authority, that
diffufed aneurifms have  been produced, although rarely,
by the arterial  coats burfting before  the teguments with
which they are  covered in cafes of  the encyfled fpecies.
  6. The moft frequent  caufes are punaures with fharp
inftruments,  as fwords and curlaffes, but particularly the
lancet: which laft may be confidered as having been pro-
duaive of nine-tenths of all  the aneurifms that ever have
occurred.
  It has  happened,  in many inftances, that aneurifms have
been miftaken for abfceffes and other colfeaions of matter;
have been opened ;  and death has  been the confequence.
Swellings of this  kind are fometimes with much difficulty
diftinguifhed from fome others.  In the beginning of the
difeafe, the pulfation and other eircumftances charaaerife
it fufficiently; but in an advanced  ftage, when the tumor
is very confiderable, and  has loft its pulfation entirely, no-
thing but a very  minute attention to the previous hiftory
of the cafe,  can  enable  us to form a judgment of its na-
ture.
   Thofe fwellings  with  which aneurifms  are mofl likely
to be confounded,   are  foft encyfled or  fcrophulous tu-
mors and abfceffes,  fituated  either immediately above, or
fo nearly in contaa with an artery,  as to receive the influ-
ence of' its pulfation ;  which is often communicated in a
very  confiderable degree when the artery is large.  But
there i s  one fymptom,  which, when  it occurs, and  is
                                             conneaed 
                      [  107  ]
conneaed with a ftrong pulfation in the tumor, may cer-
tainly determine the difeafe to be an aneurifm ;  viz. the
contents of the  tumor being  made to difappear with eafe
upon  preffure at the fame time that they return  inflanta-
neoufly  on the compreffion being removed.  This  fymp-
tom,  however,  cannot attend when the contents  of the
fwelling have become  hard  and firm.   Upon the  whole,
therefore,  as in many inftances  the nature of the  difeafe
cannot  be with  certainty afcertained, the  praaitioner
fhould always,  in  fuch doubtful cafes, proceed upon the
fuppofition of its being aneurifmatic.
  It is only in  the trunk of the body, in the neck, axilla,
upper part of the thigh, or groin, that fo much caution is
neceffary;  for when tumors  of this nature are feated on
the lower  part of the extremities,  or on the head, we may
with  fafety open them ; becaufe if they fhould chance  to
be aneurifms, there will be no danger in  removing them
in the mode hereafter recommended.
  In  forming  a prognofis in aneurifms, we muft  chiefly
attend 1. To the manner in  which  the difeafe appears  to
have been produced.  2. The part  of  the body in which
it is fituated ; and,  3. The age,  and habit of body of the
patient.
   1.  If an aneurifm has  come on  in  a gradual manner,
without any  apparent injury having been done to the
part,  and  without any violent bodily exertion having im-
mediately  preceded it, there  will be great reafon to fup-
pofe that the difeafe depends upon fome paralytic or other
general affeaion, either of the trunk of the veffel in which
it occurs, or perhaps of the whole arterial fyftem ; fo that
no great fuccefs is to be expeaed from any means attempt-
ed for the patient's relief: whereas, there will  be room
to fuppofe, if  the  tumor has  evidently  fucceeded  to  a
bruife or other  external accident, that  the operation will
be attended with complete fuccefs,  provided the ligature
                                                    to 
                      [   108   ]
to be made, does not entirely deftroy the circulation in the
part.
  In  the varicofe aneurifm, we  may generally venture to
make a more favourable prognofis than in any other fpe-
cies of the difeafe;  for it has been  found in  different in-
ftances, that this does not make fo rapid a  progrefs as the
others; that  after acquiring a certain  fize, it does not af-
terwards grow much larger ; and that any inconvenience
produced by it,  may  be fuftained with tolerable eafe for
many years.  Drs.  Hunter,  Cleghorn, Pott,  and others,
relate  inftances  that  confirm  thefe eircumftances, and
prove  that the  operation can very feldom be neceffary to
remove this variety of the difeafe.
  2.  When ah aneurifmal fwelling is  fo fituated, that no
ligature  or compreffion can be applied  for putting a flop
to the circulation in the part, if the artery is large, there
would be the utmoft hazard in opening it; as the patient
would probably lofe more blood than his ftrength  could
bear, before the  artery could be fecured.   Hence in aneu-
rifms fituated on the trunk, neck, axilla  or groin, we  can
never  make a favourable prognofis ; for  the tumor will
certainly at laft burft, and  the  mofl fatal  confequences
will probably enfue.   And in the humeral or femoral  ar-
teries  before their divifion, the fuccefs of the operation
will always be doubtful; although there  are  well attefled
inftances of  the limbs preferving nearly  all  their powers
after  the deftruaion  of the  principal  trunk.  In thofe
cafes, the circulation muft  be  carried on by the fmaller
branches, from their anaftomofing with each other.
   In aneurifms  of the extremities, as the fuccefs of  the
operations  depend,  in a great meafure,  on  the probable
chance there is for the circulation going on  in the  under
part of  the limb,  our prognofis fliould, all other eircum-
ftances  being alike,  be more  or lefs favourable according
to the lower or higher fituation of the difeafe—But when
                                                    they 
                      [  109   ]
they arife from an external caufe, other eircumftances be-
ing favourable,  it may  be eftablifhed as a general rule, that
they fhould be  always removed when the life of the pa-
tient might be endangered by the burfting of the tumor.
   3. The age and habit of body of the patient,  in every
inftance, fhould have confiderable influence in determining
the opinion of praaitioners as to the effeas to be expeaed
from the operation : for in  no  inftance does health and
youth give  greater advantages,  than in  the operation for
the removal of aneurifms.—In the earlier  periods of life,
the veffels can eafily accommodate themfelves to the chang-
es thereby produced ; but, in old age, we may readily fup-
pofe the fmaller arteries to be altogether incapable of that
degree  of diftention  which is neceffary for fupplying the
want of the principal artery of a part.
   A difference in thefe eircumftances may account for the
various fuccefs that has  attended  the operation  in  many
inftances where the caufes  and appearances were nearly
alike;  and  more particularly  for the bad fuccefs that has
followed the removal of aneurifms in the  popliteal  artery.


                    SECT.  II.

              Of the Treatment of Aneurifms.

   The ufe of preffure has  been indifcriminately recom-
mended in every fpecies of aneurifm, and in all their flages ;
but it  fhould never be employed in any period of the dif-
fufed aneurifm.  In the  early  flages of the encyfled, in-
deed,  while the blood  can  be preffed entirely out of the
fac into the artery, it  often happens, by the ufe of a ban-
dage of foft and fomewhat elaftic  materials, properly fit-
ted to the part, that much may be done in preventing the
fwelling from increafing ;  and on feme  occafions, by the
                                              continued 
                            L  HO   ]
    continued fupport thus given to the weakened veffel, com-
    plete cures have been obtained.   In the varicofe aneurifm
    more particularly, preffure is very ufeful.*
       It is to be obferved that  the  preffure  fliould  never be
    greater than to afford an eafy fupport to the parts affeaed;
    for if it is, by the reaaion which will be excited, it will
    do more harm than  good.  During the ufe of compreffion,
    the patient fliould be kept on a low diet;  when neceffary,
    blood  fhould be drawn ; the  bowels fliould  be kept lax ;
    and all violent exercife, particularly of the part affeaed,
    fhould be carefully avoided.   When there  is  much pain,
    opiates fhould be freely exhibited.
       This treatment will apply to every aneurifm not intended
    to be  operated  upon;  but is particularly  proper in  all
    fwellings  of this kind, fituated on parts where the opera-
    tion is inadmiffible.
       When the operation for the aneurifm is judged neceffary,
    the firft ftep to be taken in it,  is  to apply a tourniquet to
    the fuperior part of the member difeafed.   The patient
    fhould be  fixed  on a  table of fuch a height as will allow
    the furgeon to be feated.   The limb being properly fecur-
    ed by  an  affiftant,  the  operator is now  with a fcalpel to
    make  an incifion through the teguments,  beginning about
    half an inch above or  below  the fwelling, and carrying it
                                                        along

     * Aneurifms of the leg may fometimes be  cured by compreffion—two
   inftances have occurred, where the pofterior tibial artery was opened, and
 i  a large aneurifmal fac formed in the ufual way—the operator having fully
 .'  dilated the fac, and  cleared it of coagulated blood, applied a fmall bit of
i  fponge fixed to the extremity of a ligature, to the orifice in the artery;
   then, filling the wound completely with dry lint, continued a compreffion
   with the hand during twenty-four hours, after which, compreffion by a
   pretty clofe bandage, prevented any further hemorrhagy,  and the eighth
   day the lint was removed : the fponge adhering two or three days longer
 j  and coming away with fome difficulty, induced the operator, in a fecond
   inftance, to make ufe of lint alone.   The wound was filled up in three
   weeks, and the man preferved the perfect ufe of his limb. 
                        C   in   ]
•along the whole courfe of it, and about half an inch be-
 yond it.   The  blood fhould then be wiped away, and the
 fofteft  part of  the  tumor  being difcovered,  an opening
 ought to be made into it with a lancet large enough for
admitting the  operator's  finger; which being introduced
 into  the orifice,  the whole tumor is to be laid open by
 running  a  blunt-pointed biftouri along the  finger, firft
 from below upwards, and then from above downwards.
   All the coagulated  blood  and tough membranous fila-
 ments that are commonly found here, being now removed
by the  fingers of the operator, the cavity is  to be well  dri-
 ed ; the tourniquet muft then be entirely loofened,  in or-
der to difcover the orifice  from which the blood has flow-
ed.   This being done, we muft next  prevent  any  farther
 effufion.   Various  means have  been propofed to accom-
 plifli this.   In order more effeaually to preferve a free cir-
 culation of blood in the inferior part of the member, it has
 been recommended, 1. To apply  a piece of agaric,  vitriol,
alum, or other aftringent, to the orifice, in order if poffible
 to produce a re-union of its fides; and 2. To make ufe of
 the twifled future, with the fame intention.*
   To the firft  of thefe methods  it  may  ot  objeaed, that
no aftringent with which we are acquainted, is poffeffed
                                                        of

   * Mr. le Comte,  in wounds of the arteries, inftcad of the ufual modes,
from experiments on  fheep and dogs, recommends the introduction  of
a quill fplit  and covered with riband, in fuch a manner as to include the
whole artery ;  and to  fecure it  by tying the ends of  the riband—Mr.
Vicq d'Azyr made  fome  experiments in  prefence of his pupils on the
crural arteries of dogs, to afcertain the effects of this treatment.  A good
deal  of inflammation  and  difcharge wa9 produced—the apparatus was
removed with fome difficulty in about three days; and the wounds healed
in about fifteen—In three inftances the cavity of the artery was entirely
obliterated, yet the animals did very well.  In fome others, the circula-
tion was well carried on afterwards through the arteries.
   In every cafe, the  hemorrhagy was entirely reftrained, immediately
to tying the ribands.  Hift. de la Soc. Roy. de Med. torn. I. page 302- 
                        C   112   ]
   of  fuch powers  as  to deferve much confidence ;  for al-
   though they have often put a temporary flop to fuch he-
   morrhagies,  yet  there  are very few well authenticated
   inftances of their having produced  any permanent advan-
   tage ;  and when trufted  to, they  have generally given  a
   great deal of diftrefs to the patient  and trouble to the fur-
   geon.
   With refpea  to  Mr.  Lambert's ingenious propofal of
   Hitching the orifice in the artery,  it would probably fuc-
1   ceed  in reftraining the bleeding; but it is evident  that it
   could not be employed when the artery lies at the back
   part of the tumor, which is the cafe almoft in every in-
   ftance.  And by  the diminution of the cavity of the artery
  which it muft neceffarily produce, there is every reafon to
  fear that it muft tend very much to  the produaion of a
  dilatation immediately above the ftriaure.
    This mode has yet been employed but in  one cafe, that I
  know of:  the above objeaions  arife merely from reafon-
  ing on the fubjea ; its utility muft therefore be decided by
  future obfervation.
    Neither of the abovementioned  methods being  found
  eligible, we now proceed to defcribe the ordinary manner
  of fecuring the orifice in the artery by means of ligatures.
    A fmall probe being  introduced at  the opening in  the
  veffel, and the artery thus raifed from the adjacent parts in
  order to avoid the nerves,* a firm,  broad, waxed ligature
I muft then be paffed round, about the eighth  of an inch
I  above  the orifice, and another  at  the  fame diftance be-
|  low it by means  of  a  blunt curved needle, plate viii. and
  tied in the mode formerly direaed in chapter V.
    We direa the ligatures to be made as near as poffible to
  the  orifice for fear  of  lofing the  benefit of anaftomofing
  branches.   And  we advife a blunt needle,  becaufe when
                                                      the
   * It will facilitate this part of the operation,  when  the difeafe is on  a
  joint, to bend the limb. B. 
                      [   113   ]
the fharp-pointed needle is ufed, there is a rifk of injuring
parts unneceffarily, and the  operation is performed with
more difficulty.
   After the upper ligature is made, the tourniquet fhould
be loofened, in order to  fee  whether any blood will be dif-
charged by the  wound  in  the  artery.   If it flows  in any
confiderable quantity, it affords  a  proof that the circula-
tion will be tolerably well carried on, by the fmaller branch-
es, in  the  inferior part of  the limb.   But/we are not to
defpair of fuccefs if this fhould  not be the cafe.
   The ligatures  fliould be left long enough to hang out at
the edges  of  the wound,  that they may be eafily with-
drawn when neceffary.
   It has been  advifed to infert  two other  ligatures very
near to thofe firft made, and leave them untied, in order to
guard  more effeaually againft hemorrhagy ;  but the tour-
niquet  is  a  fufficient  and  better  fecurity, and  fhould
always  be left on  the  member  for feveral  days after  the
operation.
   When the ligatures  are  formed, the tourniquet fhould
be loofened entirely; and if no blood is then difcharged
at the  orifice in  the artery,  we may be fatisfied that they
have been properly  made.  The wound is to be now co-
vered with foft lint,  with a  pledget of fome emollient oyer
it; and  a comprefs being  applied, the whole  is to be
fupported by a bandage, juft tight enough to keep  on  the
other applications.
   The  patient  is then to be put to bed, and the member
laid in a relaxed pofture upon a pillow ;  and as the ope-
ration  is always  tedious and painful, a  full dofe of lauda-
num  fhould be given, and repeated occafionally according
to the  degrees of pain and reftlefliiefs.
   In fome cafes, the pulfe in the inferior part of the mem-
ber has been perceptible immediately after the operation:
this, however, is a rare  occurrence; for as  the  difeafe is
feldom met with but in the joint of the elbow, as a confe-
                         P                      quence 
                      [  114   1
quence  of  bleeding, and  as the brachial artery before its
bifurcation, is moft commonly the fubjea of the operation,
it can but rarely happen.
  Immediately after the operation, the  patient complains
of want of feeling in the whole member;  and as it is gene-
rally cold for a few hours afterwards, it will be proper to
keep it  covered with flannel, and  have it  gently  rubbed
now and then.  In the fpace of ten or twelve hours, al-
though  the nu'mbnefs ftill continues, the heat of the parts
generally begins to  return;  and it often happens that in
the courfe of a few  hours more, all the inferior part of the
limb becomes preternaturally warm.
  In the mean time, the patient being properly attended to
as to regimen, by giving him cordials and  nourifhing diet
when low, and confining him to a  low diet, if his conftitu-
tion is  plethoric, the limb being kept in an eafy pofture,
towards the end of the fourth or fifth day, and fometimes
fooner,  a very feeble pulfe is difcovered  in the lower part
of the member ; which becoming gradually ftronger,  the
patient  in the fame proportion recovers the feeling  and ufe
of the parts.
   As foon as matter forms freely about the fore, which is
generally about the fifth or fixth day, an  emollient poul-
tice fliould be applied over it for a few hours, to foften
the dreffings, which may then be removed.  The ligatures
 fhould  not be taken away before the fecond or third dreff-
 ing.    The  dreffings  being  renewed  every fecond  or
 third day,  according to the quantity of the difcharge, the
 fore  commonly heals eafily ;  and although the limb may
 remain fome time numb and weak, yet it generally at lafl
 recovers its powers.
   We  have hitherto defcribed the mofl favourable termi-
 nation  of the operation—In  fome inflances, inflead of a
 return  of circulation, and of the  feeling and  ufe of the
 parts,  they  continue  cold and infenfible.   From  mere
                                                   want 
                      [  115   ]
want of blood, therefore, a mortification commences, and
proceeds to its laft flages, notwithftanding every thing that
can be done to  prevent it.  If the patient furvives the ef-
feas  of the gangrene until  a  feparation occurs between
the difeafed and healthy parts, amputation of the member
will then be the only refource.
CHAP.     VIII.

        Of Hernise.
                   SECT.  I.

                 Of Hernia in general.

     THE  term Hernia,  in  its general acceptation, im-
      plies a tumor  produced by the protrufion of fome
part or parts from the cavity of the abdomen.
  The fituations in which thefe fwellings ufually appear, are
the groin,  fcrotum,  labia pudendi, the upper and fore-
part of the thigh, the umbilicus,  and the  different points
between the interftices of the abdominal mufcles.
  Part of the inteftinal canal or omentum,  are the moft
common contents  of hernise ; but  there  are inftances of
ruptures  of  the  ftomach, uterus, liver, fpleen, and blad-
der.
  From thefe eircumftances of fituation, and contents,  all
the different appellations are derived by which hernise are
diftinguiftied.   Thus they  are termed inguinal, fcrotal,
                                              femoral, 
                       [  116   ]
 femoral,  umbilical,  or ventral, from the part in which
 they make their appearance.  When the tumor is confin-
 ed to the groin, the hernia is faid to be incomplete, and is
 termed bubonocele; but  when  it reaches to the  bottom
 of the fcrotum, it is faid to be complete, and receives the
 name of ofcheocele.   When a  portion of inteftine alone
 forms the tumor, it is called an enterocele or inteftinal her-
 nia ; when a piece  of omentum only is protruded, it is
 termed epiplocele, or omental hernia; and if both inteftine
 and omentum are down, it is called an entero-epiplocele, or
 compound rupture.
   The  term rupture arofe from a fuppofition that in mofi
 cafes of hernia there was a laceration of the peritonseum,
 or membrane furrounding the abdominal vifcera ; and this
 feemed to be confirmed by thefe vifcera being, in fome cafes
 of fcrotal hernia, found in contaa with the tefticle ; but it
 is now  well afcertained,  that in hernia the peritonseum  is
 never ruptured except from  external violence ;  and that
 in common cafes it is merely carried before the protruded
 part, and only fuffers from  dilatation.   When the  part
 difp!?ced is  found in contaa with the teftis, it always paf£-
 es down along  with the  teftis, or before the opening by
 which that defcends is at all or firmly clofed.   This fpecies
 is ufually termed  the  hernia congenita,  and hardly ever is
 produced except in the early months of infancy.
   The  produaion  of hernia  in the  ufual form, is to be
 explained from one or  more of the  following  eircum-
 ftances :
   1.  Whatever tends to  produce a diminution of capacity
 in the cavity of the abdomen, muft occafion a proportional
 rifk of fome of the contained parts being pufhed from their
 natural  fituations.  Violent coughing, crying, laughing, or
 great bodily exertion,  frequently operate in this manner in
producing hernise.
   2.  Falls,  in  confequence of  the  violent derangement
                                                  thev 
                       C   117  ]
 they produce in the  abdominal vifcera, are often the im-
 mediate caufes of ruptures.
    3. Perfons of a preternatural laxity of frame, are very
 liable to hernise, on the application of the abovementioned
 caufes ; from the containing parts  not being fufficiently
 firm to refift the weight of the different vifcera.
    4. Sprains induce a laxity of che part injured, and ope-
 rate in  the manner of general weaknefs in  occafioning
 hernise.
    5. It has been obferved, that  the  inhabitants of thofe
 countries in which oil is much ufed as an  article of diet,
 are particularly liable to hernise.
   Thefe various caufes, it is evident,  muft  moft  readily
 operate in inducing hernise, in thofe parts of the parietes
 of the abdomen that are weakeft.  Hence we find them to
 occur moft commonly at the openings  of the external  ob-
 lique mufcles, under the  arch  formed  by Poupart's liga-
 ment, and at the umbilicus.  They  happen alfo in the in-
 terftices of the mufcles, but not frequently.
   Whenever an hernia is formed, except in the cafe  of
 the hernia congenita, a portion of the peritonseum muft
 go along with  the  protruded vifcus, and forms what has
 been termed the hernial fac.
   On the  firft appearance of the  difeafe, the fac is com-
 monly fmall, as fuch fwellings feldom  acquire any great
 bulk at once ; but by repeated defcents of the bowels, it
 often becomes  very large;  and then  frequently gets a
 very confiderable degree of firmnefs and thicknefs.
   Hernial fwellings frequently  arife and continue a length
 of time, without occafioning  any bad  fymptoms ; but as
 troublefome confequences   often fucceed to  them, v/hen
 their reduaion  can be accomplifhed  with  propriety,  it
 fhould always be effeaed as quickly as poffible.
   All the bad fymptoms occurring in hernias, proceed  ei-
ther from obflruaion to the  paffage  of the  fseces,  when
                                                   the 
                      L   us   ]
the inteftinal canal forms the tumor, or from a ftoppagc
of circulation, by ftriaure on the prolapfed  parts : hence
they will always be more or lefs hazardous according to
the nature of the  parts protruded.    Thus  an  omental
hernia is not fo  dangerous as a rupture of an inteftine, or
other part more effential  to  life ; but even this may occa-
fion the moft fatal effeas.
   The following are generally the fymptoms of a ftric-
ture  on the  protruded vifcera fufficient to produce either
a ftoppage of the circulation, or  of the fsecal contents of
the alimentary canal, when this is affeaed.
   An elaftic colourlefs fwelling is obferved on the part af-
feaed ; a flight pain is felt not  only in the fwelling itfelf,
but if part of the inteftines is down, an  uneafinefs is felt
over the whole abdomen; and this is always increafed by
coughing, fneezing,  or any  other  violent  exertion.  The
patient complains of naufea  ; frequent retching ; can get
no difcharge by  flool ; becomes  hot and reftlefs; and his
pulfe is commonly quick and hard.
   If the fwelling is  entirely  formed by inteftine, and no
fseces are contained  in it, it has a fmooth equal furface, is
eafily compreffible, and immediately returns  to its  former
fize on the preffure being removed ; but when fseces are
colfeaed in the gut, as  they are apt  to be when  the
difeafe is of long Handing, it has confiderable inequalities.
When the tumor is compofed  both  of omentum  and
gut, its appearance is always unequal, and it  feels foft and
fomewhat like dough, and of courfe not fo elaftic as when
inteftine  alone  is down.   If omentum  alone  forms the
fwelling, no obftruaion  to  the difcharge of fseces  ever
occurs, and of courfe the fymptoms are never fo alarming
as when trie  inteftine is concerned,  and the   tumor is
weighty in proportion to  its  fize.
   But although in fimple hernise the contents may be in
general diftinguiftied ; yet, when they are complicated, it
can never be done with any  certainty.
                                                Should 
                      [   119  ]
   Should not the fymptoms  we have  defcribed be now
removed,  the naufea and  retching terminate in frequent
vomitings, firft  of  a bilious,  and afterwards of a more
foetid  matter ; the  belly becomes tenfe ; the pain grows
more violent; a diflreffing convulfive hiccup  comes on ;
the fever,  which before was trifling, now becomes con-
fiderable ;  and a total  want  of  reft, and great anxiety
continue through the whole complaint.   Thefe fymptoms,
after fome duration,  are fucceeded by a fudden ceffation
of pain : languid and interrupted pulfe ;  cold fweats ; lan-
guor  of the eyes ; and fubfidence  of the tenfion of the
belly.  The fwelling of the affeaed parts difappears ;  the
teguments covering  them change from  a reddifh inflamed
cafl to a livid hue ;  and a  crepitous windy feel  is  diftin-
guifhable all over the fwelling.
   If,ihe protruded  parts have not of themfelves entirely
gone up, their return is now generally with eafe produced
by flight preffure, and the  patient then  difcharges  freely
by ftool;  but the cold fweats increafing, the hiccup be-
comes more violent, and death is at laft ufhered in  by its
ufual forerunners, fubfultus tendinum,  and other convul-
five affeaions.
   As the ftriaure which prevents the  return of the pro-
truded parts is the caufe of all the morbid fymptoms, the
indication  of cure  is to effea  its removal.  This is to
be accomplifhed either by a  reduaion of  the  difplaced
parts  without ^  divifion of the ftrangulating part, or by
an incifion into or through the part  producing  the ftric-
ture, fo as to admit  of  a  replacement  of the  fubftances
deranged.
  In the treatment of hernia,  the firft circumftance to be
attended to, is the placing the patient in fuch a poflure as
will probably  favour the return  of  the protruded  parts.
Thus v/hen the fwelling is in  the groin  or forepart of the
thigh, the thighs  and legs  fhould be raifed  confiderably
                                                higher 
                      [   120  ]
higher than the head and trunk ; and,  in  fome inftances
it has been found neceffary  to have the patient placed per-
pendicularly  upon his head, and there well fhook about.
In exomphalos, or umbilical rupture, the body fhould be
erea ; and in cafes of ventral hernia, a horizontal poflure
is to be chofen.
  While  the  patient is  thus  fixed, the  furgeon  fhould
endeavour to  produce a return of the parts, by  gentle
prefliire with  the  fingers.   In the inguinal  and  fcrotal
hernise, this  fhould  be  made obliquely upwards towards
the os ileum;  in the femoral, it fhould be made direaiy
backwards ;  in the umbilical, downwards and backwards;
and in the ventral hernia, direaiy backwards.
  When the hernia  is of confiderable fize, the preffure is
moft conveniently  and effeaually made, by grafping the
fwelling  with one hand from the bottom upwards,  while
with  the  fore and  middle  fingers of the  other hand, we
endeavour to pufh  up the contents  of  the tumor.  This
operation has been termed taxis.
  If a very moderate degree of preffure,  for none  other
fhould ever be applied, does not reduce  the fwelling, other
means fhould immediately be employed.  Blood-letting ac-
cording to the flrength of the patient, is here particularly
ferviceable, and may fafely be carried to very great extent;
and it has fometimes been found ufeful to  manage it fo as
to induce fainting.
  To remove the obftinate  coftivenefs  that fo commonly
attends, it has been a general praaice to order ftimulating
purgatives ;  but thefe, in almoft every cafe, do much inju-
ry by increafing the naufea, and by adding to the tenfion
and pain of the fwelling.   The beft mode of opening the
body, is by injeaing clyfters of tobacco fmoke, by means of
the machine, plate v. fig. 8. until it  has  the defired effea,
or until much naufea is produced, or fome fwelling of the
abdomen.
                                             Although 
                       [   121   ]
    Although  this remedy frequently fails, yet it is  much
 preferable to purgatives given  by  the  mouth ; and if  it
 fliould not be laxative, it may always be ferviceable by the
 anodyne quality  which  it poffeffes.   Acrid  fuppofitories
 have been ufed at the fame time with  purgatives, but no
 great dependence fhould be placed on them.
    Opiates are often of great  ufe, not only by eafing pain,
 but by tending to relax the ftriaure.*   As their  exhibi-
 tion by the  mouth is commonly prevented by the naufea,
 they may be given clyfterwife,  alternately with the  tobac-
 co fmoke.   General warm bathing is  a  very ferviceable
 remedy ;  but warm applications to the fwelling do  injury
 by rarefying the contents  of the hernia, and thus increaf-
 ing its fize.
    The  applications on  which  I  place  moft  dependence
 are the cold faturnine folutions, and vinegar and  water ;
 with thefe  cloths  are wet,  and  kept  conftantiy  on the
 fwelline.  In feveral inftances I have  ufed ice and fnow
 with evident advantage.
    By thefe feveral means hernise are often entirely remov-
 ed ;  but it alfo frequently  happens  that they produce no
 relief;  and  the fymptoms  inftead  of leffening  become
 more violent.   In this fituation, the divifion of the parts
 producing the ftriaure is our only refource.
    It is one of the  mofl difficult points in furgery  to afcer-
 / tain when this operation fhould be put  in praaice.   If it
\ fhould be too long delayed,  the patient  will infallibly die ;
 and if  performed  too early,  we may be  fubjeaed  to
 blame.   There  are many inftances of ftrangulated hernise
 continuing  for eight or ten days, and being then replaced,
 the patient has done very well: whilft, on the other hand,
                          Q                        they

   * Several  cafes of ftrangulated hernia,  attended with great pain and
 tenfion, have been happily reduced  by  a ftrong opiate, without any ma-
 nual afliftance, the protruded parts retiring themfelves as foon as the opi-
 ate had produced fleep. 
                              [   122  ]
         they have proved fatal,  and when  apparently in  the fame
         degree, within forty-eight  hours.
           From hence, although  the  operation is attended with
         fome rifk, it may with propriety be eftablifhed as a general
.»'  ! v '''  rule always to proceed to it, if a ftrangulated hernia is not
         otherwife relieved in two or three hours at fartheft.
           The French furgeons feem to be more fuccefsful than
         the German or Britifh, entirely from  the  circumftance of
       (  their having more early recourfe to  the operation.
           Although in general  if  is proper  to reduce hernise as
         foon as poffible ;  yet there are fome inftances in which it
         would be  improper to attempt it.  Thus, hernise fome-
         times  continue a long time without producing any  bad
         fymptoms whatever, and contraa  adhefions to  the   fur-
         rounding parts, which can only be removed by the opera-
         tion.   In fuch cafes,  unlefs fymptoms of  ftrangulation
         come on,  nothing  more fhould be done than to keep  the
         bowels  lax, and apply  a fufpenfory bandage to the fwel-
         ling.
           Where a hernia has  been reduced either by taxis or
         divifion, its return  can only be effeaually prevented by
         the proper application of a  fteel trufs,  (plate vi. fig. AL)  and
         by avoiding violent  exercife, and particularly fudden  ex-
         ertions.
           Many years fince, there  were a variety of methods ufed
         to cure hernise radically, fuch as ligatures applied fo as to
         clofe the fac,  and cauflics to deftroy it;  but all of thefe
         have been  found ineffeaual  to  accomplifh the end  pro-
         pofed, and many of them have been fatal to the unhappy
         patients.
SECT. 
[  123   ]
                     SECT.   II?

                    Of the Bubonocele.

   In the bubonocele the fwelling begins in the groin, and
 gradually defcends into the fcrotum in  men, and into the
 labia pudendi in women.
   The difeafes  with which inguinal and fcrotal hernise
 are  moft likely  to be confounded, are glandular fwellings
 in the groin,  hernia humoralis  or  inflamed  tefticle,  and
 the different kinds of hydrocele.
   Buboes  are readily  diftinguiftied  from hernise by their
 hardnefs in the  firft ftage, and the fluauation of fluid in
 their fuppurated ftate, and by the abfence of the  general
 fymptoms of hernise.
   In hernia humoralis the hardened ftate of the tefticle
 and  epidydimis ;  their exquifite  painfulnefs to the touch ;
 the want of fwelling in the fpermatic procefs and of the
 general fymptoms of hernia, afford fufficient means of dis-
 crimination.
   In hydrocele the fwelling is more  equal than in hernia,
 and  ufually begins below; but in hydrocele  of the fper-
 matic procefs, it fometimes  happens  that the  tumor com-
 mences even  within the opening of the  abdominal muf-
 cle,  and by  degrees falls  downwards :  in this  cafe,  the
 abfence of the general fymptoms of hernia will generally
 eftablifh the nature of the  cafe.   But in  fome inftances, it
 feems impoffible  to afcertain with certainty the real ftate of
 the difeafe.   In  thefe eircumftances we can only proceed
with fafety upon the fuppofition of its being hernial.
  When  every  other  means recommended for the re-
moval of hernia  in general has  failed in bubonocele, we
muft  then have recourfe to the operation ;  which is thus
to be performed:
                                                    A 
                      [  124   ]
   A table  of convenient height being placed in a  good
light, the patient muft  be  laid upon  it,  having the head
and body almoft horizontal, and the  buttocks fomewhat
raifed  by  pillows.   The  legs hanging  over the edge of
the table ought to  be fo far feparated as to admit the ope-
rator between them ;  and fhould be fecured by an affiftant
on each fide, who fhould keep  the  thighs fo much raifed
as to relax  all the abdominal mufcles.
   The patient fhould empty the bladder; and the parts hav-
ing previoufly been fhaved,  an incifion fhould now be made
with a  fcalpel through  the  fkin,  beginning  at leaft  an
inch above the fuperior end  of the tumor, and continuing it
down to the  bottom of the fcrotum.   This  fhould always
be done : it enables us to finifli the operation more conve-
niently, and  prevents a lodgement  of the  matter  after-
wards formed.
   The operator then goes on  to divide  flowly the cellu-
lar fubftance and the tendinous-like bands, which, unlefs
the difeafe  is very  recent, are univerfally met with, either
loofe upon  the furface of the hernial fac, or on fome occa-
fions, paffing as it  were into its fubftance.    Even this in-
cifion fhould be made very cautioufly, becaufe there are
fome inftances upon record, in which the fpermatic veffels
have been found on the anterior part of the fwelling,  al-
though they are almoft always behind it;  and we would
run a rifk of wounding them, fhould this be  the cafe, by a
hafty incifion.
   Before making the  divifion of the fkin and cellular fub-
ftance, the  tumor fhould be grafped with the left hand, fo
as to render it  fomewhat tenfe on the anterior part, and
kept fo while the incifion is made with the right hand.
   The hernial fac fhould now  be very  cautioufly diffeaed
through, as near the lower part as poffible, becaufe that is
generally filled with  bloody ferum, and we confequently
there  have the leaft  chance of wounding  the inteftine.
                                                  We 
                      [   125   ]
Wc may tell when the fac is cut through by a blunt probe
paffing eafily in.  The fac in recent cafes,  and  particular-
ly of bubonocele, is thin,  but in long continued hernise,
it often acquires an aftonifhing thicknefs.
  The opening firft made being enlarged fo as to admit
the fore-finger, a narrow blunt-pointed bifloury, (plate
vii. fig. 9.) fhould be introduced, to which  the finger ferv-
ing as a  direaor, the hernial fac is to be divided its whole
length, from below quite up to the opening in the mufcle.
   The protruded parts*  now come fully into  view; and
fhould be very carefully examined ; if they are not gan-
grened, even  although they fhould  feem  confiderably in-
flamed,  they  fhould, if poffible, be immediately returned
into the abdomen.
   In making  the reduaion, whether inteftine,  omentum,
or both have been found, thofe parts which appear  to
have come out laft  fhould be firft pufhed back ; and the
 finger fhould be  applied  to  that part of the  gut  with
 which the mefentery is conneaed; as by thefe precautions
 we are lefs liable to do mifchief, and accomplifh the reduc-
 tion with more facility.   During the reduaion, the thighs
 fhould be fomewhat more  elevated than during the pre-
 vious part of the operation.   When the difeafe is recent,
 and has not often  occurred, it  fometimes  happens that by
 pulling  out a little  more of  the gut  than was before in
 the fac,  the obftruaion to its replacement will  be remov-
 ed ;  however, when we cannot do this with great eafe, it
 fhould not be attempted.
    If our attempts  for reduaion of the  part fail, we muft
 proceed then to the enlargement  of the opening  in  the
 tendon.   This is  to be performed by entering the  finger
  at the  opening above  the protruded  parts,  introducing
                                                     the

   * In entcrocele, late  obfervations have taught us, that the coecum, ap-
I pendix vermiformis, and part of the colon, have  as  frequently been con-
* tained in herniary facs as the ileum or any other part of the tube. 
                      [  126  ]
the blunt biftouri, and the finger ferving as a direaor, and
being kept a little beyond the point of the inftrument, a
free incifion fliould be made obliquely upwards,  fo  as
merely to  continue  the feparation in the fibres of the ten-
don, without dividing them.
   It often happens in  long continued  cafes,  that  adhe-
fions not  only  of the protruded  parts to thofe adjacent to
them take place, and  to  each other,  but  alfo  that they
are difcovered by the introduaion of the finger, internal-
ly.   The  opening  fhould therefore be  large  enough  to
admit a feparation  of the latter.   When adhefions of the
parts  deplaced  to each other occur,  if flight, they fhould
be feparated by the fingers or the fcalpel; but  if confider-
able, the parts fhould be returned as they are.  When ad-
hefions of the inteftines to the  fac or omentum are found,
and are very firm,  parts of the  latter two  may be with
fafety diffeaed  off; or  when there is a firm  conneaion
between the gut and fac, or  omentum and fac, part of the
fac may be  fafely diffeaed off, and returned into the ab-
domen.
   When  the  omentum  protruded  is  gangrened, or  by
the preffure  it has fuftained in  the fac any confiderable
portion  of it becomes  much hardened, fuch part fhould
be expanded on the hand, and cut off with a pair of fcif-
fors;  and if any confiderable veffel is  divided, it fhould
be tied.  It has been obferved that ligatures on the omen-
tum, as formerly recommended,  have  been produaive of
bad confequences;—none fuch have fucceeded the return
of it without them.
   When a part of the  inteftine is difcovered to be morti-
fied, it fliould be cut out; and if this does not extend the
whole circumference of the  gut, the part above it fhould
immediately  be  conneaed by ligature to the wound in the
abdomen.    By this means, the  fseces will be difcharged
externally, and  in  fome inftances the wound in the intef-
                                                  tine 
                      [   127   ]
tine  has  gradually  healed.  Where the  mortified part is
confiderable, the found ends of  the gut fhould if poffible
be brought into contaa,  united as direaed in the chapter
on gaftroraphy, and both conneaed to  the wound.  In
fome  inftances where a very confiderable portion, a foot
e. g.  has been gangrened, by this  mode the ends of the in-
teftine have coalefced, and the patient has done very well.
But  fhould not this  fortunately happen,  a paffage is fe-
cured to the fseces by the groin :  the confequence of their
being voided internally would inevitably be death.
  When the found inteftine is conneaed to the wound, and
not till then,  the opening in the tendon fhould be enlarged
as much  as is neceffary ;  if it is done before, the mortified
portion may  flip up together with the found part.   When
the fac is found to be thick, hard, and much enlarged, as
its prefervation can anfwer no good purpofe, all the late-
ral and fore parts of it may be cut off with fafety;  but the
pofterior part fhould  be  fuffered to remain, becaufe it is
commonly conneaed  to the fpermatic veffels.
   The operation being now finifhed,  the wound  is to be
dreffed with  foft lint, retained by a fufpenfory bag ftuffed
with lint, and the patient put to bed ;  taking care  that his
loins be  fomewhat higher than the reft of the body.   An
opiate fliould then be  given ; he fhould be kept cool; if ple-
thoric, in  order  to remove the fever  which fuccee,ds,  he
fhould be bled ; a low diet fhould be direaed ; and a fre-
quent ufe of laxatives. When, however, the body has been
previoufly  much  debilitated,  a nourifhing diet fhould  be
advifed.
   The fore having eafy dreffings applied to it as often  as
feems neceffary, and  the proper  diet,  Sec. being attended
to, if the  patient furvives the firft three or four days, he
will in general recover.   And as  foon  as  the  wound is
well cicatrized, a trufs  ought to be properly fitted to the
parts, and worn conftantly afterwards.
                                                     It 
                           [   128  ]
        It has been recommended to flitch the external Wound;
      but as this may prevent the difcovery of protrufions of the
      inteftine, which are apt to occur during the cure, it ought
      never to be done.
        It has been advifed by many French furgeons to endea-
      vour to reduce the inteftine, &c. without dividing the fac ;
      but although, if this is praaicable,  we  might in fome in-
   /   fiances do  right, in many  others  we fliould probably
*  (   return mortified parts,  which  would certainly be follow-
      ed by death.   And befides, there are fome cafes in which
   I   the ftrangulation has been produced by one part of the in-
      teftine  being wound  around another, as the appendicula
      vermiformis around the ileum ; when it  is obvious no
      good effeas could refult from the operation.
        By fome authors again, it is recommended to reduce not
      only the bowels, as juft defcribed, but even the hernial fac
      itfelf, without opening it: by  others, among  whom is
      Mr.  Pott,  this is deemed impoffible.   But I have feen a
      hernia of five or fix days duration in which it certainly oc-
      curred ;  the patient died,  and diffeaion  put it beyond a
      doubt.    Mr. le Dran relates inftances of the fame kind.
      The fame objeaions occur to this  praaice  that  operate
      againft returning the inteftines  without  examination of
      them.
        Although bubonocele happens moft frequently in males,
      yet it fometimes alfo takes  place in females;  and in fome
      cafes, the protruded part has defcended to the bottom al-
      moft of the labia pudendi.    The general method of treat-
      ment is the fame in both fexes.
        In modeft women, this difeafe fometimes occurs to con-
      fiderable  degree without our being made acquainted with
      it;—it fhould always be fufpeaed when the  fymptoms of
      colic occur  to a  very  alarming degree, and examination
      fhould be made to afcertain it.

                                                   SECT. 
[  129  ]
                   SECT.  III.

                Of the Hernia Congenita.

  The treatment of this fpecies of hernia, in general ac-
cords with  that of common bubonocele.  In laying  open
the parts, when  the  operation is  advifable, great caution
is neceffary, as the thin vaginal  coat  of the teftis forms
the hernial fac.   And in dreffmg  the  wound, the  vaginal
coat fhould be brought to cover the teftis ;  and great care
fhould be taken to avoid irritating dreffings,  and long ex-
pofure to the air.


                   SECT.  IV.

             Of the Crural or Femoral Hernia.

  The feat of this fpecies of hernia is the upper and an-
terior part of the thigh, under the firm tendinous aponeu-
rofis of the fafcia lata;  the parts being protruded through
the opening by which the femoral  artery and  vein pafs
out.  In fome inftances they  are found immediately over
thefe veffels; in others on the outfide of them; but more
frequently they  lie on the infide,  between them and the
os pubis.
  The fame general treatment that was  recommended in
inguinal hernia is applicable here ;  but it muft be obferved
that the preffure in reduaion fhould be made direaiy up-
wards.
  In performing the operation, the  external incifion fhould
extend from an inch above to an inch below the tumor : and
when all the  parts  above the ligament  are  divided,  if
thofe protruded are to be returned,  their reduaion  may
                        R                        here 
                     [   130  ]
here be often accomplifhed without cutting the ligament,
by  placing the  patient in a favourable poflure.   This
fhould therefore be  always attempted;  for it is almoft
impoffible to make a free divifion  of the ligament in any
direaion, without wounding the fpermatic veffels and epi-
gaftric artery ;  and it  is by no means fo eafy a matter to
fecure the latter as has been reprefented.   On this account
an inftrument (pi. v. fig. 7.) has been invented for dilating
the opening;  but this probably would feldom be of any
ufe, becaufe the ligament, it is to be fuppofed, is ftretched
nearly as much as poffible by the protruded parts.
  I have once ufed a method which anfwered very effec-
tually, and was without the rifk of the  mode  commonly
advifed.   It confifted in gradually diffeaing the  ligament
until a very thin lamella only was left; which then admitted
of a fufficient diftention to fuffer the return of the  deplaced
parts.  I guarded the parts below by infinuating my fore-
finger into  the opening  between the gut and ligament, and
then made  my incifion,  which was about  an inch long.
  In this as well as every  other cafe of hernia,  except bu-
bonocele, it is better to  ufe an adhefive plafter to  retain
the  dreffings than any bandage.
  Women  are moft fubjea to femoral rupture ;—they are
relieved in the manner above direaed.


                   S  E C T.  V.

         Of Exomphalos,  or Umbilical Rupture.

  The parts in this rupture  pafs  out  at the navel;  its
contents are very various  ;  moft commonly they con fill of
omentum ;  fometimes of inteftine ; and in fome inftances of
part of the ftomach, the liver, and even the fpleen.  The
fac becomes fometimes fo conneaed with thefe parts, that
                                               doubts 
                      C   131   ]
doubts have been entertained of its exiftence ; but it is al-
ways very evident  in recent cafes.  The fac  and integu-
ments have been in fome inftances burfted by the contents.
  Umbilical hernia occurs moft frequently in infancy, foon
after birth ;  of adults,  the corpulent are moft liable to it,
from the greater pervioufnefs of the umbilicus in them, pro-
duced by the conftant diftention of the abdominal mufcles;
and for the fame  reafon  pregnant women, in  the latter
months, are particularly fubjea to it.
  A proper bandage  or trufs will generally be  effeaual
in preventing returns of this hernia : and pregnant women
fhould be particularly attentive to it on its firft appearance,
as their particular fituation has  a tendency to render it
worfe.
  As  omentum commonly forms  hernise  of this  kind,
they are feldom produaive of dangerous fymptoms:  but
when thefe occur,  and cannot be  removed without,  the
operation muft be had recourfe to  as in other cafes.   The
divifion of the part producing the ftriaure  may be fafely
made  in  any  direaion; but thofe who  wifh  to  avoid
wounding the  umbilical ligament or former veffels,  may
make  it on  the left  fide, a little  upwards and outwards.
In other eircumftances we muft proceed as in other cafes
of hernia.


                   SECT.  VI.

                  Of Ventral Hernia.

   In  this fpecies of hernia  the parts  are  protruded
into the interftices of the abdominal  mufcles.   It occurs
in every part of the  abdomen,  but moft frequently  near
the linea alba ; and  when the ftomach forms the fwelling
                                                     it 
                     [   132  ]
it appears juft under, or by the fide of  the  xiphoid carti-
lage.
  The treatment recommended for the exomphalos is ap-
plicable to all ventral hernise.

                   SECT.   VII.

           Of the Hernia of the Foramen Ovale.

  The general mode of treating hernias is proper here,
except that inftead of dividing the ligament, which would
be attended with the utmoft rifk of  cutting fome large
veffel that it would be impoffible to  command, it will be
proper to attempt its gradual dilatation, by the blunt curved
hook (pi. v.  fig. 7.), when an operation is neceffary.
  The tumor is generally fo fmall that this difeafe is not
often deteaed from the appearance of fwelling, till it is too
late  to  apply an effeaual  remedy,  unlefs  pain and other
fymptoms of ftrangulated hernia occur to point  it out.
  In this rupture the tumor is formed in men near the up-
per part of  the perinseum, and in women, near the under
part of one of the labia pudendi.   In both fexes it lies up-
on the obturator extcrnus, between the  peainseus mufcle
and  the firft head of the triceps femoris, and paffes down
through the  foramen  ovale  by  the  fide of the blood vef-
fels  and nerves.

                   SECT.  VIII.

          Of the Hernia of the Urinary Bladder.

   The  hernia cyftica occurs  in the  groin  or fcrotum
 through the  opening  in  Poupart's  ligament;  in the fore
                                                   part 
                      [   133  ]
 part  of the thigh under  this ligament; in the perinseum
 through the mufcular interftices;  or in the vagina.  The
 part  of the  bladder  protruded, is  never  covered by the
 peritonseum.   It  fometimes is protruded by  itfelf, and at
 other times  is  accompanied  by inteftines and omentum.
 When complicated with  bubonocele, it  is found behind
 the hernial fac, and between that and the fpermatic procefs.
   This hernia is ufually known by a tumor attended with
 fluauation, which fubfides when the patient voids urine.
 When the fwelling is fmall, water is made without preffure;
 but if large, it is neceffary not  only to prefs it, but often to
 lift it up.
   A  fimple hernia cyftica  is commonly produced by a fup-
 preffion of urine.  In the treatment therefore, this fhould
 be guarded againft as much as poffible ; and when no ad-
 hefions take place, and the bladder can be reduced, a trufs
 fhould then be  worn for a confiderable time.  When the
 parts  cannot be returned,  a  fufpenfory bag is  the only
 probable means  of relief.   When the bladder falls into
 the vagina,  after reducing the parts by laying the patient
 on her back with the loins elevated and preffing with the
 fingers from the vagina, future defcents may be prevented
 by the  ufe of a  proper peffary:  and the fame means may
 be ufed when the inteftine protrudes into the vagina.
  When the operation is neceffary to remove cyftic hernise,
 the diffeaion fhould be very cautious, on account of there
 being no fac.
  It fometimes is  thought proper to cut  into the bladder
 in order to remove ftones  from the protruded  part; in this
 cafe, as well as when it is  accidentally wounded in the ope-
ration, or part of it has gangrened, it will be  advifable  to
preferve  its prolapfed fituation until the wound is healed,
 in order to prevent the evacuation of the urine internally,
which would probably have bad effeas.
CHAP. 
[  134  ]
CHAP.     IX.

  Of  the  Hydrocele.
                    SECT.   I.

             General Remarks on Hydrocele.

     THE term Hydrocele  is  applied to watery  fwellings
      fituated in the fcrotum or  fpermatic cord.
  Thefe,  as  well as every other fpecies of tumor in the
fcrotum or groin  not immediately produced by the pro-
trufion of parts from the abdomen, are by ancient writers,
termed falfe or fpurious hernise, in oppofition to  thofe de-
fcribed in the laft chapter, which they diftiaguifhed by the
appellation of true hernise.  This diflinaion is of no kind
of ufe ; and indeed nothing written on the fubjea of her-
nise until within a century paft,. is of much ufeful applica-
tion :  the difcoveries of late anatomifts and furgeons have
now, however, made it intelligible and fatisfaaory.
  All the varieties  of hydrocele may be  comprehended
under the two following fpecies, viz. the anafarcous  and
the encyfted.   In the former, the water is diffufed all over
the part affeaed;  and in the latter,  it is  confined to one
or more diftina bags, and a  fluauation of fluid is gene-
rally perceptible to the touch. The  fcrotum and its con-
tents, as well as the fpermatic procefs, are liable to both
fpecies of the difeafe.
                                            SECT. 
[  135  ]
                    SECT.   II.

        Of the Anafarcous Hydrocele of the Scrotum.

   This difeafe is ufually fymptomatic of general dropfy ;
 but in fome few inftances,  it is merely a local affeaion.
 Thus it has been the confequence of the preffure of a tu-
 mor on the  lymphatics of the part; of  external injury;
 and  of the  effufion  of urine  from  a  rupture  of the
 urethra.
   As foon as water is colfeaed in any confiderable quan-
 tity in the fcrotum, a foft, inelaftic,  and colourlefs tumor
 is obferved over the whole of it; this gradually increafes,
 and often extends up into the groin  and penis ; and dif-
 tends  the parts fo much as at length, in fome inftance?, to
 burft them.  After fome continuance the fkin acquires a
 whitifh fhining appearance;  and the largenefs of the fwel-
 ling is frequently produaive of a great deal of inconveni-
 ence and diftrefs.
   This difeafe is fo well charaaerifed, that there can be no
 danger of confounding it with any other.   As it common-
 ly depends on a general caufe, its radical cure  muft be ac-
 complifhed by  the  general  remedies of  dropfy;  but we
 are often under the neceffity of affording  a temporary re-
 lief, by evacuating  the fluid  of the particular  part.   This
 has  been done  in four different  ways ;  by feton, by the
 trocar, by incifions, and by punaures.  All thefe, except
 the trocar,  evacuate the water very effeaually ;  but  punc-
 tures have  the leaft troublefome confequences,  and  there-
 fore fhould be preferred.
   The trocar, feton, and fcarifications,  often  produce, in
 a little time after their ufe, eryfipelatous inflammation and
confequent gangrene ;  and even punctures have had fuch
effeas, but much more feldom.
                                          Scarifications 
                     C   136   ]
  Scarifications are ufually made about an inch in length,
to the depth of the  cutis vera, and about two or three in
number,  with the fhoulder  of a  lancet.  Punaures are
made to the fame depth with the point of the lancet,  and
about five or fix  generally fuffice.   They may be repeated
in a few days if the firft feem  infufficient;  and the parts
fhould be kept as dry as poffible after the operation.
  When inflammation fucceeds, a cold folution of faccha-
rum  faturni, or aqua calcis, are the beft applications to re-
move it.    Should thefe  fail,  and gangrene come on, the
remedies for gangrene in general fhould be had recourfe to.
  Although in thefe cafes, mortification  often terminates
fatally ; yet very unexpeaed cures are fometimes obtain-
ed.   There is an inftance of the whole fcrotum feparating
and  leaving the teftes bare; but thefe were foon covered
by a cellular fubftance, and the patient recovered.
  When this difeafe is  induced by fwellings. in the abdo-
men or groin, obftruaing the  return  of the  lymph,  they
fhould, if poffible,  be removed; if this cannot be done,
punaures muft be made as palliatives.
  It fometimes happens that fuppreffion of  urine, produc-
ing a burfting of the urethra, induces this  complaint in a
very fudden manner.   In order to prevent the formation
of finufes,  which will be apt to occur in thefe cafes, an
incifion fhould be  made into  the mofl depending part of
the fcrotum, and carried deep  enough to reach the wound
in the urethra.  By this means a  free  vent will be given
to the urine which has been  colfeaed, or will be difcharg-
ed.   If a ftone in  the urethra produces this fuppreffion,
it fhould be cut out;  if it originates from a colfeaion of
matter, this fhould be difcharged ; and if the obftruaion
arifes from caruncles  in  the urethra, they fhould be re-
moved by bougies.
  The caufe being thus removed, if  there is no conftitu-
tional affeflicn, and the wound is dreffed with foft appli-
                                               cations, 
                       [  137   ]
cations, the opening into the urethra will commonly heal;
but where there are general complaints, and particularly if
the patient is fyphilitic, it often happens that it baffles all
the powers of medicine.
   Local fcrotal anafarca has been alfo produced  from the
rupture of a hydrocele of the tunica vaginalis teftis, when
large, by jumping from a great height, or a violent blow ;
and alfo in the operation of tapping in that difeafe, from
fuffering the orifice in the teguments to  recede from  that
in the vaginal coat before the water is all difcharged.
   In both thefe cafes, the cure fhould confift in laying open
the tumor ; not only for the evacuation of the diffufed wa-
ter, but alfo  for producing a radical cure of the hydrocele
of the vaginal coat.
   Of the encyfled hydrocele there are  two  varieties:  1.
When the water is contained in the tunica vaginalis:  and,
2. When it is contained in the fac of a hernia.


                    SECT.   III.

     Of the Hydrocele of the Vaginal Coat of the Teflis.

   This difeafe is induced either by a too abundant depo-
fition of the fluid ufually exhaled into the cavity of the
vaginal  tunic, or a defeaive abforption of it.
   In the commencement of the complaint, a fulnefs is ob-
ferved at the lower part of one of the tefticles,  which  gra-
dually increafes, and produces a tumor often  of confider-
able fize.  This although compreffible  at  firft, can never
be made to  difappear by preffure; and as it increafes the
fkin becomes more tenfe.  The tumor is at firft globular,
but gradually becomes  pyramidal, being larger  below
than above;  and after  fome continuance  it often rifes
quite up to the opening in the abdominal mufcles ; fo that
                          S                         it 
                      [   138  ]
if it is not combined with hernia, or hydrocele of the cord
itfelf, the fpermatic procefs may always be diftinaiy  felt
in the early ftage of the difeafe.  The weight of the fwel-
ling being now very confiderable, the fkin of the parts ad-
jacent is dragged along with it in fuch a manner, that the
penis fhrinks confiderably,  and fometimes almoft difap-
pears ; and the tefticle, which  commonly lies at  the back
part of the tumor, cannot  now be  evidently  difcovered.
On a minute examination, however, a hardnefs may be felt
where the teftis is conneaed to the fcrotum ; and a fluau-
ation of fluid may in general be diftinguifhed.
  It fometimes happens when the tumor is very tenfe, that
the fluid cannot be evidently difcovered ; neither this, how-
ever,  nor the want of tranfparency in it when  expofed to
the light of a candle, fhould determine  againft  its  exifl-
ence ; for the laft mentioned circumftance may be  occafi-
oned by a difcolouration of the fluid, or a thickening of
the tunic.  When the  fwelling, however,  appears tranf-
parent,  as it frequently  does,  it affords a corroborating
proof of the exiftence of water.
  The tumor itfelf is not painful, but its  weight always
produces fome uneafinefs in the back ; this may  however
be prevented or alleviated by the ufe of a fufpenfory ban-
dage.
  Thefe are the common fymptoms when  the difeafe is
confined to  one fide of the  fcrotum, which is  ufually  the
cafe ; but in fome inftances both fides are equally affeaed.
  The difeafes with which  this is moft likely  to  be  con-
founded are, fcrotal hernia  ; the anafarcous hydrocele of
the fcrotum ; the encyfted hydrocele of the fpermatic cord;
the farcoceleor fchirrous tefticle ; and the hernia humora-
lis, or inflamed tefticle.
  But  if we attend to the  charaaeriftic  marks of  each
of thefe affeaions, there can in general  be little danger of
miftake: thefe have been already given,  or will  be taken
                                                notice 
                          [   139   ]
   aotice of hereafter.   In fome cafes of farcocele  combined
   with an effufion of water into the vaginal coat, there will
   be fome difficulty, and it is even fometimes impoffible  to
   afcertain  the complaint;  however,  no danger  will  arife
   from the miftake, if  we proceed  in the cautious manner
   hereafter pointed out.
     In forming a prognofis in this difeafe, we muft be di-
   reaed almoft entirely by the habit  of body  of the patient,
   The affeaion is iri general local, and in  a healthy conftitu-
   tion it may almoft always  be removed, and that  with little
   or no rilk ; but in conftitutions  otherwife difeafed ; in old
   people ; and in infirm habits, although the complaint  may
   often be cured, yet there is always fome  danger to  be
   feared from the confequent inflammation, fever,  and  fup-
   puration.
     As long as  a fwelling of this kind keeps within mode-
   rate  bounds,  which  often happens for  a  confiderable
   time, patients generally fubmit  to the inconvenience it oc-
   cafions, rather than have an  operation performed to relieve
   them :  and this is the only means to be  depended on ; for
   notwithftanding what has been faid of the beneficial ef-
   feas of purgatives in thefe cafes,  I have never feen  them
   of any kind of fervice.*
     The methods of treatment propofed  are either intended
   to produce  permanent relief,  or  only  a temporary eafe.
   The laft is termed the palliative, the former the radical cure.
   When  the tumor  has  acquired  fuch  a  fize as to become
   inconvenient, if the patient either refufes to fubmit to the
   operation for the  radical cure,  or his ftate  of health ren-
   ders that  improper,  the palliative treatment, or a mere
                                                evacuation

     • Dr. Shippen, profeffor of anatomy  and furgery in this city, has in
   more inftances than one, removed this  difeafe  by the free ufe of draftic
   purges, and anointing the part with mercurial ointment.  But the Do-tor
V   is of opinion with Mr. Bell, that they will  generally be ineffectual;  and
\  in  his ledtures ftrongly recommends the ufe of the knife if the patient
 I  will fuffer it to be employed. 
                       [  140  ]
 evacuation ofthe water by punaure, is the only means we
 can employ; and this is hardly ever at all hazardous.
    The punaure is made either by a lancet or the common
 trocar.   To the ufe of the  lancet it may be objeaed,
 that it does not produce a free evacuation of the water; for
 as the opening in the fkin  recedes from that in the vaginal
 coat, the water is either entirely ftopt  or infinuates itfelf
 into the cellular fubftance of the  fcrotum.—The difficulty
 of  introducing the common trocar, renders it a dangerous
 inftrument on account of the  contiguity of  the tefticle ;
 and many inflances have occurred wherein the teftis has
 thus been materially injured, even in the hands of  expert
\ operators.  The objeaions to thefe instruments do  not,
 however,  apply to the trocar with a lancet point, (plate vii.
 fig. 3. 4.) which I fome  time fince recommended : it ought
 therefore  to be preferred to both  of them.
    In performing this operation, the patient fliould be feat-
 ed  on a chair, with the tumor  hanging over the edge of it:
 the operator with his left hand  grafping the fwelling  on the
 back part, fo as to pufh the water  as much  as poffible in-
 to the anterior and under part  where the punaure is to be
 made ; he then makes an  opening  through  the  fkin  and
 cellular fubftance, of half an inch in length,  with the
 fhoulder of a  lancet.  This enfures an eafy paffage  to the
 trocar, gives but very little pain, and divefts the operation
 of  all hazard.
    The trocar is now to  be taken in the right hand  of
 the operator,  the head of it being fixed in  the palm  and
 the fore-finger placed along the courfe  of the  inftrument,
 fo as to leave  as much uncovered  as it is thought  proper
 fhould enter the vaginal coat;  and  this being introduced
 in  a  gradual eafy manner, the ftillette is to  be withdrawn
 immediately on the end of the  canula  having  entered the
 cyft.   If the tumor is not very  large, all the water may be
 evacuated at once; but  if it  is of confiderable fize, the
                                                 fudden 
                       [  141   ]
  fudden difcharge of the fluid might,  by taking  away too
  quickly the fupport  it afforded to the veffels  of the teftis
  and its coat, endanger a rupture of fome of them ;  it will
  therefore be better to flop the difcharge  now  and then
  for a few feconds;  and when the whole is evacuated, the
  wound may be clofed by adhefive  plafter, a foft comprefs
  applied above this, and both fecured by the  T bandage.
    The patient being laid in bed, it commonly happens that
  in a few hours all uneafinefs  goes  off, and  he may go
  about  his ordinary bufinefs; in fome inftances, however,
  the wound inflames and  fuppurates;  and there are not
  wanting cafes in which a  permanent cure has  thus been
  obtained.
    This operation is eafily  performed, and  feldom produc-
  tive of mifchief; but when the patient has been allowed
  to go about immediately after the operation,  or the tap-
  ping has been incautioufly  performed, it has  fometimes
  been   fucceeded  by very  troublefome fymptoms.   And
  even when properly  managed, if the patient is very  infirm,
I  this may happen.  Mr. Pott relates two inftances of this
  kind  that  terminated  fatally.  Hence it fliould not be
  rifked in very difeafed habits.
    The intention of every means at prefent in praaice for
  the radical cure of this  fpecies of hydrocele, is   either
  to  admit of a union  between the  cellular fubftance of the
  fcrotum and the tunica albuginea, by a  deftruaion  of the
  tunica vaginalis, or by exciting fuch  a degree of inflamma-
  tion on the parts as may obliterate the  cavity of the tunica
  vaginalis,  by making it adhere to the tunica albuginea.
     The feveral modes of effeaing thefe intentions,  are ex-
  cifion of the tunica vaginalis; the application of cauftic ;
  the ufe of a feton; and a  fimple incifion of the  fac.
    The three laft are almoft the only methods now  in ufe;
  and the cauftic is the only one of them by which the fac
  has been fuppofed to be deftroyed ;  but it is exceedingly
                                               doubtful, 
                       [  H2   ]
 doubtful, notwithftanding what Mr. Elfe fays to the con-
 trary, whether this ever takes place.
    By Mr. Douglafs we are recommended  to  deftroy  the
 vaginal coat entirely ; he direas us,  firft to diffea out an
 oval piece of the fcrotum, and having then laid the vaginal
 coat open, to cut it away by a pair of fciffors ; but if any
 one is inclined to follow this mode he will feldom find it
 neceffary to cut off any part of the fcrotum, and will  per-
 form the operation more eafily with   a  fcalpel than  with
 fciflbrs.
   The method of cure  by caufiic  is thus) eonduaed at
 prefent;  the fcrotum being fhaved,  a  piece of common
 cauftic pafte, of the fize  of an Engliffi fix-pence, is to be
 applied upon the anterior and lower part of the  fcrotum,
 and to be there well fecured by adhefive plafter,  in  order
 to prevent it  from fpreading.    It is to remain five or fix
 hours, and then be removed.  An emollient poultice, or
 fome digeftive, muft afterwards be applied over the  fcro-
 tum, and the whole fufpended by a bandage.
   Inflammation we are told, is foon induced over the whole
 tunica vaginalis ; and the febrile fymptoms which fucceed
 are to be moderated by blood-letting, clyfters,  &c.  In a
 few days the efchar feparates and comes away ;  and  in a
 gradual manner, in  the courfe of four, five, or  fix weeks,
 the whole tunica vaginalis comes off; when the wound
 immediately cicatrizes and a complete cure is obtained.
   When the feton  is to be ufed, the following is  the me-
 thod direaed by Mr.  Pott.  He ufes a trocar ;  a  filver
 canula,  five inches in length, and of fuch a diameter as to
pafs eafily through the canula of the trocar ;  and  a probe
fix inches and an half long, having at one end a fine tro-
car fteel point, and at the other an  eye  which  carries a
cord of coarfe white fewing  filk,  of  fuch a thicknefs  as
will pafs eafily through the long  canula.  With  the  tro-
car, the inferior and anterior part  of  the  tumor is to be
                                              pierced; 
                      [   143   ]
pierced; and as foon as the  perforator is withdrawn, and
the water difcharged, the feton canula is  paffed through
that of the trocar, till  it  reaches the  upper part of the
tunica vaginalis, and can  be felt in the very fuperior part
of the fcrotum.  This being done, the probe armed with
its feton is to be conveyed through the latter canula, the
vaginal coat and teguments to be pierced,  and the  feton
drawn through the canula  till  a fufficient  quantity  is
brought out at the upper orifice, when the canulas are to
be withdrawn.
   About the  end of the  third day,  the parts begin to in-
flame ;  fomentations,  poultices, a  fufpenfory bandage,
temperate regimen, and laxatives, are ordered to keep the
fymptoms moderate : as foon as the inflammation fubfides,
which is generally about the tenth or twelfth day, the fe-
ton is to be diminifhed at every fubfequent dreffing, by
withdrawing  fix or eight  threads : the  dreffings confift of
a fmall pledget on the wounds, and  a  plafter of ceratum
faturninum over the fcrotum.
   This  mode of performing the operation I approve of,
except in the circumftance of introducing the feton, which
I think  is more eafily  executed,  and with  lefs danger of
injuring the tefticle, in the manner direaed in  the feflion
on abfceffes.
   The operation by the fimple incifion is thus  performed.
The patient being placed  on  a table of convenient height,
and  being  properly fecured by  two  affiftants, with the
fcrotum lying nearly upon the edge of  the  table,  the ope-
rator fhould grafp the tumor with one hand fo as  to hold
it firmly, and make it fomewhat tenfe on its  anterior  part;
and with a common fcalpel in the other,  he  fhould now
divide the teguments from the fuperior part of  the tumor,
along its anterior furface down to the moft depending
part.
                                                 The 
                      [  144  ]
   The fcrotum retraaing a little, the vaginal coat  is laid
bare, and the operator is to make an opening into it  with
a lancet large enough to receive his fore-finger, at the fu-
perior part where the firft incifion began ; the finger be-
ing  inferted, the probe-pointed biftouri is  to be  carried
along it until the fac is divided quite to its lower extre-
mity.
   The incifion is direaed to be made from  above  on ac-
count of its being thus moft eafily performed ; and to  be
carried the whole length of the tumor, becaufe  the forma-
tion cf finufes is then prevented.
   When the fac appears much thickened, it  will  facilitate
the cure to remove part of it on each  fide : but when this
is not the cafe, the dreffing fhould be immediately finifhed,
in order to prevent any bad effea  from the air coming  in
contaa with, and irritating the teftis.
   The tefticle is generally found  to  be  of a foft texture,
and pale ; in fome inftances it is confiderably enlarged;
and in others it is reduced to  a  very fmall fize :  as the
cure advances, however,  it generally regains its  former
bulk.
   It fometimes happens  that  both fides of the fcrotum
are  affeaed  with hydrocele ;  in fuch  cafes  we  are by
fome direaed to lay both open at the fame time by a dou-
ble incifion ; but it has been more common, on account of
the inflammation thus induced, to fubjea the patient to
two diftina  operations, by delaying one until a recovery
from the effeas of the other.   But it is  much more ad-
vifable, in ftead of either of thefe modes,  to  lay open the
feptum fcroti, after operating on one fide, and  thus effea-
ing the cure of both difeafes at once.  The partition of the
fcrotum is entirely cellular, confequently we run no rifk
of doing injury by dividing it.  I have done this  in two
inftances  with complete fuccefs.
                                                  The 
                      [   145   ]
  The fuccefs of this operation  depends very much on a
proper dreffing of the wound.  If the tefticle has been pufh-
ed out of the fcrotum, it fhould be immediately replaced,
and a thin piece of foft lint inferted between it and the
edges of the wound, the whole length  of the  tumor, fo
much being left out as will cover the lips of the fore, and
the remainder pufhed about half way to the  bottom of
the fac.   A comprefs of  foft linen is then to  be  applied
over the tumor, and the whole fupported by a fufpenfory
or T bandage.   The patient being now carried to  bed, an
anodyne fhould be given to him; and he fhould be direa-
ed to avoid motion as much as poffible.
  The  lint is introduced in order to exeite an inflamma-
tion over the whole furface of the tunics,  and thus prevent
partial adhefions and confequent  finufes.
  When the inflammatory fymptoms  which  fucceed to
this operation do not run high, it  is not neceffary to do
any thing for fome days ; but when they are confiderable,
we muft employ blood-letting, laxatives, and a cooling diet;
and apply fomentations and poultices to the part, in order to
induce a plentiful fuppuration, which tends more  effeau-
ally than any thing elfe to take off bad fymptoms.
   In general, about  the fourth  day the parts fliould be
fomented and  poulticed;  and  by the fifth or fixth the
dreffings come  off.  The  edges of  the  fore  now appear
hard and fwelled, and the matter difcharged is thin and
difcoloured ; the lint fhould then be  all  removed  as foon
as it will come away eafily,  which is ufually at the third
or fourth dreffing.  The fore fhould be dreffed every day
or two,  according to the quantity of the difcharge ; arid
the poultices fhould be continued till a plentiful fuppuration
conies on, which generally happens by the twelfth or four-
teenth day.
  The fwelling and fore now gradually leffening, the only
dreffing neceffary, is lint covered with a pledget of cerate ;
                        T                        and 
                       [  146   ]
 and in four, five,  or  fix weeks, according to  circunv
 fiances, the cure is completed.
   From an attentive observation  of the effeas of the three
 modes  of operation laft defcribed, in a very great variety
 of cafes, in different places, I am induced to  conclude that
 they are all equally capable of producing a  radical cure;
 but  that the fimple incifion effeas this with lefs trouble to
 the operator and rifk to  the patient than either of the other
 two ; and that of the others, the cauftic is to be preferred
 to the feton.
   I  have feen all thefe methods produce troublefome fymp-
 toms ;  fuch as great pain and  tenfion of the abdomen,  in-
 flammation and fever; but the feton, from the irritation it
 gives to the tefticle,  more frequently occafions them than
 either of  the others.   The feton induces fuch a plenti-
 ful fuppuration alfo, in many cafes, that the matter cannot
 be evacuated at the openings,  and in confequence forms
 troublefome finufes.
   Another  important objeaion is, that it does  not admit
 of a  free examination of the teftis, or of the fluid contained
 in the fac.  In fimple hydrocele this would be of  no con-
 fequence ;  but if the tefticle fhould be much difeafed, the
 irritation of the cord on  it might produce very troublefome
 and  alarming fymptoms : and there are feveral inftances
 upon record in which  the firft  furgeons have miftaken
 hydro-farcocele, for fimple hydrocele, and vice verfa; indeed
 in fome cafes, there is no  certain  means of difcrimination.
 In fuch, the furgeon fhould always proceed upon the fup-
 pofition of the difeafe being hydrocele; and  if  on laying
 open the fwelling,  the tefticle  fhould be in fuch a ftate as
 to require extirpation, it fhould be immediately removed.
  The  fluid  in hydrocele is frequently contained  in hy-
datids :  this forms  another objeaion  to  the feton ;  which
is obvioufly ill calculated for its removal in that cafe.
                                                  The 
                        [   1*7   ]
   The treatment by cauftic is liable to one very material
objeaion, viz. that  of being produaive  of finufes  and
abfceffes in the fcrotum and cellular fubftance conneaing
this to the tunica vaginalis.   This is never the confequence
of the fimple incifion ; and  on this account,  becaufe it
brings the ftate of  the tefticle more evidently into  view ;
and becaufe experience has taught me that it produces the
leaft  troublefome  fymptoms,  I  am clearly  of opinion  that
it ought to be chofen  in preference to the cure by feton or
cauftic*
                        SECT.   IV.

               Of the Hydrocele of a Hernial Sac.

     There are feveral inftances of this difeafe upon record;
   and as it occupies nearly the fame fituation with the fimple
   hydrocele of the tunica  vaginalis, it is often a matter of
   difficulty  to diftinguifh  them,  and fometimes an impof-
   fibility.
                                                            In

    * The lateft experience feems to juftify this  opinion ;  and inftead of
   applying warm poultices and fomentations,  if foft  compreffes, dipped in
   a folution of the faccharum faturni,  are immediately laid on the fimple
   dreflings, and  kept conftantly wet,  no more fwelling or inflammation
   will attend  the operation, in  moft  cafes, than  is neceffary to induce a
   union of the tunica vaginalis with the tefticle.
    Thefe tumors are fometimes of a  moft enormous fize—A man who
   had  laboured  under  one for nine  years, and  worn a  fufpenfory trufs
   for  it as a rupture, had the operation performed by incifion, and two gal-
   lons  of a brown turbid  fluid, with  a large  quantity of a fubftance like
   that of the meliceris,  was difcharged.  The veins of the fcrotum were en ■
   larged like thofe of the  gravid uterus  in the laft  month of pregnancy.
\   Warm fpirituous fomentations and dreffings were employed  in this call
   to reftore the loft tone of the parts,  and in about fix months the wound
  -was  clofed, the fcrotum and tunica vaginalis contracting to a very mtv
   Jerate fizg. 
                      [  148   .]
  In this fpecies the tefticle is ufually more evident at the
lower part of  the tumor than  in  fimple hydrocele ; but
when the  difeafe is combined with  hernia congenita, as it
frequently has been, this will not be the cafe.   When the
parts forming the hernia are down,  the fulnefs they pro-
duce along the  fpermatic  cord, ferves in fome meafure to
denote the complaint.  And if the water can be made to pafs
into the abdomen by preffure, this affords a certain charac-
teriftic : but where it happens that the neck of the fac has
been clofed by  the preffure of a trufs,  or any other caufe,
this mark cannot appear.  In fuch a  cafe, the only means of
diflinaion will be, an acquaintance  with the previous hif-
tory of the diforder :—no bad confequence could however
enfue from a miftake, as the treatment adapted to  fimple
hydrocele applies equally to this variety.
  When the protruded parts  ftill  remain down, unlefs
the operation for bubonocele is fubmitted  to  at  the fame
time,  no other fhould be attempted  than that of difcharg-
ing the  water by means of  a  fmall trocar, when  the fize
of the fwelling  renders  it neceffary : becaufe the expofure
of the inteftines to the air might be produaive  of mate-
rial injury.
  The fimple incifion  fliould always be ufed for the  ra-
dical cure of this difeafe, on account  of the rifk of injur-
ing parts that might be protruded, by the  employment
of the feton, or of cauftic


                    SECT.  V.

    Of the Anafarcous Hydrocele of the Spermatic  Cord.

   This difeafe is feated in  the Cellular membrane which
envelopes the fpermatic  procefs of the peritonseum.
   It is, in fome inftances, fymptomatic of afcites or anafarca;
                                                     in 
                      [   149   ]
in other cafes, it is a local affeaion, and is produced from
an obftruaion in the lymphatic veffels of the part, by fchir-
rous abdominal vifcera, or by the preffure of a trufs.
  When the difeafe is fymptomatic,  it is clearly marked;
when it is merely local, it  appears as  a colourlefs tumor in
the  courfe of the fpermatic  cord, foft  and inelaftic, and
not attended with fluauation.   In an erea poflure it is ob-
long, but in a recumbent fituation it is more flat, and fome-
what round.    It does not in common extend lower  than
the inferior  part of the groin; but in fome cafes,  it goes
quite to the  bottom of the tefticle, and ftretches the  fcro-
tum to a great fize.  By preffure the fwelling can be made
to recede entirely, or  at leaft in great part, into the cavity
of the abdomen ;  but it inftantly returns to its former fitu-
ation on removing the preffure.
  When this difeafe depends on a general affeaion, it com-
monly difappears with the removal of that affeaion ; but
when it is local, and has become inconvenient, an incifion
is to be made into it, the whole length of the tumor, fo as
to  evacuate all its contents ;  and the wound is then  to be
dreffed with lint,  and treated  as a fimple  fore from  any
other caufe.

                   SECT.   VI.

      Of the Encyfted Hydrocele of the Spermatic Cord.

   In this difeafe  the water is contained in one or more dif-
tina cyfts,  or cells.  It commonly begins by a fmall tu-
mor in  the fpermatic  procefs, juft above  the epidydimis ;
although, in fome inftances, it  begins in its fuperior part.
By degrees  it extends  upwards, and on fome occafions fo
far downwards, as to  reach from  the  abdominal mufcles
to  the  bottom of  the fcrotum.   The teftis can always
                                                    be 
                      C  150  ]
be diftinguiftied at the back part of this fwelling, and quite
unconneaed with it; and a fluauation of fluid is always
perceived on preffure.  The tumor is commonly of a pyra-
midal form, and is not at all altered  in fize by preffure.
   When the water  is contained in two cells, the line of
divifion is  commonly evident, by the tumor being  there
fomewhat puckered, or fometimes diminifhed in its diame-
ter.   A fimilar appearance takes plaCe when this fpecies is
combined with a real hydrocele of the tunica vaginalis at
the upper extremity of the tunic.
   The difeafes with which this  is moft likely to  be con-
founded, are the hydrocele of  the vaginal tunic, the ana-
farcous hydrocele of the fpermatic cord,  and a hernia of
the inteftines or omentum.  But an attentive confideration
of the phsenomena of thefe complaints, and of thofe attend-
ing the one we are  treating of, will in general effeaually
prevent the  miftaking one for any other of them.
   This, as well as the anafarcous hydrocele of the cord, and
the cedematous tumor of the fcrotum, are  all frequent in
infancy.  They are  then, in common, foon  removed by the
application of fpirit of wine, or infufion of rofe leaves with
alum.   Dr. Monro  recommends  the fumes  of benzoin.
But in adults, thefe applications are  feldom effeaual; and
we are under the neceffity of employing an operation, as
in hydrocele of the vaginal tunic,  when it arrives at an in-
convenient fize.
   In accomplifhing  a radical cure, the incifion is  particu-
larly proper on account of the water being  fometimes con-
tained in more than one cyft ; and becaufe there is a  pofli-
bility of confounding this difeafe with hydrocele accompa-
nied by hernia.
   In  the defcription we have given  of the five fpecies of
hydrocele,  we  have neceffarily enumerated the  particu-
lar fymptoms of each  uncombined  with thofe  of any
other; but it fometimes happens that two, three,  or even
                                                  four 
                     I   151  ]
four, occur at the fame time in the fame perfon.  In fuch
cafes there will fometimes be confiderable difficulty in af-
certaining the precife ftate of the complaints ; we can only
form a judgment of this, however, from an attention to the
fymptoms which ufually  happen in the feparate  ftate of
each variety.
CHAP.    X.

 Of the Hematocele.
     THE hematocele is  a tumor in the fcrotum or fper-
      matic cord produced  by extravafated  blood.   Its
ufual feat is in the tunica vaginalis ; but it is fometimes
produced in the fpermatic procefs,  and  now and then in
the dartos.
   Tumors  of this kind are  ufually  the confequence of a
rupture of fome of the blood veffels of the parts, from exter-
nal violence.   They have been occafioned by blows, and by
a wound from a trocar or lancet in  tapping for the hydro-
cele.   In the latter cafe,  the water  drawn off is, in com-
mon immediately tinged with  blood; but  in  fome in-
ftances, this is not the cafe ; and the effeas of the accident
do not appear until all the water is  evacuated, and then a
tumor of confiderable fize is frequently produced in a very
fhort fpace of time.   In very large hydroceles the blood
veffels  have been ruptured  merely  from  taking away the
fupport which they have received  from the preffure of the
water by its fudden evacuation.
                                           Hematocele 
                      [  152   J
  Hematocele when feated in the fcrotum,  is to be diftin-
guiftied from  hydrocele by the livid colour of the parts;
and when in the tunica vaginalis, by the greater weight of
the tumor in proportion to its bulk, and often by the man-
ner of its produaion.
  In the  beginning of the anafarcous  or diffufed hemato-
cele, whether it be feated in the fcrotum or fpermatic pro-
cefs, when produced by flight external violence, the  appli-
cation of ardent fpirits, or of a folution  of alum, will fome-
times effea a difcuffion :  but  if this  fails, the tumor is
to be laid open, and treated as a hydrocele ;  except that if
a ruptured blood-veflel is difcovered, it will be abfolutely
neceffary  to fecure it by a ligature.   The  hematocele of
the vaginal coat is to  be removed by a fimilar operation :
But  when the bleeding veffels cannot be deteaed, as fome-
times happens alfo in the hematocele of the fpermatic pro-
cefs, and the hemorrhage cannot be reftrained by the ufual
remedies, we are under the neceffity of having recourfe to ex-
tirpation of the tefticle, as the only effeflual means of relief.
  Mr. Pott defcribes a fpecies of hematocele, in which the
blood is contained within the  tunica albuginea teftis;
which  he thinks proceeds from a relaxation or diffolution
of part of the vafcular ftruaure  of the teftis ;  and which
when  any confiderable quantity  of  fluid is colfeaed,
produces a fluauation fomewhat like  that  of a hydrocele
of the vaginal  tunic.
  When this affeaion is miftaken for a hydrocele, and an
opening is made with  a trocar, a dark-coloured blood is
difcharged nearly of the confiftence of thin chocolate ; but
although the fwelling is fomewhat leffened by the operation,
yet no confiderable alteration is effeaed by it; and  as the
tefticle is rendered ufelefs  by the difeafe, Mr. Pott advifes
its removal, as the only effeaual remedy.
  I have met with a difeafe very fimilar to this ; except that
the blood never appeared to be extravafated, but to be ftill
                                             contained 
                      [  153   ]
contained in the veffels of the teftis ;  although they were
in an enlarged ftate.   In fuch cafes,  when nothing more
was done than merely to fupport the parts by a fufpenfory,
they have continued ftationary for a great length of time ;
a circumftance which  does not occur either in true hema-
tocele,  or  in hydrocele: but where upon  the  fuppofi-
tion  of the colfeaion being a hydrocele, an inftrument
was  introduced  for the evacuation of its contents,  the
tumor became painful, and increafed,  and at length grew
fo troublefome by frequent difcharge* of blood, that caftra-
tion was rendered abfolutely neceffary.
   But even extirpation of the tefticle does not afford relief
in every cafe ; for the  blood-veffels of  the whole fpermatic
cord fometimes become fo foft and fpongy, that frefh  he-
morrhagies occur, perhaps at  every dreffing, and render
repeated ligatures neceffary.   And in one cafe in  which I
was concerned,  the hemorrhage burft  out  fo repeatedly,
that the patient at length died from the effeas of it.
   This  tumor is to  be diftinguifhed from hydrocele, by
being heavier in  proportion to its fize; by the fluauation
being lefs evident; and by an increafe of it being prevent-
ed by the ufe of  a fufpenfory bandage.
U
CHAP. 
[  154   3
            CHAP.     XI.

Of the Varicocele, Cirsocele, Spermatocele,
               and Pneumatocele.
 T> Y the firft of thefe terms is meant, a varicofe diften-
 *■-* tion of the veins of the fcrotum ;  which form a tu-
 mor of hard  knotty  inequalities,  feldom attended with
 pain, and only inconvenient from its fize.
   The cirfocele is a tumor of the fame nature, feated in the
 fpermatic vein,  and extending  from the1 fuperior part of
 the fcrotum to the  abdominal mufcles.
   Both thefe affeaions are fometimes produced by tu-
 mors, the preffure  of a trufs, or other caufes  of obftruc-
 tion to the return  of  the venous  blood :—In fuch  cafes
 the removal of thefe  caufes fhould therefore be the firft
 flep towards a cure.
   But when a general relaxed ftate of the veins gives rife
 to them,  and this is the moft common caufe, remedies to
 recover their loft tone fliould be employed.  For this pur-
 pofe we fhould direa  the ufe of a fufpenfory bandage ;  a
 horizontal pofture; the cold bath ; and the application of a
folution of alum and other aftringents to the parts affeaed.
   By thefe means every affeaion of this kind may be pre-
 vented from increafing, and fo far relieved as to render the
 harfh modes of cure by the knife, the cautery and ligature,
 recommended by ancient writers, unneceffary.
   By the term fpermatocele is meant  a morbid diftention
 of the epidydimis and  vas deferens, produced by a ftagna-
                                                 tion
4 
                      C  155  ]
tion of femen.  This may be occafioned by tumors, ftric-
ture, or inflammation about the caput gallinaginis, or in
the  courfe of the vas  deferens : the laft is probably the
moft frequent caufe.
  Inflammation is to be removed by the common remedies.
In general tumors fhould  be  either extirpated or brought
to fuppuration;  if they are  venereal, a mercurial courfe
fhould be direaed.   Caftration has fometimes been em-
ployed as a dernier refort; but we cannot fuppofe it ever
to be very neceffary.
  The appellation  of pneumatocele has been applied to tu-
mors of the fcrotum produced by air.   This  difeafe  has
been defcribed by the ancients as a frequent occurrence ;
but it is extremely doubtful whether it ever exifts as a lo-
cal  affeaion : and it  is  moft  probable that hernia or  hy-
drocele  have been ufually miftaken for it.  As a part of
general  difeafe,  it may happen either from a wound of
the lungs, or from a putrefcent ftate of the fluids.   In the
former cafe, punaures  with  a  lancet  will be an effeaual
mode of cure ; but in the latter, nothing will probably be
of any advantage.
CHAP. 
[  156   ]
          CHAP.      XII.

Of the Sarcocele, or Schirrous  Testicle.
T> Y farcocele is underftood a firm flefhy kind of en-
■"■-^ iargement of the tefticle ; much more hard than that
occafioned by inflammation.
   An unufual degree of hardnefs, attended with a trifling
enlargement, and inconfiderablepain of the tefticle, are the
ufual indications of the commencement  of  this difeafe:
thefe fymptoms gradually increafe for fome time ; and
then often  remain ftationary for a  great length of time.
In a very few inftances they have been prevented from in-
creafing, or even removed, by a moderate diet, keeping
the belly open, a proper fufpenfion  Of  the tumor, and
avoiding violent exercife.  Such inftances  are however
very rare ;  and generally in more or  lefs  time, the tumor
becomes larger ; grows ragged and unequal on its furface ;
and the pain becomes more fevere, frequently darting fud-
denly through  the fubftance of the  fwelling.
   The inequalities on the furface of the tumor increafe by
degrees :—on fome occafions,  a  coKifiderable  quantity  of
ferum is extravafated into the  tunica vaginalis,  and gives
the appearance  of  a  common  hydrocele; at other times,
partial colfeaions of matter are formed  throughout the
body of the tumor ; which increafing, at  length  the fcro-
tum burfts, and a thin foetid bloody matter is difcharged.
   The fpermatic cord, after the tumor has acquired a con-
fiderable fize, becomes hard and enlarged, but feldom be-
                                                fore ; 
                      [  157   ]
fore ; and often not till matter has been formed.  By de-
grees it grows very knotty and painful  throughout its
whole extent.
  Although the difcharge of matter increafes in quantity,
the tumor  inftead of leffening continues to increafe ; the
edges of the fores  become hard, livid,  and retorted; and
fungous  excrefcences  fhoot out from  different parts  of
them.
  The patient now becomes emaciated and pale;  and the
difeafe, which in this ftage is a moft malignant cancer, con-
flantly increafing, at length carries him off in the greateft
mifery.
   This is the general  progrefs  of the complaint, unlefs it
is interrupted by a timely extirpation-  But as it affumes a
great variety of appearances, it is impoffible to convey a clear
idea of them in defcription.  In fome inftances the tumor
remains almoft  indolent for a number of years; while  in
other cafes, it goes through all the flages we have defcrib-
ed in the courfe of a few months.
   In the greateft number of cafes, the difeafe begins in the
teftis ;  but it now and then makes its  appearance firft  in
the epidydimis, and fometimes even in the fpermatic cord.
   Hernia humoralis feldom terminates  in  farcocele, but
 there are indifputable  evidences of its ending, in fome in-
 flances, in that difeafe.
   Schirrous affeaions of the  tefticle have been attribut-
 ed to the water  fometimes met with  in the tunica vagi-
 nalis at the fame time; but there can  be little doubt but
 that this colfeaion  of fluid is  produced by the difeafe of
 the teftis,  and  ought  not to be confidered as the  primary
 affeaion.   The difeafe  formed by this combination has
 been termed hydro-far cocele,-  and it is often  with difficulty
 diftinguiftied from fimple hydrocele.    In fome inftances
 there is no poffibility of determining the real nature  of the 
                      [   158  ]
cafe,  but from expofure of the parts by an incifion.  The
previous hiftory of the difeafe muft give the chief light in
thefe doubtful inftances.
   In forming a prognofis in farcocele, we are fo be direa-
ed by the age and habit of the patient, the duration of the
difeafe, and its ftate at the time.
   Thus,  we may have  more hopes of fuccefs in young
healthy fnbjeas,  particularly if extirpation is to be ad-
vifed, than in thofe of an  advanced age and infirm habit;
and  indeed when the fyftem is otherwife  much difeafed,
there can be little or no advantage expeaed from any
thing.
   If  the  complaint has  proceeded very flowly, there is
reafon to  think that it is  of a  mild  nature, and that the
habit is not fo much  affeaed  as if its- progrefs has been
very rapid.
   And, as long as the tefticle is only fomewhat hard and
enlarged,  without the  formation of matter, and without any
difeafe of the cord, if the  conftitution is otherwife healthy,
there is  a probability of fuccefs. from any operation that
ought to take place ;  but  when  the oppofites of thefe eir-
cumftances occur, and particularly if there is an ulceration
of the teftis, there will be little reafon to expea a favour-
able event.
  With  refpea  to the fpermatic  cord, whenever this is
merely enlarged by the weight of the tefticle producing a
varicofe ftate of its  veffels, or  a  watery depofition in its
cellular fubftance, and is not painful in itfelf, the extirpa-
tion of the tefticle may be admitted, if no circumftance of
general difeafe forbids it;  but if the cord has become en-
larged, hard, knotty, painful to the touch, adherent to the
neighbouring parts, and ulcerated, and the  affeaion ex-
tends quite up to the abdominal mufcles, caftration fhould
always be forbid.
  No remedy but extirpation can be  depended on for the
                                               removal 
                      [  159   ]
removal of farcocele.   The moft important circumftance
to be determined then, is the period at which the opera-
tion is  moft advifable.
   Although this difeafe, in fome inftances, remains flation-
ary for a  long time, or proceeds very flowly, yet in the
greater number of cafes, its progrefs is very rapid.  When
therefore,  bleeding, laxatives, a fufpenfory  bandage, or
mercury, when it  has  probably originated from a venereal
fource, and other  occafional remedies, have  been ineffec-
tual, and the  tumor daily increafes in fize,  and becomes
more painful, the  operation fhould be inftituted without
delay;  but while  the difeafe remains ftationary and  indo-
lent, it can never be confidered as abfolutely neceffary.
   The method of performing caftration is as follows :—
The patient muft  be  placed horizontally on a table of con-
venient height, with his legs hanging down,  to be fecured
by an  affiftant on each fide.   The parts being previoufly
fhaved, an affiftant muft hold the tumor,  if very large, if
it is not, the furgeon fhould manage it himfelf.   Grafping
it firmly with one hand, he fhould make an  incifion with
a fcalpel in  the other, along the whole  extent  of it,  be-
ginning at leaft an inch above  the part where the cord is
to be cut, and  carrying  it through the fkin  ancl  cellu"
lar fubftance quite down to the  end of the fcrotum, by
 one cut of the knife.
    The vas deferens fhould then be feparated from the blood-
 veffels ; and a firm waxed ligature being carried around the
 artery and vein, avoiding the nerve, by means of the curv-
 ed blunt needle, (plate vii. fig.  2.) a running knot ffiould
 be made on them, a quarter of  an inch  above  where the
 cord is to be divided.
    The cord being here cut acrofs, the lower part of  it and
 the tefticle, are then  to  be diffeaed out with the fcalpeL
 When this is effeaed, the ligature is to  be untied, and the
 artery and vein, if poffible, feparated from the nerve by the
                                             tenaculum.. 
                      [   166   ]
tenaculum, and  fecured.  The ligature above may be left
loofe, and is to ferve as a fecurity againft hemorrhagy.
  When  it is  neceffary to divide the cord near to the
opening in the abdominal mufcle, it will be proper to leave
the ligatures a few  inches long, left a retraaion of the
cord  within  the  abdomen,   which  fometimes  happens
when it has been  much feparated  from the parts beneath,
fhould take place.    If the fcrotal artery fliould be divided
during the operation, it fhould be immediately tied.
  The wound is now to be dreffed with foft lint, fecured
by a comprefs, and the T bandage,  or a fufpenfory bag.
  The patient being then laid to reft,  and an opiate admi-
niftered,  the fore fhould not be dreffed till a free fuppura-
tion takes place; which will generally happen  about the
fifth or fixth day;  and the dreffings may afterwards be re-
newed once in two days, or oftener, according to eircum-
ftances.
  Sometimes, after this operation  the patient complains of
much pain in the fore, and of tenfion and uneafinefs over
the abdomen: in  thefe cafes, warm fomentations fhould
be applied to the abdomen,  and an  emollient poultice to
the fore.
  In performing caftration, no  portion of the fkin fhould
be removed, unlefs from the fize of the  tumor it has be-
come very thin, or it is inflamed or ulcerated ;  in which
cafes, after making the firft incifion to the  extremity of the
fpermatic cord,  two femilunar incifions fhould be conti-
nued to  the end of the fcrotum, fo as to include all the
difeafed fkin; and this is  to be  afterwards diffeaed off
with the tefticle.
CHAP. 
C  161   3
   CHAP.     XIII.

Of the Diseases of the Penis,.
                    SECT.   I.

                   Of the Phymofis.

     THE difeafe called phymofis is formed when the pre-
       puce has got  forward over the glans  penis, and
cannot be drawn back.
   It is produced by whatever tends to fwell the glans, or
to excite inflammation and ftriaure of the preputium: and
in fome people, the prepuce is fo tight, as to render them
liable to this  difeafe  from very trifling caufes.  It origi-
nates frequently from allowing  a colfeaion of the mu-
cus behind the glans to take place,  and continue till it be-
comes  acrid ;  but  the moft frequent caufe of it is the ap-
plication of the venereal virus to thefe parts.
   In flight and recent cafes, warm  emollient  fomentations
and poultices are commonly effeaual remedies.  At the fame
time it will be  proper  to injea part of the fomentation
between the prepuce and glans frequently, in order to re-
move any  matter  that  may be  there accumulated from
chancres or other caufes.
   When the inflammation is very confiderable,  blood-let-
ting  may be neceffary ;  and this will be more  effeaual if
the blood can be taken from the  penis by the lancet;  if
this cannot be  accomplifhed,  it may be drawn from the
arm.  Topical bleeding by leeches  might be  very ufeful;
                        X                        but 
                       [  162   ]
 but when the difeafe  originates  from  a  venereal  caufe,
 the wounds thus caufed are apt to terminate in troublefome
 fores.  Laxatives,  reft, and  low diet,  ffiould alfo be di-
 rected.
   When all  thefe  remedies fail, and  efpecially if chan-
 cres are confined under the  prepuce, the  difcharge from
 which might  injure the prepuce and glans, it will be ne-
 ceffary to remove the ftriaure by  cutting  through the
 prepuce  its   whole length.    This  will  be moft* eafily
 and  effeaually accomplifhed  by  a very  fmall biftouri,
 concealed in the groove  of a direaor,  and  fomewhat
 curved at its extremity.  Thefe being introduced between
 the glans and prepuce, to the upper part of the latter, the
 operator  is to keep the direaor firm with one  hand, and
 with the other is to pufh the point of  the knife through
 the membrane ; the direaor being  then withdrawn, the
 biftouri  is to  be drawn forward fo  as  to  divide  the
 prepuce entirely.
   The operation fliould be performed on the fide  of the
 penis, in order more effeaually to avoid  the large veins.
   The  parts  beneath  fhould  now be cleaned with warm
 water ; and the fore being covered by lint, and a comprefs
 of linen laid  over it, the whole  may be fecured by  a fmall
 linen bag conneaed to a circular band around the body.
   In the fubfequent treatment, care ffiould be taken to
 infert a piece  of lint  between  the  divided prepuce  and
 glans, otherwife troublefome adhefions  may take  place •,
 and if the venereal difeafe exifts in  the  habit, a mercurial
 courfe  will be abfolutely neceffary to the  healing  of the
 fore.
   In cafes where  the prepuce is found exceffively long,
 inftead  of dividing it longitudinally, it will be better to
 take off a part of its whole circumference.*
                                             SECT,
  * This will be moft eafily  and effectually performed by making lateral
incifions firft. 
[  163   3
                   SECT.   II.

                 Of the Paraphymofis.

  By the term paraphymofis is meant a morbid retraaion
of the preputium, producing a ftriaure behind  the glans
penis.  This difeafe is produced moft frequently by a ve-
nereal taint; but it may originate from whatever tends to
occafion a preternatural fulnefs of the glans, or a conftric-
tion of the prepuce, or both.
  In the commencement of this  complaint, the prepuce
may be fometimes brought over the glans by pufhing the
nut gently back with  the  thumbs, while the fingers are
employed in moving the prepuce forward ; but this fhould
never be attempted in an advanced ftage, as it is then not
only unfuccefsful, but often injurious.
  As paraphymofis ufually arifes  from  an enlargement of
the glans, warm fomentations inftead of proving fervicea-
ble  often do mifchief.  Nothing anfwers  fo well as fatur-
nine applications ; and immerfing the fwelling frequently
in a cold folution of  faccharum  faturni will often remove
it when all other remedies fail.   When the penis is much
fwelled and inflamed, the patient fhould be kept cool, and
on a low diet, gentle  laxatives  fhould  be exhibited, and
fome blood  may be difcharged from a vein of the penis.
  Thefe remedies will often fucceed ;  but when they arc
ineffeaual,  the fwelling  and ftriaure increafing, an cede-
matous fwelling appears in the  prepuce, and often ac-
quires a confiderable  fize; and unlefs  the  ftriaure is re-
moved, a mortification of the glans will be very apt to
occur.
  When therefore, the means above advifed do not remove
the complaint, and the fymptoms  juft  mentioned begin to
come on, the ftriaure fhould be removed  by making a deep
                                           fcarification 
                      [   164   ]
fcarification on each fide of the penis, direaiy behind the
glans, about half an inch in length, and of fuch a depth as
to divide the prepuce juft at its termination.
   As foon  as the hemorrhagy flops, the wound fhould be
dreffed with lint, and a plafter of cerate, and a foft poul-
tice fhould  be applied over the whole tumor.   The parts
fhould afterwards be  dreffed in the ordinary way.  If the
ftriaure fhould not have been completely relieved by the
firft incifion, a fecond fhould be made.
   Mercury will be neceffary, if the caufe of the difeafe ha*
been venereal.

                   SECT.  III.

            Of Amputation of the Penis,  Sec.

   A necessity for amputation of the penis is moft com-
monly induced by gangrene from paraphymofis and other
caufes, and by cancerous fores affeaing it.
   In performing this operation, a circular incifion is to be
firft made through the found fkin on the verge of the fore,
and the fkin being then drawn back, all the difeafed parts
are to be removed  by one ftroke of the knife.   All the ar-
teries that  bleed freely, which are generally two or three
in number, ought then to be fecured by ligature ; and the
oozing of  blood,  that afterwards occurs from the furface
of the wound, may fometimes be commanded by fprinkling
the fore with ftarch,  or finely powdered gum arabic : but
when thefe do not fucceed, a fmall filver canula  being in-
troduced into the urethra, and there fecured by a bandage,
the difcharge may be reftrained by paffing a narrow roller,
moderately tight, upon the remaining parts.
   It  has been recommended by fome,  in  order to avoid
hemorrhagy, to remove  the penis  by  making  a ligature
                                                around 
                      [   165   ]
around it; but it  is taken  off with much  more eafe and
certainty by the fcalpel.   Others are fo little apprehenfive
of hemorrhagy,  that they advife us to truft  entirely  to
compreffion for reftraining it.   I once faw a patient lofe
his life by following this plan.*
   The wound fhould be dreffed with  lint, covered  with
ftarch,  or powdered gum arabic, and a comprefs of linen,
with a hole in it large  enough to pafs  over the canula, be-
ing applied, the whole fhould be fecured by the T band-
age.   The fubfequent treatment  muft be fimilar to that
of wounds in  other parts.
   Before proceeding to this operation, it  fhould be known
with certainty, whether the glans  penis is really difeafed ;
and when there is any doubt, the prepuce fliould be taken
off to  afcertain it.
   When the frenum of the penis is fo fhort as to produce
uneafinefs or pain on ereaion, it may  with the  utmoft
fafety  be divided  by a pair of fciffors; and  after this is
done,  a piece of lint fhould be inferted between the lips of
the wound to prevent their re-union.
   It fometimes happens, that the urethra in male children
terminates before  it reaches the end of the penis.   Some-
times there is no external opening; at other times,  there is
a fmall orifice at  fome diftance  from the extremity of the
 yard.
   When there is  no opening externally,  if the  urine is
 found to flop  at  a particular part,  the  introduaion of a
 fmall trocar from the  point of the  yard,  along  the courfe
 that the urethra ought to take, until it meets with the urine,
 will  always afford  immediate  relief; and by  the ufe of
 fmall  bougies the fides of the paffage may be rendered  cal-
 lous, and an opening thus preferved.   But when any open-
                                                     ing

   • In two cafes of amputation of the penis in th« Pennfylvania hofpitaL.
 a very trifling hemorrhage  was eafily reftrained by dry lint, and mode-
 rate compreffion. 
                      [  166  J
ing is difcovered, whatever be its fituation, if it affords a.
paffage to the urine, the operation had better be delayed to
a more advanced age,  when a piece of flexible catheter can
be introduced to preferve the opening made by the  tro-
car.
CHAP.    XIV.

      Of the  Stone.
                    SECT.  I.

           General Remarks on urinary Calculi.

    PARTICLES  of flone have  been formed  in almoft
     every cavity of the body, but they are moft frequent-
ly met with  in the  urinary organs.   A  variety  of cauf-
es may concur in producing this depofition of earthy mat-
ter from the blood or fecretions.
   1. If a greater quantity of earthy fubftance be taken into
the circulating fluids than  can be  fufpended by  them, the
fuperabundance muft neceffarily  be feparated ;  and the
depofition  will  moft readily take place in the bladder and
kidneys, from the urine containing a greater proportion of
earth than any of the other fecretions.
   2. There is reafon to fuppofe that a long continued ufe
of water,  or  of wines  which contain a great quantity of
earth, has a tendency to overcharge the circulating fluids
with earthy matter.
                                                  3. A 
                      t   167  ]
  3. A conftant ufe of  a  great  proportion of folid food
feems to have a confiderable effea in producing an accu-
mulation of earthy matter in the fluids; and hence, in fuch
cafes, probably arifes the benefit from direaing a large ufe
of diluting drinks.
   4. A fuperabundance  of earthy matter being once pro-
duced  in the blood, various eircumftances may concur to
form depofitions of it in the  different cavities ; of thefe,
a fedentary life is one of the principal; and  hence  thofe
who ufe leaft bodily exertion are moft fubjea to calculous
complaints.  When they occur in poor labouring people,
as they frequently do, they may with probability be attri-
buted to their diet; the  effeas of which are too powerful
to be obviated by exercife.
   5. Whatever effeas predifpofition may  have in  occa-
fioning calculi, the introduaion of any fubftance that can
ferve as a nucleus, will  almoft certainly  produce a ftone,
in whatever cavity it is lodged.  Thus, a particle of fand,
of blood or  coagulable  lymph, may, in  confequence of
fpafm  or inflammation, be confined in the pelvis of the
kidney or bladder, and there acquire fuch a fize, from the
conftant depofition of earthy matter, that it cannot be car-
ried off by the urine ; and afterwards, in a longer or ffiorter
time, acquire a confiderable fize, according to the quantity
of earth with which the urine  is impregnated.
   It is very doubtful, whether a  ftone is  ever formed in  .
the urinary paffages without the intervention of a nucleus.
Nuclei of various kinds,  fuch as hairs, needles, mufket and
piftol bullets, pieces of bougies, and a variety  of other ar-
ticles have been met with in the centre of urinary calculi;
but particles  of blood, or coagulable lymph, moft frequent-
ly produce them.
   By a difference of food at different periods of the difeafe;
by the ftone being formed flowly or  more quickly; and
perhaps by other caufes not known, or not eafily  expli-
                                                  cable 
                      C   168   3
 cable when  known,  it commonly happens tliat the differ-
 ent lamellse of which calculi are  compofed vary confider-
 ably in colour and confiftence ;  thus  the  external layer is
 frequently foft and friable, the  next hard as marble, and
 the internal lamella as foft  as dough.
   Calculi that are hard, covered with fpiculse, or large, are
 ufually produaive of more bad fymptoms than thofe that
 are foft, fmooth, or fmall.
   One of the firft fymptoms of urinary calculus, is an uneafy
 fenfation at the  end of the  urethra, which, for  fome time,
 is only difcovered on taking violent exercife, or immediate-
 ly after voiding urine.   This  becomes by degrees more
 fevere and frequent.   There is a ftrong propenfity to make
 urine frequently; and it is commonly voided in fmall quan-
 tities,  perhaps drop by drop.    When flowing in  a full
 flream,  it often flops fuddenly, and particularly when
 there is much colfeaed.  Nor do the efforts of  the patient
 anfwer  any good purpofe, unlefs he changes his pofture:
 for as  the  obftruaion proceeds  from the ftone  bearing
 againft the neck of the bladder and orifice of the  urethra,
 nothing elfe but its removal from that fituation  will afford
 relief; and this  is beft effeaed by elevating the pelvis.
  The urine is fometimes clear;  but it is ufually thick, and
 depofites a mucous fediment;  and when  the difeafe is in
 violent degree, it is fometimes  tinged with blood.   When
 the ftone is large, a dull uneafy  fenfation  is always expe-
 rienced about the neck of the bladder ; and the irritation
 produced by it  frequently induces a very troublefome re*
 nefmus.
  All thefe fymptoms are uniformly increafed by  exen-
 cife, particularly by  riding on  horfeback :—from a long
continuance of pain, and the want of reft which conftant-
ly is induced,  the  patient's general health becomes much
impaired ;  and unlefs the caufe  of the difeafe is now re-
moved, his mifery is, in general, only terminated by death.
                                                  The 
                       [  169  3.
   The exiftence of calculus can only be  rendered certain
 by the patient's paffing fmall ftones or fragments of ftones
 with the urine, or by feeling the ftone in the bladder by
 the intervention of a found: becaufe all the abovemention-
 ed fymptoms may  originate from a tumor or ulcer  in the
 bladder, or  from tumors preffing  on the neck of the blad-
 der.   However there will, in general, be great reafon to
 fuppofe it when all or moft of the phenomena defcribed
 occur.
   The found alfo affords us, in many inftances,  the only
 means  of determining whether the calculus be feated in the
 bladder, ureter, or kidney.   For although a ftone  in the
 pelvis renis ufually produces fymptoms which do not in com-
 mon attend vefical calculus, fuch as pain in the back,frequent
 naufea, retching and  vomiting, yet thefe are not fuch inva-
 riable concomitants as to afford any certain  charaaeriftic


                     SECT.  II.

          Of founding or fearching for the Stone*

   The operation of founding is thus to  be performed :—
 the patient being laid upon a bed, with his thighs  fome-
 what elevated, the furgeon is to grafp the  penis with the
 left hand, and then introducing the found  (pi. iii. fig.  3.)
 previoufly warmed and oiled,  into  the urethra,  with the
 concave fide  towards  the abdomen, he muft pufli it gently
 forward with his right hand, while he draws the penis
 on the  inftrument with his left.
   When the found is carried  a fufficient length, it will com-
 monly  flip eafily  into  the bladder;  but now and then
                         Y                       fome

  * The inftrument termed  a catheter, and  by means of which it is fome-
times neceffary to evacuate the urine, is ufed exactly in the  mode here
directed for the introduction of the found. 
                      [   no  ]
fome difficulty is experienced in paffing through that part
of the urethra which is furrounded by the proftate gland ;
when the inftrument flops here, we fhould not attempt to
force it forward, as it may thus be made to penetrate through
the  urethra ; but  the  fore-finger  of the left hand, well
oiled, fhould be introduced into the reaum, which by ele-
vating the flaff at the fame time that it is gently pufhed on-
ward, will commonly procure its  eafy entrance into the
bladder.   Depreffing the handle of the found will fome-
times anfwer the purpofe, but the above defcribed mode is
ufually more effeaual.
  This is fometimes a difficult  operation, and it requires
frequent performance to execute it with dexterity : an ex-
pert furgeon however will feldom fail in it, if the parts are
not much affeaed  with inflammation, fwelling,  or ulcera-
tion.
  The flaff, when entered into the bladder,  is to  be gently
moved about with one hand, in order to make it touch the
ftone.   When the calculus is  fmall,  it may  lie  near the
neck of the  bladder in fuch a manner as to fuffer the found
to pafs over  it;  when this is fufpeaed, a finger fhould be
introduced into the reaum to  alter its fituation.  If this
fhould npt fucceed, the patient ffiould be put into a variety
of poftures until the ftone can be felt.   The beft pofition, in
general, is to have the  pelvis elevated above the trunk and
head: by this, if the ftone is not contained in a cyft, which
rarely happens, it may commonly be moved to the fundus
veficse.
  The operation fhould  be repeated feveral times when
there is room to  fufpea a calculus,  and it is not difcovered
by the firft attempt.
  The fenfation communicated to the operator when a ftone
ftrikes the flaff is fo peculiar,  that an attentive and expe-
rienced furgeon can never be deceived in it; but, in fome
                                             inftances, 
                      C   HI  3
inftances, a hardened ftate of the bladder has unfortunate-
ly been miftaken for a ftone.


                    SECT.  III.

      General Remarks on the Operation of Lithotomy.

   The prefence of a ftone in  the bladder being afcertain-
ed, the  means to be employed  for the patient's relief is the
next objea of confideration.
   Although lime-water, diluted cauftic alkali, and  fome
other articles have, in particular inftances, mitigated the
pain, and leffened the frequency of  paroxyfms; yet there
has  not been one cafe  well authenticated, in which the
ftone in the bladder has been diflblved by the ufe of any
remedy  whatever.
   As all lithontriptics  are liable  to material changes in
their paffage from the ftomach to the bladder, it has been
propofed to injea fuch  fubftances into the bladder, and
thus bring  them  into  immediate contaa with the ftone.
But it has been found by various experiments, that no fub-
ftance powerful  enough to have any effea upon a ftone,
can be thus injeaed, without the greateft hazard of injur-
ing the  bladder very materially.
   From what has  been  faid, it appears that no hopes can
be reafonably entertained of the removal of a calculus, but
by a chirurgical  operation.
   Although  a great proportion of  thofe who are cut for
the ftone recover,  yet a confiderable degree of danger al-
ways attends the operation.   Children appear to recover
more readily from its effeas than adults ; and it is likewife
obferved, that old people  from the fifty-fifth to the fe-
ventieth  year, whofe conftitutions  have not  been much
broken,  run lefs rifk than men in the  full vigour of life.
                                                  This 
                     [   172  3
This  feems to arife from inflammatory fymptoms being
then lefs apt to fupervene ; for from thefe the chief danger
of the operation is produced.   But at whatever period of
life the patient  may be, the event will be  favourable or
otherwife  according to  the general health, and  degree or
continuance of the topical affeaion.
   If the bladder has even become ulcerated, and the pa-
tient is young,  and his general health  is fo good that we
need  not be apprehenfive of the effeas of the hemorrhagy,
the operation may be tried; but if, on the contrary, toge-
ther with an ulcer in  the  bladder, the  patient is advanced
in life and infirm, we fhould advife the palliatives, a free
ufe of  mucilaginous drinks, the  warm-bath and opium,
and avoid the operation ;  as it would moft probably, in
fuch eircumftances, be fatal.
   There have  been various modes of performing the ope-
ration of lithotomy ufed at different times, and in different
places.  In performing it by the leffer apparatus,  or cutting
on the gripe, the finger is introduced into the reaum, and
the ftone pufhed by it towards the perinseum; an incifion
is  then  made  immediately  on the tumor formed  by it
into  the bladder,  and  the ftone  removed.   This was
the only mode in ufe from the time of Hippocrates  to the
beginning of  the  fifteenth  century;   when Johannes  de
Romanis propofed the operation  by the greater apparatus,
which was performed nearly  in the manner of the lateral
operation, except that a blunt gorget, or fome other inftru-
ment  was  ufed, by  which  the parts were direaed to be
dilated for the paffage of the ftone ; but it always happen-
ed that  they were much torn.  The inconveniencies that
were  found to attend this method, fuggefted the idea of
cutting  into the bladder  immediately  above the os  pubis.
This was firft praflifed by Franco, a French furgeon, who
publifhed an account of it in  1561.  It has been termed
                                                   the 
                      [   173   3
the high operation 3 and was much ufed in many parts of
Europe till near 1730.
   As all thefe methods of operation  have been by  expe-
rience found much more objeaionable than the lateral ope-
ration, they have  for many years paft given place to it
almoft univerfally.*

                   SECT.   IV.

               Of the Lateral Operation.

   This  operation was invented by  Frere Jaques, a French
ecclefiaftic, about the year 1697.   Since  that  time it has
undergone various alterations.—We fhall defcribe it in its
moft improved form.
   In order to prevent the patient from going to flool foon
after the operation, the bowels ought to  be well emptied
by a laxative given the preceding day ; and a clyfter fhould
be exhibited  a  few  hours  before  the operation,  with  a
view to  evacuate entirely the contents of the reaum.—As
the bladder, when in a collapfed  ftate, is liable to be cut in
different places,  the  patient ought  to drink plentifully of
fome diluting liquor, and to retain his  urine  for fome
hours before  he is  laid  upon the  table;  and  when the
urine cannot be  retained  voluntarily, it  will be proper to
ufe a flight compreffion on the penis.
   The perinseum and parts about the anus being  ffiaved,
the patient is now to be  laid upon a table of convenient
height firmly fixed, and  there well fecured in the  follow-
ing manner :  Let a noofe be formed in the double of a
 piece of  broad  ftrong  tape  about  three feet in  length;
 the  patient's  wrift  being introduced  at this  noofe, he
                                                  ought

   * For this reafon,  it is  thought unneceffary to enter into a  particular
detail refpccting them in this work. 
                      [   174  3
ought then to take a firm hold of the outfide of the ancle
of the fame  fide, when, by  different turns of the tape
around the hand, ancle  and  foot, they are to be well  fe-
cured together ; and  the hand and  foot of the other fide
are afterwards to be tied in the fame manner.
   The operator  muft now introduce a grooved flaff, (plate
iii. fig. 2.) of a proper fize; and the  ftone being again dif-
tinaiy felt, not  only by  the furgeon, but by the affiftants
alfo,  the patient muft then be put  into the  pofture in
which he is to be kept  during  the remainder of the opera-
tion.   A  pillow, for  convenience,  may be placed under
his head; and in  order  to elevate the pelvis confiderably
above the abdomen, two pillows at  leaft, fhould  be  laid
under the buttocks, which ought to  projea an  inch or
two over the end of the table.  By obferving this direaion,
we give lefs chance of  injuring the bladder in feveral plac-
es, and more particularly if it fhould not be diflended dur-
ing the operation.
   There fhould  be an  affiftant on each  fide, to fecure the
arms  and legs of the patient; one muft prevent him from
moving the upper part  of his  body, another muft manage
the flaff, and a fifth will  be neceffary to  hand the inftru-
ments to the operator.
  The furgeon, after  having again felt the  ftone with
the flaff, is now  to make  the handle  of  it pafs over  the
right  groin, of the patient,  fo that the inftrument may  be
felt on the left fide of the perinseum ; and in this pofition
it ought  to be preferved by  the affiftant, who with his
right  hand fhould hold the  handle of the flaff, while with
his left he elevates and fupports the fcrotum.
  The thighs  of the  patient  being  fufficiently  feparated
by the affiftants ; and  the  furgeon being feated between
the patient and the window, in fuch  a manner as to make
the light  fall  direaiy  upon  the  parts to be cut, an inci-
fion is now to be made through the fkin and cellular fub-
                                                ftance, 
                       C   Hs   3
 ftance, at leaft four inches in length, in a  full grown per-
 fon, and  proportionably lefs in fmaller people; beginning
 a little to the left fide  of the rapha, about an inch from
 the termination of the fcrotum, and proceeding in an  ob-
 lique direaion  along  the  perinseum, between the tubero-
 fity of the ifchium and the  anus, until  it is extended at
 leaft an inch beyond the  latter.  This fhould be done by
 one ftroke of the fcalpel: by a  continuation of the inci-
 fion,  the ereaor penis, accelerator urinse, the tranfverfa-
 lis perinsei, and levator ani, are alfo to  be divided.   If
 in making this incifion any confiderable  veffel  fhould be
 cut, and  efpecially if the patient is much weakened, it
 fliould be immediately tied.
   It is to be particularly obferved, that the eafy extraaion
 of the ftone, and tying of arteries that may be cut, depends
 very much on  thefe incifions being very freely made.
   The operator is  now to fearch for the flaff with  the
 fore-finger of the left hand;  and having found it, he is td
 pufh his finger along the courfe of it till he paffes the bulb
 of the urethra, when, with the  edge of his  knife turned
 towards the groove of  the flaff, he is to divide the  mem-
 branous part in its whole  courfe, from  the  bulb to  the
 proftate gland, by one cut of the fcalpel;  and as the  fin-
 ger is made ufe of as a direaor, and kept between the
 reaum and the knife,  the  gut is thus preferved from  in-
 jury,  and the  incifion made with perfea fafety.  A divi-
 vifion of the bulb of the urethra, as commonly direaed, is
 never neceffary, and is  almoft always fucceeded by con-
 fiderable hemorrhagy, and the formation of finufes.
   The proftate gland, which may be evidently difcovered
 by the finger, is next to be divided.   This may be done
 by an  expert furgeon with a lateral ftroke of the fcalpel;
but as in the  hands of common operators, the reaum
might be frequently wounded by the knife, it will be beft
 to employ the cutting gorget (pi. iv. fig.  3.) as commonly
                                              direaed, 
                          [   176  3
 direaed, or what I confider as fuperior  to this,  a cutting
 dire<_lOr,* (pi. v. fig.  4, 5.)   In ufing thefe, the nail of the
 index  of the  left hand ought to ferve as  a  conduaor to
 the beak of the gorget or direaor ; which being introdu-
 ced into the groove of the flaff, the furgeon  is now to  rife
 from his feat, take that  inftrument  from the  affiftant;
 and  having raifed  it fo as  to  form  nearly a right angle
 with the body of the patient, he muft, with his left hand,
 hold it firm in this fituation ; while, with  his  right, he
 pufhes on the direaor, taking great care  that  the point
 be kept in the groove of the flaff,  till it has paffed freely
f into the bidder; a circurnftance which is evidenced by the
 urine rufhing freely out at the wound.
    The flaff is now to be withdrawn, and the finger to be
 introduced, in order,  iffpoffible, to difcover the fituation of
 the ftone ;  a pair of forceps (pi. iv. fig. 1, 4.) is then to be
 carried along  the gorget or direaor into the bladder, and
 the latter is then to be taken out flowly, and in  the  fame
 direaion in which  it was entered, left any part  might be
 cut unneceffarily.
    If the ftone has been previoufly difcovered by the finger,
 it is commonly eafily  laid  hold of  with the  forceps ;  but
 when  its  fituation  is not known,  it  is often difficult  to
 meet with it.   The forceps muft neceflarily be introduced
 fhut; but as foon as they have  entered  the  bladder, they
                                                     fliould

   * Mr. Bell fays, that his cutting diretlor, from expanding more in the cut-
 ting part, divides the proftate gland, &c.  much better and more freely
 than the gorget; and from being more contracted  in the blunt part,
 gives lefs chance of injuring the urethra,  by bruifing or lacerating it—
 But the contufion or laceration of the urethra or bladder is not occafion-
 ed by the blunt part of the gorget, but by the extraction of the ftone,
 particularly when it is large; in which cafe, an enlargement of the wound
 with the fcalpel, upon the ftone, is perhaps preferable  to breaking it  with
 the forceps.   Mr. Bell's cutting director does not appear  to poffefs as much
 certainty in its direction  and management as Mr. Hawkin's cutting  gor-
 get ; and ftill wants the teft of more general experience to recommend it. 
                          C   177   3

 fliould be gradually opened,  and  there moved about in
 various direaions,  until the ftone  can  be  laid  hold  of.
 When the calculus is fmall  and difficult to find, it is mofl
 frequently concealed in the  lower part of the bladder near
 its neck ; in this cafe  it may  be brought within reach of
 the forceps by introducing the finger into the reaum, and
 thus elevating this part of the  bladder.*
    When the ftone is got within the forceps, the operator
 fhould introduce his finger,  to difcover whether  it is pro-
 perly  fixed ; and if he finds that a ftone of  any confider-
 able length is laid hold of  in fuch a manner as to make its
 longeft  diameter  prefs  tranfverfely with  refpea to  the
 opening in the bladder, it fhould be turned with the finger ;
 or if this cannot be done,  it  fhould be fuffered to flip out
 of the inftrument, and again be laid hold of,  if poffible, in
 a  more  favourable pofition.  The furgeon   fhould  then
 gradually extraa  it; having his right  hand   firmly  fixed
 on the extremity  of the handles of  the forceps, and the
                               Z                          left


   • Mr. Bell tells us that when  much difficulty  occurs  in difcovering  a
 ftone, it has  been  alleged  that it is  often contained in a  cyft;—he
 acknowledges that  the  ftone is  often  covered  with coagulable  lymph,
 which gives the appearance of a cyft or bag, but fays we are unacquaint-
 ed with any procefs by which an adhefion can be produced between  the
 ftone and bladder ;  and that diffection has never difcovered one well  au-
 thenticated inftance of this kind.  But the following cafe would feem to
 render this opinion fomewhat doubtful.
  A boy about fixteen years of age had fuffered the fevereft fymptoms of
 the ftone for feveral years, has been  frqeuently founded  by many  gentle-
 men of the profeffion, but no ftone could  be felt; at length it was flightly
 touched  by one of them.  The  operation  was then determined on,  and
 when the operator had introduced his forceps into the bladder, no ftone
'could be found; upon which he introduced the fore finger of his left hand
 into the  bladder, and was enabled to feel  a fmall portion of the ftone thro'
 an orifice of an apparent cyft in  which it was contained; then carrying
 the cutting gorget upon his finger as a director, introduced the beak in-
 to the orifice, dilated the cyft, and turned the ftone into the common  ca-
 vity of the bladder, when it was readily laid hold of, and  extracted- 
                      [   178  ]
 left near to the common axis, and making the preffure  al-
 moft downwards, in the courfe of the wound, becaufe  he
 will thus meet with lefs refiftance, and do lefs injury, than
 by preffing in all direaions as  we are commonly advifed.
   When there is confiderable refiftance to the  paffage  of
 the ftone, the ftate of the divided parts fhould be examin-
 ed ; and if any  part  of the mufcles  which fhould  have
 been cut are ftill found entire, they fhould be immediately
 laid open  with the fcalpel, while the forceps is held firm-
 ly in the left hand.
   As the rifk of this operation is  in a great  meafure pro-
 portioned to the fize of the  ftone,  it would perhaps be ad-
 vifable, whenever this is fo great  as  to  endanger much
 injury to the parts  through which it is to be extraaed, to
 endeavour to  break it with the forceps already introduced,
 or with a pair with very large  teeth and a  fcrew.  When
 this is done, all  the fragments  muft be carefully removed
 by the forceps or fcoop, or by injeaing large quantities of
 warm water.
   When a ftone is extraaed with a fmooth polifhed  fur-
 face, it is commonly  fuppofed that there  are  others re-
 maining in the bladder,  and e contra; but no dependance
 can be placed on this; and therefore, as foon as one ftone
 is extraaed, the operator ought  to fearch firft  with his
 finger, and afterwards with the forceps, or what is better,
 the fearcher,* as long as any ftones are to be difcovered.
   The hemorrhagy from the urethra and  bladder  fhould
 not, in general, be reftrained, until the ftones are all ex-
 traaed, as it tends to prevent inflammatory fymptoms;
 when this is accomplifhed,  ligatures may commonly  be
 made on the arteries, but if this cannot be accomplifhed,
 a large canula, (pi. v. fig. 2.) covered with linen, will ufu-
 ally anfwer to comprefs them.   But fometimes it happens,
                                                   that

  * An inftrument in the form of a found, except that it is made grada-
ally fomewhat larger from the beginning of the curvature to the end. 
                      [  179   ]
that notwithftanding every precaution, fome of the deeper
feated veffels will continue to pour out blood, which colle6ts
in the bladder in great quantities.  In thefe cafes, as much
as poffible fhould be taken out with a  fcoop, (pi. iv. fig. 2.)
and warm water then injeaed to remove,  the  remainder.
In fome inftances,  when this has not been done,  the blad-
der has by  degrees become filled by  a  bloody coagulum,
which has prevented the fecretion of uri ne, and at length
occafioned  death. In order to prevent fuch an unfortunate
occurrence as much as poffible, the patient fhould, imme-
diately after the operation,  be placed with the pelvis  low,
fo as to keep the wound in a depending fituation.
   As foon  as  the hemorrhagy has  ceafed,  the patient
fliould be untied, and a piece of foft lint being  inferted
between the lips of the wound,  the thighs  fhould be  laid
together, and the patient carried to  bed ; when  a large
dofe of opium fliould be given to him.
   When the ftone has  been eafily extraaed the patient
remains tolerably free from pain, and frequently  procures
fome fleep during the firft three  or four hours after the
operation; but when the ftone has been large, and  with
difficulty extraaed, a fevere pain in the lower part of the
abdomen often fupervenes in an hour or two.   This is fome-
times eafily removed by fomentations and anodyne clyflers ;
but, in other eafes, it increafes conftantly, and when with
this, a hardnefs and fwelling of the abdomen occur, fulnefs
and quicknefs of pulfe, which go  on to  be augmented, much
danger is to be apprehended.   As thefe fymptoms origi-
nate from inflammation, bleeding, clyflers, warm  flannels
or bladders of warm water to the abdomen, fhould be ufed
freely, according to eircumftances; and particular benefit
is often derived from the femicupium.
   Thefe remedies,  together with opiates, low diet, and di-
luent drinks will frequently remove very  alarming fymp-
toms : but in fome  inftances, notwithftanding every thing
                                                  that 
                      [   180  3
that is ufed, the pain and tenfion of the abdomen increafe;
the wound has an unfavourable appearance ; the feverifh
fymptoms augment; and death at length clofes the fcene.
   When the cafe terminates happily, the wound by degrees
 acquires a healthy afpea ; the urine in fome inftances paffes
by the urethra from the  beginning; but in  moft cafes, it
comes away by the wound for the firft two or three weeks;
the pain in the abdomen  gradually abates ; and the feverifh
appearances are in a fhort time entirely removed.
   The cure is perfeaed in a longer or ffiorter period ac-
cording to the eircumftances of the patient's health.  In
a few cafes of young healthy boys, I have known  the
wound cicatrifed in  lefs  than three weeks ; but in others,
this is not accomplifhed till the  fixth, feventh,  or eighth
week.  In fome inftances again, although a great  part of
the wound is healed readily enough, yet a fmall opening is
left, at which the  urine continues to be difcharged, and
which at length becomes fiftulous ; this cannot be relieved
but by another operation.  The prevention of fuch an oc-
currence depends very much on a  proper  dreffing of  the
wound.  The dreffings fhould be light, and care fhould be
taken  that the fore heals  properly from the bottom.
   In order to prevent a troublefome  excoriation of  the
buttocks,* which is apt to be occafioned  by the conftant
paffage of the  urine over them, they fhould be frequently
wafhed with brandy, or with lime-water.
   In patients of a weak habit, an incontinence of urine is
apt to fucceed to this operation;  this commonly goes off
upon a recovery of the former ftrength; which will be much
aided by a ufe of the cold bath, of peruvian bark, and of a
nourifhing diet.  As palliatives for incontinence  of urine,
a jugum for compreffing the urethra, and a receptacle  for
                                                    the

  * This will be effectually prevented by  cleanfing the parts with a foft
fponge dipped in milk and water, and anointing them with cream two or
three times a day, changing the under fheet at every dreffing. 
                      [  181   3
the urine, properly  fitted  to the  penis, and  conftantly
worn, will be found very ufeful.
  Women, from the fhortnefs of the urethra in them, are
much lefs liable to the ftone than men, and when  it does
Occur, and an operation becomes neceffary, it is much more
eafily performed.   From the peculiar conformation of the
female,  it  cannot be executed  in  the  manner we have
direaed for males.
   The beft mode of performing lithotomy in women  i_
as  follows :■—the patient being placed on a table, and fe-
cured in the manner already direaed, a female  grooved
flaff is to be paffed through the urethra into the bladder ;
and the operator keeping  it firm  with  his left  hand,  is
with his right to introduce the beak of the cutting  direaor
or gorget into the groove,  and to run it carefully along till
it has entered the bladder.  He  fhould now introduce his
finger  upon the  direaor; and  having  difcovered  the
ftone, ne fhould proceed to extraa it  in the manner we
have already recommended.
   Inftead of cutting, it was formerly the praaice to attempt
a dilatation of the urethra ; but by the inftruments ufed, and
by the paffage of the calculus, the  parts were fo lacerated,
that an enurefis was commonly confequent to the operation.
It has alfo been propofed to cut  into the bladder from the
vagina ; but in this mode  parts are injured  which  by the
other method may be avoided; the ftone is in many  cafes
with difficulty  difcovered,  and  is not eafily extraaed:
fiftulous fores are very apt to be produced ; and a cicatrix is
occafioned which might be produaive  of  pain,  obftruc-
tion, and perhaps laceration in delivery, fliould the patient
afterwards become pregnant.   Moft  of thefe inconveni-
ences are entirely avoided by the method above advifed.
    Although the lateral operation is in  general to be prefer-
red to any other mode hitherto propofed, yet in cafes where
                                                   the 
                        C  182  ]
  the ftone is known to be of a  very  large fize,*  I mould
  undoubtedly advife the high operation, provided the patient
  was of a proper age, i. e. below thirty; for it has univerfal-
  ly happened that thofe above this age have died, when the
  lateral method has been employed.   This preference arifes
  folely from the greater eafe in extraaing the ftone; which
  is a circumftance of the utmoft confequence ; for it ap-
  pears from obfervation, that when the ftone is very large,
  e. g. above 8 oz. in weight, the proportion of deaths from
  the lateral operation,  is about 1 to 10 ; whereas when the
  ftone  is fmall, not above 1 in 20 die  from its effeas.
    Monf. Louis propofes as an improvement on  the  com-
  mon method  of performing the  lateral  operation, to cut
  the bladder itfelf, with an inftrument adapted to the  pur-
  pofe, after the external incifion, and avoid opening the ure-
  thra,  or proftate gland.  This is faid to prevent inconti-
 nence of urine, and other troublefome confequences which
 often enfue from the operation executed in the common
  way.   But it is evident, that this method muft frequently
 produce  troublefome  fiftulous  fores in  the contiguous
 parts on account of the  opening in the bladder receding
 from that of the external parts, and thus permitting the
 infinuation of the urine among them.
   Frere Cofme advifes the fubftitution of an inftrument of
 his own invention (pi. v. fig. 1.). to the gorget, for the di-
 vifion of the internal parts.   In ufing it, after the  flaff is
 laid bare in the ufual manner, the beak of the inftrument,
 or lithotome cache, as he terms it,  is  to  be introduced
 into the  groove, and being pufhed forward till it reaches
 the bladder,  the fpring is then  to be preffed down, fo as
 to raife the knife from its fheath, when the operation is to
 be finiflied by withdrawing the  inftrument in  fuch a di-
                                                reaion,

  * Which may be determined by, or at leaft inferred from, the  long
continuance of the difeafe;  the fenfe  of weight about the neck of the
bladder •, and particularly from the touch of the finger in ano.  B. 
                       [   183  3
  reaion, as may divide the neck of the bladder and proftate
  gland, in the fame manner as by the gorget: after this the
  operation is to be finifhed in the ufual way, by the  intro-
  duaion of the forceps, &c.
    The moft material objeaion to this inftrument is, that
  by it more  of the bladder may  be  injured than  ought to be
  cut; for as it muft be introduced far into that orp-an  before
  it is expanded, we will be very apt to wound the  fide,  or
  even the fundus of it.   And we can never with any cer-
  tainty  determine the extent of the  incifion that will  be
  made ; and thus if in withdrawing it, it is made to prefs in
  any degree more to one fide than the other, very different
  parts may be cut in different cafes.*


                     SECT.  V.

                     Of Nephrotomy.

    Calculi in  the kidneys always produce fuch a train of
 diftreffing fymptoms, not to be removed by internal reme-
 dies, that fome furgeons have propofed making an incifion
 down to them, in order to effea their removal.  But  the
 impoffibility of afcertaining the prefence of ftones in thefe
 parts, and the danger and difficulty of the operation,  ought
 to deter us from ever attempting it.  It is only in cafes
 where  the calculus has produced  an inflammation termi-
 nating  in abfcefs which points externally,  that  an  incifion
 can be  made with propriety: in fuch inftances, the tumor
 may be fafely opened as foon as a fluauation is perceptible,
 and the ftone extraaed, if it is not then  difcharged with
 the pus and urine.   The ulcer is afterwards to be treated
                                                     in

  * The fame  objection appears to be applicable to Mr.  Bell's  cutting
director, and will continue unlefs that inftrument  acquires a fanction  by
future experience. 
                      [  18*   3
in the ufual way—it is apt in fome inflances to become fif-
tulous.                        *


                  SECT.   VI.


                Of Stones in the Urethra.

  In calculous  complaints  ftones  are often paffed with
the urine ; and when they are pretty large and rough, they
frequently lodge in the urethra, and produce  pain, inflam-
mation and fwelling of the parts, and  always a partial, and
often a total fuppreffion of urine.  In  fome inftances, when
the difeafe is long  negfeaed, this  fuppreffion and confe-
quent tumor, terminate in  a rupture of the urethra; to
which fucceeds a diffufion of the  urine into the cellular
fubftance of the  penis,  fcrotum, and perinseum.
  When the fymptoms are not very violent indeed, blood-
letting,  general  or  topical,  according  to eircumftances
fliould be ufed; warm oil fhould  be injeaed frequently
into the  urethra; the  patient fhould be  immerfed in a
warm bath; a  full dofe of laudanum fhould be  given to
him, in order to remove the fpafmodic contraaions of
the urethra, which often very much impede the paffage of
the ftone: And  the patient fhould carefully avoid taking
any thing which will increafe the  quantity of  the urine;
as this will probably in moft cafes augment all the fymp-
toms.
  As foon as by the ufe of the above remedies  there is
reafon to  fuppofe a relaxation  is  produced, the  furgeon
fhould endeavour, by gentle preffure, to pufli the ftone for-
ward along the courfe of the urethra  : But no inftruments
ffiould be ufed to extraa it; for thefe often do injury by
irritating the membrane of the urethra.
                                                When 
                       [   185  3
    When a fuppreffion of urine is induced, it becomes ne-
 ceffary to have  recourfe to an operation, as foon as the
 means above recommended are found  ineffeaual.  If the
 difcharge of urine is praaicable, from the urethra not be-
 ing entirely filled by the ftone, the patient is fometimes in-
 duced to let it remain from  dread of the operation.  In
 fuch cafes, the  calculus often acquires, in a fhort time, a
 great increafe of fize by the depofition of earth from the
 urine.
    When calculi in  the urethra are to be removed by an
 operation, this is performed by cutting  direaiy upon them,
 and taking them out with a fcoop, or  forceps; but the
 method of doing this muft vary according to the fituation
 of the ftone.
   If the ftone is fixed in the canal near the bladder, it has
 been advifed (o pufh it back into the bladder by a flaff; but
 as it might there acquire  a  larger fize, and render litho-
 tomy afterwards neceffary, it is much more eligible to ex-
 traa it.  In doing this, the patient fhould be fecured on
 a  table in the manner direaed for lithotomy; and an af-
 fiftant fufpending the fcrotum and penis, the furgeon,  after
 oiling the firft and fecond fingers of his left hand,  fhould
 introduce them into  the anus,  and with them prefs firmly
 on the parts immediately behind the ftone; an incifion is
 then to be made  through the teguments and urethra down
 to the ftone, which fhould be removed  by the preffure of
 the fingers behind it,  or by the forceps or  fcoop.   The af-
 ter treatment muft be fimilar to that of lithotomy.
   When a ftone is fixed farther  forward in the urethra,
the fkin fhould be drawn as much as poffible paft it, either
backward or forward; and the ftone being then fecured
by preffure, a longitudinal incifion fhould  be made upon it
through the urethra,  fufficiently large to admit of its  eafy
extraaion by the forceps or fcoop.   The  edges  of the
wound are afterwards to be entirely cleared of fabulous
                        A ^                 matter, 
                      C   186  ]
matter, and the fkin allowed to regain its former fituation;
by this means the wound in the urethra will be entirely
covered by fkin  that has  not been injured,  and it will
ufually heal by the firft intention.   If, however, any urine
ffiould efcape  into  the  cellular fubftance through  the
fore, it muft be let out by an  incifion.
   When the ftone is fo near the end  of the penis as to be
feen, it may often be removed by a fmall pair of forceps;
and this may be facilitated, when  neceffary, by dilatation
of the urethra from its extremity.   But when  this fails,
an incifion muft  be made,  as before direaed.  Soft dref-
fings fhould be ufed;  and when the wound is nearly healed,
a hollow bougie, a fhort filver tube, or a fmall  catheter of
elaftic gum, fhould be introduced into the  urethra,  in or-
der  to preferve its proper fize.
   The moft unfavourable fituation in the urethra for a cal-
culus is juft  below the  fcrotum ; for if it makes its way
into the fcrotum, or  it is neceffary to make an incifion up-
on it, large and troublefome colfeaions of urine are very
 apt to be produced: as foon, therefore, as  it is difcovered
 in  this fituation, it  fhould, if poffible, be  pufhed farther
 forward or backward : but if thefe fhould both be imprac-
ticable, we ought to begin the incifion at the under part
 of the fcrotum, immediately on one  fide of the  feptum, and
 continue it upwards till the ftone is diftinaiy felt, when it
 is to be laid bare, and extraaed in  the manner already di-
 reaed.  This manner of making the incifion  gives  a  free
 paffage to  the urine that efcapes from  the urethra, and ren-
 ders the extraaion of the calculus  eafy.   During the ope-
 ration an affiftant fhould keep the teftis out of  the  way;
 and care fliould be afterwards taken that the wound  heals
 from the bottom.
   When urine continues to be difcharged by a preternatu-
 ral  opening of the urethra, for any length of  time,  if the
 calculous  diathefis remains, ftones  of a large fize will fre-
                                                quently 
                      [  187   3
quently form in  the  cellular fubftance  contiguous to the
opening; they fhould be removed by  incifion, the  for-
ceps, and fcoop, and the wound then carefully healed from
the bottom.
   In females, ftones  feldom become fixed in the urethra;
when they do, they are commonly eafily removed by infi-
nuating the end of a  blunt probe behind them, and then
pulling it forward ; or when this does not fucceed, it may
be effeaed with fafety by cutting open the extremity of the
urethra, fo as to admit a pair of forceps to extraa the
ftone.
   CHAP.     XV.

Of Incontinence of Urine.
     THE ufual caufes of this difeafe may be reduced to
        the following heads.
   1. Irritation about the neck of the bladder, produced by
the friaion of ftones contained in  it.    Hence it is fre-
quently a fymptom of calculus;  and is  entirely relieved
by lithotomy.   When this is not to be employed, it is often
confiderably alleviated by remedies which diminifh the ir-
ritability of the bladder; particularly by a free ufe of mu-
cilaginous drinks, and of opiates.
  2. Paralytic affeaions.  In thefe cafes  it  is often only
a part of general difeafe; the  fphinaer  appearing to
                                                  lofe
*  Eneurefis. 
                      C   188  3
lofe its power of contraaiori entirely,  while the detru-
for urinas or mufcular coat of the  bladder retains its  full
vigour.  The remedies to be  here  employed are tonics,
particularly  peruvian  bark,  chalybeates,  and  the  cold
bath.—But the application of cold,  by daffiing water on
the perinseum and anus, is  the moft effeaual  remedy.
Cloths wet with  vinegar and  water,  or folution of facch.
faturni, have alfo been of ufe.
   3. Laceration in the operation of lithotomy, and in  de-
livery.  In thefe cafes the fame remedies as were direaed
where the difeafe is the confequence of palfy, are to be em-
ployed, and frequently remove the complaint.
   But, in many inftances, in all the varieties of  inconti-
nence of urine, it happens that no cure can be obtained.
In fuch, all we can do is, to prevent  the urine from in-
commoding the patient as much as poffible.
   When the difeafe originates from palfy or laceration,
compreffion of the urethra by the jugum or yoke,  (pi. xi.
fig. 2.) anfwers this  purpofe very effeaually.  For wo-
men, peffaries of fponge may  be employed ; but if the ir-
ritability of the parts  do not  admit of thefe,  peffaries of
ivory  or  any  folid  wood made very  fmooth  and oiled,
ffiould be  placed acrofs in the vagina.
   When the incontinence proceeds from irritation about
the neck of the bladder, thefe inflruments cannot be ufed:
In fuch cafes, all that can be  done is  to  fit a  convenient
refervoir for the urine to the penis in men,  (fuch as in pl»
xi. fig. 1.) and to apply fponge and foft linen, to abforb it
in women.
CHAP. 
[  189  3
   CHAP.    XVI.

Of a Suppression of Urine.
     AN impediment to the evacuation of urine from the
      bladder, conftitutes a very  alarming, and  general-
 ly very painfdl difeafe.   It may originate;
   1. In paralyfis, and particularly paraplegia, from the bo-
 dy of the  bladder lofing its power of contraaion,  while
 that of the fphinaer is retained.  It is alfo thus frequent-
 ly induced from a too long continued and voluntary re-
 tention of the urine.  In thefe cafes, the introduaion of
 the  catheter, (pi.  v.  fig. 3.) which is fimilar to  the
 operation of foundingf, proves commonly a certain re-
 medy ; and when the complaint is produced  in the man-
 ner laft defcribed, it will contribute much to a permanent
 cure to ufe the catheter conftantly,  as  foon  as an  incli-
 nation is felt to difcharge the water colfeaed.
   2. From the uterus, in the laft months of pregnancy,
 preffing upon the neck of the bladder.   In fuch cafes, as
 the catheter  is very eafily introduced  in  females, in or-
 der to  prevent an  over-diftention of its coats, or a rup-
 ture of them, it  will be proper to ufe it  conftantly  when
 any difficulty in voiding urine occurs.
   Tumors in the vagina and neighbouring parts, when large
often comprefs the urethra likewife in fuch a manner as to
induce a  fuppreffion of urine ; it is alfo a  frequent confe-
quence of  prolapfus uteri.  Until  the removal of thefe
                                               caufesj
* Ifchwria.    f Chap. XIV. Sect. IL 
                      [   190  3
caufes,  the catheter fhould be  employed  occafionally as a
palliative.   When it is advifable to let a catheter remain
in the  urethra conftantly, as  thofe of filver give a great
deal of irritation, we fhould always employ the catheters
made of the elqfiic refin or gum.
   3. From fchirrofities of the  proftate gland, obftruaions
in the urethra from  gonorrhoea, and ftones  impaaed in
the urethra.   The latter cafes have been already treated
of, and the former will be the fubjeas of a  chapter here-
after.
   4.  From inflammation  about  the neck of the  bladder.
When this arrives to fuch a degree as to prevent the  in-
troduaion of the catheter, it conftitutes the moft alarming
variety  of this complaint.
   This fpecies often arifes from a  communication of  in-
flammation from the urethra,  in cafes of gonorrhaea, pro-
duced by the improper ufe of aftringent  injeaions in that
difeafe.   It may alfo originate from the general caufes of
inflammation.
   The  treatment fhould confift in general  bleeding; the
application of leeches to  the perinseum; the large ufe of
opiates; the frequent- employment of clyflers of warm
milk or water; and the general ufe of the  warm-bath.
   When all thefe remedies fail, and the introduaion of
the catheter is impoffible, we have no means of relief left
but punauring the bladder.
   There have been feveral modes of effeaing this propofed.
Mr. Sharpe, and others, advife  the bladder to be perforated
above the os pubis; this may be done with a common tro-
car, and with moft propriety about an inch or an inch and
a half above the fymphyfis pubis.   As foon as the ftillette
has entered the bladder, it fhould be withdrawn  and the
canula fhould be fuffered to remain in the opening, and be
there  fecured by a riband or tape carried around the bo-
                                                    dy 
                      [   191  3
dy.  It muft be flopped by a piece of cork, that the urine
may be evacuated only at proper intervals.
  The length of the canula fhould be particularly attended
to, left it fliould injure fome of the contents.of the pelvis ;
in fat people it may be two inches long ; but in  others not
more than an inch and an half.
  The bladder is more eafily punaured from the perinse-
um than above the pubes; the urine is more readily eva-
cuated ; and there is lefs  danger  of the canula  flipping
out  of  it and  injuring the parts  adjacent: and  hence I
am perfeaiy of opinion  that this  mode ffiould  be pre-
ferred.
  In performing  this operation, the patient fhould be laid
upon his back, and his thighs being properly feparated and
fecured by affiftants, an incifion  of an inch and an half in
length, beginning at the commencement of the membra-
nous part of the urethra, and continued towards the anus,
parallel to the raphe, and half an  inch from it,  fhould
be made through the fkin  and cellular fubftance.   The
trocar fhould then be pufhed into the bladder, a little  above
and to the left of the proftate  gland, and if the point of
the inftrument is fomewhat raifed, there will be  no dan-
ger of wounding the  uterus or vafa deferentia.   In  order
to know when the trocar  has reached the bladder, there
fhould be a groove in the ftillette to admit of an  immedi-
ate difcharge of urine.
   As foon as the urine is evacuated, the canula fhould be
fecured in the wound  by tapes, or a  riband  conneaed
with it, and a bandage paffed around the body.
   Whether the punaure is made above the  pubes,  or in
the perinasum, it will be proper to withdraw the canula
once in two or three days, in order to clean off the fabu-
lous matter that will colfea on it, and which might,  if it
was fuffered to be depofited in confiderable quantity, pre-
                                                  vent 
                      [   192  3
vent the canula from being eafily removed.  The canula
fhould remain till the urine can be evacuated by the ure-
thra.
  It has been  advifed lately,  to punaure  the bladder
through the feaum; but as this would  give confiderable
rifk of wounding the ureters, vafa deferentia, or vefkulae
feminales,  and  might afford a  paffage of fasces into the
bladder, it  fhould certainly never be employed.
  When it  becomes neceffary to punaure the bladder in
women, it  can be performed always with moft eafe and cer-
tainty from the vagina.   In doing it, the fore-finger of
the left hand fhould ferve as a direaor to the trocar, and
the perforation fhould be made in the part firft felt,  in or-
der to avoid the ureters.   The canula is to be left in the
wound as long as the caufe of the fuppreffion exifts, and
ffiould be long  enough to pafs out of the vagina,  to be
there fecured by tapes conneaed to the T bandage.
       CHAP.   XVII.

Of Obstructions in the Urethra.
    OBSTRUCTIONS in the urethra are moft frequently
      the confequence of gonorrhaea, and confift ;
   1. In caruncles or flefhy excrefcences from the mem-
brane lining the urethra.  Thefe, according to my obfer-
vation, are fimilar to thofe  warty excrefcences which fo
often appear on the glans and prepuce as a confequence of
gonorrhoea  and  generally  accompany  them.—I  have
never found them farther up the canal than half an inch
                                                from 
                      [   193  3
 from its extremity; Mr. Daran fays he has often feen then)
 in  every part of the urethra : but  it is evident that  he
 confounds them with the other  caufes of obftruaion.
   2.  In ulcers and  cicatrices from ulcers.   Ulcers are
 certainly produced  in  the urethra in fome cafes of gonor-
 rhsea.   Thefe originate,  in  many inftances, from inflam-
 mation ; but in others merely from the mechanical effeas
 of the poifon.  I have feldom found them more than an inch
 or two from the end of the penis.
   3.  In a contraaed ftate of the urethra.   Although this
 may ufually be the confequence of ulceration, yet there is
 every probability  that it may be produced folely from in-
 flammation  thickening the  parts it  affeas.  Aftringent
 injeaions, improperly ufed,  may  fometimes be confidered
 as the caufe of this fpecies of ftriaure.
   4.  In a total or partial obliteration of the canal, from
 the preffure  of tumors formed either in the cellular fub-
 ftance of the urethra, or in  the glands conneaed with it.
 This  may be the  confequence of inflammation from any
 caufe ;  and when inflammation  terminates  in fuppuration,
 the obftruaion is ufually  removed  by the difcharge  of
 matter ; but when this does not take place, and  the fwel-
 ling is of long continuance,  the oppofite fides of the ure-
 thra become conneaed, and  produce a total fuppreffion  of
 urine, unlefs, which indeed commonly happens, preter-
 natural openings are formed by the force of the urine.
   5.  In an enlargement of the corpus fpongiofum urethne.
 This fulnefs or thickening  is perhaps the moft frequent
 caufe  of obftruaion, and it has proceeded to fuch a degree,
in fome cafes, as entirely to prevent the  paffage of the
urine.   It  fometimes is confined to a particular fpot;  in
other  inftances it  extends a confiderable diftance ; and  in
fome others it attacks different parts of the  canal.
  When obftruaions  of the urethra arife from  caufes
enumerated  under the fourth head, the treatment muft  be
                      B b                     direaed 
                      [  194   3
direaed by the particular nature of the tumor or tumors.
When they are indolent or fchirrous, and do not penetrate
deep, they may  be extirpated;  but when  the proftate
gland, or any of the parts  about the neck of the bladder
are affeaed with the fchirrus or ulceration, we can only at-
tempt a cure by internal remedies.  Of thefe, cicuta has
been much ufed, but feldom with advantage.
   In  cafes of ulceration, uva urfi has been found to give
relief; but a long continued arid gentle courfe of mercury
gives the greateft profpea of benefit.  In the mean time,
mucilaginous drinks and opiates muft be freely ufed as pal-
liatives.  When the tumors  are inflammatory, if they can-
not be difcuffed, they fliould be brought to fuppuration as
fpeedily  as poffible, and as  foon  as a fluauation of fluid
is  perceived in them, they fhould  be opened.
   If on difcharging the matter, the obftruaion  is not en-
tirely removed, a bougie  or  flexible catheter fhould  be  in-
troduced, and allowed to remain feveral hours every day
until the paffage is entirely cleared.
   When the  urine, from its obftruaed flow by the ure-
thra,  forms openings from  it through the perinseum and
other contiguous parts, it produces a very diflreffing com-
plaint.  This will be confidered in the next chapter.
   In  all the other cafes of  Uriel ure we have enumerated,
if  the venereal difeafe fubfifts  in  the habit, it muft be  re-
moved by mercury, at the fame time that we pay attention
to the topical affeaion.    As all of them operate by  in-
ducing  a diminifhed capacity  or contraaed ftate of the
urethra, bougies, which  by their  preffure tend to remove
this, are  our principal  remedies.  Independent of their
mechanical power,  it is  fuppofed by many that the good
effeas of thefe are,  in a great meafure, to be attributed to a
fuppuration excited by their irritation on the difeafed parts;
and hence they have been often compofed of ftimulating
ingredients.  But I am of opinion that this is not the cafe;
                                                becaufe 
                            [   195  ]
      becaufe caruncles, which  are fuppofed to exift commonly
      when bougies are found ferviceable, do not in faa occur
      in more than  once in ten  fuch cafes, and when  they  do
      exift, they are commonly  of a warty  nature, and confe-
      quently not likely to be removed by fuppuration ; and be-
      caufe their effeas may readily be accounted for from their
      preffure only.
         It muft be evident that in general medicated bougies
      fliould therefore be  difearded from ufe ;  becaufe the irri-
      tating ingredients of  which they are compofed, muft pro-
      bably often do injury to the urethra.
         Bougies fhould be formed of mild ingredients,  and made
      very fmooth; and great care fhould be taken to have them
      of a proper confiftence.   If made too hard they are apt to
      crack, and cannot be  introduced or retained with eafe ; and
      if too foft they do not give a fufficient degree of preffure.
         The beft compofition for bougies, that I know of, is as
      follows :
 |        ;§,. Emplaft. Diachyl. Simpl. |iv.
°\          Cerse purifs.              &&•
] ^-^      Ol. Olivar. opt.          5"i-
         The  diachylon  fhould  be  flowly melted, and the wax
      being melted in the oil  in a different veffel, they  fhould
      then be mixed ; and  while the mixture is tolerably  warm,
      let pieces of fine old linen be dipt in it;  care being taken,
      by means of a fpatula, to  cover the whole  linen equally,
      and to make the plafter as  fmooth as poffible.
         As foon as the cloth is  fufficiently  cold, it may  be  cut
      with a fharp pointed knife direaed by a  ruler, into pieces
      from nine to eleven inches in length, and fomewhat  wider
      at one end than the other, for the formation of the bougies.
      They  fhould be made of  different widths;  the middle-
      fized bougies will be  formed by flips  of about five-eighths
      of an inch  broad at the  largeft end.  On account of the
       facility of introduaion it will be  neceffary to make them
                                                        taper 
                      [   196  3
 taper more or lefs, from  about two or three inches from
 the fmaller extremity.
   The ftrips of linen are to be rolled up as firmly and
 neatly  as poffible by the fingers ;  and  in  order to  give
 them a fmooth polifhed furface, they fhould be rolled for
 fome time between a piece of fmooth hard wood, and a
 plate of finely polifhed marble, and the points being round-
 ed, they are then fit for ufe.
   In the application of the bougie, one adapted to the fize
 of the paffage being fefeaed, it fhould be well oiled, and
 the penis  being firmly grafped and  extended with  one
 hand, the point  is to be inferred into the urethra with the
 other, and pufhed forward with caution until it meets with
 the obftruaion; the bougie fhould be preffed beyond this, if
 a moderate force will  accompliffi it; if  not,  it fhould be
 withdrawn, and one with a fmaller point ufed the follow-
 ing day.
   By  repeated  cautious trials,  bougies  may perhaps, in
 every inftance, be paffed; but inufing them, whenever the
 points  yield in  any degree, they fhould be immediately
 withdrawn, as  they will not then go forward, and  their
 extraaion may be rendered painful if they become twifled.
   Catgut alone, fmoothed by rubbing on marble,  or  with
 the compofition  abovementioned, forms  bougies of a fuf-
 ficient degree of firmnefs for common purpofes.
   In order to  prevent bougies from flipping into  the ure-
 thra, or  bladder, they fhould be tied by a  piece  of  foft
 thread or tape to the penis, or to a bandage paffed around
 the body.
  The length of time they fhould be fuffered to remain in
 the urethra, muft be entirely regulated by the degree of
pain or  uneafinefs they occafion ; when  this is confider-
able, they fhould not be allowed to remain long, nor be em-
ployed oftener perhaps than once in  two or three days; in
this cafe they ought  not to be ufed  but when the patient
                                                  can 
                     C   197  3
can confine himfelf to his bed, or at leaft to his apartment:
but when they give little or no pain, they fliould be worn
as conftantly as poffible.   The bougie ffiould be gradual-
ly increafed in fize until  it fills the whole urethra;  and
they fliould be ufed for a confiderable  time after the dif-
ficulty in paffing water goes off entirely. Great care ffiould
be taken that they never pafs into the bladder, as a part of
them might fall off, and form the bafis of a ftone.  When
the obftruaion is feated very near to the bladder, a cathe-
ter fhould always be made ufe of inftead of a bougie.
   Various forms of flexible  catheters to remain in  the
urethra have been employed ; the moft convenient that I
have feen confifts in a tube formed of flexible filver wire,
wrapped fpirally round a fteel probe ; and this being cover-
ed with a piece of bougie plafter, and the probe being then
withdrawn, the  inftrument is thus completed-   Thefe ca-
theters are not fo  ferviceable, however,  as has been  ex-
peaed :  and  they fhould never be fuffered to remain long
in the bladder, on account of the plafter on them.  When-
ever it is neceffary to leave a flexible  catheter in the blad-
der, thofe compofed of the elaftic refin or gum, fliould be
employed in preference to them.
   Although in general the bougies, compofed as above di-
reaed, are to be made ufe of; yet when there is reafon to
fuppofe there is a venereal ulcer in the urethra, about two
ounces of quickfilver, extinguiffied  by honey, ffiould be
added to every fix ounces of the plafter when melted.
   In women, bougies fhould always be employed for the
fame purpofes as in men ; but it often  happens that tumors
of fuch a fize form  in  the urethrse of females, that it is
neceffary to employ a ligature, or the fcalpel, to remove
them.  By thefe, even tumors that are conneaed with the
bladder,  may be taken  off.  In fuch cafes,  the  urethra
fliould be laid open on one fide, and  the vagina need not
be at all injured.  But they fhould not be meddled with,
                                                unlefs 
                      [  198   3
unlefs they give a  great deal of uneafinefs, or obftrua the
paffage of the urine very much.
  Instruments for the application  of  cauftic to carnofities
in the urethra,  have been invented and ufed ;  but it is evi-
dent,  that there muft be great  rifk of injuring  the found
parts  from this  praaice.
     C   H   A   P.     XVIII.

Of  the Fistula in  the Perinseum.
     BY the term fiftula in perinaeo is underftood a finuous
      ulcer in this  part, extending moft frequently  to the
 urethra, fometimes  to the bladder, and in other inftances
 terminating in the fcrotum or penis.
   In fome cafes there is but a fingle opening, and the con-
 tiguous parts remain nearly in their  natural ftate: but in
 others, together with one or more external openings, there
 is a hardnefs, enlargement, or inflammation of the parts
 adjacent,  extending, in  fome inftances, from the anus to
 the fcrotum and fore-part of the penis.  And as  the urine
 is more or lefs evacuated at the orifices in moft inftances,
 they are often produaive of much diftrefs.
   The caufes of fiftula in perinseo are ;
   1.  Wounds and other injuries of the urethra and blad-
der from external violence.  Thus it  is now and then the
confequence of lithotomy, or of cutting into the urethra for
the extraaion of ftones.
                                               2.  In- 
                      [   199  3
  2. Inflammation in the urethra terminating in fuppura-
tion, and difcharge of matter through the perinseum.  This
is moft frequently the  confequence of gonorrhsea.   Ab-
fceffes formed in the foft parts  about  the anus,  and ex-
tending to the urethra,  alfo occafion perinseal fiftulse.
  3. The feveral eircumftances productive of obftruaion
in the urethra, and enumerated in the laft chapter.  Thefe
by impeding the flow of urine through its natural channel,
frequently induce this complaint.
  All thefe caufes tend to produce fiftula;  1. By the for-
mation of a paffage direaiy into the urethra or bladder,  by
external violence, or ulcers and abceffes feated internally;
which may occur  independent  of  any obftruaion to the
paffage of the urine.
  2.  By the fole influence of obftruaions in  the urethra ;
in confequence  of which the urine occafions a rupture of
the urethra.
  In the treatment of  the difeafe, it is of the utmoft con-
fequence that we  attend to the mode of its produaion as
thus explained ;  and as it is fometimes conneaed with fy-
philis, fcrophula, or fcurvy, it is evident that in fuch cafes
general remedies muft  be conjoined with the topical appli-
cations.
  When the difeafe is local,  and  proceeds from obftruc-
tions  in the urethra,  and the parts  through which the
opening runs are not much affeaed, the bougie, applied in
the manner direaed in the  preceding chapter, is almoft
the only remedy neceffary, and it is  commonly effeaual.
When the obftruaion  is removed, which may be known
by the inftrument paffing in without impediment,  and  by
the urine flowing in a full ftream when the  orifice at  the
fore is compreffed ; if the ulcer does not foon heal, it will
generally be found owing to the edges having  become
callous.   Thefe muft therefore be removed in the follow-
ing manner.  The patient muft be laid upon  a table,  near-
                                                    lv 
                      [  200  3
ly in the pofture recommended  in  lithotomy, and a ftaff
being introduced into the urethra, fo as to pafs the open-
ing, it is to be  held firmly by an affiftant, while the fur-
geon introducing a fmall probe at the external orifice  of
the fore, and cutting upon it in the direaion of the finus,
is thus to lay it open its whole length, even if it extends
to the bladder.   All the finufes, in whatever direaion they
run, muft be treated  in the fame way.
  When any of the parts through which the finufes run,
have become extenfively hard, a  fmall portion  of thofe
that lie  moft contiguous to the fores may be removed,
and the remainder will commonly be  taken  off by the
fubfequent  fuppuration.   The ftaff  fhould be now with-
drawn, and the divided parts gently feparated by the intro-
duaion of lint,  fpread with fome emollient ointment; a
pledget of ointment is then to be placed over the fores, and
fecured by compreffes and the T bandage.
  About twenty-four hours after the operation, an emol-
lient poultice fhould be applied over the  dreffings ;  and  as
foon as a free fuppuration comes  on, the whole is to be re-
moved,  and light eafy dreffings fliould be continued till the
fores are healed from the bottom.  The fuccefs of the ope-
ration chiefly depends on a regular and  careful application
of dreffings.
  It has ufually been the praaice to keep a bougie or ca-
theter  in the urethra  as  conftantly as poffible after this
operation, in order to prevent, it is faid, an improper con-
traaion of the urethra, and the paffage of the urine out  at
the wound.   But, from much  experience, I can pronounce
that the wounds heal perfeaiy well without them; and that
when they are  employed, they keep  the urethra  l'o much
diftended, that they prevent the ready healing of the fores;
are not effeaual in hindering the urine from paffing off by
the orifices, if not paffed to the bladder, and if  they are
                                                paffed 
                      E  201   3
paffed fo far, almoft conftantly  excite pain, inflammation,
and fwelling about its neck.
   The paffage of the urine feems to be a very trifling im-
pediment to the healing of the  fores ; after the operation
of lithotomy, it always paffes off by the wound;  a cure is
then in common foon obtained, and the ufe of a catheter is
never thought of.  When indeed fome ftriaure occurs  in
the urethra after lithotomy, ■ or the cutting the fiftulse, it
will be ufeful to employ bougies, as in other cafes, but
never otherwife.
   When the parts in the  perinseum have  become much
hardened  and otherwife difeafed, before the operation is
put in praaice, we are commonly direaed to ufe poultices,
mercurial friaions, and gum plafters ;  but I have never
feen any material advantage  derived from  their employ-
ment.
   If the hardened parts are very extenfive, and the above-
mentioned difcutients are ineffeaual, we are ufually advif-
ed to cut them entirely away : but although it will be pro-
per to remove the callous edges of  fores  here, yet fuch a
painful operation as that muft be can rarely, if ever, be
advifable.
   When an opening is formed  in the urethra by abfceffes
feated internally or externally, or by external  violence, in-
flammation muft be moderated, or fuppuration promoted,
&c. according to eircumftances  ; and if the wounds do not
readily heal, the operation  above defcribed muft  be infti-
tuted.
   By the treatment recommended, moft of the affeaions
we have juft  defcribed may be removed; but where the
difeafe is very  extenfive, and there is fome  general  com-
plaint joined with the topical affeaion, we are in  fome in-
ftances baffled in all our attempts for a cure.
C c                  CHAP. 
E  202   3
    CHAP.     XIXj

Of the Hemorrhoids, or Piles.
HT'HE term hemorrhois or piles  is applied to tumors
 ■*■   in the rectum or its  vicinity, produced  either by a
diftention of the veins, or of  the  cellular fubftance, or
both.
   When thefe tumors do  not  difcharge any matter, they
receive the appellation of the hemorrhoides csecse or blind
piles; but  when a difcharge of  blood  or ferous  matter
takes place from them, they are termed  the apertae, open
or bleeding piles.
   Hemorrhoidal tumors that difcharge  freely are ufually
fmall; but when they do not bleed much, or  at  all, they
have  arrived fometimes to the fize of a pullet's egg.  In
the firft Cafe they  give little uneafinefs, but in the latter
they produce a great deal of pain and :rritation,  and fre-
quent tenefmus.
   Thefe fwellings have generally a dark  livid  appearance;
are at firft foft, and can ufually be much diminifhed by
preffure; when  they  become  open, they acquire a firm
confiftence, and their fize is not leffened by preffure or by
the difcharge from them.  When blind they are generally
moft painful.
   While the tumors are fmall and compreffible,  it is pro-
bable they depend entirely on an enlargement of the veins;
but  when  they  become large,  and of  a firm flefhy con-
fiftence,  they  are probably chiefly occafioned by the effu-
fion of blood into the cellular fubftance.
                                                 The 
                      E  203   ]
  The piles  are ufually  induced by a compreffion on the
hemorrhoidal veins.   This compreffion is  moft frequent-
ly occafioned by  hardened fseces in the  reaum;  by the
gravid  uterus ; and by  tumors  of the  reaum, bladder,
mefenteric glands, &c.
  In the cure, tumors muft, if poffible, be removed :—A
frequent recumbent pofture muft be advifed during preg-
nancy ; and to obviate or remove  coftivenefs gentle laxa-
tives, as cream of  tartar, and  caflor oil,  fliould be oc-
cafionally advifed.   If there is much fever, blood muft be
taken,  and  particularly by leeches  applied to the tumid
veins—The  fwelled parts fhould be bathed  with a folution
of faccharum faturni; and the patient fhould be kept upon
a low, cooling regimen.  An  ointment of equal  parts of
powdered galls and  lard or butter, is a very ufeful applica-
tion ;  and an  infufion of galls  injeaed in internal piles is
very ferviceable.  Balfam capivi is alfo very beneficial as a
laxative and anodyne.
   When the difcharge of blood in hemorrhois is fo great
as to debilitate the fyftem  much, and the above means do
not reftrain  it, it becomes neceffary either to comprefs the
bleeding veffel or veffels, or to tie them.    In flight cafes,
compreffion may be made by introducing  a filver tube,
wrapped round with foft linen ; or perhaps better, by in-
troducing a piece of fheep's gut, tied at  one end, into the
anus,  filling this by the  other extremity with water or
fome other fluid, and then tying the lower  end.
   If the veffels are fo large as  not to admit of effeaual
compreffion, and are within reach of the tenaculum, they
fhould be tied.
   When hemorrhoidal  tumors become  fo large, as to ob-
ftrua  the  paffage  of the fseces, but never before,  they
fhould be removed.  If they are feated  externally, or not
much  more than an  inch from the end  of the reaum,
                                                 when 
                     [   204  ]
when they can be brought fufficiently low,  by bearing
down, they may be eafily taken off.
  If the fwelling is  fmall, and there is no reafon to fear
hemorrhagy, it fhould always be removed by the fcalpel;
but when it  is large,  and we are apprehenfive of a confi-
derable difcharge of blood, ligatures fhould always be pre-
ferred to the knife.
  Tumors with a broad bafis may be fafely  and  eafily re-
moved in the following  manner: a needle,  armed with
two  firm  waxed threads, being introduced through the
middle of the bafis of the tumor, the ends  of one of the
threads are to be firmly tied  round one  half of the fwel-
ling, and the other is  then to be fecured in the fame man-
ner by the other ligature.   The tumor fometimes  drops
off in eight-and-forty hours, but not commonly in lefs than
three days.   When the fcalpel is ufed, the wound is to be
dreffed with lint and foft ointment.
             CHAP.   XX.

Of Condylomata, and other similar  Excre-
           scences about the Anus.
     THE parts  about the anus are liable to be affeaed by
      tumors which have received the various names of
condylomata,  fici, criftse, &c.  Thefe are all of the fame
nature, and require fimilar remedies.
  They are fometimes met with in the cavity  of  the rec-
tum, but they  moft  frequently  affea the external parts.
                                               They 
                      [   205  3
They are of various degrees of hardnefs, being fometimes
quite foft, and at other times as firm as a fchirrus.  They
are differently coloured;  fome being white, and others of
different  fhades of red.  Sometimes there is but a fingle
excrefcence  or two ;  but moft frequently all the  parts
about the anus are at laft covered by them.  They are often
not larger than warts; in many inflances, however, they
are about the ffiape and fize of fplit garden beans.  They
feem at firft to be mere produaions of the  cuticle ;  but
by long continuance they extend to the cutis, or even to
the mufcles.
  Tumors  of this kind fhould not be touched unlefs they
become troublefome.   When they  are to  be  removed, the
fofter kinds will often yield to friaion with fal ammoniac,
or wafhing with a folution of it, or to the ufe of finely pow-
dered favin.  But when the excrefcences are hard, the fcal-
pel, or lunar caufiic, muft be employed.   The former is to
be preferred ;  and after the operation, the wounds fhould
be treated with lint, &c.  as in other cafes.  When we em-
ploy cauftic, great care  nrnft be  taken  that it  does not
fpread to the reaum.
CHAP. 
[  20d  3
CHAP.     XXI.

  Of a Prolapsus Ani.
  A   PROTRUSION of any part of the inteftinum rec-
•*- ■*• turn beyond its ufual limits, is  termed a prolapfus
ani.   This varies very much in degree in different cafes.
   Whatever tends to debilitate the fphinaer ani and adja-
cent parts, will probably contribute to the  produaion  of
this difeafe; but its moft common caufe is frequent and
violent exertions excited in the reaum itfelf, by a frequent
ufe of aloetics; by afcarides; by habitual coftivenefs; he-
morrhoidal fwellings, &c.
   The reaum has often remained in  a prolapfed ftate for
a confiderable  time without injury; but it fhould always be
reduced as early as poffible.   This is  beft effeaed by the
fingers in the following  manner:  The patient being put
into bed, on his face, with his buttocks fomewhat elevated,
the furgeon fliould prefs firmly and equally  upon the pro-
truded part.  When this method fails, which is feldom the
cafe, a proper  application of the fingers of one hand to the
fuperior  part,  while  the palm of the other  hand fupports
the lower part, will always fucceed.
   We are  to obferve that this operation is only to be em-
ployed when there is no inflammation and fwelling of the
gut;  for when  thefe occur, which happens fometimes,
bleeding,  and bathing the part with folution of faccharum
faturni a  little warmed to remove them, fhould be previ-
oufly ufed.
                                                   In 
                     E  207  1
   In  order to retain the reaum in its fituation after re-
duaion,  it will be commonly neceffary to employ a thick
comprefs and the T bandage,  or Mr. Gooch's  trufs.
The patient  fhould always reduce  the  gut  immediately
after going to ftool, and apply his bandage:  and to re-
move  the debility of the parts  affeaed, he muft be di*
feaed to the  ufe of fteel, bark, and the cold bath: throw*.
ing water on  the buttocks and under part of  the back, is
particularly ferviceable.    Injeaions of ftrong aftringents,
as galls, oak-bark, &c. have alfo been  ufeful: and opium
may be advantageoufly added to remove irritability of the
reaum.   I have ufed alum and  facch. faturni with bene-
fit ; but in general all falines ffiould be  avoided.
    CHAP.   XXII.

Of an Imperforated Anus.
 TN fome cafes of this nature, the reaum is found to be
 ■*-  fomewhat prominent at the ufual fituation of the anus,
and covered merely by  the  common integuments; but in
others no veftige of the gut can be perceived.  In fome of
thefe inftances, it has been found to terminate within an
inch »f the ufual feat of the anus; in others it has reached
no farther than the top of the facrum :  in fome it has been
known to end in the bladder ; and in others in the vagina.
  As death will in all probability foon be the confequence,
unlefs an operation is performed  to relieve the patient, no
time fhould be loft.   If the end of the reaum is covered
                                                only 
                       [  208   3
only by fkin, an incifion through this is all that is neceffa-
ry.  But when the  gut lies deep, the child fhould be pro-
perly fecured,  and an  incifion  of an inch in length made
on the  part where the  anus ought to  be ; this  fhould  be
Cautioufly continued along the coccyx, the finger ferving as
a direaor, till the operator meets with the fseces, or till the
incifion is of the length of the finger; a long trocar fhould
then be pufhed forward, in  the probable  direaion of the
reaum, upon the  finger.
   When the gut is found  to terminate in  the  bladder  or
vagina, this operation fhould alfo be performed.    If in any
cafe it fhould fail of fuccefs, would it  not be advifable to
attempt an  opening above the  pubes,  or  perhaps on the
right fide, fo as to reach the caput coli, and  thus form an
artificial anus ?
   When the incifion is carried deep, it is often a matter of
difficulty to preferve the paffage fufficiently  open to ad-
mit of the difcharge of fseces.  Doffils of lint,  moiften-
ed in oil, and rolls  of  bougie plafter, I have found to be
the eafieft and beft applications ; for this purpofe, gentian,
fponge tent,  and other fimilar fubftances,  have been em-
ployed ; but they always give too much  irritation.  When
the paffage has at any time  become too ftrait,  the introduc-
tion  of a fheep's gut diftended by water, as recommended
in Chap.  XIX. is  the  beft remedy.   Much attention is
requifite  in thefe  cafes ; and they often give a great  deal
of trouble and perplexity for a long time.
   When nothing but the fkin is cut, doffils  of lint,  for a
few days, are the only neceffary  applications.
CHAP. 
E  209   3
CHAP.     XXIII.

  Of the Fistula in  Ano.
 T^VERY finuous ulcer  in the neighbourhood  of the
 -L-*  reaum is termed a fiftula in ano.   When the fore
 has no communication with the reaum, it is  faid to form
 an incomplete fiftula; when the ulcer has two openings,
 one into the reaum, and another  externally, it  is called
 complete :  and when the fore  opens into  the gut only, it
 is termed an internal or occult fiftula.
   This difeafe has alfo been diftinguiftied into fimple and
 compound.   In the fimple fiftula there  is  one or more
 finufes conneaed merely with the internal ulcer, and the
 adjacent parts are all  found : but in the complicated or
 compound,  the parts  through which the finus  runs are
 hard and fwelled;  or there is a communication with the
 bladder, vagina, os facrum, and other parts.
   In the beginning of the difeafe the contiguous parts are
 ufually found; but after a long continuance of it, and the
 difeafe has" fpread not only  over the parts about the anus,
 but even to the perinseum and buttocks, thefe  become hard
 and much fwelled.
   When the matter in  the finufes  acquires a  confiderable
 degree of acrimony, inftances  have  occurred  in  which
 the facrum  has  become  carious, and  the  vagina  and
bladder  have been corroded and  had the contents of the
reaum emptied into them ;  but fuch terrible  cafes are ve-
ry feldom met with.
                        D d                Whatever 
                      [  210  ]
   Whatever tends  to  produce the formation  of matter
 about the anus,  may  occafion this difeafe; fuch as the
 piles ; condylomatous tumors ; hardened fseces in the rec-
 tum ;  and fevers.
   On account of the languid circulation in thefe parts,
 inflammatory fwellings are very apt to terminate in fuppu-
 ration ; and fores thus induced heal with difficulty.
   As  foon as fuppuration appears to be coming on, there-
 fore, we fhould employ every  means to haften the forma-
 tion of matter; fuch as warm  poultices, fomentations, and
 the fteams of water; and as foon as pus is  produced,  it
 fhould be evacuated by a very  free incifion.
   The wound fhould be  very lightly  dreffed with fome
 emollient ointment fpread upon lint,  and a foft  poultice
 ought to be applied conftantly over  the whole.   By this
 means the hardnefs will be removed, and a cure will often
 be eafily accomplifhed.
   A furgeon is, however, feldom called until a fiftula  is
 fully formed ; his  firft objea ffiould then be, to afcertain
 the courfe of the  finus or finufes.   When the  fores are
 external, this can eafily be done by the probe alone; but
 when they run  up by  the reaum, the finger fhould be
 oiled and introduced into the gut, at the fame time that the
 probe is paffed in at the ulcer, in order to determine whe-
 ther it communicates with the inteftine, which is  a point
 of confequence.  When this will  not afcertain it, the paf-
 fing of the fseces or air at the fore, or water injedled  at
 the fore coming out by the inteftine, will fometimes direa
us.
   Aftringent injeaions, paftes and ointments, have at dif-
ferent  times been ufed for the  cure  of fiftula  in ano; but
experience has proved them to be not only ufelefs,  but of-
ten injurious.   The real indication is to excite  fuch  a
degree of inflammation on the fides of the finus  as will
produce a union of them.   This in fiftulse of other parts
                                                    is 
                      E   211   ]
is accomplifhed either by the introduaion  of a cord of
cotton or filk, along the courfe of the fore, or by laying
the whole finus open, fo as to reduce  it as nearly as pof-
fible to the ftate of a recent wound  : but as the feton here
gives too much irritation, the latter mode is to be pre-
ferred.
   The day before the operation, the bowels fhould be well
emptied by a laxative,  and the reaum fhould  be cleared"
by a clyfter given a few hours previous to it.
   The patient may be either allowed to ftand up with his
back  expofed to the light of a window, and leaning for-
ward on  a chair, table, or bed; or  he may be laid on a
table in  the  pofture  direaed  for lithotomy.   Which-
ever is chofen, the patient  muft be  firmly held  in it; and
the furgeon, after dipping the fore-finger of his left hand
in oil, muft introduce it as far as poffible into the reaum,
and with his  right hand muft then enter the probe-pointed
biftouri,  and carry it forward until he  feels the point of
it through the opening in the gut, for we fuppofe this to be
a complete fiftula;  he is then to bring the point, guarded
and fupported by the finger, out of the reaum, by which
means the finus will be entirely  laid open.   If there are
more finufes than one, they fhould all  be opened.  It fel-
dom  happens that  more than one  communicate with the
reaum, but they generally communicate with each other.
   When the fiftula is incomplete, the  only difference be-
tween the operation for it  and the  one juft  defcribed, is
that  the  biftouri muft  be pufhed through the  reaum at
the fuperior part of the finus.
   When the finus extends very far up the reaum, all that
can be fafely done is to divide the finus as high as the fin-
ger will reach.
  The hemorrhage  from this  operation  is very trifling;
and therefore the method of cure  by introducing a flexible
piece  of lead or  filver at the orifice, bringing it back by
                                                  the 
                      E  212  3
the gut, and then twifting it, is totally unneceffary on  ac-
count of the difcharge of blood.   The pain attending this
mode by ligature, and its tedioufnefs will probably prevent
it from being received into general ufe.
   The wound  being  cleaned,  a piece of foft lint or linen,
covered with a liniment of wax and  oil, fhould be infinu-
ated between its edges, but not fo far as to give uneafinefs.
A comprefs and the  T bandage being then  applied,  the
patient fhould be carried to bed ;  and the  dreffings being
renewed after every ftool, or  about  once in  twenty-four
hours, the fores will generally heal very well.
   By this method, diarrhsea  and tenefmus, which often
prove  very troublefome  when dreffings at all irritating,
even dry lint, are employed, are entirely prevented.
   Injeaions are often advifed to clean the fores, but they al-
ways do  injury.  Nothing more is in general neceffary
than to remove any fseces which may lodge in the wound.
   In fome inftances, inftead  of a favourable appearance,
the fore  acquires a foft unhealthy afpea,  and the matter
difcharged from it is  thin, foetid, and perhaps mixed with
blood.    A hitherto  undifcovered finus is in thefe  cafes
fometimes found upon examination;  this fhould be imme-
diately laid open : but it more frequently happens that this
ftate  of  the fore  depends upon fome general affeaion,
which till then had not manifefted itfelf.  In this cafe, re-
medies adapted to the difeafe fhould be employed.  It may,
in fome inftances, be the confequence of mere debility from
fever or difcharge of matter.  Tonics, and a generous diet,
will then effea a cure.
   When  the  difeafe  has  continued long, experience has
taught me  the propriety, and  indeed neceffity, of forming
an iffue ; making it difcharge freely for fome time previous
to the operation.
   By thefe feveral means, the difeafe, when  confined to the
vicinity of the reaum, may almoft always be removed.
                                                    In 
                      [  213   ]
   In an advanced ftage, the matter fometimes not only
feparates the fkin from the mufcles in all the parts adjacent
to the reaum, but even detaches the reaum itfelf from
the cellular fubftance,  with  which in health it is fo firmly
conneaed.  In fuch inftances, all that fhould be done, is
to lay open the inteftine as far as it is feparated ; and if this
is not fufficient to make it apply equally to the furrounding
parts, another  incifion fhould  be made on  the oppofite
fide of it: by this means, if the conftitution is  pretty good,
an adhefion will take place between the gut and the parts
contiguous,  and a  complete cure will be obtained.   Si-
nufes feated externally fhould be treated in the fame way.
The dreffings in both fliould be mild, and applied over the
fores only, and not infinuated between their edges.
   The occult  fiftula, or that in which there is no external
opening, is to be diftinguiflied by a difcharge of matter un-
mixed with the fseces;  by fome  degree of hardnefs, fwell-
ing or difcolouration in the vicinity of the fundament; and
by pain from preffure on it.
   In this fpecies, a fcalpel or lancet is to be plunged into
the part  where we have reafon to fuppofe the abfcefs feat-
ed ;  and  the  difeafe being then  reduced to the ftate of a
fimple, complete fiftula, the operation is to be finifhed as
was direaed for that  variety of the difeafe.    The fubfe-
quent treatment muft be fimilar to that ufed in other cafes
of fiftula.
   We have hitherto fuppofed the parts  affeaed to be no
otherwife difeafed than by having an abfcefs feated in
them, and finufes conneaed with it;  but when by ne-
gfea or improper treatment the matter colfeaed does not
find a free vent, the parts contiguous to it become inflamed
and painful, and gradually acquire a confiderable and dif-
treffing hardnefs or callofity.   In fuch eircumftances, ex-
perience has taught  us that  poultices, mercurials, &c. as
advifed by fome, are  perfeaiy inadequate to the difcuffion
                                                   of 
                       E   214   j
 of any fuch callofities as are confiderable and of long du-
 ration ; and that it is entirely unneceflary to deftroy them
 by cauftic, or extirpate them with the knife,  except they
 cannot be preferved but at the hazard of the patient's life.
   In inftances where thefe callofities occur,  the finufes
 fhould not only bejaid open as direaed in fimple  fiftulse,
 but incifions fhould be made along the  whole extent of
 the hardnefs;  and if a free fuppuration does not  fponta-
 neoufly fucceed to the inflammation  which  is  commonly
 produced, it fhould be encouraged by  warm poultices, and
 fupported till the greater part of the callofity is removed;
 which will commonly happen after fome time, if the  habit
 is healthy.   When fuppuration cannot be readily induced,
 and the edges of the fores become inflamed and  painful,
 and a foetid thin matter is  difcharged,  fome general difeafe
 may be fufpeaed.
  If the edges of the fores are very hard and reverfed, it
 may be  ufeful to take off  a part of them ; and  if the cal-
 lous  parts  are fo feparated from thofe beneath, that they
 will probably never adhere to them again, they muft  be
 removed; but in no other eircumftances can extirpation, in
 any degree, be with propriety advifed.
  It fometimes happens that the matter colleaed in fiftula
 in ano penetrates to the bones ; but it oftener happens that
 the bones  are  the parts  primarily affeaed.   Thus the
 matter may be  formed  in confequence of caries  of the
 lumbar vertebrse, os facrum or  coccyx,  and find  its way
 down to the vicinity of the anus.
  But the mofl diftreffing fymptoms attendant on fiftulse in
ano, is the formation of a paffage between the reaum and
bladder.  This is known  moft certainly by an offenfive
dark fediment in the urine, obftruaions  to  the  paffage of
the water, and the difcharge of air  by the urethra either
before or after making water.   Li fuch cafes  the patient
                                               lingers 
                     [  215  3
lingers for fome time, and at  length falls, a viaim to the
difeafe.
  When the bones have become carious from  the matter
penetrating to them in this difeafe, all that art can do is to
preferve a free  vent to the matter;  to keep the parts clean ;
to extraa pieces of loofe bone; and to ftrengthen and fup-
port the  conftitution during thg long continued difcharge
which will  probably enfue, by tonics  and  nutritious  diet.
Some few have  recovered  by  this management; but all
that can in  general be expeaed, is a mere  palliation of the
moft diftreffing fymptoms.
           CHAP.   XXIV.

Of the Paracentesis of the  Abdomen.
     THE operation of paracentefis or tapping is inftituted
      for the removal of colfeaions of fluid in the abdo-
men.
  . Afcites, or a colfeaion of  watery fluid in the  cavity of
the abdomen, is often a fymptom  of  anafarca or general
dropfy ; but it is alfo frequently a local difeafe, and origi-
nates  from  compreffion of the lymphatics, by fchirrous
vifcera, and particularly the liver.
  This difeafe is  known by fwelling and tenfenefs of the
abdomen ; difficulty of breathing, particularly in a horizon-
tal pofture;  and by  a fenfe of fluauation communicated
to the fingers placed on  one fide of the  abdomen, when
                                                  the 
                      E  216   3
the fwelling is forcibly ftruck on the other.   With  thefe
fymptoms there are alfo ufually joined great thirft, paucity
of urine, dry fkin, and other figns of dropfy.
   When the fwelling extends equally over the abdomen,
the water is commonly diffufed among the different vifcera,
and is contained in the peritonseum only.   But  it fome-
times happens  that it is colfeaed in different  cyfts,  or in
one of the ovaria,  when the tumor is not ufually  fo equal,
nor is the fluauation  fo diftinaiy perceived.   The fluau-
ation depends alfo on  the confiftence of the fluid; in fome
cafes this is thick and gelatinous, though commonly  thin
and ferous.   A great  number  of  fmall hydatids are alfo
often found fwimming in the water of afcitical fwellings.
   As diuretics and other evacuants are feldom found ufe-
ful in local dropfies, and as the  vifcera may receive injury
by being long  furrounded by  a fluid in afcites, tapping
fhould  always be advifed as foon as a fluauation is  to be
perceived.   It  is  attended with very little pain, and the
danger  arifing from it in fome cafes, is to be attributed to
the ftate of the  conftitution at the ufual time  of its  per-
formance, rather than to the nature of the operation.
   In all large colfeaions  of  fluid, and particularly in the
abdomen, it  has been  found dangerous to evacuate their
contents fuddenly, without fubftituting preffure during the
difcharge, and  for fome  time afterwards,  to  the fupport
thefe have given to the circulating fyftem—hence the utility
of applying a proper bandage to the whole  belly.
   The  inftrument now univerfally employed for tapping
is the trocar.   The flat trocar,  with  a  lancet point, (pi.
vii. fig.  3.4.) enters the abdomen with more eafe, and gives
lefs  pain than the common round trocar with  a triangular
point,  it fhould therefore be preferred to it.   The part of
the abdomen which can be perforated  with  the greatefl
fafety,  is the point lying at nearly an equal  diftance be-
                                                 tween 
                      E   217   3
tween the umbilicus and the centre of the fpine of the ile*
um.
   This  point being marked with  ink, the bandage deli-
neated for the  purpofe, (pi. xi.  fig.  4.) is to be  applied
moderately tight, one of the holes being fixed exaaiy op-
pofite to the mark.   The patient is to be placed in a ho-
rizontal pofture, with the fide in which the perforation is
to be made lying over the edge of the bed.   The  furgeon
is then to  take the trocar in his right hand, and fixing the
head of the flillette in the palm, immediately below  his
thumb,  and direaing  the  point of it with his fore-fin-
ger, he is  now to pufh it into the cavity of the abdomen;
this may be known to be effeaed by the  want of farther
refiftance to the inftrument.  The flillette being then with-
drawn,  the water is to be difcharged;  taking care  to have
the bandage tightened as the water flows—if the patient
becomes faintifh, the difcharge may be flopped now and
then for a few minutes.
   When the difcharge is obftruaed or flopped by omen-
tum or  inteftine preffing on the mouth of the canula,  a
blunt probe fhould be  inferted into  the tube to pufh them
back.  When the floppage proceeds from  the confiftence
of the fluid, a larger trocar fhould be introduced.  Some-
times it originates from the  water being colfeaed in cyfts ;
in this cafe, the canula muft be withdrawn,  and the wound
being covered with a  pledget of ointment,  the operation
may be renewed immediately, or on the  fucceeding day,
in the oppofite fide of the belly; or if fwelling appears in
any particular  part of the  abdomen, the  opening fhould
be made in the mofl depending portion of it.
  If after  this  operation notwithftanding  the ufe  of pro-
per remedies,  other  fwellings fhould follow, it   may be
repeated whenever they have  acquired any confiderable
fize.
                         E e                     The 
                      [   218  3
   The wound is to be dreffed lightly as  already direaed;
 and the ufe of the bandage  fhould  be continued, as  the
 fupport it gives may have fome effea in preventing a  re-
 turn of the difeafe.
   In tympanites, or colfeaion of air in the  abdomen,  the
 fwelling is more tenfe  than in  afcites, and  affords to  the
 touch nearly the fame fenfation as is  received from a blad-
 der filled with air.
   In tympanites the air is moft frequently contained in  the
 inteftines, and probably is hardly ever found between them
 and  the peritonseum but  in  confequence of a breach in
them.   Tapping with a fmall trocar, and with  the fame
precautions as in afcites, ffiould undoubtedly be ufed for its
removal when all the other remedies prefcribed fail, as it
will  give the only chance of relief.
   After tapping, both in afcites and tympanites, as foon
as the bandage can be removed with fafety,  i. e. in about
two  days,  it fhould be taken off for a quarter of an hour
daily, and  the belly ffiould be well rubbed with fome fpi-
rituous aftringent application,  the patient being previoufly
placed  in a horizontal pofture.
CHAP. 
[  219   ]
         CHAP.   XXV.

Of the Paracentesis of the Thorax.
     THE  operation of  tapping  the  thorax,  is indicated
      whenever the aaion of the heart or lungs  is im-
peded by fluids colfeaed in the cavity of the cheft.  The
different kinds of fluids met with  there, and ^requiring eva-
cuation by a perforation, are, ferum, blood, pus, and air-

                     S  E C T.  I.

           Of  Serum  colleBed in the  Thorax*


   Watery colfeaions  in the cheft  are frequently met
with, and are often combined with dropfy in other parts:
They are, however, in many inftances, merely local affec-
tions ;  and in thefe only are we to expea advantage from
the paracentefis.
   The fluid is contained either in one fide of the general
cavity of the thorax or both ; in the pericardium ; or in the
mediaftinum.   It requires much  attention to afcertain the
exiftence of water in the cheft, and efpecially  its particu-
lar fituation.
   A patient complaining of a fenfe of weight or oppref-
fion in the thorax ; of difficult refpiration ; of  more unea-
                                                 finefs
* HydrothoTax. 
                      E  220   3
finefs in one fide of the cheft than the other;  of inability
to lie on the found fide ; of being liable to fudden ftartings
during fleep, from a fear of fuffocation ; and if with thefe
he has frequent cough ;  fmall and irregular  pulfe; and
efpecially a dry fkin, paucity of urine, and other fymptoms
of dropfy,  there can be little doubt of the prefence of this
difeafe.  A fenfe of undulation,  as of water paffing from
one  fide of the  cheft  to the other, is  fometimes ob-
ferved by the patient upon rifing fuddenly from a horizon-
tal pofture  ; and this contributes alfo to afcertain the pre-
cife feat of the  colfeaion.  In order to determine  this point
more clearly, the patient fhould have his breaft uncovered,
and one hand being placed upon the ribs near the flernum,
we fhould ftrike with the other forcibly near to the fpine.
This will anfwer when  the  quantity of fluid  is confider-
able : When  it is fmall, we can afcertain its  prefence
moft certainly by Handing behind the patient  on a chair,
and fwinging  the upper  part of his body repeatedly, by
fudden jerks, from one fide to the other.
   In long continued affeaions of this kind, there is fome-
times a degree of fwelling in a particular part of the cheft,
produced by the colfeaed water.
   The general fymptoms of hydrothorax  do  not  vary
much in whatever part of the cheft the water is effufed.
In the hydrops pericardii the patient, it is faid,  complains
chiefly of the  middle and left fide of the thorax, and there
is a firm undulatory motion perceived between  the  third,
fourth, and fifth ribs at every pulfation of the  heart.
   This difeafe is produced by the caufes of dropfy in ge-
neral ; and when  it is afcertained, as no remedy has yet
been difcovered for  its  removal,  the operation  fliould be
always advifed as foon  as the fymptoms appear danger-
ous, and relief is not found  from other means.  It is thus
to be performed.
                                                   The 
                      E   221   3
   The patient fhould be laid in a horizontal pofture, with
 the fide  to be  operated upon over the edge of the bed:
The fkin  over  the part  to be perforated  is then to be
 drawn up as much as  poffible by  an affiftant, who muft
keep it fo during the operation ; and the furgeon is now,
with a fcalpel,  to make an incifion of about two inches in
 length, between the fixth and feventh ribs, in  the fame
direaion with them, and at an equal diftance between the
 fternum and fpine, taking care to  avoid the under edge of
the fuperior rib,  on account of the  blood-veffels running
in its  groove.   This muft be  carried through the tegu-
ments : the divifion of the mufcles muft be no more than
about an inch in length.   The pleura is to  be very cauti-
oufly diffeaed,  in order to avoid all rifk of wounding  the
lungs, if  they  fhould happen in this place  to adhere.   If
this is  not the cafe, the water will  ruffi out as foon as the
membra ne is cut through : ffiould there be an adhefion of
the lungs to it, the incifion may be carried  an inch or two
nearer  the fternum, or it may be made an inch or two
higher or lower.
   The opening fhould be fmall, and a canula introduced
into it for the  more convenient evacuation of the water,
flopping the  difcharge if the  patient fliould be faintifh,
and to prevent  the ready accefs of  the air to the  cavity of
the thorax.   When the water is not in  great quantity it
may ufually be  drawn off at once ; but when the colfeaion
is large, partial evacuations may be made at longer or ffiorter
intervals  according to eircumftances.   For this purpofe
the canula fhould be tied to the  body by a riband con-
neaed with it; and it fliould be ftopped with a piece of
cork.   A pledget of emollient  ointment  fliould be  laid
over the wound, and the whole being fecured by the nap-
 kin and fcapulary, the  patient fhould be put to reft.   Af-
ter a delay, perhaps of a day or two, an additional quan-
tity may be difcharged, and fo on till  the patient is entirely
 relieved.
                                                When 
                       E   222   3
   When the water is effufed into both fides of the cheft,
 it will be neceffary to perform two  operations  to effea its
 removal.  But as the patient might fuffer as  much from
 the air which unavoidably gets into the cavities as from the
 water, if both fides  were perforated at once, it  will be
 proper after one operation, to  endeavour  to expel the
 air from the  fide perforated  before we undertake  a fe-
 cond.  The eafieft  and  moft convenient way  of doing
 this is to let the  patient endeavour, as far as poffible, to
 fill the lungs with air, immediately after the canula is
 taken out.  This will expel a confiderable quantity by the
 orifice;  the fkin  fhould then  be  drawn inftantly over the
 fore, and preffed down during infpiration.   This muft be
 repeatedly done;  and by it moft of the air may be expel-
 led : after which the fkin fhoufd be drawn over  the wound,
 and the dreffings applied as already direaed.
   The air might alfo be  extraaed by the application of
 an exhaufted  fyringe, either of the common  kind or  of
 the elaftic gum.
   Air in the cheft may not only prove hurtful by imped-
 ing the motion of the lungs, but  alfo by inducing inflam-
 mation on them,  and the  other parts within the thorax :
 its admiffion fhould,  therefore,  be  guarded againft very
 attentively,  as  well as  its expulfion when it  has  gained
 an entrance.
   It has been propofed by fome to perforate  the  thorax
 farther  up than  we have advifed,  and by  others  lower
 down ; and a trocar has been recommended for  the per-
forator—but it muft be evident to thofe who reffea  on the
fubjea, that the  mode  we have  pointed out  is  attended
with much lefs danger and difficulty.
  In dropfies of the pericardium, this operation might be
employed with fome profpea of benefit.  It might be per-
formed by making an opening between any two  of the ribs,
from the third  to the eighth, and within fix inches of the
                                             fternum- 
                      E  223  ]
 fternum.   The incifion of the pleura fhould be about an
 inch long; and  the Water would be beft difcharged  by
 pufhing a fmall trocar into the pericardium.   If the quan-
 tity is fmall, it may all be drawn off at once; if confidera-
 ble, it fhould certainly be done very gradually.
   When water is in the mediaftinum, which will be render-
 ed probable by  particular pain and oppreffion above it, a
 piece of the fternum fhould be taken out by the trepan,
 and a perforation  fhould be  made into the  fwelling with
 a trocar, and the water cautioufly evacuated.

                    SECT.  II.

              Of Blood colleBed in the Thorax.

   In general, the fymptoms of blood colleaed  in the tho-
 rax are fimilar to  thofe produced by ferum; but they are
 ufually obferved to prove more diftreffing.
   Blood may  be extravafated into the cheft:
   1. From wounds of the blood-veffels  by fharp inftru-
 ments.
   2. From the fplinters of fraaured ribs, fternum, or ver-
tebrse entering the veffels.
   3. From erofion  of the  arteries or veins by the matter of
abfceffes or ulcers.
   4. From the rupture of the veffels by violent exertions,
and particularly by coughing.
   As fome of the  fanguiferous  veffels of the  lungs them-
felves are  ufually  the feat of the  difeafe,  relief  is  com-
monly more or lefs obtained by  the expedtoration of the
evacuated blood ; but when neither this, nor blood-letting,
a cooling regimen, and other remedies, prevent  the aflion
of the heart or lungs  from being much obftruected, the
operation  of the paracentefis fliould undoubtedly  be per-
formed.    Mr. Sharpe, indeed, is of opinion,  that we had
better truft to  the coagulation of the blood for the remo-
                                                   val 
                       [  224  3
 val of the hemorrhagy, and to the abforbent veffels for tak-
 ing away the blood thus depofited;  but it is evident that
 if the veffel is fmall,  little or no additional rifk will be in-
 curred by a perforation, as the hemorrhagy will probably
 ceafe  on the patient's becoming faint; and if the ruptured
 veffel  is large, the  patient will probably die, whether the
 operation is ufed or not.
   In performing this  operation, the direaions given in the
 preceding feaion will generally apply;  but it muft be ob-
 ferved, that  when  a fraaured  bone, or fome extraneous
 body is the caufe of the hemorrhagy, the incifion fhould
 be made as near the affeaed part as  poffible, fo that it
 may ferve for their extraaion, as well as for the evacuation
 of-^the blood.  And  when there is  an external  wound,
 this if properly fituated, fhould be  enlarged  for  the dif-
 charge of the blood, inftead of making another opening.
   As the blood is very apt to coagulate in a little  time, if
 we find it impoffible  to remove it merely by an incifion of
 an inch or fo, tepid water fhould be cautioufly injeaed in
 fmall quantities, and fuffered to remain fome time  in order
 to diffolve it.


                   SECT.   III.


    Of an Empyema, or a ColleBion of Pus in the Thorax.

   An empyema is probably never met with but as a con-
fequence of pneumonic inflammation.   And when  a pa-
tient, who has for fome time had a fixed pain in the cheft,
attended with fever, cough,  and other figns of inflamma-
tion, is at laft fiezed with an oppreffed refpiration; an in-
clination to fit in an erea poflure; with a total inability
of lying on the found fide ; a conftant tickling cough ; with
frequent fhiverings ; and efpecially if there  is an accompa-
                                                 nying 
                       E   225  J
  nying enlargement of the affeaed fide, or a foft cedematous
  fulnefs of the  part in  which the pain was at firft feated,
  we may conclude with certainty that  a large colleaion  of
  matter is formed.
    When the pus thus formed is not foon evacuated by the
  mouth,  which frequently happens, the only remedy to be
 depended  on is the paracentefis.
    The general rules already given are to be obferved in this
 operation; except  that  in  whatever  part of  the  thorax,
 whether under the fternum, ribs, or other parts, the feat
 of the abfcefs is indicated, either by a  long continuance  of
 pain, or by matter diftinguiftied, there  the operation fhould
 be performed.   But if the  particular feat of the difeafe is
 not pointed out, the perforation  muft be made in the ufna]
 place.
    Colfeaions of matter  in the thorax are ufually formed
 in the lungs and  thence poured  into the cavity or cavi- ■*'
 ties; but  in many inflances,  large quantities of pus are
 found between the pleura and  lungs, produced  from an
 inflammation of the pleura alone.   In thefe cafes ulcera-
 tions  are  commonly produced, which continue a  long
 time after the perforation is  made.
   The conftant motion of the lungs; the neceffity of avoid-
 ing the excitement of that degree of inflammation which is
 neceffary for the union of the parts; and our being preclud-
 ed from the benefit of compreffion, render the  cure of ab-
 fceffes in the lungs by far more  difficult than thofe feated
 in any other part of the body.   Hence the difcharge ufu-
 ally continues for life,  or if it ceafes  for any time by the
 healing of  the fore, it almoft conftantly burfts out again,
 or  another operation  becomes  neceffary  to  relieve  the
 dangerous fymptoms induced.  On this account it will be
proper, whenever the opening has much tendency to dofe,
to enlarge it by the introduaion of a common bougie, or
of a fhort tube of filver for a few hours.
                      F f                  SECT: 
E  226   3
                   SECT.   IV.


           Of Air Extravafated in the Thorax.

   Air colfeaed in the large cavities of the cheft, produces
the fame fymptoms of oppreffion  on the  heart and lungs
that are confequent to  the prefence  of water, blood, ot
ferum.
   This colfeaion of air  may be produced;
   1. By a gangrene of fome part within the thorax.  This
fpecies of the  difeafe  feldom  comes under the  care of the
furgeon; its removal depends entirely on the cure of the
mortification, which is feldom accomplifhed.
   2. By a rupture of the inverting membrane of the lungs
by a violent exertion, as in coughing, crying, or laugh-
ing.
   3. By an erofion of the furface of the lungs from ulcers
and abfceffes.
   4. By wounds  of the lungs  from a fharp inftrument,
pufhed obliquely into the thorax.
   5. By a wound of the lungs from fraaured vertebras,
or ribs.   A fraaured  rib is the moft frequent caufe.
   A colleaion of air in  the cheft differs from colfeaions of
pus and ferum in its fymptoms, only in refpea to the quick-
nefs of their progrefs; for there are inftances of death hav-
ing been induced by it in a few hours.  In moft  cafes the
cellular fubftance  of  the breaft becomes inflated; and if
means are not  foon employed to prevent it,  the air infinu-
ates itfelf through every part of the body.
   The particular  fymptoms confequent to a wound of the
lungs from a  fraaured  rib are as  follow; a tightnefs in
the breaft; fome  oppreffion in breathing ; pain in the parts
                                               chiefly 
                      [  227  3
chiefly affeaed ; gradual increafe of the difficulty of breath-
ing, till at length the patient can breathe only when erea
and leaning forward ; flufhing and fwelling of the face ;
feeble pulfe, at length irregular ; cold extremities; and if
relief is not foon obtained, death.
  The emphyfematous  fwelling of the cheft  and other
parts,  which fometimes occurs here, is eafily diftinguifhed
by the crackling noife produced by  preffure on it.  For the
removal of this fymptom,  fcarifications are employed.  By
making feveral incifions,  half an inch in length, along the
courfe  of the  fwelling, and  then preffing the air towards
the orifice, a good deal  may be evacuated.   The place of
this will be fupplied by  air from  the thorax, and if the
quantity which efcapes from  the wound in the lungs is not
greater than  that  difcharged  by  the  fcarifications,  the
whole  may in this manner be foon removed.  But the re-
verfe frequently happens; and, our only remedy then con-
fills in the  paracentefis.  This  operation  affords imme-
diate relief, and is to be performed  in the manner already
direaed.
CHAP. 
C  '228   3
CHAP.     XXVI.

     Of Bronchotomy.
        THE formation  of an  opening  in  the trachea, or
         the  operation of bronchotomy, is  neceffary when-
   ever refpiration becomes  fo much obftruaed from a local
   affeaion of the fuperior part of the wind-pipe, that life is
   endangered.
      This operation is attended with very little danger, and
   a neceffity for its performance may originate;
      1. From a fpafmodic affeaion of the  mufcles of the
   glottis, produced by acrid mucus in catarrh, and by bread,
   and other fubftances getting into the  trachea.
 /     2. From a piece of bone, flefh, or any other firm fub-
   ftance lodged  in the pharynx, or upper part of the cefo*
|   phagus, and preffing on the trachea.
      3. From polypous excrefcences reaching far down into
   the pharynx,   When thefe  tumors are to be extirpated,
   the operation is  much facilitated by previoufly performing
f   bronchotomy.
\      4. From tumors, particularly thofe of the fchirrous and
   flefhy kinds feated externally, as in bronchocele.
      5. From fwellings  of the  tongue and  glands of  the
   throat arifing from  inflammation, either  when the parts
   have previoufly been found,  or in a fchirrous ftate.   It can
   never be neceffary, however, when thefe have fuppurated,
   as mere punaure of the  fwelling will then relieve  the pa-
   tient.
                                                 6. From 
                      E  229   j
  6. From fufpended animation by  drowning, when the
lungs cannot be inflated by other methods.
  In order to perform  this operation, the patient fhould
be laid upon a table, with his head drawn back, and limbs
fecured by affiftants.  A longitudinal incifion fhould then
be made with  a fcalpel through the fkin and cellular fub-.
fiance, an inch in length, on the  middle and anterior part
of the trachea,  beginning at the inferior part of the thyroid
cartilage.  The flerno-thyroidaei mufcles are thus expofed,
and upon  feparating thefe, a confiderable part of the thy-
roid gland appears.  The  cellular fubftance fhould then
be divided carefully on the fuperior part where the lobes of
the gland are feparated, in  order to avoid the blood-veffels.
The trachea being then laid bare,  an opening may be made
into it between any two of the  cartilages, by an inftru-
ment nearly like a flat trocar, or,  if this cannot be had, by
a fcalpel or lancet.  The  perforation  muft be  juft large
enough to receive a fmall canula;  this fhould be about two
inches in  length, and as much  of  it introduced as will
give  a free  paflage to  the  air; the  remainder  fhould be
paffed through  flips of linen, under which is a plafter of
cerate, which may occafionally be in part removed or in-
creased in number, to  accommodate it to  the  degree of
fwelling induced. It is better to introduce a fmaller canula,
previoufly adapted to  the firft,  within  it,  in order to pre-
vent any obftruaion to the breathing which might occur
from removing the tube to clean it, if only one was em-
ployed.  A piece of crape, or fine muflin,  fhould now be
placed over the opening in the  canula, to prevent the ad-
miffion of duft, &c. and the tapes conneaed with the wings
of the tube carried round the neck, and tied.
  When  extraneous  bodies  in the  trachea cannot be re-
moved from this opening, a covered probe fliould be intro-
duced to afcertain their fituation, and  another perforation
fhould then be made.   Whatever be the caufe of the ob-
                                              ftruaion 
                     [  230  ]
itruaion for which the operation is inftituted, the camila
fhould be continued in the opening  until that is removed;
and when this is done, the fkin fhould be drawn over the
wound, and a flicking plafter applied to retain it.
CHAP.    XXVII.

    Of (Esophagotomy.
"TTTHEN fubftances lodged in'the cefophagus can be
  * *   feen, they may  commonly be removed by a pair
of forceps ; but when they are out  of fight, we are re-
duced to the neceffity either of allowing them to remain
where they are  fixed, of pufhing them into the ftomach,
or of extraaing them by laying the cefophagus open.
   If the fubftance is of a foft texture, fuch as bread, cheefe,
or flefh, the beft method is to pufh it into the ftomach by
the probang.  But when a pin,  a  piece of fharp bone, or
other firm fubftance is lodged in the paffage, we fhould not
attempt to pufh it down; for if this does  not fucceed, it
may be fixed in the cefophagus.  If the pain,  and  obftruc-
tion to breathing are not  confiderable, and if aliment can
ftill be fwallowed,  no effort fhould be made to diflodge it;
for it will probably be at length carried down, either from
the effeas  of fome degree  of diffolution in the fubftance
itfelf, or of  a fuppuration in that part of the gullet in which
it is fixed.   But when the paffage of nutriment to  the
ftomach is entirely prevented, or refpiration is impeded to
                                                    a 
                      E  231   3
a dangerous degree, an  incifion  into the cefophagus,  for
the removal of the offending caufe, is our only remedy.
   Oefophagotomy may be alfo rendered neceffary by tu-
mors and flriaures in the fuperior part of the cefophagus;
but in fuch cafes,  the relief it gives is in general merely
temporary,  as the difeafes which give  occafion to  it are
ufually incurable.
   In performing this operation, the patient being fecured
as direaed  for bronchotomy, an  incifion fhould be made
with a fcalpel, at leaft  two inches in length, through the
fkin and  cellular fubftance, on  the  left fide of the  neck,
keeping clofe by the fide of the trachea, and commencing
about half an inch above  the part  where the obftruaing
fubftance is fixed, when this is praaicable; and where
this is found impoffible, on account of the obftruaion be-
ing within the cavity of the thorax, the incifion muft begin
about an inch and an half above the fternum.
   The fterno-thyroidsei,  and fterno-hyoidsei mufeles, and
a part of the  thyroid gland being now expofed, an affift-
ant fhould  pull the mufcles gently to the left fide with a
blunt flat hook, while another draws the  trachea to  the
right, fo  as to admit of the cefophagus being brought into
view.  If any large blood-veffel fhould be unavoidably di-
vided it fhould now be  fecured.  The cefophagus  being
next opened longitudinally, the fubftance is to be extraaed
with a pair of forceps.   If the obftruaing matter is  above
the fternum, and its feat can be difcovered,  the incifion
fhould be made immediately  upon it, and  of a fufficient
fize  for its  removal by a  pair of  fmall forceps ; but  when
the fubftance is in the cheft, the  gullet is to be opened for
about two inches, and immediately above the fternum;
a blunt probe being then introduced  to difcover  the feat
of the  complaint,  the  fubftance  is afterwards to be ex-
traaed by  a pair of ftraight forceps,  when it is near at
hand, or by crooked forceps, if farther down the tube.
                                                When 
                      E  232  3
   When the operation is performed  on account of fome
difeafe, till  this can be  removed, our  principal objea is
the conveyance of  nourifhment to  the  ftomach, and the
opening fhould then be preferved ; but when it is employ-
ed for the purpofe of removing a foreign fubftance fixed in
the  paffage, as foon  as  this  is  accomplifhed, the parts
fhould be reunited as fpeedily as poffible.  It will there-
fore be prudent to recommend  total abftinence from folid
food for feveral days, and to convey nourifhment by injea-
ing broth  by the  anus, and allowing very fmall quantities
of milk or foup to be  now and then fwallowed.   The pa-
tient fhould  keep  his neck quiet, and the wound fhould be
treated as  fimilar  cafes in other parts.
   There is by  no means that  degree  of danger attending
eefophagotomy  that has been  fuppofed.   By proper cau-
tion the larger blood-veffels will be  eafily avoided,  and if
the thyroideal arteries fhould be divided, they may in com-
mon be readily fecured.  The recurrent nerve will be in
little danger, although it runs clofe by the cefophagus, if
proper care  is obferved, and  even if fome of its  branches
ffiould be divided, the  only bad confequence would be a
weaknefs of voice.
   The operation has been more than once fuccefsfully per-
formed :—and there are many inftances of large  wounds
of the gullet healing very well; and if they fhould become
fiftulous and not  heal,  the patient will have had the only
chance of relief, when they are induced by the operation.
CHAP. 
[  233   3
             CHAP.   XXVIII.


 Of the  Amputation of Cancerous Mamma;.

            —-----~-_arvHna8i_y_8-ani«M.i.

/"CANCERS  are more frequently met  with  in the
^--/ breafts of women than in any other parts ; and they
are more  to be dreaded  when feated there  than  when
in any  other fituation,  becaufe  they are  more liable to
be extenfive, from  which the blood  has a greater chance
of being affeaed by abforption.
   As fchirrous  tumors are always  liable  to degenerate
into cancers,  they fhould  be  extirpated uniformly  as
early as poffible ;  and the removal of thefe, as well as of
cancers, may always be undertaken  where all the parts
difeafed can be extirpated with  fafety ; but never other-
wife.
  In proceeding to this operation, the patient  muft be ei-
ther firmly feated in an arm chair, her head being fupport-
ed with a pillow  by an affiftant behind,  whilft her arms
are properly fecured by an affiftant on each fide; or when
no objeaion is made, what will be  better, placed  on  a
table.  The operator ffiould be feated; and if the fkin is
found, an incifion ffiould be made with a fcalpel  through
the teguments from one extremity of  the  tumor to the
other, carrying  it an inch or fo on one fide of the nipple.
When the breaft alone is difeafed, the cut fhould  be per-
pendicular, but when the difeafe is extended in  fuch a man-
ner as to make the longeft diameter of the  fwelling acrofs
the body,  the incifion fhould be formed horizontally.  In
the latter cafe, an incifion fhould alfo be made from the firft
                        G g                   wound 
                        E   234  3
  wound to the inferior part of the tumor, in order to afford
  a free difcharge to any  matter afterwards produced.
    The teguments fhould now be feparated from the parts
  below, and being kept afunder,  all the glandular  part of
  the breaft  is to be carefully diffeaed  out, with  whatever
  part it be conneaed.   In order to fave the peaoral muf-
  cle while this is done,  the arm fhould be kept extended.
  Not only the whole breaft itfelf fhould be extirpated, when
  it is in the fmalleft degree affeaed, but all enlarged glands
  that are difcovered in its vicinity.
    The arteries, which are commonly numerous, fhould now
  be fecured by  the tenaculum; and  the fore being cleared
  of blood, the divided teguments muft be brought together,
  and conneaed by ligatures, which fhould hang an inch or
  two out of the wound, that they may  be withdrawn at
  the  end of three or foe.r days.  The  wound  is to be
  covered  with  Anxt  fpread with emollient  ointment,  and
  a thick comprefs of linen being placed over this, the whole
  fhould be gently compreffed by a napkin and fcapulary.
   In this manner, when none of the integuments have been
  removed, the wound will heal by the  firft intention,  by the
  adhefion of the fkin to the fubjacent mufcles.   But it does
  not often happen that we are applied to till the fkin is much
  difeafed, or at leaft adherent to the mamma to a greater or
  lefs extent.  In this  cafe, after making the longitudinal
  incifion through that part of it which is found, a circular
  or oblong incifion communicating with the other,  fliould
  feparate the difeafed portion ; and the parts  affeaed fhould
j  then be all diffeaed  off together.   A fore is neceffarily
  left, which renders the cure  tedious  in proportion  to the
  quantity of fkin taken away.—This  is to be treated with
  lint, and emollient unguents.
   When the axillary and  other glands are alfo difeafed,
  an incifion fliould be extended  from  the  principal fore,
  through the teguments to their farther  extremity, and they
                                                  ffiould 
                       E   235  3
ffiould then be diffeaed out very cautioufly.  In perform-
ing this, it will be better  to  pafs a ligature through the
larger glands, in order to aflift in their feparation.   The fkin
is here likewife to be re-united by future or compreffion as
may feem moft proper.
  It is  a point of the utmoft importance in performing
this  operation to  preferve as much fkin as poffible.  It
faves a great deal of pain  afterwards, expedites the heal-
ing of  the fore, and leffens the chance of a return of the
difeafe from irritation.
            CHAP.   XXIX.

Of Affections of the Brain from external
                   violence.
                    SECT.  I.

                   General Remarks.

 rTHHE brain is  an organ effentially neceffary to life,
  -*-    and its parts cannot be deranged but with the ut-
moft hazard.  For although there are fome rare inftances
of it being much injured, and even of parts of it being eva-
cuated  at wounds,  without any important confequences
enfuing; yet, as in many cafes, apparently trifling wounds
and bruifes of the head,  which at firft exhibit no marks of
danger, afterwards induce a train of fymptoms that we are
                                               unable 
                       E   236  ]
 unable to remove, and which  only  terminate  with the
 death of the patient, we may juftly conclude, that affec-
 tions of the brain, both with refpea to the danger attend-
 ing them, and the difficulty which occurs in the treatment
 of them, are of more importance than any other difeafes
 that the human body is fubjea to.
   The uncertainty which  prevails with refpea to the na-
 ture  and treatment of  thefe complaints principally arifes
 from the following eircumftances.
   1. The importance of  a  found  ftate of the  brain to
 health, and the delicacy of its ftruaure, rendering injuries
 to it eafily produaive of alarming confequences.
   2. The difficulty  of afcertaining the ftate  of the de-
 rangement, on account of the brain being furrounded by
 bone.
   3. The impoffibility  of  having free accefs  to the parts
 affeaed,  when  we know  with  certainty which they are;
 And,
   4. The writers on the fubjea having attended more to
 the caufes, than to the nature and treatment of the affec-
 tions themfelves.  Thus, the various contufions, wounds,
 and fraaures of the  head,  have been  minutely defcribed,
 and almoft folely attended to, when  it is their effeas upon
 the  brain which we  ought to confider, and not their ex-
 ternal appearances; becaufe thefe effeas feem  often not at
 all proportioned to the caufe; for we find fraaures of the
 fmalleft fize will fometimes be fucceeded by the moft dan-
 gerous fymptoms, whilft others of the greateft extent pro-
 duce no alarming appearance whatever.
   All the fymptoms of affeaions of the brain  from exter-
 nal violence, feem evidently to  owe their origin to  com-
 preffion of the brain from commotion or concujfion, and to in-
flammation. Thefe fymptoms are frequently complicated with
 each other; but they are  alfo often feparate and uncom-
 bined ; and it is in this ftate only that a defcription of them
                                                   can 
                       E   237   3
 aan be  given.   The appearances induced in the  com-
 pounded affeaions can only be learned from obfervation;
 but an accurate knowledge of them, as they occur uncon-
 neaed with.each other, will contribute much to direa the
 proper treatment, under whatever form they may appear.

                    SECT.  II.

     Of Compreffion of the Brain from external Violence.

   The moft frequent and remarkable fymptoms that have
 been faid to indicate a compreffed brain from external in-
 juries, are, giddinefs ; dimnefs of fight; flupefaaion ; lofs
 of voluntary motion; vomiting ;  an apopfeaic flertor  in
 the breathing ;  convulfive tremors in different mufcles ;  a
 dilated pupil,  even when the eyes are expofed to a clear
 light; paralyfis of different parts,  efpecially of that fide
 of the body oppofite to the  part  of  the  head injured ;
 involuntary evacuation of the urine  and fseces ;  an oppref-
 fed, and  in many cafes, an  irregular pulfe : and when the
 violence  done to the head has been confiderable, a difcharge
 of blood  from  the nofe, eyes, and ears.
   Some  of the milder fymptoms, fuch as vertigo, ftupefac-
 tion, and temporary lofs of fenfibility, are frequently indu- *
 ced by flight blows on the head ;  but as they appear to be
 chiefly occafioned by a concuffion or ffiock given to the
 brain,  they  are  generally foon removed by reft, or reme-
 dies applied—But when any other of the fymptoms occur,
and particularly a large difcharge of blood from the ears,
 eyes, or  nofe,  we may with certainty conclude that  much
 violence has been done to the brain, and that compreffion
is  induced on fome part of it.
   As the cavity of the fkull is completely filled by the
brain, it follows, that whatever diminifhes that cavity will
                                              produce 
                                  [  238  3
            produce compreffion of the brain.   This diminution may
            be effeaed, by fraaures of any of the cranial bones, with
            depreffion;  by the introduaion of any extraneous body
            through both  tables of the bones; and by the effufion of
            blood, pus, ferum, or any other matter.   It may be pro-
            duced likewife by the  thickening  of the bones of the fkull
            in fyphilis,  and  by water in the ventricles of the brain in
            hydrocephalus internus.  The two laft-mentioned cafes do
            not come properly under our confideration.  The effufion
            of pus, or  any matter  not evidently blood or ferum, muft
            be the confequence of inflammation, and will be confidered
            hereafter.
               As  the introduaion of extraneous bodies into the cra-
            nium is neceffarily attended with fraaure and depreffion
            of the fkull, we fhall confider both thefe cafes together.

            j 1. Of Compreffion of the Brain from Fraclures with De-
                                   preffion.

               The only general  and  ufeful diflinaion of fraaures is,
            into thofe which are attended  with depreffion, and thofe
            which are not: thefe laft we term fiffures, and fhall con-
            fider them in a feparate feaion.
               Fraaures of the fkull may  be  produced by falls from
            a  height;  by  blows  with fharp  or  blunt inftruments;
            and by miffile  weapons fuch as ftones, &c. thrown from
            a diftance—Little advantage is  derived from  a knowledge
            of the means  by which  a fraaure is produced—For al-
            though in many  inftances when occafioned by a blunt in-
            ftrument, or a fall from a confiderable height, it is frequent-
•           ly attended by more alarming confequences than when it
            is produced by  a  fharp  inftrument, this  is  not univer-
            fally the cafe.   It is however  proper to inquire into the
            nature of the caufe.
               The indications in this affeaion are,
                                                            l.To 
                      E  239   3
   1. To difcover,  as  exaaiy  as poffible,  the  fite,  the
courfe, and the full extent of the fraaure.
   2. To obviate the effeas of the injury, by elevating or
removing the depreffed parts of the bone.
   3. To endeavour to  complete the  cure, by the applica-
tion  of proper  dreffings, and attention to the after treat-
ment.—When eircumftances admit the accompliffinient of
thefe objeas, we can often afford more certain relief than
in any other difeafe.
   If the integuments are torn away, or cut, the ftate of the
bone is immediately difcovered ; but when they are entire,
it  is  difficult to afcertain it.  In this cafe, if any mark of
external injury is perceived, particularly a tumor on any
part of the head, with evident appearances of its proceed-
ing from a recent contufion, the other fymptoms will pro-
bably, on incifion into it,  be found to originate from frac-
ture direaiy underneath.  But, as  frequently  happens,
when affeaions of the brain, and fraaures of the  fkull,
fucceed injuries which do not produce any external mark,
the whole  head fhould be fhaved, and  then fometimes a
rednefs of a particular fpot will be perceived, and indicate
the part affeaed.  When  no tumor, inflammation, or other
mark of injury occurs, we may fometimes be led to the fe2t
of the accident by preffing firmly all over the head : and if
we find  the patient to moan on preffing one particular
part, or  he puts up his hand, or draws away his head on
this  trial being repeated, we may conclude this the feat oi
the injury.   If the patient applies his hand frequently to
the fame part of the head, it will merit our attention.
   When the fymptoms of a compreffed brain are evidently
marked,  we ought to proceed  immediately  to the exami-
nation of the cranium, wherever the injury  appears  to be
feated, by laying  the bone bare by  an incifion.  When
the bone appears to be much injured, which may happen
without  a laceration of the fcalp, this fhould be done with
                                               caution, 
                       E  240  ]
 caution, for fear of hurting the brain.   But when this is
 not the cafe, the incifion may be made at once through the '
 fcalp.  In order to expofe the bone more completely, it has
 been propofed  to  make a crucial incifion, or one in the
 form of a T, and by fome  to remove  a circular or oval
 piece of the fcalp ; but when either of thefe modes are ufed,
 a painful wound  is produced, difficult to  heal; tedious
 exfoliations  are fometimes  induced;  and the  covering
 formed afterwards  never anfwers fo well as the teguments
 removed.  A fimple incifion appears to be amply fufficient;
 on this being made, the parts retraa fo as to admit of a
 free examination of the bone, and if a fraaure is difcover-
 ed, the courfe of it may be traced as well by continuing
 the courfe of the incifion along it, as by removing part of
 the fcalp ; and this will generally give room for the appli-
 cation of the trepan.  In fome few cafes indeed, where the
 bone is fraaured in different direaions, it may be neceffa-
 ry to remove a fmall corner of the divided integuments.
   Upon making the incifion, if there is a fraaure and de-
 preffion of the fkull, the means hereafter to be recommend-
 ed ffiould be immediately employed; but where no ex-
 ternal mark of fraaure is met  with, or any injury what-
 ever, and the patient continues to labour under the fymp-
 toms of a compreffed brain ;  if the pericranium  has been
 feparated; and  efpecially if  the  bone  has  become of a
 pale white or dulky hue; the trepan  fhould be applied
 where thefe  appearances occur.  We  fhall  hereafter en-
 deavour to fhew, that by this means alone, effufed blood,
 or ferum,  which may produce the compreffion, can be re-
 moved ; and that it would be highly improper to truft to
 abforption of the extravafated fluids, as advifed by fome.
   For although  no  mark of difeafe ffiould appear on the
 external table of the bone, yet there is a  poffibility that the
internal table may be broken and  depreffed, and  this may
produce as bad  confequences  as  if the  whole bone was
                                                  beat 
                       E  241   ]
 beat in.  Of this I have met with fome inftances, and au-
 thors tell us of many.
   It will often happen  that no relief is afforded  by the
 trepan in the cafes mentioned : This may arife from  various
 eircumftances, but the moft fatal is what is termed a  contra-
 fiffure,  by which the cranium is fraaured, and perhaps
 depreffed, or  effufion occafioned, at a part diftant from
 that  which received the blow,  and where alone there
 are marks of injury.
   The  exiftence of fuch a cafe has been called  in queftion
 by theorifts,  but  every  praaitioner of  experience muft
 have feen inftances of this kind.  It does not happen that
 injuries are neceffarily produced  immediately  oppofite to
 the parts receiving the impreffion, but it frequently  hap-
 pens that the fkull is fraaured in a part  not immediately
 contiguous to  thofe on which the  blow  was infliaed ; and
 this often occurs when no external mark can be difcovered
 on the  teguments correfpondent to the part  fraaured,
 and when the  bone remains entire on the part  which im-
 mediately received the injury.
   Many of the old  writers apprehended confiderable ha-
 zard from expofing the brain  to the air, by the operation
 of the trepan ; while fome of the moderns confider the
 danger fo trifling, as to direa the operation as a preventa-
 tive of bad fymptoms.  But I am clearly  of opinion,  that
 the trepan fhould never be ufed but where there are fymp-
 toms of a compreffed brain,  and  which  would probably
 foon prove fatal if their  caufe  was not  removed; becaufe
 it appears by no  means an innocent remedy,  and  is fre-
 quently of itfelf produaive of dangerous fymptoms.
  We now proceed to the fecond general indication, to re*
 move or elevate the depreffed  portion  of bone:—
  If the teguments are  not feparated at  all, or not fuffi-
ciently,  by the  accident, to admit of an examination  of the
bone injured, the head fhould  be ffiaved, and an incifion
                        H h                   made 
                       [  242   ]
 made by a fcalpel through the teguments, and continued
 along the  courfe  of the fraaure.   By this  it frequently
 happens that fome  blood-veffels are divided,  which  dif-
 charge very  freely: if the  patient is very  weak, thefe
 fhould be immediately fecured by ligature, lint, and com-
 preffion ; but when this is not the cafe, they fhould be fuf-
 fered to bleed in proportion to the patient's ftrength.  They
 will in common foon retraa  and reftrain the hemorrhagy;
 and if they do not, they may  be eafily fecured as above di-
 reaed.
   In performing  the operation  of perforating the fkul],
 the patient fhould be laid on a  firm table, and his head
 there fecured by  a  pillow.  The inftrument  now ufually
 employed  for removing a part of the  cranium, in order
 to admit of the railing of the portion depreffed, is termed
 a trephine; but the trepan, (pi. 1. fig. 5.) is much prefer-
 able, as it perforates the  bones  in half the time, and is
 equally fafe.   It  differs from the  trephine only  in  the
 handle being worked like a carpenter's wimble.
   In cafes of depreffion of the fkull in children, we have
 been advifed to try the effeas of adhefive plafters laid  up-
 on the cranial integuments, and conneaed with ligatures;
 by pulling  the firings, it was propofed to elevate  the  de-
preffed part; but this mode is evidently inadequate.
  We have by fome been direaed to introduce  a fcrew
 nearly through the cranium,  and  then by pulling it, to  en-
deavour to  raife the depreffion;  but as by this  method we
could neither remove any fplinters of the bones,  if their
internal table  ffiould be broken,  or take out extravafated
blood, if lodged on the brain, it would obvioufly be of no
fervice in moft cafes*
  When any portion of the bones injured can be removed
by the hand, or forceps, it fhould be done ; and if by this
means the depreffed part cannot be elevated to its  proper
fituation, the ufe of the trepan becomes neceffary.
                                                  The 
                      [   243   j
   The operation of trepanning may be performed on any
 part of the cranium :  but on account of hemorrhagy, and
 the difficulty  of the  operation  when  performed in thefe
 places, it will, if poffible, be proper to avoid the under part
 of the parietal and temporal bones, the inferior part of the
 frontal bones, the whole courfe of the longitudinal finus,
 and the under part of the os occipitis.
   In proceeding to this operation, as much of the peri-
 cranium fhould be taken off by the fcalpel or rafpatory,
 (pi. i. fig. 3.) as will admit a free application of the trepan ;
 and this fhould be done at the point where the greateft re-
 fiftance  feems to occur to the elevation of the bone.  'The
 perforation ought to be formed  fo as to include not only
 the fraaure or fiffure, but if poffible a fmall portion of the
 depreffed piece.
   A  fmall  hole is to be  made in a proper part of the
 undepreffed bone with the perforator, (pi. i. fig. 7.) to re-
 ceive the pin  of  the trepan faw.   By  this the  faw is
 kept in its fituation until it is carried fufficiently deep to
 render fuch fupport unneceffary, when the pin is to be re-
 moved, left it might injure the membranes of the brain.
  The furgeon is now to prefs equably and firmly upon
 the inftrument until  he  makes the  perforation.   If the
 trephine is ufed, the faw is made to cut by forming about
 half a circle with the hand alone, turned firft forwards and
 then backwards; but when the trepan is  employed, all'
 the neceffary preffure is to be applied on the head of the
 inftrument with one hand, while the handle of it is turned
 with the other.  The inftrument ffiould be frequently re-
 moved, and the depth of the perforation afcertained by a
 pointed piece of quill or a probe : and  if it is deeper in one
place than another, the faw fhould be made to  bear more
on the part leaft cut, fo as to preferve the perforation of an
equal depth all around.    While the  furgeon  examines
and cleans the cut, an affiftant fhould brufh the  faw; or
                                                 there 
                      E  244   ]
there fhould be two faws of an equal fize, that  no inter-
ruption may be  given to the operation.   A  cylindrical
form of the inftrument will contribute confiderably to ex-
pedite the fawing.
   When  the bone is probably nearly fa wed through, as
may be judged in fome cafes  from our  having  met with
the diploe, the perforation ffiould  be very frequently exa-
mined, and as foon as it is found to go through the bone,
the preffure fhould then be removed from this, and equally
applied over the remaining uncut part.   As soon  as it is
praaicable, from the bone being loofened in one  or  two
points, it ffiould be taken out by the forceps, (pi.  ii. fig. 1.)
or the levator, without waiting for its entire feparation by
the faw, for by this praaice I have feen very expert opera-
tors injure the dura mater.  If any fplinters are  left, they
may  be  removed by the forceps, or  by the lenticular,
(pi. i.  fig. 2.)
   That the intention of  this operation may be fully an-
fwered, the piece of bone removed fhould never in an adult
be lefs than an inch in diameter.  If the depreffed part can-
not be raifed by the levator, (pi. i. fig. 1.) after one perfo-
ration, as many more as may feem neceffary fhould be made.
The levator ffiould  always be fixed upon  a fmall ftand,
(pi. i. fig. 4.) as the force  ufed for elevating  the bone does
not then  materially affea the parts to which it is applied.
Great attention ffiould be paid to the  entire removal of
the  depreffion, of extravafated  blood  or ferum  on the
brain, and of all extraneous bodies ; and when this  is done,
the wound ffiould be  lightly covered with lint fpread with
cerate, a comprefs of foft linen applied over this, and  a
night-cap ffiould fecure the whole.
  When the patient is removed to bed, the head ffiould be
placed in fuch a manner that the difcharge from the wound
may have  free vent.
  If  the compreffion  of  the  brain  has been completely
taken off  by the operation, it fometimes  happens that the
                                             fymptoms 
                     [   245  3
fymptoms are  mitigated immediately, or at leaft in the
courfe of a few hours ; but when no favourable change is
perceived  in a fhort time,  we may attribute the continu-
ance of the bad fymptoms, either to  a  concuffion of the
brain itfelf, or to an inflammation of its membranes; and
the remedies hereafter direaed muft be then applied, ac-
sording to the eircumftances of the cafe.
   In all cafes after the operation of trepanning, the patient
ffiould be kept quiet; little or no light ffiould be admitted
to his apartment; his food ffiould.be of  the mildefl kind;
and his drink fhould be whey, or fome other mild diluent
liquor.
   As the membranes of the brain are very  apt to become
inflamed in thefe cafes, it will be proper, both as a preven-
tative and a curative of inflammation, to produce a plenti-
ful  fuppuration from the wound by the  application of
warm emollient poultices and fomentations over the dreff-
ings—the matter colfeaed in the fore may be removed by
lint or a fponge.
   After the floughs  formed are caft  off, the wound com-
monly fills up, and  cicatrizes in the ufual  way; but in
fome cafes, excrefcences of  confiderable magnitude ffioot
out from  the perforations.  Thefe are, in  general, pro-
duaions of the dura mater, and ffiould feldom  be  med-
dled with until the different perforations are filled up with,
bone; when, if they do not drop  off fpontaneoufly, they
ffiould be removed by excifion,  cauftic,  or ligature :  com-
preffion can never be fafely employed either to prevent or
remove them.
   When  the fcalp has been removed to any confiderable
extent,  as  the  bone  will afterwards be covered only by
cuticle and cellular fubftance, a piece of tin or lead, lined
with flannel, ffiould  be fitted to the part,  with a view to
protea it from the cold and other external  injuries.
« 2. 
[  2*6   ]
     § 2. Of Compreffion of the Brain from Extravafation.

    The  fymptoms of a compreffed  brain from extravafa-
 tion of  blood or ferum, or from the formation of pus, are
 exaaiy fimilar to thofe produced  by a  depreffion of the
 cranium and other caufes,  and therefore need not be here
 repeated.
    Extravafation of blood or ferum is a frequent concomi-
 tant of a fraaure or fiffure of the fkull;  but it alfo occurs
 in cafes where no  mark of either  is  to be perceived, or
 even the fmajleft fign  of  external  injury.   In every in-
 ftance, however, the trepan affords  the only mode of re-
 lief with which  we  are  at prefent acquainted.   When
 there is  any external injury the perforation ffiould be made
 on the part difeafed : but when there is no fuch guide, we
 fhould make repeated openings, beginning as near the  bafe
 of the fkull as poffible, until the feat of the extravafation
 is difcovered.
   When the removal of the blood  or  ferum, lying upon
 the dura mater, does not take off the  fymptoms of com-
 preffion, and when this membrane appears dark coloured
 and tenfe,  as there will be reafon to fuppofe there is  ex-
 travafated blood beneath it,  it ffiould be  cautioufly open-
 ed by the fhoulder of a lancet, and the orifice enlarged by
 crooked fciffars fufficiently  for the removal of the effufed
 matter.   And in like manner,  when we have reafon to be-
lieve there  is a colfeaion of pus, an opening ffiould cer-
tainly be made to admit of its difcharge.  In either of thefe
cafes we  give the patient the only chance  of relief.
SECT. 
[  247   ]
                   SECT.   III.

         Of Conciiffion or Commotion of the Brain.

  Every affeaion of the head, attended with flupefaaion,
and immediately confequent to external violence, but with
no external marks of injury,  is in general attributed to a
commotion or concuffion of the brain ; by which is meant
fuch a derangement of its parts as obftruas its funaions,
but which cannot be afcertained by diffe6lion.
  This  affeaion  may readily  be diftinguiftied from in-
flammation of the brain, by an attention to the charaaer-
iftic fymptoms of each ;  but it is not always fo eafy to dif-
criminate between it and compreffion of that organ.   In
flight cafes of concuffion, in which the fymptoms induced
foon difappear, there can be no difficulty; but where the
fymptoms are in a confiderable degree, a difcrimination is
fometimes not eafily to be made*
  Almoft all the  fymptoms produced by compreffion of
the brain have been  found to follow from concuffion; but
thofe which  are  moft frequently induced,  are, flupefac-
tion; torpor in greater or lefs degree ; a flow,  foft pulfe ;
and a dilated ftate of the pupils, even when the eyes are
expofed to a ftrong light.
  The chief marks of diflinaion between  concuffion and
compreffion of the brain are, according to my obferva-
tion, to be derived from  the ftate of the pulfe  and  of re-
fpiration.   In the former cafe, the pulfe is generally foft,
flow and  equal, the breathing  is free and eafy, and the
patient appears as if  in a found natural fleep;  but in the
latter the pulfe is flow, often oppreffed and irregular, and
the refpiration is deep and oppreffed, as in apoplexy.
  Concuffion of the brain appears to me to operate upon
the general fyftem in nearly the fame manner as fyncope in-
                                                duced 
                       C   248  3
 duced by  fear, inanition, or any fimilar caufe.  In what
 manrwr a blow or fall induces  fuddenly  fuch a ftate of
 debility, I cannot pretend to explain; but I have no doubt
 of the faa, from frequent and attentive obfervation of the
 fymptoms of difeafes of the brain from external violence,
 and of the effeas of remedies in different cafes.
   Blood-letting appears uniformly to be injurious in cafes
 of concuffion, whereas  it always  relieves the fymptoms of
 compreffion of the brain.
   In cafes of  concuffion, I would recommend the exhibi-
 tion of warm wine, as  in other difeafes of debility;  keep-
 ing the patient warm; the application of blifters all over
 the injured part of the head, and  of finapifms to the  feet;
 and the adminiftration  of laxatives, fo as to  keep the body
 gently open.   When wine, on which we are to place our
 chief dependance, cannot be given in fufficient quantities,
 volatile alkali, ardent fpirits, and  other  cordials ffiould be
 exhibited.  Opiates, joined with antimonials, have been re-
 commended by Mr. Broomfield ; but I have  found wine to
 be more ufeful. Repeated vefications to the  neck and head
 feem  to me more ferviceable than the iffues  advifed by
 fome.
   When patients are recovering, a liberal ufe of the bark,
 with the chalybeate waters, has fometimes been of benefit.
 Gentle emetics have likewife been ferviceable;  and where
 languor and lofs of memory have continued longer  than
 ufual, efearicity has been produaive of good effeas.
   It is to be obferved, that thefe  remedies are to be  ufed
 for the removal of fymptoms folely from concuffion, and
 which do not depend in any degree upon compreffion or
inflammation, a circumftance which may ufually be deter-
mined from what has been already mentioned, and more
particularly  from the injurious effeas of blood-letting.
But whenever  there remains  any doubt, and efpecially
when  a patient continues in  a ftate of infenfibility, we are
                                                   to 
                      E  249   3
to fufpea compreffion, and employ the trepan in the man-
ner already advifed.                             *

                   SECT.   IV.

Of Inflammation of the Membranes of the Brain from exter-
                      nal violence.

  This dangerous complaint feldom makes its appearance
until fome  days, weeks, or even months after an injury is
received.   In general the firft fymptom of it is an univer-
fal uneafinefs over the head, attended with li:tleffnefs and
fome degree of pain  in the part injured, of which perhaps
the patient has hardly  till now,  had any  caufe to com-
plain.   The liftleffnefs increafes—the patient appears flu-
pid—the pain in the injured part is gradually augmented,
while a fenfation of fulnefs is felt in the other parts of the
head—giddinefs and naufea, or even vomiting, come on—
heat and uneafinefs appear—the fleep is difturbed and not
refrefhing—the pulfe  is quick and hard—the face is com-
monly flufhed—and the eyes are from the beginning fome-
what inflamed and painful upon expofure to light.
   In fome inftances,  where the fymptoms are accompani-
ed by a wound on the head, the inflammation of the eyes
and flufhing of the face feem to be  produced by, and con-
tinued from, an eryfipelatous affe&ion around the fore; in
which cafes, the  edges of the fore firft become hard and
fwelled, and the fwelling apparently originating from the
aponeurotic expanfion of the mufcles of the head,  fpreads
very quickly over  the whole  of it,  and particularly down
the forehead, in fuch a manner as to clofe the eyes.  This
fwelling is foft, is painful to the touch,  and has an eryfi-
pelatous appearance.   It arifes in  many inftances merely
from the external fore, and is  not ufually fo dangerous as
                         I i                       that 
                        C   250  3
  that puffy circumfcribed tumor, to which the parts injured
  by the blow are often liable.  When it originates from the
  external affeaion, it may generally be foon removed by the
  common remedies of eryfipelas ; but, in a few cafes,  it is
  likewife produced from a  previous  affeaion of the dura
  mater, when it is of a very dangerous tendency.
    In the courfe of a day or two  from the time that thefe
  fymptoms become formidable, the part which received the
  blow affumes a morbid appearance. If the bone was at firft
  laid bare, it now becomes pale, white and dry, either over
  its whole furface, or in particular fpots,  which by degrees
  extend over the whole;  and the edges of the fore, from the
  beginning of the bad fymptoms, become hard, dry, painful
  and much fwelled; but when the bone has not been  de-
  nuded, and none of the foft parts have been divided, but
  merely contufed,  they now begin to fwell, become puffy,
 and fomewhat painful upon being touched ;  and if the head
 be ffiaved, the fkin over the part affeaed will be found of
 a reddifh colour.  If the fwelling be  laid open, the peri-
 cranium will be difcovered to be detached from the fkull:
 a fmall quantity of a thin,  bloody, and fomewhat foetid
 ichor will  be found beneath it; and the bone will be dif-
 coloured as above defcribed.
   By the application of proper remedies, thefe fymptoms
 may in many inftances be removed; but when  this is not
 the cafe,  or  they are not properly attended to,  they con-
 ftantly  become aggravated,  and delirium, frequent ffiiver-
 ings, coma, or ftupor, are fupcradded to them.
   About  this period, all the  fymptoms which we have
 defcribed become fo much milder, as  not to be diftinaiy
 obferved,  or are altogether loft in thofe which now begin
 to appear.  Paralyfis of one  fide is foon followed by deep
coma ;   the pupils are dilated, and  are  fcarcely affeaed by
the impreffion of light;  the urine and fsces are  paffed
involuntarily; fubfultus  tendinum, and other convulfive
                                            fymptoms 
                      E  251   3
fymptoms take place; and death is the certain confequence
if the patient is not foon relieved.
   The fymptoms defcribed in the two laft paragraphs are
indicative of the formation of matter, and can only be re-
lieved by the trepan :  thofe firft mentioned being the con-
fequence of inflammation, are to be removed by the  gene-
ral remedies of inflammation.
   External violence may induce inflammation of the brain,
by depreffing part of  the cranium ;  by contufion ; and by
producing  fiffures or fraaures of the fkull not attended
with depreffion.   The firft of thefe we have already con-
fidered, and fhall now proceed to treat of the others.

§  1.  Of Contufions of the Head producing Inflammation  of the
                        Brain.

   Contufions of the head are produced, as in other parts,
by blows or falls; and are fometimes accompanied with
wounds, at other times  they are not.
   The immediate and moft frequent effea produced from
them, when they afterwards prove  troublefome, is to de-
prive the patient of his fenfes, and leave fome degree of
giddinefs.  In a gradual manner,  however,  he recovers,
fo that after  a night's reft he appears perfeaiy well, un-
lefs a wound was produced at the fame time with the  con-
tufion, until fome days, weeks, or  even months after the
accident, according to eircumftances, when the fymptoms
above defcribed make  their appearance.
   Hence it is evident, that accidents of this  kind, which
at firft appear trifling  may be produaive  of  very danger-
ous confequences,  and therefore  that all injuries done to
the head merit a  great deal of attention.
   In the treatment of contufions of  the head, the indica-
tions are;
   1. To employ every  means  preventative of inflamma-
                                                 tion. 
                      E   252   3
tion.  2. To produce refolution of the inflammation when
it has aaually come on.   3. If this cannot be  done,  and
fuppuration  takes place, to procure a free vent to the mat-
ter :  And, 4. If a gangrene  fupervenes, to remove it or
obviate its effeas.
   1.  Patients recover  fo fpeedily from the immediate ef-
feas  of contufion, in moft inftances, that we feldom have
an opportunity of employing  the prophylactic remedies of
inflammation.   But when this is afforded, we would re-
commend blood-letting,  general and topical—laxatives—
the application of folution  of faccharum  faturni to the
part affeaed—a low  diet, and  total abftinence from ex-
ercife.
  2. For the removal of  inflammation it  will be neceffary
to employ,  1. Blood-letting—When a fufficient quantity
of blood can be obtained by  topical bleeding this ffiould
be preferred ;  hence  leeches or cupping fhould, if poffible,
be ufed near to the affeaed part. Deep fcarifications with
a lancet or fcalpel, when the parts  have  not been  divided
but merely  bruifed and inflamed,  are very ferviceable for
this purpofe.   When general bleeding is neceffary, it will
be beft  to open the  jugular vein or temporal artery, and
draw off blood until  the  pulfe begins to flag, if poffible, to
the quantity of 20 or 25 ounces:  this will be much more
ufeful than  repeated  fmall bleedings.   It will be proper to
repeat the bleeding in a few hours if the fymptoms conti-
nue violent, to an extent to be determined by the eircum-
ftances of the cafe.
   2. Strong purgatives,  or ftimulating glyfters—thefe are
very  ufeful  and fliould never be omitted.
   3. Gentle diaphoretics.  It is a matter of confequence to
keep a gentle moifture on the  fkin. If this cannot be effeaed
by warm fomentations to the feet and  legs, and by laying
the patient in blankets, we muft employ internal fudorifics.
Dover's powder is apt to excite vomiting ;  on this  account
                                                      I 
                     E   253  3
I prefer a combination of an antimonial  with opium—fif-
teen or twenty drops of antimonial wine, with four or five
of laudanum may be given every two hours until a fweat is
brought on, when a lefs quantity will ferve to fupport it.
  4. Opiates.  A prejudice againft the ufe of opium in dif-
eafes of this kind has hitherto prevailed; but experience
has convinced me that this is unfounded, and that it may
always be employed  with advantage to remove  pain  or
reftleffnefs.
  5. Suitable  applications to the  injured part.   Experi-
ence has evinced to me the utility of producing a plentiful
fuppuration from the part affeaed in all contufions of the
head.  For  this purpofe, when the accident is attended
with a wound, it ffiould be  covered  with pledget6 of lint
fpread with fome emollient ointment,  and foft warm cata-
plafms ffiould  be applied over thefe, and frequently renew-
ed.  The fymptoms  are thus generally mitigated,  and
fometimes entirely removed.  When there  is no wound,
and when from the fwelling and pain of the injured part,
fome time after the accident, there will be reafon to expea
the coming on of bad fymptoms, the tumor ffiould be im-
mediately laid open down to the pericranium ; and if this
is feparated, it ought likewife to be  divided, any matter
that may be colfeaed taken  away, and the wound treated
as juft above direaed.
   By the contrary treatment of fuffering the fwelling to
remain unopened until a  fluauation is  perceived, I have
reafon to believe that  the matter colfeaed, which is gene-
rally thin and acrid, is the moft frequent caufe of the fuc-
ceeding inflammation of the dura mater which often takes
place.  It produces this effea by firft exciting inflammation
of the parts externally,  which is  extended to the internal
parts by the  communicant  veffels.   Injuries of the head
very probably, in moft inftances, operate by inducing an  ef-
fufion between the flcull and pericranium ; this being often
                                                  very 
                      L  254  3
very fmall, does n6t occafion  any evident tumor until its   .
acrimony excites an inflammation of the furrounding parts;
and hence we may readily account  for the effeas of thefe
injuries not appearing until fome time has elapfed after the
accident.
   It is to be obferved, however, that the treatment we
have juft recommended is not applicable to tumors recently
formed from  external  injuries.  Thefe are to be removed
in common by folution of lead, or of crude fal ammoniac,
or by the application of brandy, or  fome other aftringent.
Such fwellings give a  fenfation like that afforded by frac-
tured cranium ;  but we can never be deceived if we attend
to the concomitant fymptoms.
   3. When we have reafon to fuppofe pus is formed with-
in  the  cranium, the only probable means  of relief is af-
forded by the application of the trepan, in the manner for-
merly direaed in feaions 1 and 2.
   4.  When on perforating the fkull,  it is found that the
dura  mater has become  floughy, with  fome tendency to
gangrene, the utmoft danger is to  be dreaded.   There are,
however, fome inftances of recovery, in fuch cafes, upon re-
cord : all that can  be done is to keep the fores clean ; dif-
charge any matter  that may colfea ; apply foft light dref-
fings, and give Peruvian  bark and vitriolic acid in as large
quantities as the ftomach will bear them. If there remains
any tendency to inflammation, the diet fhould be low and
cooling, and the bowels ffiould be kept moderately open;
but if the fyftem is low, and the pulfe feeble,  wine, and a
generous diet ffiould be allowed.
   The operation of trepanning has  been recommended in
inflammation of the brain, and in fome cafes of epilepfy; but
it muft  evidently be injurious in the former cafe, from the
irritation it gives to the difeafed parts; and in  two cafes of
epilepfy in which I have feen it employed, there was every
                                            probability 
                       C  255   3
 probability that it occafioned the death of the patients by
 exciting inflammation and a confequent fuppuration.

      § 2. Of Fiffures,  or Simple FraBures of the Skull.

   By a fiffure we underftand a mere divifion of the flcull,
 not attended with depreffion: This may either penetrate
 the whole thicknefs of the bone,  or be confined to one la-
 mella of it: it may alfo either be attended with a divifion of
 the correfponding teguments, or thefe may be left entire.
   Fiffures always require a great  deal of attention ;  for al-
 though there are  many inftances of thofe of great extent
 healing without the occurrence of bad fymptoms, yet there
 are alfo inftances of very fmall fiffures terminating fatally.
   Fiffures are often accompanied by original affeaions of
 the brain,  and they are  produaive of danger themfelves
 by inducing effufions of blood or  ferum  upon  the  brain,
 or by tending to excite inflammation of its membranes.
   When effufion  takes place, as it muft immediately be
 attended with fymptoms of compreffion, the remedies  for-
 merly recommended muft  be employed.   The trepan af-
 fords the only effeaual relief: the fiffures fliould be traced
 through their whole extent, and a perforation being made
 in the moft depending part of each of them, if this does not
 prove entirely fuccefsful, the operation  fhould be repeated
 along the courfe of the fraaures,  as long as the fymptoms
of compreffion remain, care being  taken to include  the
fiffure in every perforation.
  It often happens that the  fiffure is fo exceedingly fmall
that it is difficult to diftinguiffi it   from the furrows pro-
duced by the blood-veffels,  or from the futures.  This is,
however,  a matter of little confequence with regard to
praaice.
  When the pericranium is not feparated from the cranium
by the accident, but is found feparated in a particular part
                                                   on 
                      E  256  3
on cutting down to it, it affords a pretty certain  mark of
a fraaure beneath.   When the bone is bared by the acci-
dent, it has been propofed to afcertain it by various means.
By pouring ink over the bone it has been faid,  that it will
fink  into the crack and there remain,  even if we attempt
to waffi it off with water.   But it is to  be obferved, that
unlefs the bones be very firmly  offified indeed,  the ink
will always fink into the futures,  and hence this method,
can feldom be of any ufe in  discovering  a fiffure.   Some
other modes recommended, as by holding a firing between
the teeth and ftriking it; and chewing fome hard fubftance
to excite pain in the part injured,  have no effea unlefs the
injury be extenfive, and then  they are unneceffary.
  It often happens that blood continues to  ooze out con-
ftantly from the fiffure; this, when it  occurs, is a very
certain charaaeriftic.
  It has been  by fome advifed in  all cafes of fiffure to ap-
ply the trepan, chiefly with a view to evacuate any colfeaion
of fluid more  freely than it could be done by the fiffure;
but, if the fiffure is wide,  there can occur no neceffity for
it;  and we know from experience,  that thofe of fmall ex-
tent  frequently do well without the formation of any mat-
ter ; and  it would certainly not be prudent to advife  a ha-
zardous  operation merely for the chance of its becoming
neceffary.  And befides, inftances are often met with in
which fiffures  penetrate no deeper than the external table
of the fkull; this cannot be previoufly known,  and could
never need the operation.
  I am of opinion, that unlefs fymptoms of compreffion
come on, the trepan can never be neceffary, and that fiffures
while  unattended  by  bad  fymptoms,  fliould be  treated
merely as a caufe that may give rife to inflammation. The
patient  fficuld  be  bled according to eircumftances; the
bowels  fhould be  kept  open; the fore  fhould  be treated
                                                  with 
                      E   257   3
mild dreffings ; and violent exertions  of every kind fliould
be avoided.*
  By thefe means a cure  will frequently be obtained; but
when inflammation is induced,  and fuppuration  is con-
fequent to it, the trepan is to be ufed as in other cafes.
      CHAP.    XXX.

Of the Diseases of the Eyes.
                            SECT.  I.

              Of Ophthalmia, or Inflammation of the Eyes.

           THE fymptoms of ophthalmia vary fomewhat accord-
            ing  to the  particular feat  of the  complaint; but
      thofe which in general occur are, a preternatural rednefs
      of the tunica conjunaiva,  owing to  a turgefcence of its
      blood-veffels ; pain and heat over the whole furface of the
      eye, attended  with  a fenfation of  fome extraneous body
      between the palpebrae and the eye-ball: and a  plentiful
      effufion of  tears.   All thefe fymptoms are commonly in-
      creafed by motion of the eye or its coverings, and by ex-
                                K k                     pofure

        * In all thefe cafes, the experience and judgment of the furgeon muft
      govern his condud, as no precife pofitive diredions can be laid down for
\     that variety of cafes and eircumftances which occur in pradice :  the young
j->\   furgeon fliould always have recourfe to the advice and  affiftance of thofe
    \ more experienced, whenever he can procure it; they will not only re-
 *\J ■" lieve his own mind, but fecure his charader from the imputation of rafh-
      aefs or ignorance. 
                      E   258   3
pofure to light.   When the pain produced by light is con-
fiderable, we have reafon to conclude, that the parts at the
bottom of the eye, particularly the  retina,  are  chiefly af-
feaed ; but when the pain thus occafioned is  not great,
the inflammation  is probably confined  to the external co-
verings of the eye.  In fuperficial affeaions, the fymptoms
are ufually  entirely  local; but whenever  they are deep
feated, there are  fevere fhooting pains through the head,
and commonly fever to a greater or lefs degree.
  The tears difcharged  are  frequently fo  hot  and acrid
as to excoriate the cheeks ; and after fome continuance of
the difeafe, together with the tears,  there is often a confi-
derable  quantity  of a yellow  purulent like matter dif-
charged.   When the  inflammation  has extended to,  or
has originated in the tarfi, a difcharge of vifcid fluid takes
place  from them,  which  adds greatly to the patient's dif-
trefs,  by  cementing the  eye-lids fo firmly together, as to
render it very difficult to feparate them.
   Ophthalmia fometimes, though not very frequently, ter-
minates in fuppuration,  oftener in obftruaion  or indura-
tion of fome part  of the membranes  of the  eye,  but very
rarely in gangrene.
   This difeafe may be induced by whatever occafions in-
flammation in any other part of the  body.   It is  alfo pro-
duced by fmoke; by much  light,  and particularly from
much expofure to the rays of the fun; expofure to fire;
to fnow;  and by the introduaion  of fand, lime, or any
other extraneous  body beneath  the eye-lids.  It is alfo in-
duced by fcrophula, or lues venerea.
   When  ophthalmy  depends  on  the two  latter caufes,
the employment  of the  remedies adapted  to the general
diathefis  becomes neceffary.  We  propofe in  this place
merely to  confider the  difeafe when produced  by local
caufes.
                                                  The 
                      [   259  3
  The indications of cure are, to remove extraneous irri-
tating fubftances ; to diminifh pain and irritability induced;
to remove the turgefcence of the blood-veffels of the eyes;
and to prevent a return of the difeafe.
  When  inflammation  is  produced by  extraneous  fub-
ftances between the eye-lids and  eyes, they ffiould, if pof-
fible, be removed.   The eye may be opened fufficiently to
admit of  this  by the fingers ; but  it is  more  effeaually
done, if while  an affiftant lifts up the fuperior eye-lid with
a blunt hook,  the furgeon depreffes the inferior eye-lid.
The fubftance  may by this  means be difcovered,  and if
loofe, may be taken out with the  end of a  blunt probe,  co-
vered with a bit of foft linen, or filk;  or if it  is fixed in
the eye, it may be removed by a  pair of fmall forceps.
  It often happens that we cannot difcover the offending
matter; in thefe cafes tepid water, or milk  and water,
fliould be frequently injeaed under .he  eye-lids, and  the
eyes fhould be frequently  dipped  and bathed in  warm
water.—When  the inflammation has  fubfifted for fome
time,  it often  continues  even after its exciting caufe has
been removed.
  Whenever the topical fymptoms are confiderable,  and
there  is much fever, it  will be neceffary to  ufe general
bleeding,  brifk purgatives,  and a  low cooling regimen.
The light ffiould  be  excluded from  both  the  eyes;
and the difeafed eyefhould be kept conftantly covered, ei-
ther with foft linen foaked in a watery folution of lead, or
with cold poultices compofed of  this folution and crumb of
bread.
  By thefe  means very violent ophthalmias may often be
removed; but inftances frequently occur in which they ara
not effeaual. In fuch, blood may be difcharged by cupping
the  temples, or by the application of leeches to them ;  but
it will fometimes happen, that even thefe give  no  relief;
the  veffels of the eye itfelf ffiould then be  divided.
  This may be done either with the fhoulder of a lancet,
                                                    or 
                       E  260  3
 or with  a fmall  knife.  An affiftant fupporting the head
 of the patient  behind, and  another  fecuring his hands,
 the furgeon with  the fore and middle fingers of one hand,
 is  to feparate the eye-lids, while with the inftrument he
 makes repeated  fmall  fcarifications  on the turgid  veffels,
 avoiding thofe of the cornea, without they feem very much
 diftended  with  blood.   In order to produce  a  free  dif-
 charge from the veffels, the  eye ffiould be frequently dip-
 ped in warm water, or foft linen immerfed in warm water,
 ffiould be  conftantly applied  to it.
   This operation  is very  eafily and fafely performed  by
 any furgeon of a tolerable degree of fteadinefs; and a few
 drops of blood evacuated by it is  frequently of more fer-
 vice than any other remedy.
   When fcarification does not remove the pain,  or when
 it is not admitted, a little laudanum, dropped into the eye,
 will fometimes be effeaual in taking it off.  The pain as
 well as every other  fymptom produced by ophthalmia, is
 often relieved by  fhaving the head and wafhing  it fre-
 quently in cold water.   Blifters applied  to  the head,  be-
 hind the ears, or on the neck,  are likewife advantageous,
 as well as iffues and  fetons in the back of the neck.
   To obviate that  gluing together of the eye-lids which is
 apt to take place, particularly at night, it will be proper to
 infinuate a fmall quantity of  fome emollient ointment be-
 tween them, every evening.  There are often flight ulce-
 rations  of the tarfi, which  contribute to produce this ad-
 hefion : when thefe are  difcovered, and are  unconneaed
 with any general difeafe, they are mofl effeaually removed
 by  the application  of mild mercurial ointment, by  means
of a pencil, night  and morning, and the ufe of a weak fa-
turnine  or vitriolic  lotion, once or twice a-day.
  It is  of great  importance  to prevent the  admiffion of
light to the  eye as  long as it is produaive of pain; and
even when one eye only is inflamed, both of them ffiould
                                                    be 
                      I   261   3'
fee lightly covered with a  loofe bandage of filk or linen;
and when the patient  is able to  go abroad,  the bandage
(pi. vi. fig. 2.) will be found very ufeful.   The quantity of
light admitted can be eafily regulated, and the  eyes by it
are neither compreffed nor  kept too warm.
   To prevent a return of ophthalmia nothing is fo certainly
ufeful as cold bathing, general and topical.   Shaving the
head, and bathing it daily,  has been found  of  confiderable
fervice.  Peruvian  bark  is alfo very ufeful, and when the
difeafe is periodical, it is the moft effeaual  remedy: all
exciting caufes are carefully to be avoided.

                    SECT.   II.

      Of Wounds of the Eye-lids,  and of the Eye-ball.

   When the eye-lids are wounded in a longitudinal direc-
tion, all that is neceffary is to bring the lips of the cut to-
gether, and retain them  by ftrips of adhefivc plafter, un-
til a  re-union takes place :  but when the wound is tranf-
verfe, and particularly if the  tarfus is divided,  the parts
ffiould be kept  together by  one  or more futures.   The
interrupted  future is ufually  employed,  but  I prefer the
twifled future.  The pins  ufed ffiould be  fhort and  very
thin, that they may not injure the contiguous parts; and in
the introduaion of them,  care fhould be  taken  to make
them pafs through the fibres of the orbicularis mufcle, or
little advantage will be gained by  the operation,  and that
they do not pafs through the internal membrane of the eye-
lid, or they will  injure the globe of the eye.   %
  In performing this operation,  we fhould be careful that
the parts are not fo clofely drawn  together,  as to impede
the aaion of the eye afterwards;  and as foon as it is fi-
niffied, as it is of confequence to prevent the motion of the
                                                   eyes 
                      [  262  ]
eyes during the cure, the eye-lids  fhould  be clofed, and
covered with a piece of foft  linen fpread with faturnine
cerate ;  and a comprefs of lint being laid over the affeaed
as well as the  found eye, the whole ffiould be retained by
a napkin.   Inflammation fhould be guarded againft, or re-
moved if prefent, and in three days the futures may be re-
moved, as a union will then probably have  taken place.
   When fo much of the eye-lid is taken off,  that the re-
maining parts  cannot be brought into contaa without im-
peding the motion  of the eye-ball,  it will be beft to leave
them apart, ufe light eafy dreffings, and truft to nature for
fupplying the deficiency with cellular fubftance.
   Wounds of the eye-ball which penetrate deep, are fre-
quently dangerous  from the contiguity  of  the brain ; but
thofe which go no farther than the anterior part of the eye,
although  they  may deftroy  the beauty  and utility  of the
organ, are not in other refpeas hazardous.
   Wounds of the cornea, particularly if direaiy oppofite
to the pupil, are moft frequently produaive of lofs of fight
in greater or lefs degree, from the cicatrix confequent to
them ; but they do not ufually occafion fo much inflamma-
tion as thofe of the fame extent in the fclerotica.
   Thefe affeaions  are attended with rifk in proportion to
their extent; the larger the  wound is the  greater danger
will there be of inflammation, and  of deftruaion of fight,
from evacuation  of the  humors  of the eye, or from ci-
catrices.
   The circumftance which  requires our chief attention in
wounds of the  eye, is the prevention or removal of inflam-
mation ;  for if a large opening is made in the eye, a great
portion of the humors will certainly be evacuated.   All
that art  can do  is, together  with  a ftria  antiphlogiftic
courfe, to keep the eye lightly covered with fome emollient
application of the faturnine  kind,  and to bathe it now and
then with a watery folution of lead.  When pain to any
                                            confiderable 
                      [  263   3
confiderable degree occurs, opium may be given in pro-
portion to its violence.
   By thefe means, fymptoms of a very formidable appear-
ance will often be entirely removed.

                    SECT.   III.

                Of Tumors of the Eye-lids.

   The eye-lids are frequently infefted with fmall, trouble-
fome tumors of various kinds.
   Towards the internal angle of the eye, and moft  fre-
quently on the under eye-lid, near the punaum lachrymale,
many people are liable to frequent returns of a  fmall en-
cyfted  tumor  of the inflammatory kind, by nofologifts
termen hordeolum,  but commonly known by the appella-
tion of zfiye.   This begins with a fenfation of fulnefs, ftiff-
nefs, and  uneafinefs of the internal canthus of the  eye.
At firft the fkin is fcarcely if at all difcoloured, but if fup-
puration follows, which will always be the cafe if the tu-
mor is left to itfelf,  it becomes  firft of a pale red, and af-
terwards of a yellow colour towards the upper part, where
it commonly  burfts, and difcharges a fmall  quantity  of a
thick  purulent matter.  This  tumor  is very flow in its
progrefs, and the peculiar appearance of it may be readily
accounted  for from its particular fituation.
   Styes  are more frequently met with than  any other tu-
mors of the eye-lids, and are ufually feated near the nofe;
but the  other  fpecies are fituated indifcriminately in  eve-
ry part of them.  Thefe are of three kinds.
   The firft we fhall mention is  commonly of a  roundifli
form; is fomewhat foft;  it feems  to  move  when preffed
upon; the fkin retains its natural appearance;  and from
the contents of it being always  of a white and fat-like na-
                                                  ture, 
                               (   264   )
         tjfre, it is termed fteatoma.  The matter of which thefe tu-
         mors are compofed, is always furrounded by a firm mem-
         branous cyft.
           From different parts of the eye-lide, we frequently ob-
         ferve  fmall pendulous excrefcences to hang  by very  nar-
         row necks :  on other  occafions they are conneaed to the
         fkin by means of thin  broad bafes.  Some of thefe tumors
         being of a foft fleffiy confiftence are termed  farcomata:
         others being hard, are termed verruca., or warts.
           In the treatment of ftyes, we are by fome direaed to en-
         deavour to difcufs them by aftringent applications ; but by
         this mode we fometimes produce tumors of a hard and in-
         veterate nature,  and may injure the eye-lids by the appli-
     *-   cations themfelves.  I think it the beft praaice to endea-
         vour by poultices to bring them to  a fpeedy fuppuration,
         and then to  difcharge the matter;  the fore  ufually heals
         very fpeedily, and the parts foon  recover  their  tone, if
         bathed with fome mild aftringent.
           Excifion alone ffiould be  depended on for the removal
         of the farcomata and verrucse ; if cauftic or ligature are em-
         ployed,  they are always  tedious in their operation, and
         often  produce troublefome inflammatory affeaions.
           The patient being feated oppofite to a window, and his
         head being fecured by an  affiftant, if the tumor is not large
         enough  to be laid hold of by the fingers,  a ligature ought
         either to be paffed  through it or around it,  by  a needle,
         that it may be raifed  from the parts beneath :  if the  bafis
         of the fwelling is narrow,  it may be feparated by one ftroke
         of the fcalpel, but if its attachment to the fubjacent parts
         is of any confiderable extent, it  is better to remove  it by
♦         cautious diffeaion.  The only dreffing in common necef-
         fary is lint retained by adhefive plafter.
           When we have to  remove  a fteatomatous  or encyfted
         tumor,  inftead of diffeaing off the fwelling  covered  with
         the  flcin, it is better merely to divide the fkin and cellular
                                                      fubftance 
                       E  265   ]
fubftance by a fimple incifion entirely acrofs the moft pro-
minent part of the tumor with a  fcalpel, a ftrong waxed
thread being then paffed through the centre of the cyft, an
affiftant fhould by means of  it raife the tumor fufficiently,
while the furgeon diffeas it  entirely out.
  If the internal membrane  of the eye-lid is divided in the
Operation, the lips of the wound in it muft be laid as nearly
together as poffible, and any  fuperftuous matter that forms
muft be frequently removed; but nothing more fhould be
attempted.  When, however, the external fkin of the eye-
lid is cut, the wound ffiould be clofed by ftrips of adhe-
five plafter.
  In extirpating thefe tumors, whenever the cyft is pretty
firm, and the contents are fteatomatous, they are more ea-
fily and effeaually removed  by preferring the cyft entire ;
but when the cyft is  thin, and efpecially if its contents are
fluid,  from fuppuration of fome part of it,  which is fre-
quently the cafe, it will conduce to the facility and expedi-
tion of the operation, to punaure the cyft,  and difcharge
its contents as foon as it is laid bare.*
                    SECT.  IV.


          Of Inverfion of the Cilia, or Eye-lajhts.

   The eye-lafhes are fometimes fo much  turned inward*
upon the  eye,  as to irritate it  and produce  inflammation
and pain.
                          L 1                      ThU


  • This fpecies of tumor is frequently fo fituated as to admit of removal
by turning the ciliary ligament outwards, then laying hold  of it with  a
fmall hook and diffeding it out, without wounding the internal (kin of the
eye-lid. 
                        E  266   ]
    This difeafe is  ufually termed Trichiafis or Entropiuin,
  and may depend entirely upon a derangement of the hairs
  themfelves, which leaving their ufual direaion, turn in to-
  wards the eye-ball;  but it more frequently originates from
  an inverfion of the tarfus, induced either by fome unequal
  fpafmodic  affeaion of the orbicularis mufcle  in the under
  eye-lid, for it  feldom occurs in the upper palpebra,  or by
  a cicatrix in the fkin of this part.   It is alfo fometimes the
  effea of tumors;  and it has likewife been  attributed to a
  relaxation of the teguments of the eye-lid.
   When the complaint  is induced merely by a  derange-
  ment of the hairs themfelves, if the hairs  have  acquired
 their full ftrength, as it will be impoffible  to  bring  them
 back into a proper  direaion, they ffiould be pulled out by
 a fmall pair of forceps,  which ufually gives  immediate re-
 lief ; and to prevent a return of the difeafe,  as foon as the
 fucceeding  hairs have acquired about half their full  fize,
 they ffiould be turned down  upon the eye-lid with the end
 of a blunt probe, and there retained for one,  two,  or  three
 weeks, by covering them with  narrow flips  of  adhefive
 plafter, or with ftrong mucilage or glue by means of a pen-
 cil.   This method  will almoft  always fucceed in  the re-
 moval of this troublefome and painful complaint.
   If trichiafis arifes from partial  fpafms of  the orbicular
 mufcle, the  only effeaual mode of cure confifts in making
 an  incifion through the internal part  of the palpebra, fo as
 to divide the affedted fibres.  No dreffing  is neceffary to
 be applied to the wound.
  When a tumor or cicatrix appears to be the caufe of the
 inverfion,  it ffiould be diffeaed out.  When, in the latter
 cafe, the difeafe is not immediately removed by the opera-
tion, the edges of the  wound ffiould be united  by adhefive
plafter, or, if neceffary,  by the twilled or  interrupted fu-
ture.   When the operation fucceeds there will be  nothing
more than foft eafy  dreffings requifite.
                                                     It 
                       E  267   3
  It is not very probable that entropium is ever occafion-
ed by a relaxation of the teguments of the palpebra; when
it appears to be the cafe, however, a folution of alum  in
infufion of oak bark will probably remove it; but if this
does not fucceed, there  is no remedy but  the  removal  of
the relaxed fkin by the fcalpel, and afterwards  uniting the
edges of the wound by future.
   Inflammation of  the eye is a very conftant attendant of
this difeafe;  when  it is not removed by taking away  the
hairs, the  remedies  formerly directed for ophthalmy muft
be  employed.
   The  upper lid  is fubjea  to  a dropfical fwelling which
fometimes may be  productive  of trichiafis: this may  be
often cured by making two or three fmall  punaures in it
with the point • of a lancet;  but when  this does not fuc-
ceed, it will be neceffary to cut off a part of the fkin with a
fcalpel, and clofe the wound afterwards by adhefive plaf-
ter or future.

                    SECT.   V.

         Of the Turning Outwards of the Eye-lids.

    When the  internal  furface of either of the eye-lids is
turned outwards, fo as  to fold over any part  of the cilia
or of the  contiguous fkin, the difeafe is termed eftropium ;
 when  the upper eye-lid only is affeaed, it has been called
 Lagophthalmus.
    This complaint is not only produaive of deformity,  but
 alfo, in many  inftances, of confiderable pain.  It may  be
 induced  by  an enlargement of  any  part of  the eye, or
 other tumors within  the  orbit;  by  dropfical  fwellings of
 the palpebra ; by violent  inflammations of the tunica con-
jundiva  lining the eye-lids; by mere relaxation  of  the
                                              palpebra; 
                      E  268  3
palpebra; and by cicatrices  of wounds or abfceffes,  pro-
ducing a corrugation of the flcin of the eye-lid.
   When  the difeafe is induced by tumors, thefe muft be
removed; when topical dropfy is the caufe,  it  muft be
treated as direaed in  the laft feaion.   If inflammation
has given rife  to it, and it continues after that  has  fub-
fided,  deep  fcarifications  into the affeaed part will be
particularly  beneficial:  and if the  complaint originates
in relaxation, as will be particularly the cafe in old  age,
cold water,  brandy, and aftringent lotions ffiould be  fre-
quently employed; but in aged perfons no operation ffiould
be advifed.
   Cicatrices, from confluent  fmall-pox, and other caufes,
fometimes induce this difeafe.  When the contraaion  is
only in one  point,  it may be removed merely  by an inci-
fion  through the  fkin  and cellular fubftance; but when
there is an adhefion the whole length of the  cicatrix, af-
ter making an incifion, the fkin ffiould be raifed by a  pair
of fmall  forceps, and  the  whole  of it feparated by the
knife from the parts with which it adheres.   The cilium
then being  reftored  to its  natural place, the fkin is to be
kept in a proper fituation by adhefive plafter, if poffible, if
not,  by a  bandage, until the wound fills up and heals.


                   SECT.  VI.

               Of Concretion of Eye-lids.

   An  adhefion of  the eye-lids to each other, or to the
ball of  the eye, is moft frequently occafioned by inflamma-
tion—It is fometimes met with in new-born children.
   When the adhefion is flight, and not of long duration,
it may  be  removed in general by a blunt probe; but when
the concretion  is firm,  or any way extenfive> it  can only
                                                   be 
                      E  269  3
 be feparated by the knife.  In performing this  operation,
 the  patient's head  ffiould be fupported by  an affiftant,
 who fhould  likewife fupport or elevate the upper eye-lid;
 whilft the furgeon, with a pair of fmall forceps, muft
 raife  or  feparute the  under lid, and  at  the fame time,
 cautioufly remove  the  adhefion with a fcalpel.  The eye
 muft afterwards be  covered with a  pledget of lint fpread
 with faturnine  cerate; and  at every fubfequent dreffing,
 a fmall  quantity of the ointment may be  infinuated be-
 tween the eye-lids.   All means of  exciting inflammation
 ffiould he carefully  avoided ; and if it comes on, it fhould
 be removed as in other cafes.

                   SECT.  VII.

          Of Flejhy Excrefcences on the Cornea.

  This difeafe is denominated from its appearance, Ptery-
 gium, or Onyx, by different writers.  It is moft frequently
 met with at the internal angle of the eye, but  it  attacks
 Other parts in various inftances.  In fome cafes  it is fmall,
 but in others, it gradually extends over the whole cornea.
  This affeaion feems to confift in an organic membranous
 fubftance formed by a protrufion  of  fome of  the blood-
 veffels of the tunica conjunaiva from external violence,
 inflammation,  or other caufes ; and  its  increafe is probably
 owing to fubfequent inflammations.   Ophthalmia is  its
 moft  frequent  caufe;  and it feldom appears until the dif-
 eafe begins to fubfide,  or has  entirely  gone off.  During
 the  inflammatory  ftate,   this  fwelling ns  generally of a
deep red colour, and very  painful; but afterwards,  and
when it arifes without  any previous inflammation, it is of *
a pale yellow,  and  unattended  with  much  pain, unlefs
irritated.
  When the inflammation has gone off, as long  as  this
complaint does  not  impede the motion  of the  c; .-lids,  we
                                                fhould 
                       [  270  3
 ihould truft  chiefly to aftringent applications, fuch  as fo-
 lutions of alum and white vitriol, as ftrong as the patient
 can bear  them, perhaps 3fs of the former,, and ;;i.  of the
 latter to $iv. of water, ana ufed three or four times a-day
 —A weak folution of  corrofive fublimate, as gr. i.  to fiv.
 or verdegris, may alfo be employed with benefit.
   Efcharotic powders,  as  calcined alum, white vitriol, Or
 verdegris, mixed  with  loaf fugar, and fprinkled on  the
 part once or twice a-day, have been ufed.   But we  fhould
 be  very  cautious in the  application of remedies of this
 kind.  They may  be  ufed  alone,  or alternated with the
 aftringents abovementioned.
   When  thefe remedies fail in preventing the tumor from
 acquiring an inconvenient fize,  if it is attached to the eye
 by  a fmall pedicle only, it may be removed  'sy one ftroke
 of the fcalpel;  but whenever it is conneaed to the whole,
 or  a large  part of the furface of  the eye,  it has ufually
 been recommended to diffea off the whole;  but this is a
 tedious  and hazardous  operation:  The  following an-
 fwers every purpofe of it without danger.    The patient
 being placed upon a pillow on the floor, the furgeon fitting
 behind him on a chair,  ffiould  have the head of the pa-
 tient reclined on his knees, with the face fo  raifed,  that a
 fufficient  degree of  light may fall on the eyes.   The pati-
 ent's hands then being fecured, the  under eye-lid  ffiould
 be  drawn down as far as poffible  by an affiftant,  while
 the upper palpebra is fupported in  fuch a manner by the
 furgeon with his left hand, as to expofe to view the  whole
 of the difeafed part.  A fmall knife* is now to be employ-
 ed in making fcarifications through the excrefcence near
 to and all around  its  outer circumference,  fo  as  to cut
 off all communication  between the roots and extremities
                                                     of

  * The knife beft adapted to this purpofe, is made about the fize and fhape
of that ufed for  extrading the catarad, except that it is fomewhat more
rounded at the point, and has a back like a common fcalpel. 
                      E  271   3
«f thofe  veffels  of which it is formed.  And in order to
render the operation  more  certainly fuccefsful,  after the
difcharge of blood induced by  the firft incifions is fome-
what  abated,  one, two, or more  circular fcarifications
may be made within each other.
  Thefe incifions had better be made by repeated ftrokes
of the  knife through the  excrefcence,  for fear  of injuring
the eye-ball;  and they  may  be done with equal fafety,
and with more eafe, in the manner  above recommended
than by lifting the excrefcence by a ligature paffed through
it,  as advifed by fome operators.
  The incifions fhould I e  allowed  to bleed  freely, and
may afterwards be bathed  two or three times a-day with
a weak folution of faccharum faturni.   If the excrefcences
do  not feem to decreafe in a few days, die  operation may
be  repeated, and again renewed from time  to time, as long
as any part of the difeafe remains ; and whenever any part
of  the tumor  becomes  loofe,  it may be cut  off,  but not
without.
  Although this operation very commonly  proves  fuccefs-
ful, yet there are fome inftances in which no advantage  is
derived from it, and the difeafe uniformly  increafes after
its  performance : in thefe  cafes, we  muft  truft to pallia-
tives.  The eye ffiould be frequently  bathed with  a weak
faturnine folution, and be covered with pledgets of Gou-
lard's  cerate.   When thefe applications have no effea,
and the tumor  increafes to fuch a fize as to deftroy vifion,
and becomes very painful, it will be neceffary, left it ffiould
degenerate into a cancer, to remove it at once, by extirpat-
ing the whole eye-ball.
SECT, 
E  272  ]
                   SECT.  VIII.

            Of Abfceffes in the Globe of the Eye.

   When inflammation of the eye  terminates in fuppura-
 tion, which is  feldom the  cafe,  it  commonly originates
 from negligence, or from a fcrophulous or fome other
 general affeaion.
   The effufion of puriform matter into the ball of the eye,
 is commonly produced from  the internal part of its mem-
 branes ;  by mixing with the aqueous humors it  produces
 an enlargement of the eye, a lofs of  vifion,  and fuch an
 opacity,  that, in general, neither the iris, pupil, or cryftal-
 Kne  lens can be diftinguiftied.  In  fome few cafes, how*
 ever, the -iris  is pufhed forward,  and can be obferved in
 clofe contaa  with the cornea; and the coats of the eye
 being  here weaker  than in any other part, a protrufion
 eommonly takes place, which, if not opened foon, burfts of
 itfelf, and difcharges part, or perhaps all of the contents of
 the eye ; and at this opening the iris,  in  a thickened dif-
eafed ftate,  is very  generally pufhed out*   In fome cafes,
partial fwellings occur likewife in the fclerotica.
   During  the formation of  this difeafe the  patient fuf-
fers  not only a lofs  of fight,  but fevere pains in  the eyes,
fhooting  backwards  into  the head, are generally attend-
ant,  accompanied by conftant reftleffnefs, heat, and other
fymptoms  of  fever;  and thefe  continue very commonly
until the contents of the eye are evacuated.   In fome in-
ftances there is no pain; but the matter  formed  is then
fmall in quantity, and the fwelling is  chiefly  of a watery
nature, probably originating from an increafe of the aque-
ous humor.
   All the varieties of this  difeafe we  comprehend under
the name of ftaphyloma.   Small, partial  abfceffes  feated
                                                    on 
                      I  273   ]
on different parts of the cornea or fclerotica, and in which
there is no general affeaion of the eye, are included under
the title of Hypopyon.   In both thefe difeafes, the motion
of the eye-lids is more or lefs impeded.
   All  the varieties of the flaphyloma  require the fame
treatment.   As  it rarely happens that the ufe of the eye
can be preferved, our chief objea in general is, to abate
the violence of the pain, and to remove the deformity pro-
duced.  For  the accomplifhment of the  firft intention,
the difeafe is  to be treated by the remedies of ophthalmia :
And if, notwithftanding the employment of thefe, fuppu-
ration is induced, and the pain produced  by the confequent
increafed diftention of the eye is very great, nothing but
an incifion through its coats fo as to evacuate the effufed
matter and the thinner humors, will  give relief.  The
patient's  head  being  fecured by an affiftant,  and the
operator flanding before  him, the eye-lids may be fuffici-
ently feparated by one hand,  while the knife recommend-
ed in  feaion vii. being  introduced into the moft promi-
nent part of the tumor, or into  the moft  depending part
of the  tranfparent  cornea,  is to  be  carried forward hori-
zontally until an opening of a fufficient fize is formed.
   It has been recommended inftead of the above defcribed
operation,  either to diffea off the  protuberant  part  of
the eye,  or to remove it by a  ligature;  but  neither  of
thefe painful  modes are in common neceffary, nor are they
more effeaual than the method we have advifed.  In fome
very long continued cafes of flaphyloma,  indeed, where the
humors of the eye feem to be entirely abforbed or deftroy-
ed, and in which the tumor is altogether  formed by a thick-
ening of the coats of the eye, and particularly  of the iris,
the only effeaual remedy is the  removal of all the promi-
nent part of the eye ; but in common, the difeafe ffiould be
confidered merely as an abfcefs, and treated as  abfceffes in
other parts of the body.
                         M m                    After 
                      [  274   ]
   After the contents of the eye have been evacuated, the
parts ffiould be gently covered with a foft comprefs moift-
ened with weak lead water,  and the patient ffiould be kept
upon  a low,  cooling regimen,  until the wound is  healed,
or there is no rifk of inflammation.
   The hypopyon is to  be treated upon the fame plan; the
pain is to be moderated by opiates, &c.  and as foon as mat-
ter is  formed, it  fhould be  evacuated  by an incifion, in
order  to prevent a chance of its being  difcharged into the
globe of the eye, and deftroy vifion entirely.
   The fungous excrefcences that  occur after operations
in thefe difeafes, may be kept down by the occafional ap-
plication  of burnt  alum  finely powdered,  or  of lunar
cauftic.
                   SECT.  IX.


          Of Dropfical Swellings of the Eye-Ball.


   A dropsy of the eye-ball is produced folely by an in-
creafed quantity of the aqueous humor.  The firft fymp-
tom of the difeafe is, a fenfe of fulnefs in the eye, which
produces a good deal of diftrefs, long before any increafe
of fize in the eye-ball is perceptible :  This at length makes
its appearance ; the motion of the eye-lids begins to be im-
peded ; and vifion gradually becomes more imperfea,  until
at length the patient is juft able  to diftinguiffi light  from
darknefs.  At this period  too, fome part of the eye,  moft
frequently the tranfparent cornea, generally begins to pro-
trude,  fo as  to form a fmall tumor.  If the  contents of the
eye are not  now difcharged  by an operation,  the tumor
foon burfts.
In 
                      E  275  3
   In the early ftage of this difeafe there is no difficulty in
diftinguifhing it from flaphyloma; but in  the  advanced
ftate this is not always eafy to be done.  The external ap-
pearances of thefe difeafes are fometimes  exaaiy fimilar;
but in the dropfy of the eye, the patient is always fenfible
to the effeas of light; and if the pupil can be diftinguiftied,
light will commonly produce fome  degree of  contraaion
in it.   It is, however, of no confequence  to discriminate
between  them, for the treatment adapted to one is equally
proper for the other.  See the laft feaion.
   In the earlier  flages of this complaint, as the confequent
lofs of vifion feems to originate often merely from diften-
tion, would it not be better to evacuate the fluid, by an
incifion of perhaps  three-tenths of an inch long with the
knife (pi. vii. fig. 8.) into the moft depending part of the
tranfparent  cornea ;  or by introducing a flat trocar with
a lancet point,  of the fize of a crow quill,  about the tenth
of an inch from the cornea tranfparens, behind the iris, and
at the  moft  depending part of the eye ? This might be re-
peated occafionally, if the difeafe fhould return.  It is an
operation perfeaiy fafe; and after its performance,  with a
view to ftrengthen the  eye,  and prevent  a return  of the
complaint, the parts  might be bathed frequently with fome
aftringent lotion.
   Inftead of difcharging the humor by an incifion, in an
advanced ftage of the difeafe, when vifion is deftroyed,  it
has been propofed to employ a feton; but it  is probable
this would give too much irritation.
5  E C T. 
[  276   ]
                   SECT.   X.

      Of Blood ejfufed into the Cavity of the Eye-Ball.

   Blood may be effufed into one or other of the cham-
bers of the eye  by  various  caufes.  It has occurred  in
fome inftances of putrid difeafes,  and in inflammations of
the eye; hut it is more frequently the  confequence  of a
rupture of  fome blood-veffel, from  a  blow,  or from a
wound penetrating into the pofterior chamber.  When the
wound does not extend farther than the anterior chamber
of the eye, as the veffels furrounding that  do not in com-
mon convey red blood,  it feldom occurs as an effea.
   Whenever  blood is  mixed in  fuch quantity  with  the
aqueous humor as to obftrua vifion,  it ffiould be remov-
ed by an operation;  but when  it finks  below the axis  of
vifion, and produces no inconvenience, it may be fuffered
to remain.
   The operation for the  removal of blood from  the eye-
ball is fimilar to that defcribed in the laft feaion.  An
opening ffiould be made in the moft depending part of the
tranfparent cornea, with the knife, about a fixteenth part
of an inch  from the junaion of the iris with the  other
coats of the  eye ; and thence carrying the point  of it ho-
rizontally forward to the diftance of about three-tenths of
an inch, it ought at this part to be pufhed through the cor-
nea :—by proceeding flowly and  fleadily, all that part of
this membrane ffiould then be divided which lies between
the two openings made by the inftrument at its  entrance
into, and its paffage from the cavity of the eye, care being
taken to make  the incifion  at an equal diftance from the
iris through  its whole length.
  The aqueous humor, together with the commixed blood,
will now oe  difcharged, particularly if the patient turn his
                                                  face 
                      [   277   ]
face downwards, and  the  fides  of the  divided cornea be
feparated by a blunt probe, or a fmall fcoop.   The cornea
will then collapfe, and a comprefs  of lint moiftened with
lead water being applied,  the wound will foon clofe,  and
the aqueous humor be quickly regenerated.


                   SECT.  XI.

           Of the Ulcers on the Globe of the Eye.

   The danger of fores on the eyes depends chiefly on their
fituation, but in fome  meafure alfo on their form.  Ulcers
on the cornea, from the cicatrices confequent to them, are
very apt to produce lofs  of vifion  in greater or lefs  de-
gree ;  while thofe feated  on the fclerotica never produce
that  effea.   And  ulcers  that are broad and  fuperficial,
although they may induce lofs  of vifion, yet they do not
in addition to  this evacuate the humors  of the eye, as
thofe which are deep and narrow often do, either by pene-
trating entirely through the coats of the eye, or by weak-
ening them to fuch a degree that the humors force a paf-
fage for themfelves.
   In fome cafes thefe ulcers inftead of occafioning a  lofs
of fubftance, ffioot out foft and fungous excrefcences.
   Ulcers of the eye may occur from a variety of caufes, as
from wounds, burns,  bruifes, &c. and from  general affec-
tions, fuch as lues venerea, or fcrophula.  But in moft cafes
they may be traced to inflammation terminating in the for-
mation of matter.  Inflammation is likewife a frequent and
troublefome accompaniment of them.
   When thefe affeaions  are attended with  much inflam-
mation, all the remedies of ophthalmia in general become
neceffary;  and when  we  find a number of  inflamed  vef-
fels paffing direaiy from the fores along the centre of the
                                                  eye, 
                       [   278   3
 eye, it will not only contribute much to the removal of the
 inflammation to divide them, but will alfo be of great fer-
 vice in healing the ulcers.   This  muft be done very cau-
 tioufly,  for  if  the  fcarifications  are  made very extenfive
 and deep, they will be very apt to degenerate into  trouble-
 fome fores.
   After the inflammatory ftate of thefe ulcers is removed,
 they ffiould  be treated as ulcers  in general,  by the appli-
 cation of emollient, or of ftimulating ointments,*  or lini-
 ments, of efcharotics,  or of aftringents, according to the
 particular eircumftances  of the cafe.   And if any general
 difeafe is conneaed with the topical  affeaions, remedies
 adapted to this fhould be ufed at the fame time with the lo-
 cal applications.  Ointments,  or  efcharotics, can  be moft
 conveniently applied by means of a pencil.   It is hardly
 neceffary to  obferve, that lint  or bandages cannot in ge-
 neral be ufed in cafes of this kind.
   When large pendulous excrefcences are  produced from
 ulcers on the eye, they fhould be raifed by means  of a li-
 gature paffed through them, and  then diffeaed off with
 the  fcalpel.   But when they are fmall, or  broad and low,
 the  eye being fixed with a fpeculum,  lunar cauftic ffiould
 be applied by means of a pencil over their furface,  and be-
 fore the fpeculum is removed, the cauftic ffiould  be wafhed
 off by  a pencil, dipped in warm water or milk.
   When the conftitution is found, ulcers of the eye will
 commonly heal without much difficulty, but in fome in-
 flances it happens that they conftantly increafe in virulen-
 cy,  notwithftanding every thing ufed for removing them.
 In fuch cafes as foon as they have  increafed to fuch a de-
 gree as to endanger the communication  of the  difeafe to
 the  parts contiguous to  the eye,  the eye-ball ffiould cer-
 tainly be extirpated.
                                             SECT.
  * Stimulating applications may be ufed in thefe cafes with more freedom
than is generally fuppofed: Such as corrofive fublimate,  verdegris, whit<
vitriol, &c.  B. 
E  279  3
                  SECT.   XII.

            Of Specks or Films upon the Eye.

  The difeafe termed leucoma, albugo, or nubecula, con-
fifts  in  an opake fpot formed on  fome part of the eye.
When it occurs  on the Sclerotica, it feldom requires the
affiftance  of  the furgeon ; but when  it  is feated on the
cornea, it always merits great attention, as a very fmall de-
gree of it frequently induces a partial and fometimes a to-
tal lofs of vifion.
  Thefe fpecks or films are generally of a whitiffi colour,
and feem  to originate, in every inftance, from that effufion
which is fo frequent a confequence of inflammation. When
an abfcefs is  thus produced, the burfting or opening  of it
very commonly leaves an opaque fpot, attended with fome
degree of prominency of the parts in which it was feated;
but where the effufion inftead of being  near the furface of
the cornea is difperfed among the different lamellae of which
that membrane is compofed ; or when the  degree of inflam-
mation has not been fufficient for carrying it on to fuppu-
ration, the opacity induced, does not, as in the  cafe of an
abfcefs, form a protuberance, but rather appears to confti-
tute a part of the cornea itfelf.
  Thefe fpot§ on the eye are  of various forms, and of dif-
ferent degrees of magnitude.  Whenever they affea the
fight  materially, they fhould certainly if poffible  be re-
moved.   In the cure, it is  of the greateft confequence to
afcertain which of the  two varieties above defcribed the
cafe  belongs  to.  When the effufed matter feems to be
fpread through the  whole  fubftance of  that  part of the
cornea in which it is feated, without elevating it in any
degree,  no advantage  can be expeaed from any external
applications, becaufe we cannot by thefe remove the dif- 
                        [  2S0  3
 eafe without deltroying  the  cornea itfelf.   In fuch cafes,
 as the opacity is fometimes removed by an exertion of the
 fyftem alone, probably by means of abforption,  it will be
 proper to employ fuch remedies as we  know excite this
 operation,  fuch as a gentle  courfe of mercury,  now and
 then brifk  purgatives, and iffues.   But we  feldom derive
 much advantage from them.*
   When there is an evident prominency in the difeafed fpot,
 produced from an elevation  and opacity of the external
 lamina alone, we can often cure the complaint entirely, and
 almoft  in every cafe produce an alleviation of it.   This va-
 riety of Ieucoma may be removed either by the knife, or by
 efcharotics; but in general the former is  preferable.  The
 eye being fixed with a fpeculum, (pi. vi. fig. 6.) the furgeon
 ffiould  feat himfelf between the  patient and a clear light;
 and then with repeated ftrokes of the fmall knife, (recom-
 mended in fea. vii.) he ffiould endeavour to cut away all
 that portion of the cornea  which is  in  any degree feparat-
 ed from the reft.   This may be done with the  greatefl
 fafety by an operator with a fleady hand.
   As patients will not always fubmit to this operation, we
 are fometimes under the neceffity of employing efcharotics.
 Thefe may be ufed fufficiently ftrong to  remove Ieucoma,
 in many inftances, without injuring the found parts conti-
 guous to  thofe difeafed.  When efcharotic powders are
 employed alone, or mixed with emollient ointments,  they
 fhould  be  very finely levigated.   The moft effeaual of
 thefe are red precipitate,  or verdegris, mixed with three or
                                                     four

  * When the opacity is confined to the  middle of the cornea, and the
other parts of the eye are found, Mr. Pellier fays he has derived confider-
able advantage from enlarging the pupil, by means  of a fmall pair of
curved fciflars carefully introduced upon' a grooved diredor, through
an opening in the cornea  to the  back part of the iris.  The cornea is to
be cut exadly  as direded in the operation for extrading a catarad, and the
iris is to be divided its whole breadth.  If this affedion mould be compli-
cated with a catarad, the catarad is to be extraded. 
                      C   281   3;
four parts of fine fugar.  Calcined alum, and white vitriol,
combined with egg-fhells in fine powder,  have frequently
proved ufeful.  A lotion, or wafh,  feems to be the beft form
in which efcharotics can be applied  to the eye: to make
thefe, verdegris, white vitriol, or corrofive fublimate, may
be diflblved in water.
  As it is impoffible  to confine  any of thefe applications
to the difeafed part; all that can be done is to infert them
within the eye-lid; by the motion of which they are foon
conveyed over the whole furface of the eye.   In order to
reap  advantage  from  them, it will be advifable  to em-
ploy two or more at the fame time;  thus a fmall quantity
of  the  powders  or ointments  may be ufed  evening  and
morning, and  a wafh may be employed twice or thrice in
the day.

                   SECT.   XIII.

   • Of Protrufions of the Globe of the Eye from the Socket.

   The eye  may be protruded from  its focket by different
caufes:  1. By hypopyon, flaphyloma, and dropfical fwel-
lings.  2. By external violence.   And 3. By tumors form-
ed behind or beneath it.
   When the protrufion originates from the firft fet of cau-
fes, the fize of the fwelling muft be diminifhed by incifion,
and the other  means already direaed in thofe cafes.
   If external violence difplaces the eye,  and its conneaion
with the orbit is not entirely deftroyed, it fliould be imme-
diately replaced after removing any extraneous matter that
may  happen to have been introduced into  the orbit;  and
with a view to prevent or leffen the  confequent inflamma-
tion, bleeding, general and topical,  and a ftria antiphlo-
giftic regimen fhould be advifed ; the eye fliould be cover-
                          N n                       ed 
                        E  282   ]
  ed with cooling faturnine' applications; and  light ought
  to be entirely excluded from it.
    There are feveral inftances upon record of the eye being
  entirely thrown out of the orbit, and on its being afterwards
  replaced, the patients have entirely recovered the ufe of it.
    When the eye-ball is protruded by a tumor fituated be-
  neath or behind it, the cure muft depend entirely on a re-
  moval of the tumor.  If the fwelling is formed by a collec-
  tion of fluid,  a cure will fometimes be obtained merely by
  laying the cyft open; but when  it is of a firmer nature it
  muft be totally extirpated.
    An enlargement of the lachrymal gland has  in fome in-
  duced this difeafe—extirpation of the tumor is then the only
  remedy.
    Tumors within  the orbit, of whatever kind, ffiould al-
  ways be removed as foon as they begin to injure the func-
  tions of the eye ; for if this is long negfeaed, the adjacent
  bones,  as well as the eye, may be brought into a  difeafed
  ftate ; and  when this feems to be  induced in any confider-
  able degree, the operation will come  too late.

                   SECT.  XIV.

 Of Cancerous AflfeBions of the Eye, and  Extirpation of the
                       Eye-Ball.

   It fometimes happens  that ophthalmia and flaphyloma
 degenerate into  cancer.   The eye-ball becomes enlarged,
 and protrudes  beyond the  boundaries of the  focket; it
 acquires a firm, and even a hard confiftence; and the pow-
er of vifion is deftroyed.   The tumor has commonly a red
or fleffiy appearance; in fome  inftances, a yellow gluti-
nous matter, but moft frequently a thin acrid ichor is dif-
charged from the furface  of it.   For a confiderable  time
                                                  the 
                      E  283* 3
the patient complains only of heat, or a fenfation of burn-
ing in the fwelling; but at laft  he becomes diftreffed with
fevere pains fhooting through its fubftance, and acrofs the
brain to the oppofite fide of  the head.
   Whenever this difeafe occurs, as there is no profpea of
curing it but by extirpation  of  the whole  eye-ball, and as
this is-an operation attended with no danger from hemor-
rhagy, or any other caufe, it ffiould always be employed as
early as poffible.   See feaion on cancerous ulcers.
   In performing, the operation, the  patient ffiould  either
be firmly feated in a  proper  light, with the head fupported
by an affiftant, or what  anfwers better, he ffiould be laid
upon a table, with his head on a pillow.  When the eye-
lids are difeafed,  they muft  be  removed with the eye; but
when they are found, they ffiould be allowed to remain.
   By means  of two flat hooks, (pi. vi. fig.  7.) the  palpe-
bral are to be feparated by affiftants, and then the operator
is to take hold of the eye with his fingers, if it is fufficiently
protruded ; but if this cannot be done, it will be neceffary
to pafs  a broad flat  ligature through the centre of  it, in
order to fecure it during the  operation.   While this is done
with one hand, the furgeon  with a common fcalpel in the
other, muft endeavour by a flow diffeaion, to feparate the
whole  globe  of the  eye  from  the parts  with which it is
conneaed.  Every difeafed  part muft  be removed ; but
great care muft be taken to avoid injuring the bones.
   Whenever  the  hemorrhagy  is confiderable,  which is
feldom  the cafe, it  may be eafily reftrained  by preffure
alone; or a piece of dry fponge being applied to the vef-
fels, preffure may be applied  with it, by filling the orbit
with lint,  and  applying  a  napkin over  the  whole.  If
fponge is ufed, it will be proper to tie a piece of  ftrong
                                                waxed 
                        E   284  3
waxed thread to it, that ic  may be readily removed when
there is no farther rifk of hemorrhagy.*

                    SECT.   XV.

                    Of Artificial Eyes.

   Artificial eyes  are chiefly ufeful when the eye has
been but in part removed, or it has been diminifhed in fize
by the operation  for flaphyloma,  or hydrophthalmia; for
when all the  globe has been taken  away, it  is  difficult to
fit and preferve them in a proper fituation.
   They are ufually made of a concave  plate of gold,  of fil-
ver, or of glafs, coloured fo as  to match the eye remaining,
and adapted to the orbit.   Thofe of glafs can be fitted more
exaaiy,  and kept  cleaner than  thofe formed of metal;
and they ffiould confequently be preferred.

                    SECT.  XVI.

                       Of CataraBs-.

            §. 1. General Remarks on CataraBs.

   A cataract is  a  deprivation  of fight, induced  by an
opacity of the cryftalline  lens, or of its capfule.f
                                                 Inftances

  * Though the hemorrhage confequent upon this operation, may be eafily
reftrained by preffure with the  fponge and  lint  as direded, yet a violent
one has enfued the fourth day after in confequence of a fevere cough which
forced out the plug of lint from  the focket  in the night, and the patient loft
about forty ounces of  blood before any afliftance could arrive. This ought
to put young furgeons upon their guard in fuch cafes.
  f Mr. Pellier a very able and  fuccefsful French oculift, tells us, that
catarad is  fometimes induced by an opacity in the fluid, with  which the
                                                   fubftance 
                          [   285  3

    Inftances have occurred in which cataraas  have form-
 ed in a few hours ; but in common their produaion is gra-
 dual.   The firft fymptom is  ufually a weaknefs or dimnefs
 of fight;  and this commonly takes place long before any
 alteration in the appearance of the lens can be  perceived.
 This  gradually  increafes ; and after fome time,  upon ex-
 amination, the lens will be found of a dufky hue, and fome-
 what  opaque.  The patient at length either becomes totally
 blind, or perhaps is juft able to diftinguiffi bright colours,
 or light from  darknefs.   The  lens grows opaque in pro-
 portion to the degree of blindnefs, and gradually becomes
 white, or of a grey or pearl colour :  in a few inftances the
 opacity is partial,  but it is in common extended over  the
 whole lens.
                                                            In

 fubftance of the lens is immediately furrounded.   That it is in fome cafes
 complicated  with a diffolution, and in others with an opacity of the vitre-
 ous humor,  originating from  very violent  inflammation, and which are
 both incurable ; and fometimes with  adhefions of the lens to the capfule of
 the vitreous humor ;  which is probably the moft common caufe of a failure
 in couching.
   He alfo informs  us, that when a  catarad is of a firm confiftence, it is
 almoft always of a  brown colour: and when fluid of a cream  colour, ex-
 cept in children at birth, when it is of a milk white; and that the eye, in
 the latter cafe, appears full, and fomewhc t larger than ufual, and the cap-
 fule is confiderably thickened: This if it is of a yellow colour, a fmall por ■
 tion of the lens is commonly hard, and the reft fluid : And that he has feen
 inftances of a black catarad; which is to be diftinguiftied from a gutta
 ferena, by the pupil retaining its contradile power.  Mr. Bell appears to
be well convinced, that Mr. Pellier is capable of diftinguifliing thefe varie-
 ties of catarad by the marks here laid down.
  Mr. Pellier prefers extradion to depreffion of the catarad in every cafe,
except the pupil is very fmall.  He always fixes  the patient with his fide
towards the  light,  during the operation; but the eye oppofite to that
operated upon, previoufly covered, is  placed near  the light.   He feparates
adhefions of the lens,  or replaces the iris when it is thrown forward, by
means cf a fmall inftrument  which he terms a  curette.  When there i»
                                                         reafon 
                          [   286   3

   In fimple  cataraas the  pupil  contraas and  dilates ac-
cordino- to the  degree of light  in which it is placed; but
when they are combined with gutta ferena, it is immovea-
ble, and generally is much dilated.  Pain is not a common
fymptom  of this difeafe ;  and when it occurs,  it probably
originates from  an  attendant inflammation at the bottom
of the eye.
   There is no danger of confounding  cataraas with any
other difeafes of the eye, if a proper  attention  is given to
the  charafteriltic marks of each.
   The body of the lens itfelf is commonly the  feat of this
difeafe ; but in fome few inftances it is found to depend on
an affeaion of the  capfule, forming   what is termed the
membranous cataraa.
   The  proximate  caufe of cataraa  feems  generally to
confifl in fome degree  of obftruaion in  the veffels of the
                                                         lens,

reafon to fuppofe the catarad fluid, he merely introduces a knife through
the cornea and pupil, and makes  an  opening in the capfule.  When the
membrane is difeafed, he always advifes us to avoid tearing  it, and to ex-
trad it together with the lens.  That Mr. Pellier ever takes out the cap-
fule together with the lens, by preffure, as he direds, Mr. Bell from feve-
ral fads, and for  very fubftantial reafons, very  confidently denies. Mr.
Bell advifes the blunt probe to open the capfule, as lefs dangerous than the
knife.
   If the catarad is accompanied by  an incurable opacity confined to the
middle of the cornea, and every other part of the eye is found, Mr. Pel-
lier propofes to enlarge the pupil.  See Note to Sed. on  Leucoma.
   Mr. Pellier advifes repeated fmall  dofes of opiates a few  hours after the
operation.  Befides other remedies, he ufes a liniment of powdered alum,
or of white vitriol and faccharum faturni beat up with white of egg, and
applied between folds of foft linen, and a little of the latter infinuated be-
tween the eye-lids, three or four times a-day,  to remove the confequent
inflammation and pain.   When the iris, after the operation, is forced out
at the incifion by any caufe, he fays it may be touched frequently with
gentle cauftics, fuch as Goulard's extrad of lead  concentrated by long boil-
ing, or any mild antimonial cauftic; immerfing the whole eye immediately
afterwards in warm milk, or fome emollient decodion, and then covering
it with a comprefs wet with lead water, &c. 
                      [   287   j
lens, induced in fome inftances by external violence, but
in others by fome internal caufe with which we are unac-
quainted.   This is rendered probable from the difeafe of-
ten happening  to women about the period of the ceffation
of the menfes, when  obftruaions  in many parts of the
body are more particularly apt to be induced.
  The indications of cure in this difeafe are,  1. To re-
move the opacity  of the lens ; or when this cannot be ac-
complifhed, 2. To remove the lens itfelf from the axis of
vifion.
  In the incipient ftate of cataraa, mercurial preparations,
and particularly calomel,  are fometimes ferviceable.  When
inflammation occurs,  it muft be treated  as in other cafes.
The extraaum hyofcyami, the flammula jovis, and other
vegetable preparations, are much recommended by fome;
but I cannot fay  any thing of them from my own experi-
ence.
  In confirmed cataraas of long duration,  we feldom de>-
rive advantage  from any internal medicines ; and we are
confequently reduced to  the neceffity of removing the dif-
eafed lens from the axis  of vifion.  This is accomplifhed,
either by preffing it to the bottom of the eye, by an ope-
ration  termed couching, or by removing it entirely  from
the eye,  by the operation of extraaion.

      §.  2. Of Couching or Depreffion of the CataraB.

   By the operation of couching, the opaque lens is  fepa-
rated from its capfule, and being preffed  down behind the
iris, below  the axis of vifion,  if the operation fucceeds, it
either  remains there during life, or is  diffolved  in the
aqueous  humor.   And although the fight will never be
fo perfecl afterwards, as it was before the lens became dif-
eafed,  if the eye be otherwife found, it will be quite fuffi-
cient for the common purpofes of life.
                                                    As 
                      [  288  ]
   As this operation as well as extraction, is always fucceed-
ed by inflammation to a greater or lefs extent, it fliould ne-
ver be rifked unlefs the patient is blind to fuch a degree as
to prevent him from following his ordinary  bufinefs ; and
never then, when the cataraa is complicated with gutta fe-
rena,  or with an opacity of the cornea.  Although the lens
is  frequently harder than natural,  and in fome inftances
fofter, this, were it always known, ffiould not influence us
in determining upon the operation.
   In  order to obviate the inflammation  confequent to
couching, it will be proper to confine the patient to a low
regimen a few days previous  to the operation, and to give
him two or three dofes of fome cooling laxative at  proper
intervals.
   It will  be beft  to have the  patient placed in an apart-
ment  expofed  to the north, during  the operation;  for al-
though  it  may be  neceffary to have a good light, the fun-
ffiine  fliould not be admitted,  as it will,  by irritating the
eye, prevent  it from being fleadily fixed.   The patient
ffiould be  placed upon a low feat, with his face towards
the window; and the furgeon upon a chair confiderably
higher,  fliould be feated direaiy before him.  An affiftant
flanding behind muft be direaed  to  place the  patient's
head upon his breaft, while he fecures it in this fituation by
his right hand under the chin, and his left placed upon the
forehead; and the patient's hands  ffiould be properly fe-
cured by an affiftant on each  fide.
   The affiftant is now to raife the  upper eye-lid with the
fingers  of his left hand; and the  furgeon applying the
groove in the fpeculum, in fuch a manner that it may receive
the edge of the eye-lid, the opening or circle formed by the
brim of the fpeculum is to be preffed upon  the ball of the
eye till the cornea, and nearly the eighth of  an inch of the
fclerotica, is protruded.  A fteady and equal preffure being
made  on the inftrument by the left hand of the operator,
                                                   and 
                      [  289  3
and  he having the elbow of the right leaning on a table,
or oil his knee, in order to preferve the arm fteady, muft
take a  couching needle (pi. vi. fig. 3.) between the  thumb
and  fore and middle fingers, while the ring and  little fin-
gers are made to  reft upon the cheek of the  patient:  the
point of the inftrument is  to  be  carried forward beyond
the external canthus of the eye, and being brought nearly
into contaa with  the fclerotica, it muft be fuddenly plung-
ed through this coat fomewhat below the centre of the eye,
the twelfth of an  inch perhaps, and about one-tenth of an
irich behind the iris.
  In order to avoid injuring the  iris, the flat fide of the
needle  is to be introduced towards it; and it is thus to be
carried forward in a horizontal direaion, until the point of
it is difcovered behind the pupil.  The  flat furface of the
needle  is then to be turned downwards ;  and the  point be-
ing pufhed into the upper part of the lens, we endeavour to
deprefs it to the bottom of the eye by raifing the  handle of
the inftrument:  It will be inftantly known that this is ef-
feaed by the1 difappeatance of the lens, and by' the patient
difcovering more  light than he had been lately accuftomed
to.   In order to give the operation a'better chance of fuc-
cefs, it will be advifable to carry the lens flowly on  the
point of the inftrument towards the outer and  back part of
the eye.  By this means, the cryftalline will be partly lodg-
ed in the vitreous humor, and there  will be lefs rifk of its
rifing again to its former fituation, an occurrence which
has fometimes taken place.
  The needle ffiould  now be withdrawn, and the fpecu-
lum  taken  off; and there will be no harm in making a
cautious trial of the good effeas of the operation, by pre-
fenting fome objea before the eye.  A comprefs of foft
lint wet with  a weak  faturnine folution ffiould then be
lightly- applied over the eye, and  this being fecured by a
trialigular napkin, the patient ffiould be confined  in a dark
                         O o                    room 
                      [  290   ]
room, and kept upon a low regimen for fome time.  As
additional preventative remedies of inflammation, a pur-
gative  or two may be given, and  when neceffary, blood
ffiould be taken from the temporal  artery,  or jugular vein,
or from the vicinity of the eye by leeches.
   In the courfe of three or four days, the dreffings may
be removed from the eye.  It may then generally be afcer-
tained  whether the operation has fucceeded or not.  The
power  of vifion does not always immediately return; and
there  are inftances in which the fight, very imperfea at
firft, has gradually become better for feveral months after
the operation,  which probably happens from the flow fub-
fidence of inflammation excited in the capfule of the lens.
   When the firft operation is unfuccefsful,  as foon as the
inflammation produced  has  gone off,  the  trial may be re-
peated ;  and again if this fecond attempt fliould not be ef-
feaual.  A failure, I am difpofed to think, generally arifes
from  not pufhing the  lens beneath the  vitreous humor,
which by its prefliire may probably prevent it from rifing.
Experience  proves  that no  bad  effea  is  produced from
doing this, and much harm may enfue from negfeaing it.
   Couching, as above defcribed, is fuppofed to have been
performed on the  left eye ;  but in  operating on the right
eye, if the  needle  is to be entered in the ufual way at
the external canthus, it muft either be done with the left
hand,  or if the furgeon wiffies to  ufe the  right hand, he
muft fland or fit behind the patient, having the head fup-
ported on his breaft.  As there  are few furgeons who can
ufe the left hand with fufficient  dexterity,  and we cannot
have va good  command of the eye when  flanding behind
the patient,  it will be better to ufe the needle (pi. vi. fig. 4.)
with  which the operator may couch the  right eye with
the right hand very well; the only difference between this
and the method already defcribed,  confifting in  entering
                                                   the 
                       (   291   )
the needle at the internal canthus,  and drawing the cataraa
toward the nofe.
   Inftead of couching in the manner we have defcribed,
it  has been propofed to pafs the needle through the tranf-
parent cornea and pupil; but befides that the cataraa can-
not thus  be fo eafily depreffed, there muft be a very great
rifk of injuring the iris.

            §.  3. Of ExtraBing the  CataraB.

   In proceeding to this operation  the patient muft be pla-
ced and fecured exaaiy in the manner direaed for couch-
ing ; and the furgeon muft likewife be feated, and have his
arm fteadily fupported, as advifed in that operation. When
the lens is to be extraaed from the left eye, the fpeculum
muft be applied in the manner we have formerly mention-
ed, and  preffed with the left hand upon the eye, with as
much firmnefs  as is neceffary for fecuring the eye, but no
more, as  it would not only give needlefs pain,  but would
prefs the cornea fo near the iris, that this might be injured
by the knife.
   The furgeon is now to take the  knife (pi.  vii. fig. 8.)
between  the thumb and forefingers of his right hand, al-
lowing nearly an inch to projea paft the extremity of his
middle finger;  and  the point of it being brought into con-
taa with the lucid cornea,  it muft be made to penetrate
this coat at about the diftance of the fixteenth part of an
inch from the iris,  in  a line running from the external
canthus of the eye direaiy acrofs the  centre of the pupil:
the convex furface of the knife being kept next  to the iris,
it  muft be carried in this direaion until the  point of it
reaches the other fide of the eye direaiy oppofite to where
it entered, and muft there be puffied out until  nearly a
quarter of an inch of the inftrument  is through the cor-
nea.  The knife muft then  be moved flowly downwards
                                                   in 
                      L  292  ]
 in fuch a manner, that all that portion of the cornea, lying
 between the point at which it entered and that at which it
 paffed out, may be divided at an equal diftance  from the
 iris.   A femilunar opening will thus be formed fufficiently
 large for the  paffage of the cataraa: while this is made,
 the preffure of the fpeculum upon the eye-ball  fliould be
 gradually leffened, otherwife the vitreous humor may be
 preffed out; but it ffiould not be entirely removed, left the
 preffure of the knife ffiould  draw  the eye too far  down
 towards the focket, by which the incifion will not be car-
 ried  fufficiently low,  and  confequently not made large
 enough to admit of an eafy extraclion of the lens.
   The operator muft  now  lift up  the flap formed in the
 cornea with  the  flat  crooked probe, (pi. vii. fig. 2.) and
 cautioufly paffing it through the pupil,  muft fcratch  an
 opening in the capfule  of the lens ; the cataraa muft then
 be forced out by a very moderate and equable preffure  on
 the globe of the eye, by means of the fpeculum.  When
 the lens is lodged in the anterior chamber of the  eye, and
 we cannot remove it by gentle preffure, or with the fcoop,
 it will be better to enlarge the opening by a pair of fmall
 probe-pointed fciffars,  than to employ much  preffure,  by
 which a great deal of injury may be produced.
  With a view to facilitate the paffage of the lens, it will
 be proper to place a dark cloth  between the eye and  the
 light, in order to dilate the pupil as much as poffible.
  When the opacity is found to refide in the capfule  of
 the lens, we have commonly been advifed  to attempt  its
 removal by paffing forceps, and other inftruments through
 the pupil: but as this cannot be  accomplifhed without
 great  rifk of injuring the iris,  and  other parts of the eye,
I would advife rather  to  truft to time,  and an  antiphlo-
giftic  regimen to  carry off the opacity. This does no
mifchief, and I have known cures performed by it;  but I
                                                never 
                      E  293   3
never knew them to  fucceed the contrary praaice, which
has frequently deftroyed the iris entirely.
   When the operation is to be performed on the right eye,
|t may be done with the fame differences as direaed in per-
forming couching, either with the flraight knife,  or with
the crooked knife, (pi. vii. fig. 10.)
  The operation being finifhed, the patient is to be dreffed
and treated in the fame manner as direaed after couching.
As however  a greater degree  of inflammation is apt to
fucceed to extraaion than  to couching, bleeding, and a
very ftria  antiphlogiftic regimen, will be more neceffary.
In favourable eircumftances, the wound commonly heals
in ten or fourteen days, but fometimes  it continues open
for feveral  weeks.
   When this operation is not performed with fufficient
caution, it  often happens that the whole, or at leaft a con-
fiderable part of the vitreous humor efcapes at the incifion.
In fome of  thefe cafes, the eye always remains funk in the
head, and  ufelefs; but moft frequently the globe foon be-
gins to fill again,  and in the courfe of two or three weeks
it commonly acquires its ufual fize.   Whether  this arifes
merely from an aqueous  fecretion,  or whether  the vi-
treous humor  is regenerated,  is doubtful;  but I  am
difpofed to believe from the effeas  of the operation in
a cafe where  a cataraa  was removed from each eye,  that
the vitreous  humor  is in fuch  cafes reproduced.  This
fubftance was retained in one eye; it was evacuated from
the other;  and yet in a few weeks the patient faw equally
well with both.
  As an improvement on this operation, when the cornea
is to be cut, I would propofe that it be divided on its fupe-
rior part, in the fame manner as it is ufually cut below.
This,  from reafoning,  and from experiments  on brutes,
I am led to believe would tend confiderably to prevent  the
efcape  of the  glaffy humor, and to leffen the obftruaion
                                                    to 
                      E   294   ]
to vifion which always neceffarily happens, in fome degree,
from the cicatrix left on the cornea.
   But not only thefe objeaions, but all danger of injuring
the iris, which is very  frequently more or lefs hurt by the
paffage  of the cataraa, and from which our want of fuc-
cefs perhaps generally arifes, would be obviated by form-
ing a fufficient opening behind the iris, about the tenth of
an inch beyond the cornea, inftead of cutting the cornea
itfelf,  and extracting the lens by the curved fharp-pointed
probe, (pi. vii. fig. 1.)
   On account of the eircumftances juft mentioned, from
which a lofs of vifion,  fooner or later, is very frequently
produced by the common operation of extraaion of the
cataraa; frOm the lefs degree of danger  from  pain, and
injury to  the eye,  and more  efpecially,  from  the  more
frequent and permanent reftoration  of vifion, from couch-
ing, I am induced to confider it as much to be preferred to
extraaion, as this is at prefent praaifed.

                  SECT.   XVII.

                Of the Fiflula Lachrymalis.

   Evert obftruaion to the paffage of the tears from the
eye to the nofe, is ufually comprehended under the term of
Fiftula Lachrymalis.
   This difeafe affumes a  variety of appearances, accord-
ing to the feat of the obftruaion,  and to the effeas pro-
duced by it upon  the neighbouring  parts.   When the la-
chrymal punaa, and the fmall duas conneaed with them,
are obftruaed in confequence  of burns,  wounds,  or vio-
lent inflammatory affeaions,  the tears neceffarily fall over
the cheek; and this, together with  a  confequent  dry-
nefs in  the correfponding noftril,  conftitutes that varie-1 
                     E  295  3
:y of the difeafe, which alone  fhould be  termed Epi-
phora ; for when the obftruaion is  feated in any other
part of the lachrymal paffages, the complaint is attended
with fymptoms of a much more perplexing and painful
nature.
  When the lachrymal punaa and duas remain open,  if
obftruaion takes place in the under  part of the lachrymal
fac, or in the dua leading from  this  to the  nofe, the  firft
fymptom is a fmall tumor in the internal canthus of the  eye,
which is made to difappear upon preffure being applied  to
it,  by a plentiful flow of tears paffing into the eye, and from
thence over the  cheek, and perhaps a greater or lefs quan-
tity paffing into the nofe.   If the tears are now regularly
preffed out before the fwelling  acquires  any confiderable
fize, and before they have  become  acrid  by ftagnation,
they are in general, found to be  perfeaiy of a natural ap-
pearance.   This ftate of  the difeafe has been termed a
dropfy of the lachrymal fac ; and by a proper application of
 preffure may be often cured.
    It moft frequently happens however, either from  inat-
 tention in  the  patient, admitting of the fac being  over-
 ftretched, or from fome other caufe, that the difeafe gra-
 dually grows worfe—the paffage into the  nofe becomes
 entirely obftruaed—the fwelling in  the canthus increafes,
 but  ftill is unaltered in  colour—the tears  are then  pref-
 fed out with more difficulty; and are mixed with a pro-
 portion of thick,  opake, white mucus—But the patient
  feldom fuffers much pain, or any other inconvenience than
  what arifes from  the tears and mucus paffing over  the
  cheek.
    At length the tumor begins  to become  tenfe, red, and
  painful to the touch, and the matter preffed out has  much
  the appearance of pus.  The parts gradually become more
  inflamed,  until the teguments at laft burft, and form an
  opening in the moft prominent part of the fwelling, at
                                                  which 
                      [  296  3
 which the tears and matter  are now entirely difcharged.
 This  opening being ufually  fmall, heals  again  in  a few
 days;  but it burfts as foon as any confiderable colfeaion
 is again formed in it: and it continues thus to  form and
 difcharge  alternately, until  the  opening becomes fuffici-
 ently large to prevent any further colfeaion.   This forms
 a finuous, callous ulcer, fometimes with  retorted edges;
 and  the  difeafe is now  properly termed a fiftula lachry-
 malis.
  It happens in  many cafes, particularly when  the habit
 is tainted with fyphilis or fcrophula, an  occurrence by no
 means unfrequent, that the contiguous bones become cari-
 ous :  in fuch eircumftances  the difcharge  is  thin, foetid,
 and commonly fo acrid as to  corrode the adjacent integu-
 ments ; and the fore affumes aJ different appearance accord-
 ing to the general affeaion with which it is conneaed.
  The prognofis as well as the method of cure in this dif-
eafe, muft depend entirely upon the nature of the obftruc-
tion in the lachrymal paffages, and the particular ftage of
the affeaion.   When the difeafe  is recent,  and proceeds
from inflammation of the lachrymal paffages, which is the
moft frequent caufe,  and  is  induced by meafles, ophthal-
mia, catarrh, &c. our prognoftic may generally be favour-
able; but when the complaint is of long Handing, and the
bones have become carious from fcrophula, or the venereal
difeafe, the cure will  chiefly depend on the removal of the
general affeaion, and is feldom completely obtained.
  When the difeafe is a confequence of tumors in the con-
tiguous parts, e. g. of polypi in the nofe which prefs on the
lower part of the nafal dua, the prognofis muft almoft
entirely depend  on  the  practicability  of removing the
fwelling.
  If the difeafe originates from inflammation, the common
remedies of inflammation in general muft be ufed—gene-
                                                  ral 
                      E  297   ]
ral  or local  bleeding—laxatives—a low diet—and fatur-
nine applications to the parts.   In fome inftances,  thefe
remove the complaint; but in many  others, the fides of
the duas are united by the inflammation, and thus conti-
nue the complaint after the inflammation has entirely fub-
fided.
  When the  obftruaion thus  produced is feated in  the
punaa  lachrymalia, or in the duas  leading from thefe to
the fac, we are to attempt its removal by inferring a fmall
probe (pi. vi.)  into each punaum, fo as to pafs it  along
the courfe of the duas into the lachrymal fac.   The  open-
ings thus formed, may be preferved by afterwards injeaing,
twice or thrice daily  with a fmall fyringe, a weak folution
of alum, or of faccharum faturni, and by keeping at other
times fmall leaden probes conftantly  inferted, till the fides
oftheduas are rendered perfeaiy callous; the tears will
then pafs as formerly into  the nofe.  This is  a nice, but
not a difficult operation.
   Inftead of the method we have advifed, it has been pro-
pofed to introduce a  feton into the duas, and  fuffer it to
remain until their cavities become callous.  Independent,
 however, of the difficulty  of doing this, it would  proba-
 bly excite fo much pain and inflammation, that it  would
do more harm than good.
    But  the obftruaion producing this difeafe is  moft fre-
 quently fituated in the  dua leading from the lachrymal
 fac to the  nofe.   While this produces no farther inconve-
 nience than a frequent  difcharge of tears over the cheek,
 with perhaps a flight fwelling forming now and then in
 the corner of the eye, nothing more  fliould  be direaed
 than to prefs out the tears from the fac by the finger, fo
 frequently as to prevent them from becoming acrid by flag-
 nation, and to avoid  expofure to cold,  or any  other caufe
 that might excite inflammation of the eye, or other conti-
 guous  parts. 
                        [  298   ]
    We are indeed advifed  to attempt the removal  of the
  obftruaion, by  inferting  probes into  the lachrymal  or
  nafal duas, or by injeaing fluids into thefe paffages.  But
  befides the difficulty, and fometimes impoffibility of per-
  forming thefe  operations,  the pain and inflammation ex-
  cited by  them often  does a  great  deal of injury.  The
  praaice of introducing quickfilver into the fac for the re-
  moval of the  obftruaion,  will probably feldom  be found
  ferviceable, but  is lefs exceptionable than the others.  A
  continued application of preffure, as advifed by fome, does
  net appear to have  the leaft  chance of removing the dif-
  eafe.
    Although the palliatives  above defcribed fhould be truft-
  ed to in the fimple  ftate of  the  complaint, whenever the
  tumor in the angle of the eye becomes larger, inflamed, and
  painful, and there is danger of the bones being injured by
  the acrid matter  colfeaed in the part  affeaed,  we are un-
  der the neceffity of  having recourfe to  a different method
  of treatment.  In fuch eircumftances,  our views muft be,
  to difcharge the  contents of the fwelling ; to procure a free
  ^ifcharge in  future for the tears  from the lachrymal fac
.  4nto the nofe ; and to prevent the paffage from being agahi
  obliterated  : and this being  done,  to  heal the external
  opening.
   — While the fwelling continues hard, it would be impro-
  per to open it,, as  this would give  a great deal of  pain,
  and the  parts  below  could not  then  be freely examin-
  ed.   But a warm emollient poultice ffiould be  kept con-
  ftantly over the tumor until it  becomes  quite foft; the
  point of a  lancet ffiould then be puffied  into the fupe-
  rior part of it  fairly  into the fac, and fhould be carried
  downwards in a ftraight direaion  to the moft depend-
  ing part.  When  there is  already  an opening formed,
  it ffiould be fufficiently enlarged by a fcalpel introduced
  upon  a direaor.  A few  fibres  of  the orbicularis mufcle
                                                     will 
                      E  299  ]
will  thus be cut, but this will produce no inconvenience.
The  contents of the  fwelling are now to be gently forced
out; a fmall doffil of lint fpread with emollient ointment
fhould  be inferted between the lips of the wound, and a
flip of adhefive  plafter placed above to retain it.   As a
plentiful  difcharge commonly takes  place, it is neceffary
in general to renew the dreffings every day ; and in order
to preferve the  opening of a  proper fize  for admitting a
free examination of the parts beneath, a piece of prepared
fponge, of fuch  a fize as not to irritate the parts,  may be
introduced inftead of the lint every  fecond or third day;
and the more effeaually to prevent its irritation,  a piece
of foft  oiled linen fhould be put around it.   A  piece of
waxed  thread may alfo be tied to it,  that it may be eafily
withdrawn when neceffary.
   It was formerly the praaice, inftead of the  dreflings
we have recommended, to employ  the aaual cautery .pr
efcharotics for  the purpofe of deftroying the hard edges
of the fore—This produced a great deal of pain, deformi-
ty, and fometimes an obliteration of  the cavity of the dif-
ferent  duas, the confequence of which,  was a conftant
difcharge  of tears over the cheek.   In many cafes, how-
ever, the  lachrymal duas continued open,  and a frequent
recurrence of the complaint then fucceeded.
   By the  management we have  advifed, any degree of
hardnefs  remaining  in  the wound will foon be removed ;
and  the fore being cleared of a tough vifcid kind  of mu-
cus with  which it is always covered for a  few days after
the operation, we are now  to  attempt  the formation of a
free paffage for the tears from the fac into the nofe.  This
is effeaed by removing the obftru<5tion in the nafal dua ;
or when this is impraaicable, by forming an artificial open-
ing direaiy through  the os unguis, from  the under and
back part of the lachrymal fac.
                                                 With 
                      [  300  ]
   With a view to accompliffi the firft of thefe objeas, a
firm round-pointed probe, (fuch as in pi. vi. fig. 7.) ffiould
be  inferted into the bottom  of  the  fac, and pufhed for-
ward with a moderate force  in  the  direction of the nafal
duet -, if it enters the beginning of the canal we  may then
go on with fafety, and a probability  of fuccefs,  but if the
inftrument cannot be entered into the  canal we ffiould de-
fi.c, as it is  then probably rendered impervious  by an ad-
hefion of its fides.   When  the  probe can  be paffed,  the
opening may  be preferved by keeping a piece of cat-gut,
or of lead wire conftantly in  it, until it becomes fufficient-
ly large.
   Should every trial for difcovering the natural, conduit of
the tears be  ineffeaual, we  are reduced  to the neceflity
of forming an artificial  paffage for them.   This has been
accomplifhed till very lately by the aaual cautery.   But the
cautery ffiould never be had  recourfe to in thefe cafes, be-
caufe it is always produaive of  confiderable injury to the
parts contiguous to thofe which alone ought to be operated
upon; and becaufe every good  purpofe which it anfwers
can be obtained with equal certainty, and with  more eafe
and fafety, by forcing any firm fharp inftrument from  the
back part of the fac  through the os unguis : this is beft
performed by  a fmall round trocar.
   In  proceeding  to  this part of the  operation,  the  pa-
tient's head ffiould be  fupported by  an affiftant;  and  the
furgeon, fitting or ftanding between  him and the window,
muft  introduce the canula of the trocar into the under and
back part of the fac :  it muft be kept firmly in this fituation
with  one  hand, while the flillette is inferted into it with
the other ;  and the point of  it fhould then  be carried for-
ward obliquely downwards, through  the  os unguis juft
where the  fac terminates and the nafal dua begins, and
into the nofe,  taking care to  avoid following the natural
paffage, for  fear  of injuring the  os  maxillare.    The
                                              entrance 
                      E  301   ]
entrance of the inftrument into  the nofe will be followed
immediately by the difcharge of a fmall quantity of bloody
mucus from the noftril.  The flillette ffiould now be turn-
ed round until the opening is made fufficiently  free, and
then it may be  withdrawn.  A leaden probe  equal  in
fize to the flillette, being introduced through the open-
ing, the canula may likewife be taken  out, and the exter-
nal end of the  probe ffiould then be  fomewhat curved to
prevent it from flipping into the nofe.   The fore muft  be
covered with a fmall pledget of lint, fpread with  emollient
ointment, and the whole may be retained with a ftrip  of
adhefive plafter.
   The leaden probe fhould be kept in the  fore until the
fides of the  paffage become perfeaiy callous, which  will
ufually happen in about eight or nine weeks.   It ffiould  be
taken out every day or  two, that the matter adhering to  it,
and that colfeaed in the fore may be removed : and at each
dreffing, infufion of oak bark, folution of alum, or fome
other aftringent  fhould  be  injeaed  with a fmall  fyringe
from the external  opening into the nofe.   On withdraw-
ing the  leaden probe, the external opening ffiould be well
cleaned ; and as  it has  then become very  fmall,  it will
foon  heal by bringing the fides of it together  and retaining
them by adhefive plafter, or when this does not fucceed  in
a few days, touching the edges with lunar cauftic will com-
monly complete the cure very quickly.   In the mean time,
moderate preffure by the finger, frequently applied, or  by
a machine, ffiould be ufed, and ought to be continued un-
til there is reafon to fuppofe the fac and contiguous parts
have recovered their loft tone.
   What we have faid refpeaing the propriety of continu-
ing the leaden probe for a confiderable time,  and  of apply-
ing preffure afterwards on the fac,  is entirely applicable
when the natural paffage of the tears  is difcovered.  In-
                                                 ftead 
                       [   302   ]
ttead of a probe of lead fome advife a piece of cat-gut, or
of bougie ; but  thefe are more difficult to introduce—ab-
forb too eafily the mucus  of the  part—are apt to be  en-
tangled in the bone—and are not fo effeaual in rendering
the paffage callous.
   When the difeafe returns, which is  fometimes the cafe,
after the  performance of this operation, it  may originate
from fome general affeaion, as fcrophula, or fyphilis; from
a mere caries of the bone; or from too fmall an opening
being made.
   When the bones are difcovered to bo carious, the tumor
muft again be laid open; an exfoliation of the bones produc-
ed if poffible ; and then the os unguis  muft be perforated
as before, if the exfoliation does not form a fufficient open-
ing.  If this fecond operation fliould be unfuccefsful from
the fore again filling up, we will have reafon  to fufpea a
general affeaion of the habit, which muft be removed be-
fore a permanent cure can be expeaed.   When the taint
of the habit is venereal, large and tedious exfoliations ufu-
ally take place, and a perfea cure is not often obtained.
   In order to obviate the uncertainty of this operation,
it has been propofed in every cafe to introduce a filver or
gold canula, either  through the natural paffage  of  the
tears, or through the artificial opening;  and by leaving it
there, and healing the fkin  over it, thus  to form a paffage
which  no difeafe of  the  conftitution can have  any effea
upon.   But as the operation when well  performed, is ge-
nerally fuccefsful, and it is a very difagreeable and formi-
dable circumftance to moft  people to  have any extraneous
body remaining for a long time in a wound, I would never
advife it until the ufual operation is found to be ineffeaual:
it  would  the i  be  proper to ufe the canula:  in pi. vi.
fig. 9.  is one of the beft forms of it;  it fliould  always be
made of gold, and fo long as that the lower part may juft
                                                   pafs 
                         E   303   3
pafs through the os unguis, while the upper part is covered
by the integuments.*
   It has been advifed,  in  order to  prevent the imaginary
bad confequences  of  fplintering the os unguis by the ufe
of the trocar,  to employ an inftrument made  in the form
of the canula of a trocar, with a handle like that of the flil-
lette, but with  a fharp edge.   By this a piece  of the bone
is  eafily cut out;  but as the operation  is more  effeaually
done  with  the trocar, and experience fliews that there is
no danger from its ufe, it  fhould certainly be preferred.
CHAP.
  * M. Pellier conftantly employs this method, and generally accomplifli-
es a cure in three weeks, and fometimes in two.   He fays he never fails
in finding the end of the lachrymal dud; and always makes an opening in
the courfe of it.  The tube (fig. $).N is introduced on the perforator, (pi.
vi. fig. 10.)  and preffed into the orifice made, by the compreffor, ffig. 10.)
In order to afcertain whether the tube is of a proper length, a little milk
and water fhould be injeded after its introdudion, and if this paffes readily
into the nofe it will do; if it does not, the tube muft be withdrawn and
fhortened.   The wound muft be dreffed with lint and cerate for eight or
ten days, or as long as it affords much matter,  and then healed by adhefive
plafter; and milk and water fhould be daily injeded through  the canula.. 
[  304   ]
              CHAP.   XXXI.


     Of Diseases of the Nose awe? Fauces.

                      mi iii'P'jjaynn ■

                   SECT.  I.

            Of Hemorrhagies from the Noflrils.

 T TEMORRHAGIES  from  the  noflrils are in gene-
 -*- -*- ral of little importance; but as they fometimes are
 dangerous, and have even proved fatal, they always merit
 attention.
  Cold, in moft cafes, is an effeaual remedy—It fhould be
 applied in a variety of ways:  the patient fhould be plac-
 ed in a large apartment, through which a current of air
 paffes ; his food  and drink ought to be cold ; his face fre-
 quently bathed or  immerfed in cold water, or vinegar and
 water; a ftrong folution of alum, or fome other aftringent,
 fhould be ufed as a gargle, and compreffes wet with it ap-
 plied over  the nofe :—When in bed he fhould be lightly
 covered,  and have his head high.
  If thefe means fail, the uncertain remedy of compreffion
 muft be tried.   Compreffion may be made by a doffil of lint
 introduced into the noftril; but a piece of hog's gut that has
 been dried and moiftened again, tied at one end, and intro-
 duced by means  of a probe or  direaor along the noftril
 as far as the upper part of the  pharynx, and then filled
with fome cold liquid, as water, vinegar, &c. and tied at the 
                       [   305   ]
end hanging out at the noftril, is more effeaual in reftrain-
ing the hemorrhage.
  When both thefe are ineffeaual, we muft  introduce a
ftrong ligature into each noftril, by  means of a crooked
tube,  take hold of the ends in the fauces with a pair of
forceps, and draw them out; then tie a bolfter of foft lint
to each, large enough  to  fill the pofterior nares, and by
pulling the ends of the ligatures that  hang  out  of the
noftrils, firmly fix the cufliions of lint in the upper  part of
the pharynx ;  and afterwards apply a comprefs of lint to
each noftril, and  fecure them by tying  the  ligatures over
them.   By this  means, if the cufhions are well  adapt-
ed,  and firmly fixed, no blood can efcape from the nares,
and what  is effufed will coagulate.    The  doffils  of  lint
fhould remain until the re-union of the veffels has taken
place.   By ufing two ligatures, &c. a more firm and equal
preffure is applied than by  the employment  of one only,
as commonly advifed.   Reft fhould  be enjoined after the
operation.
  Future  returns of the difeafe may be prevented by bleed-
ing, cooling laxatives, and a low diet.

                    SECT.  II.

                     Of the Ozcena.

  An ozsena, or ulceration in the noflrils, is often a con-
fequence  of  catarrh,  and  is ufually  attended by a fwel-
ling of the adjacent parts.   Its moft common caufe is cold;
but external violence of every kind that terminates in an
inflamed ftate of the membrane  of the nofe,  fuch as the
application of acrid irritating fubftances,  blows,  bruifes,
&c. may alfo produce it.
  In  this ftate of  the  difeafe, aftringent applications are
ehiefly  to be depended  on,  fuch  as a  decoaion of
                        O  q                  Peruvian 
                       [   soe   ]
Peruvian or  oak  bark,  mixed  with folution  of  alum,
brandy or other ardent fpirits, diluted with water;  lime-
water,  &c.
   Doffils of lint, wet with fome of thefe, fliould be  intro-
duced to the affeaed part three or four  times a day; and
at  night, lint fpread  with an ointment  prepared with a
confiderable portion of lap. calam. or zinc. calc.
   A colfeaion of  matter  in  the antrum highmorianum
may be miftaken for an ozsena, as the matter is  fometimes
in fuch cafes difcharged through the nofe  :  confiderable at-
tention is therefore requifite  to  difcriminate thefe  com-
plaints.
   When the matter difcharged in an ozsena is thin, foetid,
and of a brown or  blackifh  colour, we have  caufe to fuf-
pea a  caries of the contiguous bones, which muft be re-
moved before  a cure can be expeaed.  This feems to orir
ginate commonly from a lues venerea; but whatever  be its
caufe,  mercury feems to be the beft remedy for it.   The
local applications abovementioned are alfo to be employed;
and as fungous excrefcences are frequently produced, oint-
ments  with corrofive fubftances  may be occafionally ufed
with the greateft fafety,  particularly  red precipitate and
verdegris, in  the proportion of an eighth or  ninth part of
the firft, and a fmaller quantity of the latter,  to  one of
wax'; and oil.
   When the carious bones have exfoliated, a continuation
of the aftringents already  mentioned will commonly effect
a cure.
   Ozsena is often difficult and  tedious of cure when a ca-
ries is attendant;  in this cafe we have no  remedy that can
with certainty be depended  on.   The mode of cure above
recommended  will however commonlv  fucceed.
SEC T. 
[  307   ]
                   SECT.   III.

                Of Imperforated Noflrils*

   Imperforated noftrils in new-born children is a rare
occurrence;  but inftances  of  preternatural  adhefions of
the noftrils, in confequence of fmall-pox, burns, or venereal
fores are often met with.
   Obftruaions of this kind are in various degree: when-
ever the breathing is  much impeded  by  them, or a con-
fiderable deformity is  produced, the affiftance of furgery
fliould be afforded.
   When any opening is left in the noftril, a fmall grooved
direaor being inferted into it, the paffage may be eafily en-
larged to its natural fize, by running  a biftouri or fcalpel
into the groove in the courfe of the adhefion.   But  when
no paffage  is difcovered,  we fhould endeavour by a cau-
tious diffeaion with a fmall fcalpel, to difcover the noftril,
keeping in a proper direaion between the feptum and ala
nafi ; and when once  difcovered,  it may be eafily enlarged
in the manner already defcribed.  We muft then proceed
in the fame manner on the other fide.   To prevent the re-
union of the divided parts, we fhould  introduce fmall me-
tallic tubes,  covered  with foft leather, and  fpread with
fome emollient ointment; thefe  are to be retained by ad-
hefive plafter, conneaed  with them, or by a  bandage  ap-
plied around the head, and fhould be ufed  as  long as any
forenefs continues.   Doffils of lint might anfwer, but the
tubes allow of breathing  through the noftrils, diftend the
parts more equably, and are more eafily retained.
   When from burns, fmall-pox, &c. an adhefion of the lip
to the nofe occurs, together with the obftruaion above-
mentioned, it fliould be feparated flowly by a fcalpel, and
the fore thus  produced healed before the noftrils are ope-
                                                 rated 
                      [  308   3
rated on.   To remove  any contraaion of the lip which
jnay occur, it ought at each dreffing to be tied down by a
double-headed roller paffed around and over the head.

                   SECT.    IV.

            Of Polypi in the Nofe and Throat.

   The whole of the  nafal cavity, and of the back part of
the throat is liable to  excrefcences, which from their fup-
pofed refemblance to the infeas of  this name,  have been
commonly termed polypi.    Thefe  moft frequently origi-
nate from that part of the membrane of the nofe which co-
vers or lines the offa  fpongiofa, and in general are confin-
ed to one fide of the  nofe.   In  fome inftances, however,
they  occupy both noftrils ; and  now and then become fo
 large  as  to be perceptible on looking into the  fauces.
Cafes have occurred  in  which they originated  from the
pharynx.
   The firft fymptom of this difeafe is commonly a partial
lofs of fmell,  attended  with a fenfation of fulnefs or ob-
ftruaion in  fome part of the nofe.   This increafes till a
fmall tumor or  excrefcence is perceived in one or both no-
ftrils, which, in fome inftances, defcends no farther than to
be merely perceptible when the head is fomewhat raifed;
in others, it falls  down  upon the upper  lip before, and
perhaps puffies back into the throat.
   In fome, this elongation of the  tumor is permanent, but
 in moft cafes the fwelling retraas within the nares in dry,
 and protrudes only in rainy or hazy weather.  In fome in-
ftances, the fwelling appears very confiderable  in the leaft
tendency to a deep atmofphere, and even in thofe who, in
 dry weather, were not known to labour under the difeafe.
   Polypi are  of  various degrees of firmnefs;  moft of
 them are foft and compreffible; but fome acquire almoft the
                                               hardnefs 
                      E  309   3
hardnefs of cartilages.  Both kinds are apt to  bleed on
being fretted, or roughly  handled ; but thofe of a  foft
fpongy nature only arc fo remarkably affeaed by the wea-
ther.
  The colour of polypi is likewife variable;  in common
they are pale and tranfparent,  and thefe according to my
obfervation, are  ufually foft  and compreffible, while the
more firm are generally of a deep red colour.
  In the commencement of the diforder the pain is incon-
fiderable,  and in the fofter kind, it is feldom  at any time
confiderable ; but the harder polypi are generally painful
in  proportion to the  increafe  of  their  fize,  particularly
when irritated.   Polypi alfo become in fome inftances un-
equal and  ulcerated;  a large,  thin, and  foetid  difcharge
takes place from them; and if they are not then extirpated
are  apt to degenerate into  cancers, but more particularly
thofe of a firm texture.
   The  fofter kinds of thefe fwellings when of confiderable
fize, produce a great deal of diftrefs, by falling on  the lip,
and by  paffing into the fauces,  and obftruaing deglutition
and refpiration.    In  fome  inftances not only the noftrils
are  much diftended, but the  bones of the nofe are  feparat-
ed  and  raifed.
   Polypi are faid moft frequently to depend on a fcrophu-
lous or venereal taint.  They  may be fymptoms of thefe
difeafes, but in fuch cafes we would  confider the general
difeafe  merely as an occafional  caufe of the local affeaion ;
 for in almoft every cafe, a local injury may be traced as the
 caufe of polypus;  and upon the  whole we conclude it is
 always of a local and  circumfcribed nature.   Even when
 it originates from  fyphilis, it remains after the general af-
 feaion is completely removed.
    The harder polypi  probably  may  arife  from the  fame
 caufes  that produce fimilar tumors in other parts ;  but they
 generally feem to be  conneaed with a caries of the bone
 beneath :  and this renders them more hazardous and diffi-
                                                   cult 
                       C  310   ]
 milt of cure than thofe of a fofter nature, which we ima-
 gine are commonly produced by a mere diftention and re-
 laxation of the membrana fchneideriana.   When  any por-
 tion of this membrane  becomes inflamed  from cold, &c.
 or is ruptured or eroded, as frequently happens from blow-
 ing or picking the nofe, a weaknefs is  produced,  which is
 apt to terminate in a prominency ; and this being increafed
 by every fucceeding cold, a polypus comes to take place.
   The further  progrefs of the difeafe may depend on vari-
 ous caufes; but generally it will advance  more or lefs ra-
 pidly according as the  parts are more  or lefs liable to  in-
 flammation.  Thus we  have inftances of polypi remaining
 fmall and flationary for a number of years,  when the pa-
 tients were not much expofed to the open air: while among
 poor people who are expofed to every inclemency of wea-
 ther, and confequently more liable to frequent catarrh, the
 difeafe advances with great rapidity.
   The rifk with which polypi are attended is, according to
 my experience, nearly in proportion to their firmnefs.   The
 removal of the fofter kinds may always be undertaken with
 a probability  of fuccefs ; but in polypi of a flefliy, or ftill
 firmer texture,  it is always attended with  confiderable ha-
 zard,  for they often cannot be entirely removed ; and even
 when their removal is praaicable, they are very apt to  be
 regenerated, or to become cancerous.
   As long as the hard  polypi remain flationary,  and are
 not attended  with pain, if the breathing or deglutition are
 not obftruaed by them, they ffiould not be touched: but
 when the reverfe of thefe eircumftances  takes  place, we
 fhould always endeavour to extraa them,  provided  they
 do not adhere throughout their whole extent to the bones,
 or thefe bones are not  carious.—A caries of the adjacent
bones is very apt to take place in an advanced ftage.
  In the  foft polypous  tumors,  aftringent  applications,
fuch as folution of alum, decoaion of  oak bark, vinegar,
                                                    or 
                      [   311  3
<*r fpirits, frequently  prevent  them from acquiring an in-
creafe of bulk, and will fometimes  diminifh,  but  never
remove  them.   Thefe applications fliould always be ufed
on their firft appearance.
  The methods employed for the removal  of polypi have
been the ufe  of cauflics, aaual and potential; the paffing
of a feton or cord through the noftril, with fome corrofive
unguent on the part in contaa with  the  tumor ;  excifion
with the fcalpel or fciffars ;  the application of a ligature
around the neck of the tumor; and evulfion or extraaion
by the forceps.
  Cauflics are not employed at prefent, becaufe they can-
not be prevented from injuring the  found as well as the
difeafed parts.   The  feton is adequate to  the removal of
polypi, and feems only ufeful  when fmall portions are left
after the extirpation of the greater by other means.  When
the tumor originates low enough to admit of excifion, the
fcalpel  fliould be employed ;  but this is rarely the  cafe:
and the noftril is often fo filled, that we have no room for
the introduaion of a  knife.
  The ligature is the beft  remedy ;  it is lefs painful than
tearing  or  twilling off the polypus by the forceps,  and
equally  praaicable.  It is thus to be applied when the tu-
mor is in the throat.
  Take  a  pliable piece of filver wire,  which when dou-
bled is  long  enough  to pafs  through the nofe into the
pharynx : let  the  double  extremity  be flowly and gently
infinuated through one of the noftrils,  and when it ap-
pears in the throat, let the operator with his  fingers  open
the doubled extremity fufficiently for paffing  it over the
pendulous  end of the  tumor;  and having preffed it  down
to the root of it, pafs  the ends of the ligature hanging out
of the noftril, through the pipes of a double canula,  fimi-
lar to  that  reprefented in  (pi.  iv. fig. 5.) except that the
end is a little  crooked;  the  canula  is to be  inferted into
                                                   the 
                      t  312  ]
the fame noftril, and puffied back  along the courfe of the
wire, till it comes in contaa with  the root of the polypus.
The fingers being ftill continued in the throat to prefervc
the ligature in a proper fituation, the wire muft now be
drawn tolerably tight, and  the  ends being fixed  on the
handle of the canula,  it muft  be left  fo till the  next day,
when it ffiould be drawn fomewhat tighter; and this be-
ing daily repeated, the tumor will foon drop  off—If fmall,
in two days,  if large, frequently  in three:  but  we muft
be careful not to draw the ligature fo tight  as to cut the
tumor and induce hemorrhagy.
   All polypi which originate in the throat, or which pro-
ceed back from the noftril into the  fauces, and even thofe
which are deeply feated in the pharynx, if the ligature can
be applied over them with  the fingers, or with a forked
or flit crooked probe, may thus be removed.—Thofe which
are feated low down in the cefophagus,  might  probably
be treated in the fame way.
   When the polypus is fixed deep in the  cefophagus, and
on all occafions in which the  application  of the ligature
is  tedious and difficult, it is  proper to fecure a free refpi-
ration, by previoufly  performing Bronchotomy: in fuch
cafes a fpeculum oris ffiould  alfo be ufed.
  To apply  the ligature to a polypus feated in the  anteri-
or part of the nofe, and  which proceeds towards the up-
per lip; let  the double of it be paffed over the  moft de-
pending part of  the  polypus, and be flowly  puffied up
to the root  of it with  a flit  probe:  the  probe  being
given to an affiftant to keep the  ligature in its  fituation,
the ends of the thread muft be paffed through the  double
canula, (pi. iv. fig. 5.) which being  inferted into the noftril
on the oppofite fide of the polypus,  and pufhed along till it
reaches the root of it, the ligature fhould now be  drawn fo
tight as to make fome impreffion on  the  tumor, and the
                                                  ends 
                      [   313  3
ends of it muft then be tied to the wings of the inftrument,
and daily tightened till the tumor drops off.
  Mr. Chefelden recommends to pafs a ligature through
the noftril into the throat, in fuch a manner that the dou-
bling may include the root of the polypus, and the oppo-
fite ends  may be taken out of the mouth and twifled fo as
to remove the tumor—this mode would often fail.
   For the  extraaion of polypi by  the  anterior nares,
ftraight forceps with eyes  have been commonly employ-
ed—and thofe who choofe to ufe forceps for the removal of
polypi which pafs into the throat behind the uvula have ufed
crooked forceps.  Dr. Richter,  of Gottingen, has inven-
ted a pair of crooked forceps, (pi. ii. fig. 2.) by which pref-
fure may be applied  equally to every part of the tumor
included  in  them—the  blades being  feparately intro-
duced, where the polypus is  large.   In this refpea  and
on account of their facility of introduaion, they  are the
beft yet invented.   The blades are  conneaed and intro-
duced like thofe of the midwifery forceps.   The part intro-
duced fliould  always be made fmall, on account of the
 ftraitnefs of the paffage.
   In proceeding to extraa a  polypus by the forceps, the
 patient  fhould  be firmly feated with his head  leaning
 back, and fupported by an  affiftant behind ; and in order
 to difcover the origin of the  tumor, it will be ufeful  to
 place the face  fo that the light of a clear fun may fall into
 the noftril.   The furgeon is now to take the forceps and in-
 fert one blade on each fide of the  polypus, and bringing
 the points as near as poffible, or quite to the root or neck
 of it,  and grafping it firmly, endeavour to extraa it entire,
 by pulling downwards, or from fide  to fide, or more pro-
 perly perhaps by twilling the polypus round till it is com-
 pletely feparated.   By turning it round, the attachment may
 be more readily loofened, probably, than by any other way,
 and the membrane is not fo liable to be torn—and if the
                      R r                       polypus 
                        [  314   3
 polypus is firm, it may frequently be brought away  at
 once ;   but  if foft,  it will  be  extraaed  piecemeal—a»
 much as poffible fhould be removed.
   A hemorrhagy in  confiderable degree often attends the
 firft attempt to  remove the tumor; but this ihould not be
 regarded,  unlefs it be very profufe ; and  in patients of a
 robuft habit, even after the operation,  it will be proper  t»
 fuffer a  moderate difcharge,  as this  will  tend  to  prevent
 the  inflammation which otherwife would  be apt to occur.
 The means  formerly recommended are proper to reftrain
 the bleeding when it  feems  proceeding too far.  If  any
 part of the polypus  remains and we can bring it into view,
 it- may he touched with lunar cauftic covered with a canu-
 la, the day after the  operation, and  every fecond  or third
 day  afterwards, till it is removed—when any remaining
 part cannot  be feen, the feton might  be employed to re-
 move it; but a bougie, probably, would  anfwer better—
 this might  alfo be  ferviceable  in  diffipating an incipient
 polypus.  I  have feen very  beneficial effeas  from it  in
 one cafe :  A hollow  filver tube covered with plafter, was
 ufed during part of the time, through which  the patient
 breathed freely, and which wa3 fecured by ftrips of adhefive
 plafter,  conneaing  it with the lip—a pcice of  tape paffed
 round the head might be employed for  the fame purpofe.
   When polypi  are fo large that  forceps cannot be intro-
 duced, it will be proper to lay  the noftril open  by divid-
 ing the  cartilaginous  parts  by means  of a longitudinal
 incifion; and after  extraaing the tumor, to re-unite the
 wound by an adhefive plafter or by future.   There is no
 rifk in cutting the ala nafi ; for if we find, on laying open
 the parts, that the  tumor cannot with propriety, be taken
 away, the wound will foon heal again.
   When a  firm polypus has ulcerated, and the cartilages
 and bones of the nofe  are affeaed, this treatment would be
imprudent; but  in  the fofter kinds which  fcarcely ever
                                               become 
                      [  313   j
become cancerous, and where the cartilages and bones are
not affeaed,  it fhould be ufed without hefitation.
   In a cafe of firm fleffiy polypus,  which filled the noftril
fo that the forceps could not be  introduced, Dr.  Richter
puffied a red hot trocar covered by a canula, through the
centre of  the tumor,  and thus  formed a paffage  through'
which the patient breathed eafily, and by which the tumor
was much leffened.
                    S  E C T.  V.

              Of Extirpation of the Totifils*


   Enlargements of the tonfils feem to  originate com-
 monly from inflammation, and are but feldom if ever fchir-
 rous ; independent of inflammation they are never pain-
 ful ; they never  terminate as far as we know in cancer;
 and when the difeafed  part  is extirpated,  the complaint
 never  returns.
   Whenever thefe tumors become fo large as to produce
 much  interruption to the paffage of the aliment and air,
 they fhould be removed.
   For this purpofe, the cauteries, aaual and potential, have
 been advifed ;  butthe impoffibility of confining their effeas
 to the difeafed parts fhould  always prevent their employ-
 ment.   Excifion with the fcalpel^ or crooked feiffars is alfo
inadmiffible, on account of the confequent hemorrhagy.—
The method by ligature is the only proper mode.   Silver
wire, or catgut may be introduced through the  nofe, as
in operating on a  polypus in the throat,  and fixed on the
amygdala,  a ftraight or fomewhat crooked  canula  being
employed  in the manner the canula is ufed  in that opera-
tion, and the procefs conduaed exaaiy in the fame way.
                                                 The 
                     [   316  ]
  The more pendulous the tumor, the more eafily will the
ligature be  fixed,  but  in any cafe the difficulty is inconfi-
derable.
  The ligature, if carried through the mouth, would  be
Very inconvenient;  but  fhould any difficulty occur in the
employment of the mode recommended, this may be ufed.
  If  it be  neceffary to remove both  almonds, it will  be
proper to allow any inflammation that may occur from the
firft operation to  fubfide,  previous to the removal of the
remaining  gland.
  The mode above defcribed I conceive to be the beft ; but
the operation may often  be done differently.   Let a fuffi-
ciently ftrong ligature be  formed of waxed thread, and
carried round the tumor, either with the fingers or a fplit
probe.  A  noofe is then  to be formed  on it and drawn
round the almond by fixing one end of the thread at its fide,
with a fmall fteel inftrument which is ftraight,  except at
the ends, where it is formed into rings, while the other is
drawn out of the  mouth by the other hand  of the  furgeon.
When  the  tumor is  of a pyramidal form,  and broad at
the bafe, a  double ligature  being put into the eye of a long
needle, fixed in a handle, with the eye near the point, the
needle is to be puffied through the middle of the fwelling
near its bafe, and the  thread being difengaged by forceps,
the needle muft be withdrawn.   By the affiftance of the
ringed inftrument, a knot muft then be formed on each half
of the tumor.
  Both thefe operations are recommended by Mr. Chefel-
den :  Mr. Sharpe concurs with me in thinking them un-
neceffary,  and properly  fuperfeded by the  mode  firft de-
fcribed.
SECT. 
[  817  ]
                    SECT.  VI.

              Of Extirpation of the Uvula.

   When the uvula, in confequence of frequent inflamma-
tion, &c. becomes relaxed to fuch a degree as by irritating
the throat, to induce cough, retching, and vomiting, and
to obftrua deglutition ;  and when this cannot be remedied
by aftringent gargles, extirpation can  alone be depended
on for a cure.
   This may be effected  by excifion or ligature : when
the uvula is merely elongated, the firft ffiould be employed ;
but where it is much enlarged, as there would be danger of
confiderable  hemorrhage from the  ufe of the knife, the
ligature  ffiould be preferred.
   The crooked, probe-pointed biftouri, is the beft inftru-
ment for cutting off the  uvula ; but it may be done with a
pair of common or curved feiffars. In both cafes the mouth
ffiould previoufly be fecured with a fpeculum oris,  and the
uvula ffiould be  taken hold of with a pair of fmall  forceps,
or a fharp hook.  If much  blood is difcharged after the
operation,  we muft ufe  an aftringent gargle, or touch the
veffel with lunar cauftic.
   When a  ligature is employed, the mode  of fixing it
defcribed in  the laft  chapter but one,  may  be adopted;
and  the  canula  may  be introduced either  through  the
mouth or nofe :  or it may be done by Mr. Chefelden's me-
thod of tying the  tonfils.   After paffing the ligature, it
ffiould be tied as direaed in the cafe of polypus,  by Mr.
Chefelden.  See Ch. penult.
S E C T. 
[  sis  g
                   SECT.  VII.

         Of Scarifying and Fomenting the Throat.

   Fomenting the throat is often ufeful in inflammatory
angina.  For this purpofe the inhaler of Mr. Mudge (pi.
viii.  fig 3.) anfwers better than  any thing yet propofed.
This inftrument is equally ferviceable in  catarrhs,  for con-
veying warm vapour to the trachea and lungs.
   Scarifying the throat alfo is often a beneficial remedy in
inflammatory  angina ;  an inftrument for this purpofe is
delineated in pi. viii. fig.  5.
  CHAP.     XXXII.

Of the Diseases of the  Lips.
                    SECT.  I.

                   Of the  Hare-Lip.

"STATURAL deficiencies occur more frequently in the
■*■     lips than in any other parts of the body: children
are often born with fiffures in one of them, but particularly
in  the upper lip.   In fome there is a confiderable deficien-
cy of parts, and in others  two fiffures with an intermediate
fpace.   Thefe affeaions are all included under the name of
                                                 kar& 
                     [  319  3
hare-lip, from a fuppofed refemblance in them to the lip of
that animal.
  The opening is commonly confined to the lip, but fome-
times it extends along the palate and uvula into the throat ;
and in many inftances the bones of the palate are feparated,
in part,  or altogether wanting.
   Deformity is a conftant confequence of this difeafe.  It
fometimes  prevents fucking,  and when in the under lip,
is commonly attended with inability  to retain the faliva:
and it is always produaive of impediment in the fpeech.
When the  divifion extends  along the bones, chewing and
fwallowing are obftruaed by the food  paffing up to the nofe.
   Thefe are reafons for  attempting  the cure as early as
poffible.  I have effeaed this, in healthy children, in the
third month  of  their age ;  and the  operation  may be
performed  thus early with  as much  probability of fuccefs
as at any time of life—Young children are more eafily ma-
naged than thofe at a more advanced age.
   The intention of this  operation is  to cut off the fides of
the fiffure,  in order to reduce it to the ftate of a frefh wound;
and then to bring the divided parts into contaa, and to re-
tain them there till a firm adhefion takes place  between
 them.
   Some contend that adhefive plafters or bandages, are
fully adequate to the retention of the parts after they are
properly cut;  thefe may fucceed in  fome cafes,  but they
will frequently fail, and induce a neceflity for a fecond ope-
ration ;  when futures are  properly  employed they never
fail.
   In performing the operation, if the patient is  an adult,
he ffiould be feared with his head to the light, properly fup-
ported by  an  affiftant behind ;  but if a child,  he will be
more firmly fecured by being laid  on a  table,  and  kept
in  a proper  pofture by an affiftant ftanding  on   each
 fide. The operator is now  to  make  an  attentive exami-
                                                nation 
                      [  320  3
nation of the difeafed parts and of thofe contiguous to them.
The upper lip is to be feparated from the gums beneath;
and if a tooth projeas it fhould be  removed, as it would
irritate the lip.  If there  is a projeaion from the angles
of the divided palate bones, it muft be taken off by cutting
pliers, (pi. ix. fig. i.) or  forceps.  One fide of the lip is
now to be taken between the thumb and fore-finger of the
left hand, and an affiftant doing the fame,  and ftretching
it pretty tightly, an incifion muft be made from the under
border of the lip to the fuperior part, with a  fcalpel,  in
which a fmall portion of the found parts muft be included 5
the fame muft be performed on the  oppofite fide, termina-
ting  in the  fame point in  the  upper part of the lip;
by this means, a piece including the fiffure, will be cut out
refembling an inverted p^.
  The  veffels ffiould be  fuffered to bleed freely  if the
patient is plethoric, and then the fides of the wound  ffiould
be  united.   To effea this  the cheeks fhould be pufhed
forward fo as to bring the edges of  the wound nearly into
contaa, and an affiftant behind ffiould fupport them in this
fituation.   Pins are then to be introduced  in the manner
defcribed, when,treating  of  the twifled future.  The firft
ffiould be near the under edge of the lip,  leaving  merely
fpace enough to fupport it. Another fhould be inferted in the
centre of the cut, and a third very  near the fuperior angle
of it.   In infants two pins will fuffice.
   In paffing the pins, they ffiould be entered nearly half an
inch from the edge of the wound ; and being carried almoft
 to the bottom, they muft be again paffed outward in a fimilar
 direction, and to an equal diftance on the oppofite fide of the
fiffure.   The affiftant ffiould  now prefs  forward the cheeks
 fo as to bring the parts into  clofe  contaa, and  a  waxed
 ligature muft be applied over the pins,  beginning with the
 under one, and having made three or four turns defcrib-
                                                    ing 
                      [  321   3
ing the figure of 8 : it fhould then be carried to the conti-
guous  pin, and being in a fimilar manner carried round that,
the operation muft be  finifhed by paffing it to the other;
taking  care to draw it fo tight as to retain the parts well in
clofe contaa, but not fo ftraight as to irritate them.   A
piece of lint  covered  with mucilage  ffiould  now  be  put
over the cut—it ffiould alfo cover the ends of the pins, that
they may  not be entangled by the bed-clothes, &c.
   When  there  is a  great  deficiency of parts, and the
edges of the  wound are with difficulty  brought together,
an oblong piece of leather fpread with common  glue, or
with a ftrong mucilage, being applied over each cheek, and
reaching  from the angle  of the jaw to within an inch of
the pins on each  fide, each  piece  of leather fhould have
three  firm ligatures  fixed to the  end next the lip, which
ffiould be made to pafs I etween the pins, and be  tied fo
as to retain the parts together.
   The pins  fliould remain five of fix  days, and  during
this time  the patient ffiould be fed on  fpoon-meats, and
be prevented from  laughing,  crying,  or  ftretching the
mouth in any way.
   When  the hare-lip  is double, there is a neceffity for per-
forming the operation twice : but  we ffiould complete the
cure of one lip before attempting to operate  on the other.
The incifion ffiould always be extended to the upper part of
the  lip : the fides of it fhould beexaaiy of an equal length,
and to infure this, it  will be  proper previoufly to mark
the  length and direaion of the cut with ink—and the lip
fhould be equally and tightly ftretched during the incifions:
for this purpofe,  curved forceps may be  ufed to  lay  hold
of the lip, and the incifions made along the fide of them in
the proper direaion.
   Some  writers  direa us  to  introduce a piece of pafte-
board, lead,  or tin beneath the lip, and cut  upon it; but
the  incifion is more eafily made as above direaed.   Scif-
                         S s                       far*= 
                      [  322  ]
fars may be employed with as much fafety and eafe as the
fcalpel.
  Flexible needles are ufed by fome  inftead  of  the  pins
we have recommended, but they  are  not fo proper.  In
paffing the pins, particular care fhould be taken that  they
go nearly through to the oppofite  fide of the lip; other-
wife a fiffure may remain in the inner part of the lip, and
a troublefome oozing  of  blood  may take  place  behind.
Death has enfued from this difcharge, in confequence of
ignorance of its quantity, from the patient's being direct-
ed to fwallow his faliva.  This fhould induce us to forbid
fwallowing the faliva, while it is tinctured with  blood—
Befides this  dangerous inconvenience, fbmetimes a fmall
quantity of blood  taken into  the  ftomach, excites naufea
and  vomiting, which ftretch the lip and  feparate the clof-
cd parts.
   Fiffures of the lip,  from whatever caufe, are to be treat-
ed in this way ; except that in a  recent wound, all that is
neceffary is  to  infert  the  pins  and apply the  ligatures.
While any inflammation continues in wounds where fup-
puration  has  commenced, we fliould avoid the applica-
tion of the  ligatures;  but as foon  as  this fubfides, the
operation may be ufed with as much fuccefs as  when the
wound is recent.
   In cafes where the  bones  of the  palate are feparated,
after uniting the foft  parts, fome advantage may be ob-
tained from a thin plate of gold or filver fitted to the arch
of  the palate, inferted in the fiffure, and fixed by a piece
of fponge ftitched to  the convex  fide:  the fponge ffiould
be  dry when inferted, and  the  moifture  it imbibes will
retain it.   By this means the fpeech and fwallowing will
be much aided.   When, however, the fiffure is wider ex-
 ternally than within, fponge cannot be applied.—A plate
 with gold fprings to fix on the contiguous parts has been
 propofed, but it does not fucceed.
                                             SECT. 
I   328  3
                    SECT.  II.

           Of the Extirpation of Cancerous Lips.

  The under lip is more fubjea to cancer than any other
part of the body;  and the fcalpel alone cag be trufted to
for relief.    When the whole  lip or a confiderable part is
affeaed, the difeafed parts muft be removed,  the arteries
tied, and  the fore dreffed as a recent wound.   This  un-
covers the  teeth and gums, and produces an incapacity of
retaining the faliva, and a difficulty of fwallowing liquids ;
but there is no alternative—When  an inconfiderable por-
tion of the lip only is affeaed, the edges  of the wound
fhould be united by the  twifted future  as  already defcrib-
ed : by this means much deformity  and inconvenience
will be prevented;  and the difeafe will be lefs apt to re-
turn, than when it is treated without employing future.—
If a third  of the lip remains, the future may be  ufed : it
fucceeded  in a cafe in  which  mere extirpation had been
twice  tried.
   When the difeafe extends to the cheek, a tranfverfe in-
cifion of the cheek as well as a longitudinal one of the lip
will be neceffary, and both are to be afterwards clofed by
pins and ligatures.
CHAR 
[  324   5
CHAP.     XXXIII.

Of Diseases of the Mouth.
                    SECT.  I.

                     Of Dentition.

   IN  Dentition, the gums covering  the teeth  that are
    about to appear become inflamed  and full—the  child
frequently  rubs them—the faliva is generally increafed,
though in fome rare  inftances  leffened  in  quantity—The
bowels are  irregular;  fometimes coftivenefs, and  fome-
times  diarrhoea occurs: fever  is produced; and  fome-
times fubfultus tendinum, and convulfions.
   When opiates, blifters,  and particularly warm bathing,
fail to relieve the fymptoms, making an incifion through the
gums direaiy upon the approaching  tooth  or teeth  is fre-
quently effeaual;  this  is commonly termed fcarifying the
gums.   It fhould be employed early, and repeated two or
three  times over the fame tooth if neceffary.  A gum lan-
cet is the belt inftrument to perform this operation  with;
but a  lancet or biftouri may be employed.   The  incifion
ffiould be of a crucial form, and carried down to the  tooth:
it commonly heals eafily ; and often inftantly  relieves chil-
dren who appear to be in the moft imminent danger.
  Pain over the whole  jaw, with inflammation and fwel-
ling of the gums and cheeks, often extending to the throat,
fometimes occur from  the approach of the fecond fet of
teeth, particularly from  the dentes fapientise;  the   fame
                                            treatment 
                       [   325   3
 treatment will commonly fuffice for the removal of thefe
 fymptoms.   It is oftener unfuccefsful when the dentes fa-
 pientiae produce the irritation, than when it originates from
 any others;  and extraaion  of the  offending tooth,  will
 alone fucceed in many inftances.


                    SECT.  II.

              Of Derangement of the Teeth.

   The fecond fet of teeth frequently  appear in an irregu-
 lar manner;  fome of them  will be farther out of the jaw,
 and others farther in, than they ought to be.   This often
 produces confiderable deformity ; and feems to occur moft
 frequently in the incifores or canini, and feldom or never
 in the molares.
   Derangements of the teeth originate ; from a deficiency
 of fpace in the jaw, in confequence of which, they cannot
 all be  admitted into one circle ; from a natural conforma-
 tion ;  or from fome of the firft fet remaining after the fe-
 cond have  appeared.
  When the derangement feems owing to any of the firft
 fet remaining, thefe ffiould be immediately removed; and if
 it is caufed by thofe  of the fecond fet being too large for
 the fpace allowed them, we fhould not hefitate to take fome
 of them away.   When the teeth which occupy the circle
 are regular and  good, the tooth or teeth which are out of
 the circle fhould be pulled ; but when either of the con-
 tiguous teeth do not  fill the  fpace fo properly as thefe
 would  do, or are rough and difagreeable  in appearance,
 it will fometimes be advifable to pull one of thofe in  the
 circle,  and endeavour  to bring the  others in the natural
range.   Nature will then fometimes fupply the vacancy; but
if ffie does  not, as foon as the body of the deranged tooth
                                                   has 
                      [326  ]
has paffed out of the gums, it ffiould be conneaed firmly te
the adjoining teeth  by a  ligature, tightened from time to
time, until the tooth is brought within the circle.   A plate
of gold or filver fixed to  the  contiguous teeth, and  made
to furround thofe deranged,  fo  that when  preffed by  the
oppofite jaw it aas  with confiderable force in bringing  the
teeth together, is a  mode  very troublefome, and much lefs
effectual.
   A ligature may be applied,  perhaps in the beft  manner
yet known,  by paffing a thin plate of gold perforated with
feveral fmall  holes, and exactly fitted to the fides  of thofe
teeth oppofite to the one to be moved, then over four con-
tiguous teeth, tying it to them by  waxed thread ;  and af-
terwards putting a piece of flexible wire or catgut through
two of the holes;  carrying  the  doubling of the  ligature
over the tooth to be moved,  drawing the ends through the
holes, and fixing them with  pliers.   The ligature ffiould
be tightened every*  three  or four days until the  tooth is
properly placed.
   Deformity  is frequently the confequence  of an opening
in the anterior part of  the jaw, produced either by a de-
ficiency of  one or more teeth, or from their being acci-
dentally knocked out.    If a furgeon is called immediately
after an accidental lofs of  teeth, he fhould replace  them if
not broken ; or if the patient choofes, one or more teeth
may be tranfplanted : if an inflammation and fwelling have
already come on,  thefe  ffiould  be previoufly  removed.
Wnen feveral teeth are loft, artificial teeth may  alfo be
fixed to thofe that remain firm.  If one tooth only is want-
ing, in young people, a ligature fixed round  the  two con-
tiguous teeth will often by  degrees draw them together:
this nature fometimes in part effeas ;  but, in that cafe, the
points only will approximate.
S E C X 
L  327   3
                    SECT.  III.

                     Of Gum-Boils.

  The gums are very frequently fubjea to abfceffes, be-
 caufe they are much expofed to the caufes produaive of
 them.  Gum-boils may originate from cold, and other com-
 mon caufes of inflammation ; but they more commonly are
 produced from tooth-ach.   They occur not only from ca-
 ries, but alfo from inflammation at the roots of the teeth.
   A gum-boil  commonly  appears after a fit of tooth-acli
 has continued for  fome time : it begins with  pain, and a
 fmall tumor in the part; the cheek  foon  after fwells, and
 frequently the whole face.  When fuppuration takes place,
 the fwelling becomes pointed, and if not opened  foon
 burfts on the fide of the gum, or  between  the  gum and
 teeth.    Effeaual  relief  is afforded  by the  difcharge of
 matter; but as the caufe commonly remains, the difcharge
 continues till this is removed ; or if the opening clofes, the
 difeafe is commonly foon renewed.  When indeed inflam-
 mation  at the  root  of a tooth is the caufe, and  the  peri-
 ofleum is not feparated, a cure may be produced, after the
 difcharge of  the matter, by  the union  of the fides of the
 abfcefs : but when  the tooth is carious,,  its root denud-
 ed, or  when a part of the  jaw is  carious, removal of the
 difeafed parts will  alone accomplifh a cure.          ***"
   Where inflammation at the root of the tooth  is the caufe,
 the abfcefs fhould be  laid  completely  open, a doffii of
 lint introduced, and the wound healed from the bottom.
 But when incifion will not be admitted, we fliould  injea
tina.  myrrhse, lime-water, fpirits, and tina. of bark dilut-
ed to remove  the difcharge.   If the affeaion is feated very,
deep, fo that there is danger of a caries of the jaw from the
                                               impoie- 
                      [  328   ]
impofthumation, we fhould ufe warm fomentations to the
part, and  warm ftimulating fubftances, fuch as a roafted
onion,  to  that part of the gum moft affeaed, in order to
excite a fuppuration, that may point into the mouth ; and
as foon as matter is formed, we ffiould open the abfcefs.  A
free depending orifice ffiould afterwards  be  preferved, till
exfoliation  takes place, and a cure is completed.   Where
there is a  fcrophulous or  other  conftitutional affeaion,
the ulceration is commonly very troublefome, and  only
yields to remedies for the general affeaion.

                   SECT.  IV.

          Of Abfceffes in the Antrum Maxillare.

  Whatever tends to produce inflammation in the mem-
brane lining the antrum highmorianum  may produce ab-
fceffes in it; fuch as blows on the cheeks ;  inflammations of
the membrane lining the nares, and even long-continued
inflammations of the  eyes  fpreading  into  the antrum.
Much  expofure to cold has frequently produced  them;
but repeated violent tooth-ach is their moft common caufe.
Mr. Hunter confiders the obliteration of  the dua leading
from the antrum to the nofe  as a frequent fource of thefe
colfeaions ;  but this appears to me to be merely a confe-
quence  of fome  of the other caufes, and  to be occafioned
in common by adhefive inflammation.
  The firft fymptom of this complaint is fome degree of
pain over the cheek; which  frequently continues a confi-
derable  time before any fwelling comes on. This increafes,
and extends perhaps  to the eye,  nofe, or ear; at  length
a hard  fwelling  appears  over the whole cheek, which af-
ter fome continuance points, moft frequently in the centre
of the cheek, a little above the roots of the pofterior mo-
                                                 Ures. 
                       [   S29   ]
hres.  In fome inftances,  the  matter burfts out between
the roots  of thefe teeth and the gums, and prevents the
difcharge externally ; this probably takes place in common,
when the  roots of the  teeth  penetrate the antrum.  For
the moft part too, as foon as  matter is formed, fome of it
is difcharged by the noftril when the  patient lies on  the
oppofite fide with the head low.   In judging of the origin
of a difcharge by the noftril, we muft confider that it may
be produced from inflammation of the membrana fchneide-
riana; from an  ozama ; from  affeaions of the frontal
finufes ; and from abfceffes in the lachrymal fac, as well as
from matter in the antrum maxillare.
   As foon as we have evidence of the difeafe, if a perfora-
tion is not made to difcharge the matter, the bones of  the
cheek will be elevated,  and at laft rendered carious.  The
opening may either be made into the fide  of the antrum,
where it  projeas over the two  great molares,  or one of
thefe teeth may be taken out, and a perforation made di-
reaiy upwards in the courfe of one of the fangs.   The laft
is the only effeaual mode.  If either of the large molares
is difeafed that fhould  be removed ; but if they  are both
found, the one next the dens fapicntise ffiould be taken
away,  becaufe the antrum is thinnefl beneath it.
   Sometimes  the matter is  difcharged  immediately on
drawing  the tooth,  either from having  penetrated  the
focket, or  from the os maxillare being corroded by its con-
tents.  If the opening thus  formed, is infufficient to admit
of a free difcharge, it fhould be enlarged ;  but if no open-
ing occurs, one is to be made by pufning a trocar, or fome
other proper fharp inftrument, into the antrum,  in the di-
reaion of one of the fangs.   In performing this, the  pa-
tient ffiould be feated on the floor oppofite to a clear light,
and his head laid on the knee of the  operator, who may
either ftand or fit behind him.  The inftrument fliould be
                       T t                      with- 
                      [  330  ]
withdrawn as foon as by the non-refiftance to its point we
find it has entered the cavity.
   As  foon as the matter is difcharged, a wooden  plug,
with a nob at its head, ffiould be introduced into the ori-
fice, to prevent  the air and food from entering it.   This
plug ffiould be removed twice or thrice a day, to admit of
a free  and quick evacuation of the colfeaed matter ;  and a
cure will commonly foon be obtained.  But in fome cafes,
either  from relaxation of the membrane of the antrum,  or
other caufes,  the difcharge  continues confiderable  a long
time.  In this cafe, liquids moderately aftringent ffiould be
frequently injeaed ; but nothing ffiould  be ufed which
contains any folid matter, that  might be depofited in the
antrum : I commonly ufe a folution of alum, brandy diluted,
or lime-water.   When the bones are carious, of which we
may be farisfied by the appearance  and fmell of the dif-
charge, or by  the probe,  we cannot expea a cure till ex-
foliation has taken place.
   Blood may be effufed into the  antrum, from blows, &c
and require this operation.—Worms fometimes are pro-
duced  in it; they are indicated by violent pains in the re-
gion of the cavity, not induced by any obvious caufe.  In
this cafe an opening ffiould be made immediately above the
roots of the  large molares, and after extraaing  all the
worms we can find, oil, a filtrated  folution of affafcetida,
or a weak infufion of tobacco, fliould be injeaed from time
to time, to deitroy any that  may remain.
   It has  been propofed by  Mr.  Hunter, to  perforate the
antrum through the noftril; and with equal  propriety  it
might  be perforated through the  roof of the mouth; but it
muft be obvious, that the mode above recommended is in-
finitely preferable to either.
   By  the means we have  advifed, almoft every difeafe
from colfeaions in  the antrum maxiliare, may be  remov-
                                                   ed j 
                      [  331  3
ed; but there are complaints, apparently originating from
an enlargement of the bones of the cheek, which frequently
terminate in the death of the patient.  In abfceffes of the
antrum, the  cheek feldom fwelis very much ; and  when
the difeafe  has been  of  long duration, if the matter does
not find an opening into the noftril,  or along the root of
the teeth,  it commonly  points towards the prominent part
of the cheek; but when no  matter  is colfeaed,  and the
difeafe proceeds from an affeaion of the bones,  although
the fwelling gradually  arrives  to  a confiderable fize, it
fpreads equally over the cheek, without pointing at any par-
ticular part, except in the laft  flages when fuppuration oc-
curs in fome of the foft parts.   Till the  flcin is  inflamed,
which only happens in  an advanced period,  the  fwelling
remains colourlefs.   But  the  moft charaaeriftic mark of
this fpecies of fwelling, is the remarkable  degree of elaftici-
ty which it acquires : The bones yield to preffure, and on
its removal inftantly return to their former fituation.   If an
incifion is now made into them,  they appear foft  and carti-
laginous, and fometimes fomewhat gelatinous.
   In  the inftances of this difeafe, where carious teeth ap-
peared to have fome  effea in producing  it,  their removal
has produced a temporary flop to its progrefs ; and in fome
others, long continued  gentle courfes of mercury,  with
decoaion of mezereon,  have had the  fame  effea ; but no
permanent benefit arifes either from internal medicines or
external applications.
SECT. 
[  332   ]
                    SECT.  V.

             Of Excrefcences on the Gums.

   The gums are liable to excrefcences of different degrees
of firmnefs,  from the hardnefs of a wart to the foftnefs of
fungus, nearly of the colour of themfelves.—Thefe excref-
cences impede maftication and the fpeech, but are  feldom
painful—they occur moft frequently in the  under jaw and
infide of the teeth,  and commonly adhere throughout their
whole extent.   They frequently originate from  carious
teeth, and fometimes from caries of the alveoli.
   Removal of the  difeafed bone will commonly be followed
in thefe inftances, by difappearance of the excrefcence ; but
if it is not, the tumor  ffiould be extirpated.  I never knew
either a hemorrhagy  of any confequence,  or a cancer to
fucceed the extirpation. When the excrefcence is attached
by a narrow neck, a ligature ffiould be  applied to it; but
when it has a broad  bafe, we  muft ufe the fcalpel.  In
proceeding to the extirpation, the patient ffiould be firmly
feated oppofite to  a clear light, and the head ffiould be
fupported by an affiftant  behind ;  and  unlefs the patient
has a  good deal of  refolution, a  fpeculum  oris fhould  be
ufed.   A common fcalpel will  frequently ferve for the
diffeaion, but a curved knife and crooked fciffars will fome-
times be better, and fliould be at hand.   The tumor muft
be elevated  with  a diffeaing hook  that has two  fangs,
which is here much preferable to the common hook. Great
care ffiould be  taken not to injure the parts conneaed
with the tumor unneceffarily ;  but if it is firmly conneaed
to the gums, a part of them fhould be  removed, even to
the  depth of  the focket; although this  may  induce a
danger of injuring the teeth.   A. moderate  difcharge of
blood may be  fuffered;  but if it  tends to  profufenefs,
                                                    the 
                      [   833   ]
ilie patient fhould take fome brandy  or tincture of myrrh,
into the mouth ;  and if this does  not reftrain it, lunar cau-
ftic fliould be applied to the wound.  Dreffings to the fore,
are, from  its fituation, inadmiffible.  For fome days after
the operation, it fhould be waflied with  a warm emollient
decoaion ;  and  if a  cicatrix does  not then readily form,
lime-water,  port-wine, or any mild aftringent, ffiould be
applied to it.

                    SECT.   VI.

                     Of  Loofe Teeth.

   The teeth are frequently loofened by  external violence;
as falls and blows ;  and  often by improper force in pulling
 thofe contiguous to  them.  In thefe cafes, they fliould be
 fixed  as  firmly as poffible in their former fituations, by
 preffing them as far as they  will go into the fockets, and
 there fecuring them by ligatures of Indian weed, cat-gut,
 or waxed fiik, carried round the adjoining teeth ; and the
 patient fhould live  on fpoon-meat till   they become fa ft.
 In youth this praaice  will commonly fucceed ;  but in
 old age,  loofe teeth  from any caufe can feldom  be again
 firmly fixed,  and  in very  advanced  periods of  life, it
 ought not  perhaps  to be attempted.  The  teeth alfo be-
 come loofened by depofition of tartar, between the roots and
 the gums ;  and in fome cafes between the roots and fockets.
 In thefe cafes, fcaling off the tartar  will commonly remove
 the complaint—this fhould be done as  early as poffible.
    Sponginefs of the gums, and their feparation from the
 teeth, frequently produce loofenefs of  the teeth.  This
 fometimes occurs from the ufe of mercury; and often hap-
 pens in fcurvy.  When it originates from fcurvy, a remo-
 val of the general difeafe is  the remedy.   But it often oc-
                                                   curs 
                      [   334  3
curs  as  a local  affection; and then  deep fcarifications
of the gums,  occafionally repeated,  is the beft and moft
effeaual mode of cure.—This often produces an adhefion
of the gums  to the teeth : and then, aftringent  gargles
made of tinaures of Peruvian and oak barks, and of myrrh,
and a ftrong folution of alum, with cold  water, ffiould be
employed frequently and the teeth  ffiould not be ufed till
they have been for fome time firm.   A'lringents ufed be-
fore  an adhefion  of the  gums to  the  teeth takes place,
often renders them  hard  and incapable of forming a con-
neaion with  the teeth.   When the  teeth have  long  been
loofe, there is  but little chance of making them fall again.
  This difeafe is fometimes produced by abfceffes between
the roots and alveoli of  the teeth—(vide chapter on gum-
boils.)  It  alfo occurs in old age,  from a new removal of
the alveoli; probably in confequence of the offeous matter
being abforbed, when nature cannot afford a fupply of it—
this cafe is irremediable.

                   SECT.  VII.

                 Of Cleaning the Teeth.

  The teeth fometimes lofe their colour, and acquire either
a dufky yellow hue, or become black to  a certain degree,
without  any  adventitious matter  being  perceptible on
them.   2.  They, on  fome  occafions  become  foul, and
give a difagreeable taint to the breath, from a long remora
of the mucus of the mouth.   But, 3.  The moft frequent
caufe of  foul  teeth,  is the depofition of a calcareous kind
of matter from the faliva.   Some  will  have  the  teeth
thickly  mcrufted with this fubftance  a  few weeks after
having them cleaned: and moft people  are  fubjea  to fuch
a depofition in greater or lefs degree.   It firft appears  on
                                                   the
j 
                      [   335   3
the fore-teeth, in the angles  between two of them,  where
they are leaft rubbed by the tongue or lips ;  but the  effeas
of maftication commonly prevent it  from fpreading to the
points of them.  In many cafes it is confined to one  or two
teeth;  but in others  a continued cruft feems formed all
over the whole jaw ; and this fometimes to  fo great a de-
gree, as to disfigure the cheek externally, and  to have been
miftaken for an exoftofis  of the jaw-bone.
   Slight ulcerations of the gums are often produced when
any  confiderable quantity of this tartar is colfeaed,  which
frequently infinuates itfelf between the gums and alveoli fo
as to feparate them a good deal from  each other.
   Acids will diffolve and remove  the tartar, but  at  the
 fame time they injure the enamel, and many have loft their
teeth from the ufe of them.  Scaling  inftruments afford
a certain relief, and from a  proper application of them  no
 harm can enfue.   When the teeth  are once well cleaned,
frequent waffling with cold water, and rubbing them every
 fecond  or third morning  with burnt bread,  Peruvian bark,
 cream  of tartar,  chalk, or  any  other mild application, in
 fine powders will  generally keep them  clean  and white.
   The  inftruments employed (fuch as in pi. ix. fig. 5.  6.)
 ffiould  be moderately fharp ; but their edges ffiould not be
 very fine, or they will  turn or break.   In performing
 the operation, the patient ffiould be feated on a low chair,
 with his  face to the light,  and  his head fupported by an
 affiftant:  the furgeon  ffiiuld  fit  oppofite  to him, and
 wrapping the fore-finger of his left hand  in a wet cloth,
 ffiould  prefs firmly on the  point of the tooth, while  the
 back part of the inftrument will  form a point of refift-
 ance for  the thumb of the fame hand.  The  fharp edge
 of the inftrument  is now to be infinuated beneath the under
 part of the incruftation, avoiding the neck of the tocth
 for fear of loofening it:  it muft then be puffied with firm-
 nefs to the fuperior  part of the tooth, and repeatedly ap-
                                                  plied 
                       [   336   ]
plied till the incruftation is removed.   When the teeth are
all  cleaned, they fhould be  rubbed well with  a  piece  of
fponge in the  lorm of a bruffi, covered with a fine powder
prepared  of equal parts of cream of tartar and Peruvian
bark.
  The teeth fometimes acquire a kind of foulnefs and lofe
their colour, when there is no apparent depofition on them.
Moderate friaion with a fcaling inftrument will frequently
remove this.   But the worft kind of foulnefs is when they
become black, and feem perforated with a number of fmall
holes.   Alkaline  applications are  the  beft in thefe cafes;
they often render the teeth clean,  and never injure them.
A lather of common foap, or a folution of fait of tartar ap-
plied over the  teeth with a pencil bruffi will often anfwer.
When the difeafe is thus removed, frequent waffling with
cold water, and rubbing them with  the above  mentioned
powders, are the moft effeaual preventatives of a return ;
but they are often unfuccefsful.   This variety of the  af-
feaion feems  to depend on a putrefcent caufe,  for it is
evidently attended with a mortification of the  teeth ;  and
hence antifeptics would  probably prove ufeful.
  Lucerne and alkanet roots dried and beat at one end into
the form of a bruffi,  are very proper to rub the interftices
between the teeth ; but no kind of bruffi fhould be employ-
ed to rub the roots of the teeth, or the upper parts of the
gums ; becaufe they may feparate the gums from the teeth.
For  this reafon I always make  ufe of a piece  of fporge,
fixed on a fmall  handle,  which may  be  ufed with  the
greateft  fafety.
SECT, 
i  337  j
                  SECT.  VIII.

                    Of the Tooth-ach.

  This difeafe,  befides its ufual fymp oms of pain in one
or more of the teeth and fwelling in the  contiguous gums,
is frequently attended with a fwelling of the cheek ; and
pain and inflammation in the eye and ear of the affeaed  fide ;
and to thefe perhaps fucceeds fever, with its confequences.
  Thefe  fymptoms may originate, 1. From  the nerve and
other  parts within the cavity of the tooth affeaed being laid
bare,  either by external  violence, or by the enamel falling
off in confequence of caries, or fome other  affeaion.  2.
From inflammation of the parts within the tooth, or of the
membrane which furrounds the root of it.  And, 3. From
fympathy,  i. e. in  confequence  of  affeaions of diftant
parts ; as  from difeafes of the eye, of the ear, and of the
ftomach.

§ 1.  Of Tooth-ach from the Nerve being laid bare, and of the
              Methods of ExtraBing Teeth.

   From  whatever caufe the nerve of a tooth becomes ex-
pofed, pain, and many other of the fymptoms abovemen-
tioned, will be the inevitable confequence.   This does not
feem  fo much to be  produced from the mere expofure of
the nerve to the aaion of the aliment and air, as from a
certain degree of irritability induced by the expofure  ; for
we frequently fee the cavity of the tooth laid open by ex-
ternal violence, and nothing more than a temporary pain
fomewhat proportioned  to the accident induced :  and it
often happens,  that  teeth gradually  moulder away with-
out  any  pain  or uneafinefs  whatever   being  produced.
Thefe occurrences could not take place  if a mere denuda-
                         U u                     tion 
                      [  338  ]
rion  of the nerve was the  ultimate  caufe of the tooth-
ach.
  An  irritable ftate of the nerve may be brought on by
various caufes ; and  more particularly by faccharine acid,
and  other ftimulating  fubftances contained  in  the food,
being  frequently  applied to it—by a too  frequent  ufe of
tooth-picks—and by much expofure to a ftream of cold air,
and efpecially  if this is at the fame time moift.
  The operation of thefe  caufes in inducing  tooth-ach
when  the nerve is already expofed, by the deftruaion of
the enamel  from external violence, or from  caries and a
confequent decay of the offeous part of the tooth, is eafily
underftood : but the produaion of a caries of the enamel,
when no external violence has been applied, the mofl fre-
quent  caufe of the complaint, has not  been fo fatisfaaorily
explained.
  It has been  placed in the large ufe  of acids, and in the
lodgment  of  putrefcent particles of  the  aliment on the
teeth  from  want  of  wafhing the  mouth  after  meals.
With  refpea  to the  firft of thefe, there  is  no doubt
that they prove injurious to the enamel, and ffiould there-
fore be avoided :  and  the fecond ffiould certainly  alfo be
guarded  againft ; becaufe it not only gives a difagreeable
fcetor  to the  breath, "but alfo contributes to the  forma-
tion of an inconvenient incruftation on the teeth.  It does
not, however, appear that caries of  the teeth is the con-
fequence of either of  them.    If  acids  occafioned it, it
ffiould affea all  the teeth, or at leaft a confiderable part
of them, at the fame time, and in an equal  degree : where-
as it almoft always, begins in  a fmall point,  and extends
itfelf very gradually.   And  if it was the  confequence of
the  lodgment of putrefcent  particles, it fhould  always
appear in thofe parts of the  teeth which are neareft to
each other ; but  we know this is not the cafe.    And it
does not appear, from experiment, that the  immerfion of
teeth extraaed from  the body, when they would proba-
                                                    bly 
                      i  339  ]
Wy be much more readily affeaed with  putrefcency thaw
while they retain the  living principle, for a confiderable
time in putrid matter,  has the leaft effea  in producing a
carious ftate of them.
   Upon  the whole, I am  of opinion  that caries of the
teeth is generally an effea  of fome conftitutional caufe.
It  often begins  in one tooth, and is afterwards extended to
a lefs or greater number of others : and I have feen inftan-
ces in which the whole of the teeth were extraaed one after
another as  the  difeafe  extended itfelf, and the  patient at
laft received no permanent benefit, from the  pain fixing
upon the jaw.
   This view of the fubjea ffiews the impropriety of re-
moving teeth fo frequently as is ufually  done.   For if,
upon extraaing the  firft  or fecond tooth that becomes
carious, as foon as the violence of the pain renders  it ne-
ceffary, a  third or a fourth fliould be affeaed, the patient
fhould always be advifed to  fubmit to the pain rather than
to have it removed, as  the  difeafe is then probably fyfte-
matical, and will foon affea more—and  it  will often hap-
pen, that if one fit of the  tooth-ach is  borne,  the  fame
tooth will never again be feized by it.
   In cafes  of carious teeth, it has been a prevailing prac-
tice to remove the affeaed part with a file, in order to pre-
vent the difeafe from fpreading ; but I have almoft univer-
fally {een this detrimental.    It cannot have the  effea ex-
pected from it; and it becomes injurious by expofing the
found parts to the air, and whatever is taken  into the mouth.
   When fo much of the enamel is removed, either by ca-
ries or external violence, as  to form a hollow of  any  mag-
nitude, we may frequently prevent the tooth-ach, and pre-
ferve the teeth, by filling up the opening.    If this is large,
and particularly if narrow at the bottom and wider exter-
nally, maftic and gum-lac, or even  bees-wax,  will be
very  proper  for  the  purpofe; but  when  the opening is
                                                  fmall 
                      I   340  ]
 fmall, and the tooth is much hollowed internally, fome of
 the  metals are  preferable.    Gold-leaf is then frequently
 made ufe of;  but nothing anfwers fo well as common tin-
 foil.   As much of this as  appears neceffary being cut off,
 it ffiould be pufhed in gradually (by the inftrument deline-
 ated pi. viii. fig. 1.) beginning at one end, until the cavity
 is completely filled ; any portion which may be left fhould
 then be cut off, and the furface of the whole made perfeaiy
 fmooth by a fmall burnifher.   Before the cavity is ftopped,
 the nerve fhould always  if poffible be  rendered infenfible,
 either by delaying the operation for a few weeks after the
 nerve is laid bare, or by  daily dropping into the opening a
 fmall quantity of oil of thyme, origanum, or fome  other
 effential oil.             (
   When the fize of the opening prevents  hard fubftances
 from being retained, inftead  of ufing wax and the  other
 foft  bodies above  recommended, it has  been propofed to
 fluff the tooth with tin-foil  or gold-leaf, and retain it by
 means of a fmall peg driven through a hole drilled in the
 tooth.  But this will not anfwer either when the external
 opening is very wide, or when  the fides of the tooth are
 very thin.
   Befides this means of  preventing  the  return  of tooth-
 ach, the patient ffiould as much as poffible avoid  expofure
 to cold ; his head fhould  be kept warm ; and it will  be  of
 great importance, and  fometimes indifpenfable, that he
 ffiould live in a dry fituation.
   For the removal of tooth-ach from expofure of the
 nerve, the only remedies  I have found  ufeful, are anodyne
 and corrofive applications to the part itfelf, and extraaion
 of the tooth.  Slight cafes are fometimes relieved, or even
 altogether removed, by applying opium  or laudanum to the
 nerve : camphor alone, or joined with thefe,  is alfo in fome
 cafes of benefit; and either is now and  then of ufe : but  as
thefe, and other applications of a milder nature,  are  often
                                                unfuc- 
                      [  341   3
unfuccefsful, we are then under the neceffity of employing
thofe which will deftroy the nerve entirely.  A long conti-'
nued ufe of any of the ftrong effential oils will in fome cafes
render the nerve fomewhat infenfible, but will not deftroy
it fo effeaually as to prevent a rifk of future returns of the
tooth-ach.    This may  be  accomplifhed by the ufe of any
of the  concentrated mineral acids, by lunar cauftic, or by
the ufe of the aaual cautery.  In making ufe of the cauftic
or  acids, however, we  fhould  be very careful to prevent
them from  fpreading to the contiguous  parts.    The ac-
tual cautery may be employed without a rifk of  this, but
it gives fo much pain, and is fo tedious in its operation, that
few patients will fubmit to an effeaual application of it.
A piece of pointed fmall wire may be made ufe of as a cau-
tery when the inftrument  (pi. viii. fig.  1.) cannot be had.
   When all thefe remedies fail, or are not employed to a
fufficient extent,  we are under the neceffity of deftroying
the nerve by the extraaion  of  the tooth ;  and this being
done, if the tooth is not much decayed, or is not broken,
particularly  if it be one of the incifores or canini,  after the
focket  is cleared  of blood, it may be replaced, and will in
time prove as ufeful as ever.    See feaion on tranfplanting
teeth.
   Teeth may be extraaed either in a  perpendicular or la-
teral direaion,  or by making  them turn upon their ae.es,
by depreffing the coronse or upper parts of them.
   As the  removal of teeth in  a perpendicular direaion,
would  neceffarily be attended with lefs violence to  the con-
tiguous foft parts, than by taking them out  laterally,  it
fliould  undoubtedly be preferred  wherever  it is praai-
cable.   This however can only be the cafe in the extrac-
tion of  the  incifores and canini, unlefs fome of the others
are loofe;  becaufe we have  not  fufficient room to ap-
ply, the  inftruments for  effeaing it  in  the   molares.
Thefe Jaft  muft therefore  always  be drawn laterally, not-
                                          withftanding 
                      [  342  3
withftanding that not only the foft parts muft  thus be
bruifed or lacerated, but the alveolar proceffes broken.
  The beft inftrument yet invented for drawing teeth in
a lateral direaion, is the common key inftrument.  In ope-
rating with  this, if the  tooth is in the  lower jaw,  the
patient fhould be feated in a chair,  in a  clear light, with
Ids head fupported by an affiftant  ftanding behind ;  but if
it be in the under jaw, he ffiould  be feated upon a pillow,
with his head turned back, and fupported upon the knees
of the operator ftanding behind him.  In order to prevent.
the gums from  being  torn, and to admit of a proper ap-
plication of the key, the gums ffiould be feparated from
the teeth by the fearificator or gum-lancet.   The patient
having cleared his mouth of blood, the point of the claw of
the key muft then be preffed as far down between the gum
and tooth as poffible, and retained there by  the fore-finger
of the left hand, while the fulcrum or  heel of the inftru-
ment, previoufly covered with foft  linen,  being placed a«
far down as it will go upon the gums on the oppofite fide
of the  tooth, the operator muft now with his  right hand
apply gradually fuch a force as he may find neceffary  for
moving it; and  by  turning the hand fufficiently, any tooth
may generally be drawn  at  one pull:   where one  effort
however  is not fufficient, and particularly in the molares,
it will be better, as foon as the tooth is loofened, to turn the
claw to  the  oppofite fide, and  thus render it fufficiently
loofe to be taken out by the forceps.
  With a view to prevent the loofening of teeth contigu-
ous to the one drawn, the edges of the latter may be taken
off by a thin file, fmooth on one fide.
  By this method the incifores and canini may likewife be
pulled, as well as in the manner hereafter defcribed.
  The alveoli of the teeth feem to be fo nearly of an equal
degree of ftrength on each fide, that in the extraaion this
merits  no attention.  Neither is it a matter of any confe-
                                               quence 
                      [   343  j
quence to regard the  direaion of the roots of moft of
the  molares,  for  thefe  run equally  divergent on either
fide, and except in the two laft, which  ffiould  always be
drawn to the infide, on account of the fituation of the co-
ronoid procefs of the lower jaw, it is perfeaiy indifferent
with refpea to both thefe eircumftances, whether  the ex-
traaion is made towards the infide or outfide of the jaw.
Even if the tooth is particularly decayed on one fide, if the
gums  are properly feparated,  it is of little importance to
which fide the tooth is pulled :—whatever direaion is ufed,
the focket muft neceffarily be broken on both fides.
   The heel of the inftrument ffiould always be made long,
as it will then injure any particular part of the gums by its
preffure much lefs than if it is fhort.
   Even  when  a tooth  has  been cautioufly  extraaed,
troublefome eircumftances fometimes  occur from the ope-
ration :—thefe  are, bruifing of the  gum, feparation of
fplinters  of  bone from  the  jaw, and alarming  hemor-
rhage.  In the firft cafe,  if any part of  the gum is nearly
feparated, it  fhould be cut off with a pair of fciffars;  the
mouth fhould then be fomented with  warm milk, or  any
emollient decoction ; and if there is a probability of a fup-
puration taking place, this ffiould be promoted by  the ap-
plication of roafted figs, and the abfcefs afterwards opened
if neceffary.
   When the alveolar  procefs only is broken, it will be of
little confequence ; but if the  folid  part  of  the  bone is
fplintered, as will  more particularly be  apt to  happen in
children, a tedious fore will very probably enfue if it is
not treated with great care.  All loofe pieces of bone fhould
be immediately  removed, and the reft will  either come
away  afterwards,  during  the  formation of matter or be
eafily taken out; and if the conftitution is found, the ulcer
will then heal, but not before.
                                               Hemor- 
                      [   344  ]
   Hemorrhagies of any importance feldom occur; but in
 cafes, where any of the larger  arteries of the parts con-
 tiguous  to  the tooth are divided by the force ufed in the
 operation,  very alarming  hemorrhagies  fometimes  take
 place.    Taking  a  mouthful  of cold  water,  red wine,
 brandy,  vinegar,  or alcohol will fometimes reftrain them;
 if thefe  fail, compreffion may be tried,  by putting a doffii
 of lint into the opening, and  making a conftant preffure
 on it by  keeping  the mouth ffiut.  This  will  almoft al-
 ways flop the bleeding; ffiould it, however, be unfuccefs-
 ful the aaual cautery is alone to be depended on.
   For the purpofe of extraaing teeth  in a perpendicular
 direaion, the common teeth forceps will  generally  an-
 fwer.  In applying this, it ffiould be preffed as far down
 upon the tooth as poffible, otherwife it will be apt to break
 off the upper part of it; and the tooth fhould not be  pul-
 led  direaiy  upwards,  but ffiould be twifted  alternately
 from one fide to the other until it becomes loofe.  If the
 forceps are found to  give infufficient force for the extrac-
 tion, the  key ffiould be employed.
   When the upper part of a  tooth is entirely deftroyed,
 leaving nothing but the fang or root, or what is  commonly
 termed a flump,  it way be removed  very readily by the
 ufe of a fimple or crooked lever, ufually called a  punch,
previoufly feparating  the  gums,  as  in  extraaing whole
teeth.  In ufing this, it fliould never  be pufhed lower
down than  is juft fufficient to give a firm reft upon  the
fang; for if it is  carried very low, the force employed is
in a great meafure loft againft the ftrong part of the alve-
olus on  the  oppofite  fide.  When the tooth  is  merely
loofened  by the punch, it may be  removed  with the for-
ceps.
§. 2- 
[  345  j
            §. 2. Of Tooth-ach from Inflammation.

   Tooth-ach fometimes originates entirely from an inflam*
 mation, either of the  membrane furrounding the root, or
 of the parts within the body of the tooth.  This fpecies is
 indicated by a fevere and permanent pain of a tooth which
 is to appearance found ; and efpecially when the affeaion
 has evidently been induced by expofure to cold, or when it
 is conneaed with other fymptoms of inflammation, fuch
 as an inflamed ftate of the contiguous cheek,  fwelling and
 fuppuration in the adjoining gums, &c.
   Although in moft inftances we may trace this variety of
 tooth-ach to cold, yet  it may alfo be induced by any other
 caufe of inflammation  in general.  It is alfo in fome cafes
 the confequence of a  fwelling  of the fang of the  tooth.
 But whatever  be the  caufe of the inflammation, it is al-
 ways attended by a very great  degree of pain; probably
 on account of the bone with  which the membrane is
 furrounded, preventing it from readily yielding to diften-
 tion.
   In the cure of tooth-ach  from inflammation, the gene-
 ral remedies of affeaions of this kind in other parts are
 found  the  moft  ufeful.   Local blood-letting, either  by
 fcarifying the contiguous  gums, or by the application of
 leeches, often gives relief.   I have known a blifter applied
 direaiy oppofite to the  affeaed parts  remove the pain en-
 tirely ;  and a large dofe of laudanum is often very ufeful,
 by leffening the irritation.  The head fhould be kept  warm
by covering it  with flannel; and  fomenting  it with the
fteams of a decoaion  of emollient  herbs, or even  with
warm water, will often procure relief when every  other
remedy has failed.  In  fome cafes, cold water, vinegar, or
fpirits, taken into the mouth prove ferviceable ; but  warm
applications are generally beft.
                         X x                    When 
                      C   346  3
   When this complaint cannot be  removed by the reme-
dies already recommended, we are reduced to the neceffity
of advifing  the extraaion of the tooth: but in this cafe,
we ffiould be particularly careful to avoid a hafty extrac-
tion, more efpecially if we have  reafon to believe there is
an enlargement of the fang or fangs.   After the tooth is
removed,  if it is uninjured, we are commonly advifed to
replace it: but in this variety of tooth-ach, and even when
none but the parts contiguous to the tooth are inflamed, I
have feldom or ever  feen the praaice fuccefsful.

  §. 3. Of Tooth-ach arifingfrom AffeBions of difiant Parts.

   We judge  that this variety of tooth-ach occurs  when
there are no fymptoms of either of the fpecies defcribed
in §.  1 and  2.  It  may originate from rheumatifm, from
an  arthritic diathefis,  from hyfteria,  from  pregnancy,
and from a  foul  ftate of the ftomach.
   In  this laft cafe,  which  is indicated by the ftate of the
tongue and other eircumftances, emetics often give imme-
diate relief; and then the exhibition of Peruvian bark, par-
ticularly if the fits of the difeafe have returned periodically,
will be the  beft means of preventing returns.  Opiates
never  are of fervice, but often do injury by  producing
naufea, &c.—and even increafe the pain.  But when the
complaint originates  from gout,  rheumatifm, or hyfteria,
opiates will generally remove it  entirely : and a return
may be obviated by keeping the parts warm.  In hyfleri-
cal tooth-ach, ether, combined with opium, has fucceed-
ed when every thing elfe had failed.  Opiates are never of
permanent benefit in tooth-ach from  pregnancy: general
blood-letting is  often the  only effeaual remedy—Apply-
ing leeches  to the gums  will fometimes  anfwer the pur-
pofe.
                                               SECT. 
[  347   ]
                    S E C T.   IX.

                 Of Tranfplanting Teeth.

  T3y this operation we underftand the removal of teeth
from one living body to another.
  In  the tranfplantation of teeth, we  are to be direaed
1»y the following confiderations :
   1. As the  operation is in general employed more with
a view to obviate deformity than  to be produaive  of any
real advantage, it is feldom praaifed  with the molares:
but it might be done with the two firft  of thefe as well  as
with the incifores and canini;  the others could hardly  in
any cafe be tranfplanted,  on account of the number and
divergence of their roots.
  2. In order to enfure fuccefs, the alveoli and gums muft
be  perfeaiy found.  They muft be  entirely  free from
fcurvy and lues venerea ;  and the patient muft not have
undergone a  falivation for fome confiderable time before ;
nor muft he ufe mercury for fome time afterwards.  His
being fubjea to gum-boils need  not  prevent  the  opera-
tion.
  3. It is alfo neceffary that the fockets be full  and com-
plete ; and hence it will feldom be admiffible where teeth
have remained  long in the ftate  of ftumps; becaufe the
wafte of the fang is  generally accompanied by a corre-
fponding diminution of the focket; whence there would
not probably be room enough left for the roots of a found
tooth.
  4. It is only in youth and middle-age that the operation
is admiffible, in childhood it can never be neceffary; and
in old age, the fockets of the teeth  are commonly much lef-
fened ; and it is not probable, that a firm  union can then
                                                  take 
                       [  348   ]
 take  place by an  inter-communication of blood-vefiels as
 in other cafes.
    5. The tranfplanted tooth ffiould fit the focket as exaa-
 ly as poffible ;  if  it be too large,  a fmall part of  the fang
 may  be filed off, but the corona ffiould never be touched,
 for fear of producing a fubfequent caries.  The furface of
 the tooth ffiould be alfo  fomewhat lower than that of the
 reft,  to prevent preffure  on it.
   6.  In order to preferve the focket and gums into which
 the tooth  is to be placed in as found a condition as pof-
 fible, the  difplaced tooth ffiould be removed with the for-
 ceps  in preference to the key.
   7.  When the focket is cleaned, and the new tooth in-
 ferted, it muft be tied to the two  contiguous,  in order to
 keep it in its place until  it becomes firmly fixed.   If it is
 one of the canini, the ligatures, which fhould be made of
 feveral threads of fine filk waxed, ffiould be firft tied round
 the upper part of the new tooth,  and after it is inferted,
 connected  to  thofe  adjoining as clofe  as poffible to  the
 gums.  But  when an incifor,  or  fmall molaris,  is tranf-
 planted, it anfwers beft to fix the ligature firft to one of
 the fattened teeth,  and afterwards to connea it to  the
 others.  If the ligatures become loofe they ffiould be im-
 mediately renewed ;  and the patient  ffiould  avoid every
 thing which has any  tendency to loofen the tooth.   He
 fhould live upon fpoon-meat during  the  cure, and guard
 very carefully againft cold and moifture.
   In  favourable  eircumftances,  the tooth will become faft
 in the courfe of eight or ten days; but it will fometimes
remain loofe for two or three months.
   Although difeafes  are  very  feldom  communicated  by
this operation, yet  as  there can  be  no doubt that  this has
fometimes been the cafe,  we fhould always guard as much
as may be againft  the poffibility  of it.  For this purpofe,
teeth ffiould never be tranfplanted from people who are  not
                                              perfeaiy 
                         [  349  3
   perfeaiy healthy; and they  ffiould  always be  immerfed
   for a few feconds in hike-warm water, and afterwards well
   wiped.

                       SECT.  X.

                       Of the Ranula.

      Tumors are frequently met with beneath the tongue, on
   one or both fides of the frenum;  thefe are all known by
   the term ranula.  They are feldom  attended with much
   pain; but they  become in fome inftances fo large  as very
   much to impede the  fucking of infants, and the maftica-
-  tion, and even the  fpeech of adults.  In fome cafes they
   contain  a fatty  matter; but in nineteen cafes of  twenty,
   they arc filled  almoft  entirely with  a thin limpid liquor,
   refembling the faliva; and we find, on cutting into them,
   that they are often produced by a  floppage of the falivary
   duas, from calculous concretions  forming  in them.  The
   tumor generally burfts when it arrives at the fize  of a large
   nut,  leaving an  ulcer which is difficult to heal,  unlefs the
   caufe be difcovered.   The concretions are of various fizes;
   I have in feveral inftances found them as large as a kidney-
   bean.
     Whenever thefe fwellings are not of a firm confiftence,
   the moft effeaual mode of treatment is to  lay them open
   with a fcalpel from one end to the other;  the calcareous
   particles will then  eafily be difcovered; and thefe being
   removed, and the fore waffied with warm water, or fome
   other emollient,  it generally foon heals.  But if there is af-
   rerwards any difficulty  in curing  the  ulcer, it may  be
   bathed with tinaure of bark, or fome  other aftringent.
   Old fiftulous fores of thefe parts will be commonly found
   to depend on a calcareous matter;  and by making an inci-
                                                    fion 
[  350  3
fion down to this,  and removing it by a fcoop or forceps,
they will foon be cured.
  When tumors in this fituation are of a fatty  or firmer
confiftence,  they ffiould be  totally  extirpated ; and this
may be eafily done unlefs they lie deep, and are very large.
They may ufually be removed without any danger of divid-
ing the larger arteries :  and the hemorrhagy may  then be
eafily reftrained by fpirit of wine, or tinaure of myrrh. But
if any large veffels ffiould be cut, as ligatures cannot poflibly
be applied to them, it will be neceffary to have recourfe to
the potential or even  the  aaual cautery.  If the tumor
cannot be held by the fingers during  the operation, a fmall
hook  will anfwer  this  purpofe  better than the  forceps
which are ufually employed.

                    SECT.   XI.

Of Ulcers of the Mouth and Tongue,  and Extirpation of the
                        Tongue.

  The tongue,  and other parts within the mouth, are li-
able to all the variety  of ulcers incident to other parts of
the body, and the treatment they require is nearly  fimilar.
When they  originate from the lues venerea, fcrophula, or
fcurvy, the general remedies of thefe difeafes become necef-
fary ; but when the affeaion is local, topical remedies are
alone to be employed.
  Local  ulcers  of the mouth  appear  to be  moft  fre-
quently occafioned by the fharp points of broken or ca-
rious  teeth,  which irritate or deftroy part of  the infide of
the cheeks,  or of the fide of the tongue;  when  this is the
cafe,  the teeth fhould be fmoothed  with a fmall file.  If
fores  appear to be induced  by the formation  of  tartar up-
on  the teeth, this muft be removed as formerly direaed.
                                                   The 
                      [   351  3
  The removal of the original caufe is ufually foon followed
by the cure of the fore ; but when this is not the cafe, we
may frequently derive advantage from wafhing the mouth
with decoaion  of bark, a  folution  of alum, and other
aftringents.   Notwithftanding the ufe of thefe, mercury,
and of every other remedy, the fores, in fome cafes, con-
ftantly become worfe :  They grow  ragged and unequal
about the edges;  difcharge a thin foetid fanies ; and then
become very painful.
   As long as a fore of this kind continues fmall, and fhews
no tendency to fpread, there will be a chance  of its heal-
ing.  But whenever it conftantly grows larger, and more
painful,  notwithftanding the employment of the remedies
above recommended, we will have reafon to fuppofe it of
a cancerous nature, and fhould certainly advife its removal
by immediate extirpation.
   When the ulcer is fmall and fuperficial, it may be remo-
 ved with eafe and fafety; but when it is large,  this is attend-
 ed with difficulty and danger.   However, whenever the
 whole of the parts affeaed can be taken away,  as the ope-
 ration affords  the  only remedy,  it  fhould  certainly  be
 rifked.
   The eafieft  and moft effeaual method of removing a
 deep-feated cancer in the  cheek, is to make  an  incifion
 through  the whole  fubftance of the cheek,  beginning  at
 the contiguous angle of the  mouth, and ending at the fame
 part, after carrying it round the fore.   The  difeafed parts
 being thus entirely removed, the  fides of  the cut muft
 be  brought into contaa, and fecured  by the twifted fu-
  ture.
    In removing any  confiderable  portion of the tongue  by
  the  knife, the hemorrhagy is the  only  occurrence  pro-
  duaive of danger.   To remove this the furgeon fhould
  provide himfelf with all the  ordinary remedies.  When
  ligatures can be paffed round the  veffels, which may be
                                                   done 
                       [  352  ]
 done farther back in the  mouth than is  commonly fup-
 pofed,  they  fhould  undoubtedly be employed.  If  the
 tenaculum or crooked needle cannot be ufed for this pur-
 pofe, the apparatus defcribed for tying fchirrous  tonfils,
 muft be had recourfe to.   But  when the veffels  cannot
 be fecured by either of thefe methods, keeping the mouth
 filled with aftringent infufions  or  folutions, and particu-
 larly a folution of alum or  diluted vitriolic  acid, will fome-
 times be  effeaual in reftraining the difcharge ; if thefe
 do not  fucceed,  the  potential or even the aaual cautery
 muft be employed as the lafl refource.
  As this is a formidable operation, it has feldom been
performed ; and indeed it ffiould not be attempted but by a
 furgeon of great firmnefs and experience.

                   SECT.   XII.

           Of the Divifion of the Frenum Lingua.

  This operation becomes neceffary when the frenum of
the tongue is either fo fhort, or continued fo near to the
point of it that it impedes the fucking of children.   It is
ufually  performed  by a fcalpel  or  p3ir of fciffars; the
child being laid acrofs the nurfe's knees, and the furgeon
elevating  the tongue with the middle finger of the left
hand, while he makes the  incifion with the right,  taking
care  to avoid the larger blood-veffels  of the  tongue.
SECT. 
t   353  ]
                   SECT.   XIII.

           Of the Divifion of the Parotid DuB.

   The dua of the parotid  gland is fometimes divided
in extirpating cancerous fores from the cheek ; fometimes
by accident;  and if the divided parts are not retained in
contaa until they heal, it often happens that the internal
part of the  wound  clofes, and a conftant difcharge of fa-
liva takes place over the cheek, which at length produces a
tedious fiftulous fore.
   In cafe of a recent divifion  of this dua, the ends ffiould
be  brought together,  and retained by adhefive plafter,
or the twifted future, as may feem  moft proper; but when
this has been negfeaed, or fails of fuccefs, as the inner part
of the dua becomes clofed, it will  be neceffary, for a cure,
to make an artificial opening into the mouth, and endeavour
to form  a union between this part and the  upper portion
of the dua which leads from  the parotid gland.   For this
purpofe, a fharp-pointed perforator, fomewhat larger than
the dua, ffiould be  entered on the fide  of the  fore op-
pofite  and contiguous to the under extremity of the fu-
perior  part of the dua, and carried obliquely, in the na-
tural direaion of the canal, into  the mouth.   A leaden
probe  exaaiy the  fize of  the perforator, ffiould  then
be introduced along the courfe of the opening,  and re-
tained there  until the fides of it become callous ; the probe
ffiould afterwards be  withdrawn,  and  the extremity  of
the dua drawn into contaa with the fuperior part  of
the artificial opening by means of adhefive plafter, and
retained  until a firm  union has  taken place.   It will
facilitate the  union between the  parts, if  the edges  of
each.are made  raw with  a lancet  or  fcalpel, before
they are brought together.    The patient ffiould live upon
                        Y y                    fpoon- 
                     [  354   ]
fpoon-meat till a cure is effeaed; ffiould  fpeak little  or
none;  and make  as little exertion  with his jaws  as
poffible.
         CHAP.   XXXIV.

Of Diseases of the Ears and Operations
            practised upon them.
                   SECT.    L

                    Of Deafnefs.

       WHATEVER tends  to obftrua either the meatus
        auditorius or euftachian tube, or to induce difeaf-
es of the tympanum, or parts conneaed with it, will be
produaive of deafnefs to a greater or lefs degree.
  Obftruaions in the euftachian tube may be occafioned
by  enlargement of  the amygdala from any  caufe;  by
venereal ulcers in the throat; and by polypous excrefcen-
ces.   A removal of the  firft and  laft of thefe caufes, will,
in many inftances, effea  a  cure  of this variety of deaf,
nefs; but when it is a confequence of ulceration or of in-
flammation, as the extremity  of  the dua will probably be
obliterated, it will be  irremediable.  It has been propofed
to open the dua by inferting  a curved blunt probe into it;
or even  to injea  fome  mild  liquid into it with a curved
fyringe: there  will probably, however, be  no advantage
                                              derived 
                      I  355   3
derived from fuch attempts,  from the  difficulty  attending
them.
  The meatus auditorius may be  obftruaed in  various
ways.  It may be imperforated at birth—it may have ex-
traneous bodies forced into it—tumors  or excrefcences may
form in it—and there may be fo copious a fecretion of wax
into it, as to give more or lefs obftruaion.  We fhall con-
fider each of thefe cafes feparately.

       §.  1. Of an Imperforated Meatus Auditorius*

  This difeafe feldom  occurs.  It may be formed either
by a thin membrane  fpread over the mouth of the  paffage,
or by a fleffiy kind of fubftance  occupying more or lefs of
the cavity.  In both thefe cafes, the only remedy is afford-
ed by an operation.
   The patient's head being fecured in a proper light, the
operator  with  a fmall fharp-pointed biftoury fliould make
an incifion of  a proper length, exaaiy on the fpot where
the external paffage fhould terminate, and carry it gradu-
ally through the obftruaing fubftances, either till the re-
fiftance is entirely removed,  or till there is reafon to fear
that the tympanum would be hurt if it were carried deep-
er : the  inftrument  fhould  then  be withdrawn ;  and in
order to prevent the parts from adhering together, a bit of
oiled bougie ffiould be  introduced and retained until  the
cure is completed, removing it daily to wipe off any mat-
ter produced.
   In this  manner deafnefs may often  be removed, when
the obftruaion does not extend  quite to the tympanum;
and it ffiould always for obvious reafons be attempted about
the time when the child begins to fpeak.  At a more early
period the child could not bear it; and if longer delayed
it might produce dunibnefs.
f ?• 
L  356   ]
       §. 2.  Of Extraneous Bodies lodged in the Ear.

   A great deal of pain and uneafinefs is often produced
 from this caufe.  Children frequently pufh fmall peas, cher-
 ry ftones, lead drops, and other fubftances into their ears ;
 and flies and other infects frequently creep into them.
  When thefe lie  near  the extremity of the paffage, fuch
 as can readily be  taken hold of fhould  be extraaed with
 fmall forceps; but peas and other round bodies are more
 eafily  removed by a curved probe, or by means  of the in-
 ftrument  (pi. viii.  fig. 4.) and their extraaion will be much
 facilitated  by previoufly dropping a little oil into the paf-
 fage.
   When infeas have got fo far into  the ear that they can- ,
 not be taken out with forceps ; the beft method of removing
 them, is  by throwing  in warm  water,  or any other mild
 fluid, with a fyringe;  and  this will be much facilitated by
 previoufly killing them with tepid oil held for  fome time
 in the paffage by reclining the head on the oppofite fide.
 I prefer oil, becaufe it is lefs liable to do  injury than almoft
 any thing elfe.
   If the fubftances infinuated have become much fwelled
 by the abforption of moifture, it will be beft to break them,
 either with the forceps,  or with a fmall  fharp hook, before
 attempting their removal.

      §. 3.  Of Excrefcences in the Meatus Auditorius.

   The auditory paffage is as liable to polypous excrefcen-
ees as the nofe and throat; but they feldom arrive to a large
fize, and are generally  of a tirm confiftence.    They are
fometimes  pendulous by one pedicle;  but in other cafes
they feem to confift merely in a general  thickening of the
membrane of the conduit.
                                                 Thefe 
                      C   357  ]
   Thefe fubftances may be removed either by the knife or
 ligature.  When they lie near the external orifice, and caw
 be laid hold of by forceps, or a diffeaing hook, they may
 be eafily cut out with a probe-pointed  biftouri;  and with-
 out any danger from hemorrhagy;  but when they lie deep,
 it will be moft  convenient to remove them by ligatures.
 This may be done by means of a fplit probe and a  double
 canula, as advifed in polypi of the nofe.                 ••
   But in cafes where the excrefcence extends a  confi-
 derable way along the membrane, inftead of being pendu-
 lous by a fmall neck, neither  of thefe methods is  appli-
 cable.   Bougies will here  generally fucceed  as well as  in
 obftruaions in the urethra.    In the introduaion of them
 however, we muft be  careful not to pafs them  to the
 depth of the tympanum, or they may do more harm than
 good.  Efcharotics have been recommended  in thefe  cafes ;
 but they muft always give fome rifk of injuring the tym-
 panum.


     §. 4. Of Deafnefs from Wax colleBed in the Ears.

   The wax is fometimes colfeaed in the ear in fuch large
 quantities as to induce a confiderable degree of  deafnefs;
 and in fome  inftances it has become almoft as hard as wood.
   This variety of deafnefs may readily be afcertained ; for
 in a proper pofition and good light, we may  fee along the
 meatus quite to the tympanum.   The fafeft and  eafieft
 method of removing the wax is by throwing in warm milk
 and water, or foap fuds, or fome fuch article; previoufly
 dropping in a little oil to  lubricate the paffage.
   Although  obftruaion  of the external paffage of the
ear is the moft frequent caufe of deafnefs ; yet it fometimes
originates from difeafes of the tympanum and parts within
it; and it will take place to a certain degree, if the  exter-
                                                  nal 
                      [  358   3
nal parts of the ear be deftroyed ;  or if there be a deficien-
cy of wax in the auditory conduit.
  The bones  of  the  ears are fometimes difeafed in fcro-
phula ; all that then can be done is to keep the parts clean,
and free from  the difagreeable fmell induced by the dif-
charge from the carious bones, by injeaing  warm milk
and  water morning  and evening.   We  ffiould however
carefully diftinguiffi  this from a  difcharge confequent to
abfceffes in the meatus,  and  to  inflammation of its mem-
brane, or perhaps of  the tympanum, which very frequent-
ly occurs, and which is, in my  opinion, generally impro-
perly treated.   Contrary to common praaice, I always
endeavour to check the difcharge  when recent,  as foon as
poffible, by the  ufe  of moderately aftringent injeaions,
fuch as  brandy  diluted, folution of alum, and  others;
and in long continued cafes, after the  introduction of an
iffue, near the part,  I do not hefitate to follow the fame
plan.  I have never feen any bad  confequences from this
mode of cure ; and if the difcharge is fuffered to remain
any length of time, it not only relaxes the  tympanum, but
may even deftroy it.
   When deafnefs arifes from  a  relaxation of the tympa-
num, or from any deficiency in the  external parts of the
ear,  fome  affiftance  may be derived from concentrating
found, fo as to make a ftronger impreffion on the organ of
hearing, by means of the inftrument delineated in pi. ix.
fig. 2. or others of a fomewhat  fimilar conftruaion.
   If a deficiency  of wax appears,  dropping  a little oil of
almonds,  or any other mild oil into the ear once or twice
daily is fometimes ufeful.  In fome cafes, I have found be-
nefit from the ufe of foft foap,  and from ftrained galba-
num mixed with  oil and onion  juice;  thefe befides keep-
ing the paffage moift, may, by aaing as gentle flimuli, in-
duce a return  of the  fegretion.
              4                              SECT. 
[  359  ]
                    SECT.  II.

           Of Perforating the Lobes of the Ears.

  This operation is feldom performed at prefent but for
the purpofe  of ornament.  The  perforation ffiould be
made as high on the lobe as with propriety it can be done;
the part fhould be previoufly marked with ink; and a piece
of cork ffiould be placed beneath the lobe.   The perfora-
tor ufually employed, is about the fize of the hare-lip pin,
has a handle  at  right  angles with it,  and is enclofed in
a canula.   After pufhing  the inftrument through the ear
until  the canula comes out  at the lower fide, the cork is to
be withdrawn with the perforator fixed into it.   A fmall
piece of lead is then to be inferted into the tube remaining
in the ear ; and this muft  be left until the paffage becomes
callous, moving it a little every day.
CHAP. 
C  360   3
CHAP.     XXXV.
                Of the Wry Neck.


     THE neck may be fo  much  bent to one fide, as to
      produce deformity either by an original mal-confor-
mation of the bones ; by a preternatural degree of contrac-
tion in the mufcles of one fide of the neck, particularly of
the fterno-maftoideus; or by a contraaion  of the  flcin in
confequence of extenfive fores and burns.
   In the firft cafe we can afford no  relief;  but in the  two
laft we can with certainty remove the complaint.
   The wry neck has almoft univerfally been attributed to
a contraaion of the fterno-maftoideus mufcle ; but in every
inllance  of this kind that has fallen under my  notice, it
has been induced by a contraaed  ftate of the fkin  alone.*
Which ever be the caufe, however, the difeafe will be mofl
effeaually and fafely removed by  a  gradual incifion with
a  fcalpel  through  all the contraaed  parts, from above
downwards.     The divided parts can only be effeaually
preferved apart afterwards,  by fupporting the head until
the wound heals.
   A contraaion of the fkin beneath  the chin, drawing the
head down upon the breaft, is to be removed in  the fame
manner.
                                            CHAP.

  * In the I ondo^  Medical Journal for 1790, there are related two cafc>
of wry neck, from an affection  of the mufcles, which were cured by elec-
tricity applied to the antagonifts of the mufcles contracted. 
[  361   3
      CHAP.   XXXVI.

Of the Diseases of the Nipples.
       HEN the nipple is fo far funk into the breaft that the
        child cannot take hold of it,  it becomes neceffary
to draw it out by means of nipple glaffes.   Thefe may be
ufed either by the patient herfelf, or by an affiftant.  They
are made of glafs alone, or of a glafs cup  conneaed  to a
bag of gum elaftic.
   The beft remedies for cracks  or  ulcerations of the  nip-
ples,  are mild, aftringent, and drying applications.   The
parts may be bathed with lime-water, port wine, or bran-
dy  and water,  and afterwards covered with  unguentum
nutritum, or Goulard's cerate.  The  firft is the  beft ;  but
whichever of thefe ointments is ufed, they ffiould be en-
tirely waffied off before the child is allowed to fuck, on ac-
count of the lead contained in them.  The child ffiould
not be permitted  to fuck oftener  than is abfolutely necef-
fary ;  and when one nipple only is fore, he ffiould if poffi-
ble be confined to the well breaft,  and the other  ffiould be
drawn occafionally.  The nipples ffiould be covered with
fmall  wooden  cups, perforated to let the milk  through;
in order to prevent the clothes from retarding the cure.
w
Zz      *   .    t  H  A  P. 
[  S62   3
CHAP.    XXXVIL

           Of Issues-
   ISSUES are fmall artificial ulcers formed in different
    parts of the body for procuring a difcharge of pus.
It is now very well eftabliffied, that thefe are only ufeful in
proportion to the quantity of the matter they afford :  (See
Chapter on ulcers.)  And as this is the cafe, they maybe
placed in any fituation, moft convenient to the patient.
  In the formation of iffues however, it is to be obferved,
that they ffiould never be placed immediately above a bone
thinly covered, direaiy above a tendon, very contiguous to
a large blood-veffel or nerve, or upon the belly of a mufcle..
The beft fituations for iffues are,  the fpace between the
tendons on the back of the  neck, the middle of the upper
fide of the humerus, and the hollow on the infide of the
knee  above the flexor tendons.  They may likewife be
inferted between two of the ribs, and on each fide of the
vertebrae of the back;  or wherever there  is a fufficient
quantity of cellular fubftance for the proteaion of the parts
beneath.
  Iffues are formed,  by removing the fkin by epifpaftics;
by making an incifion with a fcalpel or lancet; by the ap-
plication of cauftic ;  and by  the  introduaion of a cord.
  If a  blifler is ufed, it muft be  exaaiy of the fize of the
intended fore ;  and after its operation, a difcharge of mat-
ter may be kept  up by dreffing daily with cerate mixed
                                                 with 
                      £   363  3
with cantharides.   If incifion or cauftic is to be employed,
an opening muft be made of a fufficient fize, and preferved
by inferting daily fome extraneous body covered with oint-
ment, and fecured  by a comprefs and bandage.—Peas are
commonly employed: but kidney beans, gentian root, or
aurantia curaflavantia cut into a proper form, will alfo an-
fwer very well.
  When the opening is to be made by incifion, the fkin
fhould be fupported on one fide by an affiftant, and on the
other by the furgeon, who ffiould then make a -cut of a fuf-
ficient length and depth for receiving the number of peas
intended to be put into it.  The common lapis infernalis
anfwers beft for making an iffue by cauftic.  It  ffiould be
firft reduced  to  powder,  and made into  a pafte with
water or  foft foap;  a  piece of leather fpread with Bur-
gundy pitch, or any adhefive plafter, with a fmall hole cut
in the centre of it, ffiould then be  placed upon the part.
The cauftic being put into this opening, the whole ffiould
be covered with another adhefive  plafter.   Thefe precau-
tions are neceffary to prevent the  cauftic from fpreading
farther than the part upon which  it is wifhed  to operate.
In the courfe of ten or twelve hours  the cauftic may  be re-
moved, as by this time it will have produced an efchar of a
fufficient  depth.   In three or  four  days the efchar will
feparate, and the opening muft then be filled with peas as
above direaed.
   When we wiffi to  difcharge a very large quantity of
matter by iffue, and particularly from deep-feated parts,
 we effea it by the introduaion of a cord of cotton or filk,
 forming  what is termed a feton.   The parts  at which the
cord is to enter fhould always be marked with ink ; and this
being put into the flat needle (pi. ix. fig. 3.) and the parts
fupported by an affiftant, the needle ffiould be pufhed in at
 one of the fpots  marked, and carried out at  the  other,
 leaving two or three inches of the cord  hanging  out at
                                                  each 
                     [  364   3
each orifice.  The irritation which the feton gives foon
produces a plentiful difcharge of matter; which  may be
increafed or diminifhed, by  covering the cord daily before
it is drawn, with a mild or irritating ointment.
       CHAP.     XXXVIII.

Of the  Inoculation of the  Small-Pox.
 rT1 HERE  is reafon  to  fuppofe that almoft all  eruptive
  -"-   difeafes, as well as fome others, may be communi-
 cated by inoculation ; but the operation is feldom praaifed
 but for the communication of the fmall-pox.  The plague
 and meafles  have been given in this way.   The latter has
 been tried in Scotland, but without advantage.
  The fmall-pox can only be communicated with certainty,
 in inoculation, by means of the matter taken from fome of
 the puftules,  and applied to a wound made in fome part of
 the body.  This is now commonly done in a very fim-
 ple manner: The point of a lancet, previoufly moiftened in
 the matter, is infinuated through the cuticle, fo  as flightly
 to injure the cutis vera.   If the matter has become hard it
 ffio:>ld be foftened by warm water or fleam.
  The operation may be done in any part of the body;
but the arm  is generally preferred.  In order the more
certainly to enfure fuccefs, it may be performed in two or
more places ;  but  always at fuch a  diftance apart  that the
inflammation  produced may  not  extend from one to the
                                                other 
                     [   365  3
other—on each leg or thigh for inftance.   No  dreffing is
employed ; and about the end of the fecond or third day,
if the operation has fucceeded, the wounds will have be-
come red, fwelled, and painful.
CHAP.   XXXIX.

    Of Wounds.
                    SECT.  I.

                Of Wounds in General.


 A  WOUND  may  be defined, a recent folution of
       continuity in  any of the fofter parts of the body,
 attended by a correfponding divifion of the integuments.
   Wounds muft neceffarily exhibit great varietv in  their
 nature  and appearances, according to the parts  injured,
 the manner in which they are produced, and their extent.
 Thus wounds  in the mufcular parts  are very different in
 their appearances and nature, from thofe which affea ten-
 dinous  parts ; thofe  made  with a cutting inftrument are
 materially different from contufed or lacerated wounds;
and punaured wounds are generally  produaive of very
different effeas from thofe which are more extenfive.
  We  fhall at prefent confine ourfelves to the defcription
of the  phenomena which ufually take place in the  moft
                                             frequent 
                      [  366   ]
frequent form  of this affeaion,  what we  term a fimple
incifed wound.
   The  firft appearance we  obferve  in a wound of this
kind, is a feparation of the  divided  parts; the degree of
this depends on the depth and length of the wound, and
on the direaion of it with regard to the fibres of the part.
This laft circumftance  has a very confiderable influence in
this refpea, for when the fibres of a mufcle have been
cut tranfverfely, they will feparate fometimes to fuch a de-
gree,  as to give reafon for fuppofing that a part of them
has been removed ; and it often happens that a wound of
fome depth  in the direaion of the fibres, will  produce fo
little retraaion of the fkin that it appears almoft as a line.
   The next appearance is the  hemorrhagy, which takes
place to a greater or lefs extent, according to the fize of the
cut, and the fize and number of the blood-veffels divided.
If this is negfeaed, or is not worth attention, the irritation
produced by the injury, as well as by the external  air,
excites  the  veffels to contraaion, and thus flops the dif-
charge.  The  difcharge of red  blood gradually  ceafing,
a ferous fluid oozes out for  a few hours, and the whole
furface of the  fore then foon becomes more or lefs dried,
or covered over with coagulated blood.
   The pain in thefe wounds is at firft commonly inconfi-
derable, unlefs a nerve or tendon has been  partially divid-
ed, in which cafes it is  ufually fevere.  But  in a few hours
it becomes more confiderable and more  or  lefs of inflam-
mation  fucceeds;  and if the wound is  large,  a  propor-
tionate degree of fever.  Thefe fymptoms increafing, mor-
tification is at length produced in fome inftances; but for
the moft part,  the furface of the  wound, which for fome
time remained perfeaiy dry,  is  gradually  rendered moift
and foft, by a thin ferum oozing into it, which being al-
lowed to colfea,  is at  length changed into  purulent mat-
ter ; and in  general,  the general and topical fymptoms of
                                         inflammation 
                      [  367  ]
inflammation abate  more or lefs quickly according as this
formation of matter is more or lefs plentiful; and go off
entirely when a free fuppuration takes place.
  From  this view of  the progrefs of the fymptoms  of a
wound,  it is evident, that  in its treatment, it ffiould be
chiefly attended to as  an exciting caufe of inflammation.
  When no organ of importance to life is wounded, and
when the cut is feated in a fleffiy part, if nature be not im-
peded in her operation, the  whole furface of the  fore be-
comes covered with granulations,  when a proper fuppura-
tion has  taken place ;  and a cure is gradually accomplifhed
in the manner defcribed in the chapter on ulcers.
  This favourable termination may be prevented by a va-
riety of caufes ;  but thofe which arife folely from the na-
ture of the v/ound are, too  great or too fmall a degree of
inflammation, and a want of a free difcharge of the matter
that is produced :*  Thus punaured wounds are very apt
to be accompanied by too much inflammation;  and lodg-
ments of matter frequently  occur in  them.  In contufed
wounds the texture of the parts is fometimes fo much in-
jured,  that the circulation is ftopped,  and a mortification
is occafioned.  And wounds attended  with much lacera-
tion are particularly liable to produce gangrene, ultimately
from exciting too much inflammation.
  In forming a prognofis in  wounds,  befides the eircum-
ftances juft defcribed,  it will be neceffary to pay attention
to the age  and habit  of body of the  patient; the texture
of the wounded part;  the part of the  body injured; and
the rifk of a communication of the effeas of  the wound
to the adjacent parts.
  Thus it is well eftabliffied  by experience, that wound*
are  much lefs hazardous, and heal more readily in youth
and middle-age than in very advanced  periods of life ; but
it does not appear  that healthy old age is any obftruaion
                                                    in
    » Thefe are eircumftances that require particular attention.  B. 
                       [  368   3
 in a great many cafes, particularly in the operations of li-
 thotomy and  amputation,  to  the healing of wounds ;  on
 the  contrary it is often  advantageous, by  giving lefs ten-
 dency to inflammation.
   It is well known alfo, that wounds are much lefs painful,
 and heal more eafily in fome parts than in  others, in muf-
 cles,  e. g.  than in tendons, or glands.
   With refpea to the fituation of a wound, it is obvious
 that wounds in the extremities,  when confined  to  parts,
 lying above any of the hard bones, are not fo hazardous as
 thofe which pafs into any of the joints ; and in other parts,
 wounds which penetrate any of the larger cavities muft  be
 more dangerous than thofe which do not run  fo deep.  This
 may be occafioned by the chance of fome organ being di-
 reaiy injured, either by air  or  other extraneous bodies
 finding accefs to the  expofed  cavities, or by the lodgment
 of matter.
  It is alfo to be confidered  that wounds,  which at firft did
 not appear to be attended  with any  rifk, may eventually
 prove mortal; thus the lungs, ftomach,  aorta, or recep-
 taculum  chyli may be wounded  flightly,  and at length
prove a very unexpeaed caufe  of the  patient's death.
  Wounds alfo prove fatal  in fome inftances, from a com-
 munication of inflammation to parts which  were not pri-
 marily injured in any degree; and they may likewife ter-
 minate in death from  mifmanagement in diet, dreffings,
 and other eircumftances.
SECT. 
£  869   3
                   SECT.  II.

         Of the Cure of Simple Incifed Wounds.

  Our firft attention, in wounds, is to  be  direaed to the
hemorrhagy ; both on account of the fafety of the patient,
and of afcertaining the extent and nature of the injury.
  Hemorrhagies are to be reftrained by the tourniquet, or
by preffure  with the hand, according as the wound is feat-
ed on the extremities, or on the trunk, or head,  until the
veflels can  be  tied, either by means of the tenaculum or
needle.   If neceffary, the wound fliould be  enlarged in or-
der to admit of the application of the  ligature;  and  this
praaice  if properly attended to, would we  believe have
faved many limhs which  have been amputated, from the
fuppofed impoffibility of otherwife reftraining the bleeding.
  When the injured arteries run in the fubftance of a bone,
as they cannot then be tied, they ffiould be cut entirely
acrofs, and their confequent contraaion will, perhaps al-
ways, remove the hemorrhagy.
  If the difcharge proceeds  from the very fmall veffels on
the furface  of the fore, remedies of a different kind from
thofe juft mentioned muft be employed.  See chap, on the
means of removing hemorrhagies.
  The bleeding being ftopped, we are then  to examine the
wound carefully, and remove all extraneous fubftances  that
can be taken away without giving much pain, or danger of
injuring parts of importance ;  any others that may be  pre-
fent muft be left to be thrown off by the confequent  fup-
puration.   This praaice will  often prevent very trouble-
fome inflammation.   But it is to be obferved, that we are
to be in fome meafure guided in our condua here, by the
nature of the fubftance lodged in the wound ; for inftance,
                        3 A                      fead 
                      [  370   3
lead has often lain a confiderable time in the body without
being produaive of injury;  but almoft every other fub-
ftance  feems to produce  bad effects  to a greater or lefs
degree.
  Where the fingers will effea the purpofe, they ffiould
be preferred to forceps,  or any  other inftrument, for  the
removal of fubftances from wounds.   Sand, duft, or fmall
pieces of glafs, &c.  are  beft removed by bathing the parts
in warm water, either by means  of a fponge, or of a fyringe,
or by pouring it  upon them :  and in doing this, as well as
in ufing the  fingers or forceps, much of our fuccefs will de-
pend on  putting  the patient in fuch  a pofition as  will moft
effeaually relax the injured  parts,  and  produce  as wide a
feparation of the lips of the wound as poffible.
   We are in the  third place, to proceed to the employment
of thofe means which will probably heal the wound in the
mofl eafy and expeditious manner.   Wherever the nature
of  the injury will admit of it, the divided parts  ffiould be
brought  into contaa : the irritation excited by the wound
itfelf will then  generally be  productive of a  certain de-
gree of inflammation, which will accompliffi a union in the
courfe of a  few days,  by the  intervention of a glutinous
fluid exhaled from the veffels.  This conneaion is, in many
inftances, foon confiderably ftrengthened by the formation
of blood veflels.   The wound is then faid to be healed by
the firft  intention ;  and this mode  of cure fliould always,
when it  appears praaicable,  be attempted.  If the parts
cannot be brought  into contaa, they ffiould be made to
approximate as much as poffible, as this will, in every in-
ftance, expedite  the cure.
   The  advantages  of this method of treatment are,  that
very extenfive wounds are very  quickly cured,  the  parts
being  ufually united in the  courfe of five days; a  large
and often  materially  injurious  difcharge is prevented;
the free  motion  of parts  that  would otherwife be loft is
                                                  often 
                      [   371  ]
often preferved ; the fear produced is very fmall;  and the
wounded parts are well covered by found fkin.
  The means  of drawing  and preferving divided parts in
contaa, are, bandages, adhefive plafters, and futures.  With
refpea to the firft, although the uniting bandage may be   •
ufed in longitudinal wounds in the  extremities and head,
yet it feldom keeps the parts fmooth  and even, when ufed
alone, and  in tranfverfe wounds it  can be of no benefit at
all.   It may,  however,  be often ferviceable in aiding the
effeas of  adhefive plafters :  thefe fliould  always be pre-
ferred  to  any other remedies in wounds that do not pene-
trate much deeper than the cellular membrane ; and where
the  lofs of fubftance prevents the edges from coming to-
gether,  the plafters  are to be applied in fuch  a  man-
ner  as to  bring them as clofe as poffible.*   But in all
wounds that penetrate to  any confiderable depth, when
their lips can be brought into contaa, the twifted future is
the beft means of retaining them—(See chapter on Sutures.)
The interrupted future which is moft frequently employed,
does not fupport the parts  fo well; the  ligatures are apt to
tear or cut the parts; and they frequently leave  difagree-
able marks.
   It is of confequence to obferve, that where the ufe of fu-
 tures or adhefive plafters  has been  negfeaed at the firft,
 they may be employed with advantage during any ftage of
 the fore, as the parts will  unite at  any time very readily;
and it will expedite the cure very much to bring the edges
of the ulcer into contaa whenever it can be done.
   The good effeas of futures and plafters will  be much
aided by a proper pofture of the patient; and indeed with-
 out this be attended to, they will be of  little advantage.
   When the parts are brought together in the manner di-
 reaed, in order to prevent the accefs of air, it will be bet-
                                                    ter

   • The form and fire of  the plafters muft be regulated by the judgment
of the furgeon. 
                               4
                       C  372   3
 ter to cover them with lint fpread either with mucilage of
 fome mild gum or fome unauous fubftance.
    If the patient is low and emaciated, it will be proper to
 allow him a light nourifhing diet; but if he is plethoric,  or
 liable to inflammatory  complaints,  he fliould be confined  to
 a ftria antiphlogiftic courfe, in order to prevent too great a
 degree of fubfequent inflammation.
    Should the fymptoms of pain  and inflammation continue
 moderate,  the  dreffings ffiould  never be  removed till the
 cure be completed; but whenever the pain in the wound
 becomes fevere, as it will,  if not properly attended to, be
 produaive of fo much inflammation as to  f/uftrare our in-
 tention, the dreffings  fhould  be removed, and  the  parts
 gently, and  for  fome  time,  rubbed or bathed with  fome
 emollient oil.   If this proves infufficient, general and  topi-
 cal bleeding, and opiates, muft be employed,  according to
 the eircumftances of the cafe.   Thefe will  generally re-
 move  the inflammation ; but if they ffiould not have this
 effea, it will be neceffary to  take away the   ligatures  or
 plafters entirely,  and accomplifh a cure in the ordinary
 way.
   In general, even  in  very large wounds, the futures or
 plafters may be removed about the fifth  or fixth  day, as a
 union will by that time have been produced, and they may
 then be difadvantageous.
   It has been objeaed  to the method  we have advifed,
 that where arteries are tied, the  ligatures will prevent the
 union of the divided parts, and that finufes  are  very apt to
 be formed, and produce the fame  effea :  but when the cure
 has been properly conduaed, I have never found thefe eir-
 cumftances to occur in fuch degree as to  afford any valid
ground of objection.
  When wounds do not admit of a union by  the firft in-
tention, the moft effeaual method of preventing the  occur-
rence of bad fymptoms, is to promote a fpeedy  and  plenti-
                                                ,  ful 
                      [  373  ]
 ful fuppuration, by  the  remedies  formerly recommended
 for this purpofe, viz. poultices and fomentations.   Thefe
 ffiould be applied immediately when the pain is very great;
 but  when  this  is moderate,  we had better defer the ufe
 of them  until the effufion neceffary  for the formation of
 pus has taken place, which will  probably be in the courfe
 of a day or  two, left the inflammation ffiould be  prevent-
 ed from arifing  to  the  neceffary  degree.    The ufe  of
 thefe remedies fliould be omitted as  foon  as the  pain
 and inflammation  have fubfided,  and a  free fuppuration
 has taken place ;  becaufe a longer continuance of them
 would do injury by  relaxing the parts to  too  great a de-
 gree ; and the fore is then to be  treated in the manner for-
 merly  advifed, in the chapter on  ulcers.
  The immediate  applications to  recent  wounds ffiould
 always be mild ; dry lint or fponge are very commonly re-
 commended, but lint fpread with  a  mild ointment is lefs
 irritating, and in my opinion,  of  confequence more proper.
  The firft  dreffings  of wounds ffiould be removed as
 foon as  they appear to be covered with  matter:  this will
 generally happen about the fourth or fifth day ;  but, it muft
 neceffarily depend on the health of the patient,  and  other
 eircumftances.   The  application  of poultices  above  the
 dreflings after the fecond day,  puts it into our power to
 remove them fooner  than we otherwife could, by foftening
 them, and promoting the  fuppuration.  The nature of the
 fubfequent dreffings muft depend upon the particular na-
 ture and appearances of the fore.    See chapter on Ulcers.
  The fymptoms which  more particularly require atten-
 tion in wounds, are, pain, inflammation, and convulfive af-
 feaions.   The firft  of thefe  ufually goes  off in a fhort
 time ; but when it continues very violent  and for a longer
 time than ufual, it will be neceffary, in the firft place, to try
the  effeas  of  opiates :  fhould not thefe give permanent
relief, we fhould carefully fearch for the caufe.  This will
                                             fometimes 
                      [   374  3
fometimes be  found to confift  in  extraneous fubftance?
lodged in the wound; thefe ffiould therefore  be fearched
for, and removed, either by the fingers, injeaions of warm
water, or hy immerfing the parts in warm water or milk
for a confiderable time, by which they may  be diflblved
and waffied out.
   If thefe trials do  not remove  the pain, it will often be
found to originate from inflammation.   This is to be re-
moved in the  ufual way;  but particularly by  the applica-
tion  of leeches to  the edges of the wound, and by fcari-
fying the periofleum,  if  the  inflammation appears to be
feated  there.   There  is  not fo much danger of inducing
exfoliation of the bone by this proceeding, as  by fuffering
the inflammation to  continue,  and perhaps  terminate in
the formation of matter.
   When the pain appears to be  deep feated, and does not
feem to originate from either of the caufes already mention-
ed, it may  with fome reafon be attributed  to a partial divi-
fion of a nerve or tendon.   In this cafe, although-putting the
part in a relaxed pofition  may  afford  fome eafe, no effec-
tual relief will be given by any remedy, but an entire  divi-
fion  of the injured nerve or tendon.   This  being made,
the limb ffiould be  relaxed, and the part  affeaed covered
by an emollient poultice.   If this ffiould  fail, either from
the divifion being made incompletely,  or  from  its  having
been too long deferred, there will be great reafon to fear
the patient will die  convulfed, notwithftanding the ufe of
opiates, and every other remedy.
   In fome inftances, the pain inftead of being deep feated,
is  found  to originate from a peculiar degree of  irritability
of the nerves on the furface of the injured parts.   It is not
then  ufually fevere, but it  often prevents the patient from
fleeping,  and  occafions a thin acrid difcharge.   In thefe
cafes, large dofes of opium, give the  moft  certain relief;
and a weak folution  of opium,  or  of faccharum faturni,
                                                   are 
                      [   875  3
are the beft external applications.  Poultices often increafe
inftead of relieving the complaint.
   Subfultus tendinum,  and other  flight fpafmodic affec-
tions are frequent confequences of wounds ;  thefe are par-
ticularly apt to occur after  amputation, and then produce
very difagreeable  and fometimes dangerous confequences.
They are evidently the effea of pain and irritation from the
wound, and are often relieved  confiderably or entirely, by
putting the whole body, and particularly the  part wound-
ed, into an eafy relaxed pofture.  If this fails, opiates will
commonly fucceed: and thefe  fhould always be given in
fmall quantities,  frequently repeated ;   for large dofes are
very apt to naufeate or puke, and to be produaive of an
increafe  of the  fpafms  after  their  immediate effeas are
over.
   The moft alarming convulfive affeaions confequent to
wounds, are the locked-jaw and tetanus.  Thefe are mofl
apt to occur in warm countries, but occafionally  are met
with in every  variety of climate.  They are frequently the
effeas of trifling  injuries ; a fmall fcratch, for inftance,
which does not penetrate to a greater depth than the fkin
will  fometimes induce them :  and  when they  happen  as
the confequences of large wounds, they do not commonly
make their appearance until the fore feems nearly healed.
   Upon the firft fymptoms of thefe affections, the patient
ffiould be immerfed in a bath of warm water as long as he can
bear it, or what will perhaps be preferable, a bath of warm
milk, or of water impregnated with  oil; in fat broth, e. g.
   As the warm  bath has often failed, fome praaition-
ers have had recourfe to cold bathing ; but although this
has proved frequently ufeful in  tetanus, it is ftill doubtful
whether it can be equally ferviceable in  trifmus, or locked
jaw, the moft  dangerous fpecies of thefe affeaions.
   Opium appears to be the  moft ufeful internal medicine,
and it feems more proper to give it in moderate dofes, as
                                                 above 
                         [   376  ]
 above direaed, fo as to keep  the fyftem conftantly under
 its effeas, than to exhibit it in very large quantities at a time;
 as this laft method appears to induce that ftate of the body
 which it was meant to prevent, when the immediate effeas
 of the medicine are gone off, viz.  a great degree of irrita-
 bility.  _3_ther and muflc have been joined with opium, but
 they have not been produaive  of any important benefit.
   As  external applications,  emollient animal oils feem to
 be thofe that we may expert to be moft ferviceable; fuch
 as the oil obtained by boiling recent bones in water, and
 that afforded by fowls.  Mercurial ointment feems chiefly
 ufeful as  an  emollient.    Opium moiftened with  fpirit or
 water, or in the form of laudanum, has  been rubbed or ap-
 plied  on the contraaed parts with benefit.*
   At the fame time that thefe  remedies are employed, the
 patient fliould be fupported by  mild nourifhment given by
 the  mouth,  when  this  can  be  done ;  and  by clyflers of
 ftrong broths, if the  contraaion of the jaws prevents the
 exhibition of food by  the mouth.   In  order to  avoid this
                                                         laft

  • Dr. Rufh, profeffor of the theory and practice of medicine in the col-
 lege of Philadelphia, in wounds of nervous and tendinous parts, as preventa-
 tives  of thefe fpafmodic affections,  advifes  dilatation,  and dreffing with
 fpirits of turpentine, or fome other ftimulant fubftance ; and tells us, that
 where this plan has been properly followed, fo as to excite an inflammation
 of the part, he has never feen them produced.   The Doctor believes tetanus
 to be founded in relaxation, and that in order to remove the affection, it is
 neceffary not only to reftore the natural vigour, but to excite  fomething
like inflammatory diathefis in the fyftem.  Agreeably to this idea, beiides
the cold bath, oleum fuccini, Barbadoes  tar, mercury, and the other tonics
and ftimulants which have heretofore been recommended, he employs wine,
bark, and blifters, together with the  topical remedies above mentioned.
Electricity, as fuggefted by the Dodtor, has lately been ufed with fuccefs in
New-England, as we learrt from a publication of the Medical Society at
New-Haven.
  The happy effects of Dr. RuflVs method, in feveral inftances, feems much
in confirmation of his opinion.   See Med. Obf. and Inq. by Benj. Rufh,
M. D. 
                       L  377  ]
 laft circumftance, it will be advifable to remove a tooth or
 two, when the fymptoms of trifmus feem approaching; or
 if this is then negfeaed, to extrad them afterwards.
  When a locked jaw is the confequence of a wound in the
 extremities, if it does not  yield to the remedies  above  re-
 commended, it has been advifed to amputate the member;
 but experience has ffiewn this praaice to be not only in-
 effeaual, but in  many inftances to have increafed the dif-
 tafe.


                   SECT.   III.

                 Of PunBured Wounds.

  A wound is faid to be punctured  when it is made with
 a fmall, pointed  inftrument,  fuch as a fmall fword ;  and
 when the external opening is fmall and contraaed in pro-
 portion to its depth.
  Injuries of this kind  are more dangerous and difficult
 of management than incifed wounds of a much greater ex-
 tent;  from deep feated nerves and other important parts
 being more apt  to be  partially  hurt;  from extraneous
 bodies being carried to  a depth  from whence they cannot
 be eafily removed ; from the matter afforded  being more
 apt to lodge within them;  and from their edges adhering
 often with difficulty.
  In fuperficial punaures, where we are  certain of being
 able to extraa any extraneous  matter, and where the  in-
 flammation is for the moft  part moderate, compreffion may
be ufed, and will feldom fail of effeaing a cure.   When
 they are deep, and will admit of a feton being ufed, I ap-
ply  emollient poultices  until they fuppurate freely, and
there is no reafon to fear that the  inflammatory fymptoms
will afterwards go  too  far;  a  cord is  then introduced
                       3 B                    nearly 
                      t  378   ]
 nearly equal in fize to the opening,  and being allowed to
 remain till there is ground to believe that any extraneous
 matter lodged in the wound is difcharged, it is then leffen-
 ed, and the cure finifhed by compreffion alone, as direaed
 in the treatment of finuous ulcers.   When the wound is
 laid open at both ends,  the cord may be eafily introduced
 by means  of  a feton probe; but when there is but one
 external  opening, a counter-opening muft be  made, either
 by cutting with a fcalpel, on the end of a blunt probe,  or
 by means of a lancet-pointed needle paffed through a canu-
 la, and thus introduced  into the finus.
   But although a  cure of fuch wounds may be thus ac-
 complifhed, yet  I  am  well  convinced, that wherever the
 praaice  is fafe,  the laying them open immediately  after(
 the accident,  by means of a  probe-pointed biftouri, or a
 fcalpel and direaor, ffiould  be preferred:  for by  this
 means all extraneous bodies are at once brought into view;
 hemorrhagies are eafily reftrained ;  all that pain and trou-
 ble which fometimes occur from a partial divifion of nerves
 or tendons are direaiy obviated ;  the inflammation which
 fo  often follows punaured  wounds will  not be fo apt to
 run high;  and much time will be faved.
   When  the  punaure  runs  deeply among the  larger
 mufcles,  and  efpecially in fuch as are contiguous to large
 blood-veffels or nerves, this praaice cannot be fully adopt-
 ed with fafety ; and we muft be  contented to  lay open the
 parts  as far as it can be  done with  propriety, and truft to
 the confequent fuppuration for bringing off any extraneous
 matters that may be lodged in the  wound, and  to com-
 preffion for a completion of the cure.  Or, as a feton may
 in  fome  cafes be paffed where  it might be dangerous to
 make a deep incifion, that praaice may be tried.
   But it  is to  be obferved, that when a punaure runs in
 fuch a direaion as  not to admit of a counter-opening,  a fe-
ton can never be employed ; and we muft truil to a  proper
                                            application 
                      [  379  ]
application of preffure,  not  merely for preventing  any
lodgment of matter, but for effeaing a cure by producing
an adhefion of the divided parts.    And when this method,
or fetons fail, aftringent injeaions, fuch as lime-water, weak
folution of faccharum faturni or of alum, or claret or port
wine and water, may  be advantageoufly employed,  in or-
der to  check  too great  a difcharge of matter, or pro-
duce a certain degree  of callofity in the fides  of  the fore:
but they ffiould never be  ufed before, as they tend to dimi-
niffi the proper degree of inflammation, and wafh off the
pus in too great a degree ; and thus prevent the formation
of  granulations,  and the adhefion  of  the fides of  the
finus.
  In punaured wounds where fetons cannot be employed,
it is fometimes  difficult to prevent the external opening
from clofing, long before any tendency  to heal appears in
the bottom of the fore : and if this be not attended to, much
mifchief is apt to enfue from matter colfeaing beneath, and
burfting out from time to time.   With a view to prevent
this occurrence,  tents are employed.  Thofe that are  hol-
low are to be preferred to folid tents of any  kind : for they
admit of a conftant and free difcharge  of the matter  that
is formed, while folid tents, from preventing any difcharge
but at the ftated dreffings, are very apt to make the matter
infinuate itfelf between the different layers of mufcles, and
thus give time for an  abforption of it into the fyftem ; on
this account, if they are employed at all,  they fhould never
fill  the aperture entirely.   Silver and lead are commonly
employed to form hollow tents ; the latter is preferable, be-
caufe it gives leaft irritation, and may be more eafily adapt-
ed to the form of the  fore.    Solid tents may be formed of
fponge, gentian, or any other fubftance that fwells with
moifture.
  Tents ffiould never be employed when their ufe can be
at any rate difpenfed with ; and as the difcharge will com-
                                                 monly 
[  380  3
 monly preferve  the opening of a wound free, they can be
 very feldom neceffary.*

                    SECT.  IV.

            Of Lacerated and Contufed Wounds.

   A  wound is faid to be lacerated, when the parts are torn
 afunder, and the edges of the fore are ragged and unequal;
 and contufed, when made by a blunt  or obtufe body.
   Thefe varieties) of wounds, although in faa much more
 dangerous than fimple incifed wounds, do not at firft ex-
 hibit  fuch alarming  appearances.   For inftance, there  is
 feldom much hemorrhagy attending them :  a limb has been
 torn off  without any bleeding at ail being produced ;  and
 indeed the hemorrhagy as well as the pain, generally feems
 to be in an inverfe proportion to the extent  of the injury.
   The retraaed edges of lacerated and contufed wounds
 become almoft immediately fwelled, from effufion into the
 cellular membrane.   When  the injury  has not been con-
 fiderable, the affeaed parts  are generally thrown  off in.
 the form of floughs by a fubfequent fuppuration, and a cure
 is readily effeaed by the  means advifed in fimple incifed
 wounds ; but if the texture of the  parts is  very much de-
 ftroyed,  and  particularly  if any of the larger arteries have
 been  obliterated,  there  will  be reafon to fear  that gan-
 grene will be  the confequence.  When this fupervenes,
 in healthy conftitutions, and where the wound is not very
 extenfive, the mortified parts will often feparate, and a cure
                                                    will

  * As all  tents act more or lefs as extraneous bodies, they can very rarely,
if ever, be employed with propriety, in the healing of finuous or punctured
Wounds; free dilatation is the moft  certain mode of fucceeding in fuch
cafes. 
                      [  381   ]
will be afterwards accomplifhed ;  but in oppofite eircum-
ftances, there will be great reafon to expea death may be
the confequence.   If gangrene  does not fo  immediately
follow the injury,  yet where this has been very extenfive,
fo great a degree of inflammation often fucceeds as ulti-
mately to produce it.
   Hence it is obvious, that in thefe wounds our principal
objea is to  guard  againft  mortification ; and  that the
means by which we effea this muft vary according to eir-
cumftances.   As the violence of  the inflammation is the
moft frequent caufe of the gangrene, our attention muft be
principally direaed  to  obviate this.    Blood, therefore,
ffiould be taken away in fuch quantities  from the injured
veffels, as the nature of the affeaion may indicate, and the
ftrength  of the patient admit: after this, if neceffary, the
arteries may be tied.  The wound is then to  be cleared of
all extraneous  fubftances as formerly  direaed,  and the
parts  placed as  much as poffible in their natural fituation ;
but no kind of future fhould be employed.  If the violence
has been confiderable, and efpecially if the  patient com-
plains of much pain, it will be ftill neceffary to take away
blood cautioufly according  to  the ftrength of the patient;
and particularly by leeches applied as near as poffible to
the edges of the fore.
   The parts affeaed fhould then be dreffed with pledgets
of fome emollient ointment, and over this a warm poultice
ffiould be  applied.   The poultice, together  with  warm
fomentations, ffiould be renewed three or four times  a-day,
in order to promote a  fpeedy fuppuration;  which is the
beft means of removing all the bad fymptoms, and of pre-
venting gangrene.   When pus begins to be freely formed,
the parts that have been much injured, gradually feparate ;
and  as  foon as they have  come away, the edges  of the
wound  may be brought together  by plafters  or bandages,
                                                    or 
                       [   382  3
or the fore may be treated as a common ulcer, according
to eircumftances.
   When notwithftanding the means made ufe of, gangrene
aaually comes on, the mode of treatment muft be entirely
changed,  and we are  to depend on  the remedies recom-
mended in the feaion  on mortification.

                    SECT.   V.

                Of Wounds in the Veins.

   Wounds in the veins heal with much more eafe, and
are attended by much lefs  danger than wounds of the arte-
ries, both  on account  of their having lefs mufcular fub-
ftance  on them, and the lefs  degree of force with which
the blood  is moved in  them, and becaufe the obliteration
even of the  largeft external veins, is  of little confequence,
the anaftomofing branches readily fupplying the want  of
them.
   A longitudinal wound  will generally heal if covered
by a piece  of lint,  or  foft  linen; or at  any rate if dried
fponge or agaric is applied to it, and  fecured by  moderate
preffure.   But in tranfverfe cuts, when compreffion cannot
be ufed, or  is infufficient  to  reftrain the  hemorrhagy, the
veffel ffiould be tied by the tenaculum or needle,  as direa-
ed in the cafe  of wounded arteries.
SECT. 
[  383   j
                    SECT.   VI.

              Of Wounds in the Lymphatics.

   Lymphatics are fometimes cut in blood-letting, in ex-
tirpating tumors, and in opening buboes  and other glan-
dular colfeaions of  matter.   When the fmaller branches
only  are  injured, they  readily heal with the reft of the
wound ; but when the veffel is  large, and does not heal
fo foon  as  the  other parts, but continues to pour out its
contents,  producing inconveniency, and debilitating the
patient, we ffiould put a flop to the difcharge.  If this can-
not be effeaed by compreffion, the veffel ffiould be fecured
by a  ligature.  This is a much more certain method than
the application  of aftringents, dried fponge, agaric, puff
ball, or  cauteries, recommended by fome.


                   SECT.  VII.

Of Wounds in the Nerves, and  Tendons, and of Ruptures of
                        the Tendons.

   With refpea  to  wounds of the nerves and tendons, we
muft  refer to what  has  been faid on the fubjea, in the
chapter on blood-letting, and in feaion 2. of this chapter.
   In  cafes of ruptured tendons,  it was formerly the prac-
tice to bring the ends into contaa, and retain them by fu-
tures ; but it is now very well  eftablifhed by  experience,
that  this is unneceffary, and that if they can be brought
nearly together, they will contraa fuch adhefions to the
neighbouring parts, that the ufe  of the limbs will be very
                                              perfeaiy 
                       I  384  3
 perfeaiy reftored; and by this means a great deal of trouble
 to the furgeon, and pain to the patient may be prevented,
   Wherever a wounded tendon is fituated, or  even  when
 the tendon alone  is ruptured, without any injury being done
 to the external parts, the limb ffiould be placed in fuch a
 pofition as will  moft readily  admit of the retracted ends
 being brought nearly together;  the mufcles of the whole
 limb  muil then be tied down with a roller, applied mode-
 rately tight, fo as to prevent them entirely  from moving
 during  the cure,  and the parts placed  in the moft eafy and
 relaxed  pofture.    Thus,  when  the tendon of the reaus
 femoris is the feat of the injury, the  leg  ffiould be kept
 ftretched out, while the thigh  fliould  be fomewhat bent;
 and when the tendo achillis is affeaed, the knee ffiould  be
 conftantly bent, and the foot ftretched out.
   In  ruptures of the tendo achillis, in order to  keep the
 divided  parts in  their proper fituation, the patient fhould
 wear  a  flipper,  conneaed  to a broad piece of quilted
 ticken laced round the upper part of the leg, by a quilted
 ftrap.   The flipper fliould be open at the  end, in order  to
 admit of a free motion of the toes.
   When the  patient is able to go abroad, which may be
 the cafe in about  two weeks, he ffiould wear a very high-
 heeled fhoe, to the back part of which a  ftrap ffiould be
 fixed, long enough to be faftened  to the garter.
  The  patient ffiould wear this for  feveral  months  at
leaft,  and be very careful to avoid  any violent  exercife,
for a  long  time,  for  fear  of again  rupturing  the newly
healed parts.
SECT. 
[  385  3
                  SECT.   VIII.

              Of Wounds in the Ligaments.

   Our obfervations on this fubjea are chiefly applicable to
wounds of the capfular ligaments ;  as the ligaments  fitu-
ated far from  the  furface  of  the body  are not much ex-
pofed to external  violence, and are out  of  the reach of
applications.
   The ligaments are rendered  extremely fenfible by  dif-
eafe,  and wounds of them are  often produaive  of  very
alarming confequences.   For  although, in fome inftances,
lacerations,  by the heads of bones being puffied through
them, and wounds of them, have readily healed ; yet in ge-
neral, the fymptoms which enfue from injuries to them are
very  fevere and  hazardous.   Nothing alarming  appears
perhaps at firft, or for feveral days after the accident; but
at length the patient feels an uneafinefs and ftiffnefs of the
joint; thefe gradually increafe ; and the parts foon become
■fwelled, tenfe, and inflamed.—The pain now grows excef-
five ;  a fenfe of tightnefs around the articulation comes on ;
and the inflammation fpreads  all over the  limb.
   If the wound in the ligament is large, the fynovia is often
immediately difcharged in confiderable quantities ; but the
fubfequent fwelling gradually flops the flow of it,  and the
fore becomes dry and floughy.   In  a few days, however,
extenfive fuppurations begin  to  form in  the joint; and if
thefe are laid open, fynovia  is  difcharged  with the  pus.
This  relieves the tenfion and  pain ;  but a fucceffion of ab-
fceffes is apt to take place, which at length materially injure
the patient's health.
   Thefe effeas almoft always refult from wounds in the
large  joints, if they  are not  healed very quickly, and al-
moft  v/irhout  the formation of matter.   They feem  to be
                          3  C                   Vhiefly 
                      [   386  ]
chiefly the refult of the admiffion  of air to the internal
parts of the joints ; and on this account, in incifed wounds,
where it is praaicable, as foon as extraneous fubllances
that may have been carried into the cavity have  been  re-
moved, the fkin ffiould be pulled over the wound, fo that
the cut in that and in the ligament may not correfpond, and
the divided parts of it conneaed by  adhefive plafter, or
futures.  As futures are too apt to excite inflammation, the
plafters fhould in general be preferred : Thefe ffiould be
aided  by the application of a  flannel roller around the
joint.   The patient  ffiould be in bed when the dreffings
are applied,  that he may not be obliged to  move  the limb
foon ;  and the limb  fhould be placed on a pillow in fuch
a fituation, as will moft effeaually relax the integuments :
If the wound is on  the anterior part of the joint  of the
knee,  for inftance, the leg muft be extended, and if on the
back part, it muft be bent.
   In  order to  prevent inflammation,  the  patient  ffiould
be put on a low diet; laxatives ffiould be ufed ; moderate
perforation  fliould  be  excited ; and  he fhould  lofe fome
blood.
   By this treatment  I have known many of thefe wounds
to  heal very  readily;  but  when  it  has  been neglea-
ed, or is not effeaual, and inflammation has taken place,
local  blood-letting  is  the  moft beneficial  remedy.  In
robuft habits, eighteen or twenty  leeches ffiould  be  ap-
plied  as  near to  the parts affeaed as poffible ; and this
fliould be daily repeated as long as  the continuance of  the
inflammation may render it proper.   The  wound may be
dreffed with fome fimple ointment; but one of the beft ap-
plications to the joint is the fleam of warm vinegar.  Fo-
menting  the  part with  decoaion of  white  poppy  heads
will be fometimes very, ufeful in leffening the pain: but in
general it will be  neceffary to employ large  dofes of opi-
ates.
                                                Thefe 
                      [  387   3
  Thefe means properly  employed will  often remove  the
inflammation ; but when they do not, it terminates in large
abfceffes, partly within the joint, partly in the fubftance of
the ligament, and  in part in  the cellular fubftance conti-
guous.   All that can be done then, is to promote the for-
mation of thefe when they  have begun, and to difcharge
the matter as foon as fuppuration is completed, by open-
ings in the moft dependant parts of the tumors.  If not-
withftanding this treatment, the difeafe continues until the
patient becomes heaic,  and much debilitated,  as any far-
ther attempt to fave the limb will be  hazardous, amputa-
tion fliould be had recourfe to.   See chapter on Amputa-
tion.

                   SECT.   IX.

                 Of Wounds in the Face.

   In injuries of this kind, it is an objea of importance to
prevent deformity.  To effea this, the divided parts fliould
be laid as exaaiy together as poffible ; and if the wound
is in the direction of the fibres of the injured part, or is fu-
perficial  in any direaion, they  may be kept in contaa by
adhefive plafters ; but wherever the wounded parts retraa
much, it will be neceffary to employ futures.   The twifted
future, particularly for  the  lip, is to  be preferred  to  any
other.  See feaion on Hare-lip.
   When wounds penetrate the falivary duas, the treatment
direaed in chapter xxxiii. muft be employed.
   In the fore-head, wounds are apt to be attended with trou-
blefome hemorrhagy ;  and when this cannot be reftrained
by compreffion, or the artery cannot be readily tied, which
will happen fometimes, if it lies in the bone, a part of the
external  lamella, or if neceffary of the whole  fubftance of
                                                   the 
                      [  388   ]
the bone, may be removed,  in order to enable us to apply
a ligature to the veffel.

                    SECT.   X.

         Of Wounds in the Trachea and Oefophagus.

   These wounds are moft frequently the confequence of
an attempt to effea fuicide.
   When the  trachea  is  divided longitudinally, adhefive
plafters will be found adequate to the retention of the fe-
parated parts in contaa.  They  will alfo be fufficient in
flight tranfverfe  wounds,  if aided by a proper pofture of
the head :  Indeed  in  all wounds of this  kind, it is abfo-
lutely neceffary to the cure, that  the head be kept bent as
much as poffible down upon the breaft ;  this will be moft
certainly effeaed by conneaing a night-cap placed on  the
head, with a roller carried round  the body.
   In all deep tranfverfe wounds of the trachea, it will be
neceffary to employ the interrupted future.   But as the li-
gatures, if carried into the trachea, are apt to excite cough-
ing, which has in fome inftances torn out the flitches, I
have in  different inftances fucceeded very well by paffing
them merely through  the integuments,  in  the following
manner ; a flat needle with a flight curvature, and thread-
ed with a broad flat ligature, being inferted at the wound,
and paffed  flowly up for  the fpace  of an inch as clofe as
poffible to  the trachea, it is then to be  puffied out with
the ligature ; and the other end of the thread being armed
with a needle, muft in  like manner be paffed through  the
teguments  of the oppofite fide.   After a fufficient num-
ber of ligatures are paffed, they ffiould  be fecured v/ith
running knots, that they may be eafily untied if neceffary;
adhefive plafters fhould  then be applied over the whole.
                                                I have 
                      [  389  3
   I have not yet had an opportunity of afcertaining whe-
ther this method will fucceed, when the wind-pipe is en-
tirely cut through ;  but it  is probable it will.   If how-
ever, it is thought neceffary  to flitch the trachea itfelf, we
ffiould carry the needle from within outwards,  for fear of
doing mifchief.   Three ligatures will generally be found
fufficient; one anteriorly, and the others at the  fides.
   Wounds  in the oefophagus are to be managed nearly in
the fame  manner with thofe of the trachea, but they are
more dangerous ; as well on account of the greater difficulty
of reaching  the part injured, from its depth, and the lower
part of it being apL to be drawn below the fternum ; as from
the difficulty  of  conveying nourifhment  to  the  ftomach
which they produce ; and from the vicinity of the recurrent
nerves,  the carotid arteries, and jugular veins.
   Our  firft  objea in divifions of the trachea  and  oefopha-
gus muft be to ftop the hemorrhagy ; not only on account
of the lofs of blood, but to  obviate  the cough and naufea,
which are very injurious, and which are the confequences
of the blood getting into the lungs  and  ftomach.  All the
divided arteries and  veins fhould therefore be fecured im-
mediately.  A wound of the carotid  artery is ufually imme-
diately fatal: if the furgeon is called  in time he ffiould how-
ever make a  ligature on both ends of it.   Should the jugular
vein be partially divided, we may attempt to effea a cure by
compreffion, made either by  a common bandage, or where
much preffure is required,  by a machine which does not
interrupt the refpiration ; but if it be cut through, it muft
be tied.
   As foon as the bleeding is ftopped, the cefophagus muft
be Hitched in the manner advifed for  the re-union of the
trachea ;  and  in order  to effea this more readily, the ex-
ternal wound fliould be enlarged without liefitation  when
it is judged neceffary.
  Longitudinal wounds in the gullet might very probably
be cured merely by adhefive plafters.
                                           SECT. 
[  390   3
                   SECT.   XI.

               Of Wounds in the Thorax.

                §. 1.  General Remarks.

  Wounds in the thorax are in general dangerous in pro-
portion  to their  depth :  Thofe which affea the  integu-
ments only,  if properly  treated, are feldom produaive of
any important confequences ; but the fmalleft wounds pe-
netrating the cavity of the cheft, will, in fome inftances, be
attended by  the  moft alarming fymptoms, particularly if
the contained vifcera are injured.
  The firft objea in thefe wounds is to afcertain whether
they have entered the thorax : This may be generally done ;
by putting the patient into a proper pofition, and then care-
fully examining the wound by means of the fingers,  or a
probe ;  by afcertaining  the form of the inftrument with
which the wound was infliaed, and the length to which it
feemed to be puffied ; by liquids injeaed returning imme-
diately, or lodging in the wound ; by air being difcharged
from the wound ;  by an emphyfematous fwelling of the
contiguous teguments ;  by the quantity of blood difcharged
from the wound ; by the appearance of the blood;  by
blood being  difcharged from the mouth ;  and by the ftate
of the pulfe  and refpiration.
   1. The patient fliould always be placed  as nearly as pof-
fible in the pofture he was in when he received the wound,
during the examination; for it muft be obvious, that in
fome poftures, from  the mobility of the mufcles and ribs,
a wound, in reality deep, may be made to appear very fu-
perficial.
   2. The depth of the wound may,  in fome inftances, be
afcertained by the eye;  but when  this cannot be done,
                                                  nor 
                      [   391  ]
nor the fingers employed to difcover it, on  account of
the opening being very fmall, a bougie fhould be employ-
ed : This gives lefs pain, and is lefs apt to do injury than a
metallic probe.   But the examination ffiould be very cauti-
oufly made, and foon defifted from, if we cannot afcertain
the extent of the injury very readily; becaufe the patient
may fuffer from the attempt, and the fymptoms which fol-
low will foon determine the matter.
   3. The fize and  form of the inftrument, the  direaion
it appeared to take, and the depth to which it was puffied,
ffiould always be  afcertained with as much exaanefs as
poffible, as thefe eircumftances may undoubtedly affift us
in forming a judgment of the depth of the wound.
   4. When thefe means do not enable us to form an opi-
nion, the injeaion of fome mild liquid, as warm water, may
be tried.   If this returns  immediately, the  wound is pro-
bably not deep ;  if it remains altogether, or in great part,
without producing any external fwelling, we cannot doubt
of its having penetrated the cheft.
   5. If air paffes  out at the  wound during infpiration,
there will be reafon to fufpea that the lungs are injured.
However, in cafes where  there is no adhefion between the
lungs and the pleura,  this  appearance may be  produced
from the admiffion of air, by the wound, into the cavity :
The patient ffiould  therefore be direaed to make feveral full
infpirations, in order to difcharge the air that may thus be
colfeaed ; and at the end  of each, the  fkin fhould be drawn
over the wound to prevent more from  getting in : The
whole will  thus  foon  be  evacuated ;  and then if air  ftill
ruffies out during infpiration, we may conclude  with  cer-
tainty that the lungs arc wounded.
   6. Emphyfematous fwellings, produced by the air from
the lungs infinuating itfelf into the cellular membrane, are
more apt to be the confequence of punaured than  of ex-
tenfive wounds, and efpecially of thofe which run oblique- 
                       C   392   3
ly.  It is to be obferved however, that emphyfema may al-
fo be produced from the admiffion of external  air by the
wound.
   7. When the quantity of blood difcharged  is very con-
fiderable, and particularly if it is not ftopped  by compref-
fing the intercoflal artery, we  may with  certainty con-
clude that fome of the thoracic vifcera are wounded.  That
the lungs are injured may be inferred from the  frothy and
very red appearance of the blood ; and particularly if the
patient difcharges blood by the mouth.
   Laftly, When  wounds  do  not penetrate  deeper than
the teguments, the pulfe and breathing are not at all af-
feaed at firft ; but when they enter the thorax, and parti-
cularly if they  affea the  lungs, or any other  part of its
contents, an immediate change in the ftate of the pulfe and
refpiration is produced.  The wound  may, however,  pafs
to a confiderable depth, if it is infliaed where there is an
adhefion between  the lungs and pleura, without producing
any extravafation,  and confequently without  injuring the
ftate of the pulfe or breathing;  but when  either blood or
air gets into the cavity of the cheft, the breathing immedi-
ately  becomes difficult, and the pulfe feeble,  oppreffedj
and intermitting.

 §. 2.  Of Wounds in the external  Teguments of the Thorax.

   Wounds which do  not go  deeper than  the cellular
membrane, heal as readily in thefe  parts as in  any other
fituation ; but thofe that reach  the intercoflal mufcles, and
particularly punctured wounds of confiderable extent, are
very apt  to penetrate the cavity  of  the thorax  at  length,
if great attention  is not paid to the timely evacuation of
the matter formed.   When thefe kinds of wounds  are not
very extenfive, the beft method of treatment is to lay them
entirely open v/ith  a  fcalpel and direaor, and then  heal
                                                 them 
                       C   393  ]
them carefully from  the bottom ; but when the punaure
is of confiderable length, the cure by feton is to be prefer-
red.   Some advife, inftead of a feton, to employ compref-
fion ; but this cannot be ufed to a fufficient degree with-
out impeding the refpiration ;  and befides this bad effea,
it would endanger an infmuation of the  matter produced
into the cavity of the  thorax.
  It is  particularly  neceffary in wounds  of this  kind to
avoid exercife, efpecially of the cheft ;  hence coughing,
laughing, and even talking,  ffiould as much as poffible be
avoided.  The patient ffiould be kept on a low cooling re-
gimen ; the bowels ffiould be gently opened ; and,  if ne-
ceffary,  bleeding fliould be employed.

 §. 3. Of Wounds which penetrate the Cavity of the Thorax.

  These are often produaive of alarming confequences;
chiefly from the  admiflion of the external air by them,  and
from extravafation of blood between the lungs and pleura.
The  latter circumftance  generally arifes from a wound of
the intercoflal artery :  as  this veffel is  of a confiderable
fize,  it fhould always be  fecured as foon as poffible.   This
may  generally be done, by drawing it out from the groove
in which it is fituated, by means of a tenaculum fomewhat
more bent at the  point than ufual, after dilating the wound ;
but when this  cannot be executed, from the ribs  being
much covered with fat,  or  any other caufe, a broad  flat
ligature may be  readily  paffed round  the  rib, and a fmall
doffii of lint tied by means of it  upon the bleeding artery.
This, if done with care,  may be performed with the  great-
eft fafety.
  When the furgeon is called in time, he may thus prevent
any confiderable  quantity of blood from  being difcharged
into  the cheft; and as foon as the hemorrhagy is ftopped,
he may then proceed to expel the air in the manner  direaed
                        3  D                        in 
                      [1  394   j
in §. 1. of this feaion.    The wound  may  afterwards be
fecured  by adhefive plafters, a napkin, and fcapulary ban-
dage.
  If however, blood is extravafated in fuch quantities, or
fuch a formation of pus is confequent, as produces a con-
fiderable oppreffion of breathing, the paracentefis muft be
employed  as direaed in the chapter on that fubjea.   But
it ffiould  be  particularly obferved, that as inftances have
occurred in which abforption of fmall quantities  of blood
or other fluids has taken place, the operation ffiould never
be advifed unlefs the violence of the fymptoms render it ab-
folutely neceffary; and we ffiould rather truft to the chance
of the firft, than run the rifk of the laft.


             §. 4.  Of Wounds of the Lungs.

  Wounds in the lungs require the  fame  general treat-
ment with thofe which merely penetrate the cavity of the
cheft ;  but as  they are more  hazardous, they demand a
more particular attention.  The danger of them arifes from
the hemorrhagy, or  a fubfequent fuppuration in the lungs.
  The hemorrhagy  is moft effeaually checked by copious
bleeding, fo as to induce fainting;  by keeping the patient
in  a  cool  apartment,  and perfeaiy  at reft ;  by  cooling
laxatives;  and  by a low diet.   It is alfo of the greateft
confequence to keep the lungs as free from aaion as pof-
fible :  hence  coughing,  laughing, much  fpeaking,  and
even  the  making deep infpirations,  ffiould be  carefully
avoided.
  Notwithftanding  all our  efforts, however, the  patient
will fometimes die  from the hemorrhagy; or the extra-
vafation of blood will obftrua  the breathing materially;
or abfceffes will be formed in the fubftance of the lungs.
The latter circumftance only remains to be confidered.
                                           Colfeaions 
                      C  395  ]
  Colfeaions of matter in  the  lungs may be difcharged
•either by  the  mouth, by the  wound, or into the cavity of
the cheft.   We are in this place to pay attention only to
thofe cafes in which the abfcefs formed burfts into  the
wound, or at leaft is difcovered pointing towards it.   As
foon as this is known by an  oozing of pus,  or  by intro-
ducing the finger between the ribs, an opening ffiould  be
made into the abfcefs as in other cafes.   By doing this, wc
avoid the hazard of immediate death, which often happens
from the  matter being difcharged in great quantities into
the bronchial, and at the fame time prevent the pus from
paffing into the cheft, which might render another opera-
tion neceffary.   In cafes of this dangerous kind, when the
floppage of a previous difcharge  of matter has taken place,
and all the ufual fymptoms of a frefh colfeaion have come
on,  I  would  even advife the external  wound to  be en-
larged to the  extent of two or three inches, in order to
difcover the feat of the abfcefs, and when this is afcertain-
ed, to  make an  opening into  it, by the careful introduc-
tion of a biftouri along the  finger, at whatever depth  it be
feated.  I have ufed this praaice in two inftances ;  and in
both of  them was obliged  to go nearly the length of my
finger into the fubftance of the lungs : the patients were
inftantaneoufly relieved, and  are now in good health.
   In the fubfequent  treatment of thefe abfceffes, we muft
be  careful that the fore heals from the bottom ; and this
will be moft effeaually  accomplifhed by the ufe of a hol-
low oval tent.  See feaion on Punaured Wounds.
   When  any part of the lungs protrudes from a  wound
in the cheft, it ffiould be immediately replaced ; but if this
is negfeaed until a part of them becomes gangrenous, this
ffiould be cautioufly  removed,  and the reft replaced.  If
the incifion be confined to the mortified part, no hemor-
rhagy, or other bad confequence will arife from it.
$.  5? 
[  396   ]
§.  5.  Of Wounds  of the Heart, of the large Veffels conneBed
            with  it, and of the Thoracic. DuB.

   The flighteft wounds of the heart are probably always
ultimately fatal;  for the weaknefs induced by them on a
particular part, will neceffarily be produaive of aneurifm,
which always  perhaps has a rapidly fatal  termination.
The moft probable method of preventing this, or  at leaft
of delaying it  is,  to leffen the aaion  of  the heart by co-
pious blood-letting, low diet, laxatives, and  avoiding fa-
tigue of every kind.
   The fame obfervations apply  to wounds  of the large
blood-veffels about the  heart.
   We may judge the thoracic dua to be wounded, when
the inftrument has penetrated to the part  in  which  it is
fituated ; when the difcharge is altogether white like chyle,
or mixed with a confiderable quantity of it; and when the
patient becomes daily weaker from it, than he would be-
come from a wound of  the fame fize in any other part.
   In order  to  prevent the diameter of the dua from be-
ing diftended, which at  the fame time will tend to leffen
the extent of the wound, the patient ffiould be kept upon
a cooling and very fpare diet, and ffiould take his food and
drink in very fmall quantities at a time ; the bowels ffiould
be kept open ; and  bodily exertion of every kind, and par-
ticularly that  which affeas the breathing to confiderable
degree, ffiould be avoided.


  §. 6.  Of Wounds of  the Diaphragm, Mediafiinum, and
                     Pericardium.

   Wounds in the diaphragm are known by the fituation
of the injury,  and by  the concomitant fymptoms.   The
breathing is rendered difficult;  and pain  is produced  all
                                                  over 
                       [   397  ]
 over the parts to which the diaphragm is  conneaed, and
 in the region of the ftomach ; ficknefs, vomiting, and hic-
 cup, take place ; and pains in the fhoulders fometimes occur,
 together with cough, delirium,  a quick hard  pulfe, and
 other  fymptoms indicating inflammation and fever.   In-
 voluntary laughter is  faid to take place in fome inftances.
   It is a common opinion, that  wounds of the tendinous
 part of the diaphragm are more dangerous than thofe which
 affea  the mufcle itfelf; but this opinion  is not eftabliffied
 by experience :  patients feldom  recover  from the effeas
 of either.
   In order to  obviate the inflammation and  irritation,
 blood-letting is  chiefly to  be depended on ;  and together
 with this we ffiould employ gentle laxatives ; large dofes
 of opium joined with mufk; and warm  fomentations to
 the thorax  and abdomen ;  and enjoin reft, and a low diet.
   Thefe wounds, if fmall at firft, foon become enlarged by
 the conftant aaion of the diaphragm ; and fome of the ab-
 dominal vifcera  then  ufually pafs  into the cheft, and  in-
 creafe  the danger.
   The eircumftances  moft to be  feared  from wounds  of
 the mediaftinum, are extravafation  of blood into the cheft,
 and inflammation, with its confequences.   And wounds  of
 the pericardium prove fometimes  dangerous by preventing
 the colfeaion of the lymph neceffary to the eafy motion  of
 the heart, and by allowing this fluid to fpread through the
 cavity of the cheft.  The general obfervations on the ma-
 nagement of wounds penetrating the thorax, will apply  to
 that of injuries of both  mediaftinum and pericardium.
   In every wound which enters the thorax, where a cure is
 not effeaed without the formation of matter, the cure  is
apt to be tedious, and a difcharge of matter to take place
for a long time, perhaps for life.  But it is much better to
fuffer the inconveniency thus  produced, than to attempt
its removal  by the ufe  of aftringent  or other injeaions ;  as
                                                 thefe 
                      [  398   3
thefe are often produaive of inflammation, and other bad
confequences, but never of good effeas, at leaft according
to my obfervation.
                  SECT.  XII.

              Of Wounds of the Abdomen.


 $.  I.  Of Wounds of the Teguments and Mufcles of the Ab-
                       domen.

  Wounds of this kind merit particular attention, on ac-
count of the danger there is of their effeas being commu-
nicated to the contiguous vifcera.
  It muft be our firft objea in all wounds  in the region of
the abdomen, to determine whether  or not they penetrate
the cavity.   When their extent is not evident to the fight,
it may commonly be afcertained ; by a proper examination
with the fingers or probe, after putting the patient into
the pofture  in  which  he  received the wound ; by  afcer-
taining the form and  fize  of the inftrument,  the depth to
which  it went, and  the direaion  it appeared to  take;
by  the quantity of blood difcharged ; by the attending
fymptoms ; and by the matter difcharged by the wound.
  When the wound will admit the finger,  we may always
determine with  certainty  the  extent of  it;  but probes
ffiould not be depended on  in thefe cafes,  becaufe they
readily pafs among the parts, in  almoft any direaion,
with a very  little force.   Injeaions are of  no fervice to
determine this  matter, becaufe they are fo very  apt to
fpread  among the mufcles  and cellular fubftance.
  The fize of the inftrument, its direaion and the appa-
                                                  rent 
                      [  399  3
rent depth to which it entered, fliould alfo be confidered,
and may affift us in our judgment.
  When the quantity of blood difcharged is very great, we
may conclude almoft with certainty, that fome of the large
internal veffels are injured, for there is no external artery
but the epigaftric  that can afford much difcharge, and it
may be foon afcertained whether this is wounded.   It is to
be obferved however, that even the largeft internal artery
may be cut, and ftill no  external  difcharge of blood take
place.   The internal hemorrhagy will, however, foon be
evidenced ;  by the patient becoming weak and faint; by a
weaknefs of pulfe, and cold fweats ;  and if the difcharge
does not foon ftop, by every other fymptom of approach-
ing death.
   A difcharge of  fseces, of bile,  of the pancreatic juice,
and even  of chyle, fometimes  appear, and determine with
certainty that fome of the abdominal contents  are wound-
ed.  This is alfo afcertained,  if large quantities of blood
are thrown up from the ftomach, or difcharged by ftool.
Urine  may be difcharged by a wound which does not pe-
netrate the cavity of the abdomen, becaufe the kidneys and
ureters are fituated behind the  peritonseum.
   When  none of the fymptoms which we have defcribed
as indicative of  wounded vifcera  appear,  and  the pain is
not in  violent degree,  we may conclude it very probable,
that the wound has not reached the cavity of the belly.
   Our principal view in  that cafe, as in fimilar wounds of
the thorax, is to prevent inflammation, and the lodgment
of matter,  by bleeding, low diet,  laxatives, reft, and a pro-«
per attention  to the wound,  as recommended in the laft
feaion.   It will however, be neceffary to obferve, that as
any weaknefs  of a part of the  abdominal  parietes,  will be
apt to  produce a protrufion of fome of the vifcera, it will be
proper in order to prevent this, that the patient be kept as
much  as poffible in a horizontal pofition, and when he at-
                                                tempts 
                      C  400   ]
tempts to fit  or walk, that the debilitated part be fupported
by a flannel bandage, paffed two or three times around the
body :  and it  will be advifable to continue the  ufe of
this roller for a confiderable time after the wound is healed.
§.  2.  Of Wounds which penetrate the Cavity of the Abdomen
              without injuring its Contents.

   We may in general conclude, that a wound penetrating
to the cavity of the belly, has not injured  any of  its con-
tained parts, if the  abdomen does not become tenfe and
painful, if the pulfe continues foft, and if the heat of the
body is not increafed.
   Wounds of this kind are never devoid  of danger; for
thofe  which at firft fhew no alarming fymptoms whatever,
fometimes at laft  terminate fatally.   This feems  to arife,
either from the admiffion of air to the cavity of the abdo-
men, which induces inflammation of fome of the vifcera,
or from the formation of pus, which not  finding a vent,
colfeas in the peritonseum.
   In  thefe wounds  therefore,  after  fecuring any blood-
veffels of the mufcles or teguments which may he cut, and
which fliould be done as foon as they are  difcovered, our
next objea fhould be, to prevent as much as poffible the
accefs of the air.   In fmall wounds this may be done by
the ufe of adhefive plafters, a comprefs and bandage : and
the fame  attention  to the  prevention  of inflammation,
by bleeding, laxatives, and  reft, as recommended  in §. 1.
of this feaion,  ffiould be employed.    If notwithftanding
this treatment  they continue open for fome time, they
fliould be  dreffed  as feldom, and as expeditioufly as pof-
fible.   Should inflammation fupervene, the ufual remedies
muft be had recourfe to;  and  if this terminates in gan-
grene, the treatment proper for gangrene  in general, will
                                                   be 
                      [  401   3
be applicable.  When the inflammation ends in fuppura-
tion, and the quantity of matter colfeaed is produaive of
difagreeable fymptoms, it fliould be difcharged by the tro-
car introduced obliquely.   But this operation ffiould not
be advifed until we can  clearly  afcertain the cafe, and the
patient fuffers inconveniency from the matter  formed; be-
caufe it is attended with fome danger, and fmall quantities
of matter will often be abforbed.  By the ufe  of a trocar,
and  particularly by an  oblique  introduction of  it, lefs
chance will be given for the admiffion of air to the vifcera
than if a  fcalpel is ufed.    I have employed this praaice in
two cafes with fuccefs ; while two patients in fimilar eir-
cumftances died after the ufe of the fcalpel.
   Wounds penetrating the abdomen may prove dangerous
by admitting of a protrufion of fome of the vifcera contain-
ed in it.    In fuch cafes the prolapfed parts ffiould be re-
turned as fpeedily as poffible into the belly, provided they
are not aaually gangrenous ; in  which cafe, the parts of the
inteftine  at which the mortification terminates, muft be con-
neaed to  the external  wound  by future,  in  order  there
to form  an artificial anus.  If  however, the protruded
parts are covered  with fand,  dull, or  any  other extra-
neous matters, thefe ffiould be carefully waffied  off, by
bathing the parts  in warm milk and water  before they
are reduced.
   In performing the reduaion  of the  inteftines fome ad-
drefs is requifite.   The patient  ffiould be put  into the pof-
ture  that will moft effeaually relax the parts  in which
the wound is feated, v/ith his head  and cheft fomewhat
lower than the belly and buttocks.  The furgeon having
his fingers dipped in warm oil, or covered with foft oiled
linen, ffiould then endeavour to replace the parts, by begin-
ning his  preffure at one of the ends of the gut, and continu-
ing it along the doubling to the other.  If the inteftine con-
tains much air, he ffiould endeavour to make this pafs in-
                         3 E                        to 
                      [   402  ]
to the part within the belly by gentle compreffion ; and if
this is ineffeaual, or the inteftine cannot otherwife be rea-
dily returned, as muft happen fometimes when the wound is
fmall, the  external  opening muft  be enlarged.   In order
to make the enlargement in the fafeft manner, an incifion
ffiould be carried in a cautious and gradual manner  with
a fcalpel  through the integuments  and mufcles; and as
foon as  the peritonaeum is bared,  a probe-pointed biftouri
ffiould be introduced between this and the gut, with which
the membrane is to be cut until the finger can be introduc-
ed, and this ferving  as a direaor, the opening may then be
enlarged  to as great an extent as may  appear neceffary.
The  incifion ffiould always begin at  the  lower part of the
wound, be carried downwards, and in the direaion of the
mufcular fibres.
  In order to remove  the air from the protruded intef-
tine, we  have by fome been advifed  to  punaure the gut
with a needle ; but  this muft  certainly be confidered as a
very dangerous praaice.
  Small  wounds of the abdomen  may be healed by keep-
ing the patient in a proper  pofture, with his head and but-
tocks elevated ; by preventing coftivenefs ; and  by the ufe
of a flannel roller:  but extenfive wounds muft  always  be
clofed either by the  interrupted or the quilled future.  See
ch. iii. This operation is termed gaftroraphy.  In perform-
ing it, the patient ffiould be laid in  an eafy relaxed pofture ;
the fore-finger ffiould be introduced to guard the abdominal
vifcera from the needle ; and the needle  ffiould be entered
at the wound and brought  out at the diftance of  an  inch
from the  edge of it.   The futures ffiould not be more than
three quarters of an inch from each other, and the firft and
laft ffiould be made within half an inch of the extremities of
the wound.  The wound ffiould afterwards be covered with
fome  unauous fubftance  fpread upon  lint, in  order the
more effeaually to prevent the accefs of air;  and that a
                                           fubfequent 
                      [  403   ]
fubfequent protrufion of any of  the contents of the  belly
may be more effeaually guarded againft, a roller ffiould
be paffed feveral times around the body.   The patient is
afterwards to be treated according to the fymptoms which
enfue.
  We  are commonly  advifed to leave an opening in the
inferior part of the wound for the evacuation of any mat-
ter that may be formed: but as this cannot poffibly anfwer
the intended purpofe,  unlefs the injury affeas the lower
part  of the  abdomen ;   as it can only be preferved by the
ufe of a tent, the irritation of which may be very injuri-
ous ; and  as the ready  accefs thus afforded to the external
air muft neceffarily be produaive of very bad confequences
in many inftances ; I have no doubt  of the propriety of
clofing the whole wound in the manner above direaed;
and  that it will be better to truft to the abforption of any
matter which may be  afterwards formed,  or even to its
evacuation by the trocar, than to confide in this precarious
mode of treatment.
  In favourable eircumftances the wound will unite in  fix
or feven days ;  but when the ligatures give much pain,
and efpecially  when the abdomen becomes very tenfe, the
knots ffiould be untied, until by bleeding, fomentations, and
gentle laxatives, thefe fymptoms  are  removed;  and the
parts may then be again drawn together and  fecured as
before.


           §. 4.  Of Wounds of the Inteftines.

  Wounds of the inteftines  are commonly attended  by
naufea, violent pains in the belly, cold fweats, and faintings;
and by the difcharge of blood by the mouth and anus, and
of foetid air by the wound.
  In thefe cafes, where  the injured part is not protruded,
we are direaed by  fome authors to enlarge the wound
                                                 and 
                       [  404  3
 and fearch for it; but more mifchief would  probably be
 done by the extent of the cut that would thus be neceffary,
 and from the expofure of the  inteftines to the air, than
 Would be compenfated by the benefit  from the difcovery.
 The praaice therefore ffiould not be attempted ; efpecially
 as there have been inftances  of recoveries from  wounds
 of the inteftines which could not be reached.
    When the wounded part of the inteftines is prolapfed,
 it fhould undoubtedly be fewed up, in order to prevent the
 effufion of faeces into the abdomen:  this is  beft effeaed
 by the glover's flitch.   In making this, a fmall, fine, round
 needle ffiould be ufed, and armed with filk; and in order
 the more effeaually to guard againft producing a  diminu-
 tion of the cavity of the inteftines, the rieedle ffiould be in-
 ferted from within.*    The flitches are all to be in a con-
 neaed feries, and the needle always  entered in  oppofite
 places of the lips of the wound ; by this means it will go
 in a diagonal line from one fide of the wound to the other;
 and the flitches ffiould be made at about the diftance of
 two-tenths of an inch from each other.  Both ends of the
 thread are to be fecured by knots.
   We are commonly advifed to leave the end of the thread
 hanging out at the wound, that the whole may be with-
 drawn at  the  proper time ;  but when more than one or
 two flitches are taken, this muft be a matter of fome dif-
 ficulty, and lefs injury would  probably be done by leaving
 it within,  in which cafe it will chiefly pafs into the cavity
 of the gut probably, than by an attempt to draw it  out.
   When the inteftine is cut  entirely through, and  both
 ends protrude at the wound, the beft  praaice perhaps, is
'to  flitch them to the peritonseum and abdominal  mufcles,
 exaaiy oppofite and contiguous to each other; to drefs them
                                                lightly,

  » In the common method of performing this operation, both fides of the
gut are perforated at the fame time.  B. 
                       [  405   ]
 lightly, keep the wound clean, and truft to nature to effea
 a cure.   The faeces muft neceffarily for fome time be dif-
 charged by the fore, but there are inftances of the ends
 of the inteftine becoming firmly  united in a very little
 time.
   Another method of treatment, is to infert a tube of thin
 parchment or of paper, or rather a piece of tallow made
 of the diameter of the  inteftine, into the upper end of it,
 and afterwards to carry  this, with the fubftance ufed with
 it, into the lower portion of  the gut about an  inch;  and
 then connea them with a fine needle and thread all round,
 either at the end of the inferior part only, or there, and
 likewife juft above  the extremity of the fuperior portion
 of the inteftine.   Tallow ffiould be preferred to parch-
 ment or paper, becaufe  it will foon melt and come off with
 the  fseces.   The upper part of the gut may be diftin-
 guiftied  from the lower by  the  periftaltic  motion in  it
 being  more remarkable, and by the difcharge of chyle in-
 ftead  of fseces  from it.
   When only one end of a divided inteftine hangs out at the
 wound, we are ufually  advifed to connea it to the perito-
 nseum and other parts  contiguous to the wound, and  if
 this happens to be the fuperior portion, and not to be near
 to the  upper part of  the  fmall guts,  it  is faid the patient
 may live under the inconvenience of an artificial anus ;  but
 I am clearly of opinion that as the other end of the inteftine
 is  probably  not far  from  the wound, the incifion ffiould
 always be enlarged fo as to admit  of the introduaion of
 the fingers to fearch  for  it;  for this will not add much to
the danger; and ffiould the protruded part be  the lower
end,  the patient will inevitably die in a fhort time, if the
other is not found and conneaed in the manner above di-
reaed.
  In cafe  of gangrene of  the gut, whether complicated
                                                 with 
                      [  406  3
 with a wound or not, the treatment fhould be the fame.
 Vide §. 3.
   Wounds of the inteftines are always hazardous : but it
 does not appear,  from experience, that the difference of
 the  part injured makes  any difference  in  the  degree of
 danger.

             §. 5. Of Wounds of the Stomach.

   Wounds of the ftomach are known by vomiting of
 blood ; by naufea to a violent degree ; by langour and hic-
 cough ; and by the food and drink being evacuated at the
 wound foon after they are fwallowed.   Deep wounds in
 the left hypochondrium or in the epigaftrium muft necef-
 farily enter the  ftomach; but thofe which are infliaed
 obliquely in  any part of  the abdomen may reach it:  and
 wounds may penetrate this organ when it  is full, which
 would not  extend to it when empty.
   There are many inftances upon  record  of wounds of
 the ftomach  being cured  ; but they are always to be con-
 fidered as dangerous.
   Wounds of the ftomach require the fame treatment as
 thofe of the inteftines.  They are more readily difcovered;
 and when the part injured does not protrude it ffiould be
 fearched for, ftitched  and replaced : it may  always be
 reached except it be the pofterior portion.
   In order to prevent inflammation and  diftention of the
ftomach, the patient ffiould be  put upon as  low a diet as
his ftrength will bear;  and his food ffiould not be given
 in greater quantities at  a time than a couple of fpoonfuls.
Indeed we might venture here, as well as in wounds of the
upper part  of the fmall inteftines,  to truft altogether to
 nutritious clyfters, at leaft for a few  days;  but  in wounds
 of the larger inteftines the injeaion  might pafs more eafi-
                                                   ]y 
                      _  407   3
ly into the cavity of the belly than if the food was given by
the mouth.

     §. 6. Of Wounds of the Omentum and Mefentery.

   When any part of  the  omentum is nearly feparated
from the reft,  or has become cold, fo  as to induce a dan-
ger of gangrene,  it ffiould  be immediately taken off; but
when  thefe eircumftances  do not occur, it ffiould be re-
turned as foon as poffible into the abdomen.  See chap.
on Hernise.
   In wounds of the mefentery, when any of its veffels are
divided they ffiould be tied,  in order  to prevent the effufion
of blood or chyle into the cavity of the abdomen ; and the
ends of the  ligatures  ffiould be  left  hanging out  at the
wound, that thefe may be removed as foon as they fepa-
rate.

     §. 7. Of Wounds of the Liver and Gail-Bladder.

   The liver may be injured by any wound that penetrates
the right hypochondrium or epigaftrium: if the cut in it is
not deep, it often heals as readily  as  it  would in any other
part of the body, but when it paffes to a confiderable depth,
it  is always dangerous, from the rifk of  injuring fome of
the numerous  blood-veffels of this organ;  from the inter-
ruption it may give to the fecretion of bile ; and from admit-
ting the bile to be poured into the cavity of the abdomen.
   That the  liver is wounded may be  inferred from the
quantity of blood difcharged being more  confiderable than
could probably proceed from the  veflels of the teguments
and mufcles ;  from bile being mixed with this blood ; from
bile tinged with  blood,  being  difcharged  by the ftomach
and anus ; from fwelling and tenfion of the abdomen ; and
from pain on the top of the  fhoulder.
                                                  All 
                       [   408   ]
    All that  can be done in cafes of  this kind, is to guard
 againft a profufe difcharge of blood by the ufual remedies;
 and to difcharge colfeaions that may take place in  the ab-
 domen by proper openings.
   Wounds  of the gall-bladder are more dangerous  than
 thofe of the liver, becaufe they heal with more difficulty,
 and are  more  certainly produaive of effufion of bile into
 the abdomen.   In fome inftances the bile being obftrua-
 ed in its flow to the duodenum,  has  accumulated  in the
 gall-bladder, and produced a very large fwelling; an adhe-
 fion has taken  place between the bladder and the parietes
 of the abdomen ; the fwelling has burft, and the wound has
 at length healed ; but in general thefe cafes terminate un-
 favourably :—All that we  can  do is  to  procure as free a
 vent to the  bile as  poffible, and to difcharge it by an open-
 ing when it colfeas in the abdomen.

  §. 8.  Of Wounds in the Spleen, Pancreas, and Receptaculum
                         Chyli.

   When the fpleen is laid  bare we can eafily afcertain
 whether  it is wounded or not;  but unlefs this is the cafe
 we have no certain teft to difcover it.  Except that wounds
 in this vifcus are not fo dangerous as thofe in the liver, the
 fame general obfervations apply to both.
   Wounds of  the pancreas can  feldom be difcovered on
 account of its fituation ;* but  a divifion of  its  dua, by
 difcharging the pancreatic juice into the abdomen, may do
 material injury to the conftitution by injuring digeftion;
 and the  colfeaion thus made may ultimately require the
 aid of furgery.
                                                Wounds

  * A man who had received a wound in the abdomen with a fhoemakcr's
broad paring knife, had a portion  of the pancreas protruded at the orifice,
which was cut off clofe to the integuments,  and the reft  being  returned
into the cavity, the man recovered. 
                      [  409  3
Wounds of  the  receptaculum  chyli  muft  always  be
very dangerous, by depriving the patient of nouriffiment.
Nothing more can be done in fuch cafes than  to difcharge
any colfeaion formed, by an operation, when  this appears
to be neceffary.

        §. 9. Of Wounds of the Kidneys and Ureters.

   The external coverings of the kidneys may  be hurt,
without any fymptom of importance being produced; but
if the pelvis renum, or ureters are wounded, fome or all of
the following fymptoms  are  occafioned:  pain  over the
whole loinsj in the groin, yard,  and tefticles; naufea and
vomiting ; and bloody urine,  paffed with pain and difficulty;
and the wound commonly terminates in a fiftula, which
remains during life.
   When the wound  is inffiaed anteriorly, the urine  is
apt to be extravafated into  the  cavity of  the abdomen ;
but when it is given from  behind, or from the fide, the
urine will either  pafs out at the opening, or will fpread
through the  contiguous  cellular fubftance.  In the firft
cafe,  the danger  will be very great; but in the latter, if
the patient furvives the hemorrhagy,  he may  efcape with
the inconvenience of a fiftulous opening through which
the urine will be difcharged.  All that we can  attempt is
to prevent the urine from lodging ;  and if the wound  ac-
quires callous edges, to remove  thefe by the knife or cau-
ftic, fo as to give them fome chance of at laft uniting.

            §. 10. Of Wounds of the Bladder.

   Wounds of the  bladder are in general readily enough
diftinguiftied by the urine coming away by the wound, and
by that which paffes through the urethra being tinged
with blood.
   Injuries  of  the  upper part of the bladder  prove more
                         3 F                hazardous 
                      [  410   3
 hazardous than thofe of the part covered by the  perito-
 nseum : in the firft cafe, the urine is chiefly extravafated
 into the belly, by which the  moft dangerous fymptoms are
 commonly produced; and in the laft, it is  evacuated by
 the wound.
   When  the under part of the bladder is wounded, mild
 dreffings ffiould be applied ; and we  muft  obviate inflam-
 mation by bleeding, laxatives, and a low diet, and parti-
 cularly by warm bathing and fomentations.  If the up-
 per part is injured,  the edges of the wound might be con-
 neaed by the glover's flitch, as advifed in wounds  of the
 inteftines ; but fome have propofed to connea the open-
 ing in the bladder to the external wound ;  this  however
 would be  apt, for obvious reafons, to do more harm than
 good,  except when the anterior part of the  bladder  was
 wounded.  In every cafe I would prefer the  firft method.

    §.11. Of Wounds of the  Uterus, and its appendages.

   It is obvious, that in judging whether a wound has pe-
 netrated the uterus, our opinion muft be in fome meafure
 influenced by the particular ftate of that organ at the time,
 as the extent of it depends entirely on the circumftance of
 its being impregnated or not; and if impregnated, on the pe-
 riod of the pregnancy..  In the cafe of unimpregnation a
 wound of that part will not be attended  by  any peculiar
 fymptoms; but  during pregnancy, it will either produce
 abortion,  or the quantity of blood difcharged externally,
 or into the abdomen, will be confiderable.
  Where  fymptoms of abortion come on, nothing  ffiould
 be done to remove them ;  but where they  do not take
place, and there is reafon to fuppofe the patient may fuffer
from the hemorrhagy, the delivery ffiould, if poffible,  be
effeaed in the natural way  ; if this  cannot  be done, the
wound fhould be enlarged and the child taken out through
                                                    it 
                      C  4ii  3
it.   In other eircumftances thefe wounds require no pecur
liarity of treatment.
   Wounds of the larger blood-veffels of the abdomen and
pelvis always prove very foon fatal, becaufe they lie out of
the reach of chirurgical affiftance ;  and wounds of the
larger nerves of thefe  parts  are  followed by  a  palfy, for
which we know no remedy.

                  SEC T.   XIII.

                  Of Poifoned Wounds.

   The  flings of wafps, bees, and other infeas, of this
climate, although fometimes produaive of a good deal of
pain, feldom induce any other bad confequence.   The ap-
plication of vinegar or fpirit  of wine immediately after the
injury,  often prevents the   inflammation  which  would
otherwife follow;  but  when this aaually comes on, cold
water feems the beft remedy.   For the fling of a fcorpion,
as well as of the wafp and other infeas in warm climates,
the fame remedies have fucceeded.
   The bite of a  viper always merits great attention ; for
although it does  not appear that  the poifon is in general
thrown out unlefs the animal is much irritated, yet as this
cannot be  certainly determined  immediately, we  fhould
conftantly  proceed  upon  the fuppofition of the wound
being poifoned.
   This  poifon generally operates  on the fyftem in the
courfe of twelve or fourteen  hours.  The patient at firft
complains of a violent burning pain in the  injured part;
this foon begins  to fwell; inflammation fucceeds, and is
often extended  over the  whole body: The  patient be-
comes languid and faint, and the  pulfe low and feeble;
he complains of giddinefs, naufea and vomiting ; and of a
                                                 fixed 
                       t  412   3
 fixed pain in the region of the heart:  The whole furface
 of the body becomes yellow; and this as well as the yel-
 lownefs of the urine which occurs, is  evidently the confe-
 quence of the diffufion of bile  ; cold fweats, and convulfive
 twitches come on ;  and if relief is not obtained,  death is
 fpeedily the confequence.
   In order to prevent thefe fymptoms, the only certain me-
 thod is, either to cut out the injured part immediately, or
 to deftroy it with the  aaual or potential  cautery:  And
 this  may probably be done with good effea while no bad
 fymptom has come on ; but the fooner it is put in praaice,
 the greater chance will there be  of its proving effeaual.
 Suaion either by the  mouth, or by inftruments, fhould
 never be trufted to.
   After the operation, a plentiful fuppuration ffiould be
 excited, either by ftimulating ointments, or by emollient
 poultices according  to  the ftate  of the wound, with  re-
 fpea to inflammation.
   When the poifon has entered the fyftem, the rubbing
 the  body all over with warm olive oil, and giving about
 an ounce of it every hour,  has been faid to obviate its bad
 effeas in many inftances.   But the efficacy  of this remedy
 is rendered  very doubtful by late obfervations ;  and  it
 would feem that the fupporting  a plentiful perfpiration is
 more to be depended on.  For this purpofe, eau de luce
 has  been particularly recommended ;  but  it is probable,
 that the common form of volatile  alkali would  be equally
 ufeful.   Theriaca, and many other remedies,  have  been
 highly extolled, but  none of thefe appear to merit  confi-
 dence.
   With refpea to the  bites of  mad animals, when  their
 effeas are extended to the fyftem, fo as to produce hydro-
 phobia, we cannot depend on any remedy with  which we
 are at prefent acquainted for their removal.   As a preven-
 tative of thefe, the moft probable means is  to remove the
injured part by cutting it out, or deftroying it, by means of
                                                   the 
                      [  413   3
the aaual or potential cautery, and exciting a plentiful fup-
puration afterwards.   As the effeas of the bite are fel-
dom communicated to the fyftem for  feveral weeks,  and
fometimes not for  fix  months, this treatment would pro-
bably fucceed, if  employed at  any period  before thefe
come on.   The fore ffiould afterwards be kept running for
a confiderable length of time.
   Sea-bathing and friaions, with mercurial ointment, to-
gether with its application to the fore, have been  much
depended on by fome as preventatives.  When the hy-
drophobia aaually makes its appearance, it will almoft al-
ways be fatal; the treatment proper to be then direaed,
belongs to the province of medicine.
   When wounds are poifoned by the matter of difeafes, as
fometimes happens to furgeons in dreffing cancerous and
venereal ulcers, the moft effeaual remedy is, to cut out or
deftroy the part.   This muft alfo be the beft praaice when
fores  are infeaed  with vegetable poifons.   With refpea
to metallic poifons, they feem only hurtful by irritating or
corroding the edges of fores ; and require no peculiarity
of treatment.

                  SECT.   XIV.

                  Of Gun-fhot Wounds.

   As gun-fhot wounds exhibit the fame appearances, ex-
cept that they are  ufually in more violent degree, and re-
quire the fame general treatment with contufed wounds
from other caufes,* it  is not neceffary here to qnter  very
particularly into the confideration of them.
   Our  firft objea in  thefe cafes ffiould be to prevent in-
flammation ; for from the fupervention of this, gangrene, or
                                              extenfive
* &e$- Section on Contufed Wounds. 
                       C  41*.  ]
 extenfive fuppurations, which are the confequences moft
 to be dreaded, almoft always originate.   Hence, above all
 other remedies,  blood-letting ffiould be freely employed.
   The  very beneficial effeas of bleeding in general, but
 more particularly of the  abftraaion of blood from the  in-
 jured  parts themfelves,* in wounds of this  kind is very
 clearly evidenced by this faa, that fome of the  moft  re-
 markable cures  have occurred among thofe  patients who,
 after an engagement, are left fome time upon the  field; by
 which means they always lofe a great quantity of blood.
   With  refpea to the extraaion of  extraneous fub-
 ftances,  which is next to be attended to, the fame general
 directions are to be obferved as in the cafe of punaured
 wounds.
   When a ball  cannot readily be extraaed by the wound,
 or by a counter  opening, it  ffiould be fuffered to remain,
 unlefs it is lodged within  a bone, when it ffiould always be
 removed, if this can be done without danger to the pa-
 tient ; becaufe in fuch a fituation it is produaive generally
 of great inflammation, fwelling, and pain, of all the conti-
 guous parts. In taking out balls, or other fubftances, we
 fhould be very  cautious in the  introduaion of forceps
 and other inftruments.   Where they can be feen, forceps
 may be ufed ; but unlefs this be the cafe, it will be gene-
rally better to effea  their removal by  making a  counter
 opening, fo as to admit  of their being laid hold of by the
 fingers.
  When  the wound is  of  little extent, inftead of this
 praaice, whether the ball is lodged or no, if it can be done
 fafely, it will be better to  lay the wound entirely open ;  by
 this the ball is more eafily extraaed, and the cure will  be
expedited.   The dreffings fhould be  fome emollient  oint-
ment fpread on lint, and  over this a poultice of bread and
 milk.  To thefe applications the lead ointments may fome-
                                                 times
* See Section on Contufed Wounds. 
                      [  415   3
times be fubftituted with advantage.  An opiate fhould then
be given,  and the patient laid to reft in an eafy relaxed
pofture.
  The general treatment afterwards coincides very exaa~
ly with that  formerly recommended in  wounds  attended
with  contufion:  Suppuration ffiould be promoted,  and
the matter which forms, difcharged  by  a proper  pofition
of the patient, and by opening every  colfeaion which ap-
pears ; while at the fame time the patient's  ftrength  is
kept up by tonics and a nutritious diet.
  When a long continued and exceffrve difcharge affords
room for fuppofing that fome extraneous body, or pieces
of bone may ftill remain in the fore, a careful examination
fliould be  made, and  they  ffiould  be removed.   When
none of thefe can be  difcovered,  as fome fubftance, fuch
as cloth,  may ftill be there, though it cannot be felt,  if a
feton can be ufed, it ffiould be immediately introduced; and
often after a  confiderable  length of time, the drawing of
the cord has  brought out fuch fubftances, and a cure in
confequence has been foon effected.
  Opium  is particularly ferviceable to abate pain and ir-
ritation in every ftage of thefe complaints, and ffiould be
given liberally.
  Hemorrhagies are fometimes  apt  to  take place upon
the  feparation of the floughs which are produced  in gun-
fhot wounds ; and as they are often preceded by heat and
throbbing  pain in the parts,  they may frequently  be pre-
vented by copious bleeding, particularly from the  contigu-
ous parts by leeches ; but when the bleeding aaually comes
on,  if the veffels are  of any confiderable fize,  they muft be
tied in the ufual way.  When there is any danger of con-
fiderable hemorrhagy in thefe cafes,  the  patient fhould al-
ways be provided with a tourniquet,  that he may  reftrain
the  difcharge until affiftance can  be procured.
  Scarification of gun-fhot wounds, and even dilatation of
                                                them 
                           [   416   3

them, except in the eircumftances and manner we have al-
ready direaed, does not appear to  be at  all  neceffary or
ufeful.*
   When from the fituation or direaion of the  wound a
feton cannot be  ufed in the manner direaed in punaured
wounds, which fhould undoubtedly  be done in finuous ul-
                                                             cers

  * The  following  facts refpedting  gun-lhot wounds are inferted in
the  Medical  Journal for 17 90.   They  are communicated by  a Dr.
Jackfon,  and tend to fhew, that the practice  of dilating gun-lhot woundi
in the firft inftance fo generally recommended hitherto, except where
it is abfolutely neceffary for the removal of pieces  of bone, or extraneoui
fubftances, inftead of expediting their cure, often tends to retard it  by the
additional pain and inflammation it generally  excites.
  In  1779,  a  number  of  militia-men  were  wounded  in  Georgia,
where they  could receive  no furgical affiftance.   Their wounds were
merely bound up with rags;  and they  appeared to heal  much more
readily than thofe in fimilar eircumftances  that  were treated by fur-
geons in  the ufual mode.   After another engagement, a  part  of the
wounded were conveyed to  hofpitals;  fome remained  in the  woods
without  any  medical aid.  The latter, the eircumftances of the wounds
being alike,  healed with nearly twice the rapidity  with which the others
did. In 1781, after the battle of the Cowpens, in South-Carolina, thofe who
received  furgical affiftance,  neither got well fo  foon, nor with fo little
trouble as thofe who cured themfelves. The whole  were lodged in country
huts.
 . Dr. Jackfon further tells  us,  that  in the warm  climates of  Southi
Carolina  and  Georgia, he always found  warm  poultices  and  fomen-
tations injurious; and that  he derived much benefit from the  appli-
cation of laudanum  and fpirituous liquors, and more particularly from
pouring cold water on the wounded limbs.
  From  the Doctor's obfervation it  would  alfo  feem to  appear, that
reft,  in  flefh  wounds, is not only   unneceffary, but often injurious.
After the battle  of  Guilford, North  Carolina,  all  the  wounded who
could be carried off, were  either conveyed in litters, in  waggons, or
on horfeback: while  they  were in motion the progrefs to healing was,
rapid ; when  they halted for a few days, this was retarded; and when
they Hopped  altogether, it was in fome degree retrograde. The latter
circumftance  was probably owing to  the more free accefs  to fpirituon1)
liquors, which was then obtained. 
                      C  417  3
cers from this caufe, compreffion ffiould be employed as in
other fimilar cafes.
  With refpea  to the treatment of gangrene from gun-
fhot  wounds, and to  the  propriety of amputation in them
from that and other caufes, we muft refer to the feaion on
mortification, and chapter on amputation.
CHAP.    XL.

       Of Burns.
B
   URNS vary in appearance, according to their degree
    of violence, and to  the  manner in  which they are
produced.   Thofe which do not deftroy the cuticle, and
which merely irritate the fkin, operate like cantharides, by
exciting an increafed aaion in the exhaling veffels of the
part by which vefications are formed, in extent and num-
ber proportioned  to  the violence of the caufe :  but  when
the fkin or fubjacent parts are deftroyed,  no veficles are
produced;  a black  gangrenous flough is  firft obferved,
and when  this feparates, an ulcer is left of a depth propor-
tioned to the extent of the burnt part.
  The pain in burns is generally confiderable ; but it is in
common greater where the fkin has been merely irritated,
than when it  has been entirely deftroyed.   The  irrita-
tion and pain are indeed in fome cafes of extenfive burns,
fo violent as to induce a very high inflammation and  fever;
and fuch a degree of torpor fometimes comes on, that it at
                      3 G                        hft 
                      [  418   3
lafl ends in  death.  This fatal termination is, in fome in-
ftances, induced by an extenfive mortification taking place
foon after the accident.
   In the treatment of burns, our firft objea is to procure
eafe as fpeedily as poffible.   Where the fkin is not de-
ftroyed this  can be accomplifhed by immerfing the part
in cold water, or fuddenly plunging it into boiling water,
or any other fluid, nearly of the fame heat.   Emollients
fometimes procure immediate relief;  but in general, aftrin-
gents are  more beneficial, fuch as brandy or other ardent
fpirits.   In thefe the parts may be  immerfed ;  or when
this cannot be  done,  they  may be covered with  linen
foaked in  them.   Thefe applications  give a momentary in-
creafe  of pain at firft ; but this is foon fucceeded by  a very
agreeable foothing fenfation.  Strong lead water, a  ftrong
folution of  alum, or common ink,  are alfo very effeaual
remedies.   None of thefe applications feem chiefly ufeful
by preventing vefications, which they  do when early em-
ployed, becaufe they are  more  effeaual  in abating pain
after thefe are formed.   Whatever  is made ufe of  ffiould
be continued until the pain goes off.
   Together with  the external applications, opium  ffiould
be liberally  taken  internally, according  to the degree of
pain and irritation.   Befides removing thefe, it feems to
be the beft remedy  for that drowfinefs which often oc-
curs.   I am of opinion, that the vefications which occur in
burns, fhould not be opened until the pain has  gone off;
becaufe the admiffion of air always gives an increafe of this ;
but as foon  as the irritation induced has fubfided, they may
be opened with advantage ;  as the lodgment of the ferum
upon the fkin may probably render  it tender, and perhaps
even produce ulcerations.  In order  to prevent any bad ef-
feas from the admiffion of air, fmall punaures ffiould be
m ade in preference to incifions.   A liniment of wax, oil,
                                                   and 
                      I  419  ]
and faccharum  faturni is the  eafieft application after the
difcharge of the ferum.
  When the inflammatory fymptoms run high, bleeding,
laxatives, and other remedies fuited  to  inflammation  in
general become neceffary j and the ulcerations which fuc-
ceed muft be .treated in the ufual way.   See  Chapter on
Ulcers.
  When burns occafion  a lofs of fubftance, it will perhaps
be better to expofe them  to the air for a day  or two,  as
the flighteft  covering produces pain, and  to apply either a
liniment compofed of equal  parts of lime  water and lin-
feed oil, Goulard's  cerate, the unguentum  nutritum,  or
weak lead water.   The firft is generally  to be  preferred.
As foon as the pain and  irritation have thus been removed,
the fore is to be dreffed as in other cafes.
   In burns  from  the explofion of gun-powder, fome  of
the grains of the powder are apt to be forced into the fkin.
If thefe are not removed they  will increafe the irritation,
and perhaps produce permanent marks.  They may moil
readily be  removed  by  a needle or fome other fmall in-
ftrument ; if thefe do not take them all away, an emollient
poultice will complete their  removal; this  indeed is the
beft application in  injuries of this kind, for a few days, not
only for this  purpofe, but to prevent fubfequent  inflam-
mation.  There are fome parts,  fuch as the fingers, toes,
noftrils, and  palpebrse,  which will be apt to adhere toge-
ther when burnt, if attention  is not  given to prevent  it.
This will  be effeaually done  by the interpofition of fome
parts of the dreffings.
  Ulcers from  burns are very apt to become fungous :
when this  is obferved,  the fungus is to be removed  by
leaving off the  ufe  of emollients,  and employing  gentle
aftringents, and compreffion ;   and if.thefe do not fucceed,
by the ufe of cauflics.
                                           CHAP. 
[  420   ]
CHAP.     XLI.

         Of Tumors.
                    SECT.  I.

                 Of Tumors in general.

    EVERY preternatural enlargement, in whatever part of
     the body it is feated, may be termed a tumor.
   Tumors may with great propriety be divided into thofe
which from the beginning are attended with inflammation,
and  thofe  which are not evidently accompanied by this
affeaion ; the  firft may be termed acute or inflammatory,
and the laft chronic or indolent.  Phlegmon and angina are
inftances of the former; aneurifm and polypus of the latter.
Such of thefe as have not been already treated of,  or will
not be with more propriety confidered in fome other chap-
ter, we fhall now proceed to fpeak of.


                   SECT.  II.

           Of Acute or Inflammatory Tumors.

   As we have  already treated of inflammation in general,
we fhall in this  place merely take notice of thofe  eircum-
ftances which, from the peculiar fituation of the tumors, we
                                                  are 
                      [   421   3
are about to pay attention to, or fome other caufe require
fome peculiarity of treatment.

                  §.  1.  Of Eryfipelas.

   Erysipelas is a variety of external inflammation diftin-
guiftied from phlegmon,  (See chap. i. fea. 1.) by the co-
lour of the inflamed part not being of  fo bright a red,
but having a more dark copper-like appearance ; and by the
fwelling being not very evident in any particular place, but
rather diffufed, and ending as it were imperceptibly, upon
the furrounding parts.
   Eryfipelas  feldom  penetrates deeper than the fkin ;  and
any effufion with  which it is attended,  is commonly thin
and acrid, and not often convertible into pus.  As the ulce-
rations which this  effufion fometimes produces are always
difficult to heal, it ffiould be our  firft objea to prevent it
from taking place.  The fuppofed rifk attending this prac-
tice, and of attempting the difcuffion of eryfipelatous affec-
tions, appears from experience to be totally founded in pre-
judice.
   The moft common applications in the  firft ftage of eryfi-
pelas, and perhaps the beft, are fine flour,  ftarch, and hair-
powder.   Thefe commonly give  confiderable relief; but
I  believe they effea this rather  by  foothing that uneafy fen-
fation which ufually accompanies  eryfipelas, and leffening
the increafed aaion of the veffels which occafions the effu-
fion, than by abforbing the matter when poured out.  Unc-
tuous and  moift applications of every kind are generally
fuppofed to be injurious  ; neverthelefs, in fome cafes which
were not benefited by the remedies abovementioned, I have
experienced immediate relief from expofure of the part af-
feaed to the air, and wetting it now and then with a weak
folution  of faccharum faturni, without any fubfequent dif-
advantage  being occafioned by  the praaice.
                                            Experience 
                      [  422  ]
  Experience alfo eftablifhes the utility of bleeding accord-
ing to the eircumftances of the cafe.   Topical blood-let-
ting, however, being apt to be produaive of troublefome
fores, muft not be ufed.  Gentle laxatives, and mild fudo-
rifics, ffiould alfo be employed, and a cooling regimen ob-
ferved.
  By thefe means, moft eryfipelatous affeaions may be dif-
cuffed ; when however, they terminate in effufion to any
confiderable degree, an  opening ffiould be made in the
moft depending part of the colfeaion, and fome of the fa-
turnine ointments ufed as a dreffing to the fore.

           §. 1. Of Inflammation of the Ear.

  Inflammation feated in the membrane of the meatus
auditorius, is commonly very painful, from the part affea-
ed not readily yielding to the increafed quantity of fluid pro-
pelled into it.
  The treatment muft be determined by the ftage of the
complaint.   If  the inflammation has  continued fo long
as  to give reafon  for fuppofing  it  will terminate  in
fuppuration,  the ear  ffiould  be frequently bathed  with
warm  emollient fteams, and  warm  poultices  ffiould be
applied over it.   But in the beginning of the affeaion, we
ffiould generally try to prevent fuppuration; becaufe the
difcharge of matter which enfues will be apt  to continue
a confiderable time, and  perhaps terminate  in deafnefs.
Refolution will be moft effeaually promoted by the appli-
cation of a blifter behind the ear;  and by  dropping a
little  laudanum, or fpirit  of lavender, mixed  with oil,
into the  paffage,  we  may generally abate the  pain and
irritation, and confequently promote  the refolution very
much.
  We  will often  be  unable  to  prevent the formation of
matter; and when this has taken  place, we ffiould endea-
                                                  vour 
                      [  423   ]
vour to affift its evacuation by bathing the  ear  in  warm
water, or by injeaing warm  water into  it.   Thefe  will
often ftop the difcharge ;  but when they do not, lime wa-
ter, or a weak folution  of facch. faturni, may be employed,
and  will feldom  fail,  if the  foft parts  alone are affeaed.
When the bones are difeafed, which will be known  by the
fcetor, and black or brown colour of the difcharge, all that
fliould be done, is to keep  the paffage clear by injeaions.

                    §. 3.  Of Angina.

   In inflammatory angina or quinfy, befides the general
 remedies  of bleeding,  purgatives,  &c. topical bleeding is
 found to be more particularly beneficial.   In pi. viii. fig. 1.
 an inftrument is  delineated  for  fcarifying the throat; and
 when this is timely and freely employed, it will commonly
 prevent fuppuration  very effeaually : fliould this occur,
 however, the  fame  inftrument will be proper to difcharge
 the matter colfeaed.   To promote  the formation of pus,
 nothing is more beneficial   than  infpiring  the  fteams of
 warm milk, or any other  emollient deco<ftion, by means of
 the machine reprefented in  pi. viii. fig. 3.

            §.  4.  Of Inflammation of the  Liver.

    When notwithftanding  the  employment of the reme-
 dies of internal  inflammation in general, and of mercury,
 which has been found fo  particularly bene,icial in hepatitis,
 the difeafe terminates in  fuppuration, the aid of furgery of-
 ten becomes neceffary.
    When the abfcefs is feated on the convex  part of the li-
 ver, and is of confiderable  fize, it  will readily be  difco-
 vered by the touch.  But when this  is not the cafe, a
 continuance  of the pain in  the  right fhoulder and neck ;
 an appearance of fwelling in the region  of the liver;  an
                                              cedematous 
                       [  424   3
 cedematous affeaion of the integuments in this part; but
 particularly the occurrence of frequent  fhivering  fits will
 pretty certainly denote that fuppuration has taken place.
   Abfceffes of the liver have been known to burft through
 the  diaphragm, fo  as to be emptied into the thorax: in
 fome few cafes, the matter has been carried into  the duo-
 denum,  by  the  duaus  communis, choledochus ;  and
 fometimes by the great arch of the colon adhering to the
 liver, a communication  has been  formed between  them,
 by which the pus has  been evacuated  ; but for the mofl
 part, when  it  is  not  difcharged by  an  external  open-
 ing, it bur Its  into the cavity of the  abdomen.   In or-
 der to prevent fuch a fatal termination, as foon as we have
 reafon to fuppofe that matter is colfeaed, even if it ffiould
 not probably  have  yet been converted into pus, an incifion
 ffiould be made with a  fcalpel through  the teguments, in
 the moft depending  part  of the tumor,  and on reaching
 the abfcefs,  it  may  either be  opened with  the fcalpel or
 with a lancet;  but a trocar would perhaps  be preferable
 to either, as by means of that we have  it in our power to
 evacuate the matter gradually, which is a point of confe-
 quence in  all large colfeaions.   With a view to prevent
this  opening from clofing before the cyft collapfes fuffi-
ciently to hinder a  farther colfeaion of matter, it ffiould be
afterwards fomewhat enlarged.  A pledget of lint, dipped
in oil, or fpread with  fome emollient  ointment, ffiould
then be infinuated  between the edges of the wound, fo as
to prevent them from uniting until the ulcer heals from the
bottom;  a procefs which will be  much haftened by the
ufe of compreffion,  applied by  means  of a roller carried
round the body.
  Ulcers in the liver heal  fooner, and  with lefs  trouble
than in any other part of the body.  But when  they do
not readily fill up,  which will very feldom be the cafe,
                                                    it 
                      [  425   3
it will be proper  to  introduce a canula, in order to pre-
ferve a free difcharge of the matter which forms.
   A free ufe of bark, and a nutritious regimen will always
be very neceffary and ufeful in the fuppuratory ftage of this
difeafe.
   Praaitioners are  generally of opinion, that unlefs the
colfeaion of matter  takes place in  the convex part of the
liver, no attempt to difcharge it by an external opening
 can with propriety be made;  but wherever it is  fituated
 a vent ffiould certainly  be procured for the matter ;  for if
 it  is not evacuated externally,  it will moft probably be
 emptied into the abdomen, and inevitably occafion death.
 When the matter is poured into the abdomen or cheft,
 the only chance of faving the patient will be by drawing  it
 off by the operation of the paracentefis, as  foon as poffible.

   §. 5.  Of Inflammation  and  Abfceffes in the  Breafis of
                         Women.

    Inflammation  in the breaft may be produced  by any
  caufe which occafions it in other parts of the body; but
  it is more  particularly apt to be occafioned in nurfes by
  an obftruaed flow of milk from  a fudden or imprudent
  expofure to cold.   The  breaft becomes  ftiff, fwelled and
  painful; the milk runs off in fmall quantities ;  and the pa-
  tient is feized with reftleffnefs and fever.
    This complaint, in my opinion,  ffiould always be treat-
  ed in the manner advifed for inflammation in general.   In
  order to effea  the refolution of the tumor,  the  patient
  ffiould be  bled according to her ftrength;  have purgatives
  given ; and be kept upon a low cooling diet:  And as the
  pain is ufually  very confiderable, opium ^ffiould be given
  freely to alleviate  it.  In order to remove the tenfion,  the
  breaft fhould be gently rubbed with alth*a ointment or
  oil; but the applications moft to be confided in are thofe
                         3 H                         <-* 
                      £  426   ]
of  a  cooling aftringent nature,  fuch as a folution of fal
ammoniac  in vinegar and  water, fpiritus nindereri, and
the faturnine preparations.  Cloths dipped in thefe ffiould
be conftantly applied ; by which, and the other remedies
advifed above, almoft every cafe of this kind may be re-
moved.
  But inftead  of this method  of treatment, when the in-
flammation has been of long continuance, and the pain and
tenfion accompanying it are very confiderable, it  will be
better to endeavour to  bring the  tumor to fuppuration, by
warm  poultices and fomentations ; and  when  matter ap-
pears  to be formed to difcharge  it by an opening in the
moft  depending part of the colleaion ;  at leaft an open-
ing ffiould  be made  whenever  the  matter appears to be
pointing  at an improper part.
  As  I  have  always  found drawing  off the milk to give
relief,  I  conftantly advife it  to  be done ; and when the
child  cannot lay hold of the nipple, nipple glaffes  muft be
employed.

          §. 6. Of the Inflammation of the Tefles.

  Inflammation of the tefles  may be induced by coM,
external violence, or by  any  other caufe of inflammation
in general: but it is moft frequently occafioned by violent
gonorrhoea.  In this cafe it appears to be produced by an
extenfion of the inflammation from  the urethra along the
vafa deferentia; and is commonly  the  confequence of a
ftoppage  of the running from the ufe of irritating injections,
or other  caufes.   This circumftance is very  generally at-
tended by  an  increafe of inflammation ;  to  abate which
nothing is more effeaual than a  return  of the difcharge.
This is the moft probable manner of accounting for the
relief which a  return  of the  running, in fuch inftances,
gives to the  tefles.
                                                 Thi* 
                      -   427  }
  This  difeafe rarely  terminates  in fuppuration.   The
moft effeaual  remedy  for its removal  is  blood-letting;
and  particularly by means of leeches applied  to the  part
affeaed.   The  fwelling ffiould afterwards be  kept  con-
ftantly wet with a folution of facchar. faturni ;  the fcro-
tum  and tefles fliould  be fufpended; the  bowels  ffiould
be kept moderately open ; a low diet fhould be  ordered \
and  the patient fhould be confined  to  a horizontal pof-
ture.  If the cafe is venereal,  it will be abfolutely necef-
fary  to employ  mercury; and when the  difeafe  is the
confequence of a fudden  floppage of the  difcharge, we
ffiould endeavour to produce a return of this  by bathing
the penis  in  warm water; by injeaing  warm oil into tne
urethra ; or by the ufe of bougies.
   If the fwelling fhould fuppurate, which will  very  rare-
ly happen, an opening ffiould be made in the moft depend-
 ing  part of the colfeaion, and the fore  afterwards dreffed
in the manner advifed in other cafes of abfcefs.

                §. 7.  Of Venereal Buboes.

   Swellings in  the lymphatic glands  from  the  abforp-
 tion of the venereal  virus, are termed Venereal Buboes.
 They may appear in any gland feated between  a venereal
 fore and  the heart;  but they are  moft frequent in  the
 groin, in  confequence  of chancres on the penis.  In fome
 inftances  they occur  from the matter  of a gonorrhoea ;
 and in fome others they arife without any  previous ulcera-
 tion or difcharge  from the penis, the matter appearing to
 be abforbed without any erofion of the fkin.
   As it is now very well known, that the quantity  of ve-
 nereal matter is increafed by buboes being brought to fup-
 puration,  and that the fores produced  by them are often
 very difficult to heal,  few doubt  of the propriety of endea-
 vouring to remove them by refolution. 
                     [   428  3
  In order to effea this,  the patient ffiould be put upon
an antiphlogiftic regimen; his bowels fliould  be kept open
by purgatives; leeches  ffiould be applied  to the gland;
and it ffiould be kept conftantly wet with a ftrong folutiori"
of faccharum  faturni.   And  along with thefe  mercury
ffiould be employed in as  large quantities as may appear
neceffary; and  it  will  be moft beneficial if made to pafs
through the difeafed gland, by rubbing the mercurial oint-
ment into fome part where it may be abforbed by  the
lymphatics that go to the part affeaed ;  thus in inguinal
buboes, it ffiould be applied  on the leg or thigh.
  By  thefe remedies, buboes,  if  taken  in  time,  may
generally  be difcuffed ; but when this cannot  be  done,
either from the difeafe having fubfifted too long, or from
a  complication with fcrophula,   fcurvy,  eryfipelas,  or
phlegmon, the ufe  of the mercury ffiould be intermitted
for fome time, until by a change of diet and other eircum-
ftances, we may give a chance of making a fecond trial of
it more fuccefsful.
   When  a  bubo  feems  proceeding to fuppuration,  this
ffiould be promoted by the ufe of  fomentations and  poul-
tices as in other cafes; and  as foon as matter is  formed it
fliould be difcharged.  There have been various methods
of effeaing this.    Some advife a  fmall punaure  with a
lancet; others an incifion, the whole length of the fwelling:
fome again, recommend it to be accomplifhed by the applica-
tion of a cauftic ; while others are advocates for leaving the
bubo to form an opening of itfelf.    Either  of thefe  me-
thods may fucceed in fimple  venereal buboes, provided a
fufficient quantity  of mercury  is given ; and each of them
may occafionally be followed by fores difficult to heal.
   The local treatment  here  ffiould be  nearly  fimilar  to
 that advifed in colfeaions of  matter in other parts.   In
 general, an opening ffiould  be made merely fufficient for
giving vent to the matter.   In very large buboes  indeed,
                                                    the 
                     [  429  3
the teguments are often  rendered fo lax, and their texture
is  fo much deftroyed, that it will be advifable to remove
part of them by cauftic ;  but in common it will be fufficient
to  make an opening from the middle of the tumor, where
it ufually points, to the  moft depending part.   In fmall
buboes a mere punaure  will often anfwer the purpofe; or
they may even be allowed to burft ;  but this ffiould never
be depended  on  in  large colfeaions.  When the integu-
ments remain unufually  firm,  I have fometimes fucceeded
bv the introduction of a fmall cord.   And laftly, from
having obferved buboes which difcharged the matter con-
tained in them by a number of fmall openings to heal very
readily in  general, I have in feveral  inftances imitated the
procefs  by making feveral  fmall punaures with a lancet,
and with very good effeas.   I attribute the fuccefs in fuch
inftances  to  the exclufion of the external air, which muft
be the confequence of this method.
   The patient fhould continue the ufe of mercury conftant-
ly, for if he intermits it, the fore will not heal  fo readily.
The  ulcer, however, often  proves tedious,  even where we
 are convinced that a fufficient quantity of mercury has been
 given to eradicate the fyphilitic virus.  The edges become
 hard and thin ; the matter difcharged, thin, acrid, and foe-
 tid ;  and the fore gradually becomes more extenfive; or if
 it heals in fome parts it breaks out in others, giving a honey-
 comb appearance to all  the  under part of the abdomen,
 and upper parts of the  thigh.  The patient fuffers a great
 deal of pain; becomes heaical; lofes his reft and appetite ;
 and becomes very much emaciated.
    In fuch cafes, we muft firft be certain  that  the  patient
 has taken a fufficiency of mercury, and that no finufes arc
 left in  which matter can be lodged.  In thefe  inftances, I
 have known cicuta very beneficial; I have feen ulcers healed
 by mixing the juice of the frefh herb with a common poul-
 tice, which had refifted  all the common applications; when
                                                  given 
                       [  430  3
 given internally,  the  frefh juice has been more effeaual
 than any other  form of it.  The belladonna and hyofcya-
 mus, have never appeared to  me to produce any  material
 advantage.   And neither farfaparilla  nor guaiacum  have
 been ufeful;  but mezereon has alone evidently cured fome
 patients in whom all the ufual remedies had  failed.   A
 drachm and an half may be  boiled  with 3ij of liquorice-
 root, in three pints of water to a quart; and that quantity
 of the decoaion drank daily
   But the moft effeaual courfe that I have tried is, the
 application of cauftic  all round  the edges and hardened
 parts of the fore, at the fame time that opium in confidera-
 ble quantity is given internally.   On thofe days in which
 the cauftic is not applied, red  precipitate ffiould be ufed to
 the fores, either fprinkled over them, or applied in an oint-
 ment.   The firft few  applications of thefe commonly give
•pain, but this foon fubfides, and the difcharge  feldom fails
 to alter from a thin fharp fanies to a thick well  digefted
 pus.
   Opium alone has been lately given in very large quanti-
 ties  for the cure of the venereal difeafe ;—to the extent of
 half a drachm or more three times a day.    I have feen no
 proof of its curing any venereal affeaion ; but I have feen
 feveral inftances of fuch fores as we have above defcribed,
 completely cured by the  ufe of it.  It  does not however
 appear that it is more effeaual  when given in very  large
 quantities, than  when fo much only is exhibited as is necef-
 fary to alleviate  or remove the  pain.  Its utility  feems to me
 to depend entirely on its  narcotic or anodyne powers ; by
 thefe it removes that ftate of  irritability with which  thefe
 fores are affeaed, and thus deftroys the difpofition of the
 veffels to form that kind of matter, which by its acrimony
 feems to perpetuate itfelf; and this being done, and other
 eircumftances being favourable,  nature alone will  feldom
 fail in accomplifhing  a cure.
                                                   $. 8. 
[  431   3
               §.  8.   Of Lumbar Abfceffes.

    Every colfeaion  of  matter  feated on  the loins may
 be termed a Lumbar Abfcefs : but at prefent we mean to
 confine  our obfervations to  that variety  of the difeafe
 which originates about the fuperior part of the os facrum,
 and in which the matter is  contained  in a  cyft lodged
 on  the  anterior  furface  of the  internal iliac and pfoas
 mufcles.
   Thefe  abfceffes are always preceded by tenfion over the
 loins, and a pain, which often ffioots up along the courfe
 of the fpine, and down towards the thighs, and frequently
 by fome difficulty of  ftanding  erea.   In fome cafes thefe
 fymptoms  are fufpeaed  to  be  nephritic;  but for  the
 moft part they give an appearance of lumbago.    When
 fuppuration  takes place,  fhivering fits are  apt to occur;
 but the pain which was at firft acute, becoming dull and
 lefs perceptible, the  patient is made to believe that he is
 getting better, until the  matter, after  falling gradually
 down behind the peritonseum, is obferved to point exter-
 nally, either at or  near  the   anus, or on the upper and
 fore part  of the  thigh, where  the large  blood-veffels pafs
 out  beneath poupart's ligament from the abdomen.  In
 the latter cafe, which moft frequently occurs,  the matter
 being beneath the  tendinous fafcia of the thigh, inftead of
 pointing at any particular  part,  falls gradually lower, until,
 in fome cafes,  it reaches  almoft to the knee.
   The  tumor is   feldom  attended with  more pain than
 might  be  expeaed to occur from the diftention of the
 fafcia and contiguous parts by the matter beneath ; there
 is  no difcolouration of the fkin, which often retains its na-
 tural appearance to the laft ; and a fluauation of a fluid is
evidently difcovered through the whole extent of the tumor,
particularly when the  patient is erea ; for in this pofture
                                                  the 
                      [  432   3
the fwelling is always  more tenfe than when the patient
is  lying horizontally, becaufe  a  confiderable part of the
matter then runs along the fac  towards its origin in the
loins.
   When the matter paffes down towards  the  anus, this
complaint may be miftaken for a common phlegmon; and
no inconvenience will arife from treating it as fuch.  But
when it falls down  beneath  poupart's  ligament, its ap-
pearances  are fo  fimilar to thofe of a crural hernia, that
the one has often been unfortunately  miftaken for the
other.   This however, can only have arifen  from a want
of proper attention to the charaaeriftic fymptoms of each.
Befides the  other   diftinguifhing  marks,  whenever the
lumbar abfcefs extends low  down, in an erea pofture
the part of the cyft  at the top  of the  thigh exhibits no
appearance  of fwelling.    And  ffiould the  difeafes be
combined, which  muft  very  rarely  be the  cafe, as the
matter of the abfcefs and the protruded abdominal  vifcus
or vifcera  will be contained in feparate facs, the complica-
tion will be eafily deteaed.
   This difeafe feems, in general,  to be induced by a bruife,
twift, or fome other injury to the fmall of the back ; in fuch
cafes, whenever the  pain produced  is confiderable,  blood-
letting fhould be immediately advifed, and every part of the
antiphlogiftic regimen  obferved.   Cupping, with deep fca-
rifications, feems  to be the moft effeaual remedy, and I
have no doubt, would often prevent the formation of this
difagreeable complaint, if early employed to  a  proper ex-
tent :  it almoft always gives relief to  the pain, however
violent it may be.   Blifters, opiates, and gentle  purgatives,
ffiould alfo be occafionally made ufe of.
   In fome inftances thefe remedies will  fail;  and in others-
we are not  called   in until fuppuration has taken place.
When this is the cafe, I  have no doubt of the propriety of
difcharging the matter colfeaed  by an opening with a tro-
                                                   car 
                        [   433   3
 car, when the cafe is well afcertained, and by cautious dif-
 feaion  when there is any doubt of its nature.   A canula
 may afterwards be introduced  to give  a more free exit
 to the matter ; and if the difcharge does not diminiffi confi-
 derably in the courfe of two or three weeks, lime-water or
 fome other moderate aftringent may be injeaed, to put a
 ftop to it.  But if this ffiould never happen, it will be bet-
 ter for the patient to fubmit to the inconveniency than to
 rifk the difcharge of the matter into the abdomen,  or the
 corrofion of the bones adjacent, by fuffering the abfcefs to
 remain unopened.


           §. 9.  Of the Paronychia or Whitlow.


   The paronychia is a painful inflammatory fwelling, oc-
 cupying the  extremities of the fingers under the nails.
   All the varieties of  this complaint  diftinguiftied by dif-
 ferent writers, may be comprehended under the three fol-
 lowing, and  even thefe differ only in point  of depth of fitu-
 ation.
   In the  firft, the patient complains of an uneafy burning
 fenfation for feveral days over the  end of  the  finger ;  the
 part becomes tender and painful to the  touch; a flight
 degree of fwelling takes place,  but with little or no difco-
 louration  ; and if the inflammation is not removed by re-
 folution,  an  effufion is at laft produced between the fkin
 and the parts beneath this, which if difcharged, appears to
 confift in  a thin,  clear, and acrid ferum;  and its removal
 generally gives immediate relief.
  In the fecond fpecies, the fame fymptoms occur in a more
 violent degree ; the pain is  more  fevere,  and  is attended
 by uneafinefs  over the whole hand.  The effufion is  not
 fo perceptible, and is found to lie beneath  the mufcles,  or
between thefe and the periofleum of the finger.
                        3 I                        And 
                      [  434  ]
   And in the third variety, the pain in the end of the finger
 is ftill greater ; and the whole extremity becomes ft iff, fwel-
 led, and painful : The lymphatics  leading from the finger
 and even the glands in  the arm-pit,  become fwelled and
 inflamed ;  and an incifion being made, difcovers the effu-
 fion to  be  feated between the periofleum  and bone, the
 whole  phalanx being in general carious.
  Thefe fwellings are often the effeas of external violence,
 and particularly of  punaures, and contufions; but they
 happen more frequently from  fome caufe with  which we
 are  unacquainted.
  I always treat paronychia  upon the  fame plan that I
 employ in the removal of other inflammations. In the early
 ftage of it,  I  endeavour to difcufs the fwelling :  Firft,  By
 the  application of leeches to the pained part of the finger,
 and by general  blood-letting in the more extenfive fpecies
 of the complaint. The leeches often remove the moft vio-
 lent pain almoft  immediately.   After thefe have been ufed,
 immerfion of the pained parts in ftrong brandy, or even in
 fpirit of wine, is one of the beft remedies ; and when the
 wounds made by  the leeches are fomewhat  healed, or
 when thefe animals have not been applied, fpirit of turpen-
 tine or ftrong vinegar, may be employed in the fame man-
 ner. Opiates  fliould alfo be ufed in quantities proportioned
 to the violence of the pain.
  When an  effufion  has  taken place, an opening ffiould
 be made to it; becaufe there is no  chance of converting it
 into pus, and as  long as it remains it gives the patient ex-
 quifite  pain, and becaufe it is apt to injure the contiguous
 parts.   When the colfeaion is fuperficial, it may be dif-
 charged by a  punaure with a lancet;  but when it is deep-
feated,  care muft be  taken  to avoid injuring the tendons of
the  finger by the incifion which will then be neceffary.
  If the matter lies above the periofleum, the wound made
is to be treated as a  fore from any other caufe ;  but when
                                                    it; 
                       [   435   ]
it is beneath the periofleum, as the bone is always found
to be more or lefs carious; I am clearly of opinion, that the
beft practice is  to remove the whole phalanx immediately.
This may be  done with the greateft eafe, and faves much
time and trouble both to the patient and furgeon. The fore
afterwards heals without difficulty ; care being taken that
it fills up from the bottom; and little difadvantage is expe-
rienced from the lofs of bone.  The nail which is commonly
loft, is in general foon reproduced.
   If the common method of treatment by poultices, fomen-
tations, &c. is purfued,  and the bone is left to come out of
itfelf,  when difeafed, matter is apt to lodge  beneath  the
nail, troublefome  fungous excrefcences to arife, and  the
procefs is ufually painful and tedious.
   It does not  appear, that more than the laft phalanx of
the finger fuffers in this complaint; but when from impro-
per management, the furrounding  foft parts become in-
flamed, fwelled and ulcerated, it  often is  at laft neceffary
to amputate the finger, in order to prevent the difeafe from
fpreading to  the hand.

                   §. 10. Of Chilblains.

   These are painful inflammatory fwellings, to which the
 fingers, toes, heels, and  other extreme parts of the  body
 are liable,  on being much expofed to fevere cold.   The
 fwelling is generally of a deep  purple, or fomewhat of a
 leaden colour;  the  pain is not  conftant, but acute and
 fhooting ;  and for the  moft part  there is an intolerable de-
 gree of itching aU over the fwelling.  In fome cafes,  the
 fkin cracks,  and difcharges a thin, fomewhat foetid matter.
 And when the degree of cold has been very great, or it has
 been very long applied, all the affeaed parts are very apt
 to gangrene and flough off, leaving a very foul  ill-condi-
 tioned ulcer.
                                                Delicate 
                      [  436   3
  Delicate children, and old people,  are  moft fubjea to
chilblains  ; and it is obferved that they are particularly apt
to be fevere in fcrophulous habits.
  The beft mode of preventing them, is to avoid expofure
to cold and moifture ; and efpecially to fnow, which feems
particularly injurious; and when a  perfon has once beert
affeaed, as they  are  very liable to return, he ffiould be
careful to keep  the injured parts warmly covered during
the winter.   Cold bathing has alfo been ufeful.
   Every precaution that can be  taken will, however, not
always be fuccefsful in preventing this complaint.   But it
may often be mitigated by bringing the affeaed parts gra-
dually, to their natural heat, inftead of warming them very
quickly. The patient fliould be  put into a cold room ; and
the froft-bitten parts fliould be well rubbed with fnow, and
afterwards immerfed  in very cold water; he fhould keep at
a diftance from the fire for a confiderable time, and during
this,  the  parts may be rubbed with fait,  or immerfed in
warm wine.
   A  perfon  much benumbed with cold fliould not have
warm cordials given to  him immediately.   A  glafs of cold
wine may be at firft allowed : Afterwards warm wine may
be given, either alone or mixed with fome of the warmer
fpices ; or ardent fpirits may be  ufed.
   Thefe remedies are however only neceffary in the more
fevere affeaions of this kind.   In common cafes of chil-
blains,  it will be fufficient to rub the parts with fpirit of
turpentine,  or camphorated  fpirit  of wine-;  and to keep
rags moiftened with thefe conftantly applied to the parts.
   When chilblains ulcerate or crack, poultices may be ap-
 plied for a few days, to induce a proper fuppuration ; but
if they are continued for any  length  of time they render
the fores fungous  and difficult to heal.  The daily applica-
tion of cauftic to  the edges, and of precipitate ointment to
the reft of the  fore, after the poultices are difcontinued,
                                                  feems 
                      [  437  3
feems the beft method of treating them.  The diachylon
fimplex is alfo a good application.

            §.11. Of Sprains and Contufions.

  Contusions of the fofter parts of the body, and fprains
of the tendons and ligaments of joints, are ufually produc-
tive  of immediate  painful  inflammatory  fwellings,  and
which, when in confiderable degree, require a great deal
of care and attention.
  The fwelling  is  chiefly  produced by  the  effufion of
blood or of ferum, from the veffels ruptured by the inju-
ry.   When the ferum only is  poured out, the fkin retains
its natural colour for fome time ; but when blood is extra-
vafated, the fkin  is of a deep red, or of a leaden  colour
from the firft.
  In the  treatment of thefe  affeaions, our views muft be
firft direaed to  prevent  the  fwelling,  and afterwards to
prevent or remove inflammation.
  Swellings of this kind, when confined to the integuments
or mufcles, are often  removed in  a little  time by abforp-
tion ; but thofe which  affea the tendons, or ligaments, if
not properly attended to, are  very apt to continue a great
while, and prove very troublefome : On this account they
fliould have a careful attention.   Aftringents are the  beft
applications to prevent  the  fwelling; fuch as lees  of red
wine,  ardent  fpirits,  and vinegar, or even cold water  if
thefe cannot immediately be had, either in its ufual ftate,
or rendered colder  by  art.  In one or other of thefe the
part ffiould be immerfed for about an hour.
  Thefe remedies fortunately happen to be equally adapt-
ed to the  prevention of the effufion, and the inflammation
which is  fo apt  to occur.   But in confiderable injuries of
this kind, after the ufe of them as above direaed, it will be
proper further to endeavour to obviate the latter fymptom 
                      [  438  3
by the application of leeches, or if the mufcular parts only
are hurt, by cupping and fcarification.  Blood ffiould thus
be repeatedly drawn as long as the inflammation continues.
This feems equally effeaual, whether the parts affeaed be
deep-feated or near the furface.
   If the fever induced is very confiderable, it will alfo be
proper to ufe general bleeding ; and for obviating the pain,
to exhibit opiates.   Any other remedies of inflammation
in general  which may feem  indicated, ffiould likewife be
employed.
   After bleeding, the beft application to the part for a few
days is  a folution of faccharum faturni; and to remove the
thickening of the tendons which fometimes follows fprains,
pouring warm water upon the  part for a quarter of an
hour  at time,  three or  four times a day, is frequently
very ufeful. Salt water, or the water of fome of the mine-
ral fprings, feem to be more beneficial than common water.
The  rubbing the parts frequently with  warm emollients
has alfo a good effea.
   During the cure of a contufion or fprain, it is very ne-
ceffary  to keep the part in an eafy relaxed pofture.
   When the fwelling and pain are nearly  removed, and the
parts  remain weak and relaxed,  pouring cold water from
fome  height, or daffiing  it upon  them once or twice daily,
is the moft beneficial remedy. A flannel roller applied mo-
derately and equally tight over the whole  extremity, is alfo
very ufeful for preventing or  removing the oedema which
is apt to follow in thefe  cafes, from the  debility induced ;
and  likewife as a preventative of rheumatic pains, fome-
times confequent to thefe affeaions.
SECT. 
f  439  3
                   SECT.   III.

             Of Chronic or Indolent Tumors.*

               §. 1.  Of Encyfled Tumors.

  Under  this term we  ufually  comprehend  all  thofe
fwellings that are contained in cyfts of a preternatural for-
mation : and thefe as well as various tumors of the farco-
matous kind, are in common language termed wens.
  All the varieties  of encyfted tumors feem to be induced
either by an accumulation  of ferous matter, or of the fat,
which is depofited  in the  cellular membrane, from a de-
feaive abforption,  or too great a depofition of them,  in a
particular part,  which by fome caufe has had its communi-
cation with the reft of the membrane deftroyed.
  When the contents are of the  confiftence  of honey,
the tumor  has  been  termed meliceris ;  when of a foft
cheefy confiftence,  or refembling dough,  it is called an
atheroma ;  and fleatoma, when it  is formed of fat.   But
there are various degrees  of confiftence in each of them.
Thus the fleatoma is fometimes  foft like  butter, and at
other times  as  firm as  fuet; and the  contents of the
atheroma and meliceris are fometimes equal in hardnefs to
new cheefe,  and  at other  times are not firmer  than the
thinneft honey.
  The matter forming fleatomatous  tumors we conclude
to be of an  oily or fatty nature; and that their different,
degrees of confiftence will depend upon  the  remora of
their contents, and upon  the  quantity  of the  thinner
                                                  parts

  * Although chronic tumors, as has already been  mentioned, are not
primarily and  neceffarily attended by inflammation, yet it is to be obferv-
ed, that any variety of them, by  the diftention they give the fkin, may
eventually produce  it.  B. 
                       [   440  3
 parts of them that  have  been abforbed.  And we think
 it probable, that the atheromatous and melicerous tumors
 are originally formed by a depofition of ferum, with per-
 haps a confiderable proportion of coagulable lymph; and
 that their degrees of confiftence will depend upon the quan-
 tity of lymph contained in them, their duration, and parti-
 cularly upon their having been inflamed, and the degree of
 the inflammation.
   In general,  an experienced praaitioner will be able to
 diftinguiffi the nature of thefe tumors before they are open-
 ed : thus the fleatoma is ufually of a firm confiftence, loofe,
 and rolls under the fkin more readily than the others ; and
 its furface  is apt to be  unequal: the atheroma is  foft and
 compreffible, but no fluauation is obferved  in it;  and  in
 the meliceris,  the fluauation of a fluid is in general very
 diftinaiy perceived.   But, in fome inftances, from the eir-
 cumftances mentioned  in  the laft  paragraph but one, it
 muft be evident, that  we may be fometimes miftaken  in
 our judgment of the nature of thefe  tumors; and their
 combination will contribute likewife to deceive us.  The
 fleatoma is very rarely joined with either  of the  others;
 but the atheroma and meliceris are more frequently com-
 bined.  It  is to  be obferved  alfo, that the firft fpecies is
 rarely found where fat  is  not ufually  depofited in a ftate
 of health;  thus I have  never met with it on the  head,
 where the other fpecies  frequently occur.  None of them
 are often feated on the  abdomen;  probably owing to the
 parietes of the abdomen being foft and  yielding, and con-
 fequently not fo liable to ill  effeas from preffure, as the
 foft parts which lie contiguous to bone.
   Thefe tumors appear  fmall at firft, and increafe in fize
very  flowly.   They are  of very different  ffiapes  and
 fizes:   On  the  head   they  are  commonly round  and
fmooth, and feldom  grow  larger than an egg, probably
from the teguments not being fo capable of much diftenti-
                                                   on 
                      [   441   3
on as in other parts, where they have arrived fometimes to
fuch an enormous fize as to weigh forty pounds.
  They are never painful  at firft ;  and the fkin for a con-
fiderable time retains its natural colour.  But when they
become  large, the veins of the fkin, as well as thofe of the
fac, become large  and varicofe; and  the prominent part
of the fwelling acquires a clear Aiming red colour.  Even
now the tumor is not painful, unlefs it be injured by ex-
ternal violence,  which  will very  readily excite inflamma-
tion in the fkin.  It then becomes tender and painful,  and
foon burfts, if not  prevented by an artificial opening.
   From the fame caufe which influences the fize of thefe
affections, their progrefs feems rendered more or lefs rapid ;
hence they fooner terminate on the head than in any other
fituation.
   The firmnefs with which they are attached to the conti-
guous parts feems to depend on the parts with which they
are covered, and their having been inflamed or not, and
the degree to which the inflammation, when they have been
feized with it, has extended.  They are fometimes  quite
loofe  and moveable, particularly while they continue fmall:
and at other times they are  firmly fixed, and in fome in-
ftances  from the beginning.
   It was formerly  the praaice to attempt the difcuffion of
encyfted tumors by the application of mercurial ointment,
mercurial and gum plafters,  and a variety of other things ;
but experience has now proved,  that nothing but a chirur-
gical  operation can be depended on for their  removal.
   The  meliceris ffiould be treated as a common abfcefs.  If
fmall, its contents  may be difcharged by an incifion with a
lancet,  and then it may be dreffed in the ordinary way un-
til it fills up or adheres from the bottom. But if it is large,
to prevent the admiffion of  air which would be injurious,
a feton  fliould be employed  in the manner direaed in the
                         3 k                   feaion 
                      [  442  ]
feaion  on fuppuration.   This is the moft effeaual mode
of treatment I have ever feen employed.
   Wheft the contents of the tumor are too firm fo be dif-
charged in this manner,  it becomes neceffary either to emp-
ty the cyft by an extenfive incifion, or to diffea it,  with
its contents, entirely out.   If the bag adheres very firmly
to the contiguous parts, it will  be better to lay it entirely
open, and only take away thofe parts of it which are loofe.
By this, we may effeaually remove its contents; and the
cure may be afterwards accomplifhed with equal certainty,
by preferving the wound open until it heals from the bot-
tom, or by drawing the edges together, and trufting to
moderate preffure,  and the common effeas of inflamma-
tion for producing  a re-union.   It is  ufually thought ne-
ceffary  to remove the whole  of the cy't ; but experience
difproves this.   When it is to be done, however, it will
contribute much to the facility of the operation, to make a
longitudinal incifion  through the tumor, and  remove  its
contents before we begin to diffea it out.   After its remo-
val the teguments ffiould be laid together, and  fecured by
adhefive plafters or  futures,  and an  equable compreffion
then made over them, in order to produce a cure by the
firft intention.*
   If any arteries of confiderable fize are,.cut in  the opera-
tion,  they ffiould be immediately fecured by  means of the
tenaculum ;  and the ligatures ffiould be left hanging out at
the wound.   The  trifling impediment that this will give
to the  cure,  will be much  more than compenfated by the
fecurity from hemorrhagy, that is derived from the prac-
                                                   tice ;

  * Though many of the encyfted tumors, which Mr. Bell defcribes a*
fuccefsfully treated by a fimplt dilatation,  or the ufe of the feton, may
have been radically cured, yet inftances enough occur of their filling again,
where the whole or greater part  of the fac has been left, to put young
furgtons  on their guard in tumors  of any confiderable fize, where the
fafeft way is to remove  the fac entirely. 
                      I  443   ]
tice; for ffiould the bleeding be even very trifling, it might
confiderably retard the cure.  The  ligatures may generally
be taken away readily and  with fafety  at the fecond or
third dreffing.
  In common cafes it is not neceffary to remove any por-
tion of the  fkin, for although it may appear  too extenfive
at firft, it ufually contraas fo much  in a little time as mere-
ly to cover  the parts beneath.  But in large tumors, where
the fkin is in very large quantity, or where it has become
exceffively  thin, or ulcerated, it will be proper to remove a
part of it.   This will be beft effeaed by two femilunar
incifions, including as much of the fkin as  ought to be
taken away, and then diffeaing  it  off with the cyft.  The
fubfequent  treatment  is to be the  fame  as if no part of it
was removed.  In fuch cafes we  are advifed by fome to
employ cauftic for the  removal of the  fkin ; this ffiould,
however, never be done except the patient will not admit
the ufe of the fcalpel.


                  §. 2.  Of Ganglionic

   By the term ganglion, we mean an indolent, moveable
tumor, formed upon  the tendons in different parts of the
body,  but  moft frequently  on the back part of the hand,
and joint of the wrift.
   Thefe fwellings are diftinguiftied from the encyfted by
their elafticity.  They feldom become large, or painful;
and for the moft part  the fkin above them retains its natu-
ral afpea.  If laid open, they are found to contain a tough,
vifcid, tranfparent fluid, refembling the white of an egg.
   Ganglia may be generally removed, if early attended to,
either by moderate and frequent friaion, or by compref-
fing them  by means  of thin plates of lead, or  any other
duaile metal.  We  ffiould be careful not  to  ufe thefe
                                              remedies 
                      [   414   3
remedies in fuch a manner as to inflame  the  parts; as
troublefome fores may be the confequence.
   If thefe means  fail, and the  tumors become trouble-
fome by impeding the motion of the joint or in any other
way,  but not otherwife, they may be removed, either by a
mere incifion into them, or if they do not adhere firmly to
the tendons, by cutting them entirely out, in the manner ad-
vifed in the cafe of encyfted tumors.  The fore thus pro-
duced  is to be kept open until it heals from the bottom;
which will commonly happen without much difficulty.

        §. 3.   Of Szuellings of the Burfie Mucofie.

   The burfee mucofee are fmall membranous bags, feated
upon, or contiguous  to all  the larger joints, containing a
thin, tranfparent and gelatinous fluid, which feems intend-
ed to  lubricate  the parts upon which the  tendons  move
that pafs  over  the joints.  A preternatural accumulation
of this fluid, produced more particularly by fprains, con-
tufion, and rheumatifm, conftitutes the difeafe we are now
to treat of.
   This fpecies  of fwelling is  feldom attended with much
pain;  it yields to preffure, but is much more elaftic than a
tumor from pus; at firft it  is always confined to one part
of a joint,  but  in fome cafes  it at length  extends  almoft
round it;  and the fkin always retains its colour, unlefs it
becomes inflamed.   When  rheumatifm produces the fwel-
ling, its  contents are  commonly very  like the  fynovia;
but when it is  the confequence of fprains^  together with
this fluid  there is ufually a confiderable quantity of pretty
firm concretions.   In fome few inftances,  however, thefe
concretions are  foft.—Their confiftency  may generally be
afcertained by the touch.
   When thefe tumors are the effeas of rheumatifm, they
may perhaps be always difperfed in time,  by keeping the
                                                 parts 
                        [   445   ]
parts warm with flannel: by frequent friaions; by fre-
quently pumping warm water upon them ; or by the appli-
cation of blifters.   But  if they originate from fprains,  al-
though they may long remain flationary,  they can feldom
be  difcuffed.   An operation  then becomes neceffary for
their removal whenever they become troublefome.
   This confifts in forming an opening to difcharge the con-
tents of the tumor,  and preferving  the wound open  until
it  fills with granulations from below.*   When the  fac
cannot be opened through its whole length,  on account of
the contiguity of tendons, it will be beft  to lay it  open at
each end, and after preffing out the contents, to pafs a
fmall feton through  it.
   Thefe  operations  fliould be  done with a  great  deal of
care; and when the feton is ufed, it fliould be introduced
with a blunt probe,  and fuffered to remain  no longer than
till a flight  degree of inflammation is excited, on  account
of  the contiguity  of the joint; and when it is withdrawn,
the cure  is to be completed  by gentle  preffure  with a
roller.f
                                                         A

  * A great deal of difficulty has fometimes happened in confequence of a
dilatation or removal of thefe tumors, particularly where they do not heal
by the firft  intention.  The moft fuccefsful mode of openiiig them is by
drawing up the external  fkin, then puncturing the  tumor with a  lancet,
and when the fluid is entirely difcharged fuffering the external to pafs be-
yond the internal orifice.  A comprefs, dipped in lead water, is then to be
applied, and retained with a moderately  tight bandage, enjoining perfect
reft  and quiet for feveral days.
  f Dr. A. Monrt, of Edinburgh, has lately publifhed a valuable work
on the fubjecl of the burfe mucofa, or as he is difpofed  to term them, the
•veftca unguinofe; and as it is very probable, that -collections in thefe have
often been miftaken for affeelions of a very different nature, it may per-
haps be ufeful to add  fome obfervations from this treatife, to what Mr.
Bell has faid on the fubjecl:.
  The Doftor tells us,  that  he has difcovered one hundred  and forty
                                                       burfte 
                          [  44tf   3

   A confiderable ftiffnefs of  the joint ufually remains af-
ter the removal  of thefe  tumors.   The beft remedies  for
this, are friaions with emollient ointments, and the appli-
cation of warm fteams.


    §. 4.   Of ColleBions within the Capfular Ligaments.


   These collections may confift of blood ; of matter from
a previous inflammation; or of ferum, forming  what are
ufually  termed dropfical fwellings of the joints.
   They may be diftinguifhed  from  colfeaions  in  the bur-
fee mucofse,  by  the  contained fluid  paffing readily from
one fide of the joint to the other :  by  its being diffufed over
                                                            the

burfce mucofse in ajl; thirty-three in each of the  fuperior, and thirty*
feven in each of  the inferior  extremities.  Many of them  are placed on
the inner  fides of the  tendons, between thefe and the  bones.  Many others
cover not only the inner, but the outer fide of the tendons, or are inter-
pofed between the tendons and external parts, as well as  between thofe
and the bones.   Some are fituated between the tendons and the external
parts only, or chiefly ; fome between  contiguous tendons, or between the
tendons and the ligaments of the joints.  A few are  interpofed where the
proceffes of bones play upon the ligaments, or where one bone plays upon
another.  Some  of the burfae communicate  with each other; fome with
the cavities of  the joints.   In the latter cafe the communication feems
fometimes to be formed by long friction; and particularly occurs in the
joints of the fhoulder  and knee; and efpecially juft below the inferior part
of the firft, and immediately above the fuperior part of the laft.  This con-
nection does not feem to be productive of bad  effects, even when it is not
formed originally.
  The Dr. has proved very fatisfa&orily the fimilarity between the ftruc-
ture of thefe facs and that of the capfular  ligaments, u« well from an ex-
amination of their ftructure and ufes in a healthy ftate, as from the effects
of difeafes upon them.  With refpeA to the latter, he finds that they are
rendered exquifitely fenfible by inflammation;  and that either depofitions
of fluid matters,  or the formation of folid fubftances of different kinds, oc-
cur not only from rheumatifm, but alfo from gout and faophula  In one
                                                         inftance, 
                       [  447   3
the whole of  it;  and  by being generally painful: and
from abfceffes in the cellular membrane,  by the matter in
the latter being fuperficial, and extending  beyond the boun-
daries of the capfular ligaments.
   The nature of the fluid colfeaed in thefe fwellings may
be afcertained by the eircumftances preceding them, and
by the fymptoms  with  which  they are accompanied.
Thus when a violent  bruife of a joint is  immediately fuc-
ceeded by a large effufion within  the  capfular ligament,
it will probably be  found to confift  chiefly  of blood.   Of
this I have feen a remarkable cafe.  When inflammation of
a joint terminates in effufion, it will probably confift of a
ferous matter,  with fome tendency to purulency.   And if
the tumor  fucceeds  to rheumatic  affeaions, there will
be reafon to fuppofe,  that it  is produced entirely from
ferum.
   The fpecies of this affeaion which  is  confequent to
rheumatifm, may generally be  difcuffed by the remedies of
fimilar colfeaions in the burfa.  mucofte ; or, if thefe fail, by
the ufe of a laced  flocking  Or roller,  applied as  tight as
 can be borne.   But if this ihould be unfuccefsful, the pa-
 tient had better  fubmit to the  inconveniency occafioned
 by the difeafe, than  run the rifk of the inflammation fo
 apt to follow  an opening made in  the ligament for its dif-
 charge.   When, however, any matter is colfeaed  in the
joint, which may do mifchief by remaining in it, or which
can-
inftance, the Dr. has found not 1-fs than fifty cartilaginous bodies within
the burfa fituated behind the tendon of the flexor pollicis longus.  He is of
opinion, from fome facts, that ail folid fubftances in thefe facs confift in ex-
crefcencies from them, and that they are always nourifhed by peduncles
connecting them to the facs; and hence, if thefe peduncles are any how
broken, the excrefcencies never afterwards increafe in fize.
  Dr. Monro feems to be of opinion, that when an operation becomes ne-
ceffary in thefe affections, it fhould be either fimilar to that advifed in § 4.
or to the one recommended in § 5. of this fedion, according as the fub-
ftance to be removed is fluid or folid. 
                      [  448  3
cannot be readily abforbed,  an opening ffiould be made to
remove it.   This is the cafe when blood, or matter formed
by inflammation, is effufed.
  As the danger  which attends this operation,  feems to
depend greatly  on the admiffion of air into the joint; it
fhould be conduaed in fuch a manner as to prevent this
as much  as poffible.  For which  purpofe  a trocar  fliould
be employed, and the fkin being previoufly drawn  tightly
to the upper part of the fwelling as foon as all the  fluid is
evacuated, it ffiould be returned to its place.   The wound
fheuld then be clofed by adhefive plafter, and the joint mo-
derately compreffed by a  roller, or a laced flocking :  And
in order to guard more effeaually againft inflammation, if
the patient is plethoric, he ffiould be bled ;  and a  ftria an-
tiphlogiftic regimen fhould be obferved.*

§. 5.  Of Concretions and Excrefcencies with  the capfular
                      Ligaments.

  These affeaions induce a great deal of pain in fome in-
flahces, and always impede more or lefs the motion of the
joint.  In fome cafes,  the  offending  fubftances  are fmall
and loofe, and  as firm as  cartilage; and in others,  they
are of a foft membranous nature, fprouting from an eroded
furface of one of the bones forming the joint, or from the
inner furface of the capfular ligament.
  In the latter, which remain fixed nearly in the fame fitu-
ation, the pain  is conftant, but it is feldom fevere; but in
the former,  it is only felt in particular fituations, perhaps
when the conneaing membrane  gets between  the ends of
the bones, but  it is  then  often exceffively  violent,  and
fometimes fo excruciating as to produce fainting.
  Thefe fubftances can only be removed by an operation; but
as this, altho' fometimes followed by no bad confequences,
                                                   has

  * All thefe remedies will fail, if the patient  does not obferve the mofj:
perfect reft and quiet. 
                      [  449  3
has in many inftances  produced fuch  a  violent inflamma-
tion in  the ligament and adjacent parts,  and other bad ef-
fects, as to render the amputation of  the limb ultimately
neceffary, it fhould be advifed with great  caution.   From a
good deal of experience, I  am of opinion, that where
the  concretions  appear,  on examination, to be perfectly
loofe and detached, if the pain which they excite is  very
fevere, rather than fubmit to  a long continuance of it, we
ffiould venture to take them  out;  but  whenever there is
reafon to fuppofe they  are conneaed with any part of the
joint, the patient fliould be advifed to fuffer the pain, which
may in  general be rendered  moderate by  avoiding exer-
cife, rather  than  to run the rifk attending the extirpation
of them.  If, indeed, the pain, notwithftanding every means
employed to mitigate it, becomes infupportable, amputation
of the limb ffiould be recommended, as lefs hazardous than
 the excifion of the tumor when attached to the capfular li-
 gaments.
   The  operation for the removal of loofe bodies  may thus
 be performed : if the joint of the knee or ankle is affeaed,
 the patient ffiould be laid upon a table or bed; but if the
 joints of the arm are to be opened, he may fit; and the limb
 fhould  be firmly fecured in the moft convenient pofture.
 The furgeon ffiould then endeavour to  fix the fubftance with
 the left hand towards the upper part of the joint, that the
 fynovia may not efcape by the wound to be made, the fkin
 being previoufly drawn  up  as much as poffible  from the
 part to be divided.  An incifion is  now to be made with a
 fcalpel through the teguments and ligament, direaiy upon
 the fubftance, of fuch a fize  as will admit  of its being ea-
 fily taken out;  which may be done either with  the finger,
 or with a blunt probe paffed beneath it.   If it is found to be
 conneaed by fmall filaments either to the ligaments or car-
 tilages of the joint, thefe fhould be cautioufly divided with
 a probe-pointed  biftouri, or  probe-pointed fciffars,  after
 drawing out the  fubftance  itfelf  as far as poffible with
                          3  L                    fmall 
                      [   450  3
fmall forceps, or a fmall hook, when the texture of it will
admit of the ufe of this.  If there are feveral concretions,
they ffiould, if poffible, be all removed at the fame opening;
but where this is not praaicable, on account of their lying
on oppofite fides of the joints, after  allowing  the firft in-
cifion to heal, a fecond opening  muft be made.
  After the concretion is removed, the fkin ffiould be im-
mediately drawn over  the wound in  the ligament, and the
incifion of the fkin ffiould be  clofed by adhefive plafter.
The limb ffiould be kept as much as poffible in one  pof-
ture until the wound  is healed ; and a ftria  antiphlogif-
tic regimen ffiould be obferved.  For the farther treatment
of fuch cafes, we muft refer to  the  feaion on wounds of
the  ligaments.

             §.  6. Of Anafarca or Oedema.

  These terms  are applied to dropfy  in the cellular  fub-
ftance ; which is known in common by coldnefs and pale-
nefs of the part affeaed, and by its retaining the mark of the
finger when preffed.    Thefe fwellings are  generally con-
neaed with fome  fyftematical affeaion;  but they fome-
times occur in particular parts, and from caufes which af-
fea thofe parts only.   Thus they are  induced by contufions
or fprains of the legs or arms ; by tumors preffing upon
the  larger lymphatics ; and by fome of the lymphatics of a
limb being  by fome means divided.
  In cafes of local fwellings of this kind, if they are induc-
ed by  tumors, the removal of thefe will  alone  effea a
cure ; if they are the confequence of debility in a limb, from
fprains or bruifes, the  beft mode of cure will be to  fupport
the  parts by means of a flannel  roller, or laced flocking,
until they recover  their tone from the ufe of cold bathing
and friaions ;  and when they are occafioned by a lympha-
tic being cut, as fometimes happens  in extirpating glands
                                                 from 
                       C   451   3
from the arm-pit, fmall punaures in the lower part of the
limb give immediate and the only relief.
   In thofe fwellings of the  feet and legs which occur in
general dropfy,  all that a furgeon can with propriety do,
is to difcharge the fluid by punaures with a lancet.*   This
gives temporary eafe,  and I  think ought  to be employed
earlier than it ufually is, in order to prevent the lofs of tone
in the cellular membrane which muft  neceffarily be the
confequence of much diftention.  See chap. ix. fee. 2.

                $.  7.  Of the Spina Bifida.

   The term fpina bifida is applied to thofe foft fmall fwel-
lings which fometimes appear  on the  fpine, in new-born
children, moft frequently between the two laft lumbar ver-
tebrae.  A fluauation is perceived in them, and the  fluid
they contain can in part be preffed into  an opening which
occurs between the fpinous proceffes of the  two vertebrae
in which they are  feated.   This opening is found to depend
either on a deficiency of bone, or merely on a feparation of
the  proceffes.   The difeafe  always  proceeds  from ferum
depofited within the coverings of the fpinal marrow; and
is for the moft part local;  though in a few inftances it has
been found conneaed with hydrocephalus.
   In fome cafes children have lived  under this difeafe for
two or three years; but in  general they  die in  the fpace of
a few months.  All the affiftance that art has hitherto been
able to afford, has been to fupport the tumor  by a band-
age ; and thus to retard its increafe.    Opening  it has al-
ways been followed by death, either immediately, or with-
in a few hours.
   Proceeding upon the fuppofition,  that  the want of the
neceffary fupport to the membranes of  the fpinal marrow
                                                  from

  * We are commonly advifed, as one means of leffening the chance of
gangrene in thefe cafes, not to make the punctures in the mofl depeniinv
part of the limb. 
                      [  452  ]
from the deficiency of bone, may be the caufe of this dif-
eafe, and not  the  eflfeB,  as  has been generally fuppofed,
might  not  fome advantage be derived from a ligature ap-
plied round the bafe of the tumor fo as not only to remove
it, but  to draw the bottom of the cyft together, and thus
give a proper fupport to  the parts beneath ?   And as an
additional help,  as foon  as  the tumor  drops  off,  a firm
ftuffed pad might be applied over the opening in the verte-
brae, and fecured by a proper bandage.
   A fwelling  of the fame appearance, in fimilar eircum-
ftances, and probably of the  fame nature with fpina bifida,
appears fometimes  on the head; death  is alfo  the confe-
quence of opening  it.

              §. 8. Of Scrophulous Tumors.

   For a defcription of fcrophulous fwellings, and the ge-
neral remedies for them, we muft refer to  what was faid
on thefe fubjeas in chap. ii. fea. 12.
   With refpea to the chirurgical treatment of fcrophulous
fwellings, I have never obferved any  good effeas from the
ufe of any applications hitherto recommended, but have
repeatedly feen fome of them, and particularly thofe of a re-
laxing  quality detrimental;  and hence I am convinced that
the belt praaice is to truft  them to nature through their
whole  courfe, except when they are feated over the cavities
of the  thorax or  abdomen, or any  of  the  larger joints,
when  they ffiould  be opened  as foon as a fluauation of
fluid is perceived in them, either by means of  a feton or
trocar, or of a fcalpel or lancet, according as the colfeaion
is large or fmall.   With refpea to the fubfequent treat-
ment, fee feaion on Scrophulous Ulcers.
   When thefe fwellings  are deeply feated  in the breaft,
they are more firm than they  ufually are in other fitua-
tions, and have probably  fometimes been miftaken for real
fchirri; but a careful attention to the charaaeriftic fymp-
                                                  toms 
                      [  453  3
toms of the different difeafes, will always enable us with
certainty to difcriminate between them.  The circumftance
of the firft being conneaed with fymptoms of a general
difeafe, is alone fufficient for this purpofe.

                §. 9. Of the Bronchocele.

  Evert tumor of an indolent nature,  occupying the fore
part of the neck, is commonly termed bronchocele.
  The various affeaions of this kind are,
  1.  Aneurifms of the carotid artery.  Thefe do not fre-
quently occur ; they are ufually the immediate confequence
of fome violent  exertion, fuch as laughing or coughing,
and are to be known by the marks of aneurifm in general.
  2. Encyfted tumors, particularly of the melicerous kind.
Thefe frequently are met with on the courfe of the trachea,
and often extend from one ear to the other.  They are feat-
ed in  the cellular membrane, and are diftinguiftied by the
general figns of meliceris.
  3.  Tumors formed by the membrane lining the trachea
being forced out between two of the cartilages  by violent
fneezing, coughing, or laughing.    In thefe cafes the fwel-
ling will be at  firft fmall; and although foft and compref-
fible,  no fluauation will be perceived in it.
  4.  Swellings of the lymphatic  glands of the neck from
fcrophula.  Thefe are fometimes  of fuch a fize as to ex-
tend  over  the  whole courfe of  the trachea.  They  are
known by the ufual fymptoms of tumors of this kind.
  5.  Enlargements of the thyroid gland, conftituting the
difeafe which is mentioned as fo common among the inha-
bitants of the Alps,* and which is fuppofed to arife from
the  ufe of fnow-water.   This tumor has been  known  to
extend all  acrofs the throat, from one angle of the jaw  to
the other.   At  firft it is ufually foft; no fluauation is per-
                                                ceived
* Gouetre. 
                      [  454   3
eeived in it; the fkin is unaltered in its appearance ;  and it
is not painful.   As the fwelling increafes in fize it becomes
firm or elaftic  in  fome parts, and perfectly  foft in others;
the fkin acquires a copper colour, and the veins of the neck
grow varicofe; the face then becomes flufhed, and the pa-
tient complains of frequent head-achs, and of flinging pains
through the body of the tumor.
   6.  Swellings that appear to be  formed  chiefly of con-
denfed cellular fubftance with effufions of a vifcid  matter
in different parts of them.   Of thefe I have  feen two in-
ftances.  In both, the  tumor was fuppofed to  originate
in the thyroid  gland;  but  on  diffeaion this was  found
much diminifhed in fize. In one cafe, the difeafe was chief-
ly on one fide  the neck; but in the other it  reached from
car to ear, and from the fternum to the chin.   In both cafes,
the tumor fubfifted for  a great number of  years;  and it
was fatal but in one of them.  At firft it was foft and com-
preffible, no fluauation  was perceived in it, and the  fkin
was unchanged ; but as it  enlarged, it  became  hard in
fome parts, very elaftic  in others, and foft and fluauating
in other parts ; the  fuperficial veins became turgid,  and
the face of a livid colour, from  the  obftruaion  to  the
paffage of the  blood.  In one cafe, the patient complained
much of giddinefs; and in both,  the breathing was much
obftruaed.
   In the aneurifmal  bronchocele,  it muft be evident  that
the only chance the patient can have, muft be derived from
the common operation for aneurifm ; and this muft necef-
farily be in fome inftances very hazardous.
   When the difeafe arifes from encyfted tumors,  the treat-
ment applicable in other fituations, will be equally proper
in the neck.   And  however large the fieatoma may here
be, it is in general fo flightly conneaed with the contiguous
parts, that its removal may always be fafely attempted.   A
hrge opening in the lower  part will be fufficient for athe-
                                                roma ; 
                      [   455   ]
roma; and the meliceris  may be cured  either by incifion,
or by a feton.
   Where the  fwelling is formed by a hernia  of the tra-
cheal membrane, gentle compreffion, and attention to avoid
laughter, coughing, or any other exertion which might have
any effea in increafing the complaint,  is all that can be
done.  In fcrophulous bronchocele we muft depend chief-
ly on the general remedies  of fcrophula ;  and  to remove
the compreffion of the trachea or veins of the throat which
they may give, as foon as their contents are found  to be
fluid, they ffiould be evacuated.
   In an  enlargement of  the thyroid gland, frequent fric-
tions, and faponaceous and  mercurial plafters,  have  been.
ufeful in  the beginning of the complaint; but when it has
arrived to any  confiderable  fize, no internal or external
medicine with which we  are at prefent acquainted is of any
material fervice ; and an  attempt to extirpate the offending
part muft always  be very hazardous, and has we are told,
proved fatal;  but in cafes where it has  not grown large,
and is conftantly increafing,  and the  ufual  remedies fail, I
think it would be  very proper to  attempt, the relief of the
patient by cutting out the fwelling.   As we are, however,
feldom applied to in the beginning of the difeafe, we muft,
in common, be content  with  palliating  the moft  urgent
fymptoms as they arife.
   In the  laft fpecies, mercurial ointment  rubbed  on the
part has  proved ufeful in the firft ftage; blifters appeared
alfo in one cafe to  retard the progrefs  of  the complaint:
but in the latter ftage, a6 the tumor extends to  a great
depth,  and to  attempt its removal  would be dangerous,
and as it  is in great  part folid,  no confiderable advantage
could be  expeaed from merely laying it  open, and the fore
thus produced might perhaps degenerate into cancer: we
are therefore reduced to the neceffity of employing nothing
but palliatives.
                                                %.  It/. 
[  456   3
               $.10.   Of Navi Materni.

   N.&VI materni are thofe marks which are found on
 different parts of the body at birth ; and which are by fome
 fuppofed to originate from impreffions made on the mind of
 the mother during pregnancy.   They are of various forms,
 but their colour is in general a deep red.  Thofe which rife
 more or lefs above the fkin, are alone the objeas of furgery.
  Thefe tumors remain fometimes flationary for a long time,
 or perhaps during life;  but in other cafes they increafe in
 fize very rapidly.  I once faw a  tumor of this  kind in a
 child of a year  old, of  the fize  of  a goofe egg,  which at
 birth was not larger than a pea.   They feel firm and fleffiy;
 and in common have  broad  bafes;  though in fome cafes
 they are pendulous, and hang by very flender attachments
 to the contiguous parts.
   Nsevi materni feem to differ only from other farcomata,
 in being more plentifully fupplied with blood-veffels ;  and
 they require the fame treatment.   They ffiould always be
 extirpated when they  appear to be  increafing in  fize.  In
 doing this,  the  whole  tumor is to  be diffeaed off with a
 fcalpel, and the arteries being fecured, the edges of the re-
 maining fkin are to be drawn as near together as poffible, and
 retained  by  adhefive plafters or futures, and  the  cure af-
 terwards conduaed in the ufual way.   When the fwelling
 is conneaed merely  by a narrow neck to the contiguous
 parts, a ligature ffiould be employed inftead of the knife.

                  §.11. Of Warts.

  Warts appear to  be produced from  the cutis and cuti-
 cle :  if left to themfelves they generally wafte  away, or fall
off; and it is only when they grow fo large, or in iwch  fitu-
ations as to become very troublefome, that they ffiould be
                                              removed 
                      [  457  ]
removed by art.  When  they have a narrow bafe,  they
may be taken off by a ligature; but if their bafe be broad,
it will be neceffary to employ  cauflics, or the fcalpel, for
their removal.  The former are ufually preferred.
  As cauflics, the lapis infernalis, the lunar cauftic, a folu-
tion of  quickfilver in an equal quantity of nitrous, acid,
pulvis  fabinse, oleum tartari per deliquium, or fpirits of
hartffiorn, will either of them be effeaual; but as moft of
them are apt to excite too much inflammation, they fhould
be ufed very cautioufly.   The beft  remedy I have tried, is
rubbing them with fal ammoniac crud. moiftened, two or
three times a day.   It excites neither inflammation nor
pain, and feldom fails, except in the very hard fpecies.
   Warts frequently appear upon the penis in the venereal
 difeafe, and often continue long after the virus is eradicated.
 Mercury in fuch cafes is of no benefit; and if the parts are
 kept clean, or when they produce matter, waffied with fome
 gentle aftringent, fuch as lime water, they will generally
 difappear of themfelves after fome  time. When, however,
 it is determined to remove them, either the  fcalpel or cau-
 fiic may be employed. After the ufe of the former, in order
 the more effeaually  to prevent their return, the parts may
 be touched with lunar cauftic.
   It muft  be particularly obferved, that no  application
 ffiould  be  repeated which produces inflammation; and
 when the fcalpel is ufed, we  ffiould rather take off fome
 of the found fkin,  than run the  rifk of injuring the wart
 itfeh, or of leaving any part of it; for from want  of at-
 tention to thefe eircumftances, a great deal of mifchief may
 be  produced : a neceffity for the amputation of a limb has
 been the confequence of  a neglect, of the laft.
3 M
§. 12. 
[  458   ]
               §. 9. Of Flefljy Excrefcencies.

  No part of the body is exempted from the formation of
flefhy excrefcencies. They are of various fizes; are gene-
rally fomewhat more red than the healthy fkin ; have about
the fame degree of  firmnefs that the lips poffefs; and  are
feldom painful.   They have  the  appearance  of mufcle,
when laid open ; but, on  a clofe examination, appear to
confift chiefly of cellular fubftance,  in which  are  a great
number of blood-veffHs, 'very much  ramified.
   Efcharotics are  feldom effeaual  in removing thefe  tu-
mors,  and are very apt to irritate and excite inflammation
in them.  We ffiould, therefore, never truft to remedies
of this kind, and always make ufe  of the fcalpel,  or a li-
gature.   The latter fliould be employed when the  excref-
cence is pendulous by a fmall  neck; and the fcalpel, when
the bafe of the tumor is broad.  After carefully differing
out the tumor,  the fkin ffiould be brought to cover the
wound, and the cure conduaed as in other cafes.


                   §.13.   Of Corns.

   Corns appear in different parts of the body, but more
particularly on  the toes and  foles  of the  feet.  In fome
cafes they appear to be of a horny inorganic nature ; but in
others, they are evidently fupplied with blood-veffels  and
nerves.  They are commonly feated in the  fkin, but they
fometimes reach to the periofleum,  and are in that  cafe apt
to be produaive of pain and  inflammation, and particular-
ly when they  are feated on the  joints,  or parts thinly co-
vered with fleffi.
   The beft preventative of  corns  is to avoid preffure on
the parts liable to be affeaed.  The moft effeaual  method
of removing them  feems to be to pare off all the inorganic
                                                   part 
                      [   459  3
part,  after bathing them for half an hour or fo in warm
water, and immediately afterwards to apply the emplaftrum
gummofum over them, fpread on foft leather.   By repeat-
ing this occafionally, the corns will be  kept eafy, the hard
knots will often come away, and the vacancy thus produc-
ed will be fupplied by cellular fubftance.

'§. 14. Of a fimple Exofiofis,  Venereal Nodes,  and Spina
                        Vent of a.

   An exofiofis is an indolent hard tumor originating from
a bone.   In  fome cafes  it is altogether a local affeaion,
produced  by a fuperabundance of callus in fraaures, by a
deep wound of a bone, or by an  erofion of the fubftance of
a bone from an ulcer.   In others, it  is fymptomatic of fome
general difeafe, particularly of fyphilis  and fcrophula.  In
the firft cafe  it is termed a venereal node; and when it
appears as a fymptom of  fcrophula, which it frequently
does, k is ufually denominated a fpina ventofa.
   Exoftofes,  when proceeding from external injuries,  are
feldom attended  with pain; and after  attaining a certain
fize,  commonly  remain  flationary.  But when they ori-
ginate from , an  internal caufe,  they are generally  painful
from  the  firft;  probably from  the difficulty with which
the periofleum admits  of diftention ;  and  they continue
to increafe until  they ulcerate, or until the conftitutional
affeaion is eradicated.
   In  venereal nodes, the periofleum is often found inflam-
ed and much thickened ;  and in  fome cafes,  a fmall quan-
tity of a thin acrid ferum is effufed between it and the bones,
which makes the fwelling  appear larger in  the bone than
it really is.  This has given rife  to the  fuppofition that the
periofleum is the original feat  of  the  complaint; but it
feems  more probable that the bones are  primarily affea-
ed, from   the  difeafe occurring  only in  the  advanced
                                                 flages 
                      [  460   J
flages of fyphilis,  and generally  feizing the hardefl parts
of them.
  The fpina ventofa affeas the whole  fubftance of bones,
but more particularly the extremities of thofe forming the
joints of the knee, ankle,  elbow and wrift.  A pain is the
firft fymptom of it;  and it appears  to the patient to  be
feated in the very centre of the bone.  This is fometimes
the only fign for a few days;  but in general there is like-
wife fome fullnefs obferved in the part.
  When thefe fwellings occur in the middle part of bones,
as fometimes happens  in  the hands and fett, they „re ax>t
to advance rapidly; and  when the  foft  parts ulcerme, a
thin, ill-conditioned matter  is  difcharged, and the i oi;es
on examination  will  be found  carious.  But  where the
larger joints are affeaed, the difeafe arrives to  thib ftate in
a much more gradual manner; and then  lays  the founda-
tion for a fpecies of white fwelling.   See  chap, on White
Swellings.
  When the tumors terminate in fores,  the  fofter  parts
of the bones are found diflblved;  and on the matter which
they produce being difcharged,  the remaining cavities have
the appearance of being formed by all  the interior part of
the bone being fcooped out, nothing being left but the hard
external lamella.  The bone in this date exhibits appear-
ances very fimilar to thofe  of fcrophulous fores in the fofter
parts ; and as the fpina ventofa is, in one ftage or another,
almoft always accompanied by other figns of fcrophula, I
am clearly of opinion that  it ffiould be confidered as a fcro-
phulous affeaion.
  In exoftofes from a local caufe, nothing  but a chirurgical
operation will effea a cure ; this may therefore be employ-
ed whenever they become  fo large as to prove troublefome
or painful.
  The patient being placed upon a table, and fecured  by
affiftants,  if there  is  any rifk of cutting  large arteries, a
                                             tourniquet 
                      [   461   3
tourniquet fhould be  applied above the difeafe; an inci-
fion ffiould now be made through the teguments above the
tumor, and  carried,  if the parts will admit of it, an inch
or more beyond  each end of it.  It is afterwards to be
continued down  to the bone, taking great care to avoid
cutting the  contiguous mufcles, tendons, veins, arteries,
and nerves.   If  the  difeafed part is merely a fmall knob
that can  be  admitted  into the head of a trepan, it may be
taken off by that inftrument;  but when it is  too large fo*
this,  a common amputating faw may be employed to re-
move it; and after taking away all the fpiculse, the divided
parts  may be brought into contaa,  and retained by adhe-
five pie.Iter.   They may thus heal  by the firft intention;
but even if this fliould be fruftrated by pieces  of  bone
coming away, or if exfoliation fliould take place fome time
after  the healing of the wound,  it will ftill be better than
to treat the  cafe  from the firft as an open fore.
   When an exofiofis is found to furround a bone entirely,
it will be neceffary to take out that portion on which the
difeafe  is feated, when it can be  done with propriety. ,
 As this,  however, cannot well be executed when the bones
 of the hands or  feet  are affeaed, it will be better to  take
 out the whofe bone.   But in  the long  bones, as thofe  of
 the thigh, leg, or arm, we may fafely venture to perform
 this operation ;  and truft to nature for fupplying the  defi-
 ciency :  for there are many inftances of whole bones being
 regenerated in people of healthy conftitutions.  When a
 part  of a bone is to be removed,  after laying it bare, a piece
 of pafteboard,  or a thin ffieat of lead ffiould be paffed be-
 neath it, in order to protea the parts below from the faw.
   As foon  as the bone is taken off, a pledget of lint, fpread
 with common cerate, or dipped in oil, ffiould be infinuated
 between the lips of the wound,  and the manifold bandage
 may  then  be  applied.   As the free  difcharge of  mat-
 ter is of confequence, this fliould be carefully attended  to,
                                                    not 
                       [  462   ]
 not only in the after pofition of the limb, but alfo in mak-
 ing the incifion.
   When there is but one bone in the part operated upon,
 the arm for inftance, it will be neceffary to pay particular
 attention to keeping it of its natural length during the cure.
   Machines have been invented for this purpofe;  but they
 are unneceffary if the patient is attentive to the proper ma-
 nagement of the part, and when employed, they are very
 apt to be produaive  of inflammation  and other  inconve-
 niencies.
   During the cure, the chief objea is to prevent matter
 from  lodging between the contiguous found parts.  If this
 is accomplifhed, and the  wound dreffed  lightly, it  will
 foon fill up and heal.   The granulations between the ends
 of the bone will gradually become hard,  and if the health
 continues good, the limb  will become equally ufeful as
 before.
   Exoftofes wherever feated are to be always treated in the
 fame  manner.
   Venereal  nodes are in the beginning relieved by the ufe
 of  mercury alone.   Mercury  ffiould  not, however,  be
 applied to the tumors; for I have reafon to believe it has
 often  been injurious ;  but they ffiould be bathed in a folu-
 tion of faccharum  faturni,  or  fome other mild  fedati>e
 fliould be applied to them; and  thefe,  by tending to re-
 move  inflammation, may affift  in the difcuffion of the tu-
 mor.   When the fyftem is properly charged with mercury,  ,
 if the difeafe ftill increafes, I have fometimes relieved the
pain immediately  by leeches applied over  the  tumor.
 When thefe have failed, blifters have, in fome cafes,  been
 effeaual.
  Should  thefe means,  however,  have been too long ne-
gfeaed, ffiould the tumor advance with rapidity, or fliould
acrid matter  be confined within the periofteum, an incifion
down to the bone,  along the tumor, will often give imme-
                                                  diate 
                      [   463  3
diate eafe.  The matter thus evacuated is frequently a thin
brown fanies, and fometimes a vifcid tranfparent mucus.
  The incifion heals very readily by the  ordinary treat-
ment, in  fome cafes, even where the bone is confiderably
enlarged  : The tumor indeed will often remain during life,
but without producing any inconveniency; and unlefs it
occafions confiderable deformity ffiould never be meddled
with.  But  if,  notwithftanding the ufe of mercury to a
proper extent, the  wound fhews no tendency to  heal, it
will be better, for fome time at leaft, to try the effeas of a
difcontinuation of it.  Should the body be contaminated by
fome other  difeafe, the removal of this will often effect a
cure. And when there appears a tendency  to exfoliation in
the bone, as this procefs alone will remove the complaint,
fuch  remedies fliould be  employed as will expedite it as
much as poffible.   See Sea. on Carious Ulcer.
   After  all  the difeafed part of the bone  is removed, the
fore will ufually heal without  difficulty.  But when the
cure  is  retarded by a thickening  of the  periofteum  and
other parts, in confequence of a long  continuance of the
complaint, the fore fhould be dreffed with ftrong precipi-
 tate or verdegris ointment; or if  thefe are not powerful
enough,  it ffiould be touched with the common  or lunar
 cauftic,  once in two or three days.  Thefe will produce a
 feparation  of the flough, and  in  confequence, probably
 foon heal the ulcer.
   In fome inftances, venereal nodes are mere fwellings of
 the periofteum ;  and in that cafe they give little uneafinefs,
 and often fubfide merely from the  ufe of mercury, or of a
 blifter, and no advantage is derived from cutting into them.
 But when they confift in an affection of the bone itfelf, they
 are always  more or lefs  painful,  are very hard, advance
 flowly, and are never removed  but by an exfoliation.
   With refpea to the cure of fpina ventofa,  when it ap-
 pears in different  parts  of the body at the fame time, all
                                                   that 
                      [  464  3
that can be attempted, is to fupport the conftitution with a
proper diet; to advife bark and cold bathing as the beft to-
nics ; and when the  pain is fevere, to moderate it  by the
ufe of opium.   But when it is confined to one part, as of-
ten happens in the knee and other large joints in cafes of
white fwelling, it becomes frequently advifable to remove
the part affeaed by an operation.  See chap, on  Amputa-
tion, fea. laft.  When the complaint affeas the middle of
the bones, the difeafed part only may be removed, or the
whole bone taken out, as above direaed, in cafes of exof-
tofis.
CHAP.    XLII.

        Of Fractures.
                    SECT.   I.

                 General Obfervations.

A FRACTURE may be defined a folution of conti-
      nuity in a bone, produced by external violence.
  This  affeaion  receives  various  appellations,  derived
either from  its direaion,  or  from the fymptoms  with
which it is accompanied: Thus it may be tranfverfe, ob-
lique, longitudinal, or  fimple, if there is  a  mere  divi-
fion of a bone; or compound, when there is  an external
wound  of the foft  parts, leading to  the injured bone.
                                                 This 
                      [  465  3
This i6 the enly diflinaion of fraaures, that is  ufeful or
neceffary.
   The exiftence of a fra&ure is in general eafily difcovered
by manual examination.  It is only in fimple fraaures that
a difficulty can occur ; and more particularly, if the conti-
guous parts have become inflamed and painful.   In fuch
cafes we muft be direaed in our opinion, by a careful at-
tention to the age and habit of the patient; the fite of the
fuppofed fraaure ; the fituation of the limb when  the in-
jury was received ; and to the attending fymptoms.
   1. Thus the bones are much more brittle in old age than
 early in life, and  confequently are much more readily
 broken.   In  infancy the bones bend very much  inftead of
 breaking, upon the application of a moderate  force.
   Different difeafes alfo induce a brittlenefs of the bones.
 Lues venerea has this effea to fuch a degree, that the
 bones are fometimes  broken by the aaion  of the mufcles
 alone.   Scurvy has the fame effea ; and likewife what is
 termed mollities offium.
   2. Bones  are more apt to be  fraaured in thofe  parts of
 them which  are firmeft, and confequently leaft  flexible as
 in the middle; and,  thofe which are thickly covered with
 foft parts  are much  lefs liable  to be broken, than thofe
 which  lie near the furface ; thus the thigh-bone is not fo
 frequently fraaured as the  bones of the arm and leg.
    3. With  refpea to the fituation of the part  injured, it
 is evident, that a bone lying on an unequal furface may rea-
 dily be fraaured by an inconfiderable  force,  while, if
 equally fupported, it will bear  a very heavy weight with-
 out injury.
    And laftly, The concomitant fymptoms are to be attend-
 ed  to   Thofe of fraaure are generally, pain, fwelling, and
 tenfion of the contiguous parts; a more or lefs crooked
 and diftorted ftate of the limb ; a crackling or grating noife
                        3 N                         ox* 
                      [  466  3
 on the parts being handled ; and lofs of power to a certain
 extent in the injured limb.
   Pain in fraaures chiefly arifes from  the ends  of the dis-
 placed portions of bone irritating  the  foft parts, and from
 the injury to the latter by the accident.  It is feldom very
 great; but in fome cafes it is fo violent, as to be produaive
 of fpafmodic affeaions of the  mufcles  of the limb, great
 degree  of inflammation  and  fever, fubfultus  tendinum,
 general convulfions, and delirium ;  and if the caufe is not
 foon removed, death very commonly fucceeds.   This is
 ufually preceded by gangrene  of the parts contiguous to
 the fraaure; but  in fome inftances it feems to be occa-
 fioned merely by the violence  of the fever.   It muft  be
 obvious,  that thefe fymptoms will be moft readily  induced
 by an oblique fraaure.
   A. grating noife  on handling the  part, and diftortion and
 k>fs of power in the limb, almoft always  attend fraaures:
 when they are  longitudinal, which feldom happens, they
 cannot indeed occur.
   But befides thefe leading fymptoms  which immediately
 take place, there is often a great degree of ecchymofis pro-
 duced by the ends  of the bone wounding an artery or vein;
 and a wound of the teguments in compound  fradtures.
   The moft important  confequences of fraclures are, ftiff-
 nefs and  immobility of  the injured  limb ; diftortion of the
 parts  chiefly affeaed, either from a fulnefs or thicknefs re-
 maining in the contiguous mufcles  or ligaments;  an exu-
 berancy  of callus; a contraaed ftate  of the  contiguous
 joints ; or a marafmus  or wafting of the limb itfelf.   All
 thefe  will be confidered hereafter.
   In judging of the event of the fraaure, we are to confider,
 1. The age and habit of body  of the patient; thus  bones
 unite  much fooner in  youth,  and  particularly in infancy,
 than in old age.    Indeed it has been faid, that it is often
 impoffible to  procure the re-union of  bones in advanced
age ;  but I never have met with an inftance of  this kind.
                                                 Lues 
                      _  467   3
Lues venerea and fcurvy,  are often confiderable obftacles
to the cure  of fraaures,  and  fometimes prevent it  en-
tirely.
   2. The fituation and part of a bone that is  injured.
Thus we know that fraaures of the fmall  bones of  the
arms, hands,  legs,  and feet, and of the cheft, heal much
more readily than thofe of the  humerus and thigh-bone.
The difficulty in the thigh often  arifes chiefly from our not
being able to retain the ends of the bone in contaa.   And
when any of the larger bones are  fraaured near to their
extremities, we find the danger to be greater, and the prof-
pea of a complete cure much  lefs than when  they  are
broken near the middle ; for here the fhortnefs of one end of
the bone makes the retention difficult; and  the fymptoms
which enfue  are apt to be fevere, on account of the conti-
guity of the capfular ligaments, and  tendons, which may
be more or lefs injured.  And as the ends of the bones are
more fpongy, they do not unite equably and  foon ; and col-
feaions of matter and exfoliations are very apt! to take
place.   Thefe  fraaures are frequently produaive of ftiff
joints,  pains and fwellings, which  often continue  a  long
time, and fometimes during life.  Such  troublefome eir-
cumftances feem to originate more  from  the nature of the
injury in moft cafes, than from the mifmanagement either
of the patient or furgeon.
   3. The degree of the fymptoms : for the prognofis muft
obvioufly be favourable, or otherwife,  according as thefe
are mild or violent.
   4. The concomitant  eircumftances: thus the  fraaure
may be accompanied by  contufion, laceration, or difloca-
tion of the contiguous  parts; according, to  the degree  of
which will be the danger.
   5. The kind of  fraaure.  It very commonly happens
that fimple fraaures are unattended by bad fymptoms, and
are foon cured; but in general,  although there are many
                                             inftances 
                      [  468   ]
inftances to the  contrary, the fmalleft external wound
communicating with the injury in the bone, will be  pro-
duaive of danger.
  The indications in the cure of  fraaures are, 1. To re-
place the deranged parts of the  bone.   2.  To retain them
in this fituation as long as neceffary.   And,  3.  To obvi-
ate  fymptoms which occur during the  cure.
  When bones   are fraaured  direaiy acrofs,  they  are
either not moved  out of their natural  fituation, or the de-
placement is fo inconfiderable that they arc eafily reduced;
but when the fraaure  is oblique, the  ends of the broken
bones are apt to  pafs  each other fo  as to produce much
deformity and pain.
  Previous to attempting the reduaion of a fraaure,  the
limb or part ffiould  be put into fuch a pofition that all its
mufcles will be as much as poffible relaxed.  When this is
done, the furgeon may  commonly replace  the  bones him-
felf; but when affiftance is neceffary, the upper part of the
limb ffiould be  held  firm,  while  the  lower part is gently
extended, ftill keeping the mufcles relaxed as much as pof-
fible.   The difplaced portions of bone  ffiould then be gen-
tly reduced, fo as  to render the limb as fimilar as poffible to
the  found one, in order to afcertain  which, they ffiould be
brought as near together as convenient.
  The bones are to be retained in their proper fituation by
compreffes and bandages, and by keeping the limb in an
eafy pofture, and as much fixed  as poffible.   The appli-
cations  fliould be made with  no greater degree of tight-
nefs than is abfolutely neceffary for retaining the bones in
their fituation.
  The time required for rendering  the re-union  of bones
fufficiently firm,  muft depend upon  the age and habit
of body, the violence  of the injury,  attention of the pa-
tient, and other eircumftances ; but in general, in healthy
Oiiddle-aged people,  and  in favourable eircumftances,  a
                                               fraaure 
                      {  469  3
fraaure of the femur, or bones of the leg will get well in
two months; an os humeri,  or bone of the fore-arm, in
fix weeks ; and any of the bones of the hands, fingers, feet,
and toes, in three weeks.  In infancy and childhood,  frac-
tures heal more quickly; and  in  old age  they  require a
much longer time.
   In fimple fraaures,  to which  thefe obfervations more
particularly  apply,  the  inflammation and other  attending
fymptoms ufually fubfide in a few days, if the  bones are
kept in their places ; but in  fome cafes they conftantly in-
creafe from their firft appearance.   To obviate thefe, it will
be always advifable to make ufe of fome aftringent appli-
cation, fuch as a folution of  facchar. faturni, of fal amnion.
cr. or fp. mind, and when this has not the defired effea
to employ topical  bleeding, by leeches.   Thefe have a mofl
happy effea in  removing the inflammation, and  thus pre-
venting greater part of the bad confequences of  fraaures,
formerly enumerated.   If the fwelling  and pain  in a frac-
tured limb have continued long, the moft effeaual relief is
obtained  from frictions with emollient oils, and from warm
bathing, particularly in the medicinal waters.
   To check an overgrowth of callus, the application of
aftringents,  and of moderate compreffion with a thin plate
of lead, retained by a roller, are ufeful;  but thefe will not
be always fuccefsful.
   The ends of fraaured bones  fometimes remain loofe
and  unconneaed long after  they fliould, according to the
common progrefs of cures in  fuCh cafes, have been united;
this  may originate: from fome conftitutional difeafe,  as
lues venerea, fcurvy or rickets; from the ends of the bones
not having been conftantly in contaa ;  from a portion of
a mufcle, a tendon, or ligament falling in between the di-
vided parts ; and  from the bone being broken in different
parts, and in fmall pieces.   This circumftance has alfo
                                                 been 
                     I   470  3
been  obferved  to  happen  more peculiarly during preg-
nancy.
  When the want of re-union  depends on fome  general
difeafe, the proper  remedy of fuch difeafe becomes necef-
fary to a cure;  and indeed it will be always prudent to  at-
tend to this when the fraaure is  firft produced.
  If the defea of union arifes from the bones not being in
contaa, it will accompliffi a cure, in recent cafes, to appofe
them; but  when the offeous matter  which ffiould have
joined the bones has become fmooth and  hard, as  in long
continued inftances of this kind, and  they move freely on
each other without giving pain, it will  anfwer no good
purpofe to  bring them together;  and the only mode of
relief will be to lay their ends bare by an incifion, and by
removing  a  fmall  portion of  each, with a  trepan or
a common faw, reduce them to  the ftate  of a fimple frac-
ture.  This operation ffiould always be advifed when  the
injury affeas the large  bones  of the  extremities; but in
the bones of the fingers and toes, of  the metacarpus and
metatarfus,  the  clavicles and ribs, where no  great difad-
vantage is experienced from it,  it will be advifable rather
to fubmit to  the inconveniency.
  This  operation is painful and tedious  ; as the  incifion
muft  be  pretty  extenfive,  and  muft  be made with great
caution in order to avoid the large blood-veffels ; but it ia
perfeaiy  fafe,  and has been followed with complete fuc-
cefs, nature  fupplying fully the  place of the removed por-
tion of bone.
  In  compound fraaures,  all  detached portions of  the
bone  that will  not  probably unite with the larger parts
ffiould be immediately removed ;  but in fimple fraaures
where the fkin  remains entire, as we  cannot judge of the
nature of the injury to  the bone with any exaanefs, we
muft always proceed as formerly  direaed, at  firft ;  and
when the union feems to be prevented in  the ufual time by
                                                   any 
                      t  47i  3
 any detached pieces ef bone, an incifion  fhould be made
 down to them,  and they ffiould then  be  removed by the
 fingers or forceps.
   Another caufe preventing the re-union of bones, is a
 portion of mufcle, or fome other foft part  paffing between
 them.  This is to be fuppofed when the pain and tenfion
 of the injured part have  been  more fevere  than ufual from
 the firft;  when particular motions of the limb  give fe-
 vere pain and twitchings  of the mufcles that move it; and
 when the ends of the bone do not unite at the ufual time.
 In this cafe we ffiould endeavour to remove the interpofed
 fubftance, by putting  the limb into a variety of pofitions.
 As this, however, will feldom fucceed, it will be commonly
 neceffary to make an incifion down to the affeaed parts:
 if the callus is found foft, a cure may be  effeaed merely
 by bringing the  bones into contaa ; but if it has become
 hard, it  will be abfolutely neceffary to remove a fmall por-
 tion of it as above direaed.
   Effufion  of blood around the injured bone fometimes
 prevents a re-union of it.   When a large veffel is wounded
 by the bone, the extravafation of blood  is in fome cafes fo
 confiderable, and the limb becomes fo  much fwelled, that
 it will be neceffary to lay it  open, and  tie  the veffel; but
 when the fwelling does not arrive to 3n alarming height,
 we are rather to truft to  the contraaility of the artery for
 flopping the hemorrhagy, and  to  the  abforbents  for re-
 moving  the blood already  effufed.   In fome fuch cafes,
 where the blood has remained long in contaa with  the
 bone, the periofteum becomes feparated for a  confiderable
 fpace, no callus is produced, no union  takes place, and  a
 foetid fanies  is  commonly difcharged  from the fore :   a
 cure cannot  then be  effeaed  until the denuded parts of
the bone exfoliate.  As the exfoliation  is  a  very  tedious
procefs, it will render the cure more fpeedy and certain to
                                               remove' 
                      [  472  3
remove thofe parts of the bone from which the periofteum
is feparated, by means of a faw.


                    SECT.   II.

               Of FraBures of the Nofe.

  Fractures in the bones  of the nofe require very parti-
cular attention, becaufe they are  apt to impede refpiration,
to affea fpeaking, and the fenfe  of fmelling ; and in fome
cafes, to produce polypi, and tedious ulcers ;  and becaufe
of the contiguity of the brain.
  When any part of the bones have been  raifed above the
reft, it muft be preffed into  its place by the fingers;  and
fuch parts as are  forced into the noftrils muft be elevated
with the end of a fpatula, or fome fuch inftrument.  If any
portion is either  very nearly  or entirely feparated from the
reft, it ffiould be removed.
  When the reduaion is properly made, the bones will ge-
nerally remain in their fituations of themfelves—If there
is a wound  it  muft be dreffed  in the  ufual way: and in-
flammation muft  be obviated by faturnine applications, or
if neceffary by local bleeding.
  If,  however, the bones will  not remain firmly in their
places of themfelves, it will either be neceffary to introduce
fmall  tubes adapted  to the  fize of the  noftrils, previoufly
covered with  cerate  fpread  on  lint,  and fecured by tape
paffed around the head, or to  apply a comprefs and roller
over the nofe,  according as the bones fall into the  nares, or
are raifed too high.   By this treatment we may commonly
accompliffi a cure, unlefs  the  bones have been very much
broken, when if they cannot  be re-united,  all the  detached
pieces muft  be removed, and the  wound healed as well as
poffible.

                                            SECT.
4 
C  473  ]
                   SECT.  III.

  OfFraBures of the fuperior Maxillary, and Cheek Bones.

  The vicinity of thefe bones to the eye, by which they
are apt to induce ophthalmia,  and the fituation of the  an-
trum maxillare,  a removal  of  a  part of the bone forming
which is apt to induce deformity,  and render a cure tedi-
ous, make fraaures of them important.
  The difplaced parts of the bones muft  therefore be very
carefully reduced to their natural fituations, either with the
fingers, or with a narrow fpatula. When  the parts are  laid
open, the wound ffiould be  dreffed in fuch a manner as  will
moft probably prevent fubfequent deformity; and a piece
of adhefive plafter ffiould be employed to retain the dref-
fings.  Blood-letting, and an antiphlogiftic regimen, muft:
be advifed to  obviate inflammation  which might enfue.
   If the  antrum is injured, as the matter formed cannot be
readily evacuated from the  prominent part of the cheek, it
will be neceffary, in order to effea  a cure  of the ulcers pro-
duced, to make  an opening in the moft depending part of
the cavity in the manner advifed in chap,  xxxiii. fea. 5.


                   SECT.  IV.

       Of FraBures of the inferior Maxillary Bones.

  Fractures in the lower jaw bone may be always rea-
dily difcovered.
  In reducing them the patient ffiould have his head firm-
ly fecured in  a proper  light,  and the  furgeon  ffiould then
replace the parts deranged,  by introducing one hand with-
in the  mouth, and preffing on the other part of  the  jaw
                         3 O                    with 
                      t   474  3
 with the other.   If a tooth is feated in the courfe of the
 fraaure, which is the cafe very generally, as it may retard
 the cure, by aaing as an extraneous fubftance, it ffiould be
 removed ; but when any of the teeth not in the fite of the
 fraaure, are forced out, they fhould be replaced,  and tied
 to die contiguous firm teeth.
    The fraaured parts may be very well kept in their fitu-
 ^.tioxis, by a thick linen comprefs applied along the jaw from
 ear to ear, retained by a four-head linen roller.  See chap-
 ter on Bandages.
   Daring the  cure, the patient fliould be kept quiet:  he
 ihonld avoid fpeaking and laughing, or  the ufe of the jaw
 fin  any manner, as much as poffible ; and he ffiould be fed
 ■entirely  on  fpoon meat.  When the bandage  is xemoved,
 which muft be done as feldom as the nature of the cafe
 will admit of,  an affiftant ihould fupport die parts with his
 fhands during the dreffing.   The management of the frac-
 ture of one or both fides of the jaw bone is exaftly fimilai*.
 In the fi-rft cafe,  the patient  may be allowed to eat meat,
 and fpeak in about three weeks; but in the latter not  m
 iefs than five.

                   SECT.   V.

         Of FraBures of the  Clavicles and Ribs.

   The clavicles and ribs, from their ftruaure and fituation
 are more liable to fraaures  than  any other bones of the
 body.
   A fraaure  of the  clavicle is  in  common  very  eafily
 known by the ufual fymptoms  of fracture.  The end of
the bone conneaed with the flioulder is generally pulled
to  fome diftance  from the other,  and below it,  by the
weight of the arm ; and the motion of the arm is impeded.
This fraaure may be reduced merely by raifing  the arm
                                                    to 
                      [  475  J
to a proper height; and the ends of the bone may be re-
tained in their natural fituations, by affording a proper fup-
port to the arm ;  this is ufually done by- a fling hung round
the neck, adapted to the length  of  the arm, and equably
applied to it; but it is much more effeaually accomplifh-
ed by the machine, pi. xii. fig. 3.
  The pofition of the head and  fhoulders muft be varied
in different cafes; fometimes the ends of the clavicle are
beft retained when they are raifed'; and at other times when
the head is  bent forward.
  In other  eircumftances, thefe fraaures are to-be treated
as fimilar injuries in-other parts. The inflammation will, in
general, be  fufficiently moderated by the common faturnine
applications. And when the bone is fplinteredi, which muft
always be dangerous on account  of the vicinity of the fub-
clavian artery, the loofe parts muft be removed with great
care, and the wound dreffed in the ufual way.
   In general, where eircumftances are favourable, the frac-
tured parts will unite in a fortnight; but the correfponding
arm- fliould not be freely ufed for three or four weeks.
   Fraaures of the ribs are in common very eafily difcover-
ed1 by the touch.   For the moft part the fymptoms they
induce are very trifling ; but in fome cafes, the pain is very
fevere; the breathing becomes difficult,  attended by cough,
and perhaps a  fpitting of blood ;  and the pulfe becomes
quick, full,.and fometimes oppreffed.
   Thefe fymptoms are  the  confequence of the fraaured
ends of the rib  being preffed in upon, and  tearing the
pleura and  lungs.  The injury to.the latter, in fome cafes,
produces emphyfenia; (chap. xxv.)and a wound of the in-
tercoflal artery,  an effufion of blood into the cavity  of the
cheft.
   It will always be the fafeft praaice, in every cafe of frac-
tured: rib, to: difcharge as much blood as the ftrength of the
patient will admit of, to have him kept quiet,  and upon a
low regimen.  If the ends of the bone are not in  contaa,
                                                  they 
                      [   476   3
they ffiould be brought together if poffible; and to retain
them,  a broad leathern belt,  lined with quilted cotton or
flannel, fliould  be tightly applied around the body, and
worn for feveral weeks.
  When a difficulty of breathing is kept up by air efcaping
from a wound in the lungs, or by blood efcaping into the
cavity of the cheft, or when the pain is kept up by the rib
preffing upon the pleura,  it will be neceffary to make  an
opening with a fcalpel.  In the latter cafe, this ffiould be
done direaiy upon the injured part; and, on the rib being
laid bare, the depreffed portion of it ffiould be raifed, either
with the fingers, forceps, or fpatula.  When the oppreffed.
refpiration is occafioned by effufed air  or blood, the ope-
ration of the paracentefis becomes neceffary.

                   SECT. VI.

              Of FraBures of  the Sternum.

  A simple fraaure  of the fternum requires a treatment
fimilar to that of a fractured rib.  More danger, however,
may arife from a part of this  bone being forced into the
cheft, on account of the vicinity of large blood-veffels; hut
the pain of the  part, and other fymptoms  induced are the
fame.
  When the pain, cough,  oppreffed breathing, and other
fymptoms do not yield to  bleeding and an antiphlogiftic
courfe,  the only  effeaual method of affording  relief will
be, to make an incifion upon the injured part large enough
to admit a free examination of the  bone, and then to raife
the depreffed piece, either by means of a fcalpel or levator,
if the  opening  will admit them, or when this is not the
cafe, with a trepan, in the manner advifed in a fraaured
flcull;  and the fore produced may afterwards be treated in
the ufual way.
                                                  This 
                      C   477   ]
   This operation may be done with fafety,  and ffiould un-
 doubtedly be tried :  No other mode of cure yet propofed,
 gives any chance of fuccefs.


                    SECT.   VII.

Of FraStures  of the  Vertebra, os  Sacrum, Coccyx, and offa
                      Innominata.

   Fractures of the vertebrae may be produced  by falls
 and blows ;  but they are moft frequently met with as the
 confequences of gun-fhot wounds.
   The fpinous and oblique proceffes of the vertebrae may
 be broken without any immediate danger ;  but, in general,
 there is fuch a ffiock given to  the fpinal  marrow by the
 caufe producing the fraaure, that it ultimately ends in the
 death of the patient; and a fraaure extending through
 the body of the vertebra will probably always  prove fatal.
    We judge  that  the  vertebrae are  fraaured,  by  the
 touch, by the violence of the injury, and the feverity of the
 pain, and by the parts beneath the  injured  vertebra becom-
 ing paralytic when the fpinal marrow is affeaed.
   When any of the external parts of the vertebra, are loofe,
 they may be in general replaced  by the fingers;  and  by
 confining the patient as much as poffible to one pofture, and
 by the ufe of the napkin and fcapulary, and compreffes, we
 may retain them in their fituations until they unite with the
 reft  of the bone.   When this cannot  be  done,  however,
 inftead of leaving the patient to his fate, according to the
 common praaice, wherever the fpinal marrow is compreff-
 ed, we ought  certainly today the injured part freely open,
 that we may get accefs to the bone, and if poffible raife it
 to its proper fituation, or, if neceffary remove  it.  This has
 been done with fuch good effea as to relieve  a patient en-
                                                  tirely 
                      [  478   3
tirely who had been- rendered paralytic by a bullet paffing
into one of the vertebrae.  The operation can never in-
creafe the danger.
   In fraaures of the facrum, the treatment muft be nearly
fimilar to  that advifed for fraaured vertebrae, except that
where the lower part of the bone is injured, as well as in
fraaures of the coccyx, and is thrown inwards,  we may
in fome inftances replace it by introducing a finger into the
anus, while the fingers  of the other hand  are employed
externally.
   Where  any deep-feated part of the offa innominata is in-
jured, the patient fliould be confined as much as poffible to
an eafy pofition until the bones are probably united; and
bleeding and a proper regimen fliould be employed as pre-
ventatives, of inflammation.
   In more external fraaures, the difplaced parts may of-
ten, be  reduced to their proper fituation;  and a  bandage
adapted to the fire of the injury, will retain  them until 9
cure be effeaed.


                  SECT.  VIII.

               Of FraBures of the Scapula.

   A fracture  of the fcapula does not often occur; but
when it does, it is always difficult to cure, and commonly
induces a  permanently ftiff and unwieldly ftate of the eor-
sefponding arm.
   Befidesthe general fymptoms of fraaure, this  injury  is
attended by ftiffnefs and immobility of the arm; and when
a* part of the bone is forced in upon the lungs, by an em-
phyfematous fwellings,
   In reducing this fraaure, all the mufcles conneaed-with
the- fcapula muft be as much as poffible relaxed. By raifing
                                                  the 
                      [  479   3
the ftead and fhoulders, we relax ithofe oif the back ;  and
if the humerus be fupported at the lame time, the deltoid
muicle will be fo much  relaxed  that the fractured  pari;
may be eafily replaced.   The keeping all  thefe  parts as
much as poffible in this ftate, and the application of a rol-
ler for the particular retention of the feparated part, is all
that can be done.  And,  in order to obviate that violent
degree of inflammation which is apt to fucceed, blood-let-
ting,  and  particularly  topical evacuation, ffiould  be freely
employed.

                    SECT.   IX.

              Of FraBures if the Humerus.

   Fractures of the humerus  are  in  general very eafily
deteaed, by the feat of the pain, inability to move the part,
and the other general fymptoms of fracture.
   By bending the elbow  moderately and raifing the  arm
nearly to a horizontal direaion, in a line with the body, we
relax  all the mufcles of the arm, and the furgeon may then
commonly reduce this fraaure without  affiftance;  but
when this becomes neceffary, an extenfion may be made
by one perfon grafping the arm near the flioulder, and an-
other juft  above the elbow.
   When the bone is reduced, it is to be fecured in its-fitu-
ation  by a fpfint, of the kind reprefented (pi. xii. fig. 1.)
laid along the whole outfide of the arm, and another along
the infide,  both covered with foft thin flannel, to prevent
them  from galling the parts;  and while thefe are fecured
by one affiftant, and the fore-arm fupported by another, a
flannel roller fliould be applied moderately tight  over the
whole.
   The fore-arm fhould be  fupported  by  a fling, (pi. xii.
fig. 3.) but it will be better, even in bed, that it fhould be
                                                     in 
                      [  480  3
In a hanging pofition, fo that  it may have  fome effea in
pulling the lower part of the humerus gently  downwards,
and thus prevent the ends of the bone from overlapping
each other,  than to have it laid on a pillow horizontally.
   Unlefs the arm becomes much fwelled and painful,  the
bandage ffiould not be removed until the feventh or eighth
day, when we may cautioufly examine whether the bone is
perfeaiy in  place or not;  and  any accidental difplacement
may then be eafily remedied.
   Fraaures of the humerus heal more readily than thofe
of any other part; all eircumftances being favourable, ge-
nerally in lefs than four weeks; and,  if well managed, are
feldom produaive either of lamenefs or diftortion.

                   SECT.  X.

        Of FraBures of the Bones of the Fore-Arm.

   These fraaures very  frequently  occur.   When both
bones are broken, there is feldom any difficulty in disco-
vering the ftate of the injury; but when one only is frac-
tured, efpecially if it be the radius, as the firmnefs of the
other prevents its difplacement,  it requires fome attention
to difcover it.   The feat of the pain,  however,  points out
the part injured.
   If a great deal of attention  is  not given to  thefe frac-
tures, they  are very apt to induce a permanent ftiffnefs
in the arm,  and more particularly when the  radius alone
is broken;  probably from the  difficulty  of keeping it in
its fituation, owing  to  its having a rotatory motion inde-
pendent of the ulna.
   In order to  reduce  a fraaure in the fore-arm, the pa-
tient being  feated, and the mufcles of the arm relaxed by
bending the elbow and wrift,  the limb  ffiould be extend-
ed  to fuch  a  degree, by one  affiftant grafping it above
                                                   the 
                      [  481   3
the fraaure, and another  beneath it, as will allow  the
furgeon to replace the  bones with exaanefs.   This being
done, fuch a fplint  as reprefented  plate xiii. fig. 1. co-
vered with foft flannel, and fo long as to reach from the
elbow to the tops of the fingers, and of fuch a breadth as
to go round more than half the arm and hand, fhould be
placed  along the ulna.   Another fplint not quite fo broad
muft be placed along  the courfe of the radius, and  both
may be fecured  either with a  flannel  roller  or a twelve-
tailed bandage.
   The palm of the hand fhould always be turned towards
the breaft, as this is not only the moft convenient pofition
but it  moft effectually prevents the motion of the radius.
The arm  after being dreffed as above direaed, ffiould be
hung in the fling, plate xii. fig. 3. and allowed to remain
in it during the  night.
   We have direaed the fplints to  be  very long, becaufe
it is of great confequence  to prevent   the motion of  the
fingers; for  if this  is  permitted, it not  only  tends  to
fupport inflammation  and pain,  but alfo to  difplace  the
bones.
   A partial diflocation of the bones of the wrift is a fre-
quent concomitant of a fraaure of the radius ; by which
the rifk of a ftiff  joint, or  of a  painful permanent fwel-
ling of the  arm becomes  confiderable.    This  ffiould
therefore  be particularly  attended  to in  the treatment.
See chap, on Diflocations, and fea. on Fraaures  in Ge-
neral.
   The olecranon is fometimes fraaured without any inju-
ry being done  to the reft  of the ulna, particularly from
falls or bruifes on the elbow.   In  this  cafe, in order to
keep the fractured parts in contact, the fore-arm muft be
kept extended by means of  a long fplint laid  along the in-
terior part  of it, from the middle of the  humerus to the tops
ef  the fingers,  fecured by  a roller.  The .arm ffiould be
                        3  P                   allowed 
                          ['  48*  3
    allowed to hang by  the patient's fide, to which it  fhould
    be fixed with one or two ftraps.
       Eut left a ftiffnefs of the elbow might be the confequence
*,   of keeping the arm conftantly extended  during the cure,
    the dreffings fliould be removed about the eighth or tenth
    day,  and daily afterwards ; and  the  fore-arm  being  for
    fome time moved  flowly backward and  forward, and  the
    joint  rubbed with  any emollient  oil, the  arm may then be
    fecured as before.


                       SECT.   XI.

     Of FraBures of the Bones of the Wrifi, Hands, and Fingers.

       The bones of the wrift are  feldom  featured except by
    fliot from fire-arms, or by fome heavy  fubftance  paffing
    over them, from their readily giving  way to any ordinary
    force applied to them.  Fraaures of them do not  readily
    unite, becaufe of their being fo fmall; and on this account,
    as  well as of the vicinity  of tendons and ligaments, which
    induces a confiderable degree of  inflammation, anchylofis,
    or  ftiffnefs  of  the joint are very common confequences.
    After replacing  the bones, the moft effeaual preventative
    of thefe effeas is copious  bleeding from   the parts injured.
    The arm and hand  fliould then be dreffed  in the manner di-
    reaed for a fraaured fore-arm.
       Fraaures of the metacarpal bones ffiould be dreffed either
    with  a fplint of wood or of pafteboard applied  on  the in-
    ternal part of the hand and fore-arm, and above thefe with
    the fplints and bandage advifed in the laft feaion.
       Fraaures  of the fingers are  frequent, and eafily cufed.
    The beft  fplint for them  is  a piece of  firm pafteboard,
    adapted to the parts by being previoufly moiftened,  ex-
    tending the  whole length of the fingers, and fecured by
                                                         a 
                      [  483   3
a narrow roller.  The more effeaually to enfure & perfea
cure,  a  large fplint  of the kind  (Plate xii. fig.  1.) or of
firm pafteboard, may be applied  to the  infide of the hand,
and fecured by a roller, fo as to prevent any of the fin-
ge-rs from being moved ; and in order to  preferve the mo-
bility  of the  joints of the  fingers,  the  bandages and
fplints ffiould be removed  ahout  the tenth or twelfth day,
and daily afterwards,  and  the fingers bent and extended
feveral times.


                     SECT. XII.

              Of FraBures of the Thigh-Bone.

   The  os  femoris is moft  frequently broken near the mid-
dle ; and next to this,  its  neck is moft apt to be fraaured.
   When the  lower part is the feat  of the injury, the frac-
ture is in general eafily diftinguiftied by the grating noife
produced by rubbing the ends  of the  bones together; by
the limb being much fhortened, if the fraaure be oblique,
or if  the ends of the  bones  have been difplaced in cafe6
of tranfverfe  fraaure ;  by great pain and tenfion of the in-
jured part; and by the limb being unable to fuftain the body.
   It is, however, often difficult  to  diftinguiffi fraaures of
the neck of the femur from diflocations of this bone. As it
is of confiderable confequence to make this difcrimination,
a very careful attention is  requifite ; and by this the diltinc-
tion may be  commonly  made.  In nineteen  cafes out of
twenty, the head of the f cn.ur when diflocated, is  puffied
inwards and downwards,  owing to the brim of the aceta-
bulum being not fo  deep internally as in other parts, as weft
as to  the mufcles not being fo ftrong; while perhaps in an
equal number  of  fraaures  in  the neck of  the  femur,
the bone is  puffied upwards,  on account of  accidents of
                                                    this 
                     [   484  3
this kind happening moft  frequently from falls upon  the
knees,  or perhaps upon the feet, when the legs are ftretch-
ed out, by which a  very  confiderable force is neceffarily
brought to aft againft the neck of the thigh-bone, where it
is leaft able to give refiftance. In fuch fraaures, the leg is
much  fhortened, often  feveral inches ;  the  trochanter is
found  much  higher than that of the other thigh ; and the
knees and toes are turned inwards.  On the contrary, in
diflocations the leg is confiderably lengthened ;  the head
of the bone  and the trochanter are  found near the groin,
with a correfponding vacancy where the  trochanter ought
to be ;  and the toes are turned out.
  In fraaures, the extremity may be turned with much
more eafe from fide to fide, than when the head of the fe-
mur is luxated.  The tumor  formed by the head  of the
bone and trochanter  in the latter cafe, is alfo much greater
than that produced from the trochanter alone in fraaures.
  We are very apt to obtain but an imperfea cure in frac-
tures of the  thigh, and  particularly when the neck of the
bone  is the  part injured.  This  arifes, 1. From the diffi-
culty of afcertaining  the direaion of the fraaure,  on ac-
count  of the bone being fo thickly covered.  2.  From the
impoflibility  of  difcovering whether the  reduaion be pro-
perly effeaed.  3. From the difficulty of retaining the ends
of the bone  in their proper fituations, when they are well
 reduced: This  is particularly  the cafe when the neck of
 the  femur is the part affeaed, and  when the fraaure  is
oblique.  The thigh-bone  is alfo more affeaed  by bodily
exertions than moft others.
   In  reducing  fraaures of this  bone,  the thigh  fhould
 form an obtufe  angle with the body, and the joint of the
 knee  be moderately bent.   The ends of  the bone may ge-
 nerally be  eafily brought into contaa, if  there  be not
 much tenfion or fwelling, while one affiftant gently extends
 the lower part,  and  another fecures the upper part of the
                                                 thigh. 
                      C   485   3
thigh.  There is the greateft difficulty when the neck of
the b me is broken ; but we may commonly fucceed, if one
affiftant fecures the body while another makes an extenfion
at the lower part of the thigh.
   When this mode fails,  it will be neceffary to  have re-
courfe  to extending machines.
   There is ufually much greater difficulty in retaining the
ends of  the femur in contaa,  than in reducing them  to
their proper fituation.  In order to accompliffi this, a firm
 fplint  reaching from the top of the hip-joint to a little be-
low the knee, and  broad enough to  cover at leaft one-
half of the thigh, ffiould  be  covered with foft  flannel,
laid upon a twelve-tailed bandage fupported by a  pillow,
and applied to the  outfide of the thigh.   Another fplint
long enough to extend from the groin to a little below the
knee,  and  fo broad as  to cover one-third  of the thigh,
 is to be placed  on the infide ;  the manifold bandage be-
 neath  the large fplint,  muft then be applied, fo as to make
 a moderate and equable preffure over the whole limb.
   The patient fliould  be placed on a hair matrafs which
 will not yield much,  on his back, with the body turned
 toward the affeaed fide,  and have the  knee moderately
 bent,  and this as well as the leg ffiould be raifed fomewhat
 higher than the body.
   In  order to have the limb more fecure from difplace-
 ment, it will  be proper to put a long fplint of wood be-
 neath the middle of the pillow, and fix it by two broad
 ftraps firmly buckled  on the  upper  part  of the thigh :
 And befides  this, to have  the pillow  conneaed to  the
 matrafs by ftraps.  To prevent uneafinefs from the weight
 of the bed-clothes, two or three hoops fixed in  a frame
 ffiould be  placed over the thigh.
   Left the  bones might be accidentally difplaCed, but
 efpecially if pain  and fwelling fliould  come on, the  band-
 age ffiould  be undone,  and the upper  fplint removed in
                                                  order 
                      [  486  ]
order to admit  of  an examination of the injured  parts.
If pain, inflammation, or fwelling, have come on, it may be
proper, before a renewal of the dreffing,  to apply leeches
and other remedies  to the parts affeaed ; but when none
of thefe fymptoms have come  on, and  the bone  is in its
proper fituation, the bandage and fplint ffiould be immedi-
ately reapplied.
   Adults,  in favourable eircumftances, will generally be
cured in fix weeks ; hut all violent  exertions ffiould be
carefully avoided till after the eighth or renth week.
   In order to prevent rigidity and uneafinefs in moving the
limb, after the cure, it wiiJ be proper in a fortnight or lefs
after the accident, to permit tht patient to lie more on ln6
back, and the knee  to be daily  bent or extended.
   This mode of Cure  will very commonly  fucceed very
perfeaiy;  but fome cafes of oblique fraaure occafionally
occur in which  it is almoft impoffible to  prevent the ends
of the bones from flipping by  each other, and by uniting
at their fides, make  the limb ffiorter than it ought to be.
   In  order to prevent this difagreeable  circumftance, va-
rious methods have been devifed ;  by thefe it is  intended
to keep the  limb in  a conftant  ftate of extenfion :  Some
have propofed to fix the body and then extend the leg by
an  apparatus below:  others truft to an extenfion of the
extremity only.  But thefe means can never be employed
while any degree of inflammation is prefent; and even  when
this does not exift, they give fo much  uneafinefs that they
can feldom be made ufe of.  The pain, fwelling, &c. fome-
times arrive to fo great a  height, that even a fimple band-
age cannot be admitted till after their fubfidence.
SECT. 
[  487  3
                  SECT.  XIII.

              Of FraBures of the Patella.

  Falls and blows of the knee are the caufes produaive
of fraaured patella.   The bone is moft frequently broken
tranfverfely ; fometimes longitudinally :  and in fome  in-
ftances, into three or four different  pieces.
  Under proper management, this  fracture feldom pro-
duces much ftiffnefs of the knee joint, after a few months ;
and when this does occur, it  is hardly in  confequence  of
the callus produced, as this muft be in very inconfiderable
quantity, but  probably  originates  from the concomitant
inflammation  of the  internal  parts of the joint,  or from
the knee being  kept too long in a fixed and extended po-
fition.
  The patient being placed on a firm bed, and the leg ex-
tended, in order to relax the  mufcles conneaed with the
patella, a firm  wooden fplint  well covered  with foft  wool,
or fine flannel, ffiould be placed beneath the extremity, and
reaching from  the  upper part of the thigh to the end of the
leg; to this the limb  muft be fecured  by two ftraps be-
tween  the  ankle and knee, and  one or two between the
knee and top of the  thigh.   The different parts of the
bone are  then to be brought  as nearly together as poffible
by the hand.
  In order  to  prevent the  inflammation  which  probably
would  fucceed to the  injury,  blood  fliould be  drawn
from the joint by leeches ; and when it  aaually comes
on, faturnine and other aftringent  applications fliould  be
freely employed until it fubfides.    When this  is the cafe,
the  bone muft be examined : if the parts remain nearly
m contaa, a  large pledget of Goulard's cerate fliould  be
                                                  kid 
                        [   488  3
 laid over them, and a hooped frame ffiould fupport the bed-
 clothes  above ; but  if  the different parts of the bone arc
 much feparated,  it will be neceffary to replace them, and
 retain them by bandages, or flips of leather fpread with glue
 or adhefive plafter.   When the fraaure is longitudinal, this
 is eafily accomplifhed ;  but when it is tranfverfe it is a mat-
 ter of fome difficulty.
   In cafes of the latter kind it will be proper to  bring the
 parts  of the  bone as  nearly  into contact  as the patient
 can admit of without pain  or uneafinefs ; but it is not
 neceffary that they  be brought to touch, becaufe a very
 perfea  cure has  been  effected when  they could not be
 brought within an inch of each  other.   Various methods
 have been  employed to  fupport  the  parts of  the  bone
 in  contaa  ; but  whatever  bandage or machinery is em-
 ployed to keep them together,  ffiould  only aa on the fu-
 perior part of the patella, becaufe that  alone can refill the
 reduaion.*
   The bandages ffiould not be removed until  the  twelfth
 or fourteenth day, if pain and  inflammation do not render
 it neceffary earlier ; and the joint may then, and afterwards
 every fecond or third day, be moderately bent, in order to
 prevent an  immobility of it, which would be apt  to occur
 without this precaution.
   The reaus mufcle is fometimes torn from its infertion
 into the patella by a fall on the back with the  knee bent;
                                                   afuffi-

  * In tranfverfe fractures of the patella, Mr. Sabatier, from much expe-
rience, is of opinion that no fplints or  bandages are at all neceffary or ufe-
ful.   He advifes the thigh to be moderately bent, and the knee  to be in a
flight degree of flexion alfo ; and both  to be laid upon pillows.   Wherever
he has employed fplints or bandages, or feen them employed,  they have
been neceffarily foon removed, on account of the inflammation and fwelling
induced by them : it is to obviate thefe fymptoms that he has  found the
propriety of keeping the knee flightly bent.   See Hiftoire de Acad. Roy.
des Sciences, pour 1' an. 1783. 
                      [  489  ]
a fufficiently long continued  extenfion of the limb, toge-
ther with the general treatment recommended in fraaured
patella, will remove this complaint.


                  SECT.  XIV.

           Of FraBures of the Bones of the Leg.

   When  one bone of the leg only  is broken, there is
fometimes a difficulty  in afcertaining the fraaure, but
when both are broken,  which is more  commonly the cafe,
it is readily difcovered.   In  the  former  cafe,  however,
as the found bone generally fupports the other in its place,
this is of no great confequence;  nothing more  than con-
finement, till an union is effeaed, being neceffary.
   The leg is  moft frequently fraaured  juft above  the
ankle; and particularly when the  fibula is the feat of  the
injury.
   In the management of this fraaure, the general prin-
ciples apply which were  laid  down in the treatment of a
fraaured thigh.  During the reduaion, the mufcles ffiould
be relaxed by bending the knee and flightly extending  the
foot; and an affiftant at the upper end of the limb and one
below, will eafily extend the  leg fufficiently.  The limb
being laid upon its outfide, and the knee flightly bent,  the
fplints, plate xn.  fig. 2—7. or thofe made in the manner
of fig. I.  ffiould be applied,  and  retained by the twelve-
tailed bandage : the  fplint on the outfide  ffiould  always
reach from a little above the knee, below the  ankle, with
a view to prevent  the motion of either of thefe joints, by
which the bones are apt to be difpbiced.  If the patient is
very reftlefs, or troubled with fpafmodic affeaions of the
mufcles of the leg, it will be better, as an  additional fecu-
rity, to apply a fplint of wood of the form, plate  xn. fig. 2.
                         3  O                     *nd 
                     [   *90  3
and filled with foft wool,  to  the outfide of the leg, amd
faften it by means o£ a couple of ftrapsv  The foot ffiould
alfo be always fupported by a ftrip of linen, conneaed  on
each fide of the leg to the bandage.
  If it is thought proper,  inftead of lying on his fide, the
patient may have the leg  placed on the frame, plate x.
fig. 6. and lie on his back ; and  this or the fide, may
be occafionally ufed in the fame patient during the cure,
for the fake of eafe  and  variety: No change  of pofture
ffiould however  be permitted for the firft ten or twelve
days.  And when the pofition  is altered,  the  leg ffiould
always be kept in the fame degree of curvature.
  In making the appofition of thefe bones, our  fole objea
ffiould be  to raife the inferior part of the  bone; for this
is almoft always  drawn beneath the  upper, by  the weight
of the foot,  and the contraaion of the mufcles on  the
back part of the leg.

                  SECT.  XV.

       Of FraBures of the Bones  of the Foot and Toes.

  The foot is very much  expofed to injuries of this kind;
they are deteaed by  the figns which denote fraaures in
general, and require a treatment fimilar to that of fraaur-
ed hands.   In every cafe, a large fplint ffiould be applied
over the fole of the foot;  and the foot and ankle ffiould
be moved as little as  poffible during the cure.

                  SECT.  XVI.

                Of Compound FraBures.

   Compound fraaures are produced by external violence,
and frequently by the bones, in cafes of fimple fraaures
                                                being 
                      :[   491  ]
feeing ^pufhed  through the  correfponding integuments.
This may happen either from  the bone being fraaured fo
obliquely as to terminate in a fharp point,  or from the ap-
plication of a very tight bandage.
   Compound fraaures are always attended with danger.
That the Tifk in thefe cafes originates chiefly from the ad-
miffion  of air to the bone, is rendered probable from this,
that in  the  worft variety  of fimple  fraaure,  the patient
commonly gets well without the occurrence of  any bad
fymptoms ;  but if,  in the progrefs of the cure,  the end of
the bone  ffiould by any accident be puffied  through the
teguments, the pain immediately becomes more violent;
the inflammation increafes.;  fever takes place ; ipafms pro-
bably affea the limb; and to thefe frequently fucceed either
gangrene, or extenfive fuppurations.
   Our firft objea in fractures of this kind, is to reftrain
the hemorrhagy when it is prof ufe;  and our next, to de-
termine whether it  will be proper  to attempt to fave  the
limb, or to recommend immediate amputation.   The for-
mer is to be accomplifhed  by the ufual means:  The latter
is a point which has given rife to  much difpute.  I am
clearly of opinion,  that in private praaice, and in other
cafes, where the patient can be well attended to  in every
refpea immediately  after the accident, and during the whole
of theeure, that amputation fhould  never  be advifed, un-
lefs the  bones are fo much fhattered that they cannot re-
unite, or the texture of thefoft parts is completely deftroy-
ed : But when proper attention cannot poffibly  be paid to
the patient,  as is ufually the cafe in the army and navy, it
will be a good general rule to advife  the immediate remo-
val of the limb, if the accident affeas the bones of the arm,
fore-arm,  thigh, or leg.   This important point will be
more particularly confidered hereafter in the chapter on
Amputation, fea. 1.
  Where  we attempt to fave the limb, all extraneous bo-
                                                  dies 
                       [  492  3
dies ffiould be  removed,  as  likewife all  portions of bone
 that are entirely feparated, and will not be likely to unite,
 either by means of the fingers, forceps,  cutting pliers, or
 faw ;  and if this cannot be eafily done without, the wound
 fhould be enlarged by the fcalpel.   But it is to be obferved
 that any piece of feparated bone which is broad at the bafe,
 and wouid probably unite if  brought into its  proper fitua-
 tion,  ffiould be replaced.
   All the coagulated blood  being  removed,  and any  ar-
 tery that may be cut being fecured, the bones ffiould be ap-
 pofed ; the wound ffiould then be covered  with a pledget
 of lint fpread with emollient ointment, and the limb ffiould
 be laid on a firm fplint, and in a relaxed pofture.
   That we may have free accefs to the injured part without
 moving it, the many-tailed bandage fliould  always be pre-
 ferred to a roller ;* and the limb ffiould be fixed on a frac-
 ture box; (pi. x. fig. 6.) it may be  either bent or ftraight,
 as feems moft proper.
   In order to guard againft inflammation, to the violence
 of which may always be  traced the gangrene or  abfceffes
 which fometimes fupervene, it will be proper, to ufe gene-
 ral bleeding; to  apply leeches to the edges  of the fore,
 when the inflammation becomes confiderable ; and to em-
 ploy  opiates, faline  laxatives, and a low  cool regimen.
 The dreffings ffiould be removed once or twice a-day, ac-
 cording to the quantity of matter produced;  and pledgets
 of lint fpread with cerate ffiould be  applied to the wound.
   When inflammation comes on, it will be  proper to apply
 warm emollient  poultices frequently,  in  order to excite a
                                                plentiful

  * In order to preferve the bandage clean, and thus prevent a neceffity for
 a frequent removal of it, the late Dr. Jones,  of this city, always applied a
 piece of fine oil cloth next to the limb.   In all cafes of fradture, inftead of
 placing- the fplints beneath the bandage, many practitioners apply the ban-
 dage firft, and fix the fplints above  thefe, either by means of ftraps, or
 pieces of tape.  See Jones on Wounds and Fractures. 
                      [  493   3
plentiful fuppuration,  as this is the beft  preventative  of
gangrene; but as foon  as the inflammation has fubfided,
they fliould be omitted.
  V/hen the difcharge of matter becomes  very great,  the
fore ffiould be dreffed  with gentle aftringents,  fuch as lint
dipped in a folution of facchar. faturni;  and  the patient
ffiould be fupported by a nouriffiing diet, a  free ufe  of
wine, Peruvian bark,  and elixir of vitriol.  If the matter
cannot be freely difcharged  by a proper  pofition of the
limb, or cannot  be fufficiently  abforbed by lint or fponge
applied to the fore, a counter opening muft be made to
give it vent.  This exceffive  difcharge will  fometimes be
occafioned by loofe pieces  of bone: Thefe  ffiould  there-
fore be fearched for,  by the finger if poffible, if not, by
the probe, and extraaed.
  If the inflammation  ffiould terminate in gangrene, the
treatment formerly recommended,  or hereafter to be ad-
vifed, is to be employed.  See  feaion on Gangrene, and
chapter on Amputation.
  Various machines have been recommended  by different
authors,  for forcibly retaining  fraaured limbs  in  their
proper fituations, but they are in general unneceffary.   In
particular eircumftances, that mentioned  in fe<ft ion xi. of
this chapter, may be ufeful for keeping the fraaured bones
extended; and  confiderable  advantage may  be derived
from it in keeping the  bones fteady,  when it  is neceffary
to remove the patient from one place to another; but in
common praaice I have never derived any advantage from
any inftrument ufed for this  purpofe.
CHAP. 
C  494  3
CHAP.    XLIII.

        Of Luxations.
                   S E C T.  I.

             General Remarks mi Luxations.

A BONE  is faid to be  luxated when  that part of it
      forming a joint is difplaced.  If the end of the bone
is forced entirely out of the cavity in which it is lodged,
fche dislocation is faid to be complete; but where any part
of the bone refts upon the edge of the  focket, incomplete.
  Luxations may be either fimple, i. e. unaccompanied by
any :other affeaion ;  compound, when accompanied by a
wound, laying open the cavity of a joint; or complicated,
when joined with a fraaure.
  Luxations are ufually produced by external violence, ap-
plied either in leaping or falling, by blows, and  violent
twifts and diftraaions of the different bones of a part; but
they are alfo produced by a  morbid weaknefs or relaxation
of the mufcles and ligaments of a joint, from palfy or rheu-
matifm ;  and by  the preffure of matter colfeaed in a joint,
and of farcomatous tumors and exoftofes.   Thofe produc-
ed by external violence are chiefly the objeas of furgery.
  The general fymptoms of fuch diflocations are, inabili-
ty to move the limb ;  pain,  tenfion, and  deformity of the
part injured ;  and in fome  cafes, inflammation,  fubfultus
tendinum, and fever.  In general, the motion of the  limb
                                                   is 
                      [   495  3
U impaired in proportion to the extent of the luxati©*; bw.
in fome cafes, particularly in the larger joints,  the moft par-
tial affeaion renders the joint ftiff,  and immoveable, and
gives the moft exquifite pain on every attempt to move it.
The deformity muft  always be proportioned  to the extent
of the injury;  but the  inflammation and fubfultus are of-
tener excited to a greater degree by a partial than by a com-
plete diflocation.
  The fwelling that  firft takes place in  cafes  of diflocatioa
is  always inflammatory, and neceffarily confequent to the
violence  done the  parts; and ffiould be carefully diftin-
guifhed from  a  fecondary  fwelling, that, in fome  cafes,
fpreads over all the inferior part of a limb,  which is pale
and cedematous, and feems to originate from  a compreffion
of the  Lymphatics. This is  moft commonly an attendant of
diflocations of the humerus and thigh: In thefe a numhnefs,
from compreffion of the nerves, is alfo  very apt to occur.
   There is feldom any  difficulty in diftinguifhing complete
diflocations;  but it is not  always eafy  to difcriminate be-
tween contufions or fprains, and fubluxations,  or incom-
plete diflocations.
   In forming a prognofis in diflocations, we are to confider,
the form and ftruaure  of the joints ;  the nature and extent
of  the affeaion, together  with  the  degree of violence by
which it was produced, and the eircumftances with which
it may be complicated; and the duration of the  injury.
   It is chiefly in joints which admit  of much motion that
diflocations  are met with,  viz. where the articulations are
by ball and focket, and by ginglymus.
   It has been fuppofed that the capfular ligament is always
ruptured in  luxations: I  am,  however, of opinion that
partial diflocations may  happen without  any rupture  of
the ligament; but I believe this is always torn in complete
luxations, and fometimes almoft entirely from its infertion.
Where the difeafe proceeds  from the gradual formation
                                                    of 
                       [   496   ]
of a tumor within the joint, and where the ligament is per-
haps much relaxed from  any caufe,  no rupture may take
place;  but  when  the  luxation  is produced by  external
violence, it cannot  be fuppofed that the bone can be forced
feveral inches from its natural fituation without lacerating
the capfular ligament.
   The pain which  mere particularly attends partial difloca-
tions, probably proceeds  from the ftretching of  the liga-
ment, by the preffure of the difplaced bone.
   In forming a prognofis in luxation, the diftance to which
the head of the bone  is forced, and the degree of violence
producing the affeaion, are to be particularly attended  to.
A partial  diflocation  will  be more  eafily  and certainly  re-
duced than  where the  difplacement is  complete—And
where the violence has not been  very confiderable, the  in-
flammation, and  other fymptoms, will not be in great de-
gree, and  vice verfa.
   The complication of fraaure with luxation is very un-
favourable.   When the luxated bone only is  broken, and
particularly if the fraaure  is near its neck, it is difficult to
reduce it;  hut when  the receiving bone is broken, not on-
ly a great degree of inflammation, and its confequences, are
apt to follow, but if the injury extends to  the focket, there
is always a confiderable rifk of a  ftiff joint fucceeding.
   The difficulty of reducing a diflocation is, caeteris paribus,
proportioned to the duration of the difplacement.   For in
a little time, the head of the bone will form a focket for  it-
felf among the mufcles,  and be  firmly grafped  by them,
and the  natural focket will at length be more ,or lefs filled
by the contiguous foft parts, and perhaps have part of  its
brim  worn off by the  adtion of the  mufcular  fibres paffing
over it.   It does not appear from  diffeclion, that an infpif-
fation of the fynovia, which has  been  faid  often to take
place, ever occurs in thefe cafes.
   It is alfo to be obferved,  that the patient's age and health
                                              influence 
                       [   497  3
 influence the reduaion of a bone. Thus, in advanced life,
 and in delicate conftitutions, it is accomplifhed with much
 more eafe than in the vigour of youth, and in robuft habits
 of body,  where the fuperior ftrength of the mufcles has
 a confiderable influence in counteraaing it.
   The indications in diflocations are;  to reduce the difplac-
 ed bone  into its natural fituation, with as much eafe and
 expedition as poffible ; to retain it in this fituation until the
 injured parts  have  recovered their tone;  and  to obviate
 pain, inflammation, and other fymptoms that fupervene.
   If the foft parts are much contufed  and  inflamed, wc
 ffiould not attempt the reduaion, until, by the application
 of leeches, and of faturnine preparations, by a low regimen,
 and putting the limb in a relaxed pofture, thefe effeas of
 the injury have fubfided.  But where  the contiguous parts
 have not fuffered in this manner, the fooner  we attempt to
 put the bone into its proper fituation the better.
   In almoft  every cafe of luxation, it is  the bone forming the
 lower part of the joint only that is difplaced ;  hence the on-
 ly attention  we have  to give  to the upper part, is to keep it
 firm and fteady, while we endeavour  to replace the under
 part of it.   In effeaing the latter, our chief obftacle con-
 fifts in the aaion of the mufcles conneaed with the  joint;
 thefe not only refill our attempts for  reduction, by keep-
 ing the bone in the place to which it  is puffied,  but often
 draw it out of its natural direftion, and fix it firmly in fome
 adjacent  cavity; and the trials  we make are very apt to
 ftimulate the mufcles to ftronger  aaion, and thus increafe
 the difficulty of the  reduaion.  Hence the neceffity of
 putting all thefe mufcles as much as poffible into a ftate of
 relaxation, in order to remove a luxation.
   When this is done, we may commonly fucceed by the aid
 of affiftants  alone ; but  in fome cafes, fuch force is  requi-
 fite that we  are obliged to have recourfe to machinery.  It
'fhould however be very particularly obferved, that no more
                           3 R                  force 
                     L   4-9S  3
force ought to be employed,  in any cafe,  than is juft fuffi-
cient to bring the end of the diflodged bone on a line with
the end of that to which it is to be appofed; that this
force be applied only to the bone difplaced;  and that it be
applied  in a very gradual manner, and in fuch a direaion
as appears beft adapted  to  that in which the diflocation
was made.  As foon as the ends of the bones are  brought
on  a line, the ordinary aaion of the mufcles  will com-
monly bring them  into their natural fituation; but if this
is infufficient, a gentle preffure muft be employed for the
purpofe.
  There is feldom  any difficulty in retaining the bone in its
proper  fituation,  after reduction, unlefs it  has been fre-
quently difplaced ; the fureft method is, to  put the limb
into a relaxed pofture, and fupport the bone with a band-
age, until the furrounding foft parts have recovered their
tone.
  The fymptoms that require the greateft attention, both
before and after reduction,  are,  pain, inflammation, and
fwelling.   Thefe commonly abate after the replacement:
but while  any degree of inflammation continues, it ffiould
be carefully attended to,  as being the moft common fource
of the  other fymptoms, as well as of the  chronic paine
which frequently fucceed.  See chapter on Contufions.
  When luxations are complicated with fraaures of the
difplaced bones, if the fraaure is at fome diftance from the
luxated  part, it will be no impediment  to the reduction;
the fraaure  may then be treated in the ufual way;  but
when it is fo near the end of a  bone that this cannot be
taken hold of, it renders the cafe difficult and uncertain.
In the  fmaller joints,  as thofe of the fingers and toes, the
reduction  may fometimes be made ; but in  the larger, as
the hip-joint, and that of the flioulder, we muft allow the
fraaure to be cured before we remove the luxation.
   In compound luxations, where there is a  wound of the
                                                 joint, 
                      [  499  3
j.oint, the treatment recommended in compound fraaures
will be applicable after  the replacement of the bone,  our
objea being to obviate inflammation, and its confequences.
   What we have hitherto faid,  relates in general to lux-
ations produced  by external violence; when  they are the
confequence of tumors  or colfeaions of matter, they arc
almoft always  incurable.  If the difeafed parts can be tak-
en off, it ffiould always be advifed ; but when this cannot
be  done, all that art ffiould attempt is,  to give as free  a
difcharge as poffible to  any matter that may form, and to
fupport  the body by a proper diet.
   When diflocations proceed  from  a relaxation of the li-
gaments and tendons which connea the bones, a perfea
cure is feldom obtained ; all that can be  done is to fupport
the limb with  a bandage, and to  brace the relaxed parts by
cold bathing, efearicity, and other tonics.

                    SECT.   II.

        Of Luxations of the Bones of the  Cranium.

   The  bones of the cranium are frequently feparated at
the futures, in cafes of hydrocephalus: If the colfeaion is
removed, all that we can do is to fupport the parts by a
bandage.
   Openings are alfo produced by external violence, parti-
cularly  by  falls  from  great heights.  Such accidents are
almoft always  fatal.  The only affiftance furgery can afford
is to fupport the parts  by gentle preffure with a bandage;
to  direa blood-letting, and other remedies,  according  to
the violence of the fymptoms;  and to keep the patient quiet,
and in a proper pofture during the cure.
SECT. 
[  500   3
                   SECT.   III.

          Of Luxations of the Bones of the Nofe.

  These accidents feldom occur ; but they are always ea-
fily known. In reducing them, the patient's head ffiould be
fupported by  an  affiftant,  while  the  furgeon reduces the
bones with the fingers ; or more readily, when the luxation
is inwards, by introducing  a fmall tube into the noftril.
The bone may then be retained by keeping the tube in the
paffage by means of tapes paffed  round the head.   If the
luxation is outwards, it will be  neceffary  to  employ a
double-headed roller for the retention.


                  SECT.   IV.

            Of Luxations of the Lower Jaw.

  A luxation of the lower jaw can happen in no other
direaion than forward and downward :  And it is  com-
monly the effea  of yawning, by  which  the condyles are
thrown over the  anterior boundaries  of  the cavities with
which they are articulated.
  This diflocation is difcovered,  by the chin being thrown
forward and downward,  while the mouth remains open;
and by pain on attempting to fhut the mouth.  The pa-
tient can neither fpeak diftinaiy, nor fwallow but  with
much difficulty.  If only one fide of the jaw is luxated, as
fometimes happens, inftead  of falling directly down, the
bone  is puffied downwards, and towards the fide unaf-
feaed.  Convulfions, and even death, are, by the ancients,
mentioned as confequences of this accident, but f have ne-
ver feen them occur; and they can only happen, probably,
from mifmanagement.
                                                With 
                     I   501  3
  With proper attention  we can feldom fail in reducing
this luxation.  The patient being  feated on a low chair,
with his head fupported,  and the furgeon ftanding before,
with his  thumbs  properly guarded,  ffiould pufh them as
fat as poffible between the teeth, the lower part being ap-
plied to thofe of the under jaw ;  the palm of each hand is
to be fixed on the outfide, while  with his fingers he lays a
firm hold of the angles of each jaw.   The jaw ffiould  now
be pulled forward  until it moves from  its  fituation,  and
then preffed forcibly down by the thumbs, and  moderate-
ly backwards by the palms of the hands.  The jaw  will
now commonly flip into its proper fituation, and then the
thumb ffiould be inftantly withdrawn.   If but one  con-
dyle is thrown out, the only difference of treatment necef-
fary is, that the force ufed for depreffing the  jaw, ffiould
be chiefly applied to the fide diflocated.
   The thumbs are very  apt to be bitten if they are not
well proteaed, or if  they  be not inftantly  withdrawn on
the bone's flipping into its place.   The end of a handker-
chief is ufually wrapped round them ; but fine feather an-
fwers much better ; and iron  covered with leather would
be ftill preferable.
   After the luxation  is reduced, as the condyles are  very
apt to flip out again, for fome time,  the patient ffiould be
very careful to avoid  gaping, or any other caufe which
might have a tendency to produce that effea.


                    SECT.   V.

                Of Luxations of the Head.

   These luxations are produced by the head  being  forc-
ed  with fuch violence  forward,  as  to  ftretch  or rupture
the ligaments by which the tooth-like procefs of the fecond
                                               vertebra 
                      [  502  3
 vertebra is conneaed to the occiput:  And this commonly
 happens from  falls  from great heights, or  from horfe-
 back.
   When the head is luxated, it always falls  forward on the
 breaft; the patient is deprived of fenfibility inftantaneouf-
 Iy, and lies as if dead; and  foon dies, unlefs  the luxation
 is fpeedily reduced.
   Diflocations of the head  commonly  terminate fatally;
 but  as  recoveries have  fometimes happened   from them,
 there is reafon to fuppofe, that death is frequently the con-
 fequence of the want of timely affiftance.  An attempt for
 the reduaion ffiould always  be made, if poffible, inftanta-
 neoufly after the accident.
   The  patient being feated upon the ground,  and fupport-
 ed by an affiftant, the furgeon ftanding behind, ffiould raife
 the head from the breaft ; and the affiftant being defired to
 prefs down the fhoulders, the head ffiould be gradually
 pulled ftraight up till the diflocation is reduced ; and if this
 is not accomplifhed by moderate extenfion, the head may
 be gently moved  from fide  to fide.   A fudden crack is
 heard on the reduaion taking place; and if the patient be
 not dead, it is immediately afcertained by a partial,  and in
 fome cafes,  by an entire recovery of  all  his faculties.
Thefe, however,  in fome inftances,  always   remain im-
 paired.
   The patient ffiould be  laid in bed immediately after the
reduction ;  the head fliould be kept raifed, and for a  con-
fiderable time in one pofture, by means of a  proper  ban-
dage ; vensefeaion and laxatives fhould be employed; and
a low regimen advifed.
SECT. 
[  503   3
                   SECT.   VI.

  Of Luxations of the Spine, Os Sacrum, and Os Coccygis.

  A complete  luxation of any of the vertebrae probably
never happens without a concomitant fraaure ; and is, per-
haps, always immediately fatal,  from the effeas it  muft
neceffarily produce on the fpinal marrow,  and the contents
of the thorax or abdomen.  It can, therefore, never be an
objea of furgery.
  Partial diflocations may however occur, and the patient
may live a long time afterwards ;  but he will probably fel-
dom entirely recover.   Thefe are  ufually  the confequence,
of falls from great  heights, of violent blows, or of heavy
weights paffing over the body.
  They are diftinguiftied by diftortion of the parts ; by the
touch; and by the fymptoms they ufually induce, fuch as
palfy of the parts below the injury, and either a total fup-
preffion of urine, or an involuntary difcharge of urine and
faeces.
  The vertebras are, in common, luxated  either direaiy
forward, or  to one fide;  and hence it is very difficult to
accompliffi their reduaion.  The moft  certain  method
perhaps, is  to  bend the body flowly forward, as far as
poffible, over  a cafk,  or any other cylindrical  large fub-
ftance, and if the luxation is to one fide, towards the fide
affeaed :  No  machinery  by which  much  force is em-
ployed ffiould  ever be ufed.  Whatever means  is made ufe
of,  however,  will  be feldom fuccefsful when  the bone is
much difplaced.
  When any part of the facrum is diflocated,  all that can
be done is, to replace it as well as poffible by external pref-
fure, and by bending the body forward in the manner we
have mentioned.
                                                  The 
                      [  504   3
   The coccyx is more frequently luxated than any of thefe
 bones, from being more expofed to injuries.   It may be
 thrown either forward or backward.   It is apt  to be forc-
 ed outwards in  laborious births :  and fometimes  from
 large colfeaions of hardened faeces in the reaum.
   This injury is known, by pain all over the loins, parti-
 cularly about the  junaion of the coccyx with the facrum,
 and from actual examination with the  fingers.
   In luxations inwardly, from falls or blows,  the patient
 complains of pain, and a fenfation of fome hard body com-
 preffing the  under part of the reaum ;  tenefmus comes on,
 and difficulty in paffing the faeces ; and, in fome inftances,
 a  fuppreffion of urine  takes place.  Thefe luxations are
 readily deteaed,  by introducing the finger into the anus;
 and by paffing it as far as poffible up the reaum, and fup-
 porting the  external parts  with the other hand, they may
 be eafily reduced.
   Outward  luxations of the coccyx are in common reduc-
 ed, without much difficulty,  merely by external preffure
 with the fingers ;  but it is often difficult to retain the bone
 in its place.   This is moft effeaually done by a comprefs,
 and the T bandage.
   As diflocations of any of thefe bones,  and particularly
 thofe of the  coccyx, are very apt to produce inflammation,
which often terminates in abfceffes difficult to heal, we
 ffiould employ general and  topical bleeding, and laxatives,
and direa an eafy pofture for  the patient,  and a low regi-
 men, in order, if poffible, to prevent it.
SEC T. 
[  505  3
                   SECT.  VII.

              Of Luxations of the Clavicles.

   Luxations of the clavicles do not happen fo frequently
35 fraaures of them and generally take place at the  ends
next to the fternum.  They are eafily difcovered ; and are
commonly attended with a confiderable degree of ftiffnefs
and immobility in the correfponding flioulder.
   A diflocation of  the clavicle is readily reduced by mo-
derate  preffure with the fingers,  efpecially if the  arms and
ffioulders be at the  fame time drawn back; but  it is  diffi-
cult  afterwards  to  retain the bone in its place.   This is
ufually attempted by bandages ; and particularly by a long
roller,  applied fo as to form the figure of eight  upon the
ffioulders and breaft ; but this,  if applied with fufficient
tightnefs to keep the bone in its place, will always impede
refpiration.  The  machine reprefented, (pi. xii. fig. 6.)
anfwers the purpofe better than any thing elfe I have feen ;
for at the fame time that it keeps the ffioulders back, and
raifes the head,  the ftraps which pafs over the upper part
of the  breaft aa with fufficient force to keep the bone  in
its fituation.  The fore-arm  ffiould  alfo be  moderately
fupported, to prevent the ffioulders from being too much
drawn  back.


                   SECT.  VIII.

                Of Luxations of the Ribs.

  It has been generally fuppofed that the ribs cannot  be
cUflocated ;  but it has been proved  by diffeaions that they
are fometimes  luxatld inwards.
                             3S                     A 
                       [  506   3
   A luxated rib will produce nearly the  fame fymptoms
 that occur from a fraaure ; but it may be diftinguifhed, by
 the pain being moft fevere at the articulation, and by no
 part of the bone yielding to preffure except this fpot.
   In general,  a luxated rib will probably return to its na-
 tural fituation from its own elafticity, when the caufe of
 the injury is removed ; but if it  does not, the beft  method
 of reducing it  will be, to bend the  body forward over a
 cafk, or fome other cylindrical fubftance, while the vertebrae
 immediately above and below the rib are  preffed inwards
 with as much force as can with fafety be applied to them.
 After this, a thick comprefs of  linen ffiould be laid  over
 the  vertebrae mentioned,  and  another along the moft  pro-
 minent part of the diflocated rib, and the two immediately
 contiguous; and a broad roller  ffiould  then be  paffed
 over them, and two  or three  times  around the body, in
 order to  retain the replaced rib  and the vertebrae in their
 fituations : And to  prevent the roller from moving, a fca-
 pulary bandage, a ftrap  conneaed with  it  behind,  car-
 ried between the thighs  and fixed to it before, ffiould be
 employed.
   For the prevention of inflammation, and other difagree-
 able effeas,  which are very apt  to enfue from this luxa-
 tion, bleeding, a low and cooling regimen, and opiates are
 the beft remedies.

                    SECT.   IX.

       Of Diflocations of the Humerus at the  Shoulder.

  From the conftruaion  of the  joint at the flioulder,  dif-
locations oftener happen there than in all the other joints
of the body together.  The os humeri is moft frequently
luxated downwards, from its meeting with leaft refiftance
                                                    in 
                     t   507  ]
in that direaion.   It is fometimes puffied downwards and
forwards, beneath  the  peaoral mufcle, and between the
coracoid procefs of the fcapula, and the middle of the cla-
vicle and lodged on the ribs. In a few cafes, it is diflocated
downwards and backwards ; but it can never be thrown
upwards without being accompanied by a fraaure of the
acromion, of the  coracoid procefs,  or of both.   But al-
though the direaion the bone takes depends in fome mea-
fure on the refiftance it meets with,  it alfo is influenced
by the part which is the immediate feat of the injury.
   A diflocation of the humerus is evidenced,  by inability
to move the arm; by  fevere pain being  excited on attempt-
ing to  bring it near the fide; by its being ffiorter or longer
than the other arm ;  by feeling the head of the bone; and
by difcovering a vacancy beneath the acromion.   In order
to afcertain thefe  eircumftances, the found arm  ffiould be
compared with the other.
   In long continued cafes, the whole arm is apt to become
 cedematous, and fomewhat infenfible from the preffure of
 the  bone on the lymphatics and nerves.
   In fimple and recent luxations of the humerus, we may
 in almoft every inftance accompliffi a  reduaion, without
 much difficulty;  but in long continued cafes, all our at-
 tempts are frequently rendered abortive,  either  from the
 head of the bone  having formed a focket among, and be-
 coming firmly conneaed to, the contiguous parts, or from
 a diminution of the  cavity of the natural  focket.   In fuch
 cafes, therefore, no  great degree of force ffiould be much
 perfifted in to accompliffi a reduaion ; for befides giving
 a great deal of pain, it is apt to render the  motion of the
 head of the bone in the artificial focket more ftiff than it
 was before.
   It is generally faid, that a reduaion is more eafily effea-
 ed when the bone is in the axilla, than when it is pufhed
  forward  beneath the  peaoral mufcle;  and more eafily
                                                 when 
                     [  508  3
when in this fituation,  than if it is lodged backward be-
neath the  fpine of the fcapula.  The latter appears to be
the cafe ; but in the others, I have found no difference.
   I have often^ reduced  a diflocated  humerus by preffing
back  the  fcapula with one  hand, while I extended the
arm gently with the other, bending the elbow moderately,
and  raifing the arm nearly to a right angle with the body
in fuch a direaion as to prevent either the peaoral or ex-
tenfor mufcles of  the arm from being ftretched.  A great-
er degree  of  force than can  thus be applied is, however,
fometimes neceffary.  The  following  is the method by
which I have always fucceeded in recent  cafes : The pa-
tient is feated on a chair, and his  body fecured by a long
broad belt paffed  round it, and given to affiftants, or tied
round a poll; a  firm band of leather, four or  five inches
broad and lined  with flannel, as reprefented  in  pi. xi.
fig. 4. is now to be tied round the arm immediately above
the  elbow.   The three ftraps or  cords  conneaed  with
this band being given to affiftants, they muft be defired to
extend  the arm in the relaxed pofition we have mentioned,
and in a  flow,  equable  manner, while  another  affiftant
ftanding behind is employed in preffing the fcapula back-
wards.   The furgeon  himfelf ftands moft  conveniently
on the outfide of the arm :  he is to direa the degree of
force to be employed,  and to  point out the direaion in
which the arm is to be extended; he may alfo fupport the
 fore-arm, and retain it bent at the  elbow,  as already
 mentioned.  As foon as the head of the bone is drawn
paft the brim of the focket, the extending force ffiould be
leffened, and the reduaion will then  in common be accom-
 plifhed by the aaion of the  mufcles of the joint; or it may
 be effeaed by moving the arm gently in different direc-
tions.  A crack  is ufually heard on the bone flipping in ;
 immediate relief is afforded ; and the ffioulder refumes its
 prominency.
                                                  The 
                     [  509   3
  The arm muft always  be extended in that direaion
which gives the leaft  refiftance ; when the  head of the
bone is puffied forward beneath the  peaoral mufcle, or
thrown backward, the  arm fhould be raifed to a right angle
with the body ; but in the moft frequent kind of luxation
 in this part, where the bone is  fixed in the arm-pit, the
arm ffiould be drawn fomewhat obliquely downward.  It
 is to be obferved,  however, that we fliould always vary the
 direction of the extenfion as foon  as ever  we meet  with
 any confiderable refiftance.
   The mode of treatment I have juft recommended will
 fucceed generally, even in cafes of long ftanding, where a
 reduaion is praaicable ; but when a greater force is  re-
 quired than can be applied in this manner, the inftrument,
 reprefented plate  iii. fig.  1. invented by Mr. Freke, anfwers
 the purpofe with more  eafe  and fafety than any other 1
 have feen employed.  By this machine we can make a gra-
 dual extenfion in any direaion. For  the mode of applying
 it, fee the plate and explanation.
    A great  variety of methods, all however much more
 objeaionable  than the one we have advifed,  have been
 praaifed in the reduaion of a diflocated humerus.  1. The
 arm being  forcibly extended  by laying hold of the fore-
 arm, the heel of the furgeon is  by fome  direaed to be
  applied  to  the head of  the bone in  order to pufh it  up;
  and fometimes a ball, or fome other round fubftance, is
  placed between the  heel  and bone.  By this method the
  elbow and  fore-arm may be unneceffarily injured ;  the
  mufcles which may, and ought to be relaxed, are kept ex-
  tended ; and  the head of the humerus  mull be  often
  forced up  againft the neck  of the  fcapula, or other con-
  tiguous parts, and  thus tend effeaually to counteraa the
  extenfion.   2. Others attempt to reduce  the bone, by ap-
  plying a rolling-pin covered with cloth or flannel, to the head
  of the bone while an extenfion is made. This is liable to a
                                                material 
                      £  510   ]
material objection juft mentioned. And neither this mode
nor the  firft can be applicable when the  bone is luxated
backward or forward, becaufe they can at any rate only
aa in raifing the bones.   3. It has been a pra&ice with
fome  to  have a towel or  girth paffed round the os humeri
near its head, and over the head of the furgeon, in order
to raife the bone while the extenfion is made.   This is ob-
jeaionable for the third reafon mentioned in defcribing the
firft mode.
  In  order  to increafe  the powers of extenfion, when
thefe methods have been fruitlefs ; 4. The ambe of Hippo-
crates has been ufed ; but this is liable in a very great de-
gree to the objeaion  to the  3d  method.   5.  The pa-
tient has  been fuddenly fufpended, by the diflocated arm,
from a ladder or high door.  We are told this has often fuc-
ceeded.  6.  The patient  has  been fufpended  by two or
three men ftanding on a table ; and the bone thus reduced
in fome inftances.   7. The patient has been  raifed  by the
arm by means  of pullies fixed in  the  cieling of a room.
This has alfo fucceeded in cafes  where other means have
failed.
   All thefe modes are, however, liable to great objeaions;
the extenfion is made in fo forcible, fudden and  irregular
a manner,  that more mifchief is often done to the foft
parts, although defended by flannel or leather, than  can be
compenfated by the reduaion of the bone ; and as the arm
muft always  be  extended in the fame  direaion, it muft
obvioufly in  fome cafes give a great chance of fraauring
a rib, the fcapula, or the humerus itfelf.
   8. A  machine has  been invented for conjoining the
power of the ambe with the mode juft  defcribed ;  this
muft  neceffarily be  more dangerous  than  either of thofe
methods  feparately.   And,  9.  Ropes and  pullies have
been employed to diflodge the difplaced bone ; by  which
                                                    as 
                     [  5ii  ]
as much force  as ever can be neceffary may be  readily
applied.
  Swelling, inflammation, and pain, when concomitants of
luxation, are  to be removed by the ufual remedies,  but
chiefly by the application of leeches.
  The  round head  of the biceps  cubiti  which paffes
through the ffioulder-joint,  is apt to be feparated from
the humerus, and induces pain, ftiffnefs, and unwieldinefs
of the arm.   The moft certain method of reducing it is, to
move the arm in a variety of direaions from time to time;
and we know that it is replaced, by  an inftantaneous re-
moval of the  diftrefs.
   In order  to  prevent the humerus from falling out of
its place after reduaion, the beft method is to fupport it
by the fling  reprefented plate xn. fig.  3. until  the parts
recover their tone:  Blifters  and the  cold bath  have  alfo
been ufeful to reftore this.


                    SECT.  X.

  Of Luxations of the Fore-arm at the Joint of the Elbow.

   These luxations occur more  frequently upwards and
 backwards than  in  any other direaion; they can hardly
 be produced  forward or laterally, without an accompany-
 ing fraaure  of the upper part of the ulna.
   Luxations of  the fore-arm  are  readily  diftinguiftied,
 unlefs  the foft parts have become fwelled and inflamed.
 When the luxation is backward, the olecranon is felt  on
 the back part of the arm, and the condyles of the humerus
 are pufhed forward.  When the olecranon is broke, and
 the ulna and radius thrown forward, they are alfo apt to
 be drawn  upward on  the anterior part of  the humerus,
 and  the condyles of that bone are difcovered behind.  A
                                              comDlete, 
                       [   512  3
 complete lateral  luxation can never occur unlefs the foft
 parts are much lacerated. In whatever way the difplacement
 is made, the joint becomes immediately immoveable.
   In the reduaion of thefe diflocations, the patient ffiould
 be feated, and the arm firmly fecured by an affiftant:  When
 the  bones are luxated backward, the fore-arm ffiould be
 moderately bent, in  order to relax the flexor mufcles; it
 ffiould then be gradually  extended, and if while  this is
 done,  the curvature of the elbow is proportionably in-
 creafed, we will feldom fail in the reduaion.   Where the
 olecranon is broken, and the ends of the ulna and radius
 puffied forward and drawn up upon the humerus, we muft
 extend the arm while in a ftraight pofition :  and the exten-
 fion muft  be continued until the ends of both bones are
 pulled  fomewhat lower than  the moft depending part of
 the humerus, when they will foon regain  their fituation by
 the aaion of the mufcles, or be eafily forced into it.
   In lateral diflocations of thefe bones, the extenfion muft
 alfo be continued till  they have paffed the end of the hu-
 merus, and then  they  may be puffied laterally into their
 places.  In  every variety, the extenfion fliould be made
 by affiftants grafping the arm juft  above the wrift ;  and
 while this is done,  the  furgeon  fliould   prefs  down  the
 heads of the bones.
   After the reduction, the elbow  fhould be kept  mode-
rately bent, and the arm as much as poffible at reft, until the
parts have recovered their tone.
  Inftances have  occurred of the feparation of the  bones
 of the  arm from  each other  at both their points of con-
neaion ; but this has happened more frequently at  the
wrift than, at the  elbow.   It  is known by  the motion of
the joint being impaired, and  the other ufual fymptoms of
diflocation.
  In general, the luxated bone is eafily reduced, but it is diffi-
cult trj retain it in its place. The beft method of effeaing this
                                                   if. 
                      E  sis  3
is by means of fplints,  extending from the elbow to the
ends of the fingers, and fecured by a roller, and by after-
wards putting the arm in the fling, reprefented plate xn.
fig. 3.

                   SECT.   XI.

          OfLtAcatiom of tht Bones of the Wrifl.

  These  bones  are  moft readily diflocated  outwardly \
and  may be difplaced either feparately or  feveral of  them
together, and either  at their conneaion  with  the  arm,
with the metacarpus,  or with each other.
  The injury is  generally afcertained without difficulty;
but in fome cafes of incomplete diflocation  of a fingle bone,
if the parts are not examined with a great deal of atten-
tion, the fymptoms are very apt to be attributed to a fprain,
and the confequence will  be a  lamenefs  of  the limb for
life.
  We are generally advifed to pufh thefe  bones into their
places while the wrift is laid  flat upon a table; but it will
be better to have  it fupported by affiftants, as we can then
have accefs to both  fides of it.   They are to be retained
by fplints  and bandages, in the manner advifed in the laft
feaion; and topical bleeding  ffiould be freely ufed in or-
der to prevent the inflammation which is fo apt to come
on.
8 X                SECT. 
[  514   3
                  SECT.  XII.

  Of Luxations of the Bones of the Metacarpus and Fingers.

  Dislocations of  the  metacarpal bones, and  of thofe
of the fingers, do not fo often  occur as might be expeaed ;
probably from the articulations being  fo eafily moveable
that they readily yield to any force applied to them.  They
are  deteaed without  any difficulty in  every inftance.
  When the metacarpal bones arc diflocated at the wrift,
the  beft method of replacing them is,  to  keep the arm
fixed, and to pufh them downward, while the hand is left
loofe. When the firft phalanx of any of the fingers is diflo-
cated at the metacarpus, it is to be reduced by one affiftant
fixing the hand,  while  another draws down the diflocated
finger by  grafping the  firft phalanx.   Diflocations of the
other joints of the fingers and thumb are to be managed
in a fimilar manner.
  In the reduaion of  thefe diflocations it fhould be ob-
ferved that the bone ffiould never be  pulled down until it
be fomewhat raifed from the bone contiguous; on account
of the end of it  being larger than the middle, which cir-
cumftance might otherwife entirely fruftrate the reduaion.


                  SECT.  XIII.

       Of Luxations of the Femur at the Hip-Joint.

  It has been doubted whether a luxation of the femur at
the  hip-joint has ever taken place: But I have feen inftances
in which its exiftence has been proved by the patient's be-
ing-inftantaneoufly relieved by the efforts of the furgeon.
  The os femoris, it is  faid, may be luxated either upward
                                                  and 
                      I"  515   ]
and backward, upward and forward, downward and back-
ward,  downward  and forward,  or  direaiy  downward.
The firft and third of thefe  have very feldom been met
with ;  and the moft common variety,  and the only one I
have feen, is that in which the bone is thrown downward
and forward, and lodged in the foramen ovale.  The rea-
fon why this is moft frequently met with is,  that there is
a vacancy in the os innominatum  forming the focket on the
interior part, which is covered only by a ligament.
   When the luxation is upward and backward, the leg
will be confiderably ffiorter  than the  other; the great
trochanter will be higher; the knee and foot  will  be turn-
ed inward, and it will give a good deal of pain to attempt
to alter their direaion.
   If the femur  is  thrown upward and forward,  the leg
will be fhortened ; the head of the bone will be felt refting
upon the os pubis  in the groin ;  the great trochanter will
be on the upper and anterior part of the thigh, and a va-
cancy  will  be found in its proper fituation; the knee and
toes will be turned outwards;  and  if the diflocation be
not foon reduced, pain and inflammation will probably af-
fea the fpermatic cord and teftis.
   If ever the luxation be downward and backwards, the
leg will be confiderably lengthened ; the knee and  toes will
be turned inwards; and the great trochanter will be lower
than it ought to be.  When  the  head of the bone paffes
direaiy downwards, the leg  will be longer  and  the  tro-
chanter lower, but the knees  and toes will retain their na-
tural fituation.
   In the moft frequent fpecies of luxation, the leg appears
confiderably  longer than the other; the knees and  toes
turn .outwards, and cannot be moved  inward or  outward
without pain; all the mufcles of the  internal part of the
thigh arc tenfe and painful; the femur cannot be felt on
the outfide farther off  than  the middle of  the thigh; a
                                               vacancv 
                     C  51(5   3
vacancy is felt in the ufual place of the  great trochanter,
which is found farther down and on the anterior part of
the thigh, while the head of the bone is felt a little below
the groin.
   Recent luxations of the os femoris may with proper ma-
nagement be almoft always reduced;  but for the reafons
mentioned when treating of diflocations in general, thefe
of long duration often baffle all our efforts.
   In reducing this luxation, the extenfion muft vary in its
direaion according to the variety of the affeaion ; and the
head of the bone ffiould always be completely raifed above
any projeaing part of the contiguous bones  before  any
other attempt is made to reduce it: As this will remove the
principal impediment to the reduaion, if the mufcles of
the limb be at the fame time relaxed, the bone will eafily
be drawn into the focket, when the diflocation is upward,
or puffied into it, when downward.
   In the moft common luxation of the thigh, where the
head of the  bone  is  puffied  downward and forward, I
have fucceeded in the  following manner : The patient be-
ing laid upon his back acrofs a bed, and firmly fecured by
an affiftant or two, a broad ftrap, or table-cloth properly
folded,  is paffed between his thighs and over the groin,
on the found fide,  and given to two other affiftants; a fi-
milar ftrap is  paffed around  the luxated thigh as near as
poffible  to its head, the  ends of which muft be given to
an affiftant ftanding on the oppofite fide.  The belt, plate
xi. fig. 4. being previoufly  fixed upon  the under part of
the thigh, the ftraps conneaed with it are given to an af-
fiftant or two, while  the knee is fupported by another af-
fiftant with the leg moderately bent.  The extenfion ffiould
then be made by the affiftants  who have the charge of the
ftraps conneaed to the belt; but it ought not to he carried
farther than is confidered neceffary for drawing the head of
the bone down to the under part of the foramen ovale, whieh
                                                 may 
                     C  «T  3
■lay be effeaed by a moderate force.  The ftrap round the
upper part of the thigh muft be firmly pulled, and the thigh
drawn upward and inward, the affiUants ftanding fome-
what higher than the patient, until the bone has probably
cleared the foramen ovale.   At this time,  the knee ffiould
be moved fomewhat inward, and the thigh be puffied up-
ward  and obliquely outward, by the affiftant keeping one
hand on the knee,  while he holds the foot with the other,
keeping the leg moderately bent.
  The furgeon may judge  that the head of the bone is
fufficiently  raifed when it  appears to  be about an inch
higher than when the force was firft applied.   If it yields
with difficulty, we  may fuppofe that fome part of it hag
become fixed in the upper part of the foramen; in  which
cafe the force in  the direaion recommended muft be dif-
continued,  and the affiftants at the knee being direaed to
increafe the extenfion downward, it  will  afterwards be
more  eafily raifed.
   When this method fails,  and it  is judged neceffary to
employ greater force than can be  thus applied, we may.
have recourfe to  Mr. Freke's machine,  plate in. fig. 1. or
to ropes and pullies.  But it is to be obferved,  that no af-
fitance of this kind can be neceffary when  the diflocation
is downward.
   The violent diftention  of the mufcles and laceration of
the ligaments of the joint with which  this  affeaion muft
be  neceffarily attended, render  a  great deal of attention
neceffary for a long time after the reduaion.  Blood-let-
ting, topically, ffiould be freely  ufed according  to eircum-
ftances, and  reft ffiould be  enjoined until  the parts have
recovered their tone.
   I do not believe that  a  fubluxation of this joint, as
mentioned by fome,  can poffibly take place, on account of
the roundnefs of  the  head  of the thigh-bone, and the
narrownefs of the brim of its focket.
                                           SECT. 
[  518   3
                    SECT. XIV.

               Of Luxations of the Patella.

  The  patella  may be  luxated partially or completely,
upward, downward,  inward, or outward ;  and either by
itfelf, or with the bones of the leg.   It cannot, however,
be completely luxated in any direaion without a rupture
of the ligament which conneas it to the  tibia,  or of the
tendon of the reaus femoris,  which is  inferted into the
upper part of it, or  of both; and it will be moft  eafily
diflocated internally.
  Luxations  of the rotula are eafily difcovered, unlefs the
parts have become fwelled  and inflamed ;  in  every  cafe
they produce lamenefs, and pain, on motion of the knee-
joint.
  During the reduaion of  this bone, the patient ffiould
be placed on a bed  or  table, and his leg ffiould be kept
extended  by  an affiftant.  The furgeon  ffiould raife the
bone fomewhat, by preffing  down the outward edge of it,
previous to an attempt to pufh it into its place, in order
to avoid  the  condyles of the femur or the  tibia.  When
the  luxation  is complicated  with a  difplacement of the
bones of the leg, thefe muft  be replaced before the patella
can be reduced.

                  SECT. XV.

       Of Luxations  of the Leg at the Knee-joint.

  The bones of the  thigh and leg are fo  firmly connea-
ed,  that they  are lefs frequently feparated than thofe form-
ing any  other joint of the body.  They cannot be com-
                                               pletely 
                      [  519   3
pletely luxated, unlefs the teguments, tendons, and  liga-
ments which tie them together be ruptured.   When how-
ever a luxation happens, it may be produced nearly with
equal eafe on either  fide ; but it may occur  more readily
backward than forward.
   There is no difficulty in diftinguifhing a luxation of the
knee.  It is to be reduced by fixing the thigh firmly, and
extending the leg in as relaxed a pofition as poffible, until
the ends of the bones are entirely clear of each other, and
then puffiing them together.
   As inflammation is more particularly apt  to fupervene
to this luxation, the patient ffiould obferve a ftria antiphlo-
giftic courfe ;  local bleeding ffiould be freely ufed, and re-
peated according to eircumftances ; and the limb ffiould be
kept a confiderable  time at perfea reft.
   A feparation of the fibula from the tibia, at one or both
 ends, is very apt to  be miftaken for a fprain ; but an atten-
 tive examination will  fecure us from this. It ffiould be re-
 placed as foon as poffible, and retained  by a bandage until
 the parts recover their tone.


                   SECT.   XVI.

        Of Luxations  of the Foot at the Ankle-joint.

   The  aftragalus  may be luxated  either  backward or
 forward, or outward  or inward,  but it  is more frequently
 puffied inward than  in any other direaion.  It cannot be
 luxated outwardly without breaking the end of the fibula.
 Diflocations of this joint are in general eafily difcovered by
 the pain  and  lamenefs they produce, as well as by the ob-
 vious alteration which they occafion in the appearance of
 the foot.  They are  to be thus reduced : The patient be-
 ing placed either on  a table or a bed, and the leg with the
                                                  knee 
                      C  320  J
knee bent, firmly fecured by an affiftant or two;  the foot
is then to be extended in a relaxed pofture, until the moft
prominent part of the aftragalus has paffed the end of the
tibia, when it will either flip into its place, or may be eafily
forced into it.
  Befides the ufual antiphlogiftic courfe which we have re-
commended in luxations of all the larger joints, it is par-
ticularly  neceffary  here to keep the limb for a confiderable
time perfeaiy at reft, efpecially when the fibula is broken;
becaufe if the bone be  not retained exaaiy in its fituation
till  a cure is effeaed,  this  important joint may be kept
weak during life, or  be rendered ftiff and very  painful.
Any weaknefs remaining after injuries of this kind, is moft
effeaually obviated by a firm thin iron plate applied along
the outfide of the leg,  and conneaed with the ffioe.  Mr.
Gooch has invented a machine for this purpofe.


                  SECT.  XVII.

 Of Luxations of the Os Calcis,  and other Bones of the Foot.

  The os calcis is fometimes diflocated laterally, by itfelf;
and at other times, together with the aftragalus, is difplaced
at it6 junaion with the  os naviculare and cuboides down-
ward, outward, or inward ; but hardly  if ever upward.
  Luxations of thefe bones are very  readily difcovered by1
the pain  and lamenefs which they always occafion, and by
the alteration of  ffiape in the foot  which they induce.
  A diflocation  of the os calcis is more difficult to reduce
than that of almoft any other bone of the foot:  This is to
be effeaed by fixing the leg in a relaxed pofition,  and mo-
derately extending the foot, previous to attempting the co-
aptation  of the bones.
                                                  The 
                      [   521  3
  The reft of the bones of the tarfus, as well as thofe of
the metatarfus and toes, are to be replaced when diflocated
by the fame general treatment that  was recommended in
luxations of the hand.
CHAP.    XLIV.

     Of Distorted Limbs.
    DISTORTIONS  of  the limbs  may originate either
     from a difeafed ftate of the bones, or from a con-
traaed ftate of the mufcles, or both.   They may occur ei-
ther from an original mal-conformation, or as the confe-
quence of fome  difeafe at an early or  later period after
birth.
  In infancy, as the bones are foft, they may be rendered
crooked by children being made to walk too early.   There
are alfo fome difeafes which render them preternaturally
foft, fo that they readily give way to the  ordinary aaion of
the mufcles,  as well as to the weight of the  body, and
thus  lofe their natural direaion.    But the moft frequent
caufe of diftorted limbs  is that  contraaion of the flexor
mufcles, particularly in the knee and elbow, which is often
induced by an inflamed ftate of the  joints, from the patient
keeping them conftantly  bent for a confiderable length of
time.
  When the diftortion originates from an adhefion of the
bones forming a joint, nothing can give relief but amputa-
                        3  U                      tion- 
                      [  522  ]
tion.   (See chap, on Amputation).  But when the contraa-
ed date of the mufcles and tendons is the caufe of it, which
is mofl frequently the cafe, we may in almoft every inftance
afford confiderable relief:  and, where a limb is  crooked
from the bone being bent, whether it may have happened
from improper management during childhood, or from the
effeas of the rickets, or any  other difeafe, we may very
commonly, by timely attention, either remove it entirely,
or render it much lefs confiderable.
   In diftortions  from contraaed  mufcles, by the  ufe of
emollients  and gradual extenfion, I  have relieved,  and
fometimes  cured, patients, who had been lame for feveral
years,  and  whofe cafes  had been deemed hopelefs.   As
emollients,  the animal fats  and  oils are the beft; but what-
ever is ufed muft  be employed for a confiderable length of
time, and in a very ample manner to be beneficial.   All the
contraaed mufcles and tendons, from their origins to their
infertions, muft be well rubbed  with the fubftance made ufe
of at leaft half an hour three  times a-day; and the limb
fliould be kept conftantly moift  with, or as it were immerfed
in the emollient, by being  covered with flannel well foaked
in it.   While the  friaions are ufed, the limb ffiould be
flowly, though firmly, extended to as great a degree as the
patient can eafily bear ; and an apparatus  ffiould afterwards
be applied to prevent the mufcles from contraaing.
   Even where the extenfion is not neeefiary, as in joint*
merely ftiff without any diftortion, emollients are often ve-
ry ufeful.
   Where  the diftortion proceeds from the curvature of
a bone, if this is not of long duration, and efpecially when
it occurs in childhood, we may very frequently remove it
by making a conftant preffure,  gradually increafed,  on the
convex fide of the limb, until  the bone is  brought  into
its natural direaion.   This deformity  is moft frequently
met with in new-born children, and in  ricketty patients;
                                                  and 
                      [   523   3
and commonly affeas the legs.   If the bones of the leg
are bent outward, it caufes the foot  to be turned inward ;
and the foot is  turned outward  when the leg is bent in-
ward : in the latter cafe, patients are termed Valgi; and
in the former, Vari.
   The diftortion of the feet in thefe cafes,  has by  many
been attributed to a difeafed ftate of the ankle ; but who-
ever will take the trouble of examining the complaint with
attention, will be convinced that  it is, at leaft in common,
a mere confequence of the affeaion of the leg ; and there-
fore, that our views in its removal muft be chiefly direaed
to the latter.
   The cure of this variety of diftortion can only be effeaed
by a proper application of preffure to the leg-bones.   This
is moft eafily and effeaually given by a firm fplint of iron
fixed on the concave fide of the leg, and extending from
the correfponding condyle of the femur to the foot, fecur-
ed by one or two broad ftraps paffed round both the leg
and the fplint.   If the fplint is  covered with foft leather,
and properly fitted  to the  parts, it gives  no uneafinefs;
and by drawing the  ftraps  tighter from time to time,  the
 preffure  will be gradually increafed as above direaed.
   It is fometimes fufficient to fix the ends  of the fplint in
 the ffioe ;  but in other cafes,  it  is neceffary to connea it
 with a frame beneath the ffioe, and fixed to it, in order to
 keep the foot in its proper pofition.
   It is obvious  that the treatment of diftorted limbs muft
 be varied according to the particular nature of the cafe:
this muft be left to the judgment of the furgeon.
C   H   A  P. 
[  524  ]
     CHAP.   XLV.

Of Distortions of the Spine.
 ^ I "*HE fpine may be diftorted in various direaions;
  "*~  outwardly, inwardly, or  laterally; and,  in  fome
 cafes, we meet with it in all thefe  direaions at the fame
 time, and in the fame perfon.
  This  difeafe arifes from external violence ;  but it  is
 more frequently a fymptom of a weakly conftitution.
  Befides the deformity which  thefe diftortions produce,
 they are very apt to injure the health by compreffing the
 vifcera of the abdomen and thorax, and by  inducing pa-
 ralytic affeaions of the lower extremities from the preffure
 they  make upon the nerves.   They appear at all ages;
 but more frequently about puberty than at any other pe-
 riod, and more commonly in girls than in boys.   In gene-
 ral, the effeas refulting from  them are obferved before
 the caufe is fufpeaed.
  When diftortions of the  fpine occur in infancy, the pa-
 tient  appears to be  fuddenly deprived  of the  ufe of his
 limbs ; but at more advanced  periods,  he complains for
 fome  time of feeblenefs,  and of want  of feeling in the
 lower extremities.  By degrees this  infenfibility increafes;
 and he is often obferved  to flumble, and drag his legs  in
 walking; nor can he ftand erea for any length  of time
but with much difficulty.   At laft the legs become entire-
ly paralytic ; and when the fpine is thrown much forward,
 fo as  to comprefs the abdominal or thoracic  vifcera, diffi-
culty of breathing, and complaints in the bowels to a con-
                                              fiderable 
                      [  525  3
fiderable degree, are induced.   In fome cafes, the paralyfis
takes place in a few days from the firft appearance of the
difeafe ; and it fometimes becomes gradually lefs, though,
according to my obfervation, it is never entirely removed.
  When the curvature  is firft difcovered,  we  fometimes
find that only one  of the vertebrae is  difplaced ; at other
times, two or more ; and it  often happens that where  one
bone  only has been affeaed in the beginning, that feverai
adjoining are feized in the after progrefs of the complaint;
and, in  fome cafes, there is  reafon to fuppofe that the de-
formity  is a confequence of  an affeaion of the vertebral
ligaments alone.    When one bone only is deranged, the
patient  is always rendered more completely paralytic than
when feveral are affeaed, and the difeafe is more  fpeedily
fatal.   For in the firft cafe, the patient almoft always dies
within  the courfe of a year  or two, or lefs ; while in the
latter, he frequently lives as long as if no fuch difeafe had
fubfifted.  The difference of preffure on the fpinal marrow
 neceffarily produced, will account  for  this difference  in
 the appearances of the  difeafe;  and likewife for the fymp-
 toms becoming in fome inftances lefs remarkable in the
 courfe  of the complaint than they were at firft.
    As this affeaion often proceeds from weakly perfons  in-
 dulging too much  in  particular poftures, every  habit of
 this kind fhould be carefully guarded  againft on  the firft
 appearance of the  complaint; and if  a particular habit is
 already contraaed, its  oppofite ffiould be  advifed.  That
 the body may lie  as much as  poffible  upon an equal fur-
 face, a  hair matrafs, laid upon boards, fliould be  ufed  in-
 ftead of a feather bed.
    By  attention  to thefe eircumftances; by the ufe of an
 invigorating diet, the  cold bath, bark, and other tonics,
 the difeafe has, in fome cafes, been prevented from advanc-
 ing fo far as it probably would  have  otherwife gone ;  but
 where any of  the bones have been affected, I have never
                                                    feen 
                         [   526   3
feen a complete cure obtained.   Mr. Pott fpeaks highly of
the effeas  of drains placed as  near as poffible to the  tu-
mor.  He  advifes  an  iffue to  be  made  with caufiic, on
each fide of it, large enough to admit of a kidney- bean, and
the  bottom of the fore to  be fprinkled  occafionally  with
powdered cantharides  to  keep it running.*    I  have  em-
ployed this  method  with advantage when  the  ligaments
were the feat of the complaint;  but when it has appeared
to prove ferviceable where the bones  were  affeaed, I am
of opinion  that the change was rather induced by the pref-
fure upon  the fpinal marrow being leffened as above  ex-
plained.
   All the advantage that  can be derived from the ufe of
machinery  in  this difeafe, muft be  from the fupport that
it  can give  to  the  head  and   ffioulders.    This indeed
                                                           is
   *  It may perhaps not be amifs to give a more particular defcription of
Mr.  Pott's method :   To form the iffue he prefers cauftic.   He  tells us,
that the cauftic to be applied, fliould in adults, be large enough to form an
oral efchar of about an inch in length, and nearly three-quarters of an inch
in breadth at the broadeft part.  One fliould be fo applied on each fide of
the curvature, that the portion of flcin covering the fpinal proceffes of the
protruded bones fhall be left entire.  In a few days, when the floughs begin
to loofen, the middle of them fliould  be cut out, and a large kidney*bean,
or fome peas, put into each :   Upon the entire feparation of the  efchars,
the fores may be  filled conftantly with peas or beans; and powder ed  can-
tharides, or fome other ftimulant  may be now  and then applied to them ;
thefe will keep them running,  and may perhaps produce  fome other good
effects.
  The iffues fhould be kept open until the patient has recovered his general
health.  This period will vary exceedingly ; in fome, cures have been  per-
fected in two  months; in others, in not lefs than two years, two-thirds of
which perhaps has paffed without any figns of amendment.
  Mr. Pott relates many cafes in which there could be no doubt of the bones
themfelves being  difeafed, that  were perfectly relieved  by the method
above defcribed.  See Pott's Works, vol. m. 
                      t   527  3
is an objea of the firft importance;  and it can be  very
well attained  by the ufe  of the machine reprefented in
plate xii. fig. G.    If this  point  is not  attended to,  the
weight of the head will  conftantly  tend to increafe the
diftortion.
CHAP.     XL VI.

    Of Amputation.
    BY the term amputation, we ufually underftand the re-
     moval of a limb.
  This operation in itfelf is not difficult; but it is often
very hazardous; and it requires the utmoft attention to
determine the particular eircumftances in which  it can
with propriety be performed.

                   SECT.  I.


    Of the Caufes which  may render Amputation neceffary.


  Amputation,may be rendered neceffary  by the caufes
•numerated under the following heads.
  1. Bad compound fraaures.
  2. Extenfive lacerated and contufed wounds.
  3. A portion of a limb being carried off by a cannon-
ball, or  in any other manner, if  the bones be unequally
broken and not well covered, r-
                                               4.  Ex- 
                      [  528  3
   4.  Extenfive mortifications.
  ■ 5.  White fwellings of the joints.
   6.  Large exoftofes, whether they be confined to joints,
or fpread over the whole bone, or bones of a limb.
   7.  Cafes of extenfive caries accompanied with bad ul-
cers of the contiguous foft parts.
  S.  Cancer,  and fome other ulcers of an inveterate na-
ture.
   9.  Various  kinds of tumors.
   10. Particular diftortions of a limb.
   We fhall confider each of thefe cafes in the order men-
tioned.
   (1.) In cafes  of  compound fraaures which occur  in
the army  and  navy, where the patients cannot be duly at-
tended, where they muft be much jolted and moved from
place to place,  if the  bones are fo  much broken that
when appofed they do not fupport each other firmly, and
the foft parts are likewife much injured, I am perfeaiy of
opinion, that,  in general, immediate amputation ffiould be
advifed.
   In  private  praaice,  however,  where  the patient can
from  the  firft be placed in an eafy comfortable fituation,
from  which he need not  be removed until the cure is com-
pleted, where  he can have all the advantages of good air,
a proper regimen, and  good  medical affiftance, very few
cafes  will  occur in which amputation ffiould be recom-
mended.  The only caufe which, in fuch  eircumftances,
can render an  immediate performance of it proper,  is the
bones of  a limb,  together  with  the foft parts being  fo
fliattered and bruifed,  that there will be no chance of the
member being  rendered  ufeful by any attempt that might
be made to fave it.
  But it "is particularly to be obferved, that unlefs  the
operation  can  be had recourfe to foon after the accident,
it cannot again be admiffible for a confiderable time; for
                                             whenever 
                      [  529   3
whenever a limb  has become fwelled and inflamed, it can
in no cafe, but with  the  utmoft  danger,  be taken off until
thefe fymptoms fubfide.
  And numerous obfervations have afcertained the faa,
that amputation at this period, i. e. as foon as the inflam-
matory fymptoms have gone off, and before the patient has
been too much weakened by the difcharge,* fucceeds much
better than when it is inftituted immediately after the acci-
dent.  In the latter  cafe, death feems to be induced, by the
violence of the fymptomatic fever, which oftentimes induces
fatal hemorrhagies; by the  great and fudden change pro-
duced in the circulating fyftem; and by the violent agita-
tion of mind excited by the operation,  and which feems to
be more particularly induced at that time.
   Although amputation is feldom neceffary in private prac-
tice, yet in the fubfequent treatment of compound fraaures,
it is fometimes  rendered proper:
   lft. By prof ufe hemorrhagies,  which cannot otherwife
be ftopped;  produced by  fome of the  arteries  being
wounded by  the  ends  of  the fraaured  bones, as well as
other caufes.
   2dly.  By extenfive mortification.   This we fhall confi-
 der hereafter.  And,
   Sdly.  By the  ends  of  fraaured bones remaining  dif-
 united, attended with  the  difcharge of fuch large quan-
 tities of matter that the patient runs a rifk of finking under
 it.
   In every cafe,  when the  lafl mentioned  eircumftances
 occur, and continue, notwithftanding every thing is done
 which would probably tend to remove  them,  fuch as the
 taking away all  loofe pieces of bone, the preferving the
 limb fteadily in one pofture, regular dreffing  of the  fore
                          3X                       as
  • The operation feems to fucceed better, whatever may ii
fity for it, when the patient i> fomewhat weakened. 
                      [  530  3
as often as feems neceffary, allowing a nourifliing diet, and
a plentiful ufe of bark, nothing  will fo certainly fave the
patient as the removal of the limb.
  (2.) Wounds not accompanied by fraaures of the con-
tiguous  bones feldom  require  amputation:  But  when-
ever a limb is lacerated, or contufed to fuch a degree as to
have  all the large  blood-veffels deftroyed,  there will then
be no profpea that the circulation can be  preferved in it,
immediate amputation fliould  be advifed : Mortification is
particularly apt  to occur  in fuch cafes.  It alfo happens,
that amputation, although it  does not appear neceffary at
firft,  will become  advifable afterwards, either from he-
morrhagies which cannot be ftopped,  extenfive gangrene,
or large difcharges of matter,  as in  cafes of  compound
fraaure.
   (3.) When  a  portion of a limb has been removed by a
cannon-ball, or fome other means, and the bones are much
broken  and perhaps fplintered,  the mufcles and tendons
left  of  unequal  lengths, and much lacerated and bruifed,
as the operation can  be performed in the fame time that
the broken and fplintered pieces of bones,  and  the injured
parts of the mufcles  and tendons  can be removed; as it
will make a much lefs fore, which confequently will heal
fooner and form a better flump  than if the original  wound
is left,  and no  amputation employed,  I  have no  doubt
of the propriety of an immediate  performance of the ope-
ration.*
   (4.) In all cafes of mortification by which the whole or
a very  great portion  of the foft parts of the limb are de-
ftroyed, amputation is the  only refource.  But it  ffiould
never be employed until  the  gangrene has fairly ftopped
its progrefs ; and then I am of opinion we ffiould perform
                                                      it

  " Here the furgeon's judgment and experience can alone determine the
degree of injury which renders amputation neceffary. 
                      [  531   3
it as foon as poffible,  and without waiting, as advifed by
fome, for the feparation of the difeafed parts.
  (5.) White fwellings of the joints are only to be remov-
ed,  in fome cafes, by amputation.   The particular eircum-
ftances in which this  is advifable are defcribed chap. in.
The caufe of the fuccefs of the operation in long continued
inftances of Hydarthrus, is probably fimilar to that above
affigned in fome cafes  of compound fraaures.
  (6.)  Certain  cafes of exofiofis, in which the tumor is
produaive  of much inconvenience and injury to the pa-
tient, and  which cannot  be  otherwife  removed, require
amputation.  See chap. xli. fea. iii.
  (7.) When an extenfive caries is accompanied by ulcera-
tions which have deftroyed fo much of the foft parts that
a cure cannot reafonably be expeaed, even if the difeafed
bone was removed, amputation is our only remedy.   But
we have inftances  upon record, in which  the  whole of
fome of the larger bones of the extremities have been re-
moved, in  young healthy fubjeas, where the foft parts
have not been  very much injured, and  cures afterwards
obtained: In fuch cafes there has either been a reproduc-
tion of bone, or at leaft the formation of a fubftance which
fupplicd its place.
   (8.) When cancers on the extremities affea the ligaments
or bones, and efpecially if they are extenfive, nothing but
the removal  of the limb above the parts  affeaed can be
depended on ; and even this fometimes fails.  Every other
fpecies of local ulcer that injures the patient's health, and
which, notwithftanding all the remedies employed, evident-
ly becomes more extenfive, and affords fo large a difcharge
as  might by  a longer continuance endanger the patient's
life, is likewife indicative of amputation.
   (9.) Encyfted tumors feldom render amputation  necef-
fary : but  in fome inftances where they are deep feated,
 originating perhaps  from the periofteum,  they produce
                                                  caries 
                     (  532  )
caries or even:diflblution of the bones, and fo injure the
foft parts of the extremity, that the operation is the only
remedy.
  We fometimes find part of a  limb confiderably enlarged
with an uniform hardnefs in fome parts, and in others with
a foftnefs, as if a fluid was colfeaed beneath.   This fwel-
ling in the beginning ufually affeas the lower part of the
member, and gradually extends over the whole of it.   The
fkin at firft has its ufual colour, but at laft it acquires a li-
vid hue.  There is no pain  in  the commencement of the
complaint, but at laft it becomes not only painful but ex-
tremely troublefome from  its  weight.   It ufually  arifes
without any evident caufe, and often in people  who are
otherwife healthy.
  Swellings of this kind are at firft often miftaken for ana-
farca: but the effufion into the cellular membrane which
produces them,  is  tinged with  blood, and is of an acrimo-
nious nature.   When they  are  opened, the difcharge does
not ocCafion much diminution in  the fize  of them, and a
painful fore is produced which  always accelerates the dif-
eafe.  Nothing that I have ever feen ufed feems to retard
its progrefs ;  and amputation fliould always be advifed, as
foon as the  tumor becomes  materially inconvenient;  with
me'it has always prevented a return of the complaint, when
performed on a found part of the limb.
  Swellings of the aneurifmal kind, when very large,  and
feated in the ham or thigh, if they haVe continued fo long as
to hurt the texture of the foft parts,  inducing an cedema-
tous fwelling in them, and fo injure the bone, and have had
thefe effeas to fuch a  degree as to preclude all hope of
the parts being  reftored to  health, even if the operation
for aneurifm ffiould fucceed,  admit of no other treatment
than of removal by amputation  of the limb.
  The aneurifm here alluded to,  is  that which  proceeds
from a dilatation of the artery, and in which the coats of the
                                                 veffel 
                       [   5S3   3
veffel have burft,  and a confiderable effufion  of blood  has
taken  place  into  the cellular  membrane.  In  the latter
flages of this affeaion,  the fwelling becomes fo large, that
the beating of the artery is fcarcely, if at all* perceptible ;
from which it has fometimes been miftaken for a tumor of
a different kind:  The  hiftory of the  cafe will, however,
generally lead to a knowledge of its nature.
   (10.)  Where a limb is otherwife perfeaiy  found, it fel-
dom happens that mere diftortion of it can be a fufficient
caufe for amputation; but the diflrefs produced by this af-
feaion,  fometimes induces patients to requefl the perform-
ance of the operation, when more gentle means fail of re-
moving  the complaint.
   The difficulty of determining the exaa  period of the va-
rious above enumerated complaints, at  which amputation
ffiould be employed, and the blame which a furgeon is fo
apt  to incur if he proceeds to  the operation  while the
fmallefl  doubt remains of  its propriety,  ffiould induce
every praaitioner previous to a performance of it,  to re-
quefl the advice of fome others of his profeffion, in all cafes
where he confiders it neceffary.
                                               S EC T.

  * In a cafe of aneurifm of the arm from a wound in blood-letting, ope-
rated upon in the Pennfylvania Hofpital in the year 1787, and in which
part of the limb was exceffively fwelled, there was not the leaf degree of pul-
fation in the tumor : notwithftanding that it was  evident to the operator,
Dr. Foulke, as well as to moft others prefent, it was the trunk  of the bra-
chial  artery which was wounded, and that it was neceffary to tie a  confi-
derable ramification alfo, which was cut during the operation,  and which
was perhaps two inches higher than the wound of the arterial  trunk, the
patient recovered perfectly in a fhort time. 
[  531.   ]
                    SEC T.  II.

   General Remarks on the Method of Amputating Limbs.

  This operation till lately was attended with a great deal
of danger; in the prefent improved method of performing
it, however, perhaps not more than one death will hap-
pen in twenty cafes, even in hofpital praaice.
  The eircumftances which, in amputation, more particu-
larly require our attention, are,  the choice, when this is in
our power, of  the part to be operated upon; the preven-
tion of hemorrhagy ; the divifion  of the fkin, mufcles and
bones, in fuch  a manner as to admit of the ftump  being
entirely covered with flcin; the including the arteries alone
in the ligature; fecuring the teguments in a proper fitua-
tion, fo as to prevent them from retraaing after the opera-
tion ; and a proper fubfequent treatment of the cafe.
  Next  to fecuring the patient from hemorrhagy,  the
moft material of thefe is the faving fuch  a  proportion of
the  foft parts as will cover the  ftump, fo as to heal  the
fore as nearly as poffible by the firft intention ; for  with-
out  this, the wound produced  by the removal of a large
limb is always extenfive; the cure  accordingly proves te-
dious ; and in  many cafes,  the difcharge is fo exceffive,
that the patient's health is irreparably hurt by it.  In order
to remedy thefe inconveniences,  various attempts have been
made at different times.  At firft, the foft parts were  cut
down to the bone by one ftroke of the knife, and the bone
afterwards fa wed at the edge of the  retraaed mufcles.   It
was afterwards  propofed by  Mr.  Chefelden  to divide  the
foft parts by a double incifion ;  firft to cut through the fkin
and  cellular fubftance,  and then to  divide the mufcles
at the edge  of  the retracted fkin; by this means the faw
was applied higher in the bone, and the ftump was better
                                               covered 
                      [  535  3
covered both with  mufcles and fkin.  Still, however,  an
extenfive fore was  left, which in the thigh feldom healed
in lefs than three months, and often required five or fix;
the ftumps were often, from the retraaion of the foft parts,
pyramidal; and after they were healed, fometimes an exfo-
liation occurred at  a diftant period.
   To prevent the retraaion of the foft parts from the bone,
a roller was applied from the upper part of the thigh to the
end of the flump ;  and Mr. Sharp, as an additional help to
the cure, propofed  to keep the teguments near together by
futures: But the lafl method was found injurious, and the
former inadequate.
   In confequence of the fuppofed impoffibility of improv-
ing this method of operating fo as to fhorten the cure, and
prevent a pyramidal form of the ftump, about the year 1768,
different furgeons  attempted to revive  the flap operation,
which had been firft praaifed near a century  before by an
Engliffi furgeon of the name of Loudham.  See feaion v.
The objections to this method of operating were, however,
fo forcible, that it has never been brought into general ufe.
 And praaitioners by attention to the common mode of am-
putation have fo improved it, that a fufficient quantity of
teguments is faved to cover the whole  end of the ftump;
and by this means, unlefs the patient is of a bad habit of
body,  or  the  inflammation induced runs very.high,  the
whole wound ufually heals in the courfe  of two or three
weeks, and the greater part  of it,  or  perhaps the whole,
by the firft intention, without the  formation of matter.
This I confider as one of the moft important improvements
in the modern  praaice of furgery.   I was induced to em-
ploy it from obfervation of the inconveniencies refulting
from the want  of attention to the faving of fkin in various
operations, but particularly in this; and  ever fince  1772,
I  have made it  a conftant rule to fave as much integument
as poffible in all kinds of operations where I conceived it
                                                might 
                      [   536  ]
might expedite the cure.   It was  not till 1779, that Mr.
Allanfon of Liverpool publiffied an account of his improve-
ment of the  common  method of amputation, and which
he recommends from the experience of nine years.  This
is confidered by many  as the beft mode of operating yet
publiffied; but although by it the wound is chiefly healed
without the formation of matter, yet  the reafons  to  be
hereafter mentioned, induce me to give a preference to the
method I make ufe of, and which I fhall now defcribe.


                   SECT.   11,1.

               Of Amputating the Thigh.

  In amputating either the thigh or leg, the patient fhould
be placed upon a table of ordinary height, with the legs
and arms fecured and fupported by affiftants.
  The flow of blood ffiould  then be ftopped by the tour-
niquet, in the manner formerly direaed in chapter v. and
it is of confequence that  in this operation the inftrument
ffiould be applied fo high, as that the cufhion placed upon
the femoral artery ffiould reach  the groin.   The part  of
the thigh at which the  amputation is made,  muft be in a
great meafure direaed by the ftate of the difeafe, but in
every cafe, as the utility of the limb will  be proportioned to
its length, no more of it  ffiould be taken off than is abfo-
lutely neceffary.   An affiftant now grafping the upper part
of the thigh with both hands, fo as to draw up the fkin and
cellular fubftance as much as poffible, the operator ftand-
ing on the outfide of the patient,  fhould divide them with
a circular incifion down to the mufcles;  this may in gene-
ral be done by one ftroke of the amputating knife; (pi. ii.
fig. 2.) but in large limbs, it is more eafily done  by two.
The affiftant continuing to draw  the teguments upwards,
                                                  the 
                      I   537  3
the cellular fubftance conneaing them to the mufcles be-
neath, ffiould be  divided with the edge of the knife, until
as much of the  fkin is  feparated,  as the operator thinks
will cover the ftump completely.
  The mufcles fhould now be divided clofe to the edge of
the retraaed fkin, and  down to the bone, by one  perpen-
dicular  ftroke of the knife, beginning with the mufcles on
the infide of the  thigh, and  continuing it round the limb
till it terminates where it commenced.  By keeping his
eye conftantly upon the knife, the furgeon may eafily avoid
cutting  the integuments in making  this incifion.  Inftead
of proceeding now to the fawing of the bone,  in the com-
mon way, we will  more certainly  form a good ftump if
the mufcles be previoufly feparated by the  knife from the
bone for about an inch.   The whole of the foft parts be-
ing drawn up as far  as they have been feparated by a re-
traaor,* the periofteum ffiould then be  divided, by  car-
rying the knife round  the bone direaiy beneath the re-
traaory carefully avoiding  injuring the membrane above
where the bone is to be divided, as  it might produce fub-
fequent exfoliations.   The faw, (pi.  iii. fig. 4.) ffiould now
be  applied where the periofteum is  cut,  and  the bone di-
vided by long and fteady ftrokes.   During the fawing the
leg ffiould be held very  firmly and fleadily in  the fame di-
reaion  ; if it is too  much raifed, the motion of  the faw
will be  impeded,  and if depreffed, the bone will be apt to be
fplintered.    Should any fharp points or fplinters remain,
they ought to be immediately removed' with  the  nippers,
(pi. ix.  fig. 3.)
   The  retraaor muft now be taken off, and the trunk of
                       3 Y                         the

  * A retractor is ufually formed thus:  Take a piece of leather, either foft
or firm, eighteen inches  in length, and about fix wide, cut out a fmall
round or oval piece in the middle,  and from the hole thus made  divide
the ftrip to one end.  The mode of applying it is too obvious to need de-
fcription. 
                     [  538   ]
the femoral artery being drawn out with the tenaculum, a
fufficient ligature ffiould be made upon it before the tour-
niquet is loofened ;  all the arterial branches which can be
difcovered on loofening the tourniquet,  and  waffiing  the
wound with a fponge and water, ffiould then be fecured ;
taking care to leave the ends of the ligatures of a fufficient
length to hang without the lips of the wound.  The  fur-
face of the wound being well cleared of blood, the mufcles
and  teguments  ffiould be drawn down till the fkin com-
pletely covers the ftump, and retained in this fituation by
an affiftant, until a flannel or cotton roller, previoufly fixed
round the body to prevent it from flipping  down, be ap-
plied in fuch a manner as to fupport and fix them ; for
which  purpofe it ffiould  be paffed  two or three times
nearly in  a circular  direaion,  round the  upper part of
the  thigh,  and  ffiould afterwards be continued in a fpiral
direaion almoft to  the end of the ftump, and moderate-
ly tight.   It  ffiould  then  be pinned, as much of it being
left  loofe as will pafs two or three times around the ftump.
   The ends of the divided mufcles being placed with as
 much equality as poffible over  the bone, the edges of the
 fkin muft  be laid exaftly together, fo as to form a ftraight
 longitudinal line along the centre of the ftump. When  there
 are  only one or two ligatures, they ffiould be left hanging
 out of the inferior angle of the wound ; but when there are
 feveral, they ffiould  be divided between the two angles, to
 prevent the parts from fuffering by a large extraneous body
 fixed at any one place.   An affiftant retaining the edges of
 the fkin in contaa,  two or three flips  of adhefive plafter
 muft be laid acrofs  the ftump to preferve them nearly in
 this fituation : and the whole end of the ftump fhould now
 be  covered with a   large pledget  of foft lint fpread with
 Goulard's cerate, or the ceratum e lap. calam.   Over this
 there ffiould  be placed a foft  cufhion of fine tow,  and a
                                              comprefs 
                      [   539  ]
comprefs of old  linen; and for the purpofe of retaining
them as well as to make a gentle preffure on the ftump, a
flip of linen, three  inches in breadth, ffiould be laid over
them acrofs the  ftump.  The remaining part of the roller
is to'be employed to fix this, by paffing it two  or three
times round the ftump;  and  the preffure  formed by the
crofs ftrap may  afterwards be increafed or  diminifhed at
pleafure, by drawing  it with more or lefs tightnefs, and
fixing it with pins  to the circular roller.
   While we are applying the roller, the tourniquet ffiould
be taken off; but  it muft be  replaced immediately after
the ftump is dreffed.    If let loofe it gives no uneafinefs,
and it  enables the attendants  to  check any hemorrhagy
which may fucceed ; a circumftance which merits attention
for feveral  days after the amputation of any of the extre-
mities.   The  patient ffiould now  be carried to  bed, and
 the ftump, contrary to the ufual practice, ought to be laid
fomewhat lower than the reft of the body ; for this purpofe
the bed ffiould be made with  a moderate declivity from
above downwards, and nothing ffiould be put beneath the
ftump but a little fine tow.
   To prevent the limb from being  moved inadvertently, as
well as to guard in fome degree againft the effea of thofe
fpafms which often prove troublefome after this operation,
I commonly fix  the ftump down to the bed, by placing a
ftrip of linen or flannel acrofs near  the end of the ftump,
and another at the upper  part  of the thigh, and  connect-
ing them by pins  to the roller, and by pins or pieces of
 tape fewed on them to the matrafs,* to which tape is alfo
 to be fixed.   A bafket, or  hooped frame, fliould now be
 put over the ftump, to protea it from the bed-clothes ; and
 an anodyne ought then always to  be given, to prevent or
 remove pain and relUeffnefs.
* A matrafs is much preferable to a feather bed. 
                       [  540   3
    As hemorrhagies often happen  many hours after  the
 operation, the attendants ffiould be direaed to examine the
 ftump frequently ; and if any material difcharge takes place,
 to tighten the tourniquet fo as to reftrain it till the furgeon
 can attend.   This perplexing circumftance has never taken
 place in  any confiderable degree,  when the method  we
 have advifed has been employed; but in the old mode of
 operating, the large furface expofed to irritation is very  apt
 to induce fpafms, which fometimes terminate in fatal  he-
 morrhagies.  When  there  is merely a trifling oozing of
 blood, it  need not  be regarded ;  but if the difcharge is fo
 great as to lead to a fufpicion of its proceeding from a large
 artery, the dreffings fliould be removed, and the veffel tied.
    Troublefome fpafms in the mufcles of the ftump fucceed
 fometimes to this operation : if thefe are not taken off by
 laying the limb in an eafy pofition, we muft truft to opiates
 for their  removal.
    In order to remove the inflammation and tenfion  of  the
 wound, and the fever, which to a greater or lefs degree, al-
 ways fucceed to amputation, it will be proper to confine  the
 patient to as low a diet as the ftate of his ftrength will per-
 mit.   Where there is  much vigour, bleeding  ffiould be
 ufed  as foon as the fymptoms of fever come on, and gentle
 faline laxatives fliould be given.   This treatment is feldom
 neceffary  but for  a few days ; and afterwards would be in-
 jurious.
    Where the ftump is  not covered with fkin, as in the com-
 mon mode of operation, and a free fuppuration is expeaed,
 the dreffings  ffiould not be removed till  the fourth or fifth
 day; but in the method I  recommend, the ftump fliould al-
 ways be examined at the end of the third day  after the ope-
 ration.  For this purpofe it ffiould be fupported by an affift-
 ant, while a few  turns of the roller are taken off; and  the
 dreffings  totally removed.  In a few cafes, the parts  will be
• found to be united by the firft intention ; but for the moft
                                                   part 
                      [  541  ]
part there will be a fmall quantity of matter  all over the
furface of the ftump, and chiefly at the lower angle of the
wound ;  and the parts  will be red, tenfe, and painful to the
touch, with a fmall feparation between  the edges  of the di-
vided fkin.  The furface of the ftump ffiould now be cover-
ed with a pledget of emollient ointment, and a cufhion of
foft  tow being laid over this,  the crofs ftrips  of linen and
roller ffiould be again applied.
  The wound ought to be thus dreffed every other day ;*
and generally about the feventh or eighth day, the inflam-
mation  will be  fo  far removed, that the ligatures may be
drawn out; at leaft this ffiould be gently attempted at eve-
ry dreffing, becaufe they  will now impede the healing of
the wound.   While the roller continues clean, it may re-
main,  but as  foon as  it  becomes fullied with matter,  it
ffiould be changed.   It ffiould always be employed for three
or four weeks, but if continued longer, it is apt to diminiffi
the fize of the limb.
  As foon as the fore becomes clean and begins  to granu-
late, the pain and tenfion being  now  gone off, the cure
may with propriety be  completed by drawing the edges of
the wound together, by means of ftrips of a moderately ad-
hefive plafter.  By this management, even the largeft ftumps
will generally heal in three or four weeks,  often  in lefs, in
private  praaice, where every defirable advantage can  be
had ;  but in hofpitals, where the patient often fuffers more
from the bad air, &c. than from the operation, the fuccefs
is not fo great.  In fome  inftances, large finufes form in
the ftump between the teguments and mufcles, and retard
the cure  confiderably ;  and fometimes a cure cannot be ob-
tained at all, without the affiftance  of  good air  and diet.
But  for  one  inftance  of this kind from the operation we
have defcribed, there will be twenty from  the ufual mode.
                                                     It

  * In moft parts of the United  States, during the fummer feafon at leaft,
it will be generally neceffary  to drefs more frequently. 
                      [  542  ]
   It fhould not be our objea to heal the ftump in the fiirfl
 inftance,  without  the formation of matter; when this Is
 done, by the ufe of ftrong adhefive plafters, &c. the tegu-
 ments are apt to be very uneven, and the ligatures are  re-
 moved with difficulty ;  but when the cure is accomplifhed
 gradually,  as above direaed, the ligatures  may be eafily
 taken out, and the ftump is always left fmooth and equal.
   The eircumftances of confequence, in which Mr. Allan-
 fon's  method  of amputation  differs from  the mode I have
 recommended, confift chiefly in the manner of dividing  the
 mufcles: and the after pofition of the fkin.   After feparat-
 ing as much fkin as neceffary, he direas a double edged
 knife to  be applied to the inner edge  of the vaftus inter-
 nus, and at one ftroke to cut obliquely through the muf-
 cles upwards as  to the limb, and down to the bone, fo as
 to lay the bone bare about two or three  fingers breadth
 higher than is ufually done by the common perpendicular
 incifion ; the  point of the knife is then to reft  upon and
 revolve  round the bone, while the incifion of the mufcles
 is continued round the limb in the direaion that was firft
 given to  it.   The quantity  of fkin faved, and mufcular
 fubftance taken out, muft be  in fuch a proportion to each
 other, that by a removal of both, the whole furface of  the
 wound will  be afterwards eafily covered,  and the  length
 of the limb not more fhortened than is neceffary to obtain
 this end.
   Mr. Allanfon direas the fkin and mufcles to  be placed
 over the bone  in fuch a direaion as that the wound fhall
 appear only as a line, with the angles  at each fide ; and,
 inftead of fecuring the dreffings with  a part of  the roller,
 he direas a manifold bandage to be employed.
  I have ufed this  method  of operating; but  I find it
much more exceptionable than that I have above defcribed.
The removal of fuch a large portion of mufcular fubftance
as is done by Mr. Allanfon's oblique incifion, produces a
                                               hollow 
                      [   543   1
hollow, which not only retains the matter, but which pre-
vents the flump from being  fo equal and fmooth as when
the fkin is fupported by a flat mufcular furface, in the man-
ner we have advifed.   Nor is the bone fo well covered by
mufcle, and the danger of exfoliation fo well avoided, by
his method as by that  I have defcribed above.  But if the
ultimate advantages refulting from both were  equal, the
latter mode would  claim a preference  on account  of its
greater  facility of performance.   It is almoft impoffible
to avoid mangling the fkin in  making the oblique incifion
of the mufcles, and the affiftants  which Mr. Allanfon di-
reas to prevent  this,  muft be apt, not only  to embarrafs
each other, but the operator.
   Mr.  Allanfon's reafon for placing the lips of the wound
tranfverfely  is, that  after the  cure, the cicatrix will be
drawn  near the lower  edge  of the extremity by the fupe-
rior force  of the poflerior mufcles, and confequently that
the preffure  on the  flump in walking will  be afterwards
made upon the found fkin.  But I have found no inconve-
niency  from the  cicatrix  being oppofite to the  bone,  and
the lodgement of matter which is fo pernicious, and would
probably be fo apt to occur from  the method  recommend-
ed by him,  is to me a  fufficient  reafon for preferring  the
perpendicular pofition of the  integuments.


                   SECT.   IV.

               Of Amputating the Leg.

   Whenever the flate of the difeafe will admit of the leg
being amputated juft above the ankle, it fhould be  always
done in preference to taking it off at the ufual place  about
four inches  below the patella ;  becaufe the  operation is
there performed with more eafe  and fafety to the patient,
                                                   on 
                      [   5*4  ]
on account of the fmaller diameter of the leg and the great-
er proportional quantity of foft parts, which  enable us to
cover the fore  more completely, and heal it  fooner ;  and
becaufe machines may be fitted to it which  are  much
more pleafing to the eye than the wooden ones commonly
ufed;  and with  which the patients are  rendered capable
of walking very well, as they preferve the ufe of the knee
joint.
   But when this is not  admiffible,  as  the  cure of a leg
amputated immediately below the knee is. always tedious,
owing to the great extent of bone at this part, and the de-
ficiency of foft parts, and as the bone is equally well de-
fended from  the preffure of an artificial leg when the ope-
ration is performed above  the knee, I would always  give a
preference to the latter, when it was optional.
   If, however, the ufual place is chofen,  the  fame general
direaions that  were given for the amputation  of the  thigh,
will apply to  the operation here, except that the tourniquet
need not be placed much above the knee, having the cufliion
on the artery in the ham:  and as the teguments are clofe-
ly  attached to  the bone on the fore-part  of  the leg, they
muft be rolled  up, when a fufficiency of them is feparated,
to keep them out of the way of the knife.   The mufcles
are to be cut juft below the infertion of the flexor tendons
of the leg ; and the interoffeous parts muft be divided with
the end of the  amputating  knife, or with a  fmaller knife
termed a catline.
   In fawing the bones, the  inftrument fliould be applied
to both at the  fame time,  to prevent a rifk of fplintering
them; and in  the application of the roller,  two or three
turns above the knee will be fufficient.
   In operating above the  ankle, the moft convenient part
is about  nine inches below the knee,  meafuring from the
condyles of the femur, both on account of accomplifhing
a fpeedy cure, and of adapting an artificial extremity to the
                                                 flump. 
                      [  545   3
ftump.  The cure is ufually produced  in  lefs than three
weeks, and the furface of the flump will be equal, and co-
vered entirely with found fkin.

                    SECT.   V.

              Of Amputating with a Flap.

  This operation was invented a century ago, in order to
obviate the difagreeable confequences of the ufual method
of amputation.  In performing it,  a flap of fkin and mufcles
was preferved, fufficiently large to cover the whole flump.
  The flap operation was  never  received into general ufe,
becaufe it  was found difficult to  reftrain the hemorrhagy,
when it happened to recur after  the  flap was applied and
fixed in its fituation ; for, in order to  difcover the bleeding
arteries, it was neceffary to undo the whole; becaufe  the
flap was found  not  to adhere uniformly over the furface
of the ftump;  and, becaufe  the pain  and inflammation
produced,  was more confiderable  than that which was con-
fequent to the ufual mode.
  To remove thefe objeaions, Mr. O'Halloran, about  the
year  1768, propofed to drefs the ftump and flap as fepa-
rate fores  for  the firft twelve days; and the rifk of  he-
morrhagy, and the inflammation, having then gone off, to
fecure the  flap on the furface of the ftump by plafters and
bandages till they united.
  By this improvement, the operation was rendered more
fafe and certain ; and it is probable that  it would gradually
have  come into general praaice, if the improved method
which we have already defcribed,  had  not in the mean time
been introduced :  But, notwithftanding this is generally
preferable,  yet, wherever  the divided parts cannot other-
wife  be properly covered with  fkin, the  flap operation
ou^ht certainly to be employed.   This  will,be the cafe in
amputating the arm at the ffioulder,  the thigh at the hip-
                        3 Z                      joint. 
                      [   5W   ]
joint, and the fingers or toes.  But as fome may perhaps
prefer it when the operation is performed immediately be-
low  the knee  or above the ankle,  or in the arm and fore-
arm, it  will be proper to defcribe the method of doing it
in all thefe places.

                   SECT.  VI.

        Of Amputating the Thigh at the Hip-Joint.

   This has always been confidered as  a very  hazardous
operation,  and there  are confequently very few inftances
of its having been performed: but, as in the  method I
fhall recommend there is very little hazard  from hemor-
rhagy, and fo much fkin  is faved, that the fore can be en-
tirely covered  by it, and confequently will heal in  a few
weeks,  whenever cafes occur which would otherwife ter-
minate in the death cf the patient,  we ffiould certainly not
hefitate  to perform it.
   The eircumftances which  moft commonly render this
operation  neceffary, are, gun-fhot wounds,  accompanied
by fraaures of the upper part of the os femoris, and fpina
venofa,  or caries of the head of it: It may alfo be proper
in all the cafes formerly noticed,  when treating of amputa-
tion  in general.
   In performing this operation, the patient ffiould be placed
upon a table, on the found fide,  and fecured by affiftants.
Let the tourniquet be applied as near as  poffible to the top
of the limb, the femoral artery  having  the cufliion fixed
on it juft below Poupart's ligament.   Let the integuments
and tendinous fafcia of the thigh be divided by a circular
incifion, fix inches from  the  top of the  thigh;  that is, at
leaft three  inches beneath the  band  of the tourniquet.
Let  the retraaed  fkin be pulled an  inch upwards; and
then let the  mufcles be divided at its  edge down  to the
bone.  The arteries are then to  be fecured.   This being
                                                 done, 
                      E  547   ]
done, take a fcalpel larger than the common fize, and com-
mencing at the upper edge of the circular cut on the pof-
terior part of the thigh, make an incifion down to the bone,
and carry it up of the fame depth to a little above the great
trochanter, into the joint.   Let a fimilar cut be made on
the oppofite fide of the limb, at a fufficient diftance from
the femoral artery, and completely down to the bone.  Let
thefe two portions of fleffi be now diffeaed from the bone,
and the flaps formed by them be taken care of by affiftants,
while any artery  divided, is tied as foon as it is obferved.
The joint being laid bare, the femur muft be moved in dif-
ferent direaions, and particularly inwards, where it yields
moft readily, from the brim of the acetabulum being loweft,
 until it is fo far turned out of the focket as to admit of the
round ligament being reached with  the point of a fcalpel,
 or a firm probe-pointed biftouri, and  divided, when the
 limb may be removed.
   If the acetabulum is found,  our profpea of a cure will
 undoubtedly be more favourable than if it is carious : But
 in whatever ftate the bones may be, our treatment of the
 fore muft be fo direaed as  to heal it as  much as poffible
 by  the firft  intention.   After removing the  coagulated
 blood,  and placing the mufcles as nearly as poffible in their
 natural fituations, the flaps  ffiould be drawn together  fo
 as to cover the fore as completely as may be; they fliould
 be fecured in this fituation by three or four futures, by ad-
 hefive  plafters,  and by cemprefies retained  by a broad
 flannel roller paffed feveral times round the body and over
 the ftump ; care being taken to leave the ligatures hanging
 out of the wound.
    The patient muft now be put to bed, and treated as in
 other  cafes,  except that a more particular attention will
 be requifite to prevent and remove inflammation and fever :
 And it will be proper to advife a very moderate diet for a
 confiderable time afterwards.
                                                   the 
                     [  548   ]
  The ligatures may be removed  in  about ten or twelve
days.   Colfeaions of matter will probably be very apt to
form in the ftump; and if preffure does not remove them
they muft be difcharged by punaure with a lancet.


                  SECT.   VII.


     Of the Flap Operation immediately  above the Knee.

  This operation  may be performed either with one or two
flaps;  but one is  commonly to be preferred.  The fore
part of the thigh affords the beft  flap ; and  it fliould  be
chofen, not only on this account,  but becaufe any matter
colfeaed during the cure may  be more readily difcharged
than when the flap is formed on any other part.
  The patient being placed on  a table,  the tourniquet ap-
plied, and the fkin drawn up, the extent of the flap ffiould
be marked  with ink.   This ffiould be fomewhat lefs in
length than the diameter of the limb,  and equal in breadth
to the limb itfelf;  and it ought to be of the fame width all
the  way to within a little of its termination, where it ffiould
be rounded off fo as to correfpond with the figure of the
fore on the back part of the limb.  The extreme  point of
the  flap ffiould reach to the end of the limb, unlefs the  te-
guments are  difeafed,  in  which cafe  it muft terminate
where  the difeafe  commences; and  its  bafe ffiould  be
where  the bone is to be fawed.
  The flap being marked out, the furgeon ftanding on the
outfide of the limb, fhould enter a ftraight double-edged
knife, with a ffiarp point, (plate ii. fig. 5.) at the outfide of
the  bafe of the intended flap, and carrying the point clofe
to the bone,  ffiould puffi it through the teguments at the
mark on the oppofite fide.   The edge  of the knife muft
then be carried downwards,  in the direaion marked out;
                                                  and 
                     [  549   3
and as it draws towards the end, the edge of it ffiould be
fomewhat raifed from the bone, fo as to make the extremity
of the flap thinner than the bafe, by which it will apply with
more neatnefs to the furface of the fore.  The flap being fup-
ported by an affiftant,  the teguments and mufcles on the
back part of the limb,  ffiould, by one ftroke of the knife,
be  cut  down  to  the bone, about an inch below where  it
is to be fawed; and the mufcles being  feparated from the
bone, to this height, by  the point of the knife, the foft
parts muft all be feparated with the leather retraaor un-
 til the bone is fawed.  The arteries are to be tied in the
 ufual way; and  the mufcles and teguments fliould then
 be drawn down, and fecured  with a  flannel  or cotton
 roller, as advifed in the common mode of amputation.
    If the flap is  to be immediately applied to the ftump,
 the coagulated blood muft be waffied from both, and then
 they are  to be  conneaed by three or four futures, and
 dreffed as direaed in the laft feaion.   The dreffings may
 be renewed in three or four days ; and as foon as the liga-
 tures are taken away, and the inflammation has fubfided,
 any part which was  not  at  firft covered, may have the
 fkin drawn over  it and fecured by adhefive plafters.
    But, when Mr.  O'lialloran's method is adopted, the
 whole furface of the  ftump is to be covered by a pledget
 of lint, fpread on both fides with fome emollient ointment;
  the flap  is then  to be laid on this; and another pledget of
  the fame kind being placed over the whole, the drefling is
  to be finifhed in the ufual manner.  The applications may
  be removed in three or four days; and about the twelfth
  or fourteenth day,  or whenever the inflammation has fub-
  fided, and the ligatures are  taken away, any matter that
  may be on the  fores is to be  removed with a foft fponge,
  and the flap is then to be  laid  down upon the ftump, to be
  there fecured by futures, or by adhefive  plafters, and the
  common dreffings. 
                      [  550   3
   Of thefe two methods, Mr. O'Halloran's feems to me
to be much  the beft.   The cure  is accomplifhed fooner,
often in three  weeks,  and it is attended  with much  lefs
pain and inflammation, by the fecondary union he propofes,
than by attempting to heal  the wound by the firft inten-
tion, without the formation of matter.
   In order to  form two flaps, a  circular incifion muft be
made through the teguments and mufcles at the lower
part of the  limb,  having  the  edge of the knife  turned
obliquely upwards ; then let the ffiarp-pointed knife above-
mentioned, be puffied through the foft parts down to the
bone on one fide, and where the bone is to be fawed;  the
undeV edge  of it being then  turned obliquely outwards,
let  the mufcles be  divided  down  to the circular incifion.
A fimilar flap  muft be formed on the oppofite fide of the
limb; and the intermediate parts being divided, the. bone
muft be  fawed, and  the wounds dreffed as formerly di-
reaed.

                  SECT.  VIII.

          Of the Flap Operation below the Knee.

   The method of operating here,  is nearly fimilar to that
direaed to be employed above the knee. We have hitherto
been advifed to form the flap on the back part of the leg ;
but I would prefer the  outfide, whether  the operation is
performed immediately below the knee, or at the diftance
formerly  recommended  above the  ankle, on  account of
the matter that will be produced finding a more ready dif-
charge, than when  the ufual part is chofen.
SECT. 
C  551   3
                    SECT.   IX.

        On Amputating the Foot,  Fingers, and Toes.

  Whenever the whole foot is difeafed,  it becomes ne-
-eeffary to take off the extremity at the part we have men-
tioned above the ankle,  even although the joint be found ;
•for if the operation was performed at the ankle, the wound
could not well be covered by fkin, and the length of ftump
would be inconvenient.   But if only two of the metatarfat
bones remain found,  and particularly if thefe are feated
internally,  the difeafed  parts alone  ffiould be removed.
When the  middle of the foot is alone affeaed,  the bones
ffiould be  taken  off at the  joint; becaufe they are there
amputated  with more eafe,  and  the faving of  a fmall por-
tion of them could be of little or no advantage ; but if the
bones  fituated  internally or externally are the feat of the
complaint,  as it will be  an  objea to fave  as much of the
foot as poffible,  they ffiould be fawed* immediately above
the difeafed parts.
   On  account of the friaion in walking, it is particularly
neceffary to fave as much fkin as will cover the fore in this
operation.   A  flap may  generally be readily  formed for
this purpofe;  if poffible, it  ffiould be on the under part of
the foot.
   The patient fliould be placed  on a table  ; and the tour-
niquet applied above the knee.  While  we are fawing the
bone,  a  piece of  pafteboard, or of thin wood, muft de-
fend the contiguous found bone from the  teeth of the in-
ftrument.   The fubfequent  parts of the operation are to be
managed in the ufual way.   If futures are  employed, they
                                                ffiould

  *  A common fpringfaw (plate ii. fig. 3.) is to hz ufed in this ope-
ration. 
                     [   552  3
ffiould be inferted in fuch a manner as to avoid the flexor
and extenfor tendons.
  Fingers and toes are ufually amputated in the fame man-
ner as the  larger extremities,  either by preferving a flap
fufficient for covering the ftump, and afterwards dividing
the bone with a fmall fpring faw, or by the double incifion :
But it is much better always to cut them off at the joints.
A flap being marked with ink,  and diffeaed from the bone
with a  fcalpel,  a circular incifion  ffiould  then  be made
through the reft of the foft parts, a little below the joint,
and on a line with the bafe of the flap.  The finger ffiould
then be moved, to afcertain the proper place in which the
lateral ligament ffiould be  cut; and when this is divided,
the whole may be readily  taken off.   The flap is then to
be applied, and fecured by adhefive plafter, a comprefs, and
flannel roller.   If it is neceffary to tie an artery,  the tena-
culum ffiould be ufed.

                   SECT.  X.

    Of Amputating the Arm at the Joint of the Shoulder.

  This operation may be rendered neceffary by, abfceffes in
the joint; caries of the  humerus  reaching to the joint;
compound fraaures extending to the head of the bone;
gun-fhot wounds; and gangrene :  and may be performed
with fafety, by  any furgeon of fleadinefs, experience, and
accurate anatomical knowledge.
   It may be done in different ways, but  the  following
appears to be the beft.  The patient ffiould be  placed on
his back, upon  a table covered with a  matrafs and blanket.
The tourniquet might be  ufed, if the blood could not be
otherwife ftopped : But the beft mode of guarding againft
hemorrhagy, is, for  an  affiftant to place a comprefs on
                                                  the 
                       [   553   ]
the fubclavian artery, juft  above the clavicle, and make a
fufficient degree  of preffure on it to  ftop the pulfation at
die wrift.
   The ffioulder fhould be made to  projea fomewhat over
the fide  of the table ;  and the arm being ftretched out,
and fupported  by an affiftant at nearly a right angle with
the body, a circular incifion ffiould be made through the
fkin and cellular fubftance, juft  at the infertion of the del-
toid mufcle into the humerus.   The teguments may be al-
lowed to retraa about half an inch; and the mufcles are
then  to be divided at their edge down to the bone.   A
perpendicular incifion ffiould now be made with  a fcalpel
down to  the bone, beginning at the acromion, about half
way between the centre of the  deltoid mufcle, and the in-
ner edge  of it, and terminating in the circular incifion, about
an inch a iove  the brachial artery.  A  fimilar  cut  muft
then  be  made  on  the  back part of the arm,  at fuch a
diftance from the  firft, that the two flaps formed by them
may be of an equal breadth.   The brachial artery ffiould
be tied as foon as it is cut by the circular incifion, and any
arterial branches  that may be  divided,  ffiould alfo be fe-
cured as  foon as they are obferved.  The flaps ffiould now
be feparated from the bone, cautioufly  avoiding the large
artery;  and being fupported by an affiftant, fo as to bring
the capfular  ligament into  view, an opening ffiould be
made into this,  the bone diflocated, and the remaining part
of the Hgament divided.  The flaps are then to be laid
over the  joint,  and retained in  their places by futures and
dreffings, as in  other  cafes.
   The fubfequent  general treatment  is  to be  fimilar  to
that advifed in amputation of the lower extremities.  With
a  view to  prevent any rifk of hemorrhagy after the ope-
ration, an experienced affiftant ffiould  fit with the patient
for the firft: two  or  three days, with  directions  to apply
                         4. A                   preffure 
                     [  554  3
preffure above the clavicle, ffiould any confiderable quan-
tity of blood be difcharged, until the veffel can be tied.
  A cure may foon be expeaed in favourable eircumftan-
ces ; as the mufcles appear to unite as fpeedily to cartilage
as to bone.

                   SECT.  XI.

                Of Amputating the Arm.

  The general obfervations we have  made upon the me-
thod of  amputating  the thigh  and leg,  apply  with the
fame propriety  to the  amputation of the  arm and fore-
arm.  But it muft be obferved, that no more of the arm
ffiould be removed than is difeafed, becaufe the ftump left
is ufeful in proportion to its length :  and there is no ne-
ceffity for making a  flap ; as a fufficiency of teguments
and mufcles may be faved, in any part of the arm, to  cover
the ftump, by the common operation.
        CHAP.     XLVII.

Of Removing^ Ends of Bones  in  Diseas-
                es of the Joints.
r t ""HERE  are feveral inftances  upon record of the
 ■*-    ends of the larger bones being removed  when dif-
eafed, and of the deficiency thus produced being fupplied
                                                 by 
                      [   555  ]
by nature.   Mr. Park of Liverpool has lately propofed this
operation as a general  remedy in  affeaions of the joints ;
fuch as injury to them from external violence, white  fwel-
lings, and caries.   He thinks it will be  chiefly applicable
to affeaions of the knee and elbow, particularly the latter,
and more efpecially when they proceed from external vio-
lence.  Mr. Park relates a cafe of white fwelling of the
knee in which it was praaifed with fuccefs.  The fore was
healed, but not without much perplexity and  diftrefs,  in
about ten weeks, and the patient has fince been able to do
duty on board of a fhip, without the aid of a crutch.   The
operation was thus performed.
   An incifion was made, beginning about two inches above
the patella, and continued about as far below it;  another,
croffing  this at right  angles, immediately above the pa-
tella, the leg being extended, was made through the ten-
dons of the extenfor mufcles, down  to  the bone,  and
 nearly half round the  limb : the lower angles, formed
 by thefe incifions, were raifed fo  as to lay bare the  capfu-
4ar ligament;  the  patella was then taken out, and the up-
 per angles were raifed, fo as fairly to denude the head of
 the femur, and to  admit of paffing a fmall catline acrofs the
 pofterior flat part  of the bone, immediately above the con-
 dyles, taking care  to  keep one of the flat fides of the point
 of the  inftrument quite clofe to the  bone  ail the way.
 The  catline being withdrawn, an elaftic fpatula was intro-
 duced in its  place, to guard the foft  parts while the os
 femoris  was  fawed ;  which done,  the head  of  the bone
 thus feparated was  carefully diffeaed  out;  the head of
 the tibia was then with eafe turned out and fawed off,  and
 as much as  poffible  of the capfular  ligament diffeaed
 away, leaving only the pofterior part covering the veffels.
 More than two   inches of  the femur  was  taken  off,
 and  above an  inch  of the tibia; which was juft enough
 to admit of the leg being  brought  into a right  line with
                                                    the 
                      [  556  ]
 the tnigh, the previous contraaion of the flexor mufcles
 being fuch as to keep the two fawed ends of the bones
 in contaa.   To obviate the inconvenience of the redun-
 dancy  of  teguments, a few flitches  were paffed through
 the edges oi: the tranfverfe wound, as well as that  part of
 the longitudinal incifion that extended up the thigh.  The
 lig'iteft fuperficial dreffings  were applied,  and the limb
 placed  in  a cafe of tin, from the ankle to the infertion of
 the gluteous mufcle.
   Independent of the difficulty of preferving the limb in a
 fixed fituation •, of the inconvenience of a great depth of
 wound;  and of  the colfeaions  of matter which  muft
inevitably  take place, there are two other very forcible ob-
jeaions againft this operation : the firft is, that where the
 bones of large joints  are fo much difeafed as to render their
removal neceffary, the furrounding foft parts are in gene-
ral fo much thickened, inflamed, or ulcerated, as to ren-
der any attempt to fave them very uncertain, and much
 more hazardous than the amputation of the limb; and the
 fecond is,  the high degree of inflammation which common-
ly fucceeds to wounds of the larger joints.
   To the  firft objeaion, Mr. Park replies, that he thinks
this operation will be peculiarly ufeful only when the dif-
 eafe originates from   external violence; and to the laft,
that the operation has been frequently done  without any
fubfequent violent fymptoms; and that when thefe have
occurred,  they have   probably  arifen principally from  a
partial  divifion of the capfular ligaments,  and may com-
 monly  be  prevented by their total removal.  But we muft
obferve, that we can  fee no more propriety in taking off
any part of the  capfular ligament, than  there would be in
the removal of the tunica vaginalis in the operation  for the
hydrocele.   Future experience, however,  muft determine
the propriety of this  part  of  the operation, as well as  of
the merit  of the operation in general.
                                           CHAP. 
[  557   ]
            CHAP.     XLVIII.


Of preventing or diminishing Pain  in Chi-
              rurgical  Operations.



r I "^HE  pain induced by  operations may be leffcned, ei-
 -*-  ther by diminifhing the fenfibility of the  fyftem, or
by compreffing the nerves  which fupply thofe parts upon
which the operation is to be performed.  Narcotics of every
kind might be employed for the purpofe of leffening gene-
ral fenfibility ;  but nothing anfwers  this purpofe fo well as
opium.   As this, however, when given in fufficient dofes, is
very apt to induce naufea and vomiting, I feldom venture to
exhibit it before an operation.  In general it proves moft ufe-
ful when exhibited immediately after, and then it very com-
monly  alleviates that pungent forenefs  of which  patients
at this  time ufually complain ;  and by continuing to give it
in proper dofes from time to  time, we are often  enabled to
keep the patient eafy and comfortable, till relief is obtained
by the  formation of matter,  or by  the removal of the in-
flammatory tenfion which ufually accompanies every capi-
tal operation :  and as this tends very effeaually  to mo-
derate  the  fubfequent febrile fymptoms,  it ffiould never
be omitted.
  The  fenfibility of limbs is always  more  or  lefs diminifh-
ed, by  the compreffion on the nerves, produced  by the
tourniquet, in amputations and fome other operations ; but
as this  anfwers the purpofe very incompletely, it has been
                                                lately 
                      [  558   ]
lately propofed by Mr. Moore, of London, to comprefs the
principal nerves fo completely as to render the parts be-
neath altogether infenfible.  This he endeavours to accom-
pliffi by means of a femicircular plate of iron covered with
leather, having a comprefs at one end, which is to be ap-
plied immediately above the feat  of the nerves, and by a
fcrew paffed in at one end.
  In  order to obviate  the inconveniency which muft ne-
eeffarily arife from the  preffure on  the veins by this ma-
chine, Mr. Moore propofes to  open one of them during
the operation ; but as this might be very injurious to weak
patients, it would be  much better to have the inftrument
formed  fo as  to  prefs  chiefly upon the nerves ; as  this,
however, cannot  eafily be done, on account of contiguity
of the veins to the nerves, perhaps the fame purpofe may
be anfwered by compreffing the arteries of the  limb  for a
minute or two before any preffure is applied to the veins,
by which the latter may be previoufly emptied.
CHAP.    XLIX.

      Of Midwifery.
HHHE only operations in midwifery which  a furgeon  is
     called upon to perform, are,  the caefarian feaion,
and the figaultian operation  or divifion of the fymphyfis
pubis.  The  objea of both thefe is the fame, viz.  to ex-
traa tjie foetus when the delivery of it cannot be effeaed
                                                either 
                      [   559  3
cither by means of the exertions of the mother, or by the
aid of the common midwifery inftruments, on account of a
preternatural narrownefs of the pelvis.   By the firft, an
opening is made into the  uterus for the removal of the
child ; and by the latter, the diameter of the pelvis is intend-
ed to be  increafed, fo as  to allow the foetus to pafs in the
ufual way by the vagina.


                    SECT.   I.

                Of the Cafarian Operation.

   This  operation has not only been performed when the
 pelvis has been fo  narrow as  not to allow the child to pafs
 out, but alfo when the child  has been forced into the ca-
 vity of the abdomen, after a rupture of the uterus, from
 this organ contraaing too forcibly  before the os tincse has
 been fufficiently dilated.
   The csefarian fection is directed  to be performed, either
 with a view to fave both the mother and child ; to fave the
 mother only, when we know that the child is dead ;  or to
 fave the child immediately after the death of the mother.
    As there are but few inftances of the mother being faved
 by this operation, fome have advifed it never to be perform-
 ed, except in the  latter cafe ;  but if it is proper at all, it cer-
 tainly ffiould be employed, not only then, but in both the
 other eircumftances mentioned, to give fome chance of pre-
 venting death, at leaft to the mother.   The following is the
 method of performing it.
    The  patient ffiould be placed on a table, and laid upon
 her back, and her hands and legs properly fecured by affift-
 ants ; her head  ffiould be  moderately elevated with pil-
 lows, and her  thighs  fomewhat raifed.   The  operator
 ftanding one fide of the table, is  to make an incifion with 
                       [   560   3
a fcalpel through the teguments of the abdomeh, begin-
ning two inches  above the umbilicus, on the outer edge of
the reaus mufcle, and from thence  about fix inches per-
pendicularly  downwards.   The uterus  is now to be laid
bare, by continuing the cut through the tendinous parts of
the abdominal mufcles, and peritonseum ; and an opening
being then made in the uterus large enough to receive the
finger, a probe-pointed biftouri is  to  be conduced upon
this, in order to make the cut of the womb as long as the
external opening. The biftouri is alfo  the beft inftrument
to divide the peritonaeum and tendons.
   If any large blood-veffel is cut in making the incifion,
either  of the external parts or of the uterus, it  ffiould be
immediately  fecured  by the tenaculum;  and the ligature
fliould be left long enough to hang out at  the  external
wound.  The child  muft then be taken out, and the pla-
centa,  and any blood that may have efcaped, removed as
fpeedily as poffible;   the inteftines, if they have protruded,
being  then replaced, the external  wound ffiould be fe-
cured  with three or  four futures, as direaed chap, xxxix.
fea. xi. §•  3.   The wound being covered with  a pledget
of emollient ointment,  the abdomen ffiould be  fupported
by a flannel roller; and the patient ffiould then  be, put to
bed, and ftriaiy enjoined to avoid fpeaking and every kind
of exertion.  She ffiould be kept cool, and opiates fliould
be given to obviate pain-*
                                             SECT.

  » A new mode of performing the Carfarean operation  it recommended
by M. Lauvcrjat, in a volume on that fubjedt, publifhed at Paris, in 1788.
His method is, to make a tranfverfe incifion, of about five inches in length.
through the parietes of the abdomen, between the redti mufcles and fpina
dorfi.  The incifion muft  be made on the right or left fide,  higher up or
lower down, according as the fundus uteri happens to be fituated, after the
membranes have been ruptured  and the uterus has had time to contract.
The incifion  of the  uterus ought to be as near as poffible to its fundus,
                                                      and 
[   561   ]
SECT.   II.
            Of the Divifion of the Symphyfis Pubis.


   This operation  was fuggefted  by  there being in fome
inftances, a certain degree  of feparation  of the  offa pubis
during  labour;  and  by the great danger  of the operation
defcribed  in the laft feaion.    It was propofed in the fix-
teenth century by Monf. Pineau, but  Mr. Sigault of Paris,
was the firft who put it in praaice, in 1777.
                                4B                        The

and fimilar in every refpcct  to that made in the abdomen, with which it
will, at firft, correfpond.
  Having given diredions for the extraction of the child, and the proper
management of  the mother, M.  Lauverjat enumerates the advantages
which this mode  of operating has over that of the  longitudinal incifion,
hitherto in ufe.   I. In this way, there is at leaft two-thirds of the uterus,
towards its inferior part, left untouched.  This cavity retains the  lochia
till  difcharged in the natural way.  The longitudinal fection leaves no
fuch cavity; hence extravafations in the abdomen, and the death of at leaft
nine in ten  of all who  have been operated on in this manner,  z. The
tranfverfe incifion is more favourable to the fpeedy healing of jhe wound.
The uterus, in pregnancy, is  extended longitudinally  more than tranfverfe-
]y;  and as the contraction,  after delivery, muft be in proportion  to this
previous extenfion,  the lips cf the tranfverfe incifion are brought together,
and foon  united ; whereas the lips of the longitudinal incifion have a natu-
ral tendency to feparate in every part, except at  the angles.   3. The lips of
the  external wound are brought  together by the moft natural and eafy
fituation of the patient,  (the head inclined forward,  and the thighs bent),
and their union is facilitated; but let her lie in what pofition we may,  the
lips  o£ the wound, if made by a longitudinal incifion, will feparate, and it
will be impoffible to bring them together without having recourfe to  the
uniting bandage,  which he thinks a dangerous expedient.
  M.  Lauverjat performed the operation, in this way, on three patients,
with fucoefs.  The names of two othe. furgeon* are  given, who alfo per-
formed it fuc.cfcfully four times.   No unfucct fsful cafe is mentioned. 
                      [   562  ]
  The operation is eafily performed.   The  patient muft
be laid upon her  back on a table ; the  pelvis ffiould be
raifed by two or three  pillows, and the legs and arms fe-
cured by affiftants.   The bladder ffiould then  be emptied
by the catheter,  which ffiould be retained in the urethra,
by an affiftant, till the  bones are divided,  in order to point
out the urethra, and thus prevent it from being wounded.
  After fhaving the pubes, the operator,  ftanding one fide
of the patient, ffiould,  with a fcalpel,  make  a longitudinal
incifion through the teguments of the fymphyfis  of the
pubes, from  the  upper edge  of thefe bones nearly their
whole breadth :  the  cartilage  by which  they  are  joined
ffiould then he flowly  and cautioufly  divided ; which  is
eafily done on account  of its foftnefs.
  The bones now recede confiderably from each  other;
and  to prevent this from taking place fuddenly and forci-
bly,  the affiftants ffiould be direaed to fupport the thighs
carefully towards the clofe of  the operation ;  and if  a fuffi-
cient opening is not immediately produced, they may after-
wards be cautioufly feparated.
  The child and placenta are  now to be delivered  in the
ufual way; and  the  bones  ffiould  then  be  put together,
and retained in their fituation by a flannel  or cotton rol-
ler  applied round the  pelvis and thighs.  The  patient
fliould be kept as much as poffible in one  pofture until the
bones have united,  which will probably  happen in five or
fix weeks : But ffie ffiould not be allowed to walk,  or ufe
any pofture which might change the fituation of the bones,
in lefs than nine or ten weeks.  The fore in general heals
with light eafy dreffings.
  The only important objeaion to this  operation is, that it
gains fo  fmall a fpace in that part of the pelvis where  an
increafe of fize is moft  required ; between the  facrum and
pubes : For here the difficulty is almoft always met with.
After the divifion, the diameter of the pelvis in this direaion
remains nearly the fame, although a feparation  of at leaft
                                                  two 
                       [  563  ]
two inches* is produced, from fide to fide.  However, as
even this may in many inftances be of effential advantage,
and as the operation is attended with  no kind of danger,
for it has  in feveral inftances, been repeatedly performed
on the fame woman,  it ffiould always be advifed in  pre-
ference to the ca-farian feaion.  And if future experience
ffiould determine that the child may always be delivered in
this manner, it ffiould even be preferred to the mode of de-
livery by the crotchet.
       CHAP.    L.

Of  Opening  Dead Bodies.
     THIS operation  is employed with a view to afcertain
      the caufes and feats of difeafes. In order to do this
with accuracy, every preternatural appearance  fliould be
committed to paper.  After  noting  the  internal marks of
difeafe, we proceed to examine the external parts.  When
the difeafe has been feated in one cavity, we do not open the
others; but when they are all to be examined, it is proper
to begin with the  head.
                                                    The

  • Dr. Orne, of Salem, New England, performed this operation on a
woman who died in child-bed, and found that %\ inches were gained with-
out difficulty ; a quarter of an inch more might have been gained.   See an
interefting publication  by the Maffachufetts Medical Affociation, entitled
Medical Papers. 
                     (  564   )
  The body being placed upon a table, and the head firm-
ly fupported, an incifion  ffiould be made  from ear to ear,
acrofs the parietal bones.  The fcalp is now to be diffeaed
from the parts beneath ; and half of it being turned back-
ward, and the other half over the face, with a common am-
putating faw, we muft divide the cranium, beginning on the
os frontis juft above the frontal finufes,  and continuing  it
all around.  The feparated  part may then be raifed with a
levator.  If we  wiffi  merely to know whether any water
be contained in the ventricles, the brain need not be remo-
ved ; but if our objea is to  afcertain the ftate of the brain,
it muft be taken out and examined at leifure.  The extra-
vafated blood being afterwards removed by a fponge, the
parts are to be replaced and  the fcalp fewed by the glover's
flitch,  or in any other way  agreeable to  the  operator:
For this  purpofe, narrow tape and a large curved  needle,
with a triangular point, are ufually employed.
  The cavities of the thorax and abdomen are moft effec-
tually  expofed in the following manner: Let an incifion
be made  through the integuments from the top of the fter-
num to the umbilicus, and from thence on each fide and
through the mufcles,  to the top of the os ilium ;  the tegu-
ments and mufcles muft now be diffeaed from the fternum
and ribs, and the cartilages divided with a ftrong knife  as
near as poffible to the  ribs. The diaphragm being  then
feparated beneath,  the  lower part of the fternum and car-
tilages conneaed with it, being raifed and turned upward,
the fternum muft either be feparated from the clavicles,  or
cut acrofs near its upper end.
  This will bring the vifcera fully into view,  and moft  of
them may then be examined without being removed;  if,
however, much accuracy is requifite,  all or any part  of
them may be taken out, as may be judged neceffary.
   To  prevent  the  effufion of blood or excrement, two
                                                ftrong 
                     [   565  ]
ftrong ligatures ffiould be paffed, at the diftance of an inch
from each other, round the lower part of the inteftines and
large  contiguous  blood-veffels, and round  the trachea,
cefophagus,  and  large  blood-veffels of the  neck.  The
parts between the upper and lower ligatures being divided,
all the vifcera may then be eafily removed  by diffeaing
them from the contiguous parts, and raifing them up as we
go  along.   When the neceffary examination has been
made, the effufed blood all waffied off with a fponge, and
the vifcera replaced,  the  teguments muft be drawn  over
them, and flitched neatly together.*
   In opening  difeafed bodies,  the operator ffiould be very
cautious to avoid wounding his fingers and hands : Death
 has been the confequence  of negfeaing this.
CHAP.   LI.

   Of  Embalming.
    EMBALMING, formerly fo much in fafhion, is now
     feldom employed, except for preferving bodies  from
putrefaaion, during the interval between the death and bu-
rial of the perfon, when this is to be unufually long.  The
following is the prefent  method of  performing it.  The
brain, and all the vifcera of the thorax and abdomen be-
                                                  ing

  • The glover's ftitch is generally employed for this purpofe; and in per-
forming this, either a ftraight or curved needle may be made ufe of. 
                       [  566   ]
 ing removed in the manner mentioned in the laft chapter,
 they are all, excepting the heart, put into a leaden box with
 a confiderable quantity of an  aromatic antifeptic powder,
 prepared with,  myrrh, frankincenfe,  cloves,  the leaves of
 lavender,  rofemary, mint, and  other  fimilar articles;  and
 to thefe are added  fome of  the odoriferous oils.  The
 blood being taken out of the different cavities, and the
 heart replaced, they are all filled with a due proportion of
 odoriferous  oils or fpirits, and the parts afterwards fewed
 up.  By fome, the mouth  and  noftrils are  ftuffed  with
 thefe powders and oils ; and incifions are made into all the
 fleffiy parts of the body,  which are alfo ftuffed with them,
 and fewed up :  but there is no neceffity for this,  unlefs the
 body is to be kept for a confiderable length of time, *or
 to be carried a confiderable diftance; in which cafe, the
 trunk and extremities are firmly rolled up with bandages,
 and the whole varnifhed.
  The body is  afterwards to be covered with cerecloth,*
fecured by tapes or ligatures ; and  it is then dreffed, and
either laid in a coffin,  or expofed to view, according to eir-
cumftances.

                                             CHAP.
  • The cerecloth is made of linen dipped in a compofition of wax, oil, and
rofin, and coloured with verdegris, or red lead. 
[  567   ]
CHAP.   LII.

     Of Bandages.
 T> AND AGES are employed, for the retention of  dref-
 -*-*  fings; for flopping hemorrhagies ;  for removing de-
 formities ;  and for effeaing the union of divided parts.
   A  proper application of bandages  is an objea .of confi-
 derable importance; but as it can only be acquired by ma-
 nual  praaice, we fhall merely offer a few general obferva-
 tions  on the fubjea.
   1.  Bandages ffiould be  formed of fuch materials as arc
 fufficiently firm for effeaing the purpofe for which  they
 are employed, at the fame time that they will fit with eafe
 upon  the parts  to which they are applied.  Hence they
 muft  neceffarily be of different materials in different cafes.
 Thus bandages for hernise muft be very firm and elaftic;
 while in general, thofe bandages made of cotton, linen,
 or flannel,  will  ferve every  purpofe.   Till of late, linen
 was ufually employed  for bandages;  but experience has
 now ffiewn that cotton  and  flannel are preferable.  They
 abforb moifture more readily, whether produced by fweat,
 or the difcharges from fores, at the  fame time that  they
 are better calculated, from their elafticity, for yielding  to
 the fwelling which often takes place in fraaures and other
 injuries.
  2. Bandages fliould be applied juft tight enough to effea
the purpofe for which they are intended, without incurring
                                                  any 
                      [   568  ]
 any rifk of impeding the circulation, or doing harm in any
 other manner.
   3.  Bandages  ffiould be applied  in fuch a manner that
 they may be eafily loofened, and the parts examined with
 accuracy. Hence, in fraaures of the thigh, and leg, where
 the limb cannot with propriety be frequently  raifed,  we
 now prefer the manifold bandage to the roller.
   4. Bandages ffiould always be laid afide as foon as they
 have accomplifhed the purpofe for which they were  made
 ufe of; as they may often do harm afterwards by impeding
 the growth of the parts.
   5. The bandages ufed for effeaing different ends in the
 fame  parts muft neceffarily be different; and  thofe with
 the fame view in different parts of the body muft alfo vary.
   As all the variety of bandages in ufe are mentioned in the
 courfe of the work, and generally  their particular applica-
 tion, we fhall, in this place, do little more than give a  gene-
ral enumeration  and defcription of them.
   1. The night-cap, with  a band to tie it before, and ano-
 ther behind.
   2.  The  radiated  bandage; a roller applied in a crucial
 form  over the forehead, top, and  back of the  head, and
 under the chin.
   3. The uniting bandage; formed of a long roller with
 two heads,  with a flit or opening in the  middle, through
 which one of the heads is  to be paffed.
   4. The common roller :*  When this  is employed  for
 one of the eyes,  it  is termed monoculus; when for  both,
 binoculus.
   5. The four-headed roller.   This is formed of a long
 piece  of linen, or other material,  divided lengthways,  ex-
 cept for  a little fpace in the middle of it, in  the centre of
                                                which

  * In general, the width of rollers may be from one  and an half to two and
2« half inches, according to eircumftances. 
                      [  569  3
which is an oval hole ; and is employed in fraaures of the
lower jaw.  The undivided part is applied to the chin, the
end of which projeas through the whole.   The two fupe-
rior  heads are  then carried backwards over the occiput,
and returned forward over the os frontis, where they may
be pinned.  The lower heads of the roller being reffeaed
over the chin, are then  carried to the top of the head, and
there fattened.
   6. The napkin and fcapulary.  The napkin is about fix
or feven inches broad, and when ufed for the retention  of
dreffings, ffiould pafs but once around the body, and be tied
before by  pieces of tape ; but when  it is employed for a
fraaured  rib, it ffiould go  feveral times around.  It is to
be placed  immediately below the arm pits.   The fcapulary
confifts of a flip about three inches broad, and of a  length
fufficient to reach from  the  upper part of the napkin  be-
hind, and pafs  over the ffioulders to be conneaed to it
before;  and has the anterior  end of it longitudinally di-
vided, the flips being carried on  each fide of the head.
   7.  The bandage for  compreffing the abdomen after the
paracentefis.   See pi. xi. fig. 5. and explanation.
   8. The trufs for hernise.   See pi. vi. fig. 4. and expla-
nation.
   9. The fufpenfory bandage for the penis and  fcrotum.
This is formed by a fmall pouch of linen  or flannel,  or
what is  perhaps better  than either, of cotton, conneaed
to a circular bandage paffed round the body, either before
only, or both behind and before.
   10. The T bandage.  Formed of a ftrap paffing around
the body, to  which a broader piece is conneaed, and flit
longitudinally for better than half of its length ; thefe flips
pafs from behind,  on each fide of the penis and  fcrotum,
and are  pinned to the anterior part of the circular ftrap.
   11. The manifold bandage.    This is formed  generally
                       4 C                         of 
                         [   570  ]

of fix or nine flips of cotton, Knen, or flannel,  connected
in the middle by another flip, in the manner reprefented in
pi.  xi. fig.  2.*

  * This form of bandage is thought by fome to be improved, by having
the oppofite tails or flips connected fo as to form a very obtufe angle: this
makes them apply more neatly to the limb.
THE   END. 
 
 
EXPLANATION  OF  THE  PLATES.*
                    PLATE   I.

  Fig.  1. Reprefents  the inftrument termed a  trepan.
Every part of it is  here reprefented about one-third lefs
than the proper fize.  The upper part of the handle A A,
is made of wood ; all the reft of polifhed fteel.   B is the
faw.  C, the nut of a fcrew which fattens  the upper part
of the faw, which is  in the form of that  of the perforator,
fig. 7, to the handle of the inftrument.  D, the  nut of a
fcrew paffing through a flit in the handle, and fixed in the
upper part of a moveable pin, E.   By pufhing up  this nutj
the pin is raifed fo as to  be no  impediment to the fawing,
after the perforation is deep enough to render it  unnecef-
fary.   This pin is ufually fcrewed into the bottom of the
head, and is then to be removed by the key, fig. 6.
   The  trephine, which  is commonly made ufe of in this
operation, only differs  from the trepan, in  the form  of the
handle; the part of this conneaed with the faw being
ftraight, and on  a line with it, and the wooden part croff-
ing this at right angles.
   Fig.  2.  The ftand of the levator fig.  5.  In ufing this
inftrument, the  pin  on the moveable ball in the  frame, is
to be fixed  in  one  of the holes  of  the levator :  The ball
ffiould be eafily  moveable in every direaion ; and the frame
is to be held fteadily during the operation.
   Fig.  3.  A  lenticular.   This inftrument is ffiarp on one
                                                   fide,

  * In the arrangement of the figures in the plates,  the principal object has
been, to introduce as many as poffible ; but in defcribing them, the inftru-
ments particularly connected as to their ufes are generally explained in fuc-
ceffion, without regard to their numerical diftribution. 
                        [  H  3
 fide, and the button at the end is hollow for receiving the
 pieces of bone fcraped off.
   Fig. 4. A rafpatory, for removing the pericranium.
   Fig. 7. A perforator, for forming a hole for the recep-
 tion of the pin of the trepan.  The head of it is to be ex-
 aaiy of the fize  of that of the faw, as it is conneaed to the
 handle of the trepan in the fame manner.
   Fig. 8. A common gum lancet.

                    PLATE   II.

   Fig. 1. Forceps for removing the bone, in the operation
 of trepanning.  They are not here reprefented of the full
 fize.
   Fig. 2.  An amputating knife.   This inftrument is dif-
 ferent in form from the common  knife, delineated by Mr.
 Bell:  It ferves for every  mode of amputation, and renders
 the catlin totally unneceffary.   It may be about a foot in
 length, including the handle, and  an  inch and a quarter in
 breadth at the broadeft part.
   Fig.  3.  A fmall fpring faw, ufed in amputating the fin-
 gers or toes.
   Fig.  4.  Forceps for extraaing polypi from the noftrils.
 This inftrument ffiould be fomewhat  curved when ufed for
 polypi in the throat.   See chap. xxxi. fea. 4.
   Fig.  5.  An inftrument invented by Dr. Hunter, of Lon-
 don, for applying ligatures around polypous excrefcencies
 in the uterus.

                   PLATE   III.

  Fig.  1.  Mr. Freke's machine  for reducing  luxations.
 In order to render this  inftrument  readily portable, it is
 divided in the  middle, and the two halves are conneaed by
brafs  hinges  at  C, and  by two  hooks and  eyes on the
other fide of it.  It thus forms, when ffiut, a box only one
                                                  foot 
 
■ '      *       ',*^ •' ',  "> ' 
-v  -.•*?*.-
Pli'ATE     III
J.Twnrhara  S f ulp. 
 
                       [  iii  3
foot eight inches long, nine inches broad, and three inches
and a quarter deep.   When one end of it is fixed on the
ground, the other Hands high enough to become a fulcrum
or fupport to the lever  B,  which is fixed on  the roller E
by a large wooden fcrew, which turning fide-ways, as well
as with the roller, forms a circumrotatory motion, fo that
it may ferve  to  reduce a luxation  either forward,  back-
ward, or downward.
  The roller on which the lever is fixed, is juft the diameter
of the depth of one  of the boxes, and into it are driven two
iron  pins, the ends of which are received by  the fides  of
the box,  which are  an inch thick.
  The lever is two feet four inches long, and is cut and
conneaed again by  hinges at C, to fold up fo as to be con-
tained  in the box : On the back part of it is a hook to keep
it ftraight;  one  end of  it is to hang over the roller G, an
inch and an half,  which is to be excavated  and covered
with buff leather, for the more eafy reception of the head
of the  os humeri.
  The iron roller E has two holes through it, for receiving
two cords from a brace,  fig. 2. fixed on the lower part  of
the os humeri.  This roller has a fquare end  on which is
fixed a wheel D, notched round, which works as a rotchet
on a fpring ketch under the lever, by which it is ftopped
as it is wound up with a winch;  fo that at pleafure it may
be let loofe by difcharging the ketch.
  The brace,  fig. 2. confifts of a  piece of buff leather,
large enough to embrace the arm, fewed on two pieces of
ftrong iron, curved  plates rivetted together, one of  them
having an eye  at each end to faften two cords in ; the other
is bent at the ends into two hooks, which are  to receive
the cords after they have croffed the  arm above.
   In order  to keep  the  patient fteady in his chair, and to
prevent  the fcapula from raifing or depfeffing the  lever,
after the limb is drawn forward by  the winch, there muft
                                                    be 
                       [  iv  ]
be fixed over the ffioulder, a girth, with two hooks at  the
end of it:  This ffiould be long enough to reach the floor
on the other fide, where it  muft be hooked into a ring
fcrewed into the floor.
  Mr. Bell obferves, that the ftrap or  girth preffes down
the fcapula, and thus impedes the reduaion ; he therefore
propofes,  that  it ffiould either be altogether wanting, or
made with a flit to pafs over the arm, fo as  to draw back
the fcapula, and inftead of paffing obliquely downwards,
that it ffiould go ftraight acrofs, and be fixed in a poft on
a line with the  ffioulder.   The  lever  of this inftrument
ffiould, he thinks, be fixed, fo as to ferve only for a fupport
to the arm ; or if it is ever ufed as  a lever, it ffiould be ma-
naged with the  utmoft caution ;  but  this appears to him
both dangerous and unneceffary.
  The great  advantage of  this machine is, that we by it
are  able to apply any  neceffary force  in the  moft gradual
manner, and in any direaion.
  Fig. 3. A  fcrew tourniquet.   Every part  of  this  in-
ftrument is here reprefented of the full fize;  it may be
made either of brafs or fteel; and  the ftrap conneaed with
it ought to be of very firm materials, at leaft an inch broad,
and of a length rather more than fufficient to pafs round
the largeft part of the extremities.
  As an improvement on this inftrument, as here repre-
fented by Mr. Bell,  a  fmall fcrew  has been  made to pafs
through the upper part of the large female fcrew, fo as to
enable the  operator himfelf to keep the ftrap fixed to any
degree of tightnefs.
  Fig. 4.  An amputating faw.   This fliould be about fe-
venteen inches  in length, including the handle, and two
inches and a quarter in breadth, at its broadeft part.
  Fig. 5.  A common found or ftatr, ufed in fearching or
founding for the ftone.
  Fir. 6.  A grooved ftaff for the operation for lithotomy.
                                                 The 
 
PLA_TE   IV
 
                       I  v  3
The groove is here reprefented on the fide, which is prefer-
red by fome, to having it on the back,  in the ufual way.
The termination of the groove ffiould always be perfeaiy
free and  open, otherwife it  will be difficult to difengage
the gorget from it; and its edges ought to be very fmooth.
If the inftrument has a greater degree of convexity than
here reprefented, it is not eafily introduced, and always in-
jures the urethra.
   A ftaff for a  full grown fubjea ffiould be twelve inches
long, befides  the handle ; and for children of feven years
and under, ffiould be from feven to nine inches long.

                  PLATE  IV.

   Fig.  4. A gorget fomewhat  different from the ufual
form which is reprefented by Mr. Bell.  This inftrument
only differs from the common gorget in the  conftruaion
and direaion of its handle.  The handle is made of wood,
and is in the fame general direaion with the blade, but
bent downwards,  fo as to form a very obtufe angle with
it.  In the common gorget, the handle is made in the man-
ner of that of the cutting direaor in plate v.
   For adults,  the gorget  ffiould meafure  from A to B,
five inches and an half;  and  at  its  wideft part one inch.
The beak ffiould  be turned a little forward, and  ffiould
be carefully adapted  to the groove of the ftaff with which
it is ufed.
   Fig.  3, 6. Different forms of forceps for extraaing the
ftone.   For adults, they ffiould be ten inches long.   Their
blades ffiould not meet when ffiut, and the teeth fliould be
fmall, forming merely a roughnefs, and be confined to with-
in an inch of the extremity of the inftrument.  Thefe eir-
cumftances will fave the  bladder from injury, and prevent
fmall ftones from being fixed near the joint, and thus di-
lating the inftrument.
                                                  Fig. 
                       [  vi  ]
   Fig. 5. A fcoop for removing fmall pieces of ftone that
cannot be taken up by the forceps.
   Fig. 1. A probang, for pufhing fubftances fixed in the
cefophagus into the ftomach.  It confifts of a piece of foft
fponge, firmly tied  to a piece of flexible polifhed whale-
bone, from fifteen to fixteeen inches long.
   F,ig. 2. A double canula for removing polypi from the
noftrils.   When the  polypus is  feated in the  throat, a ca-
nula fomewhat curved at the end, anfwers better than the
ftraight one here reprefented.

                  PLATE  V.

   Fig.  1.  A fide view of Mr. Bell's cutting-direaor.   It
ffiould be, for an adult, five inches from A to  B, and three
inches from B to C.
   Fig. 4. A front view.   This inftrument, in the grooved
part, ffiould be exaaiy three-eighths of an inch broad, viz.
from  D  to E; and the  cutting part of it from F to G,
fhould meafure nearly an inch.
   Fig. 7. A view of Frere Cofme's inftrument  for litho-
tomy, opened.   If the  fpring C is preffed upon, fo as to
raife it out of  the nitch  B, (of which nitches  there are fe-
veral) as the handle A is made  to move upon a pivot, it
may be turned, and the projeaing part of it D, being turn-
ed entirely round, and preffure applied to E,  it  will raife
the knife F to the elevation here reprefented.   The point
G ffiould be made  blunt and round, fo as to run freely in
the groove of a ftaff.   The length of this inftrument, in-
cluding the handle, ffiould be ten inches.
   After  making the  incifion with  this inftrument,  the
forceps may either be introduced upon the fore-finger, or
upon  a blunt gorget.  It is afferted that a wound of  any
determined fize may be formed by this lithotome cachee,
as it is termed : And it is preferred by fome to the gorget, be-
                                                 caufe 
PLATE     V
 
 
                        [   vii  3
<;aufe it makes but one cut, while with the gorget, if the
greateft care is not employed we will be very apt to make
two : This, however can only arife from inattention.  See
page 175 to 183.
   Fig. 8.  A filver canula of a flat form, for compreffing
the arteries cut in lithotomy which lie too deep to be tied.
   This tube fhould be four inches in length,  and an inch
broad: The holes in the brim  of it are for the purpofe of
conneaing it, by pieces of tape, to a circular bandage paffed
around the body.
   Fig. 5.  A male catheter of filver.  The holes near its
extremity  anfwer better than  a  flit,  which  is fometimes
made,  as with thefe it is not fo apt to be entangled with
the urethra.  Female catheters are ufually made ftraight,
or with a very fmall degree of curvature ; and rather more
than half the length of the male.  The female found ffiould
always be curved.  Catheters have been alfo made of lea-
ther, of flexible wire rolled into  the form of  a tube,  and
covered with bougie  plafter,  and of the caoutchouc or
elaftic gum or refin.
   Fig. 2.  A machine for injeaing tobacco fmoke  by the
anus.  A  is a brafs box  for containing  burning tobacco,
fcrewed on a fmall  brafs tube, which is conneaed to an
elaftic leather pipe, wound round with brafs wire B,  and
which  is  again fitted  to  a common glyfter-pipe  C.  In
both ends  of the box there  is a divifion of thin brafs, per-
forated with fmall holes ; one, for the admiffion of air, and
the other,  for the tranfmiffion of fmoke.  To the box, a
pair of double bellows is to  be conneaed.
   The bellows  fliould be of the  common fize.  The box
ffiould be an inch and an half in diameter, and three inches
in length:  the  brafs tube ffiould  be fix  inches in length,
and a quarter of an inch in diameter.  The  leather pipe
ousjht to be nearly of the fame diameter with the tube, and
                        4 D                    about 
                        [   viii  3
 about two feet and an half in  length.   The glyfler pipe
 ffiould be fomewhat larger than thofe in common ufe.
    Fig. 8. A hook for enlarging the foramen ovale,  in her-
 nise of that part.
    Fig. 6. A filver canula, for introducing into the urethra
 after amputating  the penis.

                    PLATE   VI.

    Fig. 1. A new form of fpeculum oculi.  The handle of
 it  may be made  either of fteel  or of wood, but  the reft
 of it ffiould be either of filver or of finely polifhed fteel.
 In order  to enable thofe who  think it the beft  praaice to
 withdraw the  fpeculum,  in  operating for the cataraa,
 while the knife or needle is in the  eye, a vacancy may be
 left in the circular part.
   Fig. 2. A bandage for the  eyes.   It confifts  of two
 pieces of polifhed wood excavated into  the form of cups,
 and covered with a  black or green ribband.*
   Fig. 5.  A couching needle to be ufed with the right hand
 in operating on the  right eye.
   Fig. 7.  A flat oval couching needle.
   Both of thefe inftruments are reprefented of the full fize.
 The handles fliould  be  made of light wood, and the fteel
 part  ffiould be exquifitely  polifhed.   Neither of  them
 ffiould exceed forty  grains in weight.
   Fig. 8.  A flat probe,  made  of gold or filver,  for  infert-
 ing through the pupil, in order  to tear an opening  in the
 capfule of the cryftalline lens.
   Fig.  3. A  flat  round-pointed  needle,  fomewhat ffiarp
 at  the  end, for paffing a ligature around the artery, in
                                                   cafes

  • Thi» bandage, with the difference of having a fmall perforation made
oppofite to the pupil of each eye, might bt ufed in cafes of ftrabifmus in
children. 
PLATE  VI
 
 
 
PLATE    VII.
J.Trcnckard  Stuli 
                       [  i*  3
cafes of aneurifm, and around the fpermatic cord, in extir-
pating the teftis.
   Fig. 4. A fpring  or fteel trufs, for an  inguinal hernia
of the  right fide.  There is  a bolfter or pad, for preffing
upon the opening through which the  parts protrude,  at
one end, and the leather with which the fteel is covered, is
formed into a ftrap having feveral perforations near the
end, for conneaion with the knobs on the back of the pad.
They fometimes have a  ftrap to go between the legs, but
this is  in general unneceffary; and are neceffarily  double
when there is a hernia on both fides.
   Fig. 6. A curved probe  to be inferted into the lachry-
mal punaa.
   Fig. 11.  A curved  probe to be inferted, by the noftril,
into the nafal dua of the lachrymal fac.
   Fig. 9. A fmall tube, of the fize of the lachrymal punaa;
injeaions are thrown through this into the fac.  The in-
jeaions are thrown into this tube by a fyringe, with a long
and fmall pipe.
   Fig. 10. and  12.  Inftruments employed by Mr.  Pellier
in the operation  for  fiftula lachrymalis.   Fig. 10. is the
tube for leaving in the paffage.  Fig. 12. B is the perfora-
tor introduced through A the  compreffor.


                  PLATE  VII.

   Fig. 1. A ffiarp curved probe for removing the cryftalline
lens in the operation propofed in page 294.
   Fig. 2. One of the beft  forms of the knife ufed in the
operation ef extraaing the cataraa.  It ffiould be  tolera-
bly ftrong, and  highly  poliffied.   Near  the point, both
fides of it ffiould be ffiarp, by which the  cornea is more
eafily penetrated; but the other part of the back fliould
be round,  which gives ftrength  to  the  inftrument, and
leffens the rifle of hurting the iris.
                                                  Fig. 
                        C  *  3
   Fig. 4. A knife of a fimilar form with the former in the
 cutting part, but curved, for performing the operation on
 the right eye with the right hand.
   Fig. 8. A fcoop for removing either the whole or any
 part of the  lens, when it lodges in the pupil, or in the an-
 terior chamber  of the eye between the iris and cornea, in
 attempting  its extraaion.
   Fig. S. A blunt curved biftouri.
   Fig. 5. One of the beft and moft ufeful forms of curved
 needles.  It ffiould have no edge on its concave part, and
 be made fomewhat round like a lancet, on both fides.
   Fig. 6. A tenaculum.
   Fig. 7. The canula of the trocar, fig. 10.  The trocar
 here reprefented  is of the form of a flat oval; and pene-
 trates with  much more eafe than the common round trocar
 with a triangular pointed flillette.
   Fig. 9. A hook for feparating the eye-lids.  It ffiould '
 be made either of poliffied  filver or fteel.

                  PLATE   VIII.

   Fig. 1. A fcarificator for opening abfceffes in the throat,
 and  for fcarifying the amygdalae.  The wings to the ca-
 nula, are for compreffing the tongue.
   Fig. 2—5. An inftrument for fluffing hollow teeth with
 gold or lead, or for burning the nerve of a tooth.
   Fig. 3.  Mr. Mudge's inhaler, for conveying fteams of
 warm  water, and other liquids, to the throat and breaft.
 When ufed, the grating A ought to cover the hole near it
 which ffiews the paffage  to the valve.   Fig. 6. A feaion
 of the  cover, in  which is  ffiewn the conftruaion of the
 cork valve B, and alfo the conical part  C,  into which the
 flexible tube D  is fixed.
  When the inhaler, which holds about a pint, after being
three parts filled with hot  water,  is fixed in the  arm-pit,
under the  bed-clothes, the end of the tube  E is to be ap-
                                                 plied 
PLATE      VIII
J.TrencHai-d.  Sculp 
 
                       C  xi  3
plied to the mouth ; the air, in the aa of infpiration, then
ruffies  into the apertures F,  and paffing through  the hol-
low  handle, and afterwards into a hole in the lower part,
where it is foldered to the body, and therefore cannot be
reprefented, it rifes through the hot water, and is  received
into  the lungs,  impregnated  with vapour.  In expiration,
the contents of the lungs are difcharged upon the furface
of the  water; and  inftead  of  forcing  the  water • back
through  the hollow  handle,  the air efeapes by lifting the
round light cork valve B, fo as to fettle  upon the furface
of the body under the  bed-clothes.  Thus refpiration is
completely performed without removing the  inftrument
from the mouth.
   The flexible part of the tube D, is about fix  inches long,
and  fitted with a wooden mouth-piece E,  at one end, and a
part  G  of the  fame materials at the other,  to be  received
into  the  cone C on the cover.  This flexible tube is made
by winding a long flip  of  filk  oil-fkin over a fpiral brafs
wire.  This ffiould be  then covered with a  flip of the
fame fize of thin filk, and both fecured by ftrong fewing
filk,  wound fpirally round them.
   Care  ffiould be taken that the different  parts of  this ma-
chine be  clofely fitted to each other: And it is neceffary
that  the area of the holes on the upper part of the handle,
taken together, the fize of the hole in the lower part of the
handle and which opens into the  inhaler, the opening of
the conical valve itfelf, and that in the mouth-piece, as well
as the cavity or infide of the flexible tube, ffiould  be all
equally large, and  of fuch dimenfions,  as to equal the fize
of both the noftrils :  And thus refpiration may be perform-
ed with eafe.
   Fig. 4. A fmall fcoop; the moft convenient inftrument
for removing peas, and  other fubftances, which  may get
into  the noftrils or ears.
   Fig. 7. Is a reprefentation of a fpecies of forceps, of
                                                 which 
                       [   xii  3
which Mr. Bell gives no figure.  They are very conveni-
ent for  the purpofe of fupporting the parts during a dif-
feaion,  and anfwer tolerably well for drawing out blood-
veffels, when the ufe of forceps is thought advifable.  The
pin rather higher than the middle of the inftrument,  is ri-
vetted to one blade, and paffes through a fmall perforation
in the other; its ufe is to keep the blades  direaiy ap-
pofed.

                   PLATE   IX.

   Fig.  1.  A broad flat needle,  for  introducing cords or
fetons.
   Fig.  2.  An  acouftic, or inftrument  for concentrating
found in cafes of deafnefs :  Of this there are various forms.
   Fig. 3. A pair of nippers,  or cutting pliers, for remov-
ing fplinters of bone.
   Fig. 4. A peflary.  Peffaries may be made of any firm
wood, and fhould be very  highly poliffied.  Before intro-
ducing them, they fhould be oiled,  and have a firing con-
neaed to them, in order to admit of their eafy removal.
   The peffaries made of fponge immerfed in glue, or melted
wax, compreffed till cold, and then cut into proper forms,
anfwer  very well, and particularly  if covered  with foft
waxed linen, to hinder them from fretting the parts. Thofe
of the elaftic refin loofe their elafticity to foon.
   Fig. 5. A flat pin for the operation of the hare-lip.  The
end of the pin ffiould be of gold, and the point of fteel.
   Fig.  6.  and 7.  Two different forms of fcaling inftru-
ments,  for removing tartar, and  other matter  from  the
teeth.  There is much variety in the form of inftruments
of this kiijd.
PLATE 
PLATE     IX
J.TrencViard Sculp. 
 
 
 
[  xiii   3
                     PLATE  X.

   Fig. 1. A direaor.   Fig. 2.  A pair of crooked fciffars.
 Fig. 3. A pair of Forceps.   Fig. 4. A feton probe: Probes
 are fometimes made fmall and pointed at  one end, inftead
 of having an eye.  Fig. 5.  A fcalpel: When this is intend-
 ed for a pocket cafe, the handle muft be made in the man-
 ner of that of the biftouri.  (pi.  vii. fig. 3.)
   Thefe inftruments,  with the  biftouri, a tenaculum, (pi.
 vii. fig. 6.) a fcarificator, or gum lancet, (pi. i. fig. 8.) a pair
 of ftraight fciffars,  a cafe for cauftic and red precipitate, a
 fpatula, and a few crooked  needles, form a complete fet for
 a pocket cafe.
   Fig. 6.  A fraaure box.*   A A.  The  bafe  or bottom,
 formed of deal an inch and an half thick. BB, the two ends
 rifing from the bafe,  and terminating in the pillars CCCC.
 Thefe may either be fixed to the pillars, or, in order to ren-
 der the machine portable, be made moveable, and fixed for
 ufe by a double pin at each end F. DD, an excavated move-
 able piece of wood for fupporting the fraaured limb.  This
 part of the machine may be raifed to any height by the pins
 EE paffing through the holes in the pillars CCCC ; and it
 may at pleafure  be raifed at one end,  and depreffed at the
 other.  HH, two ftraps conneaed with buckles on the op-
 pofite fide for fixing the limb  after it is  properly placed.
 Before laying down the leg, the dreffings  ffiould be all ap-
 plied, and the excavated part of the box lined  with foft
                                                  wool,

  » This machine is feldom made ufe of in this place.  Compound fraaure*
are dreffed as lightly as poffible, with the bandage and fplints ufed in fim-
ple fractures.  A third fplint, applied to the back of the leg, in fradures
of this part, will enable the patient to lie on his back occafionally, and thus
anfwer in fome degree the intention of the frafture box 
                      [  xiv  3
 wool.   G, a hole for receiving the heel, to prevent it from
 being hurt when the leg is ftretched out.


                   PLATE   XI.

   Fig.  1. A jugum, for compreffing the urethra.  It con-
 fifts of a piece of elaftic fteel, lined with velvet or foft flan-
 nel.  By means of the fcrew, A, its width can be regula-
 ted : and  the cufhion  B being placed upon the urethra,
 any neceffary degree of preffure can be applied to it, with-
 out interrupting the circulation in the penis to any confide-
 rable degree.
   Fig. 3.  A receptacle for the urine.  It may be made of
 tin, filver, or any other metal: It is convex on one fide,
 and concave on the other which is applied to  the thigh.
 CD, two tubes for conneaing the part into which the pe-
 nis is put,  by tapes, to a bandage paffed round the body.
 F,  a fmall tube for fixing the inftrument to the thigh.  It
 may contain  three or four gills.
   Fig. 2.  A  manifold bandage, of 12 tails.
   Fig. 4.  This very ufeful part of the apparatus for extend-
 ing diflocated limbs,  is formed of thick ffiamoy or buff lea-
 ther.   It is to be  tied firmly around the limb with the
 ftraps at each end ; and the extenfion is made by affiftants
 pulling  the ftraps paffed over  the hooks : It anfwers much
 better than towels,  which are  ufually employed.
   Fig. 5.  A bandage for compreffing the abdomen during
 and after the operation of the paracentefis: It is made of
 foft leather lined with flannel.   A the body of the bandage,
 which  ffiould reach from ilium to ilium, to be  there fixed
 by the  ftraps  BBBB to the  buckles  CCCC.   The ftraps
DD, by paffing  over the flioulders,  ferve to fix  the buc-
 kles EE, which pafs through between the thighs.  The
 perforation is to be made through the windon F, which
                                            afterwards 
PLATE   XI
 
 
 
PLATA    Ml
JTiin'W  S»ci.l|>.
45 
                        [   xv  ]
afterwards is ffiut by the ftraps G, and the buckles H, as
reprefented by the letter I.
  Fig. 6.  A peffary  for the prevention  of hernise in  the
vagina.  As fteel is apt to ruft, this tube  ffiould  be made
of gold, filver, or ivory, with a cord at  one extremity, for
the purpofe of withdrawing it when neceffary.

                   PLATE   XII.

  Fig. 1. A form of the beft fpecies of fplints, for fraaures
of the extremities, perhaps yet invented.*   This is not the
moft  common form, which  is oblong, of the fame breadth
all the way, but rounded at the ends ; but  it  anfwers ex-
ceedingly well for the leg  or arm.    They are made by
gluing a piece of woodf about the tenth of an inch in
thicknefs,  upon  leather.   The  wood  is  afterwards  cut
through to the leather by a knife or a  faw, in  the manner
reprefented in the figure.
  Thefe fplints  are preferable to pafteboard, becaufe they
have more firmnefs, with a fufficient degree of flexibility.
  Fig.  2. and 7. Mr. Sharpe's fplints.*   They are form-
ed of ftrong pieces of pafteboard made with glue ; and are
a little convex  externally and concave internally.   The
firft is the fplint to be fixed on the outfi_de of the leg :  in
general it  ffiould be eighteen inches long, and in width,
two inches and three-quarters at  the ftrap next the knee,
and two and a quarter inches at the other  ftraps.
  DFDFDF, reprefent three leather ftraps, being perforat-
ed  near the ends to  connea them to the  knobs  AAA on
the fplint fixed upon the internal  part of the  leg.  Thefe
                         4  E                      ftraps

  * To both thefe kinds of fplints fome prefer thofe made in the fhape of
Mr. Sharpe's, but formed of flexible pieces of whale-bone, connected by li-
nen, nearly in the manner of women's flays, and fattened by thin leather
or girthing ftraps in the mode of Mr. Sharpe's.
  f Cedar is ufually  employed in this city. 
                      [  xvi  3
ftraps fliould be  from fifteen to twenty  inches in length,
and one in width, and muft  be fewed to the outfide of the
fplint.
   G, a part to fupport the foot;  from E to H, it fhould
be five inches.
   C, the foot-ftrap, twelve inches long,  fewed to  the end
of the fplint, and paffing under the  heel and  through the
leather loop B on the upper fplint, to the loweft pin A.
   I, a hole, two inches long and nearly one  wide, to re-
ceive the malleolus externus.
  Fig.  3.  A fling or machine for fupporting the fore-arm.
AA, a cafe of firm leather properly lined with flannel and
wool, of a fufficient length to cover the arm, from the el-
bow to the ends  of the fingers, for the left  fide.  B, a col-
lar of foft buff leather for paffing over the right arm, in
order to fupport  the fore part of the cafe ; this it does by
means of the ftrap F paffing over the left ffioulder  and fix-
ed to a buckle at  C, to prevent  it from  flipping down.
GH, two ftraps and buckles for fixing the arm to the cafe.
   Fig. 6. A machine for fupporting the head and ffioul-
ders ; and commonly employed in diftortions of the fpine.
A, an iron collar, properly covered, for  palling round the
neck.  By means of the long iron plate conneaed with this,
it may be raifed  or depreffed at pleafure.  BBB,  a broad
iron plate, fitted to  the back and  ffioulders.   CC, two
ftraps, to be carried over the flioulders,  brought  beneath
the arm pits, and fixed to two knobs on the ffioulder plates.
D, a ftrap  for  fixing the plate going down the back,  by
being tied round the  body.
   Fig. 4. An artificial leg, made of firm hardened leather.
A, an oval piece of the fame kind  of leather lined with
ffiamoy, fixed upon a plate of iron C, and moving  upon
an axis at  the knee.  The ftrap  I, with the  buckle con-
neaed with it, ferves to fix  it to  the thigh.   There muft
alfo be an oval piece conneaed with a fimilar piece of iron
                                                   on 
                       [  xvii   3
on the  oppofite fide of  the  thigh:  thefe plates and pads
fhould reach about nine  inches up the thigh.  B,  a  ftrap
that comes from the fole of the  foot, and goes up the in-
fide of .the leg to the middle of the thigh, where it is  fixed
by a buckle, to a  ftrap  coming from  the oppofite ffioul-
der ; this ferves to fupport the leg very effeaually.
   Fig.  5.  A piece of foft fhamoy leather, which fixes by
a buckle and ftrap  round the condyles at the  knee, and
 prevents the confequences of the leg  rubbing againft the
 knee : the flump hanging loofe within the leg, the friaion
 is entirely fuftained by the condyles and patella.
    Fig.  8. An artificial  fore-arm and hand, made of the
 fame materials, to be fixed  to  the  ffioulder by the  ftraps
 DE.
    The legs abovementioned ate equally ufeful  with  the
 common wooden legs, and  preferable from being neater,
 and not liable to break : and they anfwer better than thofe
 of copper from being confiderably lighter, and not apt  to
 be mifhapen by bruifes.
    Mr. Wilfon, of Edinburgh, who is the inventor of this
  fpecies of artificial legs  and arms, makes three different
  kinds, correfponding to  the part at  which the limb  is am-
•  putated.  When  the leg is  taken off lower than the ufual
  place below the knee, as recommended  in chap.  xlvi. fea.
  4  the leg above reprefented anfwers.  The fecond kind
  is  intended  for thofe  cafes where  the  amputation has
  been performed  at  the ufual place below the  knee ; the
  knee then refts upon a foft cuffiion, but has no flexion ; and
  the hollow  for receiving the thigh goes nearly up to the
  hip • it is fixed  with ftraps and hooks, and opens  behind
  to receive  the thigh.    When the limb is taken off above
   the knee, a joint is formed in the artificial  leg.   In walk-
   ing, the limb is made fteady by a fteel bolt, running in fta-
   ples, on the outfide of the  thigh, being puffied down; the
   knee  is  rendered flexible  by  this bolt being  pulled up.
                                                    The 
                     [  xviii  3
The reft is obtained  from the leg embracing the upper
part of the  thigh, and from the hip refting upon the ftuff-
ed thigh-box.
  The artificial arms are covered with white lambfkin, co-
loured fo as to refemble the human  fkin.  The nails are
of white horn coloured.  The joints  are  made in the
ffiape, and fo as to have the motions, of the  natural joints.
The  fingers  and  metacarpus are made  up to the proper
form, with  foft ffiamoy  leather and baked hair.   In the
palm of the hand there is an iron fcrew, in which a fcrew
nail is occafionally fixed.  The head of this nail is a fpring
plate, fo made as to hold  a knife and fork :  and by means
of a brafs ring on the firft and fecond fingers, a pen  may
be ufed for writing.
   The quantity  of parts to  be fupplied,  mufl determine
whether the ftraps are to be conneaed  to the arm alone,
or to the arm and ffioulder.
INDEX, 
[ xix 3
INDEX.
A.BSCESSES in general, -		m	9
	the antrum maxillare, -		-328
	breafts of women,	-	425
	globe of the eye,	-	272
	gums, - -	-	327
	liver,	-	423
	lumbar, -	-	431
Affeaions	of the brain from external violence,		235
Air extravafated into the thorax,		-	226
Albugo,	......	-	279
Amputation in general, -		-	527
	of the arm, -	-	554>
	at the ffioulder, -	-	552
	cancerous mammae,	-	233
	the foot, -	-	551
	fingers, -	-	ibid.
	leg,	-	543
	penis, -	-	164,
	thigh,	-	536
	at the hip, -	-	546
	toes, -	r	551
	with a flap, -	-	545
	above the knee,	-	548
	below the knee,	-	550
Anafarca,	_--.-_-	-	451
		Aneurifms,	
 
XX
INDEX.
Aneurifms,    -
          falfe or diffufed,
          true or encyfted,
          varicofe,
Angina,       -
Anus imperforated,
Arteriotomy,
100
103
100
102
423
207
 96
B.
Bandages,
Blood effufed into the eye-ball,
Blood-letting in general
              the arm,
                  ankles and feet,
                  hemorrhoidal veins,
                  jugular vein,
                  tongue,
           topical,
Bones, removal of the ends of
Bougies,
Bronchocele,      -    -
Bronchotomy,      -
Buboes, venereal       -     -    -
Burns,        -
567
276
 84
 93
 95
 96
 94
 96
 97
554
195
453
228
427
417
Caffarian feaion,
Calculi urinary,
Cancer of the eye-ball,
             breaft,
             lip,
Carbuncle,
Caftration,
     559
  -  166
     282
     233
     323
       13
     159
Cataraas, 
                   INDEX.                  xxi
Cataraas,     -     _     _    _    -     -     -   284
         depreffion of   -     -    -    -     -     287
         extraaion  of     -    -     -     -    - 291
Cerate, common,        -                           25
       faturnine,      ______  26
Chilblains,        -.....435
Cirfocele      -     -     -    -    -     -     -154
Compreffion of the brain from external violence,      237
Concretions of the eye-lids,      -                  268
           within the capfular ligaments,   -    -   448
Concuffion  of the brain,       -    -    -     -     247
Contufions,      -       _____   437
           of the  head,       -    -    -     -     251
Corns,   --------   458
Couching,        ......287
Cupping,      ______     -97


                        D.

Deafnefs,      _______   354
        from imperforated meatus auditorius,        355
             excrefcences in the meat,  audit.     -   356
             extraneous bodies in the meat, audit.    ibid.
             wax in the meatus auditorius,     -     357
Dentition,     ____---   324
Diflocations,      ___-_-     494
Diftortions of the limbs,   -    -    -     -     -   521
                 fpine,      -                     524
Dua parotid, divifion of the    -                  353


                         E-
Ears, difeafes of the        -                       354
      perforating the lobes of the   -               359
Ecchymofis,         ______    87
                                          Embalming, 
xxn
INDEX.
Embalming,         ______  565
Empyema,        ______     224
Eryfipelas,     -     -.....421
Excrefcences on the cornea,   -                    269
            condylomatous, about the anus,     -  204
            within the capfular ligaments,     -     448
Exofiofis,.......459
Extirpation of the eye-ball,    -                    282
                 teftis,.....159
Eye, difeafes of the      -    -    -     -     -     257
     cancers of the   -     -    -    -     -    -282
     dropfical fwellings of the      -     -     -     274
     films on the......279
     protrufion of the ball of the   -     -     -     281
Eyes, artificial,       ______  284
Eye-lids, inverfion of the      -    -     -     -     261
         tumors on the         -    -     -    -  263
                          F.

Fauces, difeafes of the        -                     304
Fiftula in ano       ......209
       in perinseo,      -     -     -    -     -     198
       lachrymalis,        -                       294
Fraaures in general,     -                          464
         of the arm,      _____   479
               clavicles,     -                     474
coccy
x,
477
compound,   -                    490
fingers,   -----  482
foot,.....490
fore-arm,  -----  480
hand,   -    -     -     -     -    482
leg,   ------       489
lower-jaw,    -     -     -     -    473
                             Fraaures 
                   INDEX.                 xxiii
Fraaures of the nofe,
               patella,     _      -       -       487
               os femoris,     -     -       -    483
                  facrum,     -     -       -    477
               offa innominata,     -      -       '^"-
               ribs,    -       -       -    -    474
               fcapula,     -       -       -      4'8
               fternum,     -      -       -     476
               fuperior maxillary and cheek bones,  473
               toes,     -      -       -    -    490
               vertebrae,      -      -      -    477
               wrift,     -                       4g2
 Frenum of the penis, divifion of the,     -     -     165

                         G.
Ganglions,    -              "
Gangrene,—dry,     -
Gouetre,     -----     *53
Gums, excrefcences on the,
       fcarification of the,
Gumboils,     -     -     -       -   .-
H.
Hare-lip,    -     -     -     -
Hematocele,     -
Hemorrhoids,
Hemorrhagies, means of reftraining
Herniae in general,
        congenital,
        crural or femoral,
        of the foramen ovale,
        umbilical or exomphalos,
327
     318
     151
     202
      79
     115
116—129
     129
     132
     130
4, p                   Herniae 
xxiv                 INDEX.
Herniae, inguinal, or bubonocele,     -       _      123
         of the urinary bladder,     -     -     -     132
         ventral,      -       -       -       _      131
         fcrotal, or ofcheocele,     -                 ibid.
Herpes,     -       -       _                        49
Hydrocele,     -        -__      --134
           anafarcous of the fcrotum,     -     -     185
                           fpermatic cord,     -     148
           encyfled of the fpermatic cord,     -      149
           of the tunica vaginalis,     -       -     137
           of a hernial fac,     -       -     -      147
Hydrothorax,    -       -     -       _     -219

                          I.
Inflammation in general,
             of the eyes,    -
                   ear,    -
                   mamma,
                   membranes of the brain,
                   tefles,
             eryfipelatous,
             phlegmonic,
Inoculation,     -
Incontinence of urine,
Inverfion of the eye-laffies,
Iffues,    -    -     -     -     _

                          L.
Ligature of arteries,
Lips, difeafes of the,
      cancerous, extirpation of,
Lithotomy,     -
          by the greater apparatus,
          leffer apparatus,
          lateral method,
                                               Locked
   1
257
422
425
249
426
421
   1
364
187
265
362
 79
318
323
171
172
ibid.
173 
INDEX.
XXV
Locked jaw,     -       -                        3'°
Luxations in general,     -    -      -      -    494
          of the ankle,     -                     519
                cranium,     -                   *®9
                clavicles,     -                   505
                elbow,     -       -       -      511
                fingers,      -       -       -    514
                foot,                            520
                head,                           501
                knee,    -       -     -      -    518
                lower jaw,     -                 500
                metacarpus,     -      -     -    514
                nofe,     -                      500
                os coccyx,     -      -           503
                   femoris,    -       -      -     514
                patella,     -     -    -     -     518
                ribs,     -             -     "     505
                os facrum,     -             -     503
                fpine,     -                       ibid'
                humerus at the ffioulder,      -     506
                               wrift,       -      513
M.
Mortification,
Mouth, difeafes of the,
N.
 12
324
Naevi materni,    -
Nephrotomy,    -       -
Nipples, difeafes of the,     -
Node, venereal,
Nofe, difeafes of the,    -
Noftrils, imperforated,     -
        hemorrhagies from  the,    -       -       304
                                         Obftruaions.
456
183
361
459
304
307 
 xxvi                INDEX.

                         O.

 Obftruaions in the urethra,    -       -           192
 CEdema,     -                                  450
 CEfophagotomy,     -                           230
 Opening dead bodies,     -      -                563
 Ophthalmia,     -       --      -       -257
 Ozaena,     -       -           _     _      _     305

                         P.
 Paracentefis of the abdomen,     -    -       -     215
                 thorax,    -      -       -     219
 Paraphymofis,     -      -     -      -     -     163
 Paronychia,    -      -       -       -      -     433
 Pain, of obviating, in operations,     -       -     557
 Phlegmon,    _____       1
 Phymofis,    -      -                           161
 Pneumatocele,     -     -      -      -     -     154
 Polypi in the nofe and throat,     -      -     -     308
 Prolapfus ani,    -       -      -                206
 Pus, formation of,            -      -        -       6

                         R.
 Ranula,     -       -       -                     349
 Ruptures of the tendons,     -                    383
               capfular ligaments,    -        -     385

                         S.
 Sarcocele,    -      -       -      -        -     156
 Sarcomata, or fleffiy  excrefcences,    -       -     458
 Setons,     -       -      -                      363
 Sounding or fearching for  the ftone,      -      -     169
 Spermatocele,    -                  -        -     154
Spina ventofa,      -                             459
      bifida,    -      -       -      -      -     451
Sprains,     -       -      -       -              437
                                         Suppreffion 
INDEX.
xxvii
Suppreffion of urine,
Suppuration,
Sutures,
Suture, dry,
        glover's,
        interrupted,
        quilled,
        twifled,     -
Stone, the,
Stones in the urethra,
Swelling, white,
                rheumatic,
                fcrophulous,
    189
       6
      74
    ibid.
76—404
      74
      76
      77
     166
     184
      66
      67
      69
Teeth, cleaning the,     -    #  -
       derangement of the,
       extraaing of the,
       loofe,     -
       tranfplanting of the,
Tents,     -
Tetanus,
Throat, fcarifying the     -       -
        fomenting the,
Thrombus,
Tongue, extirpation of the,
        divifion of the frenum of the,
        ulcers on the,
Tonfils, extirpation  of the,
Tooth-ach,      -
           from the nerve being laid bare,
                affeaions of diftant parts,
                inflammation,
Trifmus,
Tumors, in general,
    334
    325
    317
    333
    347
    379
    375
    318
    ibid.
     87
    350
    352
    350
    315
    337
    ibid.
    346
    345
    375
    420
Tumors, 
xxviii
INDEX.
Tumors, acute or inflammatory,	420
chronic or indolent, ' - - -	439
encyfted, - - - -	ibid.
from colleaions in the burfae mucofae,	444
capfular ligaments,	446
fcrophulous, - - -	452
U.	
Ulcer, fimple purulent, - -	21
vitiated, - - - -	28
callous, - - -	34
cancerous, -	41
carious, - - -	36
cutaneous, -	49
fungous,	30
fcorbutic, - -	62
fcrophulous, - - - -	64
finuous, - - -	32
venereal, - - -	56
Ulcers in general, - - -	17
in the mouth, ...	350
Uvula, extirpation of the,	317
Urethra, imperforate, - ...	165
V.	
Varicocele, -	154
W.	
Warts, - - - ...	456
Wounds in general, -	365
fimple incifed, - - - 366-	-369
lacerated and contufed,	380
punaured, -	377
poifoned, _ - - -	411
gun-fhot, . - - -	413
of the arteries, - -	88
Wounds	
 
INDEX.		xxix
Wounds of the lymphatics,	„	383
nerves,	89-	-383
tendons,	.	ibid.
veins, -	.	382
capfular ligaments,	-	385
face,	-	387
eye-balls,	-	261
eye-lids, -	-	ibid.
cefophagus,	-	388
trachea,	-	388
thorax, - -	-	390
large thoracic veflels,	.	396
heart,	.	396
lungs,	-	394
thoracic dua,	-	396
mediaftinum,	-	396
pericardium,	-	ibid.
diaphragm,	-	396
abdomen,	-	406
omentum,	-	407
ftomach,	-	406
inteftines,	-	403
mefentery,	-	407
liver, - - -	-	ibid.
gall-bladder,	-	ibid.
fpleen, - -	-	408
pancreas,	-	408
receptaculum chyli,	-	ibid.
kidnies,	-	409
ureters,	-	ibid.
bladder,	-	ibid.
uterus, and its appendages,	-	410
Wry neck, -	-	360
 
 
 
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